vector2

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Can someone tell me how the myth of the average arm not being arterially collateralized keeps on getting propagated? I feel like I hear at least a few times a month that a-lines in the brachial artery are inherently more dangerous because of the risk of thrombosis in an "end-artery." CC routinely does brachials for all cardiac cases and I'm pretty sure we would've seen a paper published by now detailing their horrible complication rate. The literature on the subject is sparse, but it seems from older retrospective studies that the complication rate is essentially the same. Anyone know of any newer studies? http://www.ncbi.nlm.nih.gov/pmc/articles/PMC137445/




A lot of folks' first instinct after failed bilateral radials is to try a femoral. Granted the vessel caliber is much bigger, but unlike a brachial, you are essentially sticking an end-artery since fem a-lines are placed proximal to the profunda branch, and there are no collaterals that actually travel to the distal leg.

 

Planktonmd

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You are absolutely right!
This is one of those things that keep getting taught from one generation to the next despite the complete lack of evidence!
I actually think that a brachial artery A line is definitely safer than a femoral A line!
 
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At our shop we do brachials for the vast majority of hearts as well. I'll have to track down the paper but I'm pretty sure the caveat to "the complication rates are similar between brachial/radial" is true when the patients are heparinized.

I think it's a good thing to be comfortable with brachials, especially as more and more CTS literature comes out promoting radial artery harvesting for grafts, they are starting to do this quite a bit where I'm at, therefore giving you one radial to have a shot at. With that said, I don't think there's anything wrong with a fem a-line either.
 
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nimbus

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At our shop we do brachials for the vast majority of hearts as well. I'll have to track down the paper but I'm pretty sure the caveat to "the complication rates are similar between brachial/radial" is true when the patients are heparinized.

I think it's a good thing to be comfortable with brachials, especially as more and more CTS literature comes out promoting radial artery harvesting for grafts, they are starting to do this quite a bit where I'm at, therefore giving you one radial to have a shot at. With that said, I don't think there's anything wrong with a fem a-line either.
Our surgeon often does bilateral radials so we go straight to brachial.
 

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Surgical ICU here goes absolutely nuts when we bring out brachial a-lines for the end-artery argument. It's very frustrating to try to reason with them - several of my patients have ended up with femoral a-lines because the standing policy is to get all brachial a-lines out ASAP. Thankfully, Cardiac ICU is anesthesia-run and is A-OK with brachials (and often starts them to get femoral lines out)
 
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Airlife91

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So frustrating. We suffer from the same reluctance to use the brachial artery unfortunately. Here is some data to add to your arsenal. Numbers cited in the article show of ~1600 brachial arterial lines, there were 2 (yes two) complications. Out of 62,626 arterial lines placed (including all body sites) there were at total of 21 complications. The complications studied included: temporary vascular occlusion, thrombosis, ischemia, hematoma formation, and local and catheter-related infection, sepsis, nerve damage, and severe ischemia necessitating surgical amputation.

article: http://anesthesiology.pubs.asahq.org/article.aspx?articleid=2475799

Surgical and Patient Risk Factors for Severe Arterial, Line Complications in Adults
Gregory Nuttall, M.D., Jennifer Burckhardt, M.N.A., Anita Hadley, M.N.A., Sarah Kane, M.N.A., et al
 

Mad Jack

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We specifically learned about collateral circulation in the upper extremity during first year anatomy for this very reason. I think there was some caveat in regard to ages at which the collateral circulation isn't as reliable, I want to say it was in peds patients below a certain age, but my memory could be failing me.
 

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Our surgeon often does bilateral radials so we go straight to brachial.
Wow, I would be gun-shy about put the line on the side of radial harvesting.

One note, I always use a long 12 cm, small (20 gauge) catheter. Lost a finger pulse ox once with the 5fr catheter from the micropuncture kit. Have seen the short catheters come out of the vessel in patients with skinny arms.

Advantage of femoral line? Helps t
 

BLADEMDA

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I'm not a fan of arterial lines placed in the brachial artery. I prefer the radial, axillary or femoral approaches over the brachial.

http://forums.studentdoctor.net/threads/axillary-art-lines-in-adults.1096344/#post-16861472

There is a common misconception that Axillary Artery puncture or catheterization has risks of compromising arm circulation. This is not true. Axillary Artery has six major branches and collateral circulation is provided via Dorsal Scapular, Subscapular, Anterior and posterior humeral circumflex artery to the arm.
 
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BLADEMDA

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While the relative safety of radial arterial puncture and cannulation has been well documented in studies by Slogoff et al. [4] and Mandel and Dauchot [5], cannulation of the brachial artery is usually considered more hazardous. The lack of collateral circulation about the elbow may predispose to forearm and hand ischemic complications. Mortensen [6] reported complications in 14 (42%) of 34 patients who underwent brachial arteriography, including 3 patients (9%) with major complications requiring surgical treatment. In addition, brachial cutdown arteriotomy was also associated with a more frequent complication rate compared to external iliac and subclavian arteriotomy. Bjork et al. [1] described a significant risk of angiographic and Doppler abnormalities of the brachial artery (14 of 25 patients [56%]) with short-term use of brachial arterial catheters. Barnes et al. [3] reported abnormal Doppler signals and/or absent distal pulses in 3 of 54 patients with brachial arterial catheters. However, there was no evidence of significant ischemia to the forearm or hand reported in either study.

The presence of an indwelling arterial catheter may sufficiently disrupt blood flow to the distal extremity to result in muscle and nerve ischemia in combination with increased tissue pressure, or compartment syndrome.
 

BLADEMDA

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At some institutions the placement of arterial lines in the brachial artery is routine. In fact, I bet they have a low complication rate and thousands of patients in their data base.
The problem is nothing we do is without risk or complications. So, when a complication arises the brachial artery is more controversial and could be an medical-legal issue for provider who placed it:

Nevertheless, there have been reports of serious ischaemic damage after radial artery cannulation that led to necrosis, and amputation of fingers or the whole hand [92,93,94,95,96,97,98,99
 

BLADEMDA

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A study of 3,193 arterial entries of various types disclosed 66 major complications and 321 minor complications for a total complication rate of 13%. The Seldinger technique of percutaneous arterial catheterization was followed by the highest incidence of complications, the percutaneous needle puncture method was associated with an intermediate complication rate, and the cutdown arteriotomy with suture repair resulted in the lowest complication rate. Utilizing the brachial artery as the entry site resulted in a significantly higher complication rate than utilizing other sites for entering the arterial tree did.

http://circ.ahajournals.org/content/35/6/1118
 
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Ezekiel2517

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There is a reason CCF routinely does brachials for their hearts. There is plenty of evidence to support their safety and a complication rate similar to radials. Brachials are more reliable post CPB and have a lower failure rate when these patients are in the unit. For non-cardiac stuff, I go radial then brachial then axillary and I don't sweat it one bit.
 

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BLADEMDA

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There is a reason CCF routinely does brachials for their hearts. There is plenty of evidence to support their safety and a complication rate similar to radials. Brachials are more reliable post CPB and have a lower failure rate when these patients are in the unit. For non-cardiac stuff, I go radial then brachial then axillary and I don't sweat it one bit.
Yes, we have discussed this over and over again throughout my years on SDN. I'm well aware of CCF's routine use of Brachial arterial lines. For an arterial line which will be in place for less than 24 hours (like most heart patients) the brachial stick is probably fine. For longer ICU stays the evidence (despite CCF) is still out on the safety profile for Brachial vs Radial.

http://forums.studentdoctor.net/threads/brachial-artery-lines-group-does-them-do-you-follow-suit.779087/ (read the last post in the thread for the general attitude among surgeons)

I'm glad you don't sweat it in "one bit" but there are still many older physicians and surgeons who aren't going to be happy with your routine brachial artery cannulations. Hopefully, you can adapt from the "CCF way" to the routine at most other institutions.

For most patients I go: radial, Femoral or axillary never brachial. Again, I don't see a need to do brachial arterial lines in this day and age with U/S. But, I won't argue over whether one is better than the other.

Here is a study showing "brachial a-lines are safe": http://www.ncbi.nlm.nih.gov/pubmed/24445630 (Mayo Clinic).
 
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Planktonmd

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Femoral and axillary lines are in dirty locations of the body and exposed to sweat and other bodily fluids, so I am having trouble understanding why some one would chose them over the brachial route???
Also thrombosing or dissecting the Axillary or Femoral arteries is likely to be a more devastating complication than the brachial.
 
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TimesNewRoman

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Femoral and axillary lines are in dirty locations of the body and exposed to sweat and other bodily fluids, so I am having trouble understanding why some one would chose them over the brachial route???
Also thrombosing or dissecting the Axillary or Femoral arteries is likely to be a more devastating complication than the brachial.
And not being "a fan" of something is a silly argument that should not be used to criticize other techniques unless you consider yourself some anesthesia guru who his personal likes or dislikes should matter to others!
Fem lines = dirty.....how long will it take for this to die?
 
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BLADEMDA

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Not all a-lines placed perioperatively need to be taken to the unit or kept for days. There are times when the surgery dictates a central or distal pressure.
Agreed. Many times the arterial line is in place less than 24 hours.
 

Ezekiel2517

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Yes, we have discussed this over and over again throughout my years on SDN. I'm well aware of CCF's routine use of Brachial arterial lines. For an arterial line which will be in place for less than 24 hours (like most heart patients) the brachial stick is probably fine. For longer ICU stays the evidence (despite CCF) is still out on the safety profile for Brachial vs Radial.

http://forums.studentdoctor.net/threads/brachial-artery-lines-group-does-them-do-you-follow-suit.779087/ (read the last post in the thread for the general attitude among surgeons)

I'm glad you don't sweat it in "one bit" but there are still many older physicians and surgeons who aren't going to be happy with your routine brachial artery cannulations. Hopefully, you can adapt from the "CCF way" to the routine at most other institutions.

For most patients I go: radial, Femoral or axillary never brachial. Again, I don't see a need to do brachial arterial lines in this day and age with U/S. But, I won't argue over whether one is better than the other.

Here is a study showing "brachial a-lines are safe": http://www.ncbi.nlm.nih.gov/pubmed/24445630 (Mayo Clinic).
You are so focused on making your point, you don't even read what's actually posted. I never said I follow ccf's practice. I said they have reasons for doing it their way and have a successful track record. And I have placed brachials at many different hospitals and institutions and have never heard one person bring it up as an issue.
 

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You are so focused on making your point, you don't even read what's actually posted. I never said I follow ccf's practice. I said they have reasons for doing it their way and have a successful track record. And I have placed brachials at many different hospitals and institutions and have never heard one person bring it up as an issue.
I disagree with you. I read what's posted on that thread and the link to the study which shows that Brachial arterial lines are probably safe. That said, I do not place brachial arterial lines and have no plans on doing so. My response to you is not to make a "point" about being right but rather that practice patterns differ from hospital to hospital. If you are happy placing those arterial lines in the brachial artery then so be it. I still remain skeptical of its safety vs a traditional radial or axillary line.

I think your points have been made as well on this thread. I do respect your opinion and experience with brachial arterial lines but I'll stick with my traditional approach for now.
 

BLADEMDA

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What size catheter do you use for an axillary line?
Pediatric central line kit which is 20 gauge or use a single lumen 18 gauge central line if you have one.
 

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image.jpeg

Why we never do pump cases without a femoral or brachial aline. Pink is femoral. Red is radial.

If I only had a radial, I'd be treating the spuriously low number.
 

BLADEMDA

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View attachment 208827

Why we never do pump cases without a femoral or brachial aline. Pink is femoral. Red is radial.

If I only had a radial, I'd be treating the spuriously low number.
Geez, I check the cuff after coming off bypass. It's common for the radial arterial line to read "low" for the first 15-30 minutes but typically it comes back to a reliable reading. This is what I have done at my residency then in private practice for decades without any issues. A brachial or femoral line isn't needed IMHO if one has experience and common sense in doing these cases (routine CABG). Of course, more advanced cases (aortic arch repair for example) one may choose to add a femoral line as well (which I typically do).
 

BLADEMDA

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To conclude, the radial pressure underestimated systematically the pressure at the root of the aorta after the beginning of hypothermic cardiopulmonary bypass in patients undergoing myocardial revascularization and this pressure gradient was between 3 and 5 mmHg. Although small, this difference can lead to inappropriate or even harmful management conducts. Systemic vascular resistance does not provide an accurate estimate of the magnitude of the aorta-to-radial artery pressure gradient, and this difference of 3 to 5 mmHg between the aortic and radial artery pressures should be considered when making therapeutic decisions in patients undergoing myocardial revascularization with hypothermic CPB.


http://www.scielo.br/scielo.php?pid=S0034-70942007000600004&script=sci_arttext&tlng=en
 

nimbus

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You had a small air bubble in the radial line that eventually got flushed?
No. We do double Aline's fairly frequently and the radial is often lower than the femoral or brachial. If you did it too you would see the same.
 

nimbus

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Geez, I check the cuff after coming off bypass. It's common for the radial arterial line to read "low" for the first 15-30 minutes but typically it comes back to a reliable reading. This is what I have done at my residency then in private practice for decades without any issues. A brachial or femoral line isn't needed IMHO if one has experience and common sense in doing these cases (routine CABG). Of course, more advanced cases (aortic arch repair for example) one may choose to add a femoral line as well (which I typically do).
Why not just use an accurate Aline?

For the record I've only had one Aline complication where a little old lady's hand turned numb and blue in POD 2 and it was a radial Aline.
 

BLADEMDA

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Why not just use an accurate Aline?

For the record I've only had one Aline complication where a little old lady's hand turned numb and blue in POD 2 and it was a radial Aline.
Radial a-lines are just fine. Why not check the cuff a few times and compare it against the arterial line reading? I check it maybe 3 times for a 3-4 hour case so it isn't a big deal and I avoid Brachial arterial lines. Plenty of top tier academic centers don't routinely do brachial arterial lines; the fact that you choose to do so is your prerogative until something bad happens postop. If you do this long enough something bad always happens eventually. Thus, you choose to defend the use of brachial arterial lines (reasonable decision) while I choose to avoid them (again reasonable decision).
 

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View attachment 208827

Why we never do pump cases without a femoral or brachial aline. Pink is femoral. Red is radial.

If I only had a radial, I'd be treating the spuriously low number.
Why bother putting a radial line if you have a femoral?

We do 99% of cases just with radial alines and doesn't seem to be an issue coming off. If bp seems abnormally low we ask the surgeon to measure an ascending aorta pressure via the root vent. That's like 2 cases in 100.
 
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BLADEMDA

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Why bother putting a radial line if you have a femoral?

We do 99% of cases just with radial alines and doesn't seem to be an issue coming off. If bp seems abnormally low we ask the surgeon to meassure an ascending aorta pressure via the root vent. That's like 2 cases in 100.
and the BP is usually only artificially low for 15-30 min or so. I agree with this occurring in about 2-3% of cases which is why I still like to check a cuff pressure after coming off bypass.
Placing a Brachial arterial line may indeed be safe but it certainly isn't needed to do these cases.
 
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Hawaiian Bruin

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Why bother putting a radial line if you have a femoral?

We do 99% of cases just with radial alines and doesn't seem to be an issue coming off. If bp seems abnormally low we ask the surgeon to measure an ascending aorta pressure via the root vent. That's like 2 cases in 100.
OMFG this. This is the correct answer.

I have nothing against brachial lines, and work with folks who make them their routine. I have no problem doing them if need be, and do them before I go femoral. But I'm not a fan, simply because it's not the simplest approach. I like simple.

My practice is to put in an ultrasound-guided HIGH radial with an Arrow (i.e. kink-resistant) catheter on every case. Maybe twice a year I get the issue of the line damping out. If it happens, I transduce the root vent coming off to get a sense of the pressure difference. You can also CW the MR jet to get a sense of whether your pressures make sense or not.
 
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I agree with not needing a brachial just because you may see an artificially decreased BP peripherally vs centrally the first 30min coming off bypass. Once off CPB but before de cannulated just ask perfusion what pressure they're seeing centrally, they'll tell you, then you know your central MAP/radial MAP difference.

As an aside I like how the book will say MAPS should correlate but systolic peak/pulse pressure should be only differences between peripheral and central arterial waveforms/pressures. I call BS, MAP is off by 7-15 not uncommonly.
 

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A little while later.....

View attachment 208829

I actually use the Lower systolic to my advantage. I know that most times the radial systolic pressure are lower than normal but i also know that the MAPs are only 5-10 off. This way the surgeon is more comfortable with the BP being lower for the immediate post Bypass time and the bleeding risk. With the femoral line the surgeon would be saying to lower pressure at 99 systolic, but not with a radial reading 64 (MAP of 54 compared to map of 60 I am not going crazy with drips just yet). I do however place femoral of brachial access when a patient might struggle to come off Bypass as then I dont want to be on redicuolous amounts pressors coming off. But for the routine patient I dont sweat the apparent lower BP, i use it to my advantage to keep the patient more normotensive. I have one surgeon who has a tendency to bleed, where I actually raise the BP (120's) so that he can find all the bleeding vessels before closing up !

In the end what is BP anyway? I am sure you could add a 3rd aline, then a cuff pressure and be all sorts of confused.
 
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vector2

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No pressors, just bad luck. We took her back and surgeon pulled out a long thrombus with a fogarty.
Gotta watch out with those little old ladies. If we are to trust Bedford et al from 1977 (http://www.ncbi.nlm.nih.gov/pubmed/869249), then we should keep in mind that 'The incidence of arterial occlusion increases linearly as the ratio of cannula outer diameter to vessel-lumen diameter increases.' Granted you'd have no idea unless you were using ultrasound, but I'd consider sticking axillary/brachial/fem or using a 22g if a LOL's radial was less than 2mm in diameter.
 
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DrN2O

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You can also CW the MR jet to get a sense of whether your pressures make sense or not.
Use common sense and TEE, good LV contraction, and/or max MR velocity of at least 4m/s should tell you that pulse pressure of 20 on the radial a-line is off. Run the cuff. Don't need a brachial every time.