trouble w/ A-line

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having some trouble w/ A-lines, perhaps someone can offer some tips?

I can usually get a good flash, but can't thread the damn catheter. It goes in easily 1st 2/3, then I get stuck w/ 1/3 of the way to go. And using the through-and-through method hasn't worked for me either.

When you drop your angle after the flash, do you drop it to 15 to 20 degrees?

I'm a bit frustrated w/ these things 😡

 

[jetproppilot]

having some trouble w/ A-lines, perhaps someone can offer some tips?

I can usually get a good flash, but can't thread the damn catheter. It goes in easily 1st 2/3, then I get stuck w/ 1/3 of the way to go. And using the through-and-through method hasn't worked for me either.

When you drop your angle after the flash, do you drop it to 15 to 20 degrees?

I'm a bit frustrated w/ these things 😡

IF YOU GET A FLASH, DON'T sacrifice it just because you can't thread it.

PUSH THROUGH THE ARTERY.

Remove guidewire.

Then pull catheter back VERY VERY SLOW until arterial flow is again appreciated.

Thread guidewire.

TWIST AND PUSH catheter.

Funny how you posted this since lately mosta my art lines havent threaded easily and I've reverted to the push thru the artery then pull back and cannulate approach.

Very easy to learn.

Whatcha gotta get past is after a flash, just because it won't thread doesnt mean you've lost the approach.

Push through.

Then come back.

 

[Planktonmd]

having some trouble w/ A-lines, perhaps someone can offer some tips?

I can usually get a good flash, but can't thread the damn catheter. It goes in easily 1st 2/3, then I get stuck w/ 1/3 of the way to go. And using the through-and-through method hasn't worked for me either.

When you drop your angle after the flash, do you drop it to 15 to 20 degrees?

I'm a bit frustrated w/ these things 😡

What length catheter are you using?
Use a short # 20 angiocatheter and when you see the flash don't get excited just advance the needle first 1mm and make sure you still have pulsatile blood (it helps to connect the angiocatheter's cover to the bottom of the needle or use a 3 cc syringe as an extension), then advance the catheter.

 

[coprolalia]

Funny how you posted this since lately mosta my art lines havent threaded easily and I've reverted to the push thru the artery then pull back and cannulate approach.

Now, unlike spinals, I've probably put in 200+ a-lines to date. I've done them, literally, since day-1 over three years ago.

I originally learned the through-and-through technique, and subsequently tried other methods, and I gotta say that the through-and-through technique is still consistently the best (most likely to get it, least messy, etc.) method of hitting an a-line.

We have one cardiac guy, though, who threads off like Plankton suggests. I tell you, this guy could start an a-line on a block of granite. He's a friggin' genius. I've never seen him miss, even when I can't even feel a pulse (and, he's one of the few attendings who is cool as hell too... he'll probably leave for PP land soon. )

-copro

 

[Planktonmd]

If I miss an A line it usually means the patient was born without a radial artery.
😎

 

[leaverus]

Funny that this thread comes up now. I'm usually pretty good with a-lines and for some reason, i haven't been able to get any for the past week - just can't thread the damn catheter. Appreciate all the tips, guys. One thing i've never understood is how the through-and-through technique works without causing a huge hematoma - aren't you making two holes in the artery? One on top and one on the bottom, so why doesn't the hole on the bottom continue to bleed even after you've threaded your catheter?

 

[Planktonmd]

Funny that this thread comes up now. I'm usually pretty good with a-lines and for some reason, i haven't been able to get any for the past week - just can't thread the damn catheter. Appreciate all the tips, guys. One thing i've never understood is how the through-and-through technique works without causing a huge hematoma - aren't you making two holes in the artery? One on top and one on the bottom, so why doesn't the hole on the bottom continue to bleed even after you've threaded your catheter?

Because the catheter itself tamponades the hole.
I still think that the through and through technique is brutal and unnecessary if you follow the simple technique I mentioned above.

 

[OB1🤙]

I'm a big fan of a technique with a 20g angiocath that sounds a lot like Plank's, only I use a 1cc syringe as an extension (with the plunger pulled out obviously). I'll have to try it with the 3cc, if it works makes sense to use a bigger syringe.

Go in, get your arterial flash, lower your angle, advance a tiny bit- another mm or so. Still flow into your syringe? Excellent- advance catheter. No flow? OK, then you're through and through, but no big deal. Pull back until flow resumes into syringe, now advance catheter. Giggity. No guidewire required.

I just think this is cleaner than fussing with a guidewire and the potential messiness that comes with that (doesn't apply with Arrow kit obv).

I learned with the Arrow kits as a med student and it took me a while to wean myself from them (my program for some reason just doesn't use them), but now I like this setup better than the Arrow assemblies.

 

[proman]

My success rate went up dramatically when I stopped using the Arrow kits. Now I use a 1.88 inch 20 ga Angiocath, advance it at around 30 degree angle bevel up, once I get flash, I spin the needle 180 degrees so the bevel is down, lower the angle a bit and advance another mm. Then advance the catheter off the needle. If that doesn't work I just resort to the through-and-through method and use a pediatric guidewire. I don't attach a syringe or anything else to the Angiocath.

 

[leaverus]

I don't understand what you guys are talking about when you say "attach a syringe to the angiocath." Could someone explain that a little better please.

 

[Apollyon]

I don't understand what you guys are talking about when you say "attach a syringe to the angiocath." Could someone explain that a little better please.

The angiocath has a cap on the end (of the needle, which is inside the catheter) that can be taken off and a Luer-lock fitting syringe can be attached. When the procedure is done, you have a catheter in the artery, and a needle attached to a syringe.

 

[Apollyon]

It's these - if it's a "ProtectIV", you can't hook a syringe up to it.

 

[epidural man]

IF YOU GET A FLASH, DON'T sacrifice it just because you can't thread it.

PUSH THROUGH THE ARTERY.

Remove guidewire.

Then pull catheter back VERY VERY SLOW until arterial flow is again appreciated.

Thread guidewire.

TWIST AND PUSH catheter.

Funny how you posted this since lately mosta my art lines havent threaded easily and I've reverted to the push thru the artery then pull back and cannulate approach.

Very easy to learn.

Whatcha gotta get past is after a flash, just because it won't thread doesnt mean you've lost the approach.

Push through.

Then come back.

Through and through👍👍

I used to use those stupid arrow kits. I had a cardiac anesthesiologist (who has been doing it for years) tell me "you guys all come over here trying that kit and are about 85% successful. You need a technique that is 99.9% successful." Anyway, I started the through and through technique and it works so great I think. Plus, if the artery is bounding, use an 18 guage angiocath instead of the 20. (Same guy showed me that also.) You get a huge flash, and the guidewire goes in like butter, and your a-line works MUCH better for a longer period of time. I only use the 18 on what seems to be a normal artery. That guy put it in everybody.

 

[CanGas]

Here's a tip that increased my success rate and every one I have shared it with as well.

Do the standard approach:

20g angiocath with a 1cc syringe as an extension (with the plunger pulled out obviously). (I like the 1cc better than the 3cc as you see the flow better).

Go in at 30 degrees with bevel up as usual, get your arterial flash, lower your angle, (then rotate needle 180 degrees so bevel is down and advance catheter.

I find that 180 degree rotation is the trick. My impression is sometimes the tip of the needle is in the posterior wall so you can't thread the cath. Rotating the bevel 180 degrees moves the tip of the needle intra-arterial and the cath slides easily. The rotation also seems to advance the cath a bit so you don't have to try and advance the needle yourself and potentially go through the wall.

Try it and let me know how it works.

CanGas

 

[MTGas2B]

I've gone both ways, angio cath vs. arrow, and I have to say I've come back to arrows, but I really prefer the short arrow.

They are about 1/3 the length of the regular arrow kits, and you can remove the wire (for the through and through) out the back end without cutting the end off as you need to with the long arrows. That way with one device I can place the first time (the way the arrow is supposed to work) or I can through and through.

I have heard that the arrow arterial catheters tend to last longer than the angio caths in the unit. Not an itraop concern, but spares the unit resident the headache of replacing more a-lines.

One case where I always use doppler to place a-lines: LVAD patients coming for their heart transplant. You can't really feel their pulses.

 

[CerebralEdema]

Here's a quote from a relatively old article from A&A... study wasn't the greatest (low power w/ only 140 pts) so please take it with a grain of salt.

"We conclude that the success rate for cannulation is high in male patients, and patients with a bounding pulse regardless of the use of the direct or guide-wire techniques. The guide wire is recommended as the initial technique for cannulating the radial artery of female patients. In patients with a thready pulse, no significant advantage could be obtained by using a guide wire, but in salvaging an arterial line the guide wire is efficacious." (Anesth Analg 1993;76:714–7)

 

[Monty Python]

It's these - if it's a "ProtectIV", you can't hook a syringe up to it.

Absolutely --- if your hospital has kow-towed to the almighty JCAHO, good luck finding a supply of old-fashioned Jelco IVs (free of the self-protection devices). Nowadays most places have gone strictly to the new safety-style IVs which are designed the minimize the risk of accidental needlestick. Good idea -- just the engineering in that process makes that particular style of IV needle useless for starting an A-line.

Am I wrong --- has someone on the forum found a way to use ProtectIV safety needles to start a line? Please share !




.

 

[Mman]

My technique is similar to some of the above.

I use 20 g angiocath (I think it's 1.88 inches long). Take the cap off and stick it onto the back (instead of a 1 or 3 cc syringe - I find the cap works just as good). Looks like these except with the cap stuck into the back of it...

I go in at about 30-45 degree angle and look for flash. Once I've got flash I flatten out to about 15-20 degrees. If the blood is still flowing, I slowly advance the catheter off the needle a few millimeters. If blood continues to flow at that point, I know it's in and I advance the catheter the rest of the way. If blood stops flowing when I advanced the catheter, I back it all the way out. Then I reposition the needle by advancing or withdrawing slightly. If blood is still flowing, I try advancing the catheter once more. If blood keeps flowing it's golden and if not I back it out again.


Once I get the flash of blood, it's merely an exercise in patience with small readjustments of the needle. The key is to not thread the catheter all the way down unless blood is continuing to flow through the needle. If it stops flowing at any point, I know the catheter is no longer in the vessel. If after a few times I can't get it, I'll go through and through and try to save it with a guidewire.

I've been pretty successful recently with this technique. I think I've done roughly 500 a-lines as a resident. Over the last year, I only recall 2 that I couldn't get in and my attendings were 1/2 trying after I couldn't get it (the other case we gave up and went without).

 

[Planktonmd]

Here is what we have:

It is Intocan passive safety catheter and I connect the needle cover to the needle and use it instead of a syringe as someone mentioned.
I find these catheters sweet and as close as it gets to the good old Jelco catheter:

Which they don't want us to use anymore since we can't be trusted with a needle 🙂