Ulnar Alines

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MoMoGesiologist

MoMoGesiologist

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Is anyone out there placing ulnar alines? I've seen it rarely. I've had a couple patients with small radials or tough to get radial aline, but their ulnar arteries look juicy. My thought is that the radial artery would allow collateral flow if the ulnar artery thrombosed. Some places do brachial alines routinely without issue, and there isn't collateral supply if the brachial goes down, so I figure ulnar must not be that dangerous. But then again, it's done so rarely that I figure I must be missing something. Is it because it's a larger artery so a bigger issue if it goes down? Would also prefer to avoid femoral aline in elective cases. Tried to research it but doesn't look like many studies on the topic. Thanks team!
 
MoMoGesiologist said:
Is anyone out there placing ulnar alines? I've seen it rarely. I've had a couple patients with small radials or tough to get radial aline, but their ulnar arteries look juicy. My thought is that the radial artery would allow collateral flow if the ulnar artery thrombosed. Some places do brachial alines routinely without issue, and there isn't collateral supply if the brachial goes down, so I figure ulnar must not be that dangerous. But then again, it's done so rarely that I figure I must be missing something. Is it because it's a larger artery so a bigger issue if it goes down? Would also prefer to avoid femoral aline in elective cases. Tried to research it but doesn't look like many studies on the topic. Thanks team!
Click to expand...

Do it all the time in peds. Trisomy 21 kids almost always have ulnar > radial arteries. NICU also places a lot of ulnar a-lines. Occasionally if I can't see any distinguishable radial, I'll put a pulse ox on the hand and occlude the ulnar and make sure there's collateral flow, but if I can see a radial, even if it's small, I'll usually just go for the ulnar.
 
Interesting, never heard of anyone placing an ulnar catheter. In my own opinion, if you think the radial will be difficult, why not just go to a brachial, acillary, femoral, which are all bigger, higher success rate, and proven to all be safe. Unless of course someone can show some evidence suggesting an ulnar catheter is safe.
 
If using ultrasound and the radial looks unusually small, I will occasionally place an ulnar catheter but checking the opposite extremity is probably the better move.
 
I’ve always wondered if it would be acceptable to place an adductor canal femoral aline? It’d prob be easier because you don’t have to tape the pannus out of the way and would be less of an infection risk?
 
fittipaldi1of1 said:
I’ve always wondered if it would be acceptable to place an adductor canal femoral aline? It’d prob be easier because you don’t have to tape the pannus out of the way and would be less of an infection risk?
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High risk of dislodgement though unless you are using a really long catheter.
 
Only time I’ve ever seen it done is when the resident was not paying attention to which side the thumb was doing on....
If I really need an aline I’ll try bilateral radial. If that doesn’t work, femoral, only then do I go for brachial. As a resident we did brachial art lines all the time in cardiac w/o any issues But it seems that if you put one in in the general OR the surgeons and nurses freak out and become convinced that the arm will fall off ....
Dorsal is pedis also works well
 
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N=1, but I saw a colleague fail to place a radial aline- he did hit the artery. Subsequently put in an ulnar on the same side. Hand became ischemic.
 
Why is a brachial safer than ulnar? If an artery were to go down, wouldn't you want the aline to be placed more distal where there is a collateral blood supply?
 
dr doze said:
N=1, but I saw a colleague fail to place a radial aline- he did hit the artery. Subsequently put in an ulnar on the same side. Hand became ischemic.
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By definition and anatomy, this is a horrible idea. I had a faculty member who would routinely suggest doing this and it made me and the surgeons cringe.
 
dr doze said:
Not sure, but it seems logical that the ratio of the diameter of the catheter to the diameter of the artery might have something to do with it.
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I would think this is why. We are placing a long 20G catheter in a giant vessel with fast blood flow, so unlikely to cause problems.
 
I will also add, that placing brachial or art lines in larger vessels is so much better of a line. Hardly ever have issues with dampening, positioning, etc.
 
dr doze said:
N=1, but I saw a colleague fail to place a radial aline- he did hit the artery. Subsequently put in an ulnar on the same side. Hand became ischemic.
Click to expand...

what happened after that?

people do axillary/femoral arterial lines. are the collaterals really that great/good enough if the axillary artery /femoral artery got thrombosed you'd be OK?

i had a patient with femoral arterial line, that thrombosed. leg died.
 
You can palpate a radial pulse, so that's historically where arterial punctures go. If the ulnar artery was as easily palpable, we would've put them there. And a brachial artery isn't going down from a 20 ga needle stick, wire and/or catheter.
 
drmwvr said:
You can palpate a radial pulse, so that's historically where arterial punctures go. If the ulnar artery was as easily palpable, we would've put them there. And a brachial artery isn't going down from a 20 ga needle stick, wire and/or catheter.
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I've heard multiple anecdotal stories from surgeons and anesthesiologists about brachial alines that caused someone to lose an arm. Take that for what it's worth. We didn't do them in my residency unless everyone involved with the case agreed it was necessary
 
There is a decent amount of literature out there supporting ulnar arterial access, even in cardiac catheterization. They have comparable rates of success and complications. The more important question is would you still attempt the ulnar artery if you've already attempted the radial? Or an even better question is how reliable are peripheral arterial catheters in the first place and should we be accessing brachial/axillary/femoral in patients who are likely to require long term monitoring and extensive vasopressor therapy?

Transulnar versus transradial access for coronary angiography or percutaneous coronary intervention: A meta-analysis of randomized controlled trials. - PubMed - NCBI
Radial Access Failure: When Should We Go Ulnar?
https://www.sciencedirect.com/science/article/pii/S0952818007000396?via=ihub
 
MoMoGesiologist said:
I've heard multiple anecdotal stories from surgeons and anesthesiologists about brachial alines that caused someone to lose an arm. Take that for what it's worth. We didn't do them in my residency unless everyone involved with the case agreed it was necessary
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Cleveland Clinic has done over 20000 brachial Aline’s without losing a single arm.
 
Rev Esp Anestesiol Reanim. 1991 Jul-Aug;38(4):268-70.
[Comparative study of radial and cubital arterial catheterization].
[Article in Spanish]
García-Fages LC1, Gomar Sancho C, Villalonga A, Pacheco García M, Nalda MA.
Author information

Abstract
In this prospective study we evaluated catheterization of the cubital artery as an alternative to cannulation of the radial artery. Seventy six surgical patients were randomly allocated into two groups of 38 patients according to the intention to catheterize the cubital or the radial artery. The incidence of failure and the technical difficulties were significantly higher in cubital than in radial arterial catheterization (p less than 0.001 and p less than 0.05, respectively) and they were related to the cubital pulse palpation. There were no significant differences in the time elapsed to achieve the catheterization, time of stability of the catheter, nor in the incidence of complications. The qualification of the technician, the arterial blood pressure and the anatomic characteristics of the forearm did not influence the results. We conclude that whenever the cubital arterial pulse is appropriately perceived, catheterization of this artery is a good alternative to radial catheterization.

PMID:

1771290
 
Ulnar arterial catheterisation is rarely undertaken in anaesthetic practice. While there is published evidence of ulnar artery catheterisation for percutaneous coronary intervention[vi], due to a higher complication rate of ulnar artery access many patients were treated with antiplatelet therapies, anticoagulants and or vasodilators following puncture which would not normally be possible in most critically ill patients. Routine anaesthetic and critical care doctrine would be to avoid the use of the ulnar artery for catheterisation unless no other safer alternatives exist.

In selecting an insertion site, the role of ultrasound should be considered. While radial, femoral and brachial pulses are all easily palpated, ultrasound, which provides the ability to assess patency, depth, direction and caliber of any chosen vessel is becoming better established in increasing first pass success rate, reducing complications and increasing the speed with which lines may be placed, especially in complex or haemodynamically compromised patients[vii].v

Risks associated with arterial lines; Time for a National Safety Standard?
 
Ronin786 said:
There is a decent amount of literature out there supporting ulnar arterial access, even in cardiac catheterization. They have comparable rates of success and complications. The more important question is would you still attempt the ulnar artery if you've already attempted the radial? Or an even better question is how reliable are peripheral arterial catheters in the first place and should we be accessing brachial/axillary/femoral in patients who are likely to require long term monitoring and extensive vasopressor therapy?

Transulnar versus transradial access for coronary angiography or percutaneous coronary intervention: A meta-analysis of randomized controlled trials. - PubMed - NCBI
Radial Access Failure: When Should We Go Ulnar?
https://www.sciencedirect.com/science/article/pii/S0952818007000396?via=ihub
Click to expand...

Absolutely avoid ulnar arterial catheterization if you have attempted a radial arterial line on that same side.

I don’t do ulnar catheters. Never have and never will until a large study is published showing the same degree of safety as radial a lines.
 
SaltyDog said:
Yeah, but they’re second to none.
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LOL thats funny.

Anyway i think it also depends on the patients status. ive only seen 2 ischemic complications from arterial line, both were in sick patients who went ot the ICU on pressors. both died. i imagine length of stay of the line, and pressors also complicate the scenario, and also pro inflammatory states.
 
anbuitachi said:
LOL thats funny.

Anyway i think it also depends on the patients status. ive only seen 2 ischemic complications from arterial line, both were in sick patients who went ot the ICU on pressors. both died. i imagine length of stay of the line, and pressors also complicate the scenario, and also pro inflammatory states.
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along those lines the only ischemic complications ive seen were brachial arterial line attempts BUT they were AFTER the patient had been started on pressors. So if a patient is on a good dose of pressors with no arterial line (i know, it happens) or needs a new a-line, currently I will try radial or femoral but not attempt brachial or axillary. There may be collateral flow to the arm under normal circumstances but if the patient is on pressors then stabbing the brachial and making it spasm may be a bad idea. Anecdotes.
 
T-burglar said:
along those lines the only ischemic complications ive seen were brachial arterial line attempts BUT they were AFTER the patient had been started on pressors. So if a patient is on a good dose of pressors with no arterial line (i know, it happens) or needs a new a-line, currently I will try radial or femoral but not attempt brachial or axillary. There may be collateral flow to the arm under normal circumstances but if the patient is on pressors then stabbing the brachial and making it spasm may be a bad idea. Anecdotes.
Click to expand...

why do people like to go for femorals after axillary instead of something more distal? femorals dont have collaterals?
 
Most of the valid a-line literature can be summarized as: Allen test is garbage, all sites are essentially equivalent when it comes to complications, a-line infection risk is likely higher than believed but is ultimately still very low and probably at worst similar to peripheral IV sites (despite arguments about flow).

That being said, I would not place an ulnar a-line in the same side where I had failed a radial just because there are plenty of other sites available and it can easily be argued that it's a bad idea. I have placed 2 or 3 ulnar a-lines with no issues. The times I placed them were when the ulnar artery had a more palpable pulse than the radial and I did not have access to an ultrasound.

From my recollection, the usual reason that ulnar arterial lines have not been used is more because of the fact that most patients have a more palpable radial pulse due to its relatively superficial position and relation to the bone.

Ulnar artery versus radial artery approach for arterial cannulation: a prospective, comparative study. - PubMed - NCBI

Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine
 
I think it's more along the lines of central lines where it's bacteremia that is eventually blamed on the line as the source s/p culturing for whatever it is worth.
 
Many times I’ve put the US on some kid with developmental problems and saw a smaller than expected radial artery and a much larger ulnar artery. In those cases I’ve used the ulnar without issues. I’d rather use a fat ulnar artery than a small radial or go up to a brachial, femoral, etc.
 
Dorsalis pedis is another good one, but it can be finicky. The dorsal is great bc you can double bill for a prosthesis insertion, urologists be damned.
 
Just to chime in from the interventional radiology world. Our practice is that we typically try to only access arteries where manual compression is feasible, for example, femoral over the femoral head or radial. We tend to shy away from brachials due to inability to compress well.

I suppose an ulnar line can be safe if there is flow in the radial artery on the same side, but the whole point of stick either radial or ulnar is that you don’t take down the entire hand because there is collateral supply. We also do things like Barbeau and modified allen test to establish ulnar patency but that’s because we use larger diameter sheath.
 
I had a lady in intern year who kept getting admitted to the ICU, no arms or legs. There's still a femoral artery there. Also used axillary.
 
anbuitachi said:
subclavian? how does one hold pressure when removing subclavian lines? we dont do them here but i hear its not really compressible. putting in a 14F line in a subclavian and removing it after sounds dangerous if not compressible
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Subclavian arterial line sounds like an absolutely terrible idea. Might as well go carotid, easier to compress.
 
B-Bone said:
I had a lady in intern year who kept getting admitted to the ICU, no arms or legs. There's still a femoral artery there. Also used axillary.
Click to expand...
No way .... what was the mechanism for loosing he limbs?
 
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