Why do suck so much at a-lines?

[Nasty Gas]

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Thoracic epidurals: money
PIVs: money
central lines: money
double lumen tubes: money

a-lines: I SUCK

Anyone with advice that might be useful? This is almost as embarrassing as my foot-odor problem.

Thanks.

 

[Ben Hur 17]

Talked to one attending...sain A-lines are the hardest things they do (whoda thought?!). I guess practice makes perfect.

 

[Planktonmd]

Thoracic epidurals: money
PIVs: money
central lines: money
double lumen tubes: money

a-lines: I SUCK

Anyone with advice that might be useful? This is almost as embarrassing as my foot-odor problem.

Thanks.

This has been dicussed recently, here is the link:
http://forums.studentdoctor.net/showthread.php?t=554791&highlight=arterial+line

And also look under the procedures pearls sticky thread, there are several old threads on A lines.

 

[toughlife]

Talked to one attending...sain A-lines are the hardest things they do (whoda thought?!). I guess practice makes perfect.

?

 

[nutmegs]

Talked to one attending...sain A-lines are the hardest things they do (whoda thought?!). I guess practice makes perfect.

I'm pretty much convinced it's OG tubes, actually.

Nasty, where are you hanging up? Getting the flash? Threading the catheter? Having the damn thing work at the end?

 

[numbmd]

Agree, the other thread is great for pearls of getting an a-line.

The only topic they don't cover is getting the flash. I have two pearls for that issue. First is if you don't get the flash with the first stick, don't pull out yet... wait. Feel the pulse and feel the catheter to see how you missed it (right or left). Use that info when you re-insert your needle the second time and your success rate will go up dramatically. Don't just keep sticking blindly.

Also, if your patient has sh*tty presures, give a little of ephedrine prior to sticking. It makes the artery an a-line magnet.

(I'm a fan of the angio attached to the barrel of a 3cc or 5cc syringe, plunger removed.)

 

[numbmd]

agree w/nutmegs in that sometimes an OG tube can make you look the most stupid sometimes.

You get these monster bariatric cases and you can struggle in putting the baker tube...... funny, the food never seemed to have a problem getting down.

 

[fakin' the funk]

Talked to one attending...sain A-lines are the hardest things they do (whoda thought?!).

I was told the same thing though I suspect it was to console for me for having botched one. 😀

 

[Tenesma]

a little shot of papaverine mixed with some lido injected on both sides of the radial artery will make it POP out...

also compress the artery for a while, and there will be frequently some arterial dilation soon after removing the compression (typically my index finger).

i puncture the radial artery with a 20 gauge angio cath - remove the needle, attach a syringe w/ saline (no bubbles)... slowly withdraw the angio cath until there is a pulsatile return into the syringe, slowly advance the angio cath (without kinking it)... BLOODLESS>>

 

[rsgillmd]

Agree, the other thread is great for pearls of getting an a-line.

The only topic they don't cover is getting the flash. I have two pearls for that issue. First is if you don't get the flash with the first stick, don't pull out yet... wait. Feel the pulse and feel the catheter to see how you missed it (right or left). Use that info when you re-insert your needle the second time and your success rate will go up dramatically. Don't just keep sticking blindly.

Also, if your patient has sh*tty presures, give a little of ephedrine prior to sticking. It makes the artery an a-line magnet.

(I'm a fan of the angio attached to the barrel of a 3cc or 5cc syringe, plunger removed.)

I have a question about the ephedrine. I have an attending who swears phenylephrine just makes the artery vasoconstrict and therefore harder to hit. I've rarely had a problem after using phenylephrine. When I've really struggled, I've dug out the ultrasound. I'm becoming more comfortable with that.

Anyone care to comment about phenylephrine vs ephedrine?

 

[pgg]

Funny this thread came up. Today I couldn't get my first a-line in a month of 2-3/day (cardiac rotation). I was feeling good after ~40-50 in a row, not exactly cocky, but well on my way. 🙂 Typical vasculopath trainwreck for CABG, though no explicit history of PVD.

I use the 20g 1.88 in angiocaths without a wire. (Dislike the long Arrow kits, and only use wires to rescue the occasional failed direct attempts.) Today was frustrating - first stick, right in the artery, great flash. Figured it would be another 30-seconds-til-tape a-line start. Catheter wouldn't advance easily so I went through & through. Got a wire, pulled back until I had pulsatile flow again - strong spurts. Could not thread the wire to save my life.

2nd attempt, exact same problem. Attending starts working on the other side. Over the next 15 minutes, total of 5 good arterial hits from the two of us. He also used the 20 g angiocath, also couldn't thread it, also couldn't get a wire to pass despite pulsing return. Now her radial pulses are a bit thready so we figure vasospasm is making things worse.

We ended up putting in a brachial art line.

I've never used the spin-180 technique, but I think I'll do my next 20 or 30 that way. Don't know if it would have made a difference in this patient's crusty arteries, but I'm hoping it'll reduce the number of attempts I need to rescue with wires.

 

[DET0897]

agree w/nutmegs in that sometimes an OG tube can make you look the most stupid sometimes.

You get these monster bariatric cases and you can struggle in putting the baker tube...... funny, the food never seemed to have a problem getting down.

Dip the OG in honey or add a little cream cheese to the tip, it'll go right down

 

[dfk]

Funny this thread came up. Today I couldn't get my first a-line in a month of 2-3/day (cardiac rotation). I was feeling good after ~40-50 in a row, not exactly cocky, but well on my way. 🙂 Typical vasculopath trainwreck for CABG, though no explicit history of PVD.

I use the 20g 1.88 in angiocaths without a wire. (Dislike the long Arrow kits, and only use wires to rescue the occasional failed direct attempts.) Today was frustrating - first stick, right in the artery, great flash. Figured it would be another 30-seconds-til-tape a-line start. Catheter wouldn't advance easily so I went through & through. Got a wire, pulled back until I had pulsatile flow again - strong spurts. Could not thread the wire to save my life.

2nd attempt, exact same problem. Attending starts working on the other side. Over the next 15 minutes, total of 5 good arterial hits from the two of us. He also used the 20 g angiocath, also couldn't thread it, also couldn't get a wire to pass despite pulsing return. Now her radial pulses are a bit thready so we figure vasospasm is making things worse.

We ended up putting in a brachial art line.

I've never used the spin-180 technique, but I think I'll do my next 20 or 30 that way. Don't know if it would have made a difference in this patient's crusty arteries, but I'm hoping it'll reduce the number of attempts I need to rescue with wires.

i had similar situation 3 days ago. we forgone the a-line. what is the spin-180 technique? anything similar to getting flash, 180-ing the cath and attempt threading at that point? presumably so in such vasculopaths, as this might displace plaque to allow wire/catheter to advance?

 

[pgg]

i had similar situation 3 days ago. we forgone the a-line. what is the spin-180 technique?

It was described in the other thread linked above, and I've seen people use it for a-lines and IVs alike. Looks very slick and reliable in competent hands.

Essentially, you go into the vessel as usual, bevel up, and when you get your flash you spin the needle/catheter as a unit 180 degrees. With the bevel down now, you can advance further without the tip being as likely to exit or catch on the back of the vessel. This then results in more of the catheter being in the vessel before you spin it off.

 

[dfk]

It was described in the other thread linked above, and I've seen people use it for a-lines and IVs alike. Looks very slick and reliable in competent hands.

Essentially, you go into the vessel as usual, bevel up, and when you get your flash you spin the needle/catheter as a unit 180 degrees. With the bevel down now, you can advance further without the tip being as likely to exit or catch on the back of the vessel. This then results in more of the catheter being in the vessel before you spin it off.

thanks for the spin

 

[Fastrach]

Funny this thread came up. Today I couldn't get my first a-line in a month of 2-3/day (cardiac rotation). I was feeling good after ~40-50 in a row, not exactly cocky, but well on my way. 🙂 Typical vasculopath trainwreck for CABG, though no explicit history of PVD.

I use the 20g 1.88 in angiocaths without a wire. (Dislike the long Arrow kits, and only use wires to rescue the occasional failed direct attempts.) Today was frustrating - first stick, right in the artery, great flash. Figured it would be another 30-seconds-til-tape a-line start. Catheter wouldn't advance easily so I went through & through. Got a wire, pulled back until I had pulsatile flow again - strong spurts. Could not thread the wire to save my life.

2nd attempt, exact same problem. Attending starts working on the other side. Over the next 15 minutes, total of 5 good arterial hits from the two of us. He also used the 20 g angiocath, also couldn't thread it, also couldn't get a wire to pass despite pulsing return. Now her radial pulses are a bit thready so we figure vasospasm is making things worse.

We ended up putting in a brachial art line.

I've never used the spin-180 technique, but I think I'll do my next 20 or 30 that way. Don't know if it would have made a difference in this patient's crusty arteries, but I'm hoping it'll reduce the number of attempts I need to rescue with wires.

For the crusty vasculopaths, especially the little ol grannies, an attending suggested I try the 22G Arrows, and I gotta say, since I started busting those out on em-- I like, great success!

 

[dfk]

For the crusty vasculopaths, especially the little ol grannies, an attending suggested I try the 22G Arrows, and I gotta say, since I started busting those out on em-- I like, great success!

in longer cases, normally i'll see the waveform tapering off, often requiring frequent flushes, etc.. this all from the catheter being heated and soft over time. i would assume this to be even worse with a 22. have you found this to be true at all?