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What About A Radial Arterial Line?


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#1 Paramedicmd

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Posted 14 November 2009 - 08:18 PM

With these discussions...lets add the Radial Art Line..

Who can do them?
What is the protocol?
Is it the HEMS equipment?
What patients truly need this prior to transport?

private at paramedicmd@msn.com or live and in color here....

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#2 Mike Mims

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Posted 15 November 2009 - 06:03 PM

Who can do them?
Our flight nurses.

What is the protocol?
As of now, we use the radial artery.
Invasive monitoring is required for the following meds being used:
- Sympathomimetics: Levophed, Epinephrine, Dopamine >5mcg/kg/min, Neosynephrine.
- Vasodilators: Niroprusside.
- Beta Blockers: Esmolol.
- Sedatives: Propofol, Versed.
- NMBA: Pavulon, Norcuron, Nimbex.

Is it the HEMS equipment?
Yes, it was added to our MEL, but not listed on the states mandatory list.
This is a procedure we established for our program and is recognized by the MS State Board of Nursing. I don't think any of the other programs in our state are performing PAL.

What patients truly need this prior to transport?
Any patient who are receiving OR are going to receive the meds listed above. We won't delay transport, if all possible, to start an A-line, we'll do it en route......

IMO: If you are transporting patients in a Critical Care environment, than you should be performing Invasive monitoring. There are way to many advantages with Invasive VS non-invasive monitoring, especially when you have a patient that is requiring different treatment plans that involves multiple infusions. You can not get OR even trust NIBP readings when you need to monitor for immediate changes in hemodynamics.


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Mike Mims

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#3 FloridaMedic

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Posted 15 November 2009 - 07:56 PM

Delaying transport for the insertion of an A-line may not always be a wise choice as some patients may take several attempts to cannulate especially if pressors are running or the patient is hypovolemic.

The radial artery can be easily damaged when attempting to insert one in a moving vehicle or aircraft leading to some consequences that may affect the patient adversely. Veins are much more forgiving than arteries.

It has also been found in numerous studies that the radial A-line is not accurate for BPs on patients with sepsis or serious pressors. A femoral line is usually placed in those those patients. I have seen BP inconsistencies on numerous occasions when switching to a femoral line while the radial line is still in place as is the NIBP.

For IFT, certain lab values should be documented prior to insertion and a reason listed as to why the sending facility chose not to place on. Just because you can doesn't always mean you should and even in the ICUs we have had to do without A-lines for a variety of reasons.

For HEMS that is strictly scene response, I would not advise A-line insertion unless you can afford to be at scene for extended periods of time with a lengthy flight ahead of you.

That being said, RRTs do inserts peripheral A-lines on all ages for IFT with a preference to the UAC for neonates. However, if the transport is time sensitive especially due to weather that may leave us stranded, A-line placement will be deferred and strong assessment skills will be utilized to pick up the slack on the NIBP. But, we run into these situations daily in the ICUs so we are prepared for whatever equipment we may or may not have so it does not hinder care or cost time.
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#4 Mike Mims

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Posted 16 November 2009 - 05:45 AM

Delaying transport for the insertion of an A-line may not always be a wise choice as some patients may take several attempts to cannulate especially if pressors are running or the patient is hypovolemic.

The radial artery can be easily damaged when attempting to insert one in a moving vehicle or aircraft leading to some consequences that may affect the patient adversely. Veins are much more forgiving than arteries.

It has also been found in numerous studies that the radial A-line is not accurate for BPs on patients with sepsis or serious pressors. A femoral line is usually placed in those those patients. I have seen BP inconsistencies on numerous occasions when switching to a femoral line while the radial line is still in place as is the NIBP.

For IFT, certain lab values should be documented prior to insertion and a reason listed as to why the sending facility chose not to place on. Just because you can doesn't always mean you should and even in the ICUs we have had to do without A-lines for a variety of reasons.

For HEMS that is strictly scene response, I would not advise A-line insertion unless you can afford to be at scene for extended periods of time with a lengthy flight ahead of you.

That being said, RRTs do inserts peripheral A-lines on all ages for IFT with a preference to the UAC for neonates. However, if the transport is time sensitive especially due to weather that may leave us stranded, A-line placement will be deferred and strong assessment skills will be utilized to pick up the slack on the NIBP. But, we run into these situations daily in the ICUs so we are prepared for whatever equipment we may or may not have so it does not hinder care or cost time.

I agree that central lines are your better choice......... in the ICU and long term treatment........ but in the HEMS environment and the limited factors you deal with (time, space, personnel, equipment) your best bet is going to be a peripheral A-line.

Me personally, we deal with both central and peripheral lines, and I have not seen a significant difference in the hemodynamic readings between the two, maybe by <5 mmHg, far less than a study I remember that had a difference of NIBP as much as close to 40 mmHg in the SBP and 30 mmHg in the DBP, compared to IABP.
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Mike Mims

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#5 FloridaMedic

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Posted 16 November 2009 - 12:14 PM

I agree that central lines are your better choice......... in the ICU and long term treatment........ but in the HEMS environment and the limited factors you deal with (time, space, personnel, equipment) your best bet is going to be a peripheral A-line.

Me personally, we deal with both central and peripheral lines, and I have not seen a significant difference in the hemodynamic readings, maybe by <5 mmHg, far less than a study I remember that had a difference of NIBP as much as close to 40 mmHg in the SBP and 30 mmHg in the DBP, compared to IABP.


There are lots of studies to look up since this is usually a favorite one for NP and MSN students to research. Read carefully the location of the A-line. Any ICU RN with experience can tell you about the problems of a radial A-line and serious pressors.

We generally allow 1 hour of time for an A-line set up. Some take as little as 15 minutes to get the equipment and line done depending on whether suturing is done. But then that is for practitioners who have done 100s of lines and the patients have great pulses. Generally, one on a compromised patient can take 1 hour with multiple attempts until finally a femoral is done. This again is under ideal situations. Thus, with establishing the central lines, hanging meds and packaging, some don't want to be on scene for another hour. If the patient has great pulses, an A-line done under less than ideal situations may not be necessary and may also have to be redone at the rec'g facility.
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#6 BrianACNP

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Posted 16 November 2009 - 01:09 PM

I agree that central lines are your better choice......... in the ICU and long term treatment........ but in the HEMS environment and the limited factors you deal with (time, space, personnel, equipment) your best bet is going to be a peripheral A-line.

Me personally, we deal with both central and peripheral lines, and I have not seen a significant difference in the hemodynamic readings, maybe by <5 mmHg, far less than a study I remember that had a difference of NIBP as much as close to 40 mmHg in the SBP and 30 mmHg in the DBP, compared to IABP.


Central arterial lines are often not your best choice....or your 1st choice. There's significant risk with using a femoral arterial line.....one of which is infection given its nasty location. Rarely see axillary arterial lines. Have never seen a carotid arterial line (that was a joke for some of you who are way too serious!) Radial arterial lines are for the most part the standard 1st choice. Yes there will be some differences in its reading due to the physics of the vascular system, but the MAP will not change to any degree of significance. Now certain conditions may change the reading some. The presence of significant peripheral vascular disease is one. High dose pressors is another. But we still use the radial site despite this. Anecdotally, we generally continue to have a good waveform and decent pressure readings.

Remember that it's used for trending purposes as you're treating your patient. Blood pressure is relative to the patient's clinical condition. Assure that they have adequate pressure for perfusion by looking at your endpoints for perfusion. Don't just treat a number on your monitor.

Brian
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Brian, MSN, ACNP, CCRN

#7 FloridaMedic

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Posted 16 November 2009 - 06:56 PM

Central arterial lines are often not your best choice....or your 1st choice. There's significant risk with using a femoral arterial line.....one of which is infection given its nasty location. Rarely see axillary arterial lines. Have never seen a carotid arterial line (that was a joke for some of you who are way too serious!) Radial arterial lines are for the most part the standard 1st choice. Yes there will be some differences in its reading due to the physics of the vascular system, but the MAP will not change to any degree of significance. Now certain conditions may change the reading some. The presence of significant peripheral vascular disease is one. High dose pressors is another. But we still use the radial site despite this. Anecdotally, we generally continue to have a good waveform and decent pressure readings.

Remember that it's used for trending purposes as you're treating your patient. Blood pressure is relative to the patient's clinical condition. Assure that they have adequate pressure for perfusion by looking at your endpoints for perfusion. Don't just treat a number on your monitor.

Brian

That is a broad blanket statement that does not hold true for all hospitals and definitely not for all disease processes or procedural purposes. That may be true in the OR where you are at which is largely due to access ease. I was also talking about femoral lines in the hospital situation or those inserted by Specialty teams and not just a general prehospital insertion. In our ICUs we do have the option to see different readings from different lines in the same patient especially when it is time for the radial to be changed out due to inaccuracies. Often a radial A-line may become just another line for blood draws if there is not immediate access. Sometimes it is due to vasular resistance and sometimes due to insertion technique that problems are created with the line. Those that are commonly seen on IFT have already had the "kinks" worked out and trouble shooting completed prior to your arrival. Many times we get CCTs and Flights from other teams as well as our own with the comment "don't work - blood draws only" and the line is only on a pressure bag.

When the A-line works well, it is great. But, when it doesn't or the patient is a hard stick, how long do you want to stay and stick before initiating transport. There are still many other tasks that must be considered that should be done as well.
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#8 justlookin

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Posted 16 November 2009 - 10:26 PM

We do them routinely (usually daily, sometimes multiple times per day).
Procedure is performed by either an ACNP or physician.
We do not have a protocol per se, we use the judgement of the provider in charge on the trip.
We use the same kit and transducer setup as our main hospital (where most of our patients are transported), so the ED or ICUs can simply connect their monitor cable. They don't have to change the tubing, etc.

We perform the procedure on patients whose disease process warrants accurate and continuous BP monitoring. Examples would be AAA/Dissections, shock states, patients receiving pressors or potent vasodilators, etc. 99% of our transports are sick ICU-ICU and ED-ICU interfacilities, so bedside times aren't so much of an issue.
If we think we will be placing an A-line, we usually set up the transducer on the way to save time at the bedside. We are proficient enough that we can usually place the line in 5-10 minutes or so. If the patient's condition is time-sensitive, we will not delay transport, but will attempt line placement enroute. Our aircraft setup allows full access to the patient, so its not exceedingly difficult to do the procedure during transport.

For those who don't believe that invasive BP monitoring is important in the transport environment, I can count at least 5-10 patients per week where I have made significant changes in therapy after placing an arterial line and seeing what the "real" BP is. Examples include starting or discontinuing pressors for septic shock patients, being able to adequately sedate sick ARDS patients, titrate antihypertensives for AAAs and head bleeds, etc.

If you don't believe me, stick around when you drop a patient off and compare the NBP reading to the arterial line after it is placed. I bet you will be surprised pretty often.


With these discussions...lets add the Radial Art Line..

Who can do them?
What is the protocol?
Is it the HEMS equipment?
What patients truly need this prior to transport?

private at paramedicmd@msn.com or live and in color here....

Thanks.


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#9 BrianACNP

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Posted 17 November 2009 - 11:14 AM

That is a broad blanket statement that does not hold true for all hospitals and definitely not for all disease processes or procedural purposes. That may be true in the OR where you are at which is largely due to access ease. I was also talking about femoral lines in the hospital situation or those inserted by Specialty teams and not just a general prehospital insertion. In our ICUs we do have the option to see different readings from different lines in the same patient especially when it is time for the radial to be changed out due to inaccuracies. Often a radial A-line may become just another line for blood draws if there is not immediate access. Sometimes it is due to vasular resistance and sometimes due to insertion technique that problems are created with the line. Those that are commonly seen on IFT have already had the "kinks" worked out and trouble shooting completed prior to your arrival. Many times we get CCTs and Flights from other teams as well as our own with the comment "don't work - blood draws only" and the line is only on a pressure bag.

When the A-line works well, it is great. But, when it doesn't or the patient is a hard stick, how long do you want to stay and stick before initiating transport. There are still many other tasks that must be considered that should be done as well.


You're welcome to have a different viewpoint. I spend the majority of my time in an ICU. We do not put in multiple arterial lines and our 1st option is not femoral with a few rare exceptions. And that spans across our medical and surgical populations in our regional referral center.

I will agree that other tasks will likely take priority. I would not spend a lot of time at a hospital putting in an a-line for most cases. Having said that, it may be a safety issue for that patient to have one and, if someone is present who is skilled at insertion, perhaps it's better to get it done first. I think it all boils down to the clinical scenario and risk/benefit for the patient.


Brian
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#10 Mike Mims

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Posted 17 November 2009 - 04:57 PM

I agree that central lines are your better choice......... in the ICU and long term treatment........ but in the HEMS environment and the limited factors you deal with (time, space, personnel, equipment) your best bet is going to be a peripheral A-line.

Me personally, we deal with both central and peripheral lines, and I have not seen a significant difference in the hemodynamic readings between the two, maybe by <5 mmHg, far less than a study I remember that had a difference of NIBP as much as close to 40 mmHg in the SBP and 30 mmHg in the DBP, compared to IABP.


http://emj.bmj.com/c...stract/26/3/210
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Mike Mims

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University of Mississippi Medical Center


#11 BrianACNP

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Posted 18 November 2009 - 01:25 AM

http://emj.bmj.com/c...stract/26/3/210


Mike - don't have access to the full study to determine the validity of the study or its limitations for the results that are in the abstract.


Brian
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#12 CAFLIGHTRN

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Posted 26 October 2012 - 01:22 PM

We Fly RN/RN at a University Hospital based Program and do most of the Art lines in the ICU's and ED. We place them on any of our patients who need Invasive BP monitoring for titrating drugs such as Nipride, Esmolol, Nicardipine etc in patients with SAH, IC Bleeds, Acute CVA, aortic dissections and aneurysms. We also start them in patients who need frequent ABG's. Most if not all our patients transported in to our hospitals ICU's WILL get an Art line so we help them out getting it done either at the bedside while the one RN is getting report/ examining the patient or we do it in flight (we fly in a big helicopter). Just through doing these frequently we get skilled and can do one in 10 minutes or less (in a sterile manner too). Just takes practice. Definitely a good skill to have.
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#13 Speed

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Posted 28 October 2012 - 04:19 AM

some patients may take several attempts to cannulate especially if pressors are running or the patient is hypovolemic.

one on a compromised patient can take 1 hour with multiple attempts


ULTRASOUND
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#14 BrianACNP

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Posted 28 October 2012 - 08:45 PM

ULTRASOUND


Not always as easy as it sounds.

Brian
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#15 Speed

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Posted 28 October 2012 - 10:15 PM

Not always as easy as it sounds.

Brian


Whatever, maybe you need more experience or training?
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#16 BrianACNP

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Posted 28 October 2012 - 11:31 PM

Whatever, maybe you need more experience or training?


I'm a critical care nurse practitioner in a busy quartenary and Level I trauma center working in trauma/surgical critical care service. I do PLENTY! I've used ultrasound for a-line placement and I know it's not as easy as it sounds. Of course, if you're talking about the femoral artery, then it may not be that bad. But axillary and radial arteries are pretty small to cannulate.

Brian
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#17 Speed

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Posted 29 October 2012 - 05:16 AM

I'm a critical care nurse practitioner in a busy quartenary and Level I trauma center working in trauma/surgical critical care service. I do PLENTY! I've used ultrasound for a-line placement and I know it's not as easy as it sounds. Of course, if you're talking about the femoral artery, then it may not be that bad. But axillary and radial arteries are pretty small to cannulate.

Brian


I'm a, I'm a, I'm a...ha ha. Ok, so at least you've got the skill and I absolutely applaud you for that. Tedious? Absolutely! I've had to start wearing glasses (like I'm suppose to) after squinting at the screen for long periods of time. I will say that what gives me best results more than anything is sitting on stool, getting comfortable, and taking my time. Plenty of jelly, no balcony full of question askers, color doppler, taking the time to perfect the gain, depth, and focus. Also, frequency of use. This is one skill that I will jump from others just to stay good at it. One tip which you probably already know, but I see others not appreciate is that prolonged exposure to the US beam in one spot will start to heat up tissue. I can't give you an exact number/time frame but it can start to burn after a long hold in one place. Anywho, I apologize if I was a bit of an ass in my remark, but good job on advancing your skill set. It kills me watching folks dig and dig for a gas over and over, COME ON? I wish more people would pick up this skill, it is totally a patient satisfaction issue. Just FYI, with frequent use it is possible to get good at peripherial IV's in the forearm. A trick that helps me is to start with an art dart in the vein so that the guide-wire can be used as well as the more flexible catheter has more success of passing that sharper angle of attack on the US guided IV. You can come behind that and exchange it depending on what kind of toys you have. You can get proficient at rad art lines with frequent use of the skill. If you already started Levo and Vaso, I just start working up the limb until I can see pulsatile flow. I am still waiting for the IV sets with built in guide wires to come on the market.
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#18 justlookin

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Posted 29 October 2012 - 04:36 PM

Not always as easy as it sounds.

Brian


I second that. Just because you can visualize the vessel under US guidance does not equate to being able to threat a guidewire and/or catheter.
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#19 justlookin

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Posted 29 October 2012 - 04:41 PM

I'm a critical care nurse practitioner in a busy quartenary and Level I trauma center working in trauma/surgical critical care service. I do PLENTY! I've used ultrasound for a-line placement and I know it's not as easy as it sounds. Of course, if you're talking about the femoral artery, then it may not be that bad. But axillary and radial arteries are pretty small to cannulate.

Brian


Will second this as well. I stopped counting after ~1000 art lines (~10% with US guidance) and it's not as easy as it sounds or looks.
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#20 justlookin

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Posted 29 October 2012 - 04:41 PM

I'm a, I'm a, I'm a...ha ha. Ok, so at least you've got the skill and I absolutely applaud you for that. Tedious? Absolutely! I've had to start wearing glasses (like I'm suppose to) after squinting at the screen for long periods of time. I will say that what gives me best results more than anything is sitting on stool, getting comfortable, and taking my time. Plenty of jelly, no balcony full of question askers, color doppler, taking the time to perfect the gain, depth, and focus. Also, frequency of use. This is one skill that I will jump from others just to stay good at it. One tip which you probably already know, but I see others not appreciate is that prolonged exposure to the US beam in one spot will start to heat up tissue. I can't give you an exact number/time frame but it can start to burn after a long hold in one place. Anywho, I apologize if I was a bit of an ass in my remark, but good job on advancing your skill set. It kills me watching folks dig and dig for a gas over and over, COME ON? I wish more people would pick up this skill, it is totally a patient satisfaction issue. Just FYI, with frequent use it is possible to get good at peripherial IV's in the forearm. A trick that helps me is to start with an art dart in the vein so that the guide-wire can be used as well as the more flexible catheter has more success of passing that sharper angle of attack on the US guided IV. You can come behind that and exchange it depending on what kind of toys you have. You can get proficient at rad art lines with frequent use of the skill. If you already started Levo and Vaso, I just start working up the limb until I can see pulsatile flow. I am still waiting for the IV sets with built in guide wires to come on the market.


Speed,

Where are you doing all these US guided arterial lines?
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