2017 FSA Posters

P029: WHY NOT PLACE IT RIGHT THE FIRST TIME? USE OF THE ULTRASOUND FOR ARTERIAL LINE PLACEMENT.
Ezekiel J Anderson, DO, Zachary B Deutch, MD; University of Florida-Jacksonville

Cannulating the radial artery can be a very challenging aspect of caring for patients in the operating room especially in the hypotensive, trauma, or critically ill patient. The procedure, however, is not without risk and may lead to unwanted complications.  The use of an ultrasound to guide the clinician may lead to improved first-attempt success rates and shorten time to radial artery access.

The arterial line placement procedure requires knowledge of the anatomy and procedural skills in order to avoid complications. The advantages of the radial artery are it predictable location, accessibility, and low complication rates associated with its access and use. It is usually palpable and is typically not the sole blood supply to the distal extremity, unlike the axillary, brachial, and femoral arteries.

Studies in interventional cardiology, critical care medicine, emergency medicine, anesthesia, and pediatrics have documented the advantages of using ultrasound during arterial line placement.  The use of landmark-based methods has reported failure rates and complication rates as high as 30% and 18.8%, respectively compared to ultrasound guided methods. Significantly fewer attempts were taken to cannulate the radial artery under ultrasound guidance as compared to palpation. When assessing at the benefits of ultrasound use for line placement, it was noted to reduce the time, number of attempts, and the number of sites cannulation was attempted before cannulation was completed.

When placing an arterial line under ultrasound it is important to evaluate for artery size, compression, monitor the needle angle, maintain an adequate patient blood pressure, prepare the entirety of the forearm and monitor for anomalies (dual systems) within the radial artery that may complicate placement.  The clinicians’ inability to pass the wire or catheter through the artery is the most common difficulties in catheterization. Another challenge is arterial spasm, which also may prevent the operator from advancing the catheter into the arterial lumen. If spasm occurs, use ultrasound guidance to find a more proximal site for insertion or consider radial artery catheterization of the other arm. With adjustment of the angle, a slight advance, or withdrawal of the needle, placement may yet be successful.

Arterial spasm was likely the cause for problems within in this case which was also complicated by atherosclerotic disease.  The use of ultrasound, once mastered by the clinician, has been shown to improve patient care and decrease the risks involved with placement of central and arterial lines.

Ultrasound guidance when used for arterial cannulation can be mastered by the clinician and increase the success rate of first attempt success.  It takes only a moment to set up, and only about 15 procedures before you become proficient. Practicing on the easy ones will lead to being able to cannulate even the most difficult of radial arteries.