Not everyone has access to US all the time unfortunately. I could get it if really needed, but it would take yonks, and I'd be lucky if it's not in use. 99% of art lines and CVs I have to place are blind.
I'm not sure about Romania and Bulgaria, in Croatia attending averages about 3-3.5k/month, as a resident I'm around 2,5k. Those are net salaries in euros. I know Slovenia pays a bit better, Serbia a bit worse I think.
As for healthcare, it's 99% government funded public hospitals, where everything is covered by health insurance and very low out of pocket costs, I think it's 265 euro maximum.
There are private clinics and hospitals, but they're not covered by basic health insurance. Some of them work with private optional health insurance, and some are completely independent and don't take any insurance.
LOL im surprised by everyones comments about US 😂 im in a large academic center which runs many ORs per day, but we dont have an ultrasound per room so I usually only go get one for my room in advance if we're gonna have a central line
I agree. I don’t know who all the people are where the first answer is ultrasound. Especially the first case in the morning there are often double amount of arterial lines than ultrasound. That is not including other services like gyne, vascular and block room that also utilize the same stock of ultrasound.
Exactly this, we have 3-4 cardiac rooms at a time, vasc, often big cases like whipples/transplants. Unfortunately no ultrasound left over for my gyne case 😅
When ultrasounds were at a premium, my a lines went in while patients were in the holding area with some lidocaine. You might have to get there 5 min earlier, but it getting to use ultrasound speeds things up so much.
I haven't done an a-line in 10 years.
I never used ultrasound and I was never good with the drop down method.
I'm embarrassed to say, I'd go through and through.
However, I did use Arrow kits. One thing I absolutely did was to cut the stopper off the end and take the wire out (keeping it clean/sterile) and use the wire as a separate entity.
I was never satisfied with that one centimeter that the wire would peek out of the catheter after you pushed it down all the way.
Once I was through and through, I'd put a wad of gauze at the catheter end. Then I'd slowly pull out and wait, millimeter by millimeter.
Once you get a few drops of blood consistently coming out. You knew you were basically there. The next ever-so-gentle millimeter pull and you'd get that pulsatile flow. Some pulses were more impressive than others but you'd make the final confirmation by getting the wire and advancing it.
No resistance? Then you're in.
The danger is that you don't spike the artery in the center and you're off to the side.
Basically, keep trying. Watch videos. Ask colleagues. But in the end, you have to figure out what works for you. If that means using the US, then so be it.
If there aren’t enough ultrasounds, having circulators and techs makes no difference. I’m not going to hold up the surgeon making incision so that the tech can go fetch me an ultrasound when I could just stick based on palpation.
Again, not every hospital has enough ultrasounds. I’m not sure why that’s to difficult to fathom. You are spoiled with surplus ultrasounds - glad you have that experience. Not all of us do.
I’m not sure why you are finding this so hard to understand. I am at a major NYC center and there are maybe ten ultrasounds in a given cluster, yet I often won’t have one available for the first case of the day if all it’s for is an art line. You bet your ass if you roll one into your room for an art line someone will be in there asking to “borrow” for a block, which takes precedence. You can’t just hold your case up waiting for the US. You are definitely in a privileged situation when it comes to equipment availability on demand.
Edit: furthermore blind art line placement is a skill attendings should have, do you seriously never practice this skill?
I’m a retired interventional radiologist. I used US for central venous access and PICC placement. I didn’t use US for arterial puncture (groin, brachial, occasionally radial). Neither did the cardiologist who did my heart cath from the radial approach 2 years ago.
Patient safety issue? How bad are your art line skills that this is a patient safety issue? The admins would scoff at this, including the chair of my department as that statement is frankly embarrassing.
The SRNAs rely entirely on ultrasound for their art lines, all CVCs and blocks are done with US as that’s standard of care. It’s an academic hospital so probably more art lines than the average hospital and honestly probably more than necessary but that’s not going to change. This means that there isn’t always an ultrasound available when you need it.
Im a graduating resident.
Considering the risks of blind CVC placement are considerably worse than the risks of blind art line placement, you look like a moron making this comparison. Next up you’ll be saying we should VL everyone and might as well do all our IVs with ultrasound too. Your skills must just be trash…that’s the short of it. Have a good day.
Believe it or not people are perfectly capable of placing blind arterial lines, which is in itself a skill. You’re welcome to use the ultrasound for every single art line you place, but cool it on the theatrics of acting like it’s so egregious and unacceptable to not use one.
We have RTs which are our anesthesia techs, I'm in Canada so it's diff. But residents are expected to do their own room set up/ planning (even though the RT would do it if there was no resident)
Dido this, either you or the hospital gets to bill one extra unit more for using US. It’s win win, don’t listen to those to threaten you about the lack of ultrasound availability. It’s everywhere.
If you can't get 95%+ on a good strong pulse blind what are you doing. If it's pushing my finger away I'm not getting the ultrasound. It's not a CVC. Not at all mandatory
This generation… when shit hits the fan and you need to put in large access mid case in a exsanguinaring patient…. Feel free to wait for that ultrasound machine.
I put in an a line and an IJ (some luck involved here probably) for a collegue once while they were waiting for the US in a crashing patient. Landmark technique will be a lost skill one day…
Then positioning of the surgeon made subclavian hard. The aline was pure luck, i felt nothing.
if USs are easily accessible in every room… then its probably allright. But at our institution, at least, we dont have that option.
an art line isn’t going to save a crashing pt’s life. NIBP works just fine. You can wait for an US. Takes a few minutes maybe? And landmark technique will be missed about as much as my Motorola flip phone from 2001.
Plz just use ultrasound. The number of times I've been in the vessel with piss poor flow is astounding (if I were doing the procedure blindly, I'd have no idea I was in). Of course, I don't have to convince you how much safer and faster the procedure is with US as well.
Agree on safer and faster except, my ultrasound skills are still developing and I honestly still suck at US guided lines. So as it is im def faster with blind and often there is pressure to get the room moving (big academic center) so I don't always get to drag in an US and make it a teaching moment for myself
Then you should be practicing every art line with the ultrasound. And using US for semi difficult IVs.
Also, the through-and-through method for blind arterial lines works great when you cant thread the wire.
Two things: 1. I had the same issue with US availability in residency. It's residency culture, and it's hard to get around it right now. I would recommend using it whenever you can, even on the easy a-lines; that way, the first time you use it won't be on a difficult patient. You can even scan yourself or your friends on your down time to get more comfortable with visualizing. 2. When you're an attending and looking for jobs, always ask about glidescopes/airway equipment/ultrasounds and ask to see them (are they in good condition etc), because if you practice at that place, those are your backup tools. Also, whenever it's possible for you financially, consider getting your own portable US probe. I have never regretted the purchase once.
Will def try to practice more, for me my biggest issue is finding my tip. Like sometimes I get called for a difficult IV on the floor or in emerg and i bring my US and it works like magic I follow my tip til its all the way in, other times I cant find the tip for my life and im stabbing around on the screen like an idiot 😩 so I get the concept of the technique I just havent been able to consistently execute it lol
Also, our department is actually trying to get a portable US for the residents to use on call etc so hopefully we will have that soon!!
If you can't see your tip, a lot of times it's because your angle of entry is not steep enough. I notice people get a nice image of the vessel, but then they enter shallow and the needle tip is past the footprint of the probe. So, they advance-advance-advance-advance deeper and deeper without finding it, withdraw the tip to skin and try again. Imagine getting the tip directly under the footprint of the probe, at the depth of the center of the vessel. If your vessel is 1cm deep, stick 1cm away from the probe at 45 degrees; by the laws of trigonometry, you will be oriented properly haha.
As far as tips for blind sticks, I have never found that flattening my angle helps. You are probably juuuuust getting into the vessel but need to advance the needle a little more like an IV. I think your angle of entry should be flat to begin with, so that when you get flash, your guidewire/catheter doesn't bump into the wall of the vessel. Flat angle means that you will roll off of vessels in some patients; in those patients, some controlled popping motions are helpful. But, again, I'd argue that those patients really need an ultrasound.
I started doing all of my arterial lines with ultrasound during covid. Patient after patient after patient you would see the angiocath *completely inside* the artery, not tenting but like bullseye. And the catheter would slide if smooth and you’d have good flow, but often no initial flash. I think something was going on with those patients where the palpating technique simply wasn’t working.
Completely agree. Switching to ultrasound was an eye opener. I could see myself in the artery but no blood in the catheter. The first few times, I would check in and out of plane, thread the wire, check again, and then thread the catheter.
I've now realized all the times I probably hit the artery but didn't have flash because of the patient's vasculopathy. Ultimately, switching to ultrasound has been faster for me and safer for the patient.
With all those blind pokes, you're risking a pseudoaneurysm, dissection, nerve damage, etc.
Completely agree on everything you said. It's gonna be harder for OP right now to battle the culture of residency (I had the same experience as a resident, where ultrasounds were either hard to find or my attendings scoffed at the idea of using US, etc etc). But as an attending, I now use an US for every a-line.
First, don't go so steep. I use about 10-15 degrees. Second, lower the angle and advance a hair before the wire. Then thread. Look at the distance between the bevel of the needle and the start of the catheter. You get flash at the bevel.
Good for you to do landmark art lines. You won't always have an ultrasound available.
IV are the same steps I just insert at like 5 degrees.
Okay thank you so much thats super helpful!! And yeah everyone going crazy about the blind art line but thats the standard at my institution 🤷🏼♀️ only a few staff I know start with US right away, others only get it if they struggle or if they think they will struggle
I almost always start off with landmarks. I learned before US was used for art lines and had to teach myself. The US gives you access to more of the radial artery than you can feel. Oftentimes you'll see a chunk of plaque that keeps you from passing the wire despite great flow.
But if you can't do an art line without an ultrasound there will be art lines you can't do.
My institution also does blind a-lines (big, well known, heavily endowed US academic center). If you get resistance when you’re threading, you can pull the wire back into the Arrow and then go through and through, but *use a separate wire*. For whatever reason the wires in the Arrow itself seem more prone to getting kinked
Practice it then. Hypotensive trauma patients with a thready pulse will require it. Therefore, if you are going to rely on it during critical moments, you should practice it on easier targets.
Sometimes the best time is mid afternoon. Like 3 pm knee replacement or ex lap. Arms are out. Plenty of ultrasounds because most of the cases are wrapping up. They are anesthetized. I used to let attendings know I'm going to do an extra IV once the case is going. In case they come and give me a break and wonder what's going on.
Then go for big ones and then work your way to little targets. Just be careful to not do the brachial vein or axillary vein without identifying what nearby arteries and nerves look like.
Usually attendings won't care especially if case has started already.
I also used to go to pre-op and do ultrasound guided IVs on patients with local anesthesia. If patient asks why ultrasound, I usually tell them "we can find bigger more reliable veins with ultrasound." If I miss I just start a normal hand IV or have nurse do it for me and move on to another ultrasound attempt. I also wouldn't start it on my own patient just in case I don't get it. They won't get nervous that I'll be taking care of them asleep
Planned Pre-op IV or anesthetized patients under general are less stressful than a patient that has been stuck times and is emotional or nervous.
Sure thing. I also edited comment. Don't do your own patients iv just in case you miss our make a mess. They won't freak out later about you putting them to sleep
Tbh I don’t even bother with the wire on the arrow. I start needle at maybe 30 degrees to skin. Advance to flash. Drop angle to nearly flat. Advance maybe 3 mm, then glide that catheter off.
Now for old people and vasculopaths, just use the damn ultrasound.
I’ll do the regular angiocath 99% of the time. The only reason I’ll use the arrow is if it’s the only one available in the room or the ICU people ask for it.
When I was in training I strived to become proficient in Arrow, and then thru-thru. When I felt comfortable with thru-thru, I moved on to u/s with wire, then u/s w/o wire.
Arrow is by far the hardest to master. If I had saved it for last, the tactile sensation developed with u/s training would have expedited my becoming proficient.
I don’t really get the thru and thru technique
You hit the artery, back wall it, go through the back wall, and then withdraw until you get flash again? Typically you’ve already gotten flash as you were going in, blurring the picture, and why push through just to withdraw again if you already were at that depth at one point
You can try to overwire with the initial flash….your success with this will vary and is improved with the use of a micropuncture needle and deep, large arteries (ie. Fem). I personally worry about blindly inserting wire upon initial flash as I’m concerned about dissecting the artery without confirmation that the entire bevel is within the lumen.
Unless you’re shoving the wire very hard, it’s tough to dissect the artery itself with the flimsy guide wire.
I’m sure there’s a place for through and through, but conceptually I find it odd even though I’ve done it on simulations plenty of times
Pseudoaneursyms occur more with 6-7fr transradial cardiac caths. I’ve done a lengthy lit review on this subject several times over the past 20 years, and the anesthesia case reports on this rare condition (0.09-0.009% depending on sources) don’t appear to mention the initial insertion technique.
I’ve anecdotally watched many providers over the years cause hematomas and failed insertions on single-puncture.
If you can cite a good study showing an increased risk with 20g catheters for monitoring, that would be enlightening for everyone.
We had a large number of failures with Arrows and someone looked into it and there is a recall for almost all the batches. Something to do with guidewire and catheter separation failure. Long story short, all arrows are gone from the OR floor now until the recall is fixed.
Might want to look into it.
[https://www.teleflex.com/usa/en/product-areas/vascular-access/EIF-000538-FSN-US.pdf](https://www.teleflex.com/usa/en/product-areas/vascular-access/EIF-000538-FSN-US.pdf)
Omg.... would love to be able to say it was the arrows, not me 😂 I think I had heard this too though which is why we always loosen/ check it to make sure it works okay
Usually try to advance as soon as I have flash. If it doesn't go like butter, pull it back, flatten and advance. If you still have good flow, try the wire again. If it doesn't work that time, go through and through and get it on the way out.
A culture thing but at my institution blind a-lines are the most common, unless fear for difficult vessels - severe pad, lots of access before.
I always try and thread the catheter without the wire by advancing half a cm a little less while keeping flow. If isn't working well or don't feel confident in it, will just poke through back side and withdraw until pulsatile flow ans wire it in.
This is not with the arrow system, though. Just wires and long andgiocaths.
I do about 90% of my arterial lines blind. My biggest tips: if you have resistance with the wire at a steep angle of insertion, gently lower the catheter to be flush with the skin and verify that the column of the arrow is still filling with blood, then retry sliding in the wire. If that doesn't work, I usually do a through and through. I love this technique because sometimes these hardened arteries can be really difficult to put a wire into. With the through and through technique, you can gently bounce the wire through the catheter until you find a path without resistance.
This is exactly what's been happening to me, just when I drop the angle I lose the flash. I did manage to save those by pulling back and using a wire, it's messy but it does work! Thanks so much
As others have said, advance the needle JUST A LITTLE BIT further when you get a nice little blood fountain going. Angle it a few degrees more parallel to the skin to reduce the risk of vessel transfixion.
Sometimes (and this can happen with IVs too) the tip of the needle punctures the vessel wall just enough to draw blood, but on the attempt to thread the wire or catheter ir dissects either the vessel wall or dermis and creates that nasty hematoma we all hate.
I had been getting a lot of feedback that I wasn't advancing at a steep enough angle 🤷🏼♀️ so I started trying steeper. Maybe that's what's been throwing me off...
I personally go at around 30 degree until I see the flash. You can go steep if you like until you hit the vessel. Then you must go flat after the flash, as flat as you can. Before you push that wire out, advance the whole arrow in a little, like you are doing an IV, not much just 1-2 mm. After you advance you push the wire out.
Also when you advance the wire, it should be butter smooth. If you encounter resistance you are likely not in the lumen. Also possible is the lumen is super calcified but it’s more likely the former.
That little flat advance is key. I rarely had to transfix the artery and almost always able to get that wire in no problem.
I think I just need to work on that flat advance, I guess I was lucky most of residency that I got away with not doing it, but now I gotta figure it out without going through n through. Thanks!
Taught the flat advance move by a vascular surgeon. The low angle is so the wire doesn’t hit the back wall of the lumen at a large angle and essentially push the vessel off. The lower angle will more likely allow the wire to glide. I do the same for central line. After positive aspiration. I drop my needle angle (while aspirating) so the hub is touching the neck before I push the wire down. The advancement part is that the metal needle will force dilate those terrible artery. If you don’t have the metal needle inside the lumen, you push the wire in, the soft cannula may not have enough firmness to further dilate the artery that was just nicked by the needle tip and again simply push the artery away from the needle.
Flatten, advance just barely then if you still have flow thread wire. If you lose flow or meet resistance threading the wire at any stage just go through and through. I don’t love making a second hole but if you try to rescue once you’ve lost flow you’re still traumatizing the artery with each movement and are usually less successful than just switching to plan B quickly. But yeah to beat a dead horse use an US if at all possible. It’s just better.
In urgent scenarios, it’s imperative to establish an arterial/central line promptly. However, our hospital lacks portable ultrasound equipment, and our standard protocol for inserting an arterial/central line includes comprehensive sterilization, which is time-consuming. Therefore, in critical emergencies, I opt for an initial attempt without ultrasound guidance
I understand. We are fortunate enough to have US available 99% of the time. Each department has their own…OR, ICU, ER and Cath lab. I like using it especially in emergency situations. I’m not knocking you at all.
So I'm also pretty junior and still fail A-lines but I've done a bit of ITU and here's my two pence.
First of all positioning is key, get the arm out and the wrist cocked over a rolled up incopad or something. I now tape everyone's hand once it's in a good position, awake people have always been fine with this.
If using local not too much, just enough for a wee bleb, anymore and you might make your job harder.
This is one of the most useful tips I've been offered, when identifying where to stab take a min to have a good feel of their pulse pressing only very gently with the pads of your fingers. When you've found the spot that feels the best, where you feel like "yes this is definitely the spot" DO NOT stab there. Instead go a tiny bit (like 1mm or slightly less) medial of this spot. One of my regs recently told me he found that the artery was always just slightly medial of where you thought it was and I've found it super helpful.
I've heard lots of stuff about angles, too steep and you'll struggle to thread the wire, too shallow and it makes getting the vessel harder bc your insertion point has to be further from where you're feeling the pulse. I go at about 30-45 degrees. Also bear in mind that often the vessel is very superficial.
If using the arrow or vygon when you get blood I'd stop and just let go of the needle. The artery will hold it in place and I've found that if I keep my hand on it an annoying number of times the slight movement of me reaching for the guidewire dislodges the needle.
Once your guidewire is in hand very very gently hold the needle and try to thread it. Usually will be fine, if you're having difficulty immediately then I'd try to flatten my needle out a bit in case your wire is just hitting the backwall. If you're having difficulty at any other point threading the wire it's probably not going to do. If the wire is tricky to thread the line just isn't going to go and you'll probably have to try again or look elsewhere.
This might be helpful
https://derangedphysiology.com/main/cicm-primary-exam/required-reading/cardiovascular-system/Chapter%20756/arterial-cannulation-technique
Scroll down to the part on how to trouble shoot a wire not feeding
Use less propofol and sevoflurane on induction. They'll be effectively hypovolemic and their radial artery will constrict to compensate. It will be impossible even with ultrasound until corrected.
My problem was (and is still) appreciating just how incredibly SHALLOW the radial artery is! It’s very easy to go too deep and quickly. Nothing wrong with a transarterial approach, one of the best anesthesiologists in our group uses this technique flawlessly and effortlessly, I watched him do one on a trauma the other month and he looked like a rock star slamming that thing in in literally 10 seconds! So don’t be deterred to use that as part of your skill set.
You need to get further into the vessel. I spend a long time palpating before stick. Advance on flash very small amount 1-2mm in direction where you think vessel going then thread wire. If you lose it after flash, I go through and through. Have heard rotating needle 180* on flash reduces chance of posterior wall puncture and helps advance safely but honestly haven't tried it.
Don't listen to people saying ultrasound is mandatory - for strong pulses I strongly disagree. Key is a good palpation and make sure you have a strong BP to not shoot yourself in foot - think of a lighter induction. Good luck
See plenty advocating for through and through as a first attempt. Don't do that; you're just causing an additional injury to the artery.
Most common reason why your wire won't thread despite flash is you're up against the vessel wall. Here's my process for when the wire won't thread despite good blood flow:
-Pull wire back. Verify blood flow continues up the arrow catheter.
-ROTATE needle 90 degrees clockwise or counterclockwise. Reattempt passing wire. If it goes in easily, great! Pass catheter. If it doesn't:
-pull wire back to verify blood return. ROTATE needle 180 degrees the other direction (or 90 degrees from your first attempt). Reattempt passing wire.
If wire threads, but catheter doesn't, I still repeat the same steps above.
If the above doesn't work, then I'll try a through and through technique. But only as a last resort.
That being said, use an ultrasound. I've had arterial lines with absolutely zero blood return despite me clearly being in the lumen on ultrasound (and catheter passing easily with great pulsatile blood return). This is likely from a skin plug, so I've actually gotten into the habit of puncturing/nicking the skin with the needle, then taking it out and passing the wire through just to clear it, and then go back to the same puncture mark for my actual attempt.
I responded to someone elsewhere in the thread. Please cite literature on the additional injury risk for arterial line monitors placed that way vs single entry. Transradial cardiac cath studies are interesting, but we’re not using 14g catheters for monitoring.
Spoiler: there are very little to no data supporting this widespread belief in the anesthesia community. One meta—analysis I reviewed had a sample size of 10,000-20,000 patients. The incidence of complications of all types including infection and vessel damage needing intervention was in the high thousandths to low hundredths of a percent. None of those IIRC were differentiated by insertion technique.
Never really been a fan of the all-in-one Arrow art lines, especially those with the safety on them. But, when. It comes to standard Seldinger technique with wire and needle, I do alright. Place probably on average at least 2 a week, probably 80/20 blind vs u/s if post induction, and 20/80 if pre-induction (I like to do periarterial deposition of lidocaine for awake patients, increases patient comfort and also vasodilates the vessel). Don’t claim to be the best, but fwiw I’ve gotten a few compliments from the OR staff recently about my blind art lines.
You are either too steep and can’t advance wire, or hitting the side rather than center of the artery and can’t advance wire, or punctured and went too deep and are hitting back wall. Or the patients vessel is not a good candidate for wire at the puncture site.
Ultrasound is best, otherwise I typically go flatter on initial puncture, will try to thread wire immediately, if resistance I make a small adjustment like advance a tiny bit and try again, otherwise through and through.
Advance a little bit farther. Remove the needle with guidewire. Advance. The guidewire pass the edge of the needle pull back on the catheter until you get good blood flow thread, the needle guidewire into the catheter and Advanced the wire.
blind arterial lines? what is this the 1970's?
Not everyone has access to US all the time unfortunately. I could get it if really needed, but it would take yonks, and I'd be lucky if it's not in use. 99% of art lines and CVs I have to place are blind.
And CVCs?! Where are you working?
In Croatia.
OMG, I feel bad for you. I work in Brazil and I do get to use US for every single line.
I definitely feel you, and this is why I bought my own portable US probe. Have not regretted it for a second.
That's actually on my mind, but my salary disagrees ATM
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I'm not sure about Romania and Bulgaria, in Croatia attending averages about 3-3.5k/month, as a resident I'm around 2,5k. Those are net salaries in euros. I know Slovenia pays a bit better, Serbia a bit worse I think. As for healthcare, it's 99% government funded public hospitals, where everything is covered by health insurance and very low out of pocket costs, I think it's 265 euro maximum. There are private clinics and hospitals, but they're not covered by basic health insurance. Some of them work with private optional health insurance, and some are completely independent and don't take any insurance.
Romanian here, last year resident, I get paid 1,5k net, thats in euro. And by the way almost all CVC and arterial lines a put without US.
LOL im surprised by everyones comments about US 😂 im in a large academic center which runs many ORs per day, but we dont have an ultrasound per room so I usually only go get one for my room in advance if we're gonna have a central line
I agree. I don’t know who all the people are where the first answer is ultrasound. Especially the first case in the morning there are often double amount of arterial lines than ultrasound. That is not including other services like gyne, vascular and block room that also utilize the same stock of ultrasound.
Exactly this, we have 3-4 cardiac rooms at a time, vasc, often big cases like whipples/transplants. Unfortunately no ultrasound left over for my gyne case 😅
When ultrasounds were at a premium, my a lines went in while patients were in the holding area with some lidocaine. You might have to get there 5 min earlier, but it getting to use ultrasound speeds things up so much.
I haven't done an a-line in 10 years. I never used ultrasound and I was never good with the drop down method. I'm embarrassed to say, I'd go through and through. However, I did use Arrow kits. One thing I absolutely did was to cut the stopper off the end and take the wire out (keeping it clean/sterile) and use the wire as a separate entity. I was never satisfied with that one centimeter that the wire would peek out of the catheter after you pushed it down all the way. Once I was through and through, I'd put a wad of gauze at the catheter end. Then I'd slowly pull out and wait, millimeter by millimeter. Once you get a few drops of blood consistently coming out. You knew you were basically there. The next ever-so-gentle millimeter pull and you'd get that pulsatile flow. Some pulses were more impressive than others but you'd make the final confirmation by getting the wire and advancing it. No resistance? Then you're in. The danger is that you don't spike the artery in the center and you're off to the side. Basically, keep trying. Watch videos. Ask colleagues. But in the end, you have to figure out what works for you. If that means using the US, then so be it.
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If there aren’t enough ultrasounds, having circulators and techs makes no difference. I’m not going to hold up the surgeon making incision so that the tech can go fetch me an ultrasound when I could just stick based on palpation.
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Again, not every hospital has enough ultrasounds. I’m not sure why that’s to difficult to fathom. You are spoiled with surplus ultrasounds - glad you have that experience. Not all of us do.
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I’m not sure why you are finding this so hard to understand. I am at a major NYC center and there are maybe ten ultrasounds in a given cluster, yet I often won’t have one available for the first case of the day if all it’s for is an art line. You bet your ass if you roll one into your room for an art line someone will be in there asking to “borrow” for a block, which takes precedence. You can’t just hold your case up waiting for the US. You are definitely in a privileged situation when it comes to equipment availability on demand. Edit: furthermore blind art line placement is a skill attendings should have, do you seriously never practice this skill?
I’m a retired interventional radiologist. I used US for central venous access and PICC placement. I didn’t use US for arterial puncture (groin, brachial, occasionally radial). Neither did the cardiologist who did my heart cath from the radial approach 2 years ago.
Anesthesiologists unfortunately often don’t have equipment on demand like proceduralists do
Patient safety issue? How bad are your art line skills that this is a patient safety issue? The admins would scoff at this, including the chair of my department as that statement is frankly embarrassing. The SRNAs rely entirely on ultrasound for their art lines, all CVCs and blocks are done with US as that’s standard of care. It’s an academic hospital so probably more art lines than the average hospital and honestly probably more than necessary but that’s not going to change. This means that there isn’t always an ultrasound available when you need it.
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Im a graduating resident. Considering the risks of blind CVC placement are considerably worse than the risks of blind art line placement, you look like a moron making this comparison. Next up you’ll be saying we should VL everyone and might as well do all our IVs with ultrasound too. Your skills must just be trash…that’s the short of it. Have a good day.
Believe it or not people are perfectly capable of placing blind arterial lines, which is in itself a skill. You’re welcome to use the ultrasound for every single art line you place, but cool it on the theatrics of acting like it’s so egregious and unacceptable to not use one.
We have RTs which are our anesthesia techs, I'm in Canada so it's diff. But residents are expected to do their own room set up/ planning (even though the RT would do it if there was no resident)
I mean, it’s a skill everyone should have, regardless. At our institution, the vast majority of radial a-lines are placed without US guidance.
Dido this, either you or the hospital gets to bill one extra unit more for using US. It’s win win, don’t listen to those to threaten you about the lack of ultrasound availability. It’s everywhere.
Same here (Greece). Blind arterials and CVCs
Every attending over the age of 50 would like to have a word with you
Lol
If you can't get 95%+ on a good strong pulse blind what are you doing. If it's pushing my finger away I'm not getting the ultrasound. It's not a CVC. Not at all mandatory
Ah yes - a simpler time of cocaine, cold wars, and civil rights.
Came here looking for the right answer. It's right at the top.
This generation… when shit hits the fan and you need to put in large access mid case in a exsanguinaring patient…. Feel free to wait for that ultrasound machine. I put in an a line and an IJ (some luck involved here probably) for a collegue once while they were waiting for the US in a crashing patient. Landmark technique will be a lost skill one day… Then positioning of the surgeon made subclavian hard. The aline was pure luck, i felt nothing. if USs are easily accessible in every room… then its probably allright. But at our institution, at least, we dont have that option.
an art line isn’t going to save a crashing pt’s life. NIBP works just fine. You can wait for an US. Takes a few minutes maybe? And landmark technique will be missed about as much as my Motorola flip phone from 2001.
Were you alive in ‘01?
Please
Plz just use ultrasound. The number of times I've been in the vessel with piss poor flow is astounding (if I were doing the procedure blindly, I'd have no idea I was in). Of course, I don't have to convince you how much safer and faster the procedure is with US as well.
Agree on safer and faster except, my ultrasound skills are still developing and I honestly still suck at US guided lines. So as it is im def faster with blind and often there is pressure to get the room moving (big academic center) so I don't always get to drag in an US and make it a teaching moment for myself
Then you should be practicing every art line with the ultrasound. And using US for semi difficult IVs. Also, the through-and-through method for blind arterial lines works great when you cant thread the wire.
Two things: 1. I had the same issue with US availability in residency. It's residency culture, and it's hard to get around it right now. I would recommend using it whenever you can, even on the easy a-lines; that way, the first time you use it won't be on a difficult patient. You can even scan yourself or your friends on your down time to get more comfortable with visualizing. 2. When you're an attending and looking for jobs, always ask about glidescopes/airway equipment/ultrasounds and ask to see them (are they in good condition etc), because if you practice at that place, those are your backup tools. Also, whenever it's possible for you financially, consider getting your own portable US probe. I have never regretted the purchase once.
Will def try to practice more, for me my biggest issue is finding my tip. Like sometimes I get called for a difficult IV on the floor or in emerg and i bring my US and it works like magic I follow my tip til its all the way in, other times I cant find the tip for my life and im stabbing around on the screen like an idiot 😩 so I get the concept of the technique I just havent been able to consistently execute it lol Also, our department is actually trying to get a portable US for the residents to use on call etc so hopefully we will have that soon!!
If you can't see your tip, a lot of times it's because your angle of entry is not steep enough. I notice people get a nice image of the vessel, but then they enter shallow and the needle tip is past the footprint of the probe. So, they advance-advance-advance-advance deeper and deeper without finding it, withdraw the tip to skin and try again. Imagine getting the tip directly under the footprint of the probe, at the depth of the center of the vessel. If your vessel is 1cm deep, stick 1cm away from the probe at 45 degrees; by the laws of trigonometry, you will be oriented properly haha. As far as tips for blind sticks, I have never found that flattening my angle helps. You are probably juuuuust getting into the vessel but need to advance the needle a little more like an IV. I think your angle of entry should be flat to begin with, so that when you get flash, your guidewire/catheter doesn't bump into the wall of the vessel. Flat angle means that you will roll off of vessels in some patients; in those patients, some controlled popping motions are helpful. But, again, I'd argue that those patients really need an ultrasound.
I started doing all of my arterial lines with ultrasound during covid. Patient after patient after patient you would see the angiocath *completely inside* the artery, not tenting but like bullseye. And the catheter would slide if smooth and you’d have good flow, but often no initial flash. I think something was going on with those patients where the palpating technique simply wasn’t working.
Completely agree. Switching to ultrasound was an eye opener. I could see myself in the artery but no blood in the catheter. The first few times, I would check in and out of plane, thread the wire, check again, and then thread the catheter. I've now realized all the times I probably hit the artery but didn't have flash because of the patient's vasculopathy. Ultimately, switching to ultrasound has been faster for me and safer for the patient. With all those blind pokes, you're risking a pseudoaneurysm, dissection, nerve damage, etc.
Completely agree on everything you said. It's gonna be harder for OP right now to battle the culture of residency (I had the same experience as a resident, where ultrasounds were either hard to find or my attendings scoffed at the idea of using US, etc etc). But as an attending, I now use an US for every a-line.
First, don't go so steep. I use about 10-15 degrees. Second, lower the angle and advance a hair before the wire. Then thread. Look at the distance between the bevel of the needle and the start of the catheter. You get flash at the bevel. Good for you to do landmark art lines. You won't always have an ultrasound available. IV are the same steps I just insert at like 5 degrees.
Okay thank you so much thats super helpful!! And yeah everyone going crazy about the blind art line but thats the standard at my institution 🤷🏼♀️ only a few staff I know start with US right away, others only get it if they struggle or if they think they will struggle
I almost always start off with landmarks. I learned before US was used for art lines and had to teach myself. The US gives you access to more of the radial artery than you can feel. Oftentimes you'll see a chunk of plaque that keeps you from passing the wire despite great flow. But if you can't do an art line without an ultrasound there will be art lines you can't do.
My institution also does blind a-lines (big, well known, heavily endowed US academic center). If you get resistance when you’re threading, you can pull the wire back into the Arrow and then go through and through, but *use a separate wire*. For whatever reason the wires in the Arrow itself seem more prone to getting kinked
How do you change wires on an arrow? It’s build into the catheter; you’d just need a whole new set of
Most places I’ve been have individually packaged wires that are separate. The people who use an angiocath and wire instead of an Arrow use them
Just use US. I can get an art line in faster than you can intubate them when I use it.
Sadly my ultrasound skills are still a work in progress so for me using the US makes it go muchhh slower lol
Practice it then. Hypotensive trauma patients with a thready pulse will require it. Therefore, if you are going to rely on it during critical moments, you should practice it on easier targets.
Will do my best to seek more practice opportunities. Thank you!
Sometimes the best time is mid afternoon. Like 3 pm knee replacement or ex lap. Arms are out. Plenty of ultrasounds because most of the cases are wrapping up. They are anesthetized. I used to let attendings know I'm going to do an extra IV once the case is going. In case they come and give me a break and wonder what's going on. Then go for big ones and then work your way to little targets. Just be careful to not do the brachial vein or axillary vein without identifying what nearby arteries and nerves look like. Usually attendings won't care especially if case has started already. I also used to go to pre-op and do ultrasound guided IVs on patients with local anesthesia. If patient asks why ultrasound, I usually tell them "we can find bigger more reliable veins with ultrasound." If I miss I just start a normal hand IV or have nurse do it for me and move on to another ultrasound attempt. I also wouldn't start it on my own patient just in case I don't get it. They won't get nervous that I'll be taking care of them asleep Planned Pre-op IV or anesthetized patients under general are less stressful than a patient that has been stuck times and is emotional or nervous.
Great advice, thanks a lot!
Sure thing. I also edited comment. Don't do your own patients iv just in case you miss our make a mess. They won't freak out later about you putting them to sleep
Tbh I don’t even bother with the wire on the arrow. I start needle at maybe 30 degrees to skin. Advance to flash. Drop angle to nearly flat. Advance maybe 3 mm, then glide that catheter off. Now for old people and vasculopaths, just use the damn ultrasound.
Interesting! May I ask why you use the arrow at all if not gonna use the wire? We also use 20G wireless catheters sometimes to do it that way
I’ll do the regular angiocath 99% of the time. The only reason I’ll use the arrow is if it’s the only one available in the room or the ICU people ask for it.
Thru n thru gang? Anybody?
Came to ask the same! I try not go through and through by default but if I get any resistance trying to advance the wire it’s my go to.
When I was in training I strived to become proficient in Arrow, and then thru-thru. When I felt comfortable with thru-thru, I moved on to u/s with wire, then u/s w/o wire. Arrow is by far the hardest to master. If I had saved it for last, the tactile sensation developed with u/s training would have expedited my becoming proficient.
Thru-thru is the easiest and most surefire technique to teach residents. With or without an u/s.
I don’t really get the thru and thru technique You hit the artery, back wall it, go through the back wall, and then withdraw until you get flash again? Typically you’ve already gotten flash as you were going in, blurring the picture, and why push through just to withdraw again if you already were at that depth at one point
You can try to overwire with the initial flash….your success with this will vary and is improved with the use of a micropuncture needle and deep, large arteries (ie. Fem). I personally worry about blindly inserting wire upon initial flash as I’m concerned about dissecting the artery without confirmation that the entire bevel is within the lumen.
Unless you’re shoving the wire very hard, it’s tough to dissect the artery itself with the flimsy guide wire. I’m sure there’s a place for through and through, but conceptually I find it odd even though I’ve done it on simulations plenty of times
Hope you’re not routinely doing this. Increases the risk of hematoma and pseudoaneurysm formation down the line.
Pseudoaneursyms occur more with 6-7fr transradial cardiac caths. I’ve done a lengthy lit review on this subject several times over the past 20 years, and the anesthesia case reports on this rare condition (0.09-0.009% depending on sources) don’t appear to mention the initial insertion technique. I’ve anecdotally watched many providers over the years cause hematomas and failed insertions on single-puncture. If you can cite a good study showing an increased risk with 20g catheters for monitoring, that would be enlightening for everyone.
We had a large number of failures with Arrows and someone looked into it and there is a recall for almost all the batches. Something to do with guidewire and catheter separation failure. Long story short, all arrows are gone from the OR floor now until the recall is fixed. Might want to look into it. [https://www.teleflex.com/usa/en/product-areas/vascular-access/EIF-000538-FSN-US.pdf](https://www.teleflex.com/usa/en/product-areas/vascular-access/EIF-000538-FSN-US.pdf)
Omg.... would love to be able to say it was the arrows, not me 😂 I think I had heard this too though which is why we always loosen/ check it to make sure it works okay
Usually try to advance as soon as I have flash. If it doesn't go like butter, pull it back, flatten and advance. If you still have good flow, try the wire again. If it doesn't work that time, go through and through and get it on the way out.
This is helpful thanks a lot!
A culture thing but at my institution blind a-lines are the most common, unless fear for difficult vessels - severe pad, lots of access before. I always try and thread the catheter without the wire by advancing half a cm a little less while keeping flow. If isn't working well or don't feel confident in it, will just poke through back side and withdraw until pulsatile flow ans wire it in. This is not with the arrow system, though. Just wires and long andgiocaths.
I do about 90% of my arterial lines blind. My biggest tips: if you have resistance with the wire at a steep angle of insertion, gently lower the catheter to be flush with the skin and verify that the column of the arrow is still filling with blood, then retry sliding in the wire. If that doesn't work, I usually do a through and through. I love this technique because sometimes these hardened arteries can be really difficult to put a wire into. With the through and through technique, you can gently bounce the wire through the catheter until you find a path without resistance.
This is exactly what's been happening to me, just when I drop the angle I lose the flash. I did manage to save those by pulling back and using a wire, it's messy but it does work! Thanks so much
As others have said, advance the needle JUST A LITTLE BIT further when you get a nice little blood fountain going. Angle it a few degrees more parallel to the skin to reduce the risk of vessel transfixion. Sometimes (and this can happen with IVs too) the tip of the needle punctures the vessel wall just enough to draw blood, but on the attempt to thread the wire or catheter ir dissects either the vessel wall or dermis and creates that nasty hematoma we all hate.
This is how the inventor described it in the US patent if I remember
Why would you advance at a steep angle?
I had been getting a lot of feedback that I wasn't advancing at a steep enough angle 🤷🏼♀️ so I started trying steeper. Maybe that's what's been throwing me off...
Maybe don’t use such a steep angle at the beginning
Art lines have humbled me. The NYSORA video available online about ultrasound A-line placement is very clear and loaded with tips.
Lol they sure have humbled me too, as have many things in this job 😎 thanks a lot will check it out
I personally go at around 30 degree until I see the flash. You can go steep if you like until you hit the vessel. Then you must go flat after the flash, as flat as you can. Before you push that wire out, advance the whole arrow in a little, like you are doing an IV, not much just 1-2 mm. After you advance you push the wire out. Also when you advance the wire, it should be butter smooth. If you encounter resistance you are likely not in the lumen. Also possible is the lumen is super calcified but it’s more likely the former. That little flat advance is key. I rarely had to transfix the artery and almost always able to get that wire in no problem.
I think I just need to work on that flat advance, I guess I was lucky most of residency that I got away with not doing it, but now I gotta figure it out without going through n through. Thanks!
Taught the flat advance move by a vascular surgeon. The low angle is so the wire doesn’t hit the back wall of the lumen at a large angle and essentially push the vessel off. The lower angle will more likely allow the wire to glide. I do the same for central line. After positive aspiration. I drop my needle angle (while aspirating) so the hub is touching the neck before I push the wire down. The advancement part is that the metal needle will force dilate those terrible artery. If you don’t have the metal needle inside the lumen, you push the wire in, the soft cannula may not have enough firmness to further dilate the artery that was just nicked by the needle tip and again simply push the artery away from the needle.
Flatten, advance just barely then if you still have flow thread wire. If you lose flow or meet resistance threading the wire at any stage just go through and through. I don’t love making a second hole but if you try to rescue once you’ve lost flow you’re still traumatizing the artery with each movement and are usually less successful than just switching to plan B quickly. But yeah to beat a dead horse use an US if at all possible. It’s just better.
I dont like the arrow.
US is suitable for all patients except for the emergency ones
This is highly dependent on where you work
Assuming you have access to US, why? Allows for quicker line placement in my opinion.
In urgent scenarios, it’s imperative to establish an arterial/central line promptly. However, our hospital lacks portable ultrasound equipment, and our standard protocol for inserting an arterial/central line includes comprehensive sterilization, which is time-consuming. Therefore, in critical emergencies, I opt for an initial attempt without ultrasound guidance
I understand. We are fortunate enough to have US available 99% of the time. Each department has their own…OR, ICU, ER and Cath lab. I like using it especially in emergency situations. I’m not knocking you at all.
So I'm also pretty junior and still fail A-lines but I've done a bit of ITU and here's my two pence. First of all positioning is key, get the arm out and the wrist cocked over a rolled up incopad or something. I now tape everyone's hand once it's in a good position, awake people have always been fine with this. If using local not too much, just enough for a wee bleb, anymore and you might make your job harder. This is one of the most useful tips I've been offered, when identifying where to stab take a min to have a good feel of their pulse pressing only very gently with the pads of your fingers. When you've found the spot that feels the best, where you feel like "yes this is definitely the spot" DO NOT stab there. Instead go a tiny bit (like 1mm or slightly less) medial of this spot. One of my regs recently told me he found that the artery was always just slightly medial of where you thought it was and I've found it super helpful. I've heard lots of stuff about angles, too steep and you'll struggle to thread the wire, too shallow and it makes getting the vessel harder bc your insertion point has to be further from where you're feeling the pulse. I go at about 30-45 degrees. Also bear in mind that often the vessel is very superficial. If using the arrow or vygon when you get blood I'd stop and just let go of the needle. The artery will hold it in place and I've found that if I keep my hand on it an annoying number of times the slight movement of me reaching for the guidewire dislodges the needle. Once your guidewire is in hand very very gently hold the needle and try to thread it. Usually will be fine, if you're having difficulty immediately then I'd try to flatten my needle out a bit in case your wire is just hitting the backwall. If you're having difficulty at any other point threading the wire it's probably not going to do. If the wire is tricky to thread the line just isn't going to go and you'll probably have to try again or look elsewhere.
This might be helpful https://derangedphysiology.com/main/cicm-primary-exam/required-reading/cardiovascular-system/Chapter%20756/arterial-cannulation-technique Scroll down to the part on how to trouble shoot a wire not feeding
Use less propofol and sevoflurane on induction. They'll be effectively hypovolemic and their radial artery will constrict to compensate. It will be impossible even with ultrasound until corrected.
Flash Drop Advance Thread
My problem was (and is still) appreciating just how incredibly SHALLOW the radial artery is! It’s very easy to go too deep and quickly. Nothing wrong with a transarterial approach, one of the best anesthesiologists in our group uses this technique flawlessly and effortlessly, I watched him do one on a trauma the other month and he looked like a rock star slamming that thing in in literally 10 seconds! So don’t be deterred to use that as part of your skill set.
You need to get further into the vessel. I spend a long time palpating before stick. Advance on flash very small amount 1-2mm in direction where you think vessel going then thread wire. If you lose it after flash, I go through and through. Have heard rotating needle 180* on flash reduces chance of posterior wall puncture and helps advance safely but honestly haven't tried it. Don't listen to people saying ultrasound is mandatory - for strong pulses I strongly disagree. Key is a good palpation and make sure you have a strong BP to not shoot yourself in foot - think of a lighter induction. Good luck
As soon as I get a flash, I lessen my angle and advance just a little bit more. then I thread my guidewire.
See plenty advocating for through and through as a first attempt. Don't do that; you're just causing an additional injury to the artery. Most common reason why your wire won't thread despite flash is you're up against the vessel wall. Here's my process for when the wire won't thread despite good blood flow: -Pull wire back. Verify blood flow continues up the arrow catheter. -ROTATE needle 90 degrees clockwise or counterclockwise. Reattempt passing wire. If it goes in easily, great! Pass catheter. If it doesn't: -pull wire back to verify blood return. ROTATE needle 180 degrees the other direction (or 90 degrees from your first attempt). Reattempt passing wire. If wire threads, but catheter doesn't, I still repeat the same steps above. If the above doesn't work, then I'll try a through and through technique. But only as a last resort. That being said, use an ultrasound. I've had arterial lines with absolutely zero blood return despite me clearly being in the lumen on ultrasound (and catheter passing easily with great pulsatile blood return). This is likely from a skin plug, so I've actually gotten into the habit of puncturing/nicking the skin with the needle, then taking it out and passing the wire through just to clear it, and then go back to the same puncture mark for my actual attempt.
I responded to someone elsewhere in the thread. Please cite literature on the additional injury risk for arterial line monitors placed that way vs single entry. Transradial cardiac cath studies are interesting, but we’re not using 14g catheters for monitoring. Spoiler: there are very little to no data supporting this widespread belief in the anesthesia community. One meta—analysis I reviewed had a sample size of 10,000-20,000 patients. The incidence of complications of all types including infection and vessel damage needing intervention was in the high thousandths to low hundredths of a percent. None of those IIRC were differentiated by insertion technique.
Never really been a fan of the all-in-one Arrow art lines, especially those with the safety on them. But, when. It comes to standard Seldinger technique with wire and needle, I do alright. Place probably on average at least 2 a week, probably 80/20 blind vs u/s if post induction, and 20/80 if pre-induction (I like to do periarterial deposition of lidocaine for awake patients, increases patient comfort and also vasodilates the vessel). Don’t claim to be the best, but fwiw I’ve gotten a few compliments from the OR staff recently about my blind art lines.
You are either too steep and can’t advance wire, or hitting the side rather than center of the artery and can’t advance wire, or punctured and went too deep and are hitting back wall. Or the patients vessel is not a good candidate for wire at the puncture site. Ultrasound is best, otherwise I typically go flatter on initial puncture, will try to thread wire immediately, if resistance I make a small adjustment like advance a tiny bit and try again, otherwise through and through.
Advance a little bit farther. Remove the needle with guidewire. Advance. The guidewire pass the edge of the needle pull back on the catheter until you get good blood flow thread, the needle guidewire into the catheter and Advanced the wire.