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Superficial Structures

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Presentation on theme: "Superficial Structures"— Presentation transcript:

1 Superficial Structures
Arterial Line Placement with Ultrasound Guidance Harry H. Holdorf PhD, MPA, RDMS (Ab, Ob/Gyn, Br), RVT, LRT(AS), CCP

2 Arterial Blood Gasses (ABG) What is an A-Line?
Introduction Anatomy Arterial Blood Gasses (ABG) What is an A-Line? Reasons for Placing an A-Line Method of A-Line Placement Catheter over Needle vs. Needle over Catheter Technique Possible Complications Radial Artery Line Ultrasound Guidance Utilizing the Catheter over Needle Technique Basic Troubleshooting Conclusion

3 Introduction An arterial line (also art-line or A-line) is a thin catheter inserted into an artery. It is most commonly used in intensive care medicine and anesthesia to monitor blood pressure directly and in real-time (rather than by intermittent and indirect measurement) and to obtain samples for arterial blood gas analysis. Arterial lines are generally not used to administer medication, since many injectable drugs may lead to serious tissue damage and even amputation if administered into an artery rather than a vein

4 An arterial line is usually inserted into the radial artery in the wrist, but can also be inserted into the brachial artery at the elbow, into the femoral artery in the groin, into the dorsalis pedis artery in the foot, or into the ulnar artery in the wrist. A golden rule is that there has to be collateral circulation to the area affected by the chosen artery, so that peripheral circulation is maintained by another artery even if circulation is disturbed in the cannulated artery.

5 Insertion is often painful; an anesthetic such as lidocaine can be used to make the insertion more tolerable and to help prevent vasospasm, thereby making insertion of the arterial line somewhat easier. Arterial lines are typically inserted by Physicians, ICU Physician Assistants (PAs), Anesthesiologist Assistants (AAs), Nurse Anesthetists (CRNAs), and Respiratory Therapists.

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9 Arterial Blood Gas An arterial blood gas (ABG) test is a blood gas test of blood from an artery; it is thus a blood test that measures the amounts of certain gases (such as oxygen and carbon dioxide) dissolved in arterial blood.

10 An ABG test involves puncturing an artery with a thin needle and syringe and drawing a small volume of blood. The most common puncture site is the radial artery at the wrist, but sometimes the femoral artery in the groin or other sites are used. The blood can also be drawn from an arterial catheter.

11 An ABG test measures the blood gas tension values of arterial oxygen tension (PaO2), arterial carbon dioxide tension (PaCO2), and acidity (pH). In addition, arterial oxygen saturation (SaO2) can be determined. Such information is vital when caring for patients with critical illness or respiratory disease. Therefore, the ABG test is one of the most common tests performed on patients in intensive care units (ICUs). In other levels of care, pulse oximetry plus transcutaneous carbon dioxide measurement is an alternative method of obtaining similar information less invasively.

12 The test is used to determine the pH of the blood, the partial pressure of carbon dioxide and oxygen, and the bicarbonate level. Many blood gas analyzers will also report concentrations of lactate, hemoglobin, several electrolytes, oxyhemoglobin, carboxyhemoglobin and methemoglobin. ABG testing is mainly used in pulmonology and critical care medicine to determine gas exchange which reflect gas exchange across the alveolar-capillary membrane. ABG testing also has a variety of applications in other areas of medicine. Combinations of disorders can be complex and difficult to interpret, so calculators, nomograms, and rules of thumb are commonly used.

13 ABG specimens originally were sent from the clinic to the medical laboratory for analysis.
Today the analysis can be done either in the laboratory or as point-of-care testing, depending on the equipment available in each clinic

14 The A-Line An intra-arterial catheter (A-line) is a very small plastic tube (called catheter) placed in one of your blood vessels (an artery) by highly trained personnel. This is usually done during or before certain types of surgery or in the Intensive Care Unit.

15 Reasons for an A-line Placement
To watch your blood pressure very closely To draw frequent blood samples for lab tests To test for the oxygen saturation in the blood (check how much oxygen is in your blood)

16 Method of A-Line Placement
The A-Line is usually placed on the inner side of the wrist. It could also be placed in the artery on the inner side of the elbow, the groin or the foot.

17 Catheter over needle vs. Needle vs. Catheter
Insertion, maintenance, and clinical effects were better achieved with the catheter-over-the needle design compared to the micro-catheter.

18 Arterial Line Placement technique
The radial artery is preferred for securing arterial blood and for cannulation to provide continuous blood pressure (BP) monitoring and arterial blood sampling. If the radial artery cannot be cannulated, the femoral artery offers a viable alternative.

19 Approach Considerations
Arterial line placement can be performed via multiple methods. The choice of methods is determined by location, operator preference, and available equipment. The most commonly used methods are the following [22] : Catheter over needle Catheter over wire (including direct Seldinger and modified Seldinger techniques)

20 For radial artery cannulation, either the catheter-over-needle technique or the catheter-over-wire technique may be used. The latter is more common in adults and larger children; the former is more common in infants and neonates. As a last resort, a surgical cut-down can be performed for cannulation of the radial artery.

21 For femoral artery cannulation, the catheter-over-wire technique is preferred. The puncture site for the femoral artery should be below the inguinal ligament to allow control of bleeding and prevention of bleeding into the pelvis. The catheter-over-needle technique can also be used for femoral artery cannulation, either alone or in combination with an over-the-wire technique (i.e., Seldinger) if a longer indwelling catheter is desired.

22 With either the catheter-over-needle approach or the catheter-over-wire approach, meticulous attention must be paid to preparing the cannulation site with chlorhexidine to minimize the risk of infection and to firmly securing the final intra-arterial catheter with sutures.

23 The A-line Tray

24 The area is decided mainly upon how well the radial pulse is felt
The area is decided mainly upon how well the radial pulse is felt. That area of the skin is then cleaned well with a disinfecting solution and alcohol.

25 With a small needle the skin is numbed with local anesthesia
With a small needle the skin is numbed with local anesthesia. Then, using a needle with a plastic catheter, the skin is entered.

26 Once inside the artery, the plastic catheter is advanced further in and the needle is removed.

27 The catheter is then connected to a flushed tubing.

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35 Possible Complications of the Procedure
Rare complications include: Local infection, Bleeding Damage to surrounding tissues Blockage of the artery in which the catheter was placed.

36 Things to watch for when the A-Line is established
Redness around the catheter insertion site. Disconnection of the catheter from the tubing which may result in bleeding. In the extremity in which the catheter is placed watch for numbness or pain in the fingers

37 Basic Troubleshooting
Although, ultrasound can help achieve arterial puncture, additional steps must be taken to further advance the catheter. Ideally, as the needle enters the vessel, the angle of entry is flattened and the entire device is advanced. This advances the catheter into the lumen of the artery, at which point it can be freely advanced off of the needle. When the angiocath is advanced into the radial artery, there will appear a flash of arterial blood: the angle is then flattened, and the entire device is advanced a few mm further.

38 If the catheter is advanced too far after the initial flash
the arterial tip may only puncture the back wall.

39 Flow into the flash chamber will stop.
If this happens, the catheter is kept in place, and the needle is withdrawn a few millimeters so its tip is now within the catheter. Since the catheter tip is still within the artery, a sleeve of blood will form and flow into the flash chamber will resume.

40 The catheter is carefully advanced while continuous flow is observed.
Now let’s look and see if the needle and the catheter both go through and through. When the needle is withdrawn into the catheter, flow is not re-established.

41 Now the catheter and needle are slowly withdrawn as a unit until flow resumes
The catheter is now advanced off the needle while making sure flow does not stop. With good needle over catheter technique and practice with the use of ultrasound, Radial arterial access can be achieved even with the most challenging patients.

42 Catheter over Needle Technique
Radial Artery Line Ultrasound guidance Catheter over Needle Technique

43 Arterial Artery catheterization is a commonly performed procedure in the operating room and ICU.
This technique enables continuous monitoring of systemic blood pressure as well as arterial blood analysis and other blood assays. The procedure is generally attempted using service landmarks and palpation of the radial artery pulse.

44 But, when difficulty is anticipated, ultrasound guidance can usually avoid multiple attempts.
Ultrasound can be used to identify the radial artery anywhere along its course in the forearm. This sonogram of the cubital fossa demonstrates the difference between arteries and Veins.

45 Cubital fossa

46 Radial Artery (sagittal) 1 inch below the elbow

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48 Portable US unit for A-Line Placement Guidance

49 Veins are easily compressible.
Arteries are less compressible and pulsatile

50 Radial Artery Puncture

51 Peripheral Catheter Angiocath

52 Ultrasound Guidance A-Line Puncture

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55 Ultrasound equipment comes in many forms.
There is a trend towards battery operated portable machines.

56 A 20 GA (gauge) 1.88 IN BD angiocath is a good choice for catheter over needle technique.
Safety glasses are warn. Skin prep is applied Jewelry is removed from the operator’s hand

57 Hands are cleaned, even when sterile gloves are warn.
Sterile drapes are placed around the puncture site A sterile probe cover is placed over the transducer and sterile ultrasound gel is applied to the patient’s wrist. The transducer is held in the non-dominant hand.

58 The needle is held like a pencil in the dominant hand such as it enters the skin at a 30 degree angle. Images of Radial Artery Puncture The radial artery is near the skin surface and is clearly pulsatile.

59 The operator advances the needle which is seen indenting the artery.
Looking at the sonogram, we can see the needle inserting into the radial artery with a splash of arterial blood.

60 The catheter is advanced into the artery, and the needle is removed and disposed of.
A well-flushed tubing set is attached.

61 Blood and sterile transducer gel is whipped away, and a sterile dressing is applied.
Additional tape reinforces the dressing and helps prevent catheter dislodgement An arm-board helps stabilizes the wrist

62 Catheter over needle vs. Needle vs. Catheter
Insertion, maintenance, and clinical effects were better achieved with the catheter-over-the needle design compared to the micro-catheter.

63 Arterial Line Placement technique
The radial artery is preferred for securing arterial blood and for cannulation to provide continuous blood pressure (BP) monitoring and arterial blood sampling. If the radial artery cannot be cannulated, the femoral artery offers a viable alternative.

64 Approach Considerations
Arterial line placement can be performed via multiple methods. The choice of methods is determined by location, operator preference, and available equipment. The most commonly used methods are the following [22] : Catheter over needle Catheter over wire (including direct Seldinger and modified Seldinger techniques)

65 For radial artery cannulation, either the catheter-over-needle technique or the catheter-over-wire technique may be used. The latter is more common in adults and larger children; the former is more common in infants and neonates. As a last resort, a surgical cut-down can be performed for cannulation of the radial artery.

66 For femoral artery cannulation, the catheter-over-wire technique is preferred. The puncture site for the femoral artery should be below the inguinal ligament to allow control of bleeding and prevention of bleeding into the pelvis. The catheter-over-needle technique can also be used for femoral artery cannulation, either alone or in combination with an over-the-wire technique (i.e.., Seldinger) if a longer indwelling catheter is desired.

67 With either the catheter-over-needle approach or the catheter-over-wire approach, meticulous attention must be paid to preparing the cannulation site with chlorhexidine to minimize the risk of infection and to firmly securing the final intra-arterial catheter with sutures.

68 Conclusion Without Ultrasound guidance, successful first puncture of an Arterial-Line is roughly 50%. With Ultrasound guidance, successful first puncture of an Arterial-Line is roughly 90%. This technique is something that would benefit all sonographers. An A-Line Puncture with US technique is a frequent ON-CALL exam and thus, should be mastered by the Technologist.

69 As with central venous line placement, real-time sonographic guidance can decrease the number of attempts and amount of time required to place an arterial line.

70 FIN


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