Tips for arterial sticks?

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    Anyone have any tips for arterial sticks/a-line insertion? I have attempted a few now and let's just say...well I have not been very successful! Don't know what the issue is, even when I'm palpating a great radial pulse I can't seem to get the needle in the right place. Obviously I'm doing something wrong but even the CRNAs who've watched me do this haven't had much feedback/advice for me. Any feedback is welcomed! Thanks!
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  4. 0
    Make sure your patient's arm is on a firm surface. Take a roll of soft gauze or a rolled up washcloth and place it under the supinated hand, This should gently hyper extend the hand and give it enough support.

    Palpate the pulse by GENTLY placing the flat surface of 2 or 3 fingers across the wrist. Do not use the tips of your fingers, and do not squeeze the wrist, please! Slide your fingers along the radial pulse so you can really feel the direction the artery is coming from.

    Hope this helps! Best wishes!
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    Make sure you have good collateral circulation by doing a modified Allen's test.

    Pt should be in a position of comfort with arm relaxed and supported. Something like a gauze roll or towel should be placed under the wrist to get it neutral or slightly hyperextended. Be careful not to hyperextend too much. The idea is to keep the wrist from flexing in an attempt to avoid the needle or the artery move with the wrist creasing.

    Be mindful of how much you have pulled back on the syringe in preparation. You do not need much blood for an ABG in a prepackaged syringe.

    Put yourself in a position of comfort. Don't bend over or hunch your back. I will get a chair to appear relaxed and at a better eye level with the patient. These sticks HURT. If my back spasms, so does the artery. I can also steady my hand and body better. If they jerk, I want also want to be in a better position not to be jerked around. I can also more easily hold pressure for 5 - 10 minutes.

    When you palpate a "great" artery especially on an adult, see if you can trace it. Often the pulse will sometimes feel like it is great "everywhere" which leads you to nowhere but the tissue next to it.

    Bevel up at a 45 degree angle.

    Relax. Don't jab and don't go too slow.
  6. 0
    Quote from GreyGull
    Make sure you have good collateral circulation by doing a modified Allen's test.

    Pt should be in a position of comfort with arm relaxed and supported. Something like a gauze roll or towel should be placed under the wrist to get it neutral or slightly hyperextended. Be careful not to hyperextend too much. The idea is to keep the wrist from flexing in an attempt to avoid the needle or the artery move with the wrist creasing.

    Be mindful of how much you have pulled back on the syringe in preparation. You do not need much blood for an ABG in a prepackaged syringe.

    Put yourself in a position of comfort. Don't bend over or hunch your back. I will get a chair to appear relaxed and at a better eye level with the patient. These sticks HURT. If my back spasms, so does the artery. I can also steady my hand and body better. If they jerk, I want also want to be in a better position not to be jerked around. I can also more easily hold pressure for 5 - 10 minutes.

    When you palpate a "great" artery especially on an adult, see if you can trace it. Often the pulse will sometimes feel like it is great "everywhere" which leads you to nowhere but the tissue next to it.

    Bevel up at a 45 degree angle.

    Relax. Don't jab and don't go too slow.
    Just a couple of things:

    1. Doing an ABG vs. Art Line is different. It is a lot easier to do an ABG vs. inserting an art line.
    2. We are all taught to do an modified allen's test in nursing school, but it is unreliable and that is the reason most people skip it when doing art lines.
    The value of the Allen test is controversial, and a negative Allen test may not guarantee adequate collateral circulation to the hand. Several reports exist of permanent ischemic injury, after radial artery cannulation, following a negative (normal) Allen test.5,6,7 Alternatively, a positive (abnormal) Allen test may not correlate with inadequate collateral circulation. One study showed that, in the absence of peripheral vascular disease, the Allen test was not predictive of ischemia of the hand during or after radial artery cannulation.8 Other studies have shown poor correlation of results of the Allen test with distal blood flow as demonstrated by fluorescein dye injection or photoplethysmography.9,10 Given the controversy surrounding the results of the Allen test, some experts recommend a Doppler evaluation of collateral flow be completed in all high-risk patients prior to cannulation.2

    Radial Artery Cannulation: Treatment & Medication - eMedicine Clinical Procedures

    3. When I am doing an Art line in the OR I like to tape the palm to the arm board after either putting the wrist in preformed arterial line splint or using rolled gauze to provide adequate hyperextension. Then I tape the thumb down and away separately. This technique gives you the best access to the radial arterial. It is a little overkill to tape the thumb and the palm of the hand, but it is a good technique when you are just beginning to do art lines.

    4. The best tip I ever got to doing art lines though is the radial is usually always more medial than you think it is, and if all else fails do it under ultrasound.
  7. 0
    Quote from wtbcrna
    1. Doing an ABG vs. Art Line is different. It is a lot easier to do an ABG vs. inserting an art line.
    I do both so I still try to put myself and the patient in the best position possible.

    Placing the line in a position that can create discomfort for the patient may shorten the life of that line and will have to be replaced in the ICUs which then can tie up the bedside RN working to start one on another site. Thus, be careful with hyperextension.

    Quote from wtbcrna
    2. We are all taught to do an modified allen's test in nursing school, but it is unreliable and that is the reason most people skip it when doing art lines.
    The Modified Allen's test can not predict the extent of damage on pre-existing disease processes. That is what you the clinician will have to assess for risk vs benefit with this knowledge. You can document or use whatever test or information you are comfortable with depending on when you assess the patient also. However, if you do not make some attempt to prove adequate patency of both arteries, good luck pulling up enough studies to prove or disprove your point when something does go wrong. Hopefully the bedside clinicians recognize problems which you may not always see in the short time the patient is in the OR and remove the line.
  8. 0
    Quote from GreyGull
    I do both so I still try to put myself and the patient in the best position possible.

    Placing the line in a position that can create discomfort for the patient may shorten the life of that line and will have to be replaced in the ICUs which then can tie up the bedside RN working to start one on another site. Thus, be careful with hyperextension.



    The Modified Allen's test can not predict the extent of damage on pre-existing disease processes. That is what you the clinician will have to assess for risk vs benefit with this knowledge. You can document or use whatever test or information you are comfortable with depending on when you assess the patient also. However, if you do not make some attempt to prove adequate patency of both arteries, good luck pulling up enough studies to prove or disprove your point when something does go wrong. Hopefully the bedside clinicians recognize problems which you may not always see in the short time the patient is in the OR and remove the line.
    1. The vast majority of art lines done by anesthesia are done while the patient is sedated on the OR table or just after induction. So patient comfort is not exactly easiest to confirm at that time and really not our top priority while inserting the art line since the patient rarely feels/remembers anything of the artline insertion in the OR.
    The wrist is either placed in a preformed splint or just left on the armboard in the normal position after the artline is secured. We don't leave the wrist/thumb taped to the armboard after the arterial line is placed. So, the point of over hyperextension is a mute.

    2. Most people place the pulse ox on the same hand as the arterial line which seems to be more than adequate for the vast majority of us that work in anesthesia. I have never heard of anesthetic provider having any trouble using this method.

    3. Most of the techniques you describe of getting in a comfortable position, pulling up a chair, etc. will not work in the OR. An anesthesia provider needs to be competent putting in arterial lines in awkward positions such as bending over while under the drapes in low light positions. Our jobs as anesthesia providers is to ensure safety of the patient and to keep the surgery going, so our comfort is often a very low priority.

    4. Modified Allen's test has shown not to be adequate and provides absolutely no protection for you should it go to court either if something goes wrong. Anesthesia providers not using an inadequate test is just an extension of EBP.

    5. Since the OP was asking on CRNA forum what their advice is on doing arterial lines why not let the anesthesia providers providers give them the information that is going to be most helpful to him/her in the OR.
  9. 0
    Quote from GreyGull
    I do both so I still try to put myself and the patient in the best position possible.

    Placing the line in a position that can create discomfort for the patient may shorten the life of that line and will have to be replaced in the ICUs which then can tie up the bedside RN working to start one on another site. Thus, be careful with hyperextension.



    The Modified Allen's test can not predict the extent of damage on pre-existing disease processes. That is what you the clinician will have to assess for risk vs benefit with this knowledge. You can document or use whatever test or information you are comfortable with depending on when you assess the patient also. However, if you do not make some attempt to prove adequate patency of both arteries, good luck pulling up enough studies to prove or disprove your point when something does go wrong. Hopefully the bedside clinicians recognize problems which you may not always see in the short time the patient is in the OR and remove the line.
    Agree with wtb on everything. Also, where do you work that an RN places an arterial line?
  10. 1
    Your speed of insertion should be tailored to the heart rate... in a brady pt go SLOWLY... you can pas through the artery if you are going too fast and go through during asystole.....

    It really is more medial than you think...

    If you pass through the artery..... remove the needle... push the guide wire through the end of the needle.. and pull back the catheter until you get blood flow.. insert the WIRE back into the catheter at this point and thread the catheter into the artery.... It is called the through and through technique and is described in the literature...NEVER EVER EVER put a NEEDLE back into a cath without the wire extended... you can cut the catheter end off...


    DO NOT use a very acute angle to enter the skin. This will cause the catheter to kink at the hub as it enters the skin when you tape it down....especially with a deep catheter...

    If you have a very small constricted artery... try to infiltrate lidocaine around the artery... I know.. the patient is usually asleep.. but guess what? By infiltrating a local anesthestic... you can make the artery relax and dialate...blocking nerve impulses is blocking nerve impulses.. arteries are innervated...
    NurseKitten likes this.
  11. 0
    In addition.. right before you enter the artery... you may, with practice... notice a decrease in the felt pulse as you compress the artery with the needle.. but that takes a lot of practice...
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    [quote=GreyGull;4620807]
    When you palpate a "great" artery especially on an adult, see if you can trace it. Often the pulse will sometimes feel like it is great "everywhere" which leads you to nowhere but the tissue next to it.
    quote]

    This is exactly what I've experienced...I have a hard time localizing where the artery actually is. I need to work on being able to trace the direction of the artery.

    Thank you everyone for the great tips, all of them have been helpful. Can't wait to try them out and see if I can have some success!


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