Brachial caths

[NotOnMyWatch]

Two cardiologists in my facility recently started doing caths via brachial approach. Is this being done at your facility? Up until now it has been either via groin or radial approach. I am not sure if this is a new technique, or rather if this is just a new technique for our facility. I am kinda nervous about recovering these pts as we have had no inservice or education on recovering them. Fortunately I haven't had to recover any of them yet... but I am told that we will be seeing increasing number of pts with this approach. Is there anything in particular that I should watch out for, or have you noticed any particular complications with these pts? Thanks for your response.

[dianah, ASN]

Brachial approach was used more in past years, sounds like it's making a comeback. :)

Some pts with PAD (PVD) have no or greatly dimished femoral pulses, and Cardiologists are (understandably) reluctant to cannulate those diseased arteries.

Radial or Brachial approach is a viable alternative (in most cases).

(one of our older Radiologists at another facility did Axillary sticks! Worked great for, say, aorto-iliofemoral imaging. Wouldn't work as great for cardiac, I don't think. But, I digress . . . :D)

Is it percutaneous or via cutdown?

I assume percutaneous.

There should be Cath Lab documentation of pre- and post-case distal pulses (radial, at least).

I assume (I know, bad to do but . . .) the Cardiologist or Fellow did an Allen's test or checked for circulation deficits with US before the case.

Off the top of my head, your concerns would be monitoring for

* nerve injury

* bleeding/compartment syndrome

as well as the usual: VS and mentation changes and contrast allergic reactions.

This is what we do at our facility:

The elbow is secured to an armboard and kept still and straight, for 2-4 hr.

Check radial pulse, color and warmth of hand upon arrival and with all VS checks.

Report any patient comments about perceived sensation changes, "my hand feels numb," etc.

Report any swelling at site.

Palpate, not right near the entry site, but 5cm or so around the site. Tissues should be soft. Firmness suggests hematoma formation (feel and compare the other side, if in doubt).

Our MDs don't apply pressure dressings post-cath, as if the site bleeds they want it to be seen right away, not after the dressing is saturated (some nurses don't peek under the dressing to check).

If there is a pressure dressing, peek under and make sure there is no bleeding under it.

I'm sure I've missed something. Hopefully someone else will come along and help out.

Perhaps you could cajole one of your Cardiologists (who is performing a lot of these) or one of the Fellows to give a short inservice, "so we can be sure and do things the way you want."

:)

[Grace Oz]

When DH had his angio, he was told they'd be going either via the groin or brachial. This was just 7 1/2 weeks ago here in Oz. They ended up going through the groin. I'd never heard of via brachial before and had worked in Radiology back in the day many many moons ago. I might be wrong, but I got the impression from the way the Dr spoke, this is a relatively new approach here.

[nursej22, MSN, RN]

I have pulled a few brachial sheaths and definitely found it a challenge. Most patients had chubby arms and it can be difficult to determine swelling. Some thing I found helpful was to make marks above and below the puncture site and then measure the arm circumference at those marks post hemostasis and then with VS and pulse checks (q15 min x4, q30 min x2).

A lot of blood can collect in a chubby arm before it forms a firm hematoma.