IV in an artery

Pediatric Critical Care Columnist · Oct 10, 2011

Actually this happens more frequently than most people would believe, especially in pediatrics. Scalp IVs are notoriously prone to be arterial and when a nurse is learning to insert scalp IVs they're taught to palpate for a pulse along the path of the vessel they're thinking of using, plus to watch for pulsatility in the tubing.

I've lost count of the number of times an attempt at central line placement results in giving us a second arterial line. There are a couple of giveaways, the pulsatility being one and the colour of the blood in the flashback being another. Without transducing the line, one way to assess would be to run a gas on the blood. PO2 greater than about 60 would suggest arterial.

In an emergency, drugs CAN and probably should be given into an artery. Dead is dead, losing a limb isn't. Some neonatal units give all their antibiotics arterially. But realistically, the line should be D/C'd if it's suspicious.

jrmarr · Oct 10, 2011

There was no charge nurse to call I was the only nurse on duty....that is how we work there as we are a very small facility....when I said it pulsed up the line what I meant was that it pulsed backwards but did not go past the j loop on the tubing...not actually past that....it just stayed at that level and pulsed, went no further and flushed back very easily. I did run the abt because he needed it and I was unsure that the nurse coming on would be able to start the IV at all. I am home now and can't stop thinking about it.

xtxrn, ASN, RN · Oct 10, 2011

jrmarr said:
There was no charge nurse to call I was the only nurse on duty....that is how we work there as we are a very small facility....when I said it pulsed up the line what I meant was that it pulsed backwards but did not go past the j loop on the tubing...not actually past that....it just stayed at that level and pulsed, went no further and flushed back very easily. I did run the abt because he needed it and I was unsure that the nurse coming on would be able to start the IV at all. I am home now and can't stop thinking about it.

Is there an administrative nurse on call you can get a hold of ??? There should be ? This would be a good reason to ask them- it may be that the line is in the vein- the pulsing isn't what you'd expect, but not going that far doesn't automatically scream "artery" to me. Was this a sort of puny individual? Any chance that the vessels were close together, with not a lot of muscle between them to 'buffer' the arterial pulse??

Just an idea..... (those with art line experience, feel free to crucify me )

jrmarr · Oct 10, 2011

yes, the patient was kind of puny so that was actually what I wanted to know...could the vein be close enough to an artery to be pulsing with it...I don't think the blood was very bright either...more darkish.....and as I said earlier...this fellow has very few options for lines left.

Flo., BSN, RN · Oct 10, 2011

Call someone and have them check, that way you can go to sleep knowing the pt will be taking care of.

honeykrown, MSN, NP · Oct 10, 2011

i had a pt's blood pulse back into the line after flushing. thats just how it was and it wasnt in the artery. i dont know why it happened but everyone here being so sure its the arteries.

ArtRN · Oct 10, 2011

I've noticed that with patients with respiratory troubles, COPD especially, the blood return is increased and can cause blood to back up like that. Not sure what is the scientific explanation for this.

nyrn5125 · Oct 10, 2011

jrmarr said:
There was no charge nurse to call I was the only nurse on duty....that is how we work there as we are a very small facility....when I said it pulsed up the line what I meant was that it pulsed backwards but did not go past the j loop on the tubing...not actually past that....it just stayed at that level and pulsed, went no further and flushed back very easily. I did run the abt because he needed it and I was unsure that the nurse coming on would be able to start the IV at all. I am home now and can't stop thinking about it.

Even if the next nurse was unable to start a line doesn't matter. The antibiotic was not an emergency to give and even still we only infuse ns via pressure bag which is about 10cc/hr. Some nurses are so anal about giving the med at the time ordered that they would run into an artery. if you do not have access then you do not give it until you have proper access. If that means getting a PICC then so be it. Veins go toward the heart arteries away so it just sat there if you were in an artery. If the blood was dark and not bright red you probably were in the vein. No one else was there so we really don't know

SleepynurseRN · Oct 10, 2011

I have only heard of 2 bedside med given arterially epi. ( Never done it..just heard about it as an offhand conversation) and normal saline. ALL meds are to be infused intravenously. Infusing medicine into an artery sends the medicine the OPPOSITE way.. into smaller arterial pathways and capillary beds where the agent becomes trapped and impedes circulation. Those trapped agents begin to block arterial circulation to the area resulting in impaired arterial flow, cyanosis, necrosis, and eventually (if not noticed in time) tissue death.

Arterial line placement typically requires a longer catheter gauge because they are located next to muscular tissue. Radial arteries are the more superficial; the further up the arm they travel, the deeper they become. Veins are more superficial requiring shorter guages. Also, arterial inserts are more painful. Did he complain of a lot of pain intra/post line insertion?

Chances are you accessed a really great venous site that hadn't been poked a lot. But because I know how you feel, you really should just call and talk to the nurse taking care of him so you can sleep.

blondy2061h, MSN, RN · Oct 10, 2011

I once had a patient getting a central line placed at the bedside for chemotherapy. They were going femoral. The surgeon got a line in, got wicked blood return, and was like, "Whoops, looks like I placed an art line." I'm like, "Uhm, this is for chemo, not running chemo if you think it's in an artery." We ended up sending a gas and he told me it was venous based on that. Or just to shut me up. We'll never know.

Rob72, ASN, RN · Oct 10, 2011

SleepynurseRN said:
Arterial line placement typically requires a longer catheter gauge because they are located next to muscular tissue. Radial arteries are the more superficial; the further up the arm they travel, the deeper they become. Veins are more superficial requiring shorter guages. Also, arterial inserts are more painful. Did he complain of a lot of pain intra/post line insertion?

Veins are generally 2-3 millimeters below the surface, arteries more in the 3-6mm range, cath length makes no diifference.

What disturbs me is that, no, nurses are not taught how to perform venipuncture or art access, overall. Repeatedly this is referred to as a "lower level" skill, learned OJT. :rolleyes:

At this point, the "proof-test" is to put a towel nearby, and disconnect the hub. Venous will ooze, art will spurt.

IVRUS, BSN, RN · Oct 10, 2011

Rob72 said:
Veins are generally 2-3 millimeters below the surface, arteries more in the 3-6mm range, cath length makes no diifference.
What disturbs me is that, no, nurses are not taught how to perform venipuncture or art access, overall. Repeatedly this is referred to as a "lower level" skill, learned OJT.
At this point, the "proof-test" is to put a towel nearby, and disconnect the hub. Venous will ooze, art will spurt.

I agree with the statement that nurses aren't taught this in school... Many RN's are just expected to put all the pieces together and come up with a clear picture of what to do, this doesn't happen.

Additionally though, one must always be mindful that there are Aberrant arteries, with approx 1 out of 10 people having one... This is an artery that is NOT deep, but rather superficially located and in an unusual spot.