Preventing radial arterial catheter failure in critical care - Factoring updated clinical strategies and techniques

Ultrasound-guided Axillary Artery Catheter Placement and Associated Complications in Critically Ill Patients

BACKGROUND

Arterial catheter placement for hemodynamic monitoring is commonly performed in critically ill patients. The radial and femoral arteries are the two sites most frequently used; there is limited data on the use of the axillary artery for this purpose. The aim of this study was to investigate the rate of complications from ultrasound-guided axillary artery catheter placement in critically ill patients.

METHODS

A retrospective study at a tertiary care center of patients admitted to an intensive care unit who had ultrasound-guided axillary artery catheter placement during admission. Primary outcome of interest was catheter related complications, including bleeding, vascular complications, compartment syndrome, stroke or air embolism, catheter malfunction, and need for surgical intervention.

RESULTS

This study identified 88 patients who had an ultrasound-guided axillary artery catheter placed during their admission. Of these 88, nine patients required multiple catheters placed, for a total of 99 axillary artery catheter placement events. The median age was 64 [IQR 48, 71], 41 (47%) were female, and median body mass index (BMI) was 26 [IQR 22, 30]. The most common complication was minor bleeding (11%), followed by catheter malfunction (2%), and vascular complications (2%). Univariate analyses did not show any association between demographics and clinical variables, and complications related to axillary arterial catheter.

CONCLUSION

The most common complication found with ultrasound-guided axillary artery catheter placement was minor bleeding, followed by catheter malfunction, and vascular complications. Ultrasound-guided axillary arterial catheters are an alternative in patients in whom radial or femoral arterial access is difficult or not possible to achieve.

Dressings and securement devices to prevent complications for peripheral arterial catheters

BACKGROUND

Peripheral arterial catheters (ACs) are used in anaesthesia and intensive care settings for blood sampling and monitoring. Despite their importance, ACs often fail, requiring reinsertion. Dressings and securement devices maintain AC function and prevent complications such as infection.

OBJECTIVES

To evaluate the effectiveness of peripheral AC dressing and securement devices to prevent failure and complications in hospitalised people.

SEARCH METHODS

We searched the Cochrane Wounds Specialised Register, CENTRAL, MEDLINE, Embase, and CINAHL Plus up to 16 May 2023. We also searched ClinicalTrials.gov and the World Health Organization International Clinical Trials Registry Platform up to 16 May 2023.

SELECTION CRITERIA

We included randomised controlled trials (RCTs) comparing different dressing and securement devices for the stabilisation of ACs in hospitalised people.

DATA COLLECTION AND ANALYSIS

Two review authors independently selected trials for inclusion, extracted data, and assessed risk of bias using Cochrane's RoB 1 tool. We resolved disagreements by discussion, or by consulting a third review author when necessary. We assessed the certainty of evidence using GRADE.

MAIN RESULTS

We included five RCTs with 1228 participants and 1228 ACs. All included studies had high risk of bias in one or more domains. We present the following four comparisons, with the remaining comparisons reported in the main review. Standard polyurethane (SPU) plus tissue adhesive (TA) compared with SPU: we are very uncertain whether use of SPU plus TA impacts rates of AC failure (risk ratio (RR) 0.44, 95% confidence interval (CI) 0.20 to 0.98; I² = 0%; 2 studies, 165 participants; very low-certainty evidence). Neither study (165 participants) reported catheter-related bloodstream infections (CRBSI), thus we are very uncertain whether SPU plus TA impacts on the incidence of CRBSI (very low-certainty evidence). It is very uncertain whether use of SPU plus TA impacts AC dislodgement risk (RR 0.54, 95% CI 0.03 to 9.62; I² = 44%; 2 studies, 165 participants; very low-certainty evidence). We are very uncertain whether use of SPU plus TA impacts AC occlusion rates (RR 1.20, 95% CI 0.37 to 3.91; I² = 3%; 2 studies, 165 participants; very low-certainty evidence). We are very uncertain whether use of SPU plus TA impacts rates of adverse events with few reported events across groups (RR 0.89, 95% CI 0.09 to 8.33; I² = 0%; 2 studies, 165 participants; very low-certainty evidence). Bordered polyurethane (BPU) compared to SPU: we are very uncertain whether use of BPU impacts rates of AC failure (RR 0.67, 95% CI 0.21 to 2.13; 1 study, 60 participants; very low-certainty evidence). BPU may make little or no difference to CRBSI compared to SPU (RR 3.05, 95% CI 0.12 to 74.45; I² = not applicable as 1 study (60 participants) reported 0 events; 2 studies, 572 participants; low-certainty evidence). BPU may make little or no difference to the risk of AC dislodgement compared with SPU (RR 0.75, 95% CI 0.17 to 3.22; I² = 0%; 2 studies, 572 participants; low-certainty evidence). BPU may make little or no difference to occlusion risk compared with SPU (RR 0.80, 95% CI 0.60 to 1.07; I² = 0%; 2 studies, 572 participants; low-certainty evidence). It is very uncertain whether BPU impacts on the risk of adverse events compared with SPU (RR 0.33, 95% CI 0.01 to 7.87; 1 study, 60 participants; very low-certainty evidence). SPU plus sutureless securement devices (SSD) compared to SPU: we are very uncertain whether SPU plus SSD impacts risk of AC failure compared with SPU (RR 0.78, 95% CI 0.40 to 1.52; I² = 0%; 2 studies, 157 participants; very low-certainty evidence). We are very uncertain if SPU plus SSD impacts CRBSI incidence rate with no events in both groups (2 studies, 157 participants; very low-certainty evidence). It is very uncertain whether SPU plus SSD impacts risk of dislodgement (RR 0.14, 95% CI 0.01 to 2.57; I² = not applicable as 1 study (96 participants) reported 0 events; 2 studies, 157 participants; very low-certainty evidence). It is very uncertain whether SPU plus SSD impacts risk of AC occlusion (RR 1.94, 95% CI 0.50 to 7.48; I² = 38%; 2 studies, 157 participants; very low-certainty evidence). We are very uncertain whether SPU plus SSD impacts on the risk of adverse events (RR 1.94, 95% CI 0.19 to 20.24; I² = not applicable as 1 study (96 participants) reported 0 events; 2 studies, 157 participants; very low-certainty evidence). Integrated securement dressings compared to SPU: integrated securement dressings may result in little or no difference in risk of AC failure compared with SPU (RR 1.96, 95% CI 0.80 to 4.84; 1 study, 105 participants; low-certainty evidence); may result in little or no difference in CRBSI incidence with no events reported (1 study, 105 participants; low-certainty evidence); may result in little or no difference in the risk of dislodgement (RR 0.33, 95% CI 0.04 to 3.04; 1 study, 105 participants; low-certainty evidence), may result in little or no difference in occlusion rates with no events reported (1 study, 105 participants; low-certainty evidence), and may result in little or no difference in the risk of adverse events (RR 0.35, 95% CI 0.01 to 8.45; 1 study, 105 participants; low-certainty evidence).

AUTHORS' CONCLUSIONS

There is currently limited rigorous RCT evidence available about the relative clinical effectiveness of AC dressing and securement products. Limitations of current evidence include small sample size, infrequent events, and heterogeneous outcome measurements. We found no clear difference in the incidence of AC failure, CRBSI, or adverse events across AC dressing or securement products including SPU, BPU, SSD, TA, and integrated securement products. The limitations of current evidence means further rigorous RCTs are needed to reduce uncertainty around the use of dressing and securement devices for ACs.

Perioperative arterial catheterization: A prospective evaluation of ultrasound, infection, and patient-focused outcomes

BACKGROUND

There is little information regarding complications of arterial catheterization in modern clinical care. We aimed to determine the incidence of abnormal duplex vascular ultrasound and catheter related infections following perioperative arterial catheterization.

METHODS

Patients requiring arterial catheterization for elective surgery were included and insertion details collected prospectively. Duplex ultrasound evaluation was performed 24 h after catheter removal. Symptomatic patients were identified by self-reported questionnaire. On Day 7, patients answered questions by telephone, related to the insertion site, pain, and function. Results of catheter tip and blood culture analyses were sought. Univariate associations of patient and surgical characteristics with abnormal ultrasound were assessed with p < 0.05 considered significant.

RESULTS

Of 339 catheterizations, 105 (40%) had ultrasound evaluation. Catheters were indwelling for median (IQR, range) duration of 6.0 h (4.4-8.2, 1.8-28) with no catheter-related infections. There were 16 (15.2%, 95% CI 9.0%-23.6%) abnormal results, including 14 radial artery thromboses, one radial artery dissection, and one radial vein thrombosis. Those with abnormal ultrasound results were more likely to have had Arrow catheters inserted (68.8% vs 27%, p = 0.023) and more than one skin puncture (37.5% vs 26.8%, p = 0.031). Two of the 16 (12.5%) patients with abnormal ultrasound results reported new symptoms related to the hand compared with nine of the 88 (10.2%) with normal results (p = 0.1). No patients required urgent referral for management.

CONCLUSIONS

Thrombosis was the most common abnormality and was usually asymptomatic. There were no infections, few post-operative symptoms, and minimal functional impairment following arterial catheterization.

Risk factors for poor performance in finger cuff non-invasive monitoring of arterial pressure: A prospective multicenter study

BACKGROUND

Compared to the invasive technique, non-invasive monitoring of arterial pressure favors easier and faster implementation while potentially sacrificing some reliability. This may be particularly true for the Clearsight™ system (Edwards Lifesciences), which enables continuous monitoring. We evaluated the risk factors for its poor performance.

METHODS

Patients with an arterial catheter and stable mean arterial pressure (MAP) over a 5-min period were included. Six pairs of invasive and Clearsight measurements of MAP were collected and the bias between the two techniques was calculated. Poor performance of the Clearsight™ system was defined as either a failure to measure and display MAP or displaying an erroneous MAP (individual bias > 5 mmHg). Fingertip perfusion was assessed using the plethysmographic perfusion index (PI) and the capillary refill time (CRT).

RESULTS

Among 152 ICU patients (MAP of 81 ± 14 mmHg, norepinephrine in 78 [51%]), 78 (51%) experienced a poor performance of the Clearsight™ system: failure to display MAP in 19 (13%) patients, and erroneous value displayed in 59 (44%). In multivariate analysis, PI ≤ 0.85% (adjusted odds ratio [aOR] = 2.94 [95% confidence interval (95%CI):1.34;6.45]), CRT > 4 s (aOR = 5.28 [95%CI 1.39;20.05]), and the presence of hand edema (aOR = 2.06 [95%CI 1.01;4.21]) were associated with a higher likelihood of poor performance. Cardiac arrhythmia (aOR = 1.39 [95%CI 0.64;3.02]) and other tested variables were not associated with poor performance.

CONCLUSIONS

Half of the included patients exhibited poor Clearsight™ system performance. Our results caution against using finger cuff arterial pressure monitoring in patients with low PI (≤0.85%), protracted CRT (>4 s), or hand edema.

REGISTRATION

ClinicalTrials.gov, NCT04269382, Dr. G. Muller, February 13, 2020. https://classic.

CLINICALTRIALS

gov/ct2/show/NCT04269382.

Peripheral arterial catheter securement and catheter survival in the pediatric intensive care unit

BACKGROUND

Peripheral arterial catheters (PACs), and their associated complications, are common in the pediatric intensive care unit (PICU). Accidental catheter displacement and non-functional PACs are the most common complications, and this may be related to inadequate catheter securement. There is mixed guidance on the best way to secure PACs to prevent complications. The authors hypothesized that sutures would not be associated with a decreased risk of malfunction or accidental removal.

METHODS

This was a single center retrospective cohort study at a quaternary-care PICU. PICU patients with a peripheral arterial catheter placed in the PICU from 7/2020 to 1/2023 were included. The primary outcome was unplanned PAC removal. A univariate and multivariate Cox proportional hazards regression analysis was performed, using patient weight, sedation, paralytic, and role of the proceduralist as covariates. The secondary outcome was survival probability. A log-rank test was used to compare survival curves.

RESULTS

Of 761 PACs that met inclusion criteria in 437 unique patients, 599 were sutured (78.7%) and 162 were un-sutured (21.3%). In 257 cases (33.8%), the PAC had an unplanned removal. Among all PACs, the median duration of PAC placement was 5.3 days (IQR 2.1-10.5 days). There was an unplanned removal rate of 42.2% (68) in the un-sutured group and 31.4% (188) in the sutured group (p < 0.001). In multivariable analysis, sutured PACs were also associated with a lower rate of unplanned removal (hazard ratio, 0.59; 95% CI, 0.44-0.78). Use of continuous sedation was also associated with an increased risk of unplanned removal of PACs (hazard ratio, 1.54; 95% CI, 1.10-2.16). There was a 50% survival probability at 13.3 days for un-sutured PACs and 23.7 days for sutured PACs.

CONCLUSIONS

Suturing is associated with fewer unplanned removals and longer catheter survival, compared to un-sutured PACs in pediatric patients.

The distal quarter of the forearm is the optimal insertion site for ultrasound-guided radial artery cannulation: A randomized controlled trial

BACKGROUND

Current guidelines recommend the use of ultrasound guidance for arterial cannulation. However, there are no recommendations on the best insertion site for radial artery cannulation in terms of catheter dwell time and incidence of complications.

METHODS

In this randomized controlled study 94 patients were randomly assigned into three groups, corresponding to three different sites of insertion for radial artery cannulation: hand wrist: (Site/group 1, n = 29), distal quarter part of the forearm (Site/group 2, n = 30) and the midpoint of the forearm (Site/group 3, n = 35). Age, height, weight, and diagnosis of each patient were recorded prior to insertions which were performed by a single investigator experienced in ultrasound-guided vascular access.

RESULTS

Radial artery diameters were similar (2.4 ± 0.4 vs 2.5 ± 0.3 vs 2.6 ± 0.4 mm), however skin to vessel distances were different between groups, and the depth of the radial artery increased progressively from distal to proximal sites. There was a significant difference between groups in terms of success rates at the first attempt. Only two cannulations were successful at first attempt, and overall, only 17 of 35 cannulations were successful at Site 1. Arterial cannula dislodgement rate was highest at Site 1(8/29, 26.7%), while the longest dwell time was at Site 2 with a median of 4 (IQR 3) days.

CONCLUSIONS

Considering the high removal rate at the wrist region and the high failure rate at the midpoint of the forearm, the distal quarter of the forearm can be identified as "the optimal insertion site' for ultrasound-guided radial artery cannulation.

Evidence-based systematic review of removal of peripheral arterial catheter in critically ill adult patients

OBJECTIVE

To evaluate and summarize literature pertaining to evidence of peripheral arterial catheterization in adults, and to provide a reference for clinical practice.

METHODS

We undertook a systematic review of literature on the removal of peripheral arterial manometric catheters in adult patients from various sources such as UpToDate, BMJ, National Institute for Health and Care Excellence (NICE), Medlive, Cochrane Library, Joanna Briggs Institute (JBI) Evidence-based Health Care Center Database, CINAHL, PubMed, Wanfang Data, VIP, and other databases. The retrieval time was set as from the establishment of the database till August 30, 2021. We screened the studies that fulfilled the inclusion criteria, evaluated their quality, and retrieved and summarized such articles.

RESULTS

The review included 8 articles: 1 clinical decision, 3 guidelines, 2 evidence summaries, 1 systematic review, and 1 expert consensus. In all, 17 pieces of strong evidence were collected and extracted based on the following 5 dimensions: assessment of removal timing, preparation before removal, removal procedure, compression time, and key points after removal.

CONCLUSIONS

The removal of a peripheral arterial manometry catheter requires careful consideration by medical professionals. In order to increase the removal standardization rate and decrease the incidence of clinical complications, standardized procedures and training need to be developed.

Optimal insertion site for ultrasound-guided radial artery catheterization utilizing the dynamic needle tip positioning technique: A prospective randomized controlled study

BACKGROUND

The dynamic needle tip positioning technique represents an advanced version of the short-axis out-of-plane ultrasound-guided approach employed for radial artery catheterization. The study aimed to explore the most effective insertion site capable of expeditiously and accurately executing the procedure in a clinical setting.

METHODS

A prospective randomized controlled study encompassed 246 elective surgery patients necessitating invasive arterial monitoring. Participants were randomly assigned to three distinct groups: Site 1 (targeting the radial styloid process), Site 2 (midway between Sites 1 and 3), and Site 3 (distal one-third of the forearm). The dynamic needle tip positioning technique was implemented across all groups. Crucial parameters, such as first-attempt success rate, time to success, overall success rate, total catheterization time, number of attempts, and complications, were meticulously documented and compared.

RESULTS

The Site 2 cohort presented a significantly heightened first-attempt success rate compared to Site 1 (97.5% vs 80%, p = 0.003) and Site 3 (97.5% vs 81.25%, p = 0.006). Moreover, Site 2 displayed a reduced time to success in contrast to Site 1 (31.5 vs 38, p = 0.003) and Site 3 (31.5 vs 40, p = 0.006). Total catheterization time was significantly shorter in Site 2 compared to Site 1 (32 vs 42.5, p < 0.001) and Site 3 (32 vs 43.5, p < 0.001). Site 2 necessitated fewer attempts than Site 1 (p = 0.02) and Site 3 (p = 0.03). Male gender and puncture at Site 2 were associated with expedited time to success. Adverse events manifested more frequently in the Site 3 group compared to the Site 1 group (15% vs 3.75%, p = 0.03) and the Site 2 group (15% vs 2.5%, p = 0.01).

CONCLUSIONS

The optimal insertion site for ultrasound-guided radial artery catheterization utilizing the dynamic needle tip positioning technique in adult patients is situated midway between the radial styloid process and the distal one-third of the forearm.

Comparison of procedural time with two different ultrasound-guided approaches for dorsalis pedis artery cannulation in adult patients: A randomized trial

BACKGROUND

In adult patients, there has never been an evaluation of short-axis out-of-plane versus long-axis in-plane approaches of ultrasound-guided dorsalis pedis artery cannulation. This research was conducted to compare these two techniques to cannulate the dorsal pedis artery.

METHODS

In this trial, 128 adult patients undergoing surgery and necessitating arterial cannulation were examined. Dorsalis pedis artery cannulation was performed utilizing an ultrasound by long-axis in-plane approach (group L) or short-axis out-of-plane (group S) techniques.

RESULTS

Group S had a higher first attempt success rate than group L (46.9% vs 28.6%, p = 0.039). The S group had a lower assessment time than the L group (11.48 ± 3.07 vs 19.68 ± 2.79 s; p = 0.000). Cannulation time was higher in the S group (18.91 ± 1.92 s) compared to the L group (12.48 ± 1.61 s; p = 0.000). Nevertheless, the total procedure time was comparable between the L group and the S group (32.16 ± 2.95 vs 30.42 ± 4.07 s; p = 0.107).

CONCLUSIONS

In adults, both views of ultrasonography can be used to guide DPA cannulation. The cannulation time for the DPA in L group was less than the S group, whereas the assessment time was less in S group. The total procedure time, however, was similar between both the groups.

Insertion Site Dilemma: Rethinking Radial Arterial Catheter Placement for Device Resilience

The study by Marie et al (2023) discusses their outcomes regarding the distance of radial arterial catheters from the radiocarpal joint and its association to device failure, although authors found no significant difference in failure rates between catheters inserted proximally or distally to the radiocarpal joint. However, other recent studies have reported that catheters inserted more distally are more likely to fail, with rates high as 25%. Factors that contribute to failure include poor site selection, infection, device occlusion, or dislodgement. With reliance on accurate hemodynamics from arterial catheters, providers should be aware of the risks and take steps to minimize them, as catheter failure is more than just associated infection, the inability to aspirate blood or a useable arterial waveform. Optimal insertion location, use of ultrasound-guided techniques, appropriate securement, and close monitoring of the catheter, along with accurate reporting of failure reasons, will help clarify future research outcomes.

Comparison of ultrasound-guided dynamic needle tip positioning and acoustic shadowing technique with palpation technique for radial arterial cannulation by experienced clinicians: A randomized controlled trial

BACKGROUND

Radial artery cannulation is usually done for monitoring invasive blood pressure during intraoperative period. The dynamic needle tip positioning approach allows continuous visualization of the needle tip during ultrasound-guided cannulation. The acoustic shadowing technique, using two lines on the ultrasound probe, might be used to facilitate radial artery puncture. We aimed to compare these two ultrasound-guided techniques of radial artery cannulation with the traditional palpation method in adult patients.

METHODS

In this trial, 180 adult patients requiring arterial cannulation were randomized into three groups (Traditional palpation (TP), Dynamic needle tip positioning (DNTP), and acoustic shadow technique (AST)). All cannulations were carried out by experienced anesthetists. Data was analyzed for the success rate of arterial cannulation in the first attempt, total number of attempts in 5 min, time taken to cannulate, number of cannulas used, and complications related to the procedure.

RESULTS

The first attempt success rates among TP, DNTP, and AST were 66.7%, 66.7%, and 71.7%, respectively (p = 0.794). The median time taken for cannulation was 60.5 (37.0, 129.5) s, 71.0 (50.0, 170.0) s, and 108.0 (58.0, 181.0) s, respectively (p = 0.066) and the median number of cannulation attempts was 1, in all the three groups (p = 0.684). There was also no difference in the total number of cannulas used, the overall success rate of cannulation, and complications related to the procedure in the three groups.

CONCLUSION

The TP, DNTP, and AST technique for radial artery cannulation had comparable first attempt success rate, the time taken for cannulation, the number of cannulas used, and overall complications. We conclude that radial arterial cannulation by palpation, as well as ultrasound-guided DNTP and AST techniques performed by experienced clinicians in hemodynamically stable adult patients are equally advantageous.

A randomized controlled trial comparing ultrasound-guided versus traditional palpatory methods of posterior tibial artery cannulation in adult patients

BACKGROUND

The palpation method of posterior tibial artery cannulation has not yet been compared to ultrasound-guided posterior tibial artery cannulation in adults. This research examined whether using ultrasound to cannulate the posterior tibial artery enhances first-pass cannulation success and lowers total procedure time.

METHODS

In this randomized controlled experiment, 76 adult patients were included who were undergoing surgery under general anesthesia and required artery cannulation. Cannulation of the posterior tibial artery was performed utilizing either an ultrasound-assisted method (group U) or a palpation method (group P). Data were analyzed for cannulation success on the first attempt, number of cannulation attempts, assessment time, cannulation time, and total procedure time.

RESULTS

The P group had a considerably shorter mean assessment time than the U group [14.29 ± 2.79 s vs 20.89 ± 2.70 s; p < .001]. Moreover, cannulation time was substantially longer in the P (29.20 ± 12.60 s) than in the U group (15.90 ± 6.50 s) (p < .001). The total procedure time remained statistically more in the P group than in the U group (p = 0.007). The rate of successful posterior tibial artery cannulation on the first attempt was comparable between the two groups (63.2% in the U and 55.3% in the P group, respectively; p = .484)].

CONCLUSIONS

The posterior tibial artery may be a suitable alternative to arterial cannulation for individuals with multiple failed attempts or difficult access. The application of ultrasound during posterior tibial artery cannulation in adult patients is safe and feasible and accompanied by a reduction in cannulation and total procedure time. The rate of first-attempt successful posterior tibial artery cannulation was comparable between the two groups.