Radial artery cannulation in intensive care unit patients: Does distance from wrist joint increase catheter durability and functionality?

Adverse events with arterial catheters in intensive care units: a scoping review

INTRODUCTION

The installation of an arterial line is one of the invasive procedures performed for hemodynamic monitoring and, even with its clear importance in intensive care, it is still an invasive procedure and liable to cause harms to the patients.

OBJECTIVE

To identify the adverse events associated with the use of arterial catheters in critically-ill patients in the world scientific production.

METHODOLOGY

The present scoping review was conducted according to the JBI methodology for scoping reviews. The Preferred Reporting Items for Systematic Reviews and Meta-Analyses extension for Scoping Reviews (PRISMA-ScR) checklist was used for reporting. The research question was "Which adverse events related to the use of arterial catheters in patients admitted to intensive care are more evident in the literature?". Data collection took place in the following databases: LILACS; MEDLINE; EMBASE; CINAHL, EBSCOhost; and WEB OF SCIENCE.

RESULTS

Through the search strategies, 491 articles were found in the databases. After exclusion of duplicates, peer analysis of titles and abstracts, full reading and screening of lists of references, the final sample of studies included was 38 articles. The main harms cited by the publications were as follows: limb ischemia, thrombosis, hemorrhage, accidental removal, inadvertent connection of inadequate infusion solution, pseudoaneurysm and bloodstream infection.

CONCLUSIONS

It was evidenced that patients are subjected to risks of adverse events from the insertion moment to removal of the arterial catheter, focusing on the infusion solution used to fill the circuit, the type of securement and dressings chosen, as well as the Nursing care measures for the prevention of bloodstream infection.

Severe ischemia after radial artery catheterization: A literature review of published cases

INTRODUCTION

Severe ischemia is a rare complication of radial artery catheterization (RAC). This study aims to summarize risk factors of RAC-elicited severe hand ischemia, preventive, and therapeutic management.

METHODS

Literature search was conducted in eight electronic English and Chinese databases to identify relevant published cases. Data of interest was extracted and analyzed.

RESULTS

Database search identified 28 articles reporting cases of 57 patients developing hand ischemia following RAC. Patients aged between 1 day and 88 years. The indications for RAC included surgery, shock, cardiac arrest, and Neonatal Intensive Care Unit (NICU) admission. Identified risk factors included pre-existing vascular diseases, hypotension, arterial anatomical abnormality or small diameter, vasoconstrictors, and catheter-related problems. Totally, 18 patients complained pain; 32 developed discoloration; 19 pulselessness; 3 paresthesia; 13 swolleness and 19 coldness. Eventually, 30 patients recovered well, but 20 patients unfortunately underwent digital amputation and three patients deceased due to non-RAC-related causes.

CONCLUSION

Severe hand ischemia following RAC is a rare complication, with the reported incidence of approximately 0.09%. There is no definite predictor for RAC-related hand ischemia, but patients with risk factors are prone to the occurrence of hand ischemia. It's vital to initiate early recognition and proactive strategies for a best practice RAC insertion.

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.

10 best practice tips with radial arterial catheterization

Radial arterial catheters (RAC) are used extensively across critical care settings (Anesthesia, Intensive Care, Emergency Medicine) for continuous hemodynamic monitoring, allowing for immediate adjustments in vasopressor therapies and blood collection. Radial catheter failures are an ongoing significant issue for critical care clinicians with reported incidences at almost 25%. Common complications include loss of function, lack of blood return, poor quality waveforms and dislodgement, posing potential patient risks, and sudden loss of intra-arterial monitoring frequently requires prompt replacement. Contemporary research and technological improvements have highlighted several concepts to enhance the approach of RAC insertion and management while reducing immediate and late complications. The authors have prioritized the following 10 "best practice" aspects that may improve overall device function and reliability.

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.

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.

Distal radial approach for arterial pressure monitoring with a long catheter provides safe and stable monitoring in the intensive care unit: A single-center retrospective study

BACKGROUND

To compare the distal radial artery approach (DRA) with a longer catheter to DRA with a shorter catheter in arterial catheter (AC) placement in the intensive care unit (ICU).

METHODS

This was a single-center retrospective cohort study of DRA with a long catheter (60 mm) for arterial catheterization in the ICU. DRA with a short catheter (25-30 mm) was used in the control group, and the groups were compared using multivariate regression analysis. The primary study endpoint was the incidence of unplanned AC removal. The secondary endpoint was the incidence of other inappropriate events, namely loss of arterial pressure waveforms, bleeding, catheter-related infection, pressure ulcer, and other complications associated with the AC.

RESULTS

In this study, the DRA with a long catheter was used in 50 patients. No unplanned AC removals or other inappropriate events occurred, and there were no complications associated with the DRA. The DRA procedural success rate was 100%. There was no significant difference in hemostasis times between the groups. Loss of arterial waveforms was an early predictor of unplanned AC removal.

CONCLUSIONS

The DRA with a long catheter provided stable monitoring and was associated with a low unplanned removal rate. This method has the advantages of fewer complications and shorter hemostasis time compared with the DRA with a short catheter, and may become a new AC option in the ICU.

On-demand use of peripheral arterial catheters outside the Intensive Care Unit: Development and retrospective evaluation of an internal protocol for insertion and management

BACKGROUND

COVID-19 patients require frequent arterial blood gas analysis for the assessment of oxygenation status.

OBJECTIVE

The main objective of this research is to describe a dedicated protocol developed to standardize the insertion and management of peripheral Arterial Catheters (AC) for on-demand use, in the Emergency Department of "Maggiore" Hospital (Lodi, Italy).This strategy represents a valid alternative to repeated arterial punctures outside the intensive care unit.

METHODS

The crucial points of the protocol were defined: vessel selection criteria, device used, technique of insertion, choice of securement and dressing device, and procedures had been created for correct management.

RESULTS

During April and December 2020, 50 AC were inserted, two dislocations and one malfunction were observed. No major complications (Catheter Related Bloodstream Infection, thrombosis, bleeding, pseudoaneurysms, hematoma, artery occlusion - even temporary - and skin irritation) were observed.

CONCLUSIONS

To the authors knowledge, this is the first article describing the insertion and management of ACs for on-demand utilization outside the intensive care unit. The safe and effective use of this technique could be clinically relevant in patients requiring multiple ABG without need of invasive monitoring; it also allows the reduction of both artery sticks and workload of health care providers. However, clinical studies are needed to confirm the validity of the proposed treatment, especially the use of the most appropriate securement system and the most effective solution for locking catheters.

Effect of side guide marks of ultrasound transducer on the success rate of ultrasound transducer-guided radial artery puncture: A randomized trial

BACKGROUND

Compared with blind technique, ultrasound (US) transducer-guided technique for radial artery puncture can improve the success rate. However, difficulty in handling US transducer-guided technology is a key limitation to its wider use. The aim of the study was to explore the effect of guide marks on the side of US transducer on the success rate of US transducer-guided radial artery puncture.

METHODS

In this parallel-group trial, 127 patients undergoing elective liver cancer resection and splenectomy under general anesthesia were randomly allocated to the traditional group or the Intervention group. The traditional group used the conventional US transducer-guided radial artery puncture technology, while the Intervention group used the US transducer-guided radial artery puncture technology with the guide marks on the side of the US transducer probe. The primary observation index was success rate of radial artery cannulation at the first attempt; the secondary observation indices were failure rate of cannulation, location time, and total time for successful cannulation.

RESULTS

The successful rate of cannulation in the Intervention group (59 out of 63, 93.6%) was greater than that in the traditional group (50 out of 64, 78.1%, p = 0.01). The posterior wall puncture rate in the Intervention group was lower than that in the traditional group (11.1% vs 32.8%, p = 0.005). The location time in the Intervention group was longer than that in the traditional group (20.1 ± 3.8 vs 16.6 ± 4.0 s, p < .001), while the total cannulation time was significantly shorter (20.7 ± 4.3 vs 32.4 ± 7.4 s, p < 0.001).

CONCLUSION

Using guide marks on the side of US transducer can help improve success rate of US transducer-guided radial artery puncture at the first attempt and reduce the risk of puncture-related complications.

Comparison of ultrasound guided dorsal radial artery cannulation and conventional radial artery cannulation at the volar aspect of wrist: A pilot randomized controlled trial

BACKGROUND

Distal radial artery cannulation at the "anatomical snuffbox" carries several theoretical advantages over conventional radial arterial cannulation at the wrist. However, these two techniques have not been evaluated in perioperative settings.

METHODS

In this randomized controlled trial, n = 200 patients requiring arterial cannulation for perioperative monitoring were recruited. Patients were randomized to either ultrasound guided distal radial artery cannulation group (group D) or ultrasound guided conventional radial artery cannulation group (group W). Primary outcome of this study was first attempt cannulation success rate.

RESULTS

First attempt cannulation success rate was significantly lower in distal radial artery cannulation (57% in group D and 77% in group W; p = 0.003). Use of alternative cannulation site was significantly higher in group D when compared to group W (p = 0.015) and number of attempts for successful cannulation was significantly higher in group D when compared to group W (p = 0.015). None of the patients in any group developed thrombosis and related complications and intraoperative catheter dislodgement. Time to puncture the artery (p < 0.0001), total cannulation time (p < 0.0001), and actual catheter insertion time (p < 0.0001) were significantly higher in group D in comparison to group W.

CONCLUSION

Distal radial artery cannulation was associated with lower first attempt cannulation success rate and requires longer time to perform. As distal radial artery is a new technique, further studies are required in different clinical settings.

Arterial cannulation in adult critical care patients: A comparative study between ultrasound guidance and palpation technique

OBJECTIVE

To compare first attempt success rate for ultrasound-guided (USG) versus direct palpation (DP) for radial, femoral, and dorsalis pedis artery cannulations in adult intensive care unit (ICU) patients.

DESIGN

Prospective randomized clinical trial.

SETTING

Mixed adult ICU of a University Hospital.

PARTICIPANTS

Adult patients (≥18 years) admitted to the ICU requiring invasive arterial pressure monitoring were included. Exclusion criteria were patients with a pre-existing arterial line and cannulated with other than a 20-gauge cannula for radial and dorsalis pedis artery.

INTERVENTION

Comparison of arterial cannulation by USG versus palpation technique in radial, femoral and dorsalis pedis arteries.

MAIN VARIABLES OF INTEREST

Primary outcome was first attempt success rate, secondary outcomes were assessing time for cannulations, number of attempts, overall success rate, complications, and comparison of two techniques on patients requiring vasopressor.

RESULTS

201 patients were enrolled in study, with 99 randomized to DP group and 102 to USG group. Arteries (radial, dorsalis pedis, femoral) cannulated in both groups were comparable (P = .193). Arterial line was placed on first attempt in 85 (83.3%) in USG group versus 55 (55.6%) in DP group (P = .02). Cannulation time in USG group was significantly shorter compared to DP group.

CONCLUSIONS

In our study, USG arterial cannulation, compared to palpatory technique, had a higher success rate at first attempt and a shorter cannulation time.

CLINICAL TRIAL REGISTRY OF INDIA NUMBER

CTRI/2020/01/022989.

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

Radial artery catheterization is a frequently performed procedure for critically ill patients. The correct function of arterial catheters is essential to provide accurate and continuous hemodynamic monitoring, facilitating intermittent blood sampling and helping to optimize the workload for critical care nurses and physicians. However, they are not without their own problems. This narrative practice review discusses several clinical aspects that are not frequently considered but may contribute to enhanced catheter functionality, less device-related failure and more acceptable dwell times. Ultrasound has demonstrated unequivocal efficacies and safety with the procedure, improving first attempt success rates with children, the obese or patients with unstable clinical vital signs and shock. Moreover, anatomic variations of the radial artery are not rare, and ultrasound-guided catheterization reduces the incidence of insertion-related complications such as hematoma, posterior wall puncture, intimal dissection, and radial nerve injury. Ultrasound guidance offers several immediate benefits by enhancing the most appropriate insertion techniques, allows for the correct catheter to vessel ratio measurements to be performed and reduces the angle of insertion, which may affect catheter failure due to inappropriate catheter length. A deeper and more proximal cannulation site at least 4 cm from wrist joint, avoiding the area of wrist flexion, reduces mechanical complications related to patient movements and may improve catheter functionality and dwell along with a better area for stabilization and securement.