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How to Get An Arterial Line on the First Stick

October 9, 2020

Written by Max Hensel

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In novice interns, ultrasound guidance for radial arterial line placement improved first-pass success in addition to accomplishing cannulation with fewer attempts and in less time over a landmark-based approach.

Why does this matter?
Often when we really need an arterial line, the radial pulse is hard to palpate due to hypotension. Placement by palpation is technically challenging and time consuming. Yet, arterial line placement is a common ED procedure. Is there a way to increase success, reduce complications, and improve efficiency when placing arterial lines? Ultrasound for the win!

Palpate the ultrasound, not the pulse
This was a single-center, prospective RCT comparing ultrasound guided (USG) vs landmark guided (LMG) radial arterial line placement. PGY-1 emergency medicine interns with <15 previous attempts were randomized, with a primary outcome of overall success and secondary outcomes of first-pass success, attempt number, time to completion and complications. Overall success in USG and first-pass success with ultrasound were 100% and 75%, respectively. LMG was 15% for overall success and 0% for first-pass success. Time to cannulation (264 sec vs 524 sec) and overall number of attempts (1.3 vs 2.95) were about half in the USG compared to LMG as well. There was an isolated hematoma as a complication in the LMG group, with no reported complications in the USG group. For the 17 failed lines using LMG, all crossed over to USG and were then successful.

In addition to being a small study of 40 patients, there are several other limitations mentioned in the paper. This was a single-center, ultrasound division-run trial at a Level-1 medical center, which is not directly representative of the broader EM community, possibly biasing toward ultrasound use. This also focused on novice interns who received 4 hours of ultrasound-guided cannulation didactics rather than all levels of providers and experience levels. Nonetheless, the data here supports ultrasound use as being more successful and efficient and causing less harm, making a strong case for ultrasound as the preferred method of placement of radial arterial lines.

Ultrasound Guidance Versus Landmark-Guided Palpation for Radial Arterial Line Placement by Novice Emergency Medicine Interns: A Randomized Controlled Trial. J Emerg Med. 2020 Sep 8:S0736-4679(20)30711-3. doi: 10.1016/j.jemermed.2020.07.029. Online ahead of print.

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Reviewed by Clay Smith

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