{"id":1897,"date":"2020-11-18T08:00:00","date_gmt":"2020-11-18T08:00:00","guid":{"rendered":"https:\/\/emultrasound.sdsc.edu\/?p=1897"},"modified":"2021-05-04T16:58:09","modified_gmt":"2021-05-04T16:58:09","slug":"radial-artery-line","status":"publish","type":"post","link":"https:\/\/emultrasound.ucsd.edu\/index.php\/2020\/11\/18\/radial-artery-line\/","title":{"rendered":"Will Ultrasound Help Your Success with Arterial Lines?"},"content":{"rendered":"<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-text-obj\">\n<h2 style=\"text-align: center;\">Background<\/h2>\n<p dir=\"ltr\">&nbsp;<\/p>\n<p dir=\"ltr\">Traditionally, we are taught to place radial artery catheters - A lines - using anatomy and pulse palpation. First-time success rate varies in the literature from as low as 15% to about 70%, with complications including hemorrhage or hematoma. Patients with particularly challenging insertions include small children, as well as adults with hypotension, obesity, or peripheral edema.<\/p>\n<p dir=\"ltr\">Improved procedural success rates, safety and cost effectiveness using ultrasound guidance has been demonstrated extensively in central venous catheterization, however, this has not yet been established for arterial catheterization, as literature for US guided radial artery catheterization has been both limited and presents conflicting results.<\/p>\n<p><a href=\"https:\/\/www.ncbi.nlm.nih.gov\/pmc\/articles\/PMC4056628\/\">Efficacy of ultrasound-guided radial artery catheterization: a systematic review and meta-analysis of randomized controlled trials.&nbsp;<\/a><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-accordion-obj motopress-accordion motopress-accordion-dark\" data-atts=\"{&quot;active&quot;:&quot;false&quot;,&quot;collapsible&quot;:true,&quot;header&quot;:&quot;&gt; div &gt; h3&quot;,&quot;heightStyle&quot;:&quot;content&quot;}\">\n<div class=\"motopress-accordion-item\"><h3>Clinical Question<\/h3><div>\n<p><span style=\"font-weight: 400;\">Is US guidance of radial artery catheterizations effective compared to standard methods of palpation\/Doppler in either adult or pediatric patients?<\/span><\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Methods & Study Design<\/h3><div>\n<p class=\"p1\"><span class=\"s1\"><b>\u2022 Design\u00a0<\/b><\/span><\/p>\n<p><span style=\"font-weight: 400;\">Systematic review and meta-analysis\u00a0<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>\u2022 Population\u00a0<\/b><\/span><\/p>\n<p><span style=\"font-weight: 400;\">Adult or pediatric patients requiring radial artery catheterization, inclusion criteria varied by study.\u00a0<\/span><\/p>\n<p class=\"p1\"><span class=\"s1\"><b>\u2022 Intervention\u00a0<\/b><\/span><\/p>\n<p><span style=\"font-weight: 400;\">Ultrasound-guided radial artery catheterization compared to doppler-assisted or landmark technique.<\/span><\/p>\n<p><span class=\"s1\"><b>\u2022 Outcomes\u00a0\u00a0<\/b><\/span><\/p>\n<p><span style=\"font-weight: 400;\">First attempt success rate and complications from attempts at radial artery catheterization.<\/span><\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Results<\/h3><div>\n<p><span style=\"font-weight: 400;\">7 RCTs were used to calculate a pooled estimate of first-attempt success<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Rate of first-attempt success in US group: 48.5%<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Rate of first-attempt success in control group: 30.7%<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">US-guided radial arterial catheterization was associated with increased first-attempt success (RR 1.55, 95% CI, 1.02 to 2.35, P = 0.04)<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">US-guided radial arterial catheterization significantly reduced mean attempts to success (WMD \u22121.13, 95% CI \u22121.58 to \u22120.69, P <0.001), mean time to success (WMD \u221272.97 seconds, 95% CI \u2212134.41 to \u221211.52, P = 0.02), and incidence of hematoma (RR 0.17, 95% CI 0.07 to 0.41, P <0.001)<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p><span style=\"font-weight: 400;\">Subgroup Analyses<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">No difference in primary outcome between elective insertion (five trials, RR 1.91, 95% CI, 1.45 to 2.53) and emergency insertion (two trials, RR 1.05, 95% CI, 0.38 to 2.83)\u00a0<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">US-guided radial arterial catheterization was associated with significantly increased first-attempt success in small children\/infants (RR 1.94, 95% CI, 1.31 to 2.88, P = 0.001)<\/span><\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Strength & Limitations<\/h3><div>\n<p><span style=\"font-weight: 400;\">Strengths:<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Well-performed systematic review and meta-analysis with a clear primary outcome and relevant secondary outcomes.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Limitations:<\/span><\/p>\n<ul>\n<li style=\"list-style-type: none;\">\n<ul>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">There were major differences in ultrasound experience of operators, ranging from those without any experience and only an observational training period to expert operators.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Overall, the studies had small sample sizes and only a small number of studies met inclusion criteria for the review.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Not enough samples to conduct additional subgroup analyses of patients who might be characterized as difficult-to-insert, including hypotension, obesity, edematous, and pulseless.<\/span><\/li>\n<li style=\"font-weight: 400;\"><span style=\"font-weight: 400;\">Lack of inclusion of other potential factors including patient pain or patient\/operator satisfaction.<\/span><\/li>\n<li style=\"font-weight: 400;\">Lack of comment and description on specific US-guidance techniques<\/li>\n<\/ul>\n<\/li>\n<\/ul>\n<p>\u00a0<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Authors Conclusion<\/h3><div>\n<p><span style=\"font-weight: 400;\">\"<\/span><span style=\"font-weight: 400;\">US guidance is an effective and safe technique for radial artery catheterization, even in small children and infants. However, results should be interpreted cautiously due to the heterogeneity among studies.<\/span>\"<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>Our Conclusion<\/h3><div>\n<p><span style=\"font-weight: 400;\">Though data from RCTs is limited, with proper operator training US-guidance can be an effective method of improving radial artery catheterization accuracy, especially in small children\/infants with smaller and more difficult-to-palpate anatomy.<\/span><\/p>\n<p><span style=\"font-weight: 400;\">Conflicting results in previously conducted RCTs may be attributed to differences in operator training or lack of a proper observational training period and thus careful consideration of the operator should be conducted in future RCTs. A physician who has performed dozens of A-lines using the palpation technique, who is unfamiliar with bedside ultrasonography, is unlikely to benefit significantly from adding this modality to their procedure, while residents who are trained with ultrasounds in their hands will likely benefit more.\u00a0<\/span><\/p>\n<p><span style=\"font-weight: 400;\"> Future RCTs should focus on patient populations that have been characterized as difficult-to-insert including hypotension which is in particular significant to emergency medicine, as well as edematous or obese patients.<\/span><\/p>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-prvt-1570-5ef827785bcec mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-text-obj\">\n<h1 style=\"text-align: center;\">The Bottom Line&nbsp;<\/h1>\n<p dir=\"ltr\"><span id=\"docs-internal-guid-83ed10dc-7fff-6f40-711b-d149c2f2b337\">Ultrasound-guided placement of radial artery catheters is effective compared to standard palpation techniques, and should be taught to current Emergency Medicine residents. Further studies are needed to elucidate the effect of US on difficult-to-cath patients, as the effect is hypothesized to be magnified in patients who are hypotensive or edematous.<\/span><\/p>\n<\/div>\n<\/div>\n<\/div>\n<div class=\"mp-row-fluid motopress-row mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-clmn mp-span12  mpce-dsbl-margin-left mpce-dsbl-margin-right\">\n<div class=\"motopress-accordion-obj motopress-accordion motopress-accordion-dark\" data-atts=\"{&quot;active&quot;:&quot;false&quot;,&quot;collapsible&quot;:true,&quot;header&quot;:&quot;&gt; div &gt; h3&quot;,&quot;heightStyle&quot;:&quot;content&quot;}\">\n<div class=\"motopress-accordion-item\"><h3>Authors<\/h3><div>\n<p>This post was written by Jessica Wen, MS4 at UCSD School of Medicine, Charles Murchison, MD and Amir Aminlari, MD.\u00a0<\/p>\n<\/div><\/div>\n<div class=\"motopress-accordion-item\"><h3>References <\/h3><div>\n<p><span style=\"font-weight: 400;\">Gu W, Tie H, Zeng X. Efficacy of ultrasound-guided radial artery catheterization: a systematic review and meta-analysis of randomized controlled trials. <\/span><i><span style=\"font-weight: 400;\">Critical Care<\/span><\/i><span style=\"font-weight: 400;\">. 2014; 18(3): R93 doi:10.1186\/cc13862<\/span><\/p>\n<\/div><\/div>\n<\/div>\n<\/div>\n<\/div>\n","protected":false},"excerpt":{"rendered":"Background &nbsp; Traditionally, we are taught to place radial artery catheters - A lines - using anatomy and pulse palpation. First-time success rate varies in the literature from as low as 15% to about 70%, with complications including hemorrhage or hematoma. Patients with particularly challenging insertions include small children, as well as adults with hypotension, &hellip; <p class=\"link-more\"><a href=\"https:\/\/emultrasound.ucsd.edu\/index.php\/2020\/11\/18\/radial-artery-line\/\" class=\"more-link\">Continue reading<span class=\"screen-reader-text\"> \"Will Ultrasound Help Your Success with Arterial Lines?\"<\/span><\/a><\/p>","protected":false},"author":2,"featured_media":1900,"comment_status":"open","ping_status":"open","sticky":false,"template":"","format":"standard","meta":{"_eb_attr":"","_jetpack_newsletter_access":"","_jetpack_dont_email_post_to_subs":false,"_jetpack_newsletter_tier_id":0,"_jetpack_memberships_contains_paywalled_content":false,"_jetpack_memberships_contains_paid_content":false,"footnotes":""},"categories":[5],"tags":[88,87],"class_list":["post-1897","post","type-post","status-publish","format-standard","has-post-thumbnail","hentry","category-journal-club","tag-arterial-lines","tag-procedures"],"yoast_head":"<!-- This site is optimized with the Yoast SEO plugin v28.6 - https:\/\/yoast.com\/product\/yoast-seo-wordpress\/ -->\n<title>Will Ultrasound Help Your Success with Arterial Lines? - UCSD Ultrasound<\/title>\n<meta name=\"description\" content=\"Does ultrasound help with placing radial arterial lines? 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