Wednesday, December 26, 2007

Wednesday December 26, 2007


Case:
You have been called by nurse as radial artery "A-line" continue to have 'problems'. You decide to change it over wire. Despite changing it over wire, it does not produce satisfatory waveform on monitor. What should be your next thought?


Answer:
Probable radial artery occlusion

Radial artery occlusion can be encountered in upto 30% of patients and incidence is higher than expected. It is of legal importance to document Allen's test prior to radial artery insertion and assessment of flow with ultrasound is desirable. 20-gauge cannulae is safest. Radial artery occlusion is relatively more common in females. Other factors include insertion technique (causing hematoma), low cardiac output, anticoagulation (prone to cause hematoma), duration of cannulation, vasopressors and previous surgical history etc. Heparinized solution has no advantage over regular saline flushes.

In case of suspected ischemia, catheter should be removed and the hand should be monitored closely. Its not advisable to apply warm wrap as it may make ischemia worse. Arterial duplex Doppler sonography should be ordered to rule out arterial spasm, delineate areas of occlusion, thrombus formatiom and flow through the artery. If arterial duplex suspects spasm, a sympathetic block can be performed at bedside to induce vasodilatation. In such cases, vascular consult is recommended. If required angiography should be performed to evaluate the the need of operative intervention for clot removal, repair of lacerated radial artery, or to perform a graft procedure. Intravenous heparin can be used if no contraindication and local thrombolytic therapy can also be applied.

Beside above treatment modalities, nursing interventions include close monitoring, splinting of arm and demarcation of ischemic area.




References / recommended readings; click to get abstract / article


1.
Cannulation Injury of the Radial Artery: Diagnosis and Treatment Algorithm Am. J. Crit. Care., July 1, 2004; 13(4): 315 - 319.
2.
RADIAL ARTERY CANNULATION - British Journal of Anaesthesia, 1980, Vol. 52, No. 1 41-47
3. Cannulation Injuries of the Radial Artery Am. J. Crit. Care., July 1, 2004; 13(4): 314 - 315.
4.
Severe ischemia of the hand following radial artery catheterization. Surgery. 1976;80:449–457
5.
Ischaemia of the hand after radial artery monitoring. Cardiovasc Surg. 1996;4:456–458
6.
Complications during and following radial artery cannulation: a prospective study. Intensive Care Med. 1986;12:424–428
7. Radial artery cannulation in 1000 patients: precautions and complications. J Hand Surg [Am]. 1977;2:482–485.
8. On the safety of radial artery cannulation. Anesthesiology. 1983;59:42–47.