Radial Artery ???Mycotic??? Pseudoaneurysm Occurring After Arterial Line Placement

Ultrasound Guided Procedures and Radiologic Imaging for Pediatric Anesthesiologists is intended as a ready resource for both experts and novices. It will be useful to those with extensive training and experience as well as beginners and those with distant experience or training. A wealth of knowledge in the human factors of procedure design and use has been applied throughout to ensure that desired information can be easily located, that steps are clearly identified and comprehensible, and that additional information of high relevance to procedure completion is co-located and salient. This book begins with the basics but quickly progresses to advanced skill sets. It is divided into four parts. Part I starts with a primer on ultrasound machine functionality as well as procedural chapters on lung ultrasound to detect a mainstem intubation or pneumothorax and gastric ultrasound to assess gastric contents in incompletely fasted patients. Part II covers ultrasound guided peripheral intravenous line placement through the incremental advancement method, ultrasound guided arterial line placement, and ultrasound guided central line placement. Part III details several ultrasound guided regional anesthesia techniques. Part IV covers radiology of the pediatric airway and mediastinum, lungs, gastrointestinal, genitourinary, musculoskeletal, and neurologic systems.

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Variability in Critical Care–Related Charge Markups in Medicare Patients

The American Surgeon ◽

10.1177/000313481808401017 ◽

2018 ◽

Vol 84 (10) ◽

pp. 1622-1625 ◽

Cited By ~ 1

Author(s):

Joshua Tseng ◽

Harry C. Sax ◽

Rodrigo F. Alban

Keyword(s):

Internal Medicine ◽

Critical Care ◽

Endotracheal Intubation ◽

Chest Tube ◽

Critical Care Medicine ◽

Tube Placement ◽

Arterial Line ◽

Fee For Service ◽

Related Services ◽

Line Placement

Charge markups for health care are variable and inflated several times beyond cost. Using the 2015 Medicare Provider Fee-For-Service Utilization and Payment Data file, we identified providers who billed for critical care hours and related procedures, including CPR, EKG interpretation, central line placement, arterial line placement, chest tube/thoracentesis, and emergent endotracheal intubation. Markup ratios (MRs), defined as the amount charged divided by the amount allowable, were calculated and compared; 42.1 per cent of physicians billing for critical care–related services were specialized in emergency medicine (EM). EM had the highest overall MR (median 4.99, IQR 3.60–6.88) and provided most of the services. MRs differed between genders in select cases (critical care hours: anesthesiology, EM, internal medicine, pulmonary and critical care medicine; CPR, pulmonary and critical care medicine; chest tube placement/thoracentesis, internal medicine). These differences in MR did not correspond to higher rates of Medicare allowable amounts ( P = NS). In conclusion, charge markups significantly varied by physician specialty. EM physicians had the highest MRs for most critical care–related services, including critical care hours, EKG interpretation, CPR, central venous line placement, and emergent endotracheal intubation. EM physicians also provided most of these services. Charge markups are associated with adverse consequences and represent potential targets for cost containment and consumer protection.

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Thrombolytic Therapy in the Setting of Arterial Line-Induced Ischemia

Journal of Endovascular Therapy ◽

10.1177/152660280301000327 ◽

2003 ◽

Vol 10 (3) ◽

pp. 590-594 ◽

Cited By ~ 2

Author(s):

Jean-François H. Geschwind ◽

Mandeep S. Dagli ◽

Ew L. Lambert ◽

Hicham Kobeiter

Keyword(s):

Radial Artery ◽

Arterial Line ◽

Radial Artery Cannulation ◽

Artery Cannulation ◽

Significant Clinical Improvement ◽

Flow Restoration ◽

Systemic Anticoagulation ◽

Residual Thrombus ◽

Hand Symptoms ◽

Age Range

Purpose: To evaluate the use of percutaneous transcatheter thrombolysis in the treatment of thrombosis due to radial artery cannulation. Methods and Results: Seven patients (4 women; age range 41–62 years) with symptomatic cannulation-induced thrombosis and failure to improve after systemic anticoagulation underwent 8 catheter-directed thrombolytic infusions at our institution over a 3-year period. Access was either antegrade through the brachial artery or retrograde through the femoral artery. Thrombolytic infusions with urokinase began 2 to 12 days (average 6) after removal of the radial artery catheter. The thrombolytic infusion was successful in 5 of 7 patients based on angiographic flow restoration with <20% residual thrombus and significant clinical improvement in the ischemia. Conclusions: When systemic anticoagulation has failed, percutaneous catheter-directed thrombolytic infusion appears to be effective in the treatment of most patients with severe ischemic hand symptoms due to thrombosis after radial artery cannulation.

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Wrist Hyperextension Leads to Median Nerve Conduction Block

Anesthesiology ◽

10.1097/00000542-200402000-00017 ◽

2004 ◽

Vol 100 (2) ◽

pp. 287-291 ◽

Cited By ~ 16

Author(s):

Anne L. Chowet ◽

Jaime R. Lopez ◽

John G. Brock-Utne ◽

Richard A. Jaffe

Keyword(s):

Median Nerve ◽

Nerve Conduction ◽

Action Potentials ◽

Conduction Block ◽

Neutral Position ◽

Arterial Line ◽

Line Placement ◽

Compound Action Potentials ◽

Contralateral Hand ◽

The Right

Background It is common practice to hyperextend the wrist to facilitate insertion of a radial intra-arterial catheter. This position may be maintained for prolonged periods. Although there has been much discussion about optimal patient management to protect the ulnar nerve and brachial plexus, little attention has been paid to the median nerve during wrist hyperextension. The authors report the effects of wrist hyperextension on conduction in the median nerve. Methods Median nerve conduction was studied in 12 awake, healthy volunteers using standard nerve conduction tests consisting of the measurement of compound sensory and motor action potentials, as well as their amplitudes and latencies. With the contralateral hand as a control, the right wrist was placed in hyperextension (angled between 65 and 80 degrees), and compound action potentials were recorded to determine the onset and magnitude of effects. Subsequently, the hand was released from hyperextension and recovery was recorded. Results In 83% of subjects, hyperextension resulted in a significant decrease in compound sensory action potential amplitudes, sufficient to qualify as conduction block (16.6% of baseline). The average time to conduction block was 43 +/- 13.2 min. All subjects who manifested conduction block showed marked improvement 5 min after release from hyperextension. Conclusions Wrist hyperextension for arterial line placement and stabilization is likely to result in profound impairment of median nerve function. Although the effects were transient in this study, the results suggest that prolonged hyperextension may be associated with significant changes in median nerve conduction. To minimize the chance for nerve injury, the authors recommend that wrists be returned promptly to the neutral position following arterial line placement.

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Prospective Comparison of Ultrasound-Guided Versus Palpation Techniques for Arterial Line Placement by Residents in a Teaching Institution

Journal of Graduate Medical Education ◽

10.4300/jgme-d-18-00592.1 ◽

2019 ◽

Vol 11 (2) ◽

pp. 177-181 ◽

Cited By ~ 4

Author(s):

Yar Luan Yeap ◽

John W. Wolfe ◽

Jennifer Stewart ◽

Kevin M. Backfish

Keyword(s):

Elective Surgery ◽

Baseline Heart Rate ◽

Arterial Line ◽

Teaching Institution ◽

Line Placement ◽

Prospective Comparison ◽

Baseline Systolic Blood Pressure ◽

American Society ◽

American Society Of Anesthesiologists ◽

Emergent Surgery

ABSTRACT Background Arterial line insertion is traditionally done by blind palpation. Residents may need multiple attempts for successful insertion, leading to longer procedure times and many failed attempts. Objective We hypothesized that ultrasound guidance (USG) would be faster and more successful than traditional blind palpation (TBP) for radial artery line placement by residents. Methods Patients undergoing elective surgery requiring a radial arterial line were randomized to either the USG or TBP groups. Exclusion criteria included a need for arterial line placement in an awake patient, emergent surgery, or American Society of Anesthesiologists (ASA) physical status class VI. After the induction of anesthesia, a postgraduate year 3 (PGY-3) or PGY-4 anesthesia resident placed an arterial line by either USG or TBP. Results A total of 412 patients and 85 of 106 residents (80%) in the training program were included. The 2 groups were similar with respect to sex, weight, height, ASA class, baseline systolic blood pressure, and baseline heart rate. USG was faster than TBP (mean times 171.1 ± 16.7 seconds versus 243.6 ± 23.5 seconds, P = .012), required fewer attempts (mean 1.78 ± 0.11 versus 2.48 ± 0.15, P = .035), and had an improved success rate (96% versus 90%, P = .012). Conclusions We found that residents using USG in an academic institution resulted in significantly faster placement of the arterial lines, fewer attempts, and fewer catheters used.

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Predictors of Prehospital On-Scene Time in an Australian Emergency Retrieval Service

Prehospital and Disaster Medicine ◽

10.1017/s1049023x19004394 ◽

2019 ◽

Vol 34 (03) ◽

pp. 317-321

Author(s):

Patrick T. Fok ◽

David Teubner ◽

Jeremy Purdell-Lewis ◽

Andrew Pearce

Keyword(s):

Model Building ◽

South Australia ◽

Therapeutic Interventions ◽

Arterial Line ◽

Patient Age ◽

Line Placement ◽

Patient Âgé ◽

Time Required ◽

The Impact ◽

Rotary Wing

AbstractIntroduction:Prehospital physicians balance the need to stabilize patients prior to transport, minimizing the delay to transport patients to the appropriate level of care. Literature has focused on which interventions should be performed in the prehospital environment, with airway management, specifically prehospital intubation (PHI), being a commonly discussed topic. However, few studies have sought additional factors which influence scene time or quantify the impact of mission characteristics or therapeutic interventions on scene time.Hypothesis/Problem:The goal of this study was to identify specific interventions, patient demographics, or mission characteristics that increase scene time and quantify their impact on scene time.Methods:A retrospective, database model-building study was performed using the prehospital mission database of South Australian Ambulance Service (SAAS; Adelaide, South Australia) MedSTAR retrieval service from January 1, 2015 through August 31, 2016. Mission variables, including patient age, weight, gender, retrieval platform, physician type, PHI, arterial line placement, central line placement, and finger thoracostomy, were assessed for predictors of scene time.Results:A total of 506 missions were included in this study. Average prehospital scene time was 34 (SD = 21) minutes. Four mission variables significantly increased scene time: patient age, rotary wing transport, PHI, and arterial line placement increased scene time by 0.09 (SD = 0.08) minutes, 13.6 (SD = 3.2) minutes, 11.6 (SD = 3.8) minutes, and 34.4 (SD = 8.4) minutes, respectively.Conclusion:This study identifies two mission characteristics, patient age and rotary wing transport, and two interventions, PHI and arterial line placement, which significantly increase scene time. Elderly patients are medically complex and more severely injured than younger patients, thus, may require more time to stabilize on-scene. Inherent in rotary wing operations is the time to prepare for the flight, which is shorter during ground transport. The time required to safely execute a PHI is similar to that in the literature and has remained constant over the past two years; arterial line placement took longer than envisioned. The SAAS MedSTAR has changed its clinical practice guidelines for prehospital interventions based on this study’s results. Retrieval services should similarly assess the necessity and efficiency of interventions to optimize scene time, knowing that the time required to safely execute an intervention may reach a minimum duration. Defining the scene time enables mission planning, team training, and audit review with the aim of improved patient care.

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