Femoral Arterial Line Research Articles

Hemodynamic Monitoring In The Cardiac Surgical Patient: Comparison of Three Arterial Catheters

ObjectiveSystemic systolic (SAP) and mean (MAP) arterial pressure monitoring is the cornerstone in hemodynamic management of the cardiac surgical patient and the radial artery is the most common site of catheter placement. The present study compares three different arterial line procedures. It is hypothesized that a 20-G 12.7cm catheter inserted in the radial artery will be equal to 20-G 12.7cm angiocath placed in the brachial artery, and superior to a 20-G 5.0cm angiocath placed in the radial artery. DesignA prospective randomized control was performed. SettingSingle Academic University Hospital ParticipantsAdult patients ≥ 18 years old undergoing non-emergent cardiac surgery utilizing cardiopulmonary bypass. InterventionsAfter approval by the Rhode Island Hospital institutional review board, a randomized prospective control study to evaluate three different peripheral intra-arterial catheter systems was performed: 1) Radial Short (RS). 20-G 5cm catheter, 2) Radial Long (RL): 20-G 12cm catheter, 3) Brachial Long (BL): 20-G 12cm catheter. Measurements&ResultsGradients between central aortic and peripheral catheters (CA-P) were compared and analyzed prior to CPB, and 2 and 10 minutes after separation from CPB. The placement of femoral arterial lines, and administration of vasoactive medications were recorded. After exclusions 67 BL, 61 RL, and 66 RS patients were compared. Prior to CPB CA-P SAP and MAP gradients were not significant among the three groups. Two minutes after CPB the CA-P SAP gradient was significant for the RS group (p=0.005) and insignificant for BL (p=0.47) and RL (p=0.39). Two-group analysis reveal that CA-P SAP gradients are similar between BL and RL (p=0.84), both of which were superior to RS (p=0.02 and p=0.04 resp.). At 10 minutes after CPB, the CA-P SAP gradient for RS remained significant (p=0.004) and similar to the gradient at 2 minutes. The CA-P SAP gradients increased from 2 to 10 minutes for BL (p=0.13) and RL (p=0.06). Two minutes after CPB the CA-P MAP gradients are significant for BL(p=0.003), RL(p< 0.0001), and RS(p< 0.0001) groups. Two-group analysis reveal that the CA-P MAP gradients were lower for the BL group compared to RL (p=0.054) and RS (p< 0.05) groups. Ten minutes after CPB, the CA-P MAP gradients in the RL and RS groups remained significant (p< 0.0001) and both greater than the BL group (p=0.002). A femoral arterial line was placed more frequently in the RS group (8/66=12.1%), than RL group (3/61=4.9%), and the BL group (2/67=3.0%). Vasopressin was administered significantly more frequently in the RS group… ConclusionRegarding CA-P SAP gradients, the RL group performed equally to the BL group, both being superior to RS. Regarding CA-P MAP gradients BL was superior to RL and RS. Clinically, femoral line placement and vasopressin administration was less for the BL and RL groups when compared to the RS group. This study demonstrates the benefits of a long (12.7cm) 20 G angiocath placed in the radial artery.

Doppler ultrasound peak systolic velocity versus end tidal carbon dioxide during pulse checks in cardiac arrest

BackgroundAn accurate, non-invasive measure of return of spontaneous circulation (ROSC) is needed to improve management of cardiac arrest patients. ObjectivesDuring a pulse check in Emergency Department (ED) cardiac arrest patients, we compared the correlation between 1) end tidal carbon dioxide (ETCO2) and systolic blood pressure (SBP), and 2) Doppler ultrasound peak systolic velocity (PSV) and SBP. Additionally, we assessed the accuracy of PSV ≥ 20 cm/sec in comparison to previously suggested ETCO2 ≥ 20 or ≥ 25 mmHg thresholds to predict ROSC with SBP ≥ 60 mmHg. MethodsThis was a secondary analysis of a previously published prospective observational study of ED cardiac arrest patients with an advanced airway and femoral arterial line in place. During each pulse check, highest SBP, highest PSV, and ETCO2 at the end of the pulse check were recorded. Spearman correlation coefficients were calculated and compared using a Fisher Z-transformation. Accuracy of previously determined PSV and ETCO2 thresholds for detecting ROSC with SBP ≥ 60 mmHg were compared using McNemar’s tests. ResultsBased on data from 35 patients with 111 pulse checks, we found a higher correlation between PSV and SBP than ETCO2 and SBP (0.71 vs 0.31; p < 0.001). Diagnostic accuracy of PSV ≥ 20 cm/sec for detecting ROSC with SBP ≥ 60 mmHg was 89% (95% CI: 82%-94%) versus 59% (95% CI: 49%-68%) and 58% (95% CI: 48%-67%) for ETCO2 ≥ 20 and ≥ 25 mmHg, respectively. ConclusionsDuring a pulse check, Doppler ultrasound PSV outperformed ETCO2 for correlation with SBP and accuracy in detecting ROSC with SBP ≥ 60 mmHg.

Central Versus Peripheral Invasive Arterial Blood Pressure Monitoring in Liver Transplant Surgery.

Introduction Invasive blood pressure monitoring is essential in liver transplant surgery due to expected major hemodynamic shifts.The use of central versusperipheral arterial access, however, is institution-dependent, which can affect clinical decisions regarding vasopressor therapy.Although there are studies that demonstrate inconsistencies based on arterial cannulation sites, few studies have compared femoral and radial artery blood pressures in patients undergoing liver transplant surgery.To our knowledge, there are no studies investigating the differences between continuous minute-to-minute femoral and radial artery measurements during all three phases of liver transplant surgery. Objective The main objective of this study was to evaluate for any differences between central and peripheral blood pressure measurements in liver transplant surgeryand to assess for any correlation between vasopressor infusion dose and femoral-arterial pressure differences. Methods In this retrospective study, we reviewed and studied the data of 61 patientswith American Society of Anesthesiologists (ASA) grade 4who underwent liver transplant surgery at Loma Linda University Medical Center between January and December of 2019.All patients had both femoral and radial arterial lines placed for liver transplant surgery.Femoral and radial arterial blood pressure values were obtained continuously over 60 minutes in the pre-anhepatic phase, 45 minutes during the anhepatic phase, and 60 minutes into the neo-hepatic phase. Vasopressor infusion doses were also recorded for each patient during these time frames. Results This pilot study found statistically significant differences between the mean femoral and radial systolic blood pressure (SBP; p < 0.0001), diastolic blood pressure (DBP; p < 0.0001), and mean arterial pressure (MAP; p < 0.0001)during all phases of liver transplantation.The meanSBP and MAP differences between femoral and radial arteries were highest (femoral blood pressure reading higher than radial blood pressure measurements) in the late anhepatic and early neo-hepatic phases with SBP differences of 20.8 ± 0.8 mmHg and 22.8 ± 0.8 mmHg, respectively, and MAP differences of 10.0 ± 0.4 mmHg and 9.8 ± 0.4 mmHg, respectively. Higher vasopressor infusion doses were strongly associated with greater differences in femoral-radial SBP and MAP measurements (r = 0.69 for vasopressin, 0.68 for norepinephrine, and 0.68 for epinephrine; p < 0.0001) during the anhepatic phase. Conclusions Peripheral invasive blood pressure monitoring may result in underestimation of the central blood pressure, as was seen in all phases of liver transplantation. This may lead to excessive vasopressor use with potentially adverse effects. Although the cause for the difference between femoral and radial artery measurements is unclear, increasing vasopressor infusion dosages appears to contribute. Femoral artery blood pressure monitoring allows clinicians to interpret hemodynamic status and administer appropriate vasopressors more accurately.

DO NOT RUSH TO BLAME THE ARTERIAL LINE. BEFORE TAKING IT OUT, SCAN THE AORTA

<h3>Objective</h3> Cardiac Anaesthesiologists has the unique advantage of assessing the cardiovascular system through various methods. Non-invasive and invasive hemodynamic monitoring accompanied by Transoesophageal Echocardiography (TOE) with 3D imaging, create an integrated profile of pressure, volume, flow velocity and anatomical information for every patient. In the current case report, we highlight the role of TOE and 3D imaging in diagnosing a previously unknown Coarctation of the Aorta (CoA), and thus interpreting correctly the arterial waveform of a femoral arterial line that was initially considered to be malfunctioning. <h3>Design and Method</h3> A 53yr old male patient was scheduled for Aortic Valve plus partial Aortic Root plus Ascending Aorta replacement. The background included a bicuspid aortic valve (Sievers Type 0: no raphe) with moderate mixed valvular disease, aortic root aneurysm with unequal dilatation of the sinuses of Valsalva, and an ascending aorta aneurysm. Intraoperatively, a right brachial cuff for Non-Invasive Blood Pressure (NIBP) was placed before the anesthesia induction, whilst after that an arterial line was introduced in the left femoral artery (Figure 1). Because of the fact that the arterial waveform had a damped shape, a delayed upslope and a 30mmHg difference with the NIBP, after having ruled out any connection issues, a second arterial line was inserted into the left radial artery. The second waveform had a normal shape and was numerically matching the NIBP, having therefore the same pressure difference with the femoral line (Figure 2,3). Keeping in mind the patient's background, the suspicion of CoA was raised. <h3>Results and Conclusion</h3> The comprehensive TOE examination that followed, including 3D imaging, confirmed the already known patient's background, but more importantly proved the existence of CoA, showed its precise anatomy and appreciated quite accurately the previously noticed pressure difference between the two arterial waveforms (Figure 4,5,6,7,8). Due to the fact that the summary of the preoperative CT angiography was not describing any pathology in the descending aorta, a further analysis of the CT with 3D reconstruction was requested at that moment; the clinical suspicion and the echocardiographic findings were verified (Figure 9,10). As fas as the surgical procedure is concerned, the patient underwent a mechanical aortic valve replacement, replacement of the non-coronary sinus of Valsalva and of the ascending aorta with an interposition graft. No intervention regarding the CoA was performed. In conclusion, in this case report we showed that a damped arterial waveform - a clinical finding that could have been overlooked and the arterial line to be consequently removed - constituted the first step towards a definite diagnosis. Undoubtedly, crucial in the diagnostic process proved to be the role of TOE, and more specifically a comprehensive and not only focused to the main pathology TOE examination. However, it is the clinical suspicion that should be always kept high.

Abstract 199: Femoral Artery Doppler Ultrasound Blood Flow Patterns Predict Intrinsic Pulsatility In Cardiac Arrest Patients Receiving Active Chest Compressions

Introduction: Pulse detection requires chest compression interruption, which is associated with poor outcomes in cardiac arrest. Currently no modality can reliably identify return of spontaneous circulation with ongoing chest compressions. Hypothesis We hypothesized that patients with intrinsic pulsatility have anterograde dominant blood flow (ADF) on arterial Doppler ultrasound; whereas those with intrinsic pulselessness have bidirectional blood flow moving antero/retrograde during chest compression/decompression. Methods: We conducted a prospective, diagnostic accuracy study on a convenience sample of adult Emergency Department (ED) cardiac arrest patients with a femoral arterial line in place. Immediately prior to a pulse check, pulsed-wave Doppler ultrasound of the common femoral artery was performed during active chest compressions. Bidirectional flow was present when the anterograde flow waveform was equal in peak systolic velocity to the retrograde flow waveform. All other Doppler waveforms were ADF. A pulse was present when there was an arterial line waveform. Sensitivity, specificity, and accuracy of ADF versus bidirectional flow for predicting pulsatility was assessed. Results: We enrolled 42 patients and performed 104 pulse checks: a pulse was present for 73 (70.2%) and absent in 31 (29.8%). ADF was present in 82 (78.9%) and bidirectional flow was present in 22 (21.2%). Sensitivity of ADF for detecting a pulse was 95.9% (95% CI: 91.3%-100.0%). Specificity of bidirectional flow for detecting pulselessness was 61.3% (95% CI: 44.1-78.4%) and accuracy was 85.6% (95% CI: 77.3-91.7%). Patients with ADF have 36.9 times the odds of having an arterial line pulse compared with patients with bidirectional flow (OR: 36.9; 95% CI: 9.5-144.4). Conclusion: In ED cardiac arrest patients, ADF on Doppler ultrasound has high sensitivity for detecting an arterial line pulse. Further studies are needed to further evaluate this novel finding.

Save the Leg: Utilization of Distal Perfusion Catheter With Impella CP® May Prevent Morbidity of Limb.

Leg ischemia is a potential complication of percutaneous left ventricular assist device (Impella CP®) placement. To avoid leg ischemia in at-risk patients, a distal perfusion catheter (DPC) should be placed. In utilizing a passive distal perfusion system from the contralateral femoral artery, we optimized blood flow to the distal limb mitigating leg ischemia. A 65-year-old female with dilated cardiomyopathy complicated by hemodynamic instability was placed on an Impella CP via the right femoral artery. A DPC was placed to the right distal femoral artery and connected to the wire re-access port of the Impella CP. Despite this, the leg became ischemic shortly after admission to the ICU. A contralateral femoral arterial line was placed in standard fashion, and it was connected to the DPC while the wire re-access port was capped. Shortly after placement of the new DPC system, the right lower extremity distal pulses returned, and distal leg ischemia was resolved. Another patient, a 67-year-old male with acute myocardial infarction, was placed on an Impella CP via the left femoral artery for cardiogenic shock. His hemodynamics continued to deteriorate, requiring initiation of veno-arterial extracorporeal membrane oxygenation (VA ECMO) via the right femoral artery and vein with associated DPC placement. Shortly after the initiation of VA ECMO, the Impella CP-related extremity (left leg) became ischemic. A left femoral DPC was placed and connected to the side port of the right femoral arterial cannula. After initiation of the additional DPC system, the left leg ischemia resolved. Distal leg ischemia with Impella CP is not a rare event. Utilization of a DPC to Impella CP may decrease the morbidity of limb malperfusion.

P50: Save leg: using contralateral femoral inflow for distal perfusion catheter placed for Impella CP

Background: Leg ischemia is a possible complication of percutaneous left ventricular device (Impella CP TM) placement. To avoid leg ischemia in atrisk patients, a distal perfusion catheter (DPC) should be placed. The DPC can be connected to the wire-reaccess port of the Impella CP as an inflow to the DPC to perfuse the leg. However, the wire-reaccess port of the Impella was not designed to bypass arterial blood to the distal limb, but rather for wire passage. We introduced a passive distal perfusion system from the contralateral femoral artery to optimize blood flow to the distal limb. Methods: A 65 year-old female with dilated cardiomyopathy developed refractory ventricular tachycardia. She was taken to the catherization laboratory because of hemodynamic instability requiring high doses of vasopressors. By left heart catheterization, we noted normal coronary arteries with elevated left ventricular end-diastolic pressure (38 mm Hg) and a poor cardiac index. Thus, Impella CP was placed from the right groin to stabilize her hemodynamics. A DCP was placed on right distal femoral artery and connected to the wire-reaccess port of the Impella CP. The leg appeared perfused by DPC via reaccess port in the catherization laboratory; however, despite this as well as appropriate anticoagulation, the leg became ischemic (cold leg, low leg regional saturation) shortly after admission to the ICU, where a lack of flow in the DPC was confirmed. Results: An additional contralateral femoral arterial line was placed. The contralateral femoral arterial line was then connected to the DPC (figure), and the reaccess port of the Impella was capped. Shortly after placement of the new DPC system, the pulse was returned and leg saturation improved. Additionally, leg ischemia during Impella support did not reoccur. Conclusion: A DPC using the Impella CP reaccess port provided inadequate distal flow. When a DPC is indicated during femoral Impella CP use, the contralateral femoral artery should be chosen for inflow cannulation. Figure 1. Impella CP and distal perfusion catheter (DPC) in the right femoral artery. The arterial line in the left femoral artery is feeding DPC in the right femroal artery.

Dimethyl malonate slows succinate accumulation and preserves cardiac function in a swine model of hemorrhagic shock.

Succinate (SI) is a citric acid cycle metabolite that accumulates in tissues during hemorrhagic shock (HS) due to electron transport chain uncoupling. Dimethyl malonate (DMM) is a competitive inhibitor of SI dehydrogenase, which has been shown to reduce SI accumulation and protect against reperfusion injury. Whether DMM can be therapeutic after severe HS is unknown. We hypothesized that DMM would prevent SI buildup during resuscitation (RES) in a swine model of HS, leading to better physiological recovery after RES. The carotid arteries of Yorkshire pigs were cannulated with a 5-Fr catheter. After placement of a Swan-Ganz catheter and femoral arterial line, the carotid catheters were opened and the animals were exsanguinated to a mean arterial pressure (MAP) of 45 mm. After 30 minutes in the shock state, the animals were resuscitated to a MAP of 60 mm using lactated ringers. A MAP above 60 mm was maintained throughout RES. One group received 10 mg/kg of DMM (n = 6), while the control received sham injections (n = 6). The primary end-point was SI levels. Secondary end-points included cardiac function and lactate. Succinate levels increased from baseline to the 20-minute RES point in control, while the DMM cohort remained unchanged. The DMM group required less intravenous fluid to maintain a MAP above 60 (450.0 vs. 229.0 mL; p = 0.01). The DMM group had higher pulmonary capillary wedge pressure at the 20-minute and 40-minute RES points. The DMM group had better recovery of cardiac output and index during RES, while the control had no improvement. While lactate levels were similar, DMM may lead to increased ionized calcium levels. Dimethyl malonate slows SI accumulation during HS and helps preserve cardiac filling pressures and function during RES. In addition, DMM may protect against depletion of ionized calcium. Dimethyl malonate may have therapeutic potential during HS.

Femoral artery Doppler ultrasound is more accurate than manual palpation for pulse detection in cardiac arrest

ObjectivesOur primary objective was to assess the accuracy of Doppler ultrasound versus manual palpation in detecting any pulse with an arterial line waveform in cardiac arrest. Secondarily, we sought to determine whether peak systolic velocity (PSV) on Doppler ultrasound could detect a pulse with a systolic blood pressure (SBP) ≥ 60 mmHg. MethodsWe conducted a prospective, cross-sectional, diagnostic accuracy study on a convenience sample of adult, Emergency Department (ED) cardiac arrest patients. All patients had a femoral arterial line. During a pulse check, manual pulse detection, PSV and Doppler ultrasound clips, and SBP were recorded. A receiver operator characteristic curve analysis was performed to determine the optimal cut-off of PSV associated with a SBP ≥ 60 mmHg. Accuracy of manual palpation and Doppler ultrasound for detection of any pulse and SBP ≥ 60 mmHg were compared with McNemar’s test. Results54 patients and 213 pulse checks were analysed. Doppler ultrasound demonstrated higher accuracy than manual palpation (95.3% vs. 54.0%; p < 0.001) for detection of any pulse. Correlation between PSV and SBP was strong (Spearman correlation coefficient = 0.89; p < 0.001). The optimal cut-off value of PSV associated with a SBP ≥ 60 mmHg was 20 cm/s (area under the curve = 0.975). To detect SBP ≥ 60 mmHg, accuracy of a PSV ≥ 20 cm/s was higher than manual palpation (91.4% vs. 66.2%; p < 0.001). ConclusionsAmong ED cardiac arrest patients, femoral artery Doppler ultrasound was more accurate than manual palpation for detecting any pulse. When using a PSV ≥ 20 cm/s, Doppler ultrasound was also more accurate for detecting a SBP ≥ 60 mmHg.

Dynamic changes in arterial blood gas during cardiopulmonary resuscitation in out-of-hospital cardiac arrest

We aimed to investigate the prognostic value of dynamic changes in arterial blood gas analysis (ABGA) measured after the start of cardiopulmonary resuscitation (CPR) for return of spontaneous circulation (ROSC) in patients with out-of-hospital cardiac arrest (OHCA). This prospective observational study was conducted at the emergency department of a university hospital from February 2018 to February 2020. All blood samples for gas analysis were collected from a radial or femoral arterial line, which was inserted during CPR. Changes in ABGA parameters were expressed as delta (Δ), defined as the values of the second ABGA minus the values of the initial ABGA. The primary outcome was sustained ROSC. Out of the 80 patients included in the analysis, 13 achieved sustained ROSC after in-hospital resuscitation. Multivariable logistic analysis revealed that ΔpaO2 (odds ratio [OR] = 1.023; 95% confidence interval [CI] = 1.004–1.043, p = 0.020) along with prehospital shockable rhythm (OR = 84.680; 95% CI = 2.561–2799.939, p = 0.013) and total resuscitation duration (OR = 0.881; 95% CI = 0.805–0.964, p = 0.006) were significant predictors for sustained ROSC. Our study suggests a possible association between ΔpaO2 in ABGA during CPR and an increased rate of sustained ROSC in the late phase of OHCA.

A comparison between Invasive and Non-Invasive Blood Pressure monitoring for postoperative patients in Cardiac Intensive Care Unit

Background: Blood pressure monitoring is essential for hemodynamically ill patients in Intensive Care Unit. Invasive measurement from an arterial line is considered as the method of choice in spite of the errors that may occur due to calibration error, movement artifacts and over or under damping. Furthermore, because of the frequent need for continuous and prolonged monitoring of blood pressure for critically ill patient in cardiac intensive care unit, automated noninvasive blood pressure measurements are commonly used. Objective: To compare Invasive with Non Invasive Blood Pressure. And to observe whether femoral and radial arterial lines can be used interchangeably in cardiac intensive care unit. Methods: 70 patients were divided into two equal groups. First group underwent standard femoral artery catheterization for invasive blood pressure monitoring. The second group underwent standard radial artery catheterization for invasive blood pressure monitoring. A cuff was placed in the arm for noninvasive monitoring for all 70 patients. For each patient data were obtained by performing noninvasive blood pressure measurement for 4 times which was at time of admission to intensive care unit (T1), one hour later (T2), two hours later (T3) and three hours after admission (T4). At the same time the invasive blood pressure measurement was recorded for comparison. Results: There were significant differences between diastolic invasive blood pressure measurement obtained from femoral arterial line or radial arterial line with diastolic noninvasive blood pressure measurement. No significant statistical difference in mean arterial pressure between invasive and noninvasive blood pressure was detected. Conclusion: Noninvasive blood pressure measurement alone is insufficient for monitoring of postoperative patients admitted to cardiac intensive care unit after cardiac operation. And femoral or radial arterial line can be used interchangeably for blood pressure monitoring in cardiac intensive care unit.

Complications of femoral arterial lines in infants under 12 months

Background: The risks of femoral arterial line placement in young children have been incompletely defined. We hypothesized that a low complication rate would be associated with ultrasound use. Subjects and Methods: Infants aged 0–12 months undergoing placement of a femoral arterial line at our institution over a 3.5-year period were identified through billing data, and their records were reviewed. Events concerning each line were recorded individually. Patients were excluded if there was incomplete documentation or if the line was in place for under 24 h. Demographics, information about line placement, and complications were recorded. Results: Three hundred and sixty-four femoral arterial lines were included. Eighty percent of lines were placed in the operating room, with the rest placed in the cardiac intensive care unit (ICU) (11%), the cardiac catheterization lab (6%), or the pediatric ICU (3%). Femoral artery occlusion occurred with 16% of lines placed, and limb ischemia in 6%. One patient had tissue loss. Occlusion was associated with lower gestational age at birth (44 [40–57] vs. 50 [41–60], P = 0.04), lower weight (3.7 [3.1–5.7] vs. 4.3 kg [3.3–6.2], P = 0.05), left-sided lines (52% vs. 66%, P = 0.05), placement in interventional catheterization lab (odds ratio [OR]: 3.28, confidence interval [CI]: 1.24–8.67, P = 0.02), &gt;2 attempts (27% vs. 13%, P &lt; 0.01), and catheter diameter (OR: 2.86, CI: 1.18–6.92, P = 0.02). Conclusion: Femoral arterial catheter placement in infants younger than 12 months resulted in a 16% rate of arterial occlusion at our institution, which was associated with low gestational age, larger catheter size, and left-sided lines but not ultrasound use, line duration, catheter length, use of anticoagulation, physician specialty, or physician training level.

Major Short-term Complications of Arterial Cannulation for Monitoring in Children.

Perioperative arterial cannulation in children is routinely performed. Based on clinical observation of several complications related to femoral arterial lines, the authors performed a larger study to further examine complications. The authors aimed to (1) describe the use patterns and incidence of major short-term complications associated with arterial cannulation for perioperative monitoring in children, and (2) describe the rates of major complications by anatomical site and age category of the patient. The authors examined a retrospective cohort of pediatric patients (age less than 18 yr) undergoing surgical procedures at a single academic medical center from January 1, 2006 to August 15, 2016. Institutional databases containing anesthetic care, arterial cannulation, and postoperative complications information were queried to identify vascular, neurologic, and infectious short term complications within 30 days of arterial cannulation. There were 5,142 arterial cannulations performed in 4,178 patients. The most common sites for arterial cannulation were the radial (N = 3,395 [66.0%]) and femoral arteries (N = 1,528 [29.7%]). There were 11 major complications: 8 vascular and 3 infections (overall incidence, 0.2%; rate, 2 per 1,000 lines; 95% CI, 1 to 4) and all of these complications were associated with femoral arterial lines in children younger than 5 yr old (0.7%; rate, 7 per 1,000 lines; 95% CI, 4 to 13). The majority of femoral lines were placed for cardiac procedures (91%). Infants and neonates had the greatest complication rates (16 and 11 per 1,000 lines, respectively; 95% CI, 7 to 34 and 3 to 39, respectively). The overall major complication rate of arterial cannulation for monitoring purposes in children is low (0.2%). All complications occurred in femoral arterial lines in children younger than 5 yr of age, with the greatest complication rates in infants and neonates. There were no complications in distal arterial cannulation sites, including more than 3,000 radial cannulations.

The REBOA Dissipation Curve: Training Starts to Wane at 6 Months in the Absence of Clinical REBOA Cases

Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a low-frequency, high-acuity intervention. We hypothesized that REBOA-specific knowledge and comfort deteriorate significantly within 6 months of a formal training course if REBOA is not performed in the interim. A comprehensive REBOA course was developed including didactics and hands-on practical simulation training. Baseline knowledge and comfort were assessed with a precourse objective test and a subjective self-assessment. REBOA knowledge and comfort were then re-assessed immediately postcourse and again at 6 months and 1 year. Performance trends were measured using paired Student's t and Wilcoxon signed-rank tests. Thirteen participants were evaluated including trauma faculty (n = 10) and fellows (n = 3). Test scores improved significantly from precourse (72% ± 10% correct) to postcourse (88% ± 8%, p < 0.001). At 6 months, scores remained no different from postcourse (p = 0.126); at 1 year, scores decreased back to baseline (p = 0.024 from postcourse; 0.285 from precourse). Subjective comfort with femoral arterial line placement and REBOA improved with training (p = 0.044 and 0.003, respectively). Femoral arterial line comfort remained unchanged from postcourse at 6 months (p = 0.898) and 1 year (p = 0.158). However, subjective comfort with REBOA decreased relative to postcourse levels at 6 months (p = 0.009), driven primarily by participants with no clinical REBOA cases in the interim. A formal REBOA curriculum improves knowledge and comfort with critical aspects of this procedure. This knowledge persists at 6 months, though subjective comfort deteriorated among those without REBOA placement in the interim. REBOA refresher training should be considered at 6-month intervals in the absence of clinical REBOA cases. Level III, prognostic.

Design and Impact of a COVID-19 Multidisciplinary Bundled Procedure Team.

Design and Impact of a COVID-19 Multidisciplinary Bundled Procedure Team.

Derivation of a procedural performance checklist for ultrasound-guided femoral arterial line placement using the modified Delphi method.

Many specialties utilize procedural performance checklists as an aid to teach residents and other learners. Procedural checklists ensure that the critical steps of the desired procedure are performed in a specified manner every time. Valid measures of competency are needed to evaluate learners and ensure a standard quality of care. The objective of this study was to employ the modified Delphi method to derive a procedural checklist for use during placement of ultrasound-guided femoral arterial access. A 27-item procedural checklist was provided to 14 experts from three acute care specialties. Using the modified Delphi method, the checklist was serially modified based on expert feedback. Three rounds of the study were performed resulting in a final 23-item checklist. Each item on the checklist received at least 70% expert agreement on its inclusion in the final checklist. A procedural performance checklist was created for ultrasound-guided femoral arterial access using the modified Delphi method. This is an objective tool to assist procedural training and competency assessment in a variety of clinical and educational settings.

REBOA as a rescue strategy for catastrophic vascular injury during robotic surgery.

Catastrophic bleeding is a feared complication of robotic abdominal procedures that involve dissection in close proximity to major vessels. In the event of uncontrollable hemorrhage, standard practice involves emergency undocking with conversion to laparotomy. Resuscitative endovascular balloon occlusion of the aorta (REBOA) is a rapid and life-saving technique gaining acceptance in the trauma setting for the management of catastrophic hemorrhage. The purpose of this study was to evaluate feasibility of REBOA for emergency hemostasis during robotic surgery. The surgical robot was docked to a REBOA mannequin to simulate an upper abdominal surgery. A femoral arterial line was placed in the mannequin. Supplies needed for REBOA insertion were opened and arranged on the surgical back table. The surgeon was seated at the console with an assistant scrubbed. A catastrophic vascular injury was announced. The time it took the surgeon to achieve aortic occlusion by the REBOA was recorded. Four surgeons participated and performed three timed trials each. Each surgeon, irrespective of experience with REBOA or years in surgical practice, was able to obtain aortic occlusion in less than 2min. The mean time to aortic occlusion for all surgeons was 111s. No manipulation of the robotic arms was required to perform the procedure. Aortic occlusion was achieved rapidly with REBOA. Ability to achieve prompt aortic control was not associated with surgical experience or prior familiarity with the REBOA device. Prophylactic femoral access and preparation of supplies facilitates prompt placement of the occlusion balloon. REBOA should be considered as a viable alternative to open laparotomy for temporary hemorrhage control during robotic surgery.

PC216. Ultrasound-Assisted Retrieval of Embolized Femoral Arterial Catheter

Intravascular foreign body embolization as a result of catheter fracture is a rare but serious event that most often requires retrieval. Whereas many instances of central venous catheter fractures have been reported, arterial catheter fracture with embolization has rarely been described. Herein, a successful ultrasound-assisted endovascular retrieval of a fractured femoral arterial line catheter using a three-lobe snare is illustrated (Figs 1 and 2). After retrieval, there were excellent femoral and pedal pulses. Doppler flow through the vessels was normal, and the patient was discharged without further vascular complications. Considering the potential risks of vessel obstruction, thrombosis, end-organ ischemia, and perforation, arterial foreign bodies should generally be retrieved. However, there are many considerations in such endeavors that need to be contemplated, including location and associated symptoms, procedural techniques, and optimal imaging tools to locate and help in the extraction of the foreign body. In this case report, an ultrasound-assisted endovascular retrieval of a fractured femoral arterial catheter from the iliac artery is presented and discussed.Fig 2View Large Image Figure ViewerDownload Hi-res image Download (PPT)

Insights into the Development of a Life-Sustaining Orthotopic Cardiac Xenotransplant Model

Introduction Advances in clinical immunosuppression and characterization of optimal donor genetics continue to move the field of xenotransplantation toward a clinical reality. Cardiac xenograft survival in a non-life supporting heterotopic model has been extended to greater than 900 days as previously described by our lab. Orthotopic life supporting models for cardiac xenografts are being developed with the major barrier being significant peri-operative mortality. We detail the development of an orthotopic pig-to-baboon cardiac xenotransplant model, offering insights gained over time for replication of the model. Materials and Methods Specific pathogen free baboons were transplanted with GTKO.CD46 donor pig hearts in the orthotopic position (n = 3) by cardiac transplant and congenital cardiac surgeons. The clinical team also included a perfusionist and cardiac anesthesiologist. Detailed reports were generated regarding equipment and medications required for the cases to approximate clinical orthotopic cardiac transplantation. Monitoring capabilities were optimized as well as resuscitative access and strategy. These baboons were recovered from prior experiments and per institutional protocol were approved for non-survival studies; cases were performed with intended short term survival under anesthesia followed by elective euthanasia. Results and Discussion All recipient baboons were transplanted and weaned off of cardiopulmonary bypass with life sustaining cardiac function. Low dose inotropic support was continued in all cases; vasopressor support was continued in one case. Two cases were electively terminated after wean from bypass; one recipient suffered arrest three hours post wean from bypass. Recipients were monitored using femoral arterial lines, transesophageal echocardiogram, external EKG, continuous pulse oximetry, and serial bloodwork including ABG, CBC, BMP, and ACT. Central venous access with multiple lumens was critical to post-operative care. Invasive hemodynamic monitoring, pretreatment with anti-arrhythmics, and availability of cardioversion for the donor pig allowed rapid reversal of fibrillation episodes during procurement. Ideal cold ischemia time was found to be close to one hour; shorter ischemia time resulted in poorer xenograft function (n = 1) as evidenced by difficult wean from bypass and persistent need for vasopressor support. Atrial and ventricular pacing wires proved integral to the cardiopulmonary bypass weaning process. Conclusion Cardiac xenotransplantation is a potential solution to the paucity of human organs. Technical refinement of the life-supporting orthotopic cardiac xenotransplant with expert clinical help and applying human standards of post-operative care are the critical next step toward a clinical reality. Here we detail our experience developing an operative and critical care approach to the orthotopic cardiac xenotransplantation model.

Effect of Automated Simultaneous Sternothoracic Cardiopulmonary Resuscitation Device on Hemodynamics in Out-of-Hospital Cardiac Arrest Patients

BackgroundAn automatic simultaneous sternothoracic cardiopulmonary resuscitation (SST-CPR) device is an apparatus that performs CPR by providing simultaneous cyclic compressions of the thorax with a thoracic strap and compression of the sternum with a piston. ObjectiveThis study was conducted to compare the hemodynamic effects of CPR with an automatic SST-CPR device to those with standard CPR (STD-CPR) in cardiac arrest patients. MethodsA randomized trial was performed on victims of out-of-hospital cardiac arrest resistant to initial 20 min of CPR after emergency department (ED) arrival. Patients were instrumented with femoral arterial and internal jugular venous lines before enrollment. Informed consent was waived per protocol. Patients were randomized to SST-CPR or STD-CPR based on the day of the month. The primary outcome was a comparison of the mean estimated coronary perfusion pressure (CPP) between SST-CPR and STD-CPR. The secondary outcome was a comparison of compression arterial systolic pressure, compression arterial diastolic pressure, right atrial systolic pressure, right atrial diastolic pressure, return of spontaneous circulation rate, survival to hospital admission, survival at 30 days, favorable neurologic outcomes at 30 days, and adverse events between two groups. ResultsOf 62 patients with non-traumatic, adult, out-of-hospital cardiac arrest who presented to the ED, 24 received CPR with an automatic SST-CPR device (SST-CPR group), and 38 received standard CPR (STD-CPR group). Acquisition and analysis of hemodynamic data were completed in 11 (46%) patients in the SST-CPR group and 14 (37%) patients in the STD-CPR group. Compression arterial systolic pressure, right atrial systolic/diastolic pressures, and end-tidal carbon dioxide tension were not different between the two groups. Median compression arterial diastolic pressure (femoral arterial pressure during relaxation) was 20 mm Hg (mean 22 mm Hg; 95% confidence interval [CI] 5 to 38 mm Hg) and 0 mm Hg (mean −2 mm Hg; 95% CI −21 to 18 mm Hg) in the SST-CPR group and the STD-CPR group (p = 0.002), respectively. Median estimated CPP was 10 mm Hg (mean 16 mmHg; 95% CI 1 to 31 mm Hg) and 2 mm Hg (mean 4 mm Hg; 95% CI −4 to 12 mm Hg) in the SST-CPR group and the STD-CPR group (p = 0.017), respectively. ConclusionsCPR with an automatic SST-CPR device results in higher estimated CPP compared to standard CPR in patients with non-traumatic, out-of-hospital cardiac arrest.