From the Guidelines
In a patient with severe hypotension and hypoxia who has experienced a failed arterial cannulation attempt, the best course of action is to immediately attempt cannulation at an alternative site while simultaneously addressing the underlying hypotension and hypoxia. For the second attempt, consider using ultrasound guidance if available, as this significantly improves success rates in difficult vascular access situations, as recommended by the European Society of Intensive Care Medicine 1. Alternative sites include the femoral artery, brachial artery, or the contralateral radial artery. While preparing for the second attempt, ensure adequate volume resuscitation with crystalloids (500-1000mL bolus) or vasopressors such as norepinephrine (starting at 0.05-0.1 mcg/kg/min) to improve blood pressure, as suggested by guidelines for managing bleeding and coagulopathy following major trauma 1. For hypoxia, optimize oxygenation with high-flow oxygen, consider positive pressure ventilation, and position the patient appropriately, following recommendations for the management of heart failure in adults 1. Some key points to consider in the management of this patient include:
- The use of ultrasound guidance for vascular access, which is recommended as a basic skill for intensivists 1
- The importance of addressing underlying hypotension and hypoxia simultaneously with attempts at arterial cannulation
- The consideration of alternative sites for arterial cannulation, such as the femoral or brachial artery
- The use of volume resuscitation and vasopressors, such as norepinephrine, to improve blood pressure, as guided by principles of managing hemorrhagic shock 1
- The optimization of oxygenation and ventilation to address hypoxia, as per guidelines for heart failure management 1. Given the patient's critical condition, withdrawing the entire set: guidewire, needle, and catheter before another attempt is the most appropriate action to take, to prevent further complications and allow for a more controlled approach to establishing arterial access.
From the Research
Appropriate Action for Failed Arterial Cannulation
The patient's condition, with severe hypotension and hypoxia, requires careful consideration during arterial cannulation attempts. Given the situation where a flash of blood is seen in the hub of the catheter but the guidewire meets resistance when attempted to be advanced, the most appropriate action is:
- Withdraw the entire set: guidewire, needle, and catheter before another attempt.
Rationale
This approach is supported by the principles outlined in studies related to vascular access procedures 2, 3. When resistance is met during guidewire advancement, it may indicate that the needle is not properly positioned within the artery or that the guidewire is against the arterial wall, which could lead to complications such as arterial damage or failure to secure the catheter properly.
Consideration of Ultrasound Guidance
The use of ultrasound guidance for vascular access procedures, including arterial cannulation, is highly recommended, especially in difficult cases or when patients have severe hypotension and hypoxia 2, 4. Ultrasound can help in visualizing the artery and the needle in real-time, reducing the risk of complications. However, in the scenario described, the immediate next step after encountering resistance during guidewire advancement does not involve the initiation of ultrasound guidance but rather the safe management of the current attempt.
Patient Condition
The patient's severe hypotension (70/60 mm Hg) and hypoxia (arterial oxygen saturation of 70%) necessitate careful and swift action to secure appropriate vascular access for monitoring and potential intervention. The choice of action should prioritize minimizing further complications and ensuring the patient's safety during the procedure.
Potential Complications
The potential for complications, such as accidental arterial cannulation or vascular damage, underscores the importance of careful technique and decision-making during vascular access attempts 4, 5. The chosen action should aim to mitigate these risks while achieving the necessary access for patient care.