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Table of Contents
CASE REPORT
Year : 2020  |  Volume : 4  |  Issue : 4  |  Page : 198-199

Atypical picture of peripheral arterial access in a neonate


1 Department of Anaesthesiology, AIIMS, Rishikesh, Uttarakhand, India
2 Department of Anaesthesiology and Critical Care, AIIMS, Jodhpur, Rajasthan, India
3 Department of Anatomy, AIIMS, Jodhpur, Rajasthan, India

Date of Submission01-Jun-2020
Date of Decision22-Jul-2020
Date of Acceptance10-Aug-2020
Date of Web Publication10-May-2020

Correspondence Address:
Dr. Ravi Shankar Sharma
Flat No 203, Maa Vaishno Apartment, Aam Bagh, Rishikesh - 249 203, Uttarakhand
India
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Source of Support: None, Conflict of Interest: None


DOI: 10.4103/BJOA.BJOA_103_20

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  Abstract 


Arterial line placement in the pediatric population is a challenging task. Even with the help of ultrasound, multiple attempts may be required for its successful placement. Even in the expert hands, complications such as thrombosis and distal gangrene have been encountered in the past. In recent times, Doppler's ultrasound assistance has reduced the number of attempts required for its successful placement, thereby reducing the unforeseen complications. Sometimes, pediatric arterial line placement can produce a picture like extravasations of injectate into subcutaneous tissue. Hence, one must confirm the position of arterial line with blood pressure tracing and arterial blood gas analysis before removal of the placed cannula in order to avoid unnecessary pricks. We present a case of an atypical picture of a radial artery cannulation in a neonate, which may have led to unnecessary repeated arterial puncture.

Keywords: Aarterial blood gas, arterial line, Doppler, pediatric, radial artery cannulation


How to cite this article:
Sharma RS, Balakrishnan N, Kaloria N, Kamal M, Suyashi. Atypical picture of peripheral arterial access in a neonate. Bali J Anaesthesiol 2020;4:198-9

How to cite this URL:
Sharma RS, Balakrishnan N, Kaloria N, Kamal M, Suyashi. Atypical picture of peripheral arterial access in a neonate. Bali J Anaesthesiol [serial online] 2020 [cited 2020 Nov 24];4:198-9. Available from: https://www.bjoaonline.com/text.asp?2020/4/4/198/299865




  Introduction Top


In today's era, pediatric arterial cannulation is performed routinely, which not only allows sampling of arterial blood for arterial blood gas (ABG) analysis but also provides access for removal of blood during exchange transfusion. Inside operation theatres and intensive care units, it allows for accurate blood pressure (BP) estimation, which aids clinicians in fluid and inotropes supplementation at the time of hemodynamic instability.[1] The risks associated with inadvertent or repeated arterial line placement in the pediatric population are vasospasm, thrombosis, and thromboembolism, which can compromise arterial circulation and result in limb-threatening soft-tissue necrosis. Here, we discuss a case of an atypical picture of a radial artery cannulation in a neonate, which may have led to unnecessary repeated arterial puncture.


  Case Report Top


An 8-day-old girl weighing 2.39 kg was posted for surgical correction of occipital encephalocele. During preanesthetic check-up, modified Allen's test was performed on both sides, which yielded negative results.[2] Informed written consent was obtained from the guardian. In the operation theater, standard monitors were applied as recommended by the American Society of Anaesthesiologists. We managed this case with general anesthesia, and the airway was secured with an endotracheal tube (size 3). Anesthesia was maintained with controlled ventilation under an oxygen and air mixture with a total of 1 minimum alveolar concentration of sevoflurane.

Under all aseptic precautions, the left radial artery was cannulated using an arterial cannula under ultrasonography guidance. The correct placement of the arterial line was suggested via the pulsatile flow of blood through the cannula. In order to prevent inadvertent occlusion, an arterial cannula was flushed using heparinized saline. While flushing the cannula, forearm areas along the course of the radial artery became pale, and a picture like the extravasation of injected heparinized saline into surrounding subcutaneous tissue was noticed while flushing of an arterial line [Figure 1]a and Video 1].
Figure 1: (a) Atypical skin discoloration. (b) Arterial wave form with readings

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In order to confirm our line placement, we tried negative aspiration for the second time, which again yielded similar results. Finally, we decided to transduce the line, which confirmed arterial line placement through the display of arterial waveform and continuous BP on the monitor screen [Figure 1]b. After fixing the cannula, an ABG sample was also sent, which confirmed our findings.


  Discussion Top


Arterial catheters are routinely inserted in neonates and infants in critical care units and major surgeries such as neonatal neurosurgery, cardiothoracic surgeries, and major abdominal surgeries for hemodynamic monitoring.[3] Intra-arterial BP management permits the rapid recognition of BP changes that is essential for patients on continuous infusions of inotropes, and at the same time, it also allows for repeated ABG samples to be drawn without multiple pricks to the patients.

It required a considerable amount for clinicians to secure an arterial line in a neonate. Commonly encountered complications during pediatric arterial line placement are hematoma formation, vasospasm, hemorrhage, thrombosis, and distal gangrene.[4] Although in the past, the palpatory method has been used for the placement of arterial lines in the paediatric population, it is associated with a high degree of failure. In most cases, clinicians may require multiple punctures before the successful placement of the arterial line.

In the recent era, the use of ultrasound-guided arterial line placement has gradually increased. Although it requires a skilled clinician to perform ultrasound-guided cannulation, at the same time, it has multiple advantages over palpatory techniques. Ultrasound not only improves the visual anatomy of vessels but also provides Doppler assistance, which improves the success rate to a greater extent.[4] It also reduces the number of attempts and risks associated with multiple punctures.

Anatomy of the paediatric population is quite different from that of adults in terms of the smaller diameter of blood vessels and their superficial location. The smaller diameter of arteries makes it difficult for the placement of arterial cannula in infants.[5] This pattern of skin pallor, which we obtained, may be due to the compression of the subcutaneous capillaries around the artery by the vessel itself or may be due to the presence of an abnormal arterio-venous fistula. Another explanation can be high injection pressure, which might have exceeded the arterial pressure of neonate, yielding subcutaneous extravasations-like finding.


  Conclusion Top


Intra-arterial BP management permits the rapid recognition of BP changes that is vital for patients on continuous infusions of vasoactive drugs and also allows repeated ABG samples to be drawn without injury to the patient. This atypical discoloration of the skin, as like in our patient, can make us think that the arterial cannula has been misplaced or incorrectly placed, which could unnecessarily lead to multiple punctures despite difficult insertion. This mishap can be prevented by transducing the arterial line along with ABG estimation.

Declaration of patient consent

The authors certify that they have obtained all appropriate patient consent forms. In the form, the legal guardian has given his consent for images and other clinical information to be reported in the journal. The guardian understands that names and initials will not be published and due efforts will be made to conceal identity, but anonymity cannot be guaranteed.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.



 
  References Top

1.
Garg, R, Pandey, R, Darlong, V, Punj, J. Radial artery cannulation—prevention of pain and tenchniques of cannulation: review of the literature. Internet J Anesthesiol. Available from: http://www.ispub.com/journal/the-internet-journal-of-anesthesiology/volume-19-number-1/radial-artery-cannulation-prevention-of-pain-and-techniques-of-cannulation-review-of literature. html#sthash. jK4Hk64k.dpbs. [Last Accessed on 2020 Jun 01].  Back to cited text no. 1
    
2.
Eiting E, Kim HT. Arterial puncture and cannulation. In: Roberts JR, Custalow CB, Thomsen TW, editors. Roberts and Hedges' Clinical Procedures in Emergency Medicine and Acute Care. 7th ed. Philadelphia: Elsevier; 2019. p. 377-93.  Back to cited text no. 2
    
3.
Scheer B, Perel A, Pfeiffer UJ. Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care 2002;6:199-204.  Back to cited text no. 3
    
4.
Anantasit N, Cheeptinnakorntaworn P, Khositseth A, Lertbunrian R, Chantra M. Ultrasound versus traditional palpation to guide radial artery cannulation in critically Ill children: A randomized trial. J Ultrasound Med 2017;36:2495-501.  Back to cited text no. 4
    
5.
Schindler E, Kowald B, Suess H, Niehaus-Borquez B, Tausch B, Brecher A. Catheterization of the radial or brachial artery in neonates and infants. Paediatr Anaesth 2005;15:677-82.  Back to cited text no. 5
    


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Abstract
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