Download Long-term Arterial Cannulation in ICU Patients Using the Radial

Long-term Arterial Cannulation in ICU
Patients Using the Radial Artery or
Dorsalis Pedis Artery*
Claude Martin, MD, FCCP; Pierre Saux, MD; Laurent Papazian, MD; and
François Gouin, MD
Study objectives: To evaluate the rate of arterial thrombosis and catheter-related infection
following radial artery or dorsalis pedis artery (DPA) cannulations lasting > 4 days.
Design: Prospective, observational study of two cohorts of ICU patients.
Setting: ICU of a university hospital.
Patients: In a first group of 131 consecutive patients, the DPA was selected for arterial
cannulation. In the second group, 134 consecutive patients were considered for radial artery
cannulation.
Measurements and results: In the DPA group, the overall success rate for catheter placement was
85%. Patients were cannulated for 16 ⴞ 5 days (mean ⴞ SD). In the radial artery group, the
overall success rate was 97.7% (129 of 132 patients; p < 0.0001 vs DPA group). Patients were
cannulated for 13.3 ⴞ 4.0 days. In both groups, no signs of ischemia were detected at the clinical
examination. In the DPA group, no thrombosis was detected at the angiographic examination in
21 patients (38%), a thrombosis without vessel obstruction was observed in 21 patients (31%), and
a thrombosis with vessel obstruction was observed in 21 patients (31%). In the radial artery
group, no thrombosis was observed in 31 patients (24%; not significant vs DPA group), a partial
thrombosis was found in 73 patients (57%), and a total thrombosis with vessel obstruction was
found in 25 patients (19%). Two cases of catheter-related infection were observed in the DPA
group. In the radial artery group, four cases of catheter-related infection were diagnosed vs DPA
group (not significant).
Conclusions: The rate of serious complications was similar for both sites of arterial cannulation.
Accepting a 12.7% lower rate of successful placement, the DPA route provides a safe and easily
available alternative when radial arteries are not accessible.
(CHEST 2001; 119:901–906)
Key words: arterial cannulation; dorsalis pedis artery; invasive monitoring; radial artery
Abbreviation: DPA ⫽ dorsalis pedis artery
most frequently used site for direct arterial
T hecannulation
and BP measurement is the radial
artery.1–5 Cannulation of this artery also makes it
possible to draw blood samples for blood gas analysis. Other sites, such as the dorsalis pedis artery
(DPA), have been used.6 –12 Percutaneous cannulation of the DPA has been demonstrated as being
easy to perform and safe for short-term monitoring
of BP.6 –12 Arterial thrombosis, with subsequent ischemia, and catheter-related infections are the most
severe complications following intra-arterial cannulation.13–18 Experience for many years with long*From the ICU and Anesthesia Department, Marseilles School of
Medicine and Hopital Sainte Marguerite, Marseille, France.
Manuscript received December 22, 1999; revision accepted
August 14, 2000.
Correspondence to: Claude Martin, MD, FCCP, Hopital Nord,
Reanimation, 13915 Marseille, Cedex 20 France; e-mail:
[email protected]
term DPA cannulation at our institution has been
very satisfactory, this arterial route being easy to
catheterize and clinically safe. To our knowledge,
there has been no large-scale prospective study
specifically examining the risks of long-term DPA
cannulation in ICU patients. This prospective study
was designed to compare the rates of arterial thrombosis and catheter-related infection following radial
or DPA catheterizations lasting ⱖ 4 days in ICU
patients.
Materials and Methods
After institutional approval and informed consent from the
closest relatives were obtained, two consecutive groups of ICU
patients were considered for inclusion in the study.
In the first group, all patients were selected to undergo DPA
percutaneous cannulation (the DPA group) for monitoring purposes and to facilitate drawing of arterial blood samples. ExcluCHEST / 119 / 3 / MARCH, 2001
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901
sion criteria were as follows: diabetes mellitus, arteriosclerotic
disease of the leg, and age ⬎ 70 years. The DPA was not palpable
in 4 of the 131 patients investigated. In order to check for
collateral flow, the patient was placed in the supine position and
the DPA was occluded with external pressure; the great toe was
blanched by compressing the toenail. Then, the nail pressure was
released and rapid return to color indicated adequate lateral
plantar flow. If return of color was not rapid (⬍ 7 s), the patient
was not cannulated. This was the case in two patients who did not
undergo arterial cannulation. Thus, the 125 remaining patients
were included in the present study.
In the second group, all patients underwent radial artery
cannulation (the radial artery group). Allen’s test was performed
in order to check for collateral flow. In two patients, collateral
circulation was not considered adequate and they did not undergo arterial cannulation. The 132 remaining patients were
evaluated in the present study and compared with the patients in
the DPA group.
All patients were catheterized with a 22-gauge polyethylene
cannula (Leader Cath 115; Vygon; Ecouen, France). The skin was
prepared with a iodine solution (Bétadine; Sarget, France) and
allowed to dry. The operator wore gloves, mask, hat, and surgical
suit. Sterile drapes were used to protect the insertion zone. The
arteries were cannulated using Seldinger’s technique. The artery
was punctured percutaneously as for IV cannulation. After
insertion, the catheter was firmly secured to the skin with a
suture and covered by a standard occlusive dressing. No antibiotic ointment was used. The foot was left in the neutral position.
Radial artery cannulation was performed with the hand supinated
and the wrist turned upward at a 60° angle. Dressings were
changed daily by a team a nurses trained in catheter management. The insertion site was disinfected with an iodine solution
and the stopcocks were changed daily by a nurse wearing sterile
gloves, hat, and face mask. Each manipulation of the line and all
samples were performed with a gauze impregnated with the same
iodine solution, but gloves were not necessarily used for samples.
In order to maintain patency of the catheter, a continuous
infusion of heparinized (50 IU/mL) 0.9% saline solution was
maintained at a constant flow rate of 3 mL/h (Intraflow; Vygon).
After catheter insertion, the physician performing the procedure
collected the following information: the number of puncture
attempts, the time of catheter insertion, whether or not the vessel
was transfixed, and use of local anesthetic.
During catheter use, patients were monitored by a team of
ICU physicians and trained ICU nurses. Each patient was
examined for signs of ischemia, distal embolization, skin necrosis,
and evidence of infection. Body temperature was checked six
times daily; when a catheter-related infection was suspected, the
cannula was withdrawn and blood cultures were obtained by
venipuncture. The criteria for catheter-related infections were as
follows: (1) for catheter-related infection, positive results of
culture of the tip (ⱖ 1,000 cfu), no other identified source of
infection, and at least partial resolution of the septic syndrome
within 48 h after catheter removal (reduction in body temperature and in WBC count); (2) for catheter colonization, positive
results of culture of the tip (ⱖ 1,000 cfu) and septic syndrome, if
present, fully explained by an identified source; and (3) for no
catheter infection, no growth, or ⬍ 1,000 cfu of the catheter tip
and septic syndrome, if present, fully explained by a known
source.
Bacteremia was considered catheter related if the same organism was isolated from the catheter tip culture and from blood
collected by venipuncture. All catheter tips were cultured at the
time of catheter removal.
Catheters were removed for the following reasons: suspicion of
catheter-related sepsis, catheter no longer necessary or obstructed, or death of the patient. Catheters were never changed
routinely or over guidewires. Catheters were removed aseptically
with a sterile forceps after local disinfection with the iodine
solution. The distal 5- to 6-cm catheter segment was cut and sent to
the microbiology laboratory in a sterile dry glass tube. Cultures were
performed as described by Cleri et al19 and modified by BrunBuisson et al.20 All colony types were identified by colony morphology, Gram’s stain, and standard microbiological techniques.
While the catheters were in use, the following items were
prospectively recorded in addition to catheter-related infection:
episodes of collapse (drop in systolic BP ⱖ 40 mm Hg), use of
cardioactive and vasoactive drugs, and number of arterial blood
samples.
Radial artery and DPA thrombosis was diagnosed by bedside
angiography performed by a staff radiologist immediately prior to
decannulation. Ten milliliters of contrast solution (Hexabrix;
Omnium Medical; Paris, France) were injected through the
cannula while an radiograph was taken of the ankle and foot, or
the hand and wrist. Angiograms were interpreted by another staff
radiologist with no clinical information. The amount of thrombosis visible in the arterial vessel was graded as follows: grade 0, no
thrombosis; grade 1, thrombosis without vessel occlusion; or
grade 2, vessel obstructed by the thrombus.
Angiograms were obtained in the last 67 patients in the DPA
group (at that time, the radiologist team was reinforced and a
staff radiologist could come to the ICU when required) and in the
129 patients who underwent radial artery cannulation.
Statistical Analysis
Data are presented as mean ⫾ SD. Statistical analysis consisted of paired or unpaired t tests with two-tailed probabilities to
make comparisons between the natural frequency data. Categorical variables were evaluated with a ␹2 test. Differences with a
probability of ⱕ 0.05 were considered as significant.
Results
Table 1 shows the clinical characteristics of the
study patients. The two groups of patients were
similar at study entry for the evaluated parameters.
Conditions of catheter placements are presented
Table 1—Clinical Characteristics*
Characteristics
DPA Radial Artery
Group
Group
(n ⫽ 131) (n ⫽ 134)
Patients with palpable artery and adequate
125
collateral circulation, No.
Males/females, No.
71/54
Age, yr
56 ⫾ 16
Weight, kg
63 ⫾ 11
ICU admission, No. of patients
Acute respiratory failure
67
Shock state
37
Neurologic crisis
21
APACHE II score
17 ⫾ 5
McCabe score, No. of patients
1
61
2
40
3
24
132
96/36
57 ⫾ 12
64 ⫾ 11
71
41
20
16 ⫾ 4
71
46
15
*Data are presented as mean ⫾ SD unless otherwise indicated.
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Clinical Investigations in Critical Care
in Table 2. A higher success rate of placement was
achieved with radial artery catheter (p ⬍ 0.0001). In
an “intention-to-treat” approach, the success rate
was 80.9% (106 of 131 patients) in the DPA group
and 96.3% (129 of 134 patients) in the radial artery
group (p ⬍ 0.0001). During the cannulation period,
42 ⫾ 4 (range, 6 to 178) arterial blood samples were
collected in the DPA group, and 38 ⫾ 5 (range, 5 to
155) samples were collected in the radial artery
group (not significant). In the DPA group, patients
were cannulated for 16 ⫾ 5 days (range, 4 to 54
days), 45 of 125 patients (36%) for 4 to 10 days, 51 of
125 patients (41%) for 11 to 20 days, and 29 of 125
patients (23%) for ⬎ 20 days. In the radial artery
group, the length of cannulation was 13.3 ⫾ 4.0 days
(range, 4 to 51 days), 51 of 132 patients (39%) for 4
to 10 days, 58 of 125 patients (44%) for 11 to 20 days,
and 23 of 125 patients (17%) for ⬎ 20 days.
On angiographic examination, no case of DPA
thrombosis was observed in 25 of 67 patients (38%).
Grade 1 thrombosis was observed in 21 of 67
patients (31%; Fig 1), and grade 2 thrombosis was
observed in 21 of 67 patients (31%; Table 3). In the
radial artery group, vessel thrombosis was not observed in 31 of 129 patients (24%; not significant vs
DPA group; Table 3). Grade 1 thrombosis was
observed in 73 of 129 patients (57%), and grade 2
thrombosis was observed in 25 of 129 patients (19%;
Fig 2; p ⫽ 0.009 when comparing the rate of grade 1
vs grade 2 thrombosis between the two groups). All
thromboses were clinically asymptomatic in both
groups, and no signs of ischemia were observed in
the 125 study patients in the DPA group and the 132
patients in the radial artery group who fulfilled the
clinical evaluation (the patients who failed to be
catheterized were clinically followed up). The occurrence of DPA or radial artery thrombosis was not
associated with the duration of arterial cannulation
(Table 1) or with the other studied parameters
(Table 4).
In the DPA group, pathogenic bacteria grew in 12
Table 2—Conditions of Arterial Catheter Placement in
the Two Groups*
Conditions
DPA
Group
(n ⫽ 125)
Radial
Artery
Group
(n ⫽ 132)
Success
Fewer than three puncture attempts
No. of puncture attempts
Time for catheter placement, min
Range
106 (85)
86 (69)
1.9 ⫾ 0.9
9.5 ⫾ 4
2–16
129 (97.7)
99 (77)
1.2 ⫾ 0.7
7.6 ⫾ 3
1–35
*Data are presented as No. (%) or mean ⫾ SD unless otherwise
indicated.
Figure 1. Angiographic examination of the DPA performed at
the patient’s bedside immediately prior to decannulation. A grade
1 thrombosis was diagnosed: intravascular thrombosis without
vessel obstruction.
of 106 catheter tips (11%) and was responsible for
catheter colonization in 10 patients. Isolated bacteria
were Staphylococcus epidermidis (six patients),
Pseudomonas aeruginosa (three patients), Streptococcus (two patients), and Staphylococcus aureus
(one patient). No case of catheter-related bacteremia
Table 3—Rate of Arterial Thrombosis in the DPA and
the Radial Artery Groups and Influence of the Length
of Cannulation*
Groups
Grade 1,
Partial
Thrombosis
Grade 2,
Complete
Thrombosis
25 (38)†
18 ⫾ 6
21 (31)‡
14 ⫾ 6
21 (31)‡
13 ⫾ 7
4/25
11/25
10/25
8/21
6/21
7/21
9/21
6/21
6/21
31 (24)†
14 ⫾ 5
73 (57)‡
13 ⫾ 5
25 (19)‡
12 ⫾ 6
11/31
7/31
13/31
21/73
28/73
24/73
9/25
7/25
9/25
No
Thrombosis
DPA group (n ⫽ 67)
Thrombosis
Duration of
cannulation, d
Length of cannulation
and thrombosis rate,
No./total patients§
4–10 d
11–20 d
⬎20 d
Radial artery group
(n ⫽ 129)
Thrombosis
Duration of
cannulation, d
Length of cannulation
and thrombosis rate,
No./total patients§
4–10 d
11–20 d
⬎20 d
*Data are presented as No. (%) or mean ⫾ SD unless otherwise
indicated.
†No significant differences between the DAP and the radial artery
groups (p ⫽ 0.074) when comparing the rate of thrombosis (grade
1 and 2) vs no thrombosis.
‡p 0.009 when comparing the rate of grade 1 vs grade 2 thrombosis
between the two groups.
§No influence of the length of cannulation on the rate of arterial
thrombosis was detected.
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Figure 2. Angiographic examination of the radial artery performed at the patient’s bedside immediately prior to decannulation. A complete (grade 2) thrombosis was diagnosed; only the
arterial catheter was opacified by the contrast solution.
and two cases of catheter-related infection were
observed in this group of patients. In the radial artery
group, 12 pathogenic bacteria grew on the 129
cultured catheters (9.3%). Isolated bacteria were
S epidermidis (eight patients), S aureus (two patients),
Klebsiella pneumoniae (one patient), and P aeruginosa
(one patient). No case of catheter-related bacteremia
was diagnosed. Bacteria were considered responsible
for four cases of catheter-related infection.
Discussion
In the present study, which evaluated two consecutive groups of patients catheterized via the DPA or
the radial artery, the rate of serious complications
(arterial thrombosis and infection) was quite similar
for both sites of arterial cannulation. A higher rate of
asymptomatic grade 2 arterial thrombosis (angiographic examination) was observed in the DPA
group.
Johnstone and Greenhow21 recommended cathe-
terization of the DPA as a safe and reliable alternative to cannulation of the radial artery. The arterial
supply to the foot is from the DPA, the posterior
tibial artery, and the malleolar network. In previous
studies, the DPA could not be palpated in 3 to 14%
of subjects.9,10,22 In the study by Husum et al,8 the
DPA was palpable in all patients; in the present
study, it was palpable in 127 of 131 patients. Anatomic studies23 have shown that DPA is absent in 3
to 12% of subjects. The main arterial arch of the foot
(the plantar artery) is supplied by the DPA and the
lateral plantar arteries, analogous to the radioulnar
communication in the volar arch of the hand. Thus,
should the DPA be damaged following lengthy cannulation, collateral flow is available.
It is suggested21 that the adequacy of sufficient
collateral circulation can be evaluated by observing
capillary refilling on release of great toe compression. We performed this test prior to cannulating our
patients, but it may be difficult to interpret when the
feet are cold or in states of vasoconstriction. Spoerel
et al7 found that 16% of subjects had a DPA that
carries almost the entire flow to the toes. As judged
from a decrease in arterial pressure in the great toe
to ⬍ 40 mm Hg after manual compression of the
DPA, the frequency of inadequate collateral supply
is 2 to 21%, increasing with age.8,10 From our
experience, the clinical test that we use to evaluate
collateral circulation at the foot is adequate for
clinical use, despite its limitations.21
With regard to radial artery cannulation, the value
of Allen’s test in predicting potential ischemic damage after cannulation is a matter of controversy. The
original test described in 1929 was for the purpose of
evaluating palmar collateral circulation in thromboangiitis obliterans.24 In the study by Slogoff et al,25
the test was performed in 411 of 1,699 patients; ulnar
collateral circulation was absent in 16 patients who
underwent arterial cannulation with no ischemic
complication. Projecting this 4% incidence to their
Table 4 —Factors Potentially Associated With the Occurrence of DPA or Radial Artery Thrombosis
No Thrombosis (n ⫽ 25)
Factors*
Age ⬎65 yr, %
Male/female gender, %
Episode collapsus, %
Use vasoactive agents, %
More than three puncture attempts, %
Time for catheter insertion, min, mean ⫾
SD
Vessel transfixed, %
Positive culture of catheter tips, %
Thrombosis (Grades 1 and 2)
DPA Group
(n ⫽ 25)
Radial Artery
Group (n ⫽ 31)
DPA Group
(n ⫽ 42)
Radial Artery
Group (n ⫽ 98)
29
59/41
37
43
28
9⫾5
27
64/36
41
49
28
7⫾4
29
52/48
26
52
33
8⫾4
31
70/30
33
47
21
8⫾6
34
9
37
13
30
13
39
9
*None of these factors were significantly related to arterial thrombosis.
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Clinical Investigations in Critical Care
entire population, 68 patients were cannulated without suffering ischemic damage. The conclusion was
that the test was not predictive of ischemia in the
absence of vascular disease. However, Allen’s test
can be improperly performed, and complete extension of the hand with wide separation of the fingers
will occlude the transpalmar arch, resulting in an
incorrect interpretation of the test. The modified
test, avoiding hyperextension of the wrist and fingers,
allows a better evaluation of the dual palmar arterial
circulation of the hand and is recommended in our
institution.26
Our success rate of 85% of attempted cannulation
compares well with those reported by Johnstone and
Greenhow (51%),21 Youngberg and Miller (87%),6
and Husum et al (80%).8 The success rate was higher
(97.7%) following radial artery cannulation and similar to that reported in the largest study on radial
artery cannulation (95.4%).25 The rate of DPA
thrombosis was 64% in the present study. It is much
higher than that reported after short-term cannulation. Spoerel et al7 observed no such complication in
⬎ 100 patients cannulated for the duration of neurosurgical procedures. However, they did not quote
the frequency of thrombosis of the artery.
By Doppler flow technique, Youngberg and Miller6
found a 6.7% rate of thrombosis following a mean
cannulation time of 492 min. Using the same technique, Husum et al8 reported a 25% thrombosis rate
despite a median cannulation time of only 160 min.
Naguib et al11 reported a 14% rate of DPA thrombosis
diagnosed by a bidirectional Doppler velocimeter
probe. The reported incidence of radial artery occlusion following cannulation varies from 0 to 79% using
different techniques (Doppler ultrasound, angiography). The possible influence of cannula equipment, the
number of puncture attempts, the duration of cannulation, the occurrence of hematoma, and the wrist
circumference have all been investigated.25,27–36 It is of
interest to note that in the largest study25 on the risk of
radial artery cannulation, the authors were unable to
identify any risk of serious ischemic complication and
they reported a high incidence of arterial thrombosis
(⬎ 25%). In a large study of 1,000 patients, Mandel and
Dauchot29 reported a similar incidence (24.3%) of
abnormal radial artery flow using a Doppler ultrasonic
flowmeter. Bedford30 reported a 29% incidence of
occlusion in cannulations lasting 4 to 10 days in ICU
patients. The rate of radial artery thrombosis was 76%
in the present study and similar to that observed
following DPA cannulation (62%). In the present
study, none of the 257 evaluated patients had clinical
signs of skin ischemia in their feet or hands. This
strongly suggests that despite the high risk of partial or
complete occlusion of the DPA or radial artery after
cannulation with a polyethylene catheter, the blood
supply to the great toe or the fingers was not jeopardized and there were no important clinical consequences of thrombosis. Materials that are more biocompatible than polyethylene are available, and as for
radial artery cannulation, the use of Teflon or polyurethane catheters may be followed by a lower rate of
arterial thrombosis.27,28 For instance, using Teflon cannula, Naguib et al,11 in the only study comparing radial
and DPA cannulation, report a 14% rate of vessel
occlusion in the DPA group, which favorably compares
with the 12% rate observed after radial artery cannulation.
In present study, we evaluated the infectious risk
following long-term cannulation of the DPA and the
radial artery. The catheter colonization rate was low
(10 of 106 catheters), as well as the rate of catheterrelated sepsis (2 of 106 cases) and that of catheterrelated bacteremia (0 of 106 cases) after DPA decannulation. This low rate of infectious complication
can be explained by the use of maximal aseptic
precautions during catheter placement and by a
team of trained nurses for catheter management. For
the same reasons and since the same maintenance
protocols were used, a low rate of infectious complication was observed following radial artery cannulation. In the study by Naguib et al,11 the DPA
contamination rate was 19%, close to that observed
in the group of patients who underwent radial artery
cannulation (16%). In our study, the rate of contamination was less than that previously reported after
arterial or venous catheterization.15,16,18 This
strongly suggests that provided adequate management during catheter placement and utilization, the
infectious risk following DPA or radial artery cannulation is very low. One limit to the conclusions of the
present study is the absence of randomization. This
was due to the fact that it was not until that the study
was already begun that the radiologist team was
reinforced and a staff radiologist could come to the
ICU at each time of catheter removal.
Conclusion
With the increasing use of invasive arterial techniques, the DPA provides a safe and easily available
alternative to the radial artery. In the present study,
conducted in two groups of ICU patients being
catheterized via the DPA or the radial artery, the
rate of serious complications was similar for both
sites of cannulation. Our findings suggest that the
DPA route can be used in ICU patients for longterm monitoring. The DPA route is especially useful
when immobilization of a patient’s hand is undesirable or when both radial arteries are inaccessible due
to extensive trauma, burns, or damage from previous
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catheterizations. Since in older patients and in diabetic patients arteriosclerosis may adversely affect
the collateral circulation in the foot, cannulation of
DPA should be considered with caution in these
patient groups.
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Clinical Investigations in Critical Care