Ultrasound vs Landmark Guided Radial Artery Line Placement in the Emergency Department

• Published in: The Journal of emergency medicine Vol. 64; no. 3; pp. 411 - 412
• Main Authors: Zanaboni, Allison, Patterson, Jessica, Gibbons, Ryan C., Costantino, Thomas G.
• Format: Journal Article
• Language: English
• Published: Elsevier Inc 01.03.2023
• ISSN: 0736-4679; 2352-5029
• DOI: 10.1016/j.jemermed.2023.03.003

The primary objective of this study is to compare ultrasound guided (USG) and landmark guided (LMG) radial arterial line cannulation by novice emergency medicine interns with respect to success. Secondary objectives include number of attempts, time to completion, and complications. Over ten million arterial lines are placed annually worldwide, many of which happen in the emergency department. Radial arterial lines are utilized five times more often than common femoral lines and ten times more frequently than axillary ones. Prior to the introduction of point of care ultrasound, landmark guided palpation was considered standard of care. However, anatomic landmarks are not helpful in 30% of patients. This was an IRB-approved single-center, prospective, randomized clinical trial (NCT03326739) of a convenience sample of adult patients who presented to an urban, university hospital with over 105,000 visits annually. There was no funding for this study. Patients who required an arterial line were randomized into LMGP or USG groups. Novice emergency medicine interns, defined as <15 previous placements, performed the cannulation. Statistical analyses included t and Fisher exact tests. The sample size calculation of 38 was based on a power of 80% with an estimated difference of successful placement of 40% between techniques based on previous literature. Forty patients were enrolled with 20 patients randomized to each group. USG had a first-pass success of 75% vs. 0% for LMGP (p < 0.00001) and an overall success of 100% vs. 15% for LMGP (p < 0.00001), a mean of 1.30 attempts vs. 2.95 attempts for LMGP (a difference of 1.65; p < 0.0001), and a mean time for placement of 264 s vs. 524 s for LMGP (a difference of 260; p = 0.0025). Of the failed LMGP, USG crossover was 100% successful with a mean of 1.37 attempts (95% confidence interval 0.58–2.16) and 180 s for placement (95% confidence interval 97.92–262.08). Five percent of LMGP had a complication vs. 0% for USG (p = 1.0). USG improved first-pass and overall success of radial arterial line cannulation while reducing time to access and attempts when used by novice emergency medicine interns.