ORIGINAL CONTRIBUTION arterial access, pediatric; catheterization
Arterial Access in the Pediatric Emergency Department Arterial catheters are used frequently to monitor critically ill children in ICUs, but their role in the emergency department has not been described. The medical records of all patients admitted to the ICU from the ED of a children's hospital during a 30-month period were reviewed retrospectively. Forty-one patients were identified as having arterial catheters placed in the ED. Catheterization was performed for serial blood gas determinations (59%) or continuous blood pressure mordtoring (41%). The radial artery was catheterized in 73% of the 41 patients, and a 22-gauge catheter was used in 78% of the patients. The original catheter was discontinued before the end of medical indication in only 24% of cases 17% were discontinued for failure to draw and 7% for vascular changes at the site of the catheter. We conclude that arterial access can be used for children in the ED to monitor blood pressure and that blood gas tensions and complications are few and generally minor. [Saladino R, Bachman D, Fleisher G: Arterial access in the pediatric emergency department. Ann Emerg Med April 1990;19:382-385.]
INTRODUCTION Indwelling arterial catheters are used routinely to monitor critically ill children in ICUs. Arterial catheterization allows continuous observation of cardiovascular function and ready access to arterial blood for serial sampling. Although the advantages and complications of arterial catheters have been examined in pediatric ICU settings, u6 their role in the emergency department has not been described. The purpose of our study was to determine the indications for arterial access in an ED setting and to examine the duration and outcome of the catheterizations.
Richard Saladino, MD David Bachman, MD Gary Fleisher, MD Boston, Massachusetts From the Division of Emergency Medicine, The Children's Hospital, Boston, Massachusetts. Received for publication July 17, 1989. Revision received November 2, 1989. Accepted for publication November 9, 1989. Presented at the Ambulatory Pediatrics Association Annual Meeting in Washington, DC, May 1989. Address for reprints: Richard Saladino, MD, Division of Emergency Medicine, The Children's Hospital, 300 Longwood Avenue, Boston, Massachusetts 02115.
METHODS The admission log books of both the medical/surgical units and the cardiac ICUs of The Children's Hospital in Boston were examined; all children with arterial catheters were admitted to one of these areas. All patients who were admitted to the ICU from the ED from July 1986 through December 1988 were eligible for inclusion in the study. Data collected from the medical records included age, diagnosis on admission, indication for arterial catheterization, site and technique of catheter placement, catheter size and duration in situ, level of training of the physician placing the catheter, and reasons for discontinuation of the line. The data were analyzed with SPSS statistical software on a microcomputer. Continuous variables were analyzed with the Mann-Whitney U test, and categorical data were analyzed with the X2 test. For correlations, Pearson's coefficient was used.
RESULTS During the 30 months of review, 41 of 418 patients admitted to the ICU from the ED were identified as having arterial catheters placed while in the ED. The ages of these patients ranged from 1 month to 36 years (mean age, 9 years -+ 94 months [SD]; median age, 7 years and 10 months). Intraarterial catheters were inserted in patients throughout the pediatric age range (Figure). Diagnostic categories on admission to the ED included respiratory disease in 22 of 41 patients (54%), shock in ten (24%), multiple
19:4 April 1990
Annals of Emergency Medicine
382/67
ARTERIAL ACCESS Saladino, Bachman & Fleisher
FIGURE. Age distribution of 41 children in w h o m arterial catheters were placed in the ED.
trauma in six (15%), cardiorespiratory arrest in one (2.4%), burns in one (2.4%), a n d d y s r h y t h m i a in o n e (2.4%). T h e i n d i c a t i o n for p l a c e m e n t of the arterial catheter was need for serial blood gas determinations in 24 of 41 p a t i e n t s (59%) and c o n t i n u o u s b l o o d p r e s s u r e m o n i t o r i n g in 16 (41%). Patients w h o required arterial c a t h e t e r i z a t i o n for serial blood gas determinations were significantly older than those w h o required catheterization for continuous blood pressure m o n i t o r i n g (10 years and 11 m o n t h s vs 6 years and 5 months; P = .02). The site of arterial catheterization was the radial artery in 30 of 41 patients (73%), the dorsalis pedis artery in six (15%), and the femoral artery in five (12%). C a t h e t e r size was 24 gauge in one of 41 patients (2.4%), 22 gauge in 32 (78%), 20 gauge in six (15%), and 18 gauge in two (4.9%). The t e c h n i q u e used for c a t h e t e r placement was percutaneous in all cases; the Seldinger catheter-overthe-wire m e t h o d was used for the five catheters placed into the femoral artery. T h e arterial catheters were placed by pediatric residents in ten of 41 patients (25%), by pediatric emergency medicine fellows in 12 (29%), and by attending staff in 19 (46%). The mean n u m b e r of days that the original arterial catheter remained in situ was 1.9 (+ 1.7), with a range of from one to nine days. No correlation was found between age and duration of catheterization. The original catheter was removed on end of medical indication in 31 of 41 patients (76%). Five patients died with the IV line in situ, and one patient was transferred to a specialized burn facility with the arterial catheter in place. Seven catheters were discontinued for failure to draw (17%), and three were removed for vascular changes at the site (7%). Vascular changes consisted of persistent blanching of skin at or distal to the site of entry of the catheter. There was no significant difference in m e a n age between patients with catheters discontinued before the end of medical indication and those disc o n t i n u e d at the r e s o l u t i o n of the medical indication. Children younger 68/383
No. of Intra-arterial Catheters
4iiD 0
i 18
through the use of arterial catheteri z a t i o n is a w i d e l y a c c e p t e d proc e d u r e in c r i t i c a l l y ill p a t i e n t s treated in the intensive care setting. Results of our study indicate that arterial catheters m a y be placed in children in the ED, b o t h to m o n i t o r blood pressure and to allow for frequent blood sampling for blood gas analyses and other laboratory tests. Insertion was achieved in children of all ages, including the first year of life. The duration of catheterization after leaving the ED (range, one to nine days; mean, 1.9 days) attests to the usefulness of arterial access in these patients. S e v e r a l s t u d i e s h a v e b e e n performed to assess the risks compared with the benefits of arterial catheterization in critically ill adults. 7-11 The most serious complication of arterial catheterization is thrombosis of the vessel. Using physical examination and Doppler ultrasound flow studies, Bedford and Wollman 9 found thrombotic occlusion in 40 of 105 radial artery catheterizations (38%). Arterial occlusion occurred in 25% of 43 vessels c a t h e t e r i z e d for less t h a n 20 hours, 50% of 40 vessel catheterizations lasting from 20 to 40 hours, and 46% of 22 c a t h e t e r i z a t i o n s lasting from 40 to 144 hours. All vessels recannulated; no major ischemic complications were noted. Puri et al 7 reported decreased arterial flow in four of 59 femoral artery c a t h e t e r i z a t i o n s and an additional four instances of bleeding and hema19:4 April t990
TABLE 1. Data on arterial catheters discontinued for failure to draw
Age (yr/mo)
Catheter (gauge)
12/9
22
Radial
21/7
22
Dorsalis pedis
10/9 20/8
22 22
Radial Radial
15/6
22
Radial
t8
Femoral
22
Radial
10/5 3/11
Site
TABLE 2. Data on arterial catheters discontinued because of vascular changes
Age (yr/mo)
Catheter (gauge)
7/10
22
Radial
8
22
Dorsalis pedis
2/11
18
Femoral
toma formation at the site; this gave an overall complication rate of 14%. Gardner et ab o reported, on followup, detectable flow reduction at the site of catheter insertion in 17% and absent flow in 2% of 280 patients. All authors agreed that factors that increased the risk for thrombosis included duration in situ of more than five to seven days, low-flow states such as hypotensive-episodes, surgical cutdown technique, and use of vasoconstrictive agents. The risk of infection associated with indwelling arterial lines also is well described in the adult literature. Systemic catheter-related infections have been reported to occur in from 0% to 5% of cases, although local infection has been seen in from 4% to 18% of patients with arterial catheters.g, lo Risk factors included extended duration of catheterization, surgical cutdown technique, and deviation from sterile technique. In no reports were the complication rates considered to preclude the use of arterial catheters for monitoring critically ill patients. Studies in children show complications of arterial catheterization similar to those observed among adults. Miyasaka et all found radial artery obstruction by Doppler flow studies in 51% of 53 catheterizations. All vessels had recannulated by ten days,
19:4 April 1990
Site
Smith-Wright et al 3 found only three instances of arterial obstruction in 330 catheterizations. These and other studies describe local infection at the site of catheterization in from 0% to 4% of cases; no c a t h e t e r - r e l a t e d sepsis was reported.3,5, 6 Overall, complications were found to occur with greater frequency in children younger than 5 years old. 3 Other risk factors included prolonged catheterization beyond four to six days, cutdown technique of catheter placement, hypotension, and use of vasoconstrictive agents.l,3, 5 The data in the literature that examine arterial catheter use and complications are studies of arterial catheters placed in the surgical operating room or the ICU. The percentage of arterial catheters that were placed in our ED and were discontinued before the end of medical indication (24%) is compatible with the complication rates of from 4% to 40% found in the literature. Our study demonstrates the feasibility of arterial access in the ED, but invasive and noninvasive monitoring were not directly compared. N o n i n v a s i v e m o n i t o r i n g of blood pressure, t r a n s c u t a n e o u s o x y g e n measurement, pulse oximetry, and end-tidal CO 2 monitoring are currently available in many EDs. Each of these modalities has value as well as
Annals of Emergency Medicine
limitations. Transcutaneous oxygen monitoring is very reliable in the neonate but has been shown to correlate less well with Pao2 values in the older child and adult.t~, 13 Pulse oximetry has been shown to be accurate within 2% of measured oxygen saturation, but accuracy may be affected by low-flow states and hypothermia.~3,14 T h e s e m e t h o d s are valuable indicators of trends but, because of their dependence on cardiac output, may at times be qualitative rather than quantitative monitors of the critically ill patient. End-tidal CO2 monitoring is a useful guide to the adequacy of CPR 15 but is reliable only in the intubated patient. Blood pressure obtained by Doppler sonography is often unreliable, especially in small children. Because of these limitations, there was a need to use invasive monitoring of critically ill or injured children in our ED. This is similar to experiences in other settings where critically ill or injured p a t i e n t s are treated, such as the ICU and operating room. Regardless of the site within the hospital where such monitoring is used, reliable and wellm a i n t a i n e d e q u i p m e n t as well as trained personnel are essential to the appropriate application of invasive monitoring. Noninvasive monitoring decreases the use of arterial catheters but does not obviate the need for arterial access in selected patients. CONCLUSION Care of critically ill and injured children in an ED often requires reliable and continuous observation of blood pressure and/or serial arterial blood sampling for blood gas analysis and measurement of glucose, electrolytes, or other parameters. Because of the technical difficulties associated with repeated arterial blood sampling and the l i m i t a t i o n s associated at times with noninvasive blood pressure monitoring in small, critically ill children, arterial catheterization m a y be n e c e s s a r y to a c c o m p l i s h these goals. Our study demonstrates the feasibility of arterial catheterizations in the ED. The procedures were performed by physicians at a variety of training levels and the complications were few, as previously reported from several ICUs. Considering the potential mortality of children who are critically ill or injured, the risk of arterial access
384/69
ARTERIAL ACCESS Saladino, Bachman & Fleisher
is outweighed by the value of the information that can be obtained from catheterization.
5. D a m e n J, Van Der Tweel I: Positive tip culture and related risk factors associated w i t h intravascular catheterization in pediatric cardiac patients. Crit Care Med 1988;I8:221-228.
REFERENCES
6. Ducharme F, Gauthier M, Lacroix J, et al: Incidence of infection related to arterial catheterization in children: A prospective study. Crit Care Med 1988;18:272-276.
1. Miyasaka J, Edmonds J, Conn A: Complications of radial arterial lines in the pediatric patient. Can Anaesth Soc J 1976;23:9-14. 2. Edmonds J, Barker G, Conn A: Current concepts in cardiovascular monitoring in children. Crit Care Med 1980;8:548-553. 3. S m i t h - W r i g h t D, G r e e n T, Egar M, et al: C o m p l i c a t i o n of v a s c u l a r c a t h e t e r i z a t i o n in c r i t i c a l l y ill c h i l d r e n . Crit Care Med 1984; 12:1015-1017. 4. Todres I, Rogers M, Shannon D, et al: Per k cutaneous catheterization of the radial artery in the c r i t i c a l l y ill n e o n a t e . J Pediatr 1975;87: 273-275.
70/385
7. Puri V~ Carlson R, Bander J, et al: Complications of vascular catheterization in the critically ill. Crit Care Med 1980;8:495-499. 8. Band J, Maki D: Infections caused by arterial c a t h e t e r s used for h e m o d y n a m i c monitoring. Am J Mecl 1979;67:735-741. 9. Bedford R, W o l l m a n H: C o m p l i c a t i o n s of p e r c u t a n e o u s radial a r t e r y c a n n u l a t i o n . Anaesthesiology 1973;38:228-236. 10. Gardner R, Schwartz R, Wong H, et al: Percutaneous indwelling radial artery catheters for
Annals of Emergency Medicine
m o n i t o r i n g cardiovascular function. N E~gl / Med 1974;290:1227-1231. 11. Shinazaki T, Deane R, Mazuzan J, et al: Bac ~ t e r i a l c o n t a m i n a t i o n of a r t e r i a l lines. JAMA 1983;249:223-225. 12. Rooth G, Huch A, Huch R: Transcutaneous monitors are reliable indicators of arterial o x y gen t e n s i o n (if u s e d c o r r e c t l y ) . Pediatrics 1987;79:283-286. 13. W a x m a n K: N o n i n v a s i v e m o n i t o r i n g in e m e r g e n c y r e s u s c i t a t i o n . A n n Emerg Med 1986;15:1434-1436. 14. Taylor MB, W h i t m a n JG: The current status of pulse oximetry. Anaesthesia 1986;41:943-949 15. Trevino RP, Bisera J, Well MH, et al: End tidal CO2 as a guide to successful cardiopulmo nary resuscitation: A p r e l i m i n a r y report. Crir Care Med 1985;13:910-91I.
19:4 April 1990
Arterial Access in the Pediatric Emergency Department Arterial catheters are used frequently to monitor critically ill children in ICUs, but their role in the emergency department has not been described. The medical records of all patients admitted to the ICU from the ED of a children's hospital during a 30-month period were reviewed retrospectively. Forty-one patients were identified as having arterial catheters placed in the ED. Catheterization was performed for serial blood gas determinations (59%) or continuous blood pressure mordtoring (41%). The radial artery was catheterized in 73% of the 41 patients, and a 22-gauge catheter was used in 78% of the patients. The original catheter was discontinued before the end of medical indication in only 24% of cases 17% were discontinued for failure to draw and 7% for vascular changes at the site of the catheter. We conclude that arterial access can be used for children in the ED to monitor blood pressure and that blood gas tensions and complications are few and generally minor. [Saladino R, Bachman D, Fleisher G: Arterial access in the pediatric emergency department. Ann Emerg Med April 1990;19:382-385.]
INTRODUCTION Indwelling arterial catheters are used routinely to monitor critically ill children in ICUs. Arterial catheterization allows continuous observation of cardiovascular function and ready access to arterial blood for serial sampling. Although the advantages and complications of arterial catheters have been examined in pediatric ICU settings, u6 their role in the emergency department has not been described. The purpose of our study was to determine the indications for arterial access in an ED setting and to examine the duration and outcome of the catheterizations.
Richard Saladino, MD David Bachman, MD Gary Fleisher, MD Boston, Massachusetts From the Division of Emergency Medicine, The Children's Hospital, Boston, Massachusetts. Received for publication July 17, 1989. Revision received November 2, 1989. Accepted for publication November 9, 1989. Presented at the Ambulatory Pediatrics Association Annual Meeting in Washington, DC, May 1989. Address for reprints: Richard Saladino, MD, Division of Emergency Medicine, The Children's Hospital, 300 Longwood Avenue, Boston, Massachusetts 02115.
METHODS The admission log books of both the medical/surgical units and the cardiac ICUs of The Children's Hospital in Boston were examined; all children with arterial catheters were admitted to one of these areas. All patients who were admitted to the ICU from the ED from July 1986 through December 1988 were eligible for inclusion in the study. Data collected from the medical records included age, diagnosis on admission, indication for arterial catheterization, site and technique of catheter placement, catheter size and duration in situ, level of training of the physician placing the catheter, and reasons for discontinuation of the line. The data were analyzed with SPSS statistical software on a microcomputer. Continuous variables were analyzed with the Mann-Whitney U test, and categorical data were analyzed with the X2 test. For correlations, Pearson's coefficient was used.
RESULTS During the 30 months of review, 41 of 418 patients admitted to the ICU from the ED were identified as having arterial catheters placed while in the ED. The ages of these patients ranged from 1 month to 36 years (mean age, 9 years -+ 94 months [SD]; median age, 7 years and 10 months). Intraarterial catheters were inserted in patients throughout the pediatric age range (Figure). Diagnostic categories on admission to the ED included respiratory disease in 22 of 41 patients (54%), shock in ten (24%), multiple
19:4 April 1990
Annals of Emergency Medicine
382/67
ARTERIAL ACCESS Saladino, Bachman & Fleisher
FIGURE. Age distribution of 41 children in w h o m arterial catheters were placed in the ED.
trauma in six (15%), cardiorespiratory arrest in one (2.4%), burns in one (2.4%), a n d d y s r h y t h m i a in o n e (2.4%). T h e i n d i c a t i o n for p l a c e m e n t of the arterial catheter was need for serial blood gas determinations in 24 of 41 p a t i e n t s (59%) and c o n t i n u o u s b l o o d p r e s s u r e m o n i t o r i n g in 16 (41%). Patients w h o required arterial c a t h e t e r i z a t i o n for serial blood gas determinations were significantly older than those w h o required catheterization for continuous blood pressure m o n i t o r i n g (10 years and 11 m o n t h s vs 6 years and 5 months; P = .02). The site of arterial catheterization was the radial artery in 30 of 41 patients (73%), the dorsalis pedis artery in six (15%), and the femoral artery in five (12%). C a t h e t e r size was 24 gauge in one of 41 patients (2.4%), 22 gauge in 32 (78%), 20 gauge in six (15%), and 18 gauge in two (4.9%). The t e c h n i q u e used for c a t h e t e r placement was percutaneous in all cases; the Seldinger catheter-overthe-wire m e t h o d was used for the five catheters placed into the femoral artery. T h e arterial catheters were placed by pediatric residents in ten of 41 patients (25%), by pediatric emergency medicine fellows in 12 (29%), and by attending staff in 19 (46%). The mean n u m b e r of days that the original arterial catheter remained in situ was 1.9 (+ 1.7), with a range of from one to nine days. No correlation was found between age and duration of catheterization. The original catheter was removed on end of medical indication in 31 of 41 patients (76%). Five patients died with the IV line in situ, and one patient was transferred to a specialized burn facility with the arterial catheter in place. Seven catheters were discontinued for failure to draw (17%), and three were removed for vascular changes at the site (7%). Vascular changes consisted of persistent blanching of skin at or distal to the site of entry of the catheter. There was no significant difference in m e a n age between patients with catheters discontinued before the end of medical indication and those disc o n t i n u e d at the r e s o l u t i o n of the medical indication. Children younger 68/383
No. of Intra-arterial Catheters
4iiD 0
i 18
through the use of arterial catheteri z a t i o n is a w i d e l y a c c e p t e d proc e d u r e in c r i t i c a l l y ill p a t i e n t s treated in the intensive care setting. Results of our study indicate that arterial catheters m a y be placed in children in the ED, b o t h to m o n i t o r blood pressure and to allow for frequent blood sampling for blood gas analyses and other laboratory tests. Insertion was achieved in children of all ages, including the first year of life. The duration of catheterization after leaving the ED (range, one to nine days; mean, 1.9 days) attests to the usefulness of arterial access in these patients. S e v e r a l s t u d i e s h a v e b e e n performed to assess the risks compared with the benefits of arterial catheterization in critically ill adults. 7-11 The most serious complication of arterial catheterization is thrombosis of the vessel. Using physical examination and Doppler ultrasound flow studies, Bedford and Wollman 9 found thrombotic occlusion in 40 of 105 radial artery catheterizations (38%). Arterial occlusion occurred in 25% of 43 vessels c a t h e t e r i z e d for less t h a n 20 hours, 50% of 40 vessel catheterizations lasting from 20 to 40 hours, and 46% of 22 c a t h e t e r i z a t i o n s lasting from 40 to 144 hours. All vessels recannulated; no major ischemic complications were noted. Puri et al 7 reported decreased arterial flow in four of 59 femoral artery c a t h e t e r i z a t i o n s and an additional four instances of bleeding and hema19:4 April t990
TABLE 1. Data on arterial catheters discontinued for failure to draw
Age (yr/mo)
Catheter (gauge)
12/9
22
Radial
21/7
22
Dorsalis pedis
10/9 20/8
22 22
Radial Radial
15/6
22
Radial
t8
Femoral
22
Radial
10/5 3/11
Site
TABLE 2. Data on arterial catheters discontinued because of vascular changes
Age (yr/mo)
Catheter (gauge)
7/10
22
Radial
8
22
Dorsalis pedis
2/11
18
Femoral
toma formation at the site; this gave an overall complication rate of 14%. Gardner et ab o reported, on followup, detectable flow reduction at the site of catheter insertion in 17% and absent flow in 2% of 280 patients. All authors agreed that factors that increased the risk for thrombosis included duration in situ of more than five to seven days, low-flow states such as hypotensive-episodes, surgical cutdown technique, and use of vasoconstrictive agents. The risk of infection associated with indwelling arterial lines also is well described in the adult literature. Systemic catheter-related infections have been reported to occur in from 0% to 5% of cases, although local infection has been seen in from 4% to 18% of patients with arterial catheters.g, lo Risk factors included extended duration of catheterization, surgical cutdown technique, and deviation from sterile technique. In no reports were the complication rates considered to preclude the use of arterial catheters for monitoring critically ill patients. Studies in children show complications of arterial catheterization similar to those observed among adults. Miyasaka et all found radial artery obstruction by Doppler flow studies in 51% of 53 catheterizations. All vessels had recannulated by ten days,
19:4 April 1990
Site
Smith-Wright et al 3 found only three instances of arterial obstruction in 330 catheterizations. These and other studies describe local infection at the site of catheterization in from 0% to 4% of cases; no c a t h e t e r - r e l a t e d sepsis was reported.3,5, 6 Overall, complications were found to occur with greater frequency in children younger than 5 years old. 3 Other risk factors included prolonged catheterization beyond four to six days, cutdown technique of catheter placement, hypotension, and use of vasoconstrictive agents.l,3, 5 The data in the literature that examine arterial catheter use and complications are studies of arterial catheters placed in the surgical operating room or the ICU. The percentage of arterial catheters that were placed in our ED and were discontinued before the end of medical indication (24%) is compatible with the complication rates of from 4% to 40% found in the literature. Our study demonstrates the feasibility of arterial access in the ED, but invasive and noninvasive monitoring were not directly compared. N o n i n v a s i v e m o n i t o r i n g of blood pressure, t r a n s c u t a n e o u s o x y g e n measurement, pulse oximetry, and end-tidal CO 2 monitoring are currently available in many EDs. Each of these modalities has value as well as
Annals of Emergency Medicine
limitations. Transcutaneous oxygen monitoring is very reliable in the neonate but has been shown to correlate less well with Pao2 values in the older child and adult.t~, 13 Pulse oximetry has been shown to be accurate within 2% of measured oxygen saturation, but accuracy may be affected by low-flow states and hypothermia.~3,14 T h e s e m e t h o d s are valuable indicators of trends but, because of their dependence on cardiac output, may at times be qualitative rather than quantitative monitors of the critically ill patient. End-tidal CO2 monitoring is a useful guide to the adequacy of CPR 15 but is reliable only in the intubated patient. Blood pressure obtained by Doppler sonography is often unreliable, especially in small children. Because of these limitations, there was a need to use invasive monitoring of critically ill or injured children in our ED. This is similar to experiences in other settings where critically ill or injured p a t i e n t s are treated, such as the ICU and operating room. Regardless of the site within the hospital where such monitoring is used, reliable and wellm a i n t a i n e d e q u i p m e n t as well as trained personnel are essential to the appropriate application of invasive monitoring. Noninvasive monitoring decreases the use of arterial catheters but does not obviate the need for arterial access in selected patients. CONCLUSION Care of critically ill and injured children in an ED often requires reliable and continuous observation of blood pressure and/or serial arterial blood sampling for blood gas analysis and measurement of glucose, electrolytes, or other parameters. Because of the technical difficulties associated with repeated arterial blood sampling and the l i m i t a t i o n s associated at times with noninvasive blood pressure monitoring in small, critically ill children, arterial catheterization m a y be n e c e s s a r y to a c c o m p l i s h these goals. Our study demonstrates the feasibility of arterial catheterizations in the ED. The procedures were performed by physicians at a variety of training levels and the complications were few, as previously reported from several ICUs. Considering the potential mortality of children who are critically ill or injured, the risk of arterial access
384/69
ARTERIAL ACCESS Saladino, Bachman & Fleisher
is outweighed by the value of the information that can be obtained from catheterization.
5. D a m e n J, Van Der Tweel I: Positive tip culture and related risk factors associated w i t h intravascular catheterization in pediatric cardiac patients. Crit Care Med 1988;I8:221-228.
REFERENCES
6. Ducharme F, Gauthier M, Lacroix J, et al: Incidence of infection related to arterial catheterization in children: A prospective study. Crit Care Med 1988;18:272-276.
1. Miyasaka J, Edmonds J, Conn A: Complications of radial arterial lines in the pediatric patient. Can Anaesth Soc J 1976;23:9-14. 2. Edmonds J, Barker G, Conn A: Current concepts in cardiovascular monitoring in children. Crit Care Med 1980;8:548-553. 3. S m i t h - W r i g h t D, G r e e n T, Egar M, et al: C o m p l i c a t i o n of v a s c u l a r c a t h e t e r i z a t i o n in c r i t i c a l l y ill c h i l d r e n . Crit Care Med 1984; 12:1015-1017. 4. Todres I, Rogers M, Shannon D, et al: Per k cutaneous catheterization of the radial artery in the c r i t i c a l l y ill n e o n a t e . J Pediatr 1975;87: 273-275.
70/385
7. Puri V~ Carlson R, Bander J, et al: Complications of vascular catheterization in the critically ill. Crit Care Med 1980;8:495-499. 8. Band J, Maki D: Infections caused by arterial c a t h e t e r s used for h e m o d y n a m i c monitoring. Am J Mecl 1979;67:735-741. 9. Bedford R, W o l l m a n H: C o m p l i c a t i o n s of p e r c u t a n e o u s radial a r t e r y c a n n u l a t i o n . Anaesthesiology 1973;38:228-236. 10. Gardner R, Schwartz R, Wong H, et al: Percutaneous indwelling radial artery catheters for
Annals of Emergency Medicine
m o n i t o r i n g cardiovascular function. N E~gl / Med 1974;290:1227-1231. 11. Shinazaki T, Deane R, Mazuzan J, et al: Bac ~ t e r i a l c o n t a m i n a t i o n of a r t e r i a l lines. JAMA 1983;249:223-225. 12. Rooth G, Huch A, Huch R: Transcutaneous monitors are reliable indicators of arterial o x y gen t e n s i o n (if u s e d c o r r e c t l y ) . Pediatrics 1987;79:283-286. 13. W a x m a n K: N o n i n v a s i v e m o n i t o r i n g in e m e r g e n c y r e s u s c i t a t i o n . A n n Emerg Med 1986;15:1434-1436. 14. Taylor MB, W h i t m a n JG: The current status of pulse oximetry. Anaesthesia 1986;41:943-949 15. Trevino RP, Bisera J, Well MH, et al: End tidal CO2 as a guide to successful cardiopulmo nary resuscitation: A p r e l i m i n a r y report. Crir Care Med 1985;13:910-91I.
19:4 April 1990
