J Clin Monit Comput DOI 10.1007/s10877-014-9648-5

ORIGINAL RESEARCH

Radial artery cannulation decreases the distal arterial blood flow measured by power Doppler ultrasound Atsushi Numaguchi • Yushi U. Adachi • Yoshitaka Aoki • Yasuhiro Ishii • Katsumi Suzuki • Yukako Obata • Shigehito Sato • Kimitoshi Nishiwaki • Naoyuki Matsuda

Received: 30 August 2014 / Accepted: 8 December 2014 Ó Springer Science+Business Media New York 2014

Abstract Radial arterial cannulation is a popular technique for continuous hemodynamic monitoring in an area of anesthesia and intensive care. Although the risk for invasive monitoring is considerable, there is scarce information about the change in blood flow of cannulated vessel after the catheterization. In the current investigation, we evaluated the change in the cannulated arterial blood flow. Six volunteers (study 1) and eight post-surgical patients (study 2) were enrolled into the studies. In the study 1, the both side of diameter of radial artery (RA), ulnar artery (UA) and dorsal branch of radial artery (DBRA) of participants were measured using power Doppler ultrasound (PDU) with or without proximal oppression. In the study 2, the diameter of RA, UA and DBRA of the both intact and cannulated side were compared. Study 1: The diameter of RA was 3.4 (0.52) [mean (SD)] mm and the proximal oppression significantly decreased the diameter to 1.8 (0.59) mm. The diameter of DBRA measured by PDU also The part of results was presented in Euroanaesthesia 2010 at Helsinki, Finland. A. Numaguchi  Y. U. Adachi (&) Department of Emergency Medicine, Nagoya University Hospital, 65 Tsurumai-cho, Showa-ku, Nagoya 4668550, Japan e-mail: [email protected] A. Numaguchi Department of Pediatrics, Developmental Pediatrics, Nagoya Graduate School of Medicine, Nagoya, Japan Y. Aoki Department of Anesthesia, Shizuoka General Hospital, Shizuoka, Japan Y. Ishii Department of Anesthesia, Fujinomiya Municipal Hospital, Fujinomiya, Japan

decreased 2.0 (0.60)–1.3 (0.59) mm. Study 2: There was no difference between the diameters of right and left RA, however, the UA was larger [3.4 (0.60) vs. 2.8 (0.83) mm] and the DBRA was narrower [1.4 (0.43) vs. 2.0 (0.47) mm] in the cannulated side. The diameters of DBRA were different between the intact and cannulated side in the patients. Although there is no information of relationships between cause of severe complication and decreased flow, significant reduction of blood flow should be concerned. Keywords Radial artery  Cannulation  Ultrasound sonography  Blood flow

1 Background Radial arterial cannulation is one of the most popular interventions for continuous hemodynamic monitoring and frequent blood sampling in the area of anesthesia and intensive care [1, 2]. Although radial arterial cannulation has been accepted as a low-risk procedure [3], preK. Suzuki Department of Anesthesia, Enshu Hospital, Hamamatsu, Japan Y. Obata  S. Sato Department of Anesthesia and Resuscitation, Hamamatsu University School of Medicine, Hamamatsu, Japan K. Nishiwaki Department of Anesthesia and Resuscitation, Nagoya University Graduate School of Medicine, Nagoya, Japan N. Matsuda Department of Emergency and Critical Care, Nagoya University Graduate School of Medicine, Nagoya, Japan

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evaluation and the diagnostic trials, including Allen’s test and ultrasound assessment, were applied to confirm sufficient blood flow at the distal site of wrist joint for preventing from ischemic complications [4]. More recently, radial artery (RA) becomes a preferable accessing site for percutaneous coronary angiography and intervention [5]. The diameter of RA is smaller than that of femoral artery. Despite of the disadvantage, better accessibility and fewer complications are widely accepted. However, the fluoroscopic procedures are usually temporal and the cannula was immediately removed after the intervention. There is scarce new information about the changes in the distal blood flow of continuously cannulated vessel after the arterial catheter placement [6]. In the current investigation, we conducted two studies. The first is measurements of the intact radial arterial blood flow in volunteers for evaluating the usefulness of measurements using ultrasound sonography. The second is assessments of the effect of continuous cannulation on the arterial blood flow in the post-surgical patients in the intensive care unit.

measured using power Doppler ultrasound (PDU) mode with short axis and longitudinal scanning as appropriately. The diameters of RA and ulnar artery (UA) were measured 3-cm proximal site from wrist joint. The diameters of dorsal branch of the radial artery (DBRA) were measured at the root of thumb finger. The data of images were saved on the removable media and the other independent investigators evaluated the changes in diameter with PC and graphic software. The values of the maximal width of color flow image were hypothesized as functional blood flow of each artery. 2.1 Study 1 Six volunteers were enrolled into the study. All participants were the staffs of the intensive care unit. The both side of diameters of RA, UA and the DBRA of the participants were recorded with or without approximately 20-N proximal oppression using a tourniquet (TR bandageTM, Terumo, Tokyo, Japan) on RA approximately 5-cm proximal site from the wrist joint (Fig. 1). 2.2 Study 2

2 Materials and methods All study protocols were consisted of observational interventions, and the Institutional Ethical Committee of Hamamatsu University School of Medicine required no review and registration for the study. However, an informed consent from the volunteers and the patients were obtained in accordance with the department guidelines. The all ultrasound measurements were carried out using Venue 40 Ultrasound (GE Healthcare Japan, Tokyo) with 12L-SC linear array transducer (5.0–13.0 MHz imaging frequency). The internal diameters of vessels were

Fig. 1 The images of change in arterial blood flow by power Doppler ultrasound were shown. The gain and scale were modified appropriately for each site

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Eight post-surgical patients were enrolled into the study. All arterial catheters were placed in an operating room for the scheduled surgery with 22-G needle (BD InsyteTM, Becton, Dikinson and Company, Tokyo, Japan). The patients were continuously monitored invasive arterial blood pressure more than 24 h after the end surgery using the radial artery in the intensive care unit. The pulsatile diameters of the radial, ulnar and dorsal branch of the radial artery of the both intact and cannulated side were measured using PDU approximately 24 h after the ICU admission.

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2.3 Analysis The data were analyzed using Wilcoxon matched-pairs signed-rank tests. Both data with or without oppressions were considered as a pair of results. The data of study 2 were analyzed using Wilcoxon signed-rank tests. A p value \0.05 was considered as statistically significant.

3 Results Fig. 2 The changes in diameter of each artery in volunteers with or without oppression were shown. The results were expressed as mean and SD (mm). *p \ 0.05 between groups

3.1 Study 1 The age of volunteers was 37.1 ± 7.1 years (mean ± SD), body height was 172 ± 7.1 cm and weight was 61.5 ± 5.6 kg (Table 1). The diameter of RA was 3.4 ± 0.52 mm and the proximal arterial compression significantly decreased the PDU diameter to 1.8 ± 0.59 mm without a noticeable change of anatomical diameter assessed by 2-D sonography (not shown). The diameter of DBRA measured by PDU also decreased 2.0 ± 0.60 to 1.3 ± 0.59 mm by the compression of ipsilateral proximal site (Fig. 2).

The measurement of actual and absolute value of blood flow was difficult and hardships in clinical settings. In the study 1, we determined the effect of oppression on the proximal site of artery on the diameter in health volunteers. It is widely accepted that the tourniquet decreases the blood flow as determined by pulsatile diameter in extremities [7]. The arterial oppression would apparently reduce the pulsatile diameter determined by color Doppler signal, not the anatomical diameter of artery. Thus, our results indicated that the pulsatile diameters determined by PDU would be correlated with actual blood flow [8]. In the study 2, we found the significant differences in arterial pulsatile diameter between the intact side and the cannulated side at more than 24 h after the continuous cannulation in the surgical patients. In the cannulated side, the pulsatile diameter of DBRA was decreased despite of no change in the diameter of RA. We measured the RA pulsatile diameter at proximal site from the cannula, thus, the decrease of DBRA that is distal site of the cannula would be an important result. There is a possibility that obstructive effect of arterial catheter on the blood flow would retain the RA diameter. The pulsatile diameter of UA was unchanged in the cannulated side. If the compensatory increase of UA

3.2 Study 2 The age of patients was 71.6 ± 12.3 years, body height was 156.1 ± 1.1 cm and body weight was 54.8 ± 8.4 kg (Table 2). There was no difference in the RA diameters using PDU. The diameter of UA was lager in the cannulated side of upper extremities when the results were compared within each patient. The DBRA was significantly narrower (1.4 ± 0.43 vs. 2.0 ± 0.47 mm) in the cannulated side (Fig. 3).

4 Discussions The blood flow was evaluated by the changes in the pulsatile diameter using PDU in the current preliminary investigation. Table 1 The demographics and results of volunteers (study 1) Age (year)

Sex

Height (cm)

Weight (kg)

Right

Left

Intact

Oppressed

Radial

Ulnar Dorsal branch

Radial

Ulnar

Intact Dorsal branch

Radial

Oppressed Ulnar

Dorsal branch

Radial

Ulnar

Dorsal branch

29

M

174

60

3.1

3.2

1.4

1.6

3.2

0.2

3.7

2.7

1.2

1.0

2.8

1.4

37

F

162

52

2.6

3.1

2.3

l.8

3.2

2.4

2.7

2.3

1.2

2.7

2.3

1.1

31

M

172

64

3.8

2.6

2.5

1.9

2.5

1.3

4.1

3.7

1.9

3.0

3.6

l.8

46

M

173

60

4.2

2.4

1.7

1.2

2.6

1.2

3.4

2.7

2.6

l.8

2.7

0.5

35

M

171

65

3.2

2.8

3.1

1.7

2.7

0.8

3.2

2.6

2.4

1.2

2.7

1.6

45

M

177

68

3.6

2.2

1.9

2.2

2.3

1.7

3.0

2.3

2.1

1.0

2.4

1.4

The diameters of each artery are expressed using millimeter

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J Clin Monit Comput Table 2 The demographics and results of patients (study 2) Age (year)

Sex

Height (cm)

Weight (kg)

Cannulated side

Radial Intact

Ulnar Cannulated

Intact

Dorsal branch Cannulated

Intact

Cannulated

83

M

156

48

Right

2.1

2.8

3.0

3.9

l.8

1.6

50

F

155

54

Left

3.2

2.6

2.5

1.6

2.0

1.5

79

F

150

44

Right

3.8

4.0

1.9

2.4

2.0

1.1

69

F

150

47

Right

2.8

3.2

2.3

2.5

2.4

1.6

57

M

156

69

Right

3.5

4.2

3.0

4.1

2.1

2.0

82

M

161

58

Left

3.5

3.7

2.1

2.4

2.3

1.3

80 73

M M

165 156

57 62

Right Right

2.9 3.7

2.8 3.6

2.8 2.0

3.0 2.7

1.0 2.3

0.6 l.8

The diameters of each artery are expressed using millimeter

Fig. 3 The differences in diameter of each artery in patients with or without cannulation were shown. The results were expressed as mean and SD (mm). *p \ 0.05 between groups

blood flow was absent [9], the risk of ischemia at distal site would be increased by the cannulation. Kim et al. [10] extensively studied the effect of the RA cannulation and of the difference of catheter diameter on the blood flow during the induction of general anesthesia. The results of the investigation reported a significant decrease in the blood flow and the compensatory increase of blood flow in ulnar artery until 5 min after radial artery cannulation. The study was comprehended and the results were acceptable, however, the measurements were limited during the induction of anesthesia and the changes after the continuous cannulation were not evaluated. The effect of catheter diameter on the blood pulsatile diameter was also studied by Eker et al. [11]. The authors measured the postoperative RA diameter after 24 h from the surgery and decannulation. The significant change in the RA diameter and the systolic blood flow were observed in the group of the patients whom placed the larger size of catheter. The authors concluded that the complications of cannulation would be decreased by the use of small gauge needles [11]. The 10 %-difference of diameter indicates the 20 %-difference of cross sectional area of the catheter in

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the thin vessels, and the obstructive effect on blood flow seemed considerable. In our study, all cannulation was performed with 22-G needle. From the above results of investigations, the RA cannulation would decrease blood flow from immediately after the catheter placement and the compensatory increase of UA blood flow might be quickly commenced [10]. The significant changes were observed after 24 h from the beginning of monitoring (the current investigation). The reduction of blood flow of distal part of RA persisted not only during the cannulation but also after the decannulation. The smaller size of needle could ameliorate the unfavorable decrease of blood flow, however, the risk of ischemic complication consistently remained [11]. The limitation of the investigation should be addressed. The current preliminary studies did not evaluate the chronological changes during perioperative period. The sample size of investigation including prior study was small [9– 11]. A significant statistical difference was enough to demonstrate the significant and certain changes in blood flow of peripheral arteries concerning to the cannulation in each result. However, the clinical relevance of the observational change is not established. The evaluation of safety and incidence of RA cannulation had been discussed by only large retrospective analysis and reviews [1, 6, 12]. Although larger prospective study for ensuring safety including the evaluation of blood flow might require huge resources, a further investigation is required.

5 Conclusions The pulsatile diameters of DBRA were different between the intact and cannulated side in the patients. There is no information of the relationships between a cause of severe complication and a decreasing level of blood flow induced

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by RA cannulation, however, significant reduction of blood flow should be concerned. Conflict of interest All authors have no conflict of interest for the current investigation.

References 1. Brzezinski M, Luisetti T, London MJ. Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesth Analg. 2009;109:1763–81. 2. Slogoff S, Keats AS, Arlund C. On the safety of radial artery cannulation. Anesthesiology. 1983;59:42–7. 3. Smith A. Lest we forget: learning and remembering in clinical practice. Anaesthesia. 2013;68:1099–103. 4. Ruengsakulrach P, Brooks M, Hare DL, Gordon I, Buxton BF. Preoperative assessment of hand circulation by means of Doppler ultrasonography and the modified Allen test. J Thorac Cardiovasc Surg. 2001;121:526–31. 5. Kanei Y, Kwan T, Nakra NC, Liou M, Huang Y, Vales LL, Fox JT, Chen JP, Saito S. Transradial cardiac catheterization: a review of access site complications. Catheter Cardiovasc Interv. 2011;78:840–6.

6. Frezza EE, Mezghebe H. Indications and complications of arterial catheter use in surgical or medical intensive care units: analysis of 4932 patients. Am Surg. 1998;64:127–31. 7. Nielsen HV. External pressure–blood flow relations during limb compression in man. Acta Physiol Scand. 1983;119:253–60. 8. Gaudino M, Serricchio M, Tondi P, Gerardino L, Di Giorgio A, Pola P, Possati G. Chronic compensatory increase in ulnar flow and accelerated atherosclerosis after radial artery removal for coronary artery bypass. J Thorac Cardiovasc Surg. 2005;130:9–12. 9. Ruengsakulrach P, Brooks M, Hare DL, Gordon I, Buxton BF. Preoperative assessment of hand circulation by means of Doppler ultrasonography and the modified Allen test. J Thorac Caridiovasc Surg. 2001;121:526–31. 10. Kim SY, Lee JS, Kim WO, Sun JM, Kwon MK, Kil HK. Evaluation of radial and ulnar blood flow after radial artery cannulation with 20- and 22-gauge cannulae using duplex Doppler ultrasound. Anaesthesia. 2012;67:1138–45. 11. Eker HE, Tuzuner A, Yilmaz AA, Alanoglu Z, Ates Y. The impact of two arterial catheters, different in diameter and length, on postcannulation radial artery diameter, blood flow, and occlusion in atherosclerotic patients. J Anesth. 2009;23:347–52. 12. 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.

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Radial artery cannulation decreases the distal arterial blood flow measured by power Doppler ultrasound.

Radial arterial cannulation is a popular technique for continuous hemodynamic monitoring in an area of anesthesia and intensive care. Although the ris...
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