“There’s been a lot of discussion about sterility precautions for the line placement,” said Christopher Y. Tanaka, MD, an attending cardiothoracic anesthesiologist at Montefiore Medical Center and an assistant professor of anesthesiology at Albert Einstein College of Medicine of Yeshiva University, in New York City. “We were also startled and rather disappointed to find that a large percentage of people are not following the CDC recommendations.”

The analysis of more than 1,200 responses also showed the radial artery is the most commonly preferred initial cannulation site for both cardiac and noncardiac procedures, as predicted (Table). But researchers discovered an unexpectedly high percentage of respondents preferred the brachial artery as the next alternate site.
Table. Survey Responses for Arterial Catheterization Site Selection Preferences (Respondents by Site Selection)
N=1,182a Radial Brachial Femoral Axillary
First Preferred Site
Cardiac procedures, % 93.8 5.8 1.3 0.3
Noncardiac procedures, % 99.9 0.3 0.1 0.0
Second Preferred Site
Cardiac procedures, % 5.4 63.3 36.5 5.7
Noncardiac procedures, % 0.1 72.6 36.1 8.1
Third Preferred Site
Cardiac procedures, % 0.7 23.2 54.5 23.8
Noncardiac procedures, % 0.0 19.8 55.1 24.2
Fourth Preferred Site
Cardiac procedures, % 0.1 7.6 7.7 70.2
Noncardiac procedures, % 0.0 7.3 8.7 67.7
a Inclusion criteria: attending anesthesiologists in active clinical practice.

“We were surprised to see just how often anesthesiologists are placing brachial arterial lines, as approximately 70% of respondents indicated using it as their first or second site of preference,” Dr. Tanaka said.

Even more surprising to the researchers, however, was the low level of compliance with CDC guidelines concerning specific sterility precautions, including use of sterile gloves, occlusive dressings with chlorhexidine and antibiotic-impregnated catheters. While 86% of respondents reported wearing a scrub hat for radial procedures, only 78% of respondents used a mask, less than 70% used sterile gloves, and less than 40% used a sterile drape.

“It was disappointing to see that so many people are not compliant with CDC recommendations,” said Dr. Tanaka, who added that academic institutions were slightly more likely to follow sterility precautions, based on survey results. “If we can find geographic regions where there are differences, that will help us focus educational efforts on those areas that need more quality improvement.”

Co-author of the study, Elizabeth M. Vue, MD, a cardiothoracic anesthesiology fellow at Montefiore Medical Center, added that she hopes this study will stimulate anesthesiologists to reflect on their practices and think about compliance.

Frequent Use of Brachial Arterial Lines for Catheterization

Few formal recommendations exist regarding cannulation site selection, techniques employed and sterility practices. To better quantify arterial catheterization practices across various institutions, Dr. Tanaka and his colleagues distributed an anonymous survey created from SurveyMonkey to current Society of Cardiovascular Anesthesiologists (SCA) members. The survey remained open for three months (August-October 2017). The researchers then examined the results using chi-square analysis for differences between subgroups.

As Dr. Tanaka reported at the SCA 2018 annual meeting (abstract 206), researchers received 1,215 responses from the 3,580 surveys emailed (33.9% response rate). Of those who responded, 1,199 were at the attending level. Unsurprisingly, said Dr. Tanaka, the radial artery was the most commonly preferred initial cannulation site for both cardiac (99.2%) and noncardiac (99.9%) procedures.

However, analysis showed that 69.1% and 72.9% of respondents indicated a preference for cannulating a brachial artery (defined as first or second site of preference) in cardiac and noncardiac procedures, respectively. According to the authors, recent data demonstrated relatively low complication rates with brachial artery catheterization.

“There’s a common perception that the brachial artery is not suitable for catheterization due to lack of collateral flow, but brachial intra-arterial pressure monitoring has been shown to have better correlation with aortic pressure and provide a more reliable method for hemodynamic management,” said Dr. Tanaka, who noted possible geographic differences in cannulation site selection.

“Anecdotally, in the New York City area, a lot of anesthesiologists tend to shy away from the brachial artery as a selection site, but our nationwide survey found that approximately 70% of attendings use it as their first or second preferred site,” Dr. Tanaka explained.

“For future studies, we will explore whether the predilection for brachial cannulation is uniform across the country or if there is localization of practices.”