Clinical paperArterial line in prehospital emergency settings – A feasibility study in four physician-staffed emergency medical systems☆
Introduction
Since its first description in human patients in 1949,1 the insertion of arterial lines has become a widespread routine technique in many clinical settings, e.g. operating rooms and critical care or emergency departments.2 The main goals for the use of arterial lines are continuous invasive blood pressure monitoring (IBP) and the collection of repeated blood samples, especially for arterial blood gas analysis (ABG). However, arterial lines are rarely used under prehospital emergency medical conditions, although current technical solutions for out-of-hospital emergency medical care usually offer the possibility of IBP monitoring and portable ABG analyzers have been available since the mid 1990s.3, 4 Furthermore, no studies on this topic have been published so far. The reasons for this reluctance seem to be of different origins.
Economical considerations and the question of cost effectiveness, which have shown up over the whole health care sector, may play an important role. Also, there is still considerable lack of scientific proof of outcome improvement by transferring critical care techniques into the prehospital phase. Furthermore, the application of medical procedures thought to be sophisticated might neither seem feasible in emergency medical care systems predominantly operated by emergency medical technicians or paramedics nor in systems staffed with emergency physicians unfamiliar with such procedures, and may prolong scene time. Finally, pre-hospital operators in some EMS systems may not all be currently capable of advanced practical procedures.
Since arterial lines have been increasingly used in our urban prehospital emergency medical system, we conducted a study on the feasibility, indications and possible consequences of arterial line insertion in the field.
Section snippets
Materials and methods
The prospective observational study took place in four physician-staffed emergency medical care systems in the province of Styria, Austria. Three are ground-based, two of them serving the urban and suburban area of the province capital with nearly 500,000 inhabitants; one is situated in a smaller district capital with rural environment (supplying emergency care for approximately 40,000 people). One system is helicopter-powered with a service area of 120 km in diameter (approx. 1 million
Results
During the one-year observation period (January 1st to December 31st, 2008), 137 patients were chosen to obtain an arterial line. In 22 cases (16.1%), the cannulation was not possible, of the remaining 115 (83.9%) patients with successfully completed arterial line insertion, 70 (60.9%) were male, 45 (39.1%) female. The usually well-staffed province capital emergency medical systems achieved arterial access in 72 out of 88 (81.8%) of the cases, the district capital and the helicopter system in
Discussion
The use of arterial lines has become a routine procedure for severely or critically ill or injured patients in emergency department, critical care and operating room settings. Unquestioned indications are patients in shock with existent or anticipated need for vasoactive therapy as well as patients with respiratory insufficiency, need for ventilatory support, severe acid–base balance disturbances or multimorbid patients undergoing complex surgical procedures. The use of indwelling arterial
Limitations
One major limitation of our study is that there was no strict indication list for the establishment of arterial lines and the decision was made merely at the attending physician's discretion. Therefore, the measure was for the most part applied by anaesthetists accustomed to both insertion technique and result interpretation, which might lead to a positive bias of our data. Furthermore, the study protocol sheet was usually filled out after completion of the call, which might also influence our
Conclusion
In this study, we demonstrate that the insertion of arterial lines is feasible in the prehospital setting without prolonging or complicating emergency medical care. Indications originating from intrahospital use are also valid in the field. It offers an unrivalled possibility of accurate haemodynamic monitoring. In particular when combined with measurement of arterial blood gases, the use of arterial lines often leads to important therapeutic consequences and might therefore be a powerful
Conflict of interest statement
Gernot Wildner and Geza Gemes received honoraria for lectures by Roche, Austria. Gernot Wildner, Geza Gemes and Gerhard Prause received honoraria for lectures by a former distributor for blood gas analyzers, AMP, Austria. There are no other conflicts of interest.
Acknowledgements
We appreciate the contributions of all participant members of the Medizinercorps Graz and the emergency medical care systems of LKH Bruck/Mur, Christophorus Flugrettungsverein “Christophorus 12”, LKH Graz-West/UKH and LKH-Universitätsklinikum Graz. We also thank Dr. Katherine Tiede for thoroughly revising the manuscript.
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2014, Journal of Cardiothoracic and Vascular AnesthesiaCitation Excerpt :An additional strategy to improve CPR quality is to provide feedback on systemic blood flow by extended monitoring.14 Monitoring of invasive arterial blood pressure15 and end-tidal CO216 have been reported to improve efficacy of manual chest compressions. In the authors’ case, NIRS was used as an additional monitoring tool for CPR quality.
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A Spanish translated version of the abstract of this article appears as Appendix in the final online version at doi:10.1016/j.resuscitation.2011.05.002.