ABGs and Access (WARNING: graphic and potentially sensitive material)

Hi,

This post is aimed at the more severe/brittle asthmatics out there.

Just wondering if anyone else has any problems with access whilst in hospital? I have disgustingly veiny arms- venous access is never an issue but arterial access is. Having had too many ABGs/A-Lines over the past year or so my radial arteries are scarred. My hospital is not keen to do brachial blood gases and I am not keen for femoral ones!

I figured there must be a few other people in this situation on the board and just wondered how other peoples medical teams got round the issue?

Hoping this finds everyone well,

Thanks,

STX

16 Replies

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  • I actually find that femoral ABGs are often less painful that brachial ones. Yes being female there are certain "" intimacy' issues but its worth it (once u have kids there is a caertain what needs to be done goes!!). I actually have a couple of drs who now give me the option of where they go as i have also had probs with radial artery gasses/a lines. I have only had a brachial ABG done once and never again as far as im concerned!!

    Hope this helps

  • the only problem with radial ABGs is that it leaves horrendous bruising, i had it done on tuesday and my poor right wrist looks like its been battered, but for some reason, even with the bloods from the IV line, i just did not want to let the blood go, thats the only issue ive had really

  • I have a bit written on my protocol to tell them not to do ABGs unless my sats are below 90% (or I can't argue back, swear at them or am confused & out of it)

    Femoral ones are better pain wise but embarasing when the doc keeps the pressure on for a couple of minutes & starts cracking jokes.

    They can get radial ones if desperate but the digging around often makes me more stressed and hence worse so cons agreed to the statement on protocol.

    Venous access is a bit bad at times!

    Kate

  • Kate - How did you persuede them to put that on yr protocol my local insists on them if you meet a large range of perameters and of course during a severe attack i do but even then sometimes my sats as just over 90%.

    i would like to have good ammo in persueding them to avoid unless essential.!!!!

  • Hi ST,

    I have the same problem - my radial arteries are badly scarred, there aren't really any pulses palpable there, and they're pretty much useless for gases or art lines. I agree femorals do usually hurt less as they don't have to 'dig' as much for the artery - and speaking from the other side, they are usually a lot easier to do as well! - but there is the embarrassment factor of having a doctor (and potential ex-colleague in my case!) routing around in your groin for several minutes! However, the biggest factor when I am having an acute attack is that I cannot lie back enough to allow access to my femorals unless I am pretty out of it.

    I usually end up with brachial gases and art lines, but of course these are not without risks. For those who don't know, the brachial artery is the one which passes down the inside of the upper arm and the gas is usually taken on the inside of the elbow. At this point it is more or less the sole blood supply for the lower arm (unlike the radial artery at the wrist, which usually has collateral (alternative) supply via the smaller ulnar artery on the other side). There is a (very small) risk of causing clots when a gas is done, which is obviously potentially problematic if there is no alternative blood supply.

    During my prolonged ICU admission last year I had a right brachial art line for about 6 weeks (they couldn't use the left due to a venous clot which was obstructing drainage and therefore arterial supply). I now have a probable brachial artery stenosis on that side with impaired circulation in my right hand, which causes my hand to be cooler and to be painful if I overuse it. It is improving with time, presumably either due to the artery opening up or due to collateral blood vessels developing round the obstruction. Complications like that are pretty rare, but are more common with brachial lines than with radial, which explains why doctors are reluctant to do them.

    My venous access is also difficult, and last admission I had to have two central lines because it was impossible to cannulate me. Due to previous clots/stenoses I only have one good site for central access too - my right internal jugular - which means the whole thing becomes a bit of a nightmare. I'm waiting to have a portacath put in to try and get round this issue (if anyone has any experience of portacaths to share I'd be glad to hear from them!)

    I think this is an issue a lot of us have to face. I'd just like to add a note of reassurance, though - in an absolute emergency situation, I've never seen doctors NOT get venous access or a gas. Drugs can also be given by other routes, such as intramuscularly or even via the ET tube in an intubated patient. I know it is painful, distressing and frightening when you are unwell and access is proving a problem, but if they have to, they will always find a way to give you the drugs you need.

    Take care all

    Em H

  • Hi there,

    Sorry if this is too much/too sensitive - but it is in reply to what is posted so I hope not.

    I have recently had an admission where iv access was a major problem (2 hours, 3 doctors...), but have had the additional problem of understaffing at night, and nobody around who could put in a central line without calling ITU, which they were reluctant to do (despite the fact that I was probably bad enough to justify it). I have a bit on my protocol which suggests giving im adrenaline in that situation, but because my heart was doing funny things they couldn't use it (I had a run of VT). Eventually they gave up trying - I had one line in anyway but they were wanting another so they could give me more different things at once - eventually stopped one to give me the other.

    I then asked on one of the doctors fora, to see if anyone had bright ideas, and the folks from a+e and itu came up with a lot of options - using ultrasound to find peripheral veins, central lines, intraosseous access (where they put a needle into bones, used to only be used in kids but now they have gadgets to allow its use in adults), cut downs etc. Reassuring to know there are lots of options - but none of them things that the folk who look after me would be capable of at 3am, which is a little scary.

    I am planning to have a conversation with my consultant about all of this - to be honest I think that they need a lower threshold for phoning for help rather than anything else- I don't think I am at the stage where I should need a portacath, just someone who is expert at difficult veins, and if that means calling itu then fair enough.

    Sorry, rant over!

    re ABGs etc - I actually find brachial ones easy to do and less painful than radial, but don't use them normally because of the risks as Em has pointed out. Femoral ones are usually easy except when you need to lie the patient down more than you can.

    The trick to avoiding bruises is to press really hard for at least 5 minutes - or get someone else to. Easier said than done!

    Also, they can avoid ABGs sometimes by doing capillary gases - not as reliable but can be used for monitoring, and worth asking your unit if they use them because sometimes that prevents the need for an a-line/repeated ABGs.

  • Hi Owl,

    Personally I don't think what you've written is too much or too sensitive, but I've added a warning to the thread subject just to make sure everyone is aware of the content.

    Em H

    (Mod's hat briefly on head)

  • Last time I had a wee splatt I had ""shutdown"" so arms and legs were out, they put a venflon in across my chest, apparently it was supposed to be very painful I don't remember it. So even with my rubbish veins they got some fast access. They did try a C line sitting up but that was not successful and then went for a femoral line before eventually a few days later when I was able to lie down they wacked in a central line for the remainder of the admission. Dr at football keeps reminding me about the bone thing for access I think he has the kit but has never used it and is secretly looking for a guinea pig, well he can keep looking!

  • Hey,

    I too have alot of problems with ABGs and art lines. I am on oxygen 24/7 so ABGs are a must on every admission no matter how well I may look.

    I've only had a major problem before with a brachial line. After a few days of having it in I got pain in my fingers, like a burning pain I couldn't get rid of. Nobody had a clue as to what it was. After another day or 2 a rash appeared a day later it appeared to be traveling up my arm to the line. I was started on IVs and the line was removed but it was to late, I got MRSA septicaemia and cellulitis (deep skin infection). After 2wks of IV antibiotics the infection cleared up but the cellulitis was so bad that it left me with osteomyelitis (bone infection) in one of my fingers. I had to have surgery to remove the bone the infection had killed off then a second operation to remove the a joint in my finger completely.

    I think maybe my case was a bit of a one off and I was just unlucky. Wherever possible now I try to refuse art lines especially brachial ones but sometimes there really is no choice.

    Tks xxx

  • Kirsten,

    didn't need to persuade them - My consultant suggested it! Perhaps he had to mop up the stressed out doctors after attempting ABGs!

    They only worry now if they suddenly plumet or I am too confused to bother etc.

    The few times they have been really off, ( eg 6!) I don't really remember much anyway.

    Kate

  • I think maybe at my next appt i will ask for it to be put on my protocol as it certainly doesnt do me any good as its the only thing that i find really distressing. After the thing up during my last admission my protocol needs reviweing anyway.

    I had a dr who was going to discharge me after 2 lots of adrenaline, mag sulph b2b nebs etc and 4 hrs in resus, where she was coming from i dont know!!!

    Thankfully i have never had brachial abgs or lines , the Drs dont lie me down to do the femoral abgs

  • Hey,

    Thanks for all the replies, it's comforting to know there are others in similar situations.

    Saw my consultant friday who has agreed to ABGs only from R wrist (every A-Line attempt on it has failed in last year) to try and save L wrist for dire emergencies/A-Lines.

    As I work with the doctors who end up stabbing me I told him I would not let them do Femoral ABGs and he agreed brachial ones would be OK.

    Its a shame more hospitals can't do capillary blood gases really,

    Hope everyone is enjoyinh their weekend,

    STX

  • My radial arteries are also very scarred so making ABGs difficult/impossible at times. I've had brachial ABGs done on several occasions and, to be honest, I haven't found them as bad as radial ones, but maybe I'm just strange (nobody need agree with me ;oP ). I've also had a few brachial A-lines in my time too. They weren't pleasant, but then A-lines never are.

  • l

  • I believe a general anaesthetic isn't necessarily required for portacath insertion. Certainly, I have been told that I can have it done under local +/- sedation.

    Em

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