Saudi Journal of Anaesthesia

LETTERS TO EDITOR
Year
: 2021  |  Volume : 15  |  Issue : 2  |  Page : 231--232

Contemplating and innovating the arterial line placement in COVID times


Kaminder Bir Kaur1, Kiran Kalshetty1, Vishal Mangal2, Debashish Paul1, Shalendra Singh1,  
1 Department of Anaesthesiology and Critical Care, Armed Forces Medical College, Pune, Maharashtra, India
2 Department of Internal Medicine, Armed Forces Medical College, Pune, Maharashtra, India

Correspondence Address:
Vishal Mangal
Department of Internal Medicine, Armed Forces Medical College, Pune - 411 040, Maharashtra
India




How to cite this article:
Kaur KB, Kalshetty K, Mangal V, Paul D, Singh S. Contemplating and innovating the arterial line placement in COVID times.Saudi J Anaesth 2021;15:231-232


How to cite this URL:
Kaur KB, Kalshetty K, Mangal V, Paul D, Singh S. Contemplating and innovating the arterial line placement in COVID times. Saudi J Anaesth [serial online] 2021 [cited 2021 May 17 ];15:231-232
Available from: https://www.saudija.org/text.asp?2021/15/2/231/312982


Full Text



Sir,

Novel coronavirus (COVID-19) pandemic has been reining the whole world since the end of the last year. It started in Wuhan, China, and has been declared pandemic by the World Health Organization in March 2020.[1],[2]

The severe acute respiratory syndrome novel coronavirus 2 virus enters the cells by binding on alveolar endothelium and its activation causes the procoagulant state, subsequent thrombosis, and raised D-dimer level in blood. Although many inflammatory processes can influence D-dimer levels, it certainly reflects intravascular thrombosis in patients with COVID-19.[3] In the early studies emerging from China, an elevated D-dimer (>1 μg/mL) at admission had increased risk of in-hospital death.[4]

We present an innovative technique to place an intra-arterial line for invasive blood pressure monitoring in a COVID-positive patient with ongoing thrombosis. A 33-year-old morbidly obese (body mass index 40.89 kg/m2) COVID-positive male presented with a history of low-grade fever and dyspnea in 2 days duration. On examination, he had tachycardia, tachypnea, and hypoxia with saturation of 58% on room air. Patient was shifted to intensive care unit where noninvasive ventilation (NIV) was started. The initial laboratory investigations revealed neutrophilic leukocytosis with raised D-dimer levels (9.6 μg/ml). After 2 h on NIV, his SpO2 dropped to <80% with RR of >40/min. In view of clinical deterioration, he was intubated and mechanical ventilation was started. It was decided to insert a central line and an intra arterial line for real time monitoring of BP , as the patient was planned to be placed in prone position for 14-16 h. Ultrasound-guided 7-Fr triple lumen catheter was placed in right intrajugular vein. After performing Allens' test, right forearm was positioned parallel to ground and supinated. The right wrist was dorsiflexed and the right hand was taped to the side of the bed to maintain the position. After taking all sterile precautions, right radial artery was palpated with nondominant hand, 1–2 cm proximal to the wrist, and a 20-G intravenous (iv) cannula was used to prick the artery. After seeing the flash of blood in the hub, the catheter was advanced in the artery. Free flow was confirmed but as soon as the pressure monitoring line was connected, blood got clotted in the cannula. The cannula was removed and pressure was maintained. The next attempt was taken in left radial artery but had the similar result. A few more attempts were repeated in the right radial artery with similar course of events. Keeping the procoagulant state of COVID-19 in mind, an innovation was tried. The 20-G iv cannula was flushed with heparin and left radial artery was now again cannulated. After seeing the flash of blood in the hub, needle was removed and the catheter was advanced in the artery. Free flow was confirmed, and the pressure monitoring line was attached. Arterial line tracing was confirmed on the monitor and a sterile dressing was placed.

As the knowledge of thrombotic complications of COVID-19 is growing, the more guidelines are being developed on their prevention and management.[5] We hereby present a common problem of arterial line blockage faced by the intensivist in managing COVID-19 patients and an innovation to counter that. The emerging disease is teaching us new ways to perform the older techniques.

Financial support and sponsorship

Nil.

Conflicts of interest

There are no conflicts of interest.

References

1Chen N, Zhou M, Dong X, Qu J, Gong F, Han Y, et al. Epidemiological and clinical characteristics of 99 cases of 2019 novel coronavirus pneumonia in Wuhan, China: A descriptive study. Lancet 2020;395:507-13.
2World Health Organization. Rolling updates on coronavirus disease (COVID-19). 2020. Available from: https://www.who.int/emergencies/diseases/novel-coronavirus-2019/events -as-they-happen.
3Cui S, Chen S, Li X, Liu S, Wang F. Prevalence of venous thromboembolism in patients with severe novel coronavirus pneumonia. J Thromb Haemost 2020;18:1421-4.
4Zhou F, Yu T, Du R, Fan G, Liu Y, Liu Z, et al. Clinical course and risk factors for mortality of adult inpatients with COVID-19 in Wuhan, China: A retrospective cohort study. Lancet 2020;395:1054-62.
5Thachil J, Tang N, Gando S, Falanga A, Cattaneo M, Levi M, et al. ISTH interim guidance on recognition and management of coagulopathy in COVID-19. J Thromb Haemost 2020;18:1023-6.