Journal of Cardiovascular and Cardiology

Retrograde Flow of Radial Arterial Line Flush Solution Captured with Ultrasound Imaging in a Neonate

Jeffrey C Waldman MD* and Mark D Twite MA MB BChir FRCP

Department of Anesthesiology, Section of Pediatric Anesthesiology, Children’s Hospital Colorado, University of Colorado Anschutz Medical Campus, Aurora, CO, USA

*Corresponding author
Jeffrey C Waldman MD,  Department of Anesthesiology, Children’s Hospital Colorado, Anschutz Medical Campus, 13123 E. 16th Ave, Aurora, CO 80045, USA.  Email: jeffrey.waldman@childrenscolorado.org

A 3.5kg, four-day-old, term infant with prenatal diagnosis of transposition of the great arteries (TGA) presented for arterial switch operation (ASO). Following induction of general anesthesia and nasotracheal intubation, a right radial arterial line and right internal jugular vein central line were placed using the Seldinger technique and ultrasound guidance. When guidewire position in the jugular vein was confirmed with ultrasound, turbulent flow was seen in the right common carotid artery. It was recognized this flow occurred during manual flush of the arterial line and represents retrograde flow in the arterial system. Video documentation of the event was obtained and still images are shown below.

Arterial line placement is performed routinely in cardiac surgical patients. The radial artery is frequently chosen for cannulation because of its accessibility and low incidence of complications in infants, children, and adults [1,2]. After aspiration of arterial blood, the line must be flushed to prevent thrombosis and maintain catheter patency. However, retrograde flow in arteries proximal to the site of catheter insertion has been clearly demonstrated in pediatric and adult patients during use of the pressurized flush system and during manual flush of the line. In these studies, the rate of flush solution injection was directly related to the probability of retrograde flow. A rate of manual injection faster than 0.5-1mL/5s in neonates and 1mL/s in adults has been shown to embolize microbubbles and reverse arterial flow respectively [3,4].

References

1. Selldén H, Nilsson K, Larsson LE, Ekström-Jodal B. Radial arterial catheters in children and neonates: a prospective study. Crit Care Med. 1987. 15: 1106-1109.
2. Scheer BV, 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: 198-204.
3. Cornelius A, Fischer J, Frey B, Baenziger O, Gerber A, et al. Pressurized bag pump and syringe pump arterial flushing systems: an unrecognized hazard in neonates? Intensive Care Med. 2002. 28: 1638-1643.
4. Murphy GS, Szokol JW, Marymont JH, Avram MJ, Vender JS, et al. Retrograde blood flow in the brachial and axillary arteries during routine radial arterial catheter flushing. Anesthesiology. 2006. 105: 492-497.