Anesthesia and Sedation

  • May be used when pain or anxiety may impede performance and success 
  • Relative contraindications: old age, dementia, respiratory difficulty. 
  • Aim to use local anesthesia with l% to minimize procedural sedation 
  • Creating wheal: 
    • Clean surface with chlorhexidine or alcohol swab. With 22-25G needle, advance needle nearly parallel to skin and aspirate to ensure no blood vessel involved, then inject anesthetic to create 1-2 cm of raised skin. If deeper subcutaneous anesthesia is needed, advance needle perpendicular to skin, aspirate as advancing then inject the tract and inject anesthetic as needle is withdrawn 
  • Local anesthesia can alter landmarks, always double check anatomy after injection 
  • Minimal sedation: 0.25mg-2mg Ativan IV or 1mg-2.5mg Midazolam IV 
    • Midazolam (Versed): faster on (2-5 min) and faster off (30-60 min) 
    • Lorazepam (Ativan): onset 5-10 min; Duration 4-8 hour 

NEJM video Guide: https://www.youtube.com/watch?v=8hK04ai17- k&list=PLaxEyg3FbHI8x5IQMWD0qtbXEzN5RdIKM&index=3 

  • Indications 
  • Continuous, accurate hemodynamic monitoring (e.g. vasopressor titration, BP accuracy) 
  • Need for frequent ABGs

Contraindications 

  • Abnormal Allen's test, thrombosis of selected site, distorted anatomy at selected site (known prior fistulas, grafts, malformations), severe PAD at selected site, Raynaud's of selected limb 
  • Allen Test if placing radial artery access: goal to assess collateral ulnar blood flow to avoid ischemia. Compress both radial and ulnar artery 10-15 sec to allow blanching of palm, then release ulnar artery to assess re-perfusion. If blanching quickly resolves, ulnar artery will allow distal perfusion.

Consent 

  • Bruising, pain, damage to adjacent structures, infection, bleeding (possible extension to RP bleed with femoral placement), hematoma formation, vascular complications (dissection, AV fistula, pseudoaneurysm), thrombosis, rarely distal ischemia

Pre-procedural considerations 

  • Bleeding risk guidelines: no definitive guideline (suggest plts > 50K, INR < 3, PTT < 100) 
  • Allen Test if placing radial artery access to assess collateral ulnar blood flow. Compress both radial and ulnar artery 10-15 sec to allow blanching of palm, then release ulnar artery to assess reperfusion. If blanching quickly resolves, ulnar artery will allow distal perfusion. 
  • Radial access: ensure wrist is adequately extended; can use towel roll under wrist or tape hand 
  • Discuss with fellow prior to brachial, femoral a-line placement 
  • Ask RN to prepare tubing and waveform monitoring prior to time-out
Last updated on