Nurse Practitioner Lucile Packard Childrens Hospital Stanford Hayward, California, United States
Abstract: Introduction Invasive monitoring of blood pressure by arterial line is a routine and valuable hemodynamic tool in the pediatric cardiac intensive care unit (ICU). Due to the complexity of the anatomy and physiology as well as the high acuity of pediatric cardiac patients, they often require multiple arterial accesses during their lifetimes. Though peripheral arterial monitoring lines are preferred, these patients may require central arterial access due to peripheral line complication or poor peripheral perfusion. The most common central arterial access in this patient population is via the femoral artery, however, due to the need to preserve femoral access for future cardiac catheterizations, our center has utilized axillary artery cannulation as a secondary method for extended monitoring. Axillary arterial lines for monitoring has been successfully used in critically ill adults and low birth weight neonates, but little has been published about its use in children with critical cardiac disease. This study aims to demonstrate the feasibility of axillary arterial cannulation for hemodynamic monitoring in this patient population.
Methods We performed a retrospective review of all patients with an axillary arterial monitoring line in the Lucile Packard Children’s Hospital pediatric cardiovascular ICU from July 1, 2020 through July 2022. Children cannulated percutaneously by anesthesia or critical care providers were included.
Results We reviewed 114 patients with 169 axillary arterial monitoring lines. Median patient age was 4 months (IQR 1-9 months) with a median weight of 5.26 kg (IQR 3.7- 7.56 kg). The axillary artery was considered for access only if upper extremity peripheral cannulation was not achievable. Axillary artery cannulation was performed by advanced practice providers or physicians utilizing ultrasound guidance in all cases. Patients were cannulated with 2.5Fr or 3Fr, 2.5cm to 5cm in length catheters, based on patient size. Median duration of line cannulation was found to be 18 days (IQR 7-33 days). Thrombosis occurred in 3 patients (1.7%). All 3 patients were treated with systemic anticoagulation. One patient had resolution of thrombosis within 1 week, 1 patient expired due to complications unrelated to the axillary arterial line and one patient required amputation of their distal upper extremity, however this patient had ischemia of multiple distal extremities after a prolonged cardiac arrest and disseminated intravascular coagulation.
Conclusion Axillary artery cannulation is a practical and safe alternative for invasive monitoring in pediatric cardiovascular ICU patients. Further prospective studies are needed to evaluate long-term complications related to this method.
