|Year : 2021 | Volume
| Issue : 2 | Page : 61-62
Femoral arterial catheters for hemodynamic monitoring in infants: Is it time to look more peripheral?
Manjinder Singh Randhawa, Karthi Nallasamy
Department of Pediatrics, Division of Pediatric Critical Care, Post Graduate Institute of Medical Education and Research, Chandigarh, India
|Date of Submission||10-Jan-2021|
|Date of Acceptance||20-Jan-2021|
|Date of Web Publication||10-Mar-2021|
Dr. Manjinder Singh Randhawa
Department of Pediatrics, Division of Pediatric Critical Care, Post Graduate Institute of Medical Education and Research, Chandigarh
Source of Support: None, Conflict of Interest: None
|How to cite this article:|
Randhawa MS, Nallasamy K. Femoral arterial catheters for hemodynamic monitoring in infants: Is it time to look more peripheral?. J Pediatr Crit Care 2021;8:61-2
|How to cite this URL:|
Randhawa MS, Nallasamy K. Femoral arterial catheters for hemodynamic monitoring in infants: Is it time to look more peripheral?. J Pediatr Crit Care [serial online] 2021 [cited 2021 Apr 20];8:61-2. Available from: http://www.jpcc.org.in/text.asp?2021/8/2/61/311061
Arterial catheterization has become an integral part of care for critically ill patients and those with cardiac diseases. The advantages of having an indwelling arterial catheter include continuous and direct monitoring of the vascular pressures, avoidance of multiple pricks for repeated blood gas sampling, and access for endovascular interventional procedures. Peripheral arterial catheters (PACs) have become the standard of care in adults for intraoperative and intensive care unit monitoring as the reported complication rates are below 1%. The safety of PACs has been reasonably documented in children, and invasive blood pressure monitoring is now recommended for all critically ill children requiring advanced life support measures. Recent data have also highlighted their importance for monitoring the quality of cardiopulmonary resuscitation (CPR) by targeting diastolic blood pressure above certain age-related cutoffs. However, despite these recommendations, establishing a PAC has its own challenges in younger children. The smaller blood vessel size, lack of expertise in inserting pediatric PACs, and nonavailability of small-sized catheters have limited their use in young infants, despite the availability of ultrasound for guiding vascular access. Femoral artery is a large vessel accessible to percutaneous palpation and catheterization. The larger size of the vessel also makes it amenable to the placement of bigger sheaths to facilitate percutaneous endovascular interventions. Femoral arterial catheters also provide more reliable arterial pressure monitoring in infants and neonates undergoing cardiopulmonary bypass than radial artery catheters. Arterial catheterization in children can be associated with significant short- and long-term complications. The incidence ranges from 3% to 40% in different studies. The data from these studies, however, are old. Advances in catheter placement technique and size and material of the catheters are expected to bring along a reduction in complications. There is a dearth of recent data in this regard.
Carr et al., in the current issue of Journal of Pediatric Critical Care, presented data from a large cohort of children who underwent femoral arterial catheterization (FAC) for varied indications. This study is a welcome addition to the existing literature as it measured a complication rate in a sizeable sample of young infants followed up till 90 days. A large proportion of these children (85%) underwent cardiac surgical procedures, and a majority of the lines (80%) were placed inside the operation room. Their findings are in concurrence with the existing data that increasing catheter size, multiple attempts, and lower patient age are associated with higher incidence of arterial occlusion. They have also demonstrated interesting associations with left femoral lines, showing significantly increased odds of occlusion. The collected variables could not explain this association. It would be interesting to see if there was an association between handedness of the physician performing the procedure and occlusion; however, these data were not recorded. The authors have explained the threefold increase in occlusion when the catheter was placed in the cardiac catheterization laboratory by the greater size of catheters and greater manipulation required for such interventional procedures. This finding and conclusion are similar to other published reports. The overall occlusion rate of 16% in the current study is substantial, consistent with the previous data; however, it must be interpreted with the study's design and its set of limitations. The retrospective, single-center nature of the data would deter the boldest of clinicians to draw generalizable conclusions, even with the large sample size. The study comprised a high-risk cohort, including neonates and infants younger than 12 months who had indwelling femoral arterial catheters for <24 h. Selection bias becomes unavoidable in retrospective enrollment from documents as both missing uncomplicated cases and underreporting of complications could influence the reported incidence. The absence of an imaging protocol also brings in subjectivity and operator dependence. A short follow-up period also does not allow the authors to monitor for long-term complications such as limb length discrepancy which have been reported in the literature.
The anatomical disadvantage with FACs is the end artery nature of the femoral artery. Radial artery catheterization (RAC) for monitoring overcomes this disadvantage due to the presence of a collateral ulnar circulation. Advent of smaller catheters and ultrasound guidance have made RAC safer and easier. Although some published literature suggests that RACs underestimate central aortic pressures as compared to FACs, Cetin et al. found radial mean arterial pressure (MAP) to be reliably reflective of the femoral MAP. Gleich et al. in their recent report from a large cohort of 5142 arterial lines in children found complications to be exclusively associated with femoral arterial lines in children under 5 years of age. RACs, the predominantly used catheters in this cohort, were found to be safe in children without resulting in any occlusions or infections. These findings, seen with the current report by Carr et al., point toward an unfavorable risk–benefit ratio for FACs in children. Does that mean we should abandon their use? – A large, prospective, multicenter study is probably warranted to give us the answer.
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