Subcutaneous Nitroglycerin to Prevent Radial Artery Occlusion in Pediatric Patients: A Randomized Clinical Trial.

Summary

In infants and toddlers undergoing radial arterial catheterization under general anesthesia, a single subcutaneous dose of nitroglycerin before cannulation and removal reduced post-removal radial artery occlusion from 73.8% to 25.4% without causing hypotension. Hemodynamic surrogates (peak radial artery flow velocity and perfusion index) improved, and safety was favorable.

Key Findings

• RAO incidence after catheter removal was 25.4% with nitroglycerin vs 73.8% with placebo (OR 0.12; absolute risk reduction 48.5%).
• Higher post-removal radial artery peak flow velocity (13.0 vs 7.4 cm/s; P=0.002) and perfusion index (1.37 vs 0.65; P<0.001) with nitroglycerin.
• No hypotension or local adverse effects were observed; RAO duration did not differ.
• Per-protocol cohort included 132 of 200 randomized due to protocol violations.

Clinical Implications

Consider subcutaneous nitroglycerin (5 μg/kg) prior to ultrasound-guided radial artery cannulation and before catheter removal in pediatric patients to prevent RAO, with monitoring but minimal concern for hypotension.

Limitations

• Single-center trial with substantial protocol exclusions (68/200) may affect generalizability
• Primary RAO assessment via reverse Barbeau test plus oximetry; limited long-term vascular follow-up

Future Directions

Replicate in multicenter settings with standardized duplex ultrasound endpoints and evaluate dosing ranges, timing, and generalizability to older children and catheter dwell times.