Received: 2 September 2021 | Revised: 28 February 2022 | Accepted: 16 March 2022

DOI: 10.1111/pan.14442

RESEARCH REPORT

Intraarterial papaverine for relief of catheter-­induced

peripheral arterial vasospasm during pediatric cardiac surgery:
A randomized double-­blind controlled trial

Nischal K. Gautam1 | Evelyn Griffin1 | Richard Hubbard1 | Olga Pawelek1 |

Kayla Edmonds1 | Eric Rydalch1 | Xu Zhang1 | Sahithi Sharma2 | Cassandra Hoffmann1

1
Department of Anesthesiology,
McGovern Medical School, UT Health
Houston, Houston, Texas, USA
2
Mayo Clinic, Scottsdale Arizona, USA
Correspondence
Nischal K. Gautam, Department of
Anesthesiology, McGovern Medical
School, UT Health Houston, 6431 Fannin
St, MSB 5.020, Houston, TX 77030, USA.
Email: nischal.k.gautam@uth.tmc.edu
Section Editor: Chandra Ramamoorthy
Abstract
Background: Maintaining the patency of peripheral arterial lines in pediatric patients
during surgery can be challenging due to multiple factors, and catheter-­related ar-
terial vasospasm is a potentially modifiable cause. Papaverine, a potent vasodilator,
improves arterial line patency when used as a continuous infusion in the pediatric
intensive care setting, but this method is not convenient during surgery.
Aim: Extrapolating from the benefit seen in the intensive care unit, the authors hy-
pothesize that a small-­volume intraarterial bolus of papaverine immediately after ar-
terial line placement will reduce vasospasm-­related arterial line malfunction.
Methods: This was a prospective, randomized, double-­blind study. Patients less than
17 years of age undergoing cardiac surgery were enrolled. Patients were randomized
into the heparin or papaverine groups. Immediately after arterial line insertion, an in-
traarterial bolus of heparin (2 units/ml, 1 ml) or papaverine (0.12 mg/ml, 1 ml) was ad-
ministered (T1, Figure 1). An optimal waveform was defined as the ease of aspirating a
standardized blood sample within 30 s, absence of cavitation when sampling, absence
of color change at the catheter site during injection, and presence of a dicrotic notch.
The primary outcome evaluated was the presence of an optimal arterial waveform at
5 min after the first randomized dose (T1 + 5 min). The secondary outcomes were the
presence of optimal arterial waveform an hour after the first dose and the ability of
papaverine to rescue suboptimal waveforms.
Results: A total of 100 patients were enrolled in the study. Twelve patients were ex-
cluded from the analysis. Complete datasets after randomization were available in 88
patients (heparin group, n = 46; papaverine group, n = 42). At baseline, groups were
similar for age, weight, arterial vessel size, and arterial line patency. At T1 + 5 min, an
improvement in the waveform characteristics was observed in the papaverine group
(heparin,39% [8/46] vs. papaverine, 64% [27/42]; p = .02; odds ratio, 2.8; 95% CI,
1.2 to 6.6, Figure 3, Table 2). At the end of 1 h, both groups showed continued im-
provement in arterial line patency. After the second dose, a higher number of patients
in the heparin group had suboptimal waveforms and were treated with papaverine
(heparin,37% [17/46] vs. papaverine,17% [7/42], p = .05). Patients in the heparin group

764 | © 2022 John Wiley & Sons Ltd. wileyonlinelibrary.com/journal/pan Pediatric Anesthesia. 2022;32:764–771.
GAUTAM et al. | 765

treated with papaverine showed significant improvement in patency (13/17 vs. 3/7,
p = .01). No serious adverse events were reported.
Conclusions: In pediatric patients, papaverine injection immediately after peripheral
arterial catheter placement was associated with relief of vasospasm and improved
initial arterial line patency. Further, papaverine can be used as a rescue to improve and
maintain arterial line patency.

KEYWORDS
arteries, child, heparin, papaverine, patency, transducers, vasospasm

1 | I NTRO D U C TI O N
Pediatric patients undergoing complex surgical repairs frequently
require arterial pressure monitoring. However, the accuracy or the
presence of an optimal arterial waveform is subject to variability
due to modifiable and nonmodifiable factors. Some of these are the
site of arterial cannulation, size of artery cannulated, number of at-
tempts, the type of arterial catheter, and fidelity of transducer-­flush
system. 1–­4
Also, maintaining the patency of pediatric peripheral ar-
terial catheters during complex surgeries can be challenging due to
lengthy surgical procedures, temperature instability, inotropic medi-
cations, and frequent sampling compounding the effects on subop-
timal arterial waveforms. 2–­4
Arterial vasospasm around the catheter site is a potentially
modifiable factor that significantly impacts peripheral arterial
line patency. Papaverine is known to cause relaxation of arterial
smooth muscle when spasmodically contracted and, therefore, of-
5
fers a potential solution to arterial vasospasm-­related variability.
In the pediatric intensive care setting, continuous infusion of pa-
paverine has been associated with improved patency of peripheral
arterial catheters.6 However, a continuous pump-­based infusion
is not a practical solution for the operating room setting due to
the use of rapid-­flush transducer systems and the need for aspi-
rating arterial blood samples. Extrapolating from the benefits seen
from continuous papaverine infusions, we hypothesize that small-­
volume boluses of papaverine in the operating room can relieve
peripheral arterial vasospasm and improve arterial waveforms in
pediatric patients. This study compares the effects of intraarterial
papaverine versus heparin on pediatric peripheral arterial lines
during cardiac surgery.
2 | M E TH O D S
This study was approved by the institutional review board, and this
manuscript conforms to enhancing the quality and transparency of
health research guidelines (Figure 2). The trial was registered at clini​
caltr​ials.gov prior to patient enrollment (No. NCT03894904, princi-
pal investigator: Nischal K Gautam, Registration date: 03/27/2019).
Patients were recruited between April and October 2020. All pa-
tients less than 17 years of age undergoing cardiac surgery with
What is already known about the topic
Papaverine as a continuous infusion improved arterial line
patency in pediatric patients when used as continuous in-
fusions in the intensive care unit.
What new information this study adds
In pediatric patients, papaverine injection immediately
after peripheral arterial catheter placement was associated
with improved initial arterial line patency. This drug was
further associated with improved arterial patency when
used as a rescue medication.
cardiopulmonary bypass were screened and enrolled in the study.
Exclusion criteria were patients with preexisting peripheral arterial
catheters, the presence of significant liver dysfunction, and infants
with corrected gestational age less than 37 weeks at the time of
surgery. A written informed consent was obtained. Patients were
randomly allocated to the heparin or papaverine group (50 in each
group) based on the sealed-­envelope method (Figure 2), thus blind-
ing both the patient and the provider.
The intraoperative small-­volume bolus of papaverine (1 ml,
0.12 mg/ml) was based on the 1-­h continuous infusion dose that
patients would have received postoperatively in the intensive care
unit. Standard heparin concentration of 2 units/ml was used as con-
trol. Once consent was obtained, a team member not involved in
patient care chose the appropriate pharmacy prepared clear syringe
and relabeled it with patient identifiers.
After induction of anesthesia, arterial cannulation was per-
formed using a standardized technique. A dedicated team of expe-
rienced anesthesia care providers performed cannulation of radial
or ulnar arteries at the distal wrist. Femoral arteries were avoided
as per institutional protocol. A 25 mm, 13–­6 MHz linear array probe
(Sonosite) was used to guide access. The short-­axis view was used to
measure the diameter of both radial and ulnar arteries, and the larger
vessel was chosen for cannulation. An ultrasound-­guided dynamic
needle tip positioning technique was used to facilitate arterial ac-
cess with a 22G or 24G standard angiocatheter. After reliable access,
the needle was withdrawn, and a 0.012-­inch double-­ended nitinol
766 | GAUTAM et al.
wire (Babywire™, EV3) was introduced through the angiocatheter.
A 2.5 Fr polyethylene arterial catheter of appropriate length (2.5 cm
for <5 years; 5 cm for >5 years) was then exchanged atraumatically
in all patients as per institutional protocol. The arterial catheter was
sutured, and the wrist was placed in an extended position to achieve
the best possible waveform. The arterial line was connected with
standard length tubing to a pressure transducer and pressurized bag
of heparin (2 units/ml) to 300 mmHg.
Data collection was performed immediately after securing the
arterial line as per study protocol (Figure 1). The arterial metrics col-
lected to minimize subjectivity were:
(i) Ease of aspirating a standardized blood sample. A 3 ml Luer-­lock
syringe was attached to a stopcock and aspiration to the 3 ml
mark performed within 30 s (yes/no).
(ii) Absence of cavitation when sampling (air bubbles or cavitation
within the transducer line seen during aspiration, yes/no).
(iii) Color change or the presence of any blanching at the catheter
site during sample aspiration or injection (yes/no).
(iv) The presence of a dicrotic notch after performance of these tests
(yes/no).
(v) The number of postflush oscillations on the square wave test.
A square wave test with the number of oscillations was utilized to
document waveform damping.
Significant arterial vasospasm immediately after arterial catheter
placement was defined when the arterial catheter was confirmed
within the vessel on ultrasonography, generated a mean arterial
pressure more than 20 mmHg, narrow pulse pressure less than 20
with a severely dampened waveform and inability to aspirate any
sample. These waveforms were observed for 5 min to assess for
spontaneous recovery of any of the parameters and then treated
with papaverine rescue, or catheters were re-­sited to other periph-
eral or central locations. We did not include them in the study since
the primary anesthesiologist would not be blinded at this point and
would lead to a potential bias in measurement.
After baseline data collection, 1 ml of the randomized drug was
administered intraarterially (T1). The primary outcome was the arte-
rial line characteristics demonstrating an “optimal arterial waveform”
at 5 min after randomization (T1 + 5 min). The definition of an opti-
mal arterial waveform for this study was when all characteristics were
considered ideal. In other words, the line was easy to aspirate blood
within 30 s without cavitation, presence of a dicrotic notch, and no
color changes at the catheter insertion site during the rapid flush
or square wave test. Subsequent interventions and measures are as
illustrated in the flowchart (Figure 1). One hour after randomization,
arterial line characteristics were re-­checked (T1 + 60 min). A second
dose was administered if any of the individual characteristics were
not considered optimal (T2). Five minutes after the second dose, if
the waveforms remained suboptimal, then papaverine was used to
F I G U R E 1 Study protocol
GAUTAM et al.
treat potential vasospasm. The secondary outcomes were defined as
optimal arterial waveform 1 h after the first dose (T1 + 60 min) and
the ability of papaverine to rescue suboptimal waveforms. As per
institutional protocol, at the end of the surgery, the fast flush sys-
tem was transitioned to a continuous pump-­based infusion system
(papaverine, 0.12 mg/ml + heparin, 2 units/ml) before transport-
ing patients to the intensive care unit, regardless of randomization
status. Other data recorded on each patient included basic demo-
graphics, operative and hemodynamic data at the above time points.
Postoperatively, arterial line placement-­related complications such
as distal ischemia and the necessity to re-­site arterial catheters were
collected until 72 h after surgery.
Since this was a pilot or exploratory study, a pragmatic sample
size of 100 patients was considered for testing the hypothesis. The
Shapiro–­Wilk test was used to test for normality. A Fisher's exact T-­
test was used to examine the significance of association between the
groups. An alpha of 0.05 was used to test for significance. Statistical
analyses were performed using IBM SPSS Statistics 22 (SPSS Inc.,
IBM Corporation) and Jamovi software (https://www.jamovi.org).
3 | R E S U LT S
From April 2019 to Oct 2020, 100 pediatric patients undergoing
cardiac surgery were enrolled in the study. Complete datasets after
randomization were available in 88 patients (heparin group, n = 46;
papaverine group, n = 42). Of these 12 excluded patients, three pa-
tients in the heparin group and one patient in the papaverine group
had their arterial catheters re-­sited due to significant arterial vasos-
pasm. No other study protocol violations were reported during the
entire study period. (Figure 2).
The heparin and papaverine groups were similar for the number
of infants enrolled, age, weight, the size of the artery cannulated,
and the number of attempts for arterial cannulation (Table 1). At
baseline, the optimal arterial waveform and individual arterial line
patency metrics were similar for both groups (Table 2).
For the primary outcome, 5 min after administering the first dose
(T1 + 5 min), a significant improvement in the optimal waveform was
observed in the papaverine group (papaverine, 64% [27/42] vs hepa-
rin,39% [8/46]; p = .02; odds ratio, 2.8; 95% CI, 1.2–­6.6; Figure 3 and
Table 2). The absence of color change at the arterial insertion site
during flush test occurred at a lower rate in the papaverine group
(heparin, 56% [26/46] vs. papaverine 88% [37/42]; p = .002; odds
ratio, 5.7; 95% CI, 1.9–­17.1).
For secondary outcomes, at the end of 1 h (T1 + 60 min), there
was continued improvement in arterial line patency in both groups
(heparin, 61% vs. papaverine, 71%, p = .37; odds ratio 1.6; 95%
CI 0.6–­3 .9, Table 3 and Figure 3). Five minutes after a second
dose (T2 + 5 min), the papaverine group of patients exhibited an
improvement in waveforms (heparin, 63% vs. papaverine, 81%,
p = .06; odds ratio 2.5; 95% CI 0.9–­6 .6). However, a higher number
of patients in the heparin group required rescue with papaverine
to improve arterial line characteristics (heparin,37% [17/46] vs.
| 767
papaverine,17% [7/42], p = .05). Additionally, the patients in the
heparin group rescued with papaverine showed further improve-
ment in patency metrics (heparin,76% [13/17] vs. papaverine, 42%
[3/7], p = .01). The median time from arterial line placement to
skin incision was 61 min (IQR 22). During this time, patients were
being prepped for cardiac surgery. At the time of the second dose,
none of the patients were on cardiopulmonary bypass, and core
temp in all patients was maintained near the baseline, as shown
in Table 3.
The difference in systolic arterial and noninvasive systolic blood
pressures measured at baseline in the heparin and papaverine group
was similar (mean diff, −5 mm Hg; p = .09). At 5 min after random-
ization, there was a reduction in the difference in systolic arterial
and noninvasive blood pressures, but the groups did not differ sig-
nificantly (mean diff, −2 mm Hg; p = .4). No patients in either group
developed distal ischemia for the first 72 h after the procedure, in-
cluding the four patients where arterial lines had to be re-­sited due
to concerns of vasospasm.
4 | DISCUSSION
The primary finding of this randomized controlled study was that
administration of papaverine immediately after placement of a pe-
ripheral arterial line was associated with improved arterial waveform
characteristics and relief of temporary arterial vasospasm. We also
found that papaverine could be used as a rescue medication to treat
vasospasm later during the case.
At our institution, the radial or ulnar arteries are the preferred
access sites for blood pressure monitoring during pediatric cardiac
surgery. 2 Given this preference, maintaining the intraoperative pa-
tency of peripheral arterial catheters in pediatric patients, especially
in neonates, can be challenging.7 Arterial vasospasm, however, is a
natural defense mechanism against vascular trauma. In pediatric pa-
tients, the arterial vasospasm effect is compounded by two other
variables, namely the size of the vessel and number of attempts.
Vasospasm-­related overdamping and the inability to aspirate or
to take blood samples at multiple time intervals over a range of
body temperatures minimize their utility during complex pediatric
surgeries.
We observed that the diameter of radial and ulnar vessels in our
study was small (median of 1.1 mm, IQR 0.5) and consistent with
previous pediatric studies.8,9 The use of ultrasound-­guided dynamic
needle tip positioning technique for arterial cannulation resulted in
85% first attempt and 94% second attempt success. This was similar
to previously reported pediatric studies.8,9 Despite a high success
of first attempt arterial cannulation in small-­sized vessels, it was
not surprising to observe suboptimal waveforms (81%) immediately
after cannulation, justifying the need for this study. This temporary
vasospasm is also comparable to studies in adult patients where a
high incidence of vasospasm was reported immediately after radial
artery cannulation.10,11 Nonetheless, 5 min after the first dose of pa-
paverine, we observed a clinical response in all individual metrics
768 | GAUTAM et al.

F I G U R E 2 CONSORT flow diagram

TA B L E 1 Demographics and arterial line characteristics 11% and similar an hour later (T1 + 60 min, Figure 3). However, after
randomized intervention at both these time points, the margin be-
Heparin Papaverine
(N = 46) (N = 42) tween the groups widens significantly, demonstrating a short-­term
benefit of papaverine in the concentration or dosage used. Also,
Age (months) 6 (0, 38) 3.5 (0, 16)
after administration of a second randomized dose, we observed that
Infants (<12 months) 26 (56%) 30 (71%)
a third of the patients in the heparin group remained with subop-
Weight (kg) 6.9 (3.3, 5.7 (2.9, 9.1)
timal waveforms and required rescue treatment with papaverine
12.8)
(Table 3). After papaverine was administered with an intention to
Cyanosis (<90% oxygen 28 (61%) 26 (62%)
treat, both groups demonstrated a high percentage of patients with
saturation)
optimal waveforms, indicating the clinical utility of papaverine as a
Artery size, diameter (mm) 1.1 (1.0, 1.5) 1.1 (0.9, 1.4)
rescue medication in this setting.
Arterial access in first attempt 40 (87%) 35 (83%)
Potent vasodilators such as nitroglycerin and papaverine have
Note: Values are median (IQR), Fisher's exact test. been employed via alternative routes to treat arterial vasospasm.9,12
Subcutaneous infiltration of nitroglycerin dilates the target artery
of arterial line patency with relief of temporary vasospasm in two-­ and improves the success of arterial cannulation at the first at-
thirds of the patients. tempt.9,12 Similarly, subcutaneous infiltration of papaverine enables
The initial gain with the use of papaverine was not evident an successful harvesting of the radial artery grafts during adult cardiac
hour after the first dose. We observed that the absolute differences bypass surgery.9,12 However, the effect of vasodilation by subcu-
for optimal patency between the two groups at baseline were around taneous route is limited to the site of arterial puncture and serial
GAUTAM et al. | 769

infiltration along the length of the arterial catheter might be needed or topical applications of these vasodilators are one-­time options and
to prevent proximal vasospasm. Also, the subcutaneous infiltrations might not be practical considerations for serial treatment of tempo-
rary vasospasm as seen during lengthy pediatric cardiac surgeries.

TA B L E 2 Arterial line characteristics An intraarterial bolus of nitroglycerin (100–­200 μg) and other va-
sodilators have also been used to relieve radial artery spasm during
Heparin Papaverine radial artery cardiac catheterization in adults, but no data exist for
(N = 46) (N = 42) p-­value
pediatric patients.13 Also, continuous use of intraarterial nitroglycer-
Baseline (immediately after placing arterial line) ine as a postoperative infusion to maintain patency of arterial lines
Optimal arterial 6 (13%) 10 (24%) .27 may have risks of tachyphylaxis, withdrawal, and hypotension.13
waveform
In pediatric patients, arterial vasospasm can occur during vari-
Easy aspiration of 42 (91%) 41 (98%) .36 ous time points of cardiac surgery due to temperature changes, vas-
blood sample
cular tone issues, and trauma from frequent sampling and flushing
Absence of cavitation 39 (85%) 38 (90%) .53
of catheters resulting in suboptimal hemodynamic measurements
during sampling
and limiting the efficacy of the above-­listed choices. However, it
Presence of dicrotic 17 (37%) 16 (38%) .91
is known that intraarterial papaverine acts directly on the smooth
notch
muscle of the arterial vessel, is unrelated to innervation, and arte-
Absence of color 19 (41%) 26 (62%) .06
change at catheter rial relaxation is prominent if vasospasm exists. 8 Also, papaverine
site with flush has shown similar effectiveness in treating established vasospasm
Core Temperature 36 ± 0.7 36.2 ± 0.6 .15 in adult patients rather than its prevention.9,14 In this current study
5 min after randomization on pediatric patients, we demonstrate that periodic intraarterial

Optimal arterial 18 (39%) 27 (64%) .021 administration of papaverine to radial and ulnar arteries is associ-
waveform ated with improved waveform characteristics. This ability to res-
Easy aspiration of 44 (96%) 42 (100%) .50 cue vasospasm-­related malfunction could provide clinicians with a
blood sample valuable technique to troubleshoot hemodynamics during critical
Absence of cavitation 42 (91%) 40 (95%) .68 phases of the procedure.
during sampling In this study, no systemic complications were observed with the
Presence of dicrotic 31 (67%) 33 (79%) .34 intraarterial injection of papaverine in the concentrations used. Four
notch patients were excluded from the study for not receiving random-
Absence of color 26 (56%) 37 (88%) .002 ization allocation due to significant vasospasm noted immediately
change at catheter
after arterial line placement. Peripheral arterial access was chal-
site with flush
lenging in all four of these patients requiring multiple attempts. The
Core Temperature 36 ± 0.7 36.2 ± 0.7 .31
peripheral arterial waveforms exhibited severe vasospasm in three

F I G U R E 3 Optimal waveform
770 | GAUTAM et al.

TA B L E 3 60 min after randomization

Heparin Papaverine
(N = 46) (N = 42) p-­value

Optimal arterial waveform 60 min after the 28 (61%) 30 (71%) .37

first dose (T1 + 60 min)
Optimal patency after second dose 29 (63%) 34 (81%) .06
(T2 + 5 min)
Papaverine Rescue 17 (37%) 7 (17%) .05
Response to Papaverine Rescue 13 (76%) 3 (42%) .01
Core Temperature 36.1 ± 0.8 36.3 ± 0.7 .28

patients requiring immediate rescue with papaverine and remark- C O N FL I C T O F I N T E R E S T

able recovery in waveform characteristics. In the fourth patient, the
peripheral line was in severe vasospasm and unresponsive to papav-
erine rescue. The arterial catheter had to be re-­sited to the femo-
ral artery in this patient. However, no patient suffered from distal
hand ischemia. Hypotension due to intraarterial papaverine bolus
was not observed. Instead, the systolic blood pressure was higher at
5 min after the first dose in the papaverine group (79 ± 17 mmHg vs.
76 ± 18 mmHg, p = .2).
There are some limitations to the current single-­center pilot
study. First, we did not measure the size of the peripheral arteries
at the tip of the catheter after cannulation at all time points due
to practical constraints. Adding these measures could have added
to the study's strength; however, we believe that incorporating all
four arterial characteristics in the definition of an optimal waveform
may have bridged this gap. Second, the absence of a control group
of patients (saline only) to compare the effectiveness of heparin or
papaverine was not possible as this would be against standard insti-
tutional procedures of routine heparin usage and might have added
additional risk to the patients. Third, we did not study a papaver-
ine dose-­related response in this study. Fourth, anesthesiologists
were blinded to randomization until papaverine was used with an
intention to treat vasospasm (T2 + 5 min). Responses to papaver-
ine rescue might have been biased at that point. Fifth, all patients
were transitioned to pump-­based continuous papaverine infusions
on arrival to the intensive care units, thereby limiting our ability to
study comparative longitudinal outcomes of patency in the intensive
care unit. Additionally, recovery after surgical repair and the patient
co-­morbidities often determine the duration for arterial monitoring
post-­procedure. Postoperatively, however, no arterial lines were re-­
sited or replaced during the first 72 h after intensive care admis-
sion. Finally, we did not analyze the impact of randomization on
hemodynamic parameters. The inability to control for surgical ma-
nipulation, the timing, and the dosing of anesthetic medications on
frequently changing hemodynamic parameters would have limited
their reporting.
In summary, intraarterial papaverine administration immediately
after placement of pediatric arterial lines during pediatric surgeries
relieves temporary arterial vasospasm with minimum risks. Further,
papaverine can be used as a rescue to improve and maintain arterial
line patency.
None for all authors.
AU T H O R C O N T R I B U T I O N S
Nischal K Gautam: conceived the study, protocol design, performed
study, data collection, data analysis, and majority of manuscript prepa-
ration. Evelyn Griffin and Olga Pawelek: helped implement, performed
study, and assisted in data collection. Richard Hubbard: performed
study, data collection, and manuscript preparation. Kayla Edmonds
and Eric Rydalch, helped implement, performed study, data collec-
tion, and assisted in manuscript preparation. Zhang Xu: helped study
design, data analysis, statistical support, and manuscript preparation.
Sahithi Sharma: data analysis and manuscript preparation. Cassandra
Hoffmann: helped with study design, protocol design, performed
study, data collection, data analysis, and manuscript preparation.
DATA AVA I L A B I L I T Y S TAT E M E N T
Data are available on request from the authors.
ORCID
Nischal K. Gautam https://orcid.org/0000-0002-2491-6705
REFERENCES
1. Hebal F, Sparks HT, Rychlik KL, Bone M, Tran S, Barsness KA.
Pediatric arterial catheters: complications and associated risk fac-
tors. J Pediatr Surg. 2018;53:794-­797.
2. DuMond AA, da Cruz E, Almodovar MC, Friesen RH. Femoral ar-
tery catheterization in neonates and infants. Pediatr Crit Care Med.
2012;13:39-­41.
3. King MA, Garrison MM, Vavilala MS, Zimmerman JJ, Rivara FP.
Complications associated with arterial catheterization in children.
Pediatr Crit Care Med. 2008;9:367-­371.
4. Adler AC, Helman S, Field C, et al. Reducing ischemic injury from
indwelling peripheral arterial catheters in a pediatric cardiac ICU.
Pediatr Crit Care Med. 2018;19:228-­236.
5. Vardiman AB, Kopitnik TA, Purdy PD, Batjer HH, Samson DS.
Treatment of traumatic arterial vasospasm with intraarterial papav-
erine infusion. Am J Neuroradiol. 1995;16:319-­321.
6. Griffin MP, Siadaty MS. Papaverine prolongs patency of peripheral
arterial catheters in neonates. J Pediatr. 2005;146:62-­65.
7. Cho HJ, Lee SH, Jeong IS, Yoon NS, Ma JS, Ahn BH. Differences in
perioperative femoral and radial arterial blood pressure in neonates
and infants undergoing cardiac surgery requiring cardiopulmonary
bypass. J Pediatr. 2018;94:76-­81.
GAUTAM et al. | 771

8. Eckard DA, Purdy PD, Girson MS, Samson D, Kopitnik T, Batjer H. and pooled analysis of clinical studies. Cardiovasc Revasc Med.
Intraarterial papaverine for relief of catheter-­induced intracranial 2015;16:484-­490.
vasospasm. Am J Roentgenol. 1992;158:883-­884. 14. Mills NL, Bringaze WL. Preparation of the internal mammary ar-
9. Girard DS, Sutton JP, Williams TH, et al. Papaverine delivery to tery graft which is the best method? J Thorac Cardiovasc Surg.
the internal mammary artery pedicle effectively treats spasm. Ann 1989;98:73-­79.
Thorac Surg. 2004;78:1295-­1298.
10. Kim JM, Arakawa K, Bliss J. Arterial cannulation: factors in the de-
velopment of occlusion. Anesth Analg. 1975;54:836-­8 41.
How to cite this article: Gautam NK, Griffin E, Hubbard R,
11. Ho HH, Jafary FH, Ong PJ. Radial artery spasm during transradial
et al. Intraarterial papaverine for relief of catheter-­induced
cardiac catheterization and percutaneous coronary intervention:
incidence, predisposing factors, prevention, and management. peripheral arterial vasospasm during pediatric cardiac
Cardiovasc Revasc Med. 2012;13:193-­195. surgery: A randomized double-­blind controlled trial. Pediatr
12. Jang Y-­E, Ji S-­H, Kim E-­H, et al. Subcutaneous nitroglycerin for Anesth. 2022;32:764–­771. doi: 10.1111/pan.14442
radial arterial catheterization in pediatric patients. Anesthesiology.
2020;133:53-­63.
13. Kwok CS, Rashid M, Fraser D, Nolan J, Mamas M. Intra-­arterial
vasodilators to prevent radial artery spasm: a systematic review
Copyright of Pediatric Anesthesia is the property of Wiley-Blackwell and its content may not
be copied or emailed to multiple sites or posted to a listserv without the copyright holder's
express written permission. However, users may print, download, or email articles for
individual use.