Arterial line: Difference between revisions

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==Indications==
==Indications==
*Hemodynamic instability
*Hemodynamic instability
*Titration of pressors or other cardioactive drugs
*Unreliable non-invasive BP monitoring
*Titration of [[vasopressors]] or other cardioactive drugs
*Need for recurrent or serial ABG analysis
*Need for recurrent or serial ABG analysis


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*Known arterial insufficiency or occlusion distal to placement site
*Known arterial insufficiency or occlusion distal to placement site
*Traumatic or vascular injury proximal to placement site
*Traumatic or vascular injury proximal to placement site
*Dialysis fistula at site


==Equipment Needed==
==Equipment Needed==
[[File:Arterial kateter (Seldinger).jpg|thumb|Arterial catheter (Seldinger technique)]]
[[File:Arterial kateter.jpg|thumb|Arterial catheter (Punktion technique)]]
*Sterile gloves, gown, cap, mask
*Sterile gloves, gown, cap, mask
*Sterile drape
*Sterile drape
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==Procedure<ref>Tegtmeyer K, Brady G, Lai S, Hodo R, Braner D. Videos in Clinical Medicine. Placement of an arterial line. N Engl J Med. 2006 Apr 13;354(15):e13.</ref>==
==Procedure<ref>Tegtmeyer K, Brady G, Lai S, Hodo R, Braner D. Videos in Clinical Medicine. Placement of an arterial line. N Engl J Med. 2006 Apr 13;354(15):e13.</ref>==
*Identify landmarks and palpate pulse
===General Setup===
**Radial - 1-2 cm proximal to wrist
#Identify landmarks and palpate pulse
**Femoral - anteromedial thigh distal to inguinal ligament
#*Radial - 1-2 cm proximal to wrist
*Cleanse skin with iodine or chlorhexidine
#**Supinate hand and hold wrist in extension
*Anesthetize skin and subcutaneous tissue over site with local anesthetic
#**Check for collateral circulation by performing the Allen test
*"Over-the-needle" technique
#*Femoral - anteromedial thigh distal to inguinal ligament
**Gently palpate pulse with nondominant hand to guide needle placement
#Cleanse skin with iodine or chlorhexidine
**Insert needle at 30-45 degrees to the skin
#Anesthetize skin and subcutaneous tissue over site with local anesthetic
**Advance until pulsatile blood is seen in flash chamber or catheter
**Lower angle of catheter to 10-15 degrees to the skin
**Advance over needle into artery
*"Over-the-wire" technique (Seldinger or modified Seldinger)
**Gently palpate pulse with nondominant hand to guide needle placement
**Insert needle at 30-45 degrees to the skin
**Advance until pulsatile blood is seen in flash chamber or catheter
**Insert wire through needle into artery
**Remove needle and advance catheter over wire into artery
***Some arterial line needles have the wire integrated into flash chamber, allowing the wire to be advanced into artery and the catheter over the needle/wire system without removing the needle


==Complications==
==="Over-the-needle" technique===
*Gently palpate pulse with nondominant hand to guide needle placement
*Insert needle at 30-45 degrees to the skin
*Advance until pulsatile blood is seen in flash chamber or catheter
*Lower angle of catheter to 10-15 degrees to the skin
*Advance catheter over needle into artery


==="Over-the-wire" technique (Seldinger or modified Seldinger)===
*Gently palpate pulse with nondominant hand to guide needle placement
*Insert needle at 30-45 degrees to the skin
*Advance until pulsatile blood is seen in flash chamber or catheter
*Insert wire through needle into artery
*Remove needle, leaving wire in place, and advance catheter over wire into artery, then remove wire
**Some arterial line needles have the wire integrated into flash chamber, allowing the wire to be advanced into artery and the catheter over the needle/wire system without removing the needle


==See Also==
===Ultrasound guidance===
*Ultrasound guidance of arterial line placement has been shown to significantly increase first attempt success and decrease time to placement<ref>Shiver S, Blaivas M, Lyon M. A prospective comparison of ultrasound-guided and blindly placed radial arterial catheters. Acad Emerg Med. 2006 Dec;13(12):1275-9.</ref><ref>Gu W-J, Tie H-T, Liu J-C, Zeng X-T. Efficacy of ultrasound-guided radial artery catheterization: a systematic review and meta-analysis of randomized controlled trials. Critical Care. 2014;18(3):R93. doi:10.1186/cc13862.</ref><ref>Tang L, Wang F, Li Y, et al. Ultrasound Guidance for Radial Artery Catheterization: An Updated Meta-Analysis of Randomized Controlled Trials. Lazzeri C, ed. PLoS ONE. 2014;9(11):e111527. doi:10.1371/journal.pone.0111527.</ref>, and should be considered in all arterial line placements


==Complications<ref>Scheer BV, Perel A, Pfeiffer UJ. Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Critical Care. 2002;6(3):199-204.</ref>==
*Bleeding
*Hematoma at puncture site
*Infection
*Temporary occlusion of artery (permanent occlusion reported, but rare)
*Pseudoaneurysm formation
==Miscellaneous==
*While you are trying to get an arterial line to get a crude estimate of the systolic pressure (especially if automatic cuff BP machine is not working due to BP too low) you can try one of the following:<ref>Scott Weingart. EMCrit 267 – They are not All Right!! An interview on Hemodynamic Assessment with Mike Patterson. EMCrit Blog. Published on March 6, 2020. Accessed on March 8th 2020. Available at https://emcrit.org/emcrit/hemodynamic-lows/</ref>
**POCUS blood pressure: inflate cuff and watch when you stop getting flow stops on ultrasound of brachial artery.
**SpO2 blood pressure: inflate cuff and watch when you stop getting SpO2 on the finger.
*Arterial line still preferred over the above methods since these are just rough estimates.
==External Links==
*[https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-peripheral-vascular-procedures/how-to-do-radial-artery-cannulation?query=arterial%20line Merk Manual - How To Do Radial Artery Cannulation]
*[https://www.merckmanuals.com/professional/critical-care-medicine/how-to-do-central-vascular-procedures/how-to-do-femoral-artery-cannulation,-ultrasound-guided?query=arterial%20line Merk Manual - How To Do Femoral Artery Cannulation]
*[http://www.emdocs.net/unlocking-common-ed-procedures-under-pressure-arterial-lines-in-the-emergency-department/ emDocs - Under Pressure: Arterial Lines in the Emergency Department]
*[https://rebelem.com/rebel-cast-ep90-ultrasound-vs-landmark-guided-palpation-for-radial-arterial-line-placement/ REBEL EM - Ultrasound vs Landmark-Guided Palpation for Radial Arterial Line Placement]
===Videos===
{{#widget:YouTube|id=_VNEZtZtww8}}
{{#widget:YouTube|id=EFnUaYRAdro}}


==References==
==References==
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[[Category:Procedures]]
[[Category:Procedures]]
[[Category:Critical Care]]
[[Category:Critical Care]]
[[Category:Cards]]
[[Category:Cardiology]]
[[Category:Vascular]]

Latest revision as of 17:19, 30 August 2021

Indications

  • Hemodynamic instability
  • Unreliable non-invasive BP monitoring
  • Titration of vasopressors or other cardioactive drugs
  • Need for recurrent or serial ABG analysis

Contraindications

  • Infection overlying insertion site
  • Known arterial insufficiency or occlusion distal to placement site
  • Traumatic or vascular injury proximal to placement site
  • Dialysis fistula at site

Equipment Needed

Arterial catheter (Seldinger technique)
Arterial catheter (Punktion technique)
  • Sterile gloves, gown, cap, mask
  • Sterile drape
  • Iodine or chlorhexidine prep
  • Local anesthetic
  • 27-30ga needle and syringe for local anesthetic administration
  • Appropriately sized needle and catheter for chosen site
  • Guidewire (may be integrated into needle/catheter)
  • Nonabsorbable suture
  • Armboard to hold wrist in extension (radial site only)
  • 500cc IV NS with pressure bag
  • Transducer kit with tubing
  • Transducer cable
  • Bioderm patch
  • Tegaderm dressing
  • Ultrasound (if using ultrasound-guided technique)

Procedure[1]

General Setup

  1. Identify landmarks and palpate pulse
    • Radial - 1-2 cm proximal to wrist
      • Supinate hand and hold wrist in extension
      • Check for collateral circulation by performing the Allen test
    • Femoral - anteromedial thigh distal to inguinal ligament
  2. Cleanse skin with iodine or chlorhexidine
  3. Anesthetize skin and subcutaneous tissue over site with local anesthetic

"Over-the-needle" technique

  • Gently palpate pulse with nondominant hand to guide needle placement
  • Insert needle at 30-45 degrees to the skin
  • Advance until pulsatile blood is seen in flash chamber or catheter
  • Lower angle of catheter to 10-15 degrees to the skin
  • Advance catheter over needle into artery

"Over-the-wire" technique (Seldinger or modified Seldinger)

  • Gently palpate pulse with nondominant hand to guide needle placement
  • Insert needle at 30-45 degrees to the skin
  • Advance until pulsatile blood is seen in flash chamber or catheter
  • Insert wire through needle into artery
  • Remove needle, leaving wire in place, and advance catheter over wire into artery, then remove wire
    • Some arterial line needles have the wire integrated into flash chamber, allowing the wire to be advanced into artery and the catheter over the needle/wire system without removing the needle

Ultrasound guidance

  • Ultrasound guidance of arterial line placement has been shown to significantly increase first attempt success and decrease time to placement[2][3][4], and should be considered in all arterial line placements

Complications[5]

  • Bleeding
  • Hematoma at puncture site
  • Infection
  • Temporary occlusion of artery (permanent occlusion reported, but rare)
  • Pseudoaneurysm formation

Miscellaneous

  • While you are trying to get an arterial line to get a crude estimate of the systolic pressure (especially if automatic cuff BP machine is not working due to BP too low) you can try one of the following:[6]
    • POCUS blood pressure: inflate cuff and watch when you stop getting flow stops on ultrasound of brachial artery.
    • SpO2 blood pressure: inflate cuff and watch when you stop getting SpO2 on the finger.
  • Arterial line still preferred over the above methods since these are just rough estimates.

External Links

Videos

{{#widget:YouTube|id=_VNEZtZtww8}} {{#widget:YouTube|id=EFnUaYRAdro}}

References

  1. ↑ Tegtmeyer K, Brady G, Lai S, Hodo R, Braner D. Videos in Clinical Medicine. Placement of an arterial line. N Engl J Med. 2006 Apr 13;354(15):e13.
  2. ↑ Shiver S, Blaivas M, Lyon M. A prospective comparison of ultrasound-guided and blindly placed radial arterial catheters. Acad Emerg Med. 2006 Dec;13(12):1275-9.
  3. ↑ Gu W-J, Tie H-T, Liu J-C, Zeng X-T. Efficacy of ultrasound-guided radial artery catheterization: a systematic review and meta-analysis of randomized controlled trials. Critical Care. 2014;18(3):R93. doi:10.1186/cc13862.
  4. ↑ Tang L, Wang F, Li Y, et al. Ultrasound Guidance for Radial Artery Catheterization: An Updated Meta-Analysis of Randomized Controlled Trials. Lazzeri C, ed. PLoS ONE. 2014;9(11):e111527. doi:10.1371/journal.pone.0111527.
  5. ↑ Scheer BV, Perel A, Pfeiffer UJ. Clinical review: Complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Critical Care. 2002;6(3):199-204.
  6. ↑ Scott Weingart. EMCrit 267 – They are not All Right!! An interview on Hemodynamic Assessment with Mike Patterson. EMCrit Blog. Published on March 6, 2020. Accessed on March 8th 2020. Available at https://emcrit.org/emcrit/hemodynamic-lows/
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