Arterial line
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
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- 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
- 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
- Radial - 1-2 cm proximal to wrist
- Cleanse skin with iodine or chlorhexidine
- 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
- Merk Manual - How To Do Radial Artery Cannulation
- Merk Manual - How To Do Femoral Artery Cannulation
- emDocs - Under Pressure: Arterial Lines in the Emergency Department
- REBEL EM - Ultrasound vs Landmark-Guided Palpation for Radial Arterial Line Placement
Videos
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References
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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.
- ↑ 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/