Arterial Line Placement (Anesthesia)

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SAMPLE EXCERPT
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PRE-PROCEDURE
INDICATIONS
  • Continuous blood pressure measurement is necessary because of hemodynamic instability.
  • Continuous blood pressure measurement is necessary for the safety of certain anesthetic techniques, such as deliberate hypotension, cardiopulmonary bypass, or major vascular surgery involving arterial clamping.
  • Continuous blood pressure measurement is necessary for monitoring administration of vasoactive drugs.
  • Frequent blood gas measurements are needed.
  • Frequent blood sampling is needed in patients without central venous access.
  • Noninvasive blood pressure monitoring is difficult or impossible, such as in patients who are severely obese, have burned extremities, or are in shock.
CONTRAINDICATIONS
  • Absolute contraindications
    • Infection at the site of insertion
    • Traumatic injury proximal to the site of insertion
  • Relative contraindications; may be outweighed by other considerations
    • Failure to demonstrate collateral flow in small vessels (e.g., by Doppler ultrasonography)
    • Presence of arteriovenous (AV) shunt in the limb in question
    • History of surgery disrupting lymphatics of the upper extremity, such as a mastectomy with lymph node dissection
    • Arterial insufficiency in the distribution of the artery to be cannulated
EQUIPMENT

Upper Extremity Arterial Catheterization

  • Sterile prep solution, preferably chlorhexidine
  • 1% lidocaine solution if patient is awake
  • 20- to 22-gauge angiographic catheter and needle
  • Arm board
  • Sterile dressing
  • Tape
  • Transduction system for monitoring
  • Optional devices: ultrasound, wire

Femoral Artery Catheterization

  • Sterile prep solution
  • 1% lidocaine solution if patient is awake
  • 16- to 20-gauge angiographic catheter and needle
  • Wire of small enough gauge to pass through the angiocatheter or needle
  • Sterile dressing
  • Tape
  • Transduction system for monitoring
  • Optional devices: ultrasound, suture
ANATOMY
  • Multiple arteries are available for easy cannulation and transduction.
  • Choice of arteries to be cannulated include but are not limited to the radial, brachial, axillary, dorsalis pedis, and femoral arteries.
  • The radial artery can be palpated on the distal portion of the forearm between the radius and the tendon of the flexor carpi radialis.
  • The brachial artery can be palpated as it courses medial to the biceps muscle and tendon into the antecubital fossa, with the arm extended and the palm facing up.
  • The axillary artery may be palpated best in the axillary space, with the arm abducted and externally rotated.
  • The femoral artery may be best palpated below the inguinal ligament, midway between the anterior superior spine of the ilium and the symphysis pubis.
  • The dorsalis pedis artery may be palpated on the arch of the foot, between the first and second metatarsals.
  • Choice of artery is dependent on the ability to palpate a pulse or to locate it by Doppler ultrasonography.
  • The published literature does not support a higher infection rate in femoral artery catheters when compared to radial artery catheters.
  • Physicians may want to assess the collateral circulation if cannulating the smaller arteries such as the radial or dorsalis pedis arteries.
    • Allen’s test is not a reliable way to evaluate collateral circulation.
    • In one large series of 1,782 patients, Allen’s test was not found to predict postcannulation complications. In fact, complete radial artery occlusion was found in 25% of patients, without associated ischemic consequences.

PROCEDURE
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The full content of this section includes:
  • Step-by-step text instructions for performing the procedure
  • Clinical pearls providing practical clinical tips from medical experts
  • Patient safety guidelines consistent with Joint Commission and OHSA standards
  • Links to medical evidence and related procedures

POST-PROCEDURE
CARE
  • Clearly label the arterial line to prevent misidentification of the line as venous, with subsequent unintentional injection of drugs or other therapeutic substances into a peripheral artery. 
  • Use sterile technique when injecting saline or connecting tubing to lumens of catheter. **STERILE TECHNIQUE**
  • Always aspirate catheter and tubing to clear bubbles before injecting saline, heparin flush, or blood to avoid air embolism.  
  • Routine dressing changes with use of sterile prep
  • Daily exam of insertion site for signs of infection
  • Upon catheter removal, maintain pressure at the insertion site for 5 to 15 minutes. In coagulopathic patients, this period may need to be longer.
COMPLICATIONS
  • Common
    • Kinking of the catheter
    • Blockage or obstruction of the catheter
    • Air embolism
    • Hematoma
    • Arterial vasospasm during insertion attempts
    • Vascular disease making catheter insertion difficult
    • Radial artery occlusion; at least one study suggests this may occur in up to 25% of patients, but was not associated with ischemia or other serious sequelae.
    • Accidental injection of drugs or other substances intraarterially because of misidentification of the line as an intravenous catheter.
  • Infrequent
    • Thrombosis can occur in up to 25% of catheters; clinically significant thrombosis rarely occurs (<1%).
      • Thrombosis risk can be lowered by infusing the catheter with heparinized saline.
    • Neuropathy
    • Thromboembolism
  • Serious, rare complications
    • Infection is rare (<0.5%). Studies do not indicate that infection rates are higher with femoral than with radial artery cannulation.
    • Arterial aneurysm, pseudoaneurysm, or arteriovenous fistula formation
    • Peripheral ischemia due to arterial occlusion
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