Arterial Cannulation

Aka: Arterial Cannulation, Arterial Line

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II. Indications: Critically Ill Patient

  1. Serial Arterial Blood Gas monitoring (e.g. ARDS, esp. if >4 samples needed in 24 hours)
  2. Continuous Blood Pressure Monitoring optimized for accuracy
    1. Accurate systolic and diastolic Blood Pressures for titrated vasoactive medications in shock
    2. Cardiac Arrest
    3. Hypertensive Emergency
      1. Intracranial Hemorrhage
      2. Aortic Dissection
  3. Other hemodynamic monitoring parameters may be estimated electronically (based on wave form)
    1. Cardiac Output
    2. Stroke Volume
    3. Pulse Pressure Variation

III. Contraindications

  1. Affected limb injury (Trauma, Fractures, burns, Cellulitis)
  2. Raynaud Syndrome
  3. Thromboangiitis Obliterans (Buerger Disease)
  4. Coagulopathy
    1. Ultrasound guidance of a 6 Fr catheter may be safely placed if INR<3 and Platelet Count >20k

IV. Precautions

  1. Never use arterial catheters for medication or fluid infusions
  2. Monitor line continuously
    1. Alarms that would indicate open catheter (with blood loss)
    2. Inspect for ischemic limb or infection
      1. Remove catheter immediately if these occur
  3. Remove catheters as soon as they are no longer needed
  4. Must calibrate catheter and transducer first at heart level
  5. As with Blood Pressures in general, normal arterial pressure does not exclude hypoperfusion
    1. Compensatory Vasoconstriction may mask hypoperfusion until precipitous drop
    2. Use other measures (e.g. IVC Ultrasound for Volume Status) to further evaluate vascular status
  6. Abnormal pressure readings from catheter should be confirmed with manual Blood Pressure readings
    1. Waveform may be distorted by vascular and transducer changes
    2. Mean arterial pressure typically remains accurate despite waveform distortion

V. Preparation: Arterial Line Sites (in order of preference)

  1. Radial artery (preferred)
    1. Lowest rate of complications (4%)
    2. Lowest failure rate (5%)
  2. Femoral artery (requires longer catheter)
    1. Higher systolic Blood Pressure (+5 mmHg) in the femoral Arterial Lines compared with radial artery
    2. Highest risk for complications (12%, including bleeding, Hematoma, pseudoaneurysm)
    3. Highest failure rate (30%)
    4. Place the line below the inguinal ligament (compressible)!
    5. Consider in Unstable Patients undergoing active Resuscitation efforts
      1. Femoral site may be prepped for both Femoral Central Line and Arterial Line
  3. Avoid Brachial artery cannulation (risk of distal hand ischemia)
    1. However good evidence for safety of brachial artery line in cardiac surgery (placed by skilled operators)
    2. Singh (2017) Anesth 126:1066 +PMID: PMID: 28398932 [PubMed]
  4. Other sites
    1. Axillary artery (requires longer catheter)
    2. Dorsalis pedis artery (less reliable reading in adults)

VI. Technique: Preparation for Wrist Arterial Cannulation

  1. Confirm collateral circulation
    1. Ultrasound may be used to demonstrate pulsatile flow in both ulnar and radial arteries
    2. Modified Allen Test has poor correlation and prediction of distal extremity ischemia
      1. Valgimigli (2014) J Am Coll Cardiol 63(18): 1833-41 +PMID: 24583305 [PubMed]
  2. Obtain IV catheter
    1. Needle of 18 or 20 gauge with plastic cannula
    2. Flush with Heparinized saline
  3. Position patients wrist and hand
    1. Ideal wrist flexion to 45 degrees
    2. Patient dorsiflexes wrist over sterile gauze roll (e.g. Kerlix)
    3. Tape palm and upper Forearm to arm board
  4. Clean radial entry site
    1. Chlorhexidine or Povidone-Iodine solution (Betadine) scrub
  5. Local Anesthetic at entry site
    1. Small skin wheal (1-2 ml) of Lidocaine 1-2% WITHOUT Epinephrine
    2. Do NOT use Lidocaine with Epinephrine (causes vasospasm, interfering with arterial placement)
  6. Ultrasound
    1. Use high frequency linear probe with sterile probe cover and sterile gel between skin and probe
    2. Transverse probe orientation is adequate (short distance from skin surface to vessel)

VII. Technique: Placing Radial Arterial Line

  1. Optimize first pass success (best chance for successful cannulation)
    1. Sit for the procedure
    2. Take time to identify maximal pulse
  2. Identify radial artery with gentle pressure
    1. Palpate with 2 parallel fingertips (identifies artery orientation)
    2. Initial vasospasm may interfere with vessel identification (may need to wait for vasospasm to subside)
  3. Enter skin just distal to palpated artery site
    1. Entry is 2 cm (1 finger breadth) proximal to the distal wrist crease
    2. Needle angled 30 to 45 degrees toward arm
  4. Slowly advance needle until spontaneous blood enters
    1. After vessel entry, reduce the angle of entry and reconfirm pulsatile blood in catheter
  5. Guidewire
    1. Guidewires are often incorporated into Arterial Line catheter
    2. Guidewire passed into artery
    3. Remove needle
  6. Advance flushed plastic cannula over top of guide wire
    1. Uses modified Seldinger technique
    2. Gentle twisting motion of catheter may be needed to advance catheter fully
  7. Secure catheter to skin
    1. Use 2-0 Silk Suture
    2. Apply transparent dressing
  8. Turn 3-way Stopcock to seal artery
  9. Remove pad under wrist and secure arm board

VIII. Technique: Arterial Line Connection and Calibration

  1. Connect transducer and high-pressure infusion set to catheter hub
    1. Transducer should be at the level of the right atrium
  2. Prepare the tubing
    1. Three-way stop cock should be off to patient (and open to the atmosphere)
    2. Catheter tubing is flushed with saline
    3. Remove any air bubbles from the line
    4. Increase pressure in the line using a pressure bag
  3. Zero the monitor
    1. Press zero on the monitor
  4. Once the monitor reads zero
    1. Turn the stopcock to be open to the patient and closed to the atmosphere
  5. Visualize wave form on monitor
    1. Adjust monitor scale as needed to adequately visualize wave form
    2. Adjust patient position as needed so that the transducer remains at right atrium level

IX. Monitoring

  1. A-Line compatible monitors
    1. Continuous reading of systolic and diastolic Blood Pressure as well as mean arterial pressure
    2. Requires calibration and special tubing
  2. Disposable monitors
    1. Attach inline to the catheter and have a small digital screen displaying mean arterial pressure

X. Complications

  1. Arterial Thrombosis
    1. Risk increases with decreasing wrist circumference
    2. Risk increases rapidly in first 24 hours, than slowly
  2. Bleeding Complications (1.8-2.6%)
    1. Hematoma or line oozing are most common bleeding complications
    2. Open Arterial Line can result in rapid, life-threatening blood loss
    3. Risk Factors
      1. Femoral Arterial Lines are the highest risk for bleeding complications
      2. Multiple attempts at placement
      3. Landmark-based line placement (without Ultrasound)
  3. Catheter embolization (e.g. CVA)
    1. Occurs with vigorous Flushing of radial catheters
    2. Gentle irrigation with 1-2 ml boluses should be used
  4. Arterial Line infections
    1. Risk increases after 72 hours
    2. Follow same preventive strategies as for Central Line-Associated Bloodstream Infection (CLABSI)
      1. Arterial Line bloodstream infections occur at the same rate (0.9 to 3.4%) as CLABSI
      2. Arterial Line bloodstream infections carry the same morbidity and mortality of CLABSI
    3. Use sterile technique on placement as with Central Line Placement
    4. Remove catheter at earliest possible time
    5. Provide careful wound and dressing care
  5. Other arterial complications (esp. femoral Arterial Lines)
    1. Pseudoaneurysm
    2. Arteriovenous Fistula

XI. Resources

  1. Arterial Line Placement - Ultrasound Guided (Dr. Mellick, Youtube)
    1. https://www.youtube.com/watch?v=VtoVavr0W9k

XII. References

  1. Rutherford (2025) Arterial Line, Hospital Procedures Course
  2. Killu and Sarani (2016) Fundamental Critical Care Support, p. 93-114

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