Keywords

Preference Card

  • 18 ga, 22 ga, and 24 ga needles

  • Arterial line catheter

  • 5 or 10 ml syringe

  • Vascular access needle with syringe

  • Guidewire

  • 11-blade scalpel

  • 3-0 silk or Prolene suture

  • Sterile saline flushes

  • Local anesthetic lidocaine 1% with or without epinephrine

  • Occlusive dressing

Patient Positioning

  • Position the patient for appropriate visualization of the target artery.

  • The wrist is placed on dorsiflexion slit (Fig. 29.1).

  • Palpate the target artery with the second and third fingers.

  • ChloraPrep is used as skin preparation.

  • Maximum sterile barrier is used.

Fig. 29.1
figure 1

The wrist is placed on dorsiflexion with appropriate access and visualization of the targeted artery

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Nodal Points

Skin Preparation and Artery Location

  • Sterilely open the arterial catheter kit, and verify that all necessary components are present.

  • Allen test should be performed to assess for adequacy of ulnar artery and palmar arch.

  • Prep the area with ChloraPrep to a diameter of about 5 inches, wear sterile gloves, and place a sterile drape over the prepped area.

  • Local anesthesia should be placed around the site by first drawing up the provided lidocaine (or other local anesthetic) with an 18 ga needle then instilled around the marked site with a 22 or 24 ga needle.

  • A skin wheal should be avoided as it makes palpation of the arterial pulse more difficult.

Technique 1: Catheter-over-Needle

  • Catheter-over-needle utilizes a needle with an integrated catheter similar to those used in standard intravenous cannulation.

  • The skin is punctured 2–3 cm distal to the artery at a 30–45 degree angle advancing the needle toward the palpated pulsations (Fig. 29.2).

  • When blood is observed to “flash back” into the catheter hub, the apparatus is advanced slightly (1–2 mm) to ensure cannulation of the artery.

  • While holding the needle in place, the catheter is advanced up to its hub and the needle removed (Fig. 29.3).

  • With blood return observed, the catheter is held in place, and the arterial line transducer tubing is connected to the catheter (Fig. 29.4).

  • The catheter is secured in place with a barrier dressing such as Tegaderm®. Usually the tubing is then run between the thumb and index fingers and secured with tape when placed in the radial artery (Fig. 29.5).

Fig. 29.2
figure 2

The skin is punctured 2–3 cm distal to the artery at a 30–45 degree angle toward the palpated pulsations

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Fig. 29.3
figure 3

Slowly advance the catheter into the artery

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Fig. 29.4
figure 4

Arterial blood is returned; the catheter is held in place

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Fig. 29.5
figure 5

The catheter is connected to the transducer; the line is sutured in placed and covered with an occlusive dressing

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Technique 2: Seldinger

  • The vascular access needle should be loaded onto a syringe (usually 10 ml)

  • The needle should be held in the dominant hand and inserted at an approximately 30–45 degree angle to the skin in the direction of the palpated pulsations (Fig. 29.2).

  • When blood return is obtained, the syringe is then removed while holding the needle in place.

  • The guidewire is introduced through the needle leaving sufficient length outside the needle to maintain control of the wire. The wire should never be advanced with force. If resistance is met, the wire may be retracted several centimeters and advanced again. If resistance continues, the wire should be removed and steps 8–10 repeated (Fig. 29.6).

  • With a firm grip on the end of the wire, it and the needle should be retracted together until the needle is fully extracorporeal.

  • Control of the wire should then be established proximally (next to the skin) and the needle removed from the end of the wire.

  • A #11 scalpel is then used to make a nick in the skin (a few millimeters is usually sufficient) next to the guidewire.

  • The arterial line catheter is then threaded over the guidewire and inserted while ensuring control of and contact with the guidewire. Once inserted to its maximal depth, the guidewire is removed (Fig. 29.7).

  • With blood return observed, the catheter is held in place, and the arterial line transducer tubing is connected to the catheter.

  • The catheter is secured in place with a barrier dressing such as Tegaderm®. Usually the tubing is then run between the thumb and index fingers and secured with tape when placed in the radial artery (Fig. 29.5).

Fig. 29.6
figure 6

Observed for blood flash back into the syringe to ensure cannulation of the artery

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Fig. 29.7
figure 7

Slowly advance the wire to assure cannulation of the vessel

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Technique 3: Modified Seldinger

  • The modified Seldinger technique uses the same principles as the Seldinger technique except that the needle, wire, and catheter are a single unit. Some units require assembly, while others are preassembled. In either case, prior to starting the procedure, the wire must be fully retracted to within the catheter before starting.

  • If using ultrasound, the transducer should be held in the non-dominant hand or by an assistant. The needle should be held in the dominant hand and inserted at an approximately 30–45 degree angle to the skin either under ultrasound guidance or in the direction of the palpated pulsations (Fig. 29.2)

  • When blood return is obtained, the ultrasound probe is placed to the side while keeping it sterile, and the blood visually verified to appear arterial.

  • The needle should be stabilized in this position and the wire advanced to its maximal designed depth.

  • The catheter is then advanced over the wire and needle assembly to its maximal depth, the catheter is held in place, and the needle and wire removed as a single unit.

  • With blood return observed, the catheter is held in place, and the arterial line transducer tubing is connected to the catheter (Figs. 29.8 and 29.9).

  • The catheter is secured in place with a barrier dressing such as Tegaderm®. Usually the tubing is then run between the thumb and index fingers and secured with tape when placed in the radial artery (Fig. 29.5).

Fig. 29.8
figure 8

Observed for blood flash back into the catheter hub, the apparatus is advanced slightly (1–2 mm) to ensure cannulation of the artery

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Fig. 29.9
figure 9

Slowly advance the wire to assure cannulation of the vessel

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Pitfalls and Pearls

  • Using ultrasound to identify the anatomy will make the procedure easier as it is associated with fewer attempts.

  • Hand vascularization should be assessed before catheterization. Multiple techniques can be used for this purpose including a modifier Allen test, pulse oximetry, or Doppler ultrasound.

  • The use of local anesthesia will make the procedure easer.

  • Arterial lines can cause severe complications if not handled correctly. It would be advisable not to keep arterial lines for longer than 1 week.

  • Due to high pressure in the artery, full barrier precautions will minimize the risk of disease dissemination or infection.