What are the tips for radial arterial line insertion?

From the Guidelines

Radial arterial line insertion should be performed using ultrasound guidance to improve first-attempt success rates, as evidenced by a meta-analysis suggesting its superiority 1. When inserting a radial arterial line, it is essential to consider the patient's overall condition and potential contraindications, such as severe peripheral vascular disease, coagulopathy, and local synthetic grafts 1.

Key Considerations

• The Allen's test is unreliable for assessing collateral perfusion, and ultrasound can be used instead to evaluate vessel patency and size 1.
• The method of insertion can be either catheter-over-needle or catheter-over-wire (Seldinger technique), with the latter being a suitable option 1.
• Major procedural complications, such as permanent ischemic damage, sepsis, and pseudoaneurysm, are rare, occurring in less than 1% of cases, and are similar for radial, femoral, and brachial sites 1.

Best Practices

• Use saline heparin as the only safe solution to flush catheters, as recommended by the AAGBI guidelines, to avoid severe hypoglycemia from misdirected administration of insulin 1.
• Regularly assess the insertion site and distal perfusion to detect potential complications, such as hematoma, thrombosis, infection, and distal ischemia.
• Position the patient with the wrist extended over a rolled towel for radial access, and use lidocaine for local anesthesia to minimize discomfort.
• Secure the catheter with suture or specialized dressing to prevent dislodgment and ensure accurate monitoring.

From the Research

Tips for Radial Arterial Line Insertion

• The use of ultrasound guidance can significantly increase the likelihood of successful cannulation and decrease complications compared with traditional landmark-based techniques 2.
• The distal radial approach (DRA) is as safe and effective as the traditional radial approach (TRA) for arterial line insertion, suggesting that it is useful as a new insertion site 3.
• Guidewire use during insertion is significantly more common in the DRA group, while post-puncture splint fixation is significantly more common in the TRA group 3.
• The 'classical' Seldinger technique is recommended for arterial line insertion in critically ill patients, as it is associated with a lower failure rate and fewer complications compared with the direct-puncture technique 4.
• The use of a polyurethane catheter is recommended, as it is less likely to block and require re-insertion compared with a Teflon catheter 4.
• Ultrasound guidance may not affect insertion times, the number of re-directs, or the number of attempts when compared with direct palpation in experienced operators 5.

Key Considerations

• Accidental removal of the arterial line can be problematic in the intensive care unit (ICU), and the choice of insertion site and technique should take this into account 3.
• The use of ultrasound guidance and the choice of catheter type can impact the success and complication rates of arterial line insertion 2, 4.
• Operator experience and technique can also impact the success and complication rates of arterial line insertion 5.