What is the recommended procedure for arterial line placement?

Recommended Procedure for Arterial Line Placement

The recommended procedure for arterial line placement involves using maximal barrier precautions with appropriate aseptic technique, preferably with ultrasound guidance, and placement in the right radial artery for most patients. 1

Site Selection

1. Primary site recommendation: Right radial artery

   • Preferred site for elective cases 2
   • Use non-dominant hand when possible 2
   • Always perform Allen test before radial artery cannulation to assess collateral circulation 2

2. Alternative sites (in order of preference):

   • Left radial artery
   • Femoral artery (preferred in emergency situations or hemodynamic instability) 1, 3
   • Brachial artery (only when other sites unavailable)
   • Dorsalis pedis (limited use)

3. Site-specific considerations:

   • Femoral lines have significantly lower failure rates (5.4% vs 25.6-30.7% for radial) 3
   • In suspected aortic dissection, place arterial line in right radial artery; if brachiocephalic trunk involvement suspected, use left side 1
   • For cardiac surgery patients, longer catheters (12.7 cm) in radial or brachial sites provide more accurate readings than short radial catheters 4

Equipment

1. Catheter selection:

   • Teflon or polyurethane catheters recommended 2
   • Size: 20-gauge for radial/dorsalis pedis, 18-gauge for femoral/axillary 2
   • Length: 3-5 cm for small arteries (radial), 12.7 cm for better accuracy in cardiac patients 2, 4

2. Monitoring system:

   • Use flush device with constant flow of 2 mL/h 2
   • Include fast flush valve connected to normal saline under pressure 2
   • Add heparin (2500 IU/500 mL) to flush solution for catheters expected to remain >24 hours 2
   • Use low volume, low compliance, low resistance devices to minimize pressure wave distortion 2
   • Minimize connections, use Luer-lock type 2
   • Clearly identify stopcocks to prevent accidental intra-arterial injection 2

Procedure Steps

1. Preparation:

   • Follow maximal barrier precautions: full hand washing, sterile gloves, gown, cap, mask, and large sterile drape 1
   • Clean site with alcoholic chlorhexidine gluconate or povidone-iodine solution 1
   • Allow antiseptic to dry before proceeding 1

2. Insertion technique:

   • Use ultrasound guidance when available (significantly faster placement, fewer attempts, and higher success rates) 5
   • For conscious patients, use local anesthesia by injection and/or topical application (EMLA) 2
   • Prefer direct arterial puncture rather than transfixion 2
   • For deep vessels, use Seldinger technique 2
   • Secure catheter properly to prevent accidental removal

3. Confirmation and connection:

   • Verify arterial waveform
   • Connect to pressure transducer system
   • Calibrate at heart level
   • Set appropriate alarms

Maintenance and Monitoring

1. Dressing care:

   • Change dressing every four days 2
   • Use chlorhexidine or povidone-iodine for site manipulation 2

2. Line management:

   • Only change catheter if evidence of local infection or ischemia 2
   • Monitor for complications: thrombosis, infection, ischemia, hemorrhage
   • For blood sampling, manipulate with compresses soaked in chlorhexidine or povidone-iodine 2

3. Removal procedure:

   • Treat removal as an aseptic surgical procedure 2
   • Apply firm pressure for hemostasis after removal
   • Check catheter completeness 2
   • Systematic culture of catheter is not required 2

Special Considerations

1. In patients with suspected aortic dissection:

   • Measure pressure on both arms to rule out pseudo-hypotension due to arch branch obstruction 1
   • Place arterial line on right side unless brachiocephalic trunk involvement suspected 1

2. In cardiac surgery patients:

   • Consider longer catheters (12.7 cm) for more accurate readings 4
   • Femoral arterial lines may be preferable due to lower failure rates 3

3. In highly infectious disease patients:

   • Consider secured arterial line to allow safe serial blood sampling without additional needle procedures 1

Common Pitfalls and Caveats

• Avoid manual intermittent flushing with a syringe (contraindicated) 2
• Never puncture a vascular prosthesis 2
• Do not use arterial line flush solutions containing glucose to prevent hypoglycemic brain injury from contaminated samples 1
• Only use sodium chloride 0.9% (with or without heparin) as arterial line flush solution 1
• Ensure arterial lines are clearly identifiable with labels and color differentiation 1
• Remember that short radial catheters (5 cm) show significant pressure gradients compared to central aortic pressure, especially after cardiopulmonary bypass 4

By following these evidence-based recommendations, clinicians can optimize arterial line placement success while minimizing complications and ensuring accurate hemodynamic monitoring.