What is the process of placing an arterial line?

Arterial Line Placement Procedure

Arterial line placement should be performed using ultrasound guidance to improve success rates, reduce complications, and minimize procedural attempts. 1

Indications and Site Selection

• Primary indications: Continuous blood pressure monitoring and frequent arterial blood sampling
• Common sites (in order of preference):
  • Radial artery (most common, first-line choice)
  • Femoral artery (lower failure rate compared to radial - 5.4% vs 25.6%) 2
  • Brachial artery (avoid when possible due to 40% complication rate) 3

Equipment Required

• Sterile gloves, gown, mask, and cap
• Chlorhexidine skin preparation
• Sterile drapes
• Local anesthetic (1% lidocaine)
• Arterial catheter kit
• Ultrasound machine with high-frequency linear probe
• Sterile ultrasound probe cover
• Pressure transducer system
• Sodium chloride 0.9% flush solution (with or without heparin) 1
• Suture material or securement device
• Sterile transparent dressing

Procedural Steps

1. Preparation Phase

• Position the patient appropriately (wrist extended for radial approach)
• Perform Allen's test for radial approach to assess collateral circulation
• Prepare and check all equipment
• Set up pressure transducer system with sodium chloride 0.9% flush solution 1

2. Ultrasound Assessment

• Apply sterile ultrasound probe cover
• Identify the target artery in both short-axis (transverse) and long-axis (sagittal) views
• Assess vessel depth, course, and surrounding structures
• Identify optimal insertion site

3. Sterile Technique

• Perform hand hygiene
• Don sterile attire
• Prepare skin with chlorhexidine and allow to dry
• Apply sterile drapes

4. Anesthesia

• Infiltrate 1% lidocaine at the insertion site
• Allow adequate time for anesthetic effect

5. Catheter Insertion Using Ultrasound Guidance

• Two accepted techniques: 1

  • Static technique: Identify vessel position with ultrasound, mark site, then proceed with traditional landmark approach
  • Dynamic technique (preferred): Real-time ultrasound guidance throughout the procedure

• Dynamic technique steps:

  1. Hold ultrasound probe in non-dominant hand
  2. Visualize artery in short-axis view
  3. Insert needle at 30-45° angle under direct visualization
  4. Observe for flash of blood in catheter hub
  5. Lower angle and advance guidewire (if using Seldinger technique)
  6. Thread catheter over guidewire or advance directly (depending on catheter type)
  7. Remove guidewire if applicable
  8. Connect to pressure transducer system
  9. Secure catheter and apply sterile dressing

6. Confirmation and Documentation

• Verify arterial waveform on monitor
• Document procedure details including site, catheter size, number of attempts, and complications

Flush System Setup

• Use only sodium chloride 0.9% (with or without heparin) as flush solution 1
• Independently double-check flush solution with a second practitioner 1
• Ensure arterial lines are clearly labeled and identifiable 1
• Use transparent pressurizing devices to permit inspection of flush bag 1

Blood Sampling Technique

• Use 'closed' arterial line sampling systems when possible 1
• If using 'open' system:
  1. Turn stopcock off to flush solution
  2. Remove dead space volume with dedicated syringe
  3. Obtain sample with separate syringe
  4. Flush line after sampling
  5. Ensure dead space syringe is distinguishable from sampling syringe 1

Common Pitfalls and Complications

• Technical pitfalls: 4

  • Suboptimal angle of approach
  • Inadequate advancement of catheter
  • Through-and-through vessel puncture

• Complications: 3, 5

  • Vascular insufficiency (3.4-4.6%)
  • Bleeding/hematoma (1.8-2.6%)
  • Infection (0.4-0.7%)
  • Thrombosis
  • Arterial spasm
  • Accidental removal

Special Considerations

• Femoral arterial lines have significantly lower failure rates than radial lines (5.4% vs 25.6%) 2
• Avoid brachial artery when possible due to high complication rates (40%) 3
• Ultrasound guidance significantly improves success rates and reduces complications 1
• In donation after circulatory death organ procurement, arterial lines are essential for accurate determination of hemodynamic thresholds 1

By following this structured approach to arterial line placement with ultrasound guidance, clinicians can maximize success rates while minimizing complications and ensuring accurate hemodynamic monitoring.