Overview
Arterial line insertion involves the placement of a catheter into an artery (typically radial, femoral, or brachial) to provide continuous blood pressure monitoring and arterial blood gas sampling. It is essential for hemodynamic monitoring in critical care and major surgery.
Arterial lines provide continuous, real-time blood pressure monitoring and allow for frequent arterial blood gas sampling without repeated arterial punctures. They are crucial for patients requiring precise hemodynamic control, such as those undergoing major surgery, in shock, or requiring vasoactive medications.
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Indications
Continuous blood pressure monitoring in critically ill patients
Cardiac, vascular, and major abdominal procedures
Septic, cardiogenic, or hypovolemic shock
Patients requiring inotropes or vasopressors
Respiratory failure, acid-base disorders
Cardiopulmonary bypass procedures
Severe trauma requiring intensive monitoring
Intensive care unit patients
Contraindications
Absolute Contraindications
Relative Contraindications
📋 Equipment Checklist
Check off items as you gather them:
Pre-procedure Preparation
Preparation includes patient assessment (coagulation status, peripheral pulses, Allen test), equipment check (arterial catheter kit, transducer, monitoring), informed consent, and understanding the anatomy of the target artery and surrounding structures.Step-by-Step Procedure
Step 1: Patient Assessment
Assess patient for contraindications, perform Allen test, check peripheral pulses, and obtain informed consent. Position patient appropriately.
⚠️ Common Mistakes to Avoid:
- Inadequate assessment
- Missing Allen test
- Poor positioning
💡 Pro Tip:
Always perform Allen test before radial artery cannulation. Check for adequate collateral circulation.
Step 2: Equipment Setup
Prepare arterial catheter kit, set up ultrasound machine, draw up local anesthetic, and ensure sterile technique.
⚠️ Common Mistakes to Avoid:
- Incomplete equipment check
- Wrong catheter size
- Poor sterile technique
💡 Pro Tip:
Use ultrasound guidance for all arterial line insertions to improve success rate.
Step 3: Sterile Technique
Perform sterile preparation with antiseptic solution, drape the area, and maintain strict aseptic technique throughout the procedure.
⚠️ Common Mistakes to Avoid:
- Inadequate sterile technique
- Poor skin preparation
- Contamination
💡 Pro Tip:
Maintain strict aseptic technique to prevent catheter-related bloodstream infections.
Step 4: Artery Localization
Use ultrasound to identify target artery, assess patency, and mark insertion site. Confirm artery anatomy and absence of thrombosis.
⚠️ Common Mistakes to Avoid:
- Poor ultrasound technique
- Not checking artery patency
- Wrong artery identification
💡 Pro Tip:
Always use ultrasound guidance. Identify artery and vein to avoid venous cannulation.
Step 5: Needle Insertion
Insert needle under ultrasound guidance, confirm arterial blood return, and advance guidewire through needle into artery.
⚠️ Common Mistakes to Avoid:
- Venous puncture
- Poor needle angle
- Guidewire advancement problems
💡 Pro Tip:
Confirm arterial blood (bright red, pulsatile) before advancing guidewire. Venous blood is darker and non-pulsatile.
Step 6: Catheter Insertion
Dilate tract, insert catheter over guidewire, remove guidewire, and confirm catheter position.
⚠️ Common Mistakes to Avoid:
- Catheter too deep
- Poor catheter securing
- Air embolism
💡 Pro Tip:
Keep the patient in supine position during insertion to prevent air embolism.
Step 7: Position Confirmation
Confirm catheter position with blood return, connect to transducer, and secure catheter properly.
⚠️ Common Mistakes to Avoid:
- No blood return
- Poor catheter securing
- Inadequate monitoring
💡 Pro Tip:
Always confirm blood return and proper waveform before securing catheter.
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Post-procedure Care
Post-procedure care includes confirming catheter function, monitoring for complications (thrombosis, infection, distal ischemia), securing the catheter, and documenting the procedure details.Complications & Management
| Complication | Incidence | Signs | Management | Prevention |
|---|---|---|---|---|
| Thrombosis | 5-15% | Absent distal pulses, pain, pallor, paresthesia | Remove catheter, anticoagulation, vascular consultation | Proper technique, early removal, prophylactic anticoagulation |
| Infection | 2-8% | Erythema, purulent discharge, fever, positive blood cultures | Remove catheter, antibiotics, blood cultures | Strict aseptic technique, proper dressing, early removal |
| Hematoma | 3-10% | Swelling, pain, ecchymosis, nerve compression | Compression, monitoring, surgical evacuation if needed | Check coagulation status, gentle technique, ultrasound guidance |
| Distal ischemia | 1-3% | Pallor, pain, paresthesia, absent pulses | Remove catheter, vascular consultation, monitoring | Allen test, proper technique, monitor distal perfusion |
| Air embolism | <1% | Sudden dyspnea, chest pain, cardiovascular collapse | Left lateral decubitus position, oxygen, supportive care | Proper technique, avoid air in system, occlude hub |
| Nerve injury | <1% | Paresthesia, weakness, pain, sensory changes | Neurological consultation, monitoring, documentation | Proper technique, avoid nerve proximity, ultrasound guidance |
Clinical Pearls
Always perform Allen test before radial artery cannulation - check collateral circulation.
Use ultrasound guidance for all arterial lines - it improves success and safety.
Confirm arterial blood before advancing guidewire - bright red and pulsatile.
Monitor distal perfusion continuously - check pulses and color regularly.
Document procedure details including site, complications, and outcomes.
Practice sterile technique religiously - arterial line infections are serious.
Be prepared for complications - have emergency equipment ready.
Check catheter function regularly - thrombosis can develop quickly.
Use appropriate catheter size - too large increases thrombosis risk.
Remove arterial lines as soon as possible to reduce complications.