Close
New

Medscape is available in 5 Language Editions – Choose your Edition here.

 

Arterial Line Placement

  • Author: Alex Koyfman, MD; Chief Editor: Vincent Lopez Rowe, MD  more...
 
Updated: Sep 02, 2015
 

Background

Arterial line placement is a common procedure in various critical care settings. Intra-arterial blood pressure (BP) measurement is more accurate than measurement of BP by noninvasive means, especially in the critically ill.[1] Intra-arterial BP management permits the rapid recognition of BP changes that is vital for patients on continuous infusions of vasoactive drugs. Arterial cannulation also allows repeated arterial blood gas samples to be drawn without injury to the patient.

Overall, arterial line placement is considered a safe procedure, with a rate of major complications that is below 1%.[2] It is not entirely without risks, however, and it requires appropriate knowledge of the anatomy and procedural skills. Arterial lines can be placed in multiple arteries, including the radial, ulnar, brachial, axillary, posterior tibial, femoral, and dorsalis pedis arteries.

In both adults and children, the most common site of cannulation is the radial artery,[3, 4, 5] primarily because of the superficial nature of the vessel and the ease with which the site can be maintained. Additional advantages of radial artery cannulation include the consistency of the anatomy and the low rate of complications.[6]

After the radial artery, the femoral artery is the second most common site for arterial cannulation. One advantage of femoral artery cannulation is that the vessel is larger than the radial artery and has stronger pulsation. Additional advantages include decreased risks of thrombosis and of accidental catheter removal,[7] though the overall complication rate remains comparable.[2]

There has been considerable debate over whether radial or femoral arterial line placement more accurately measures BP and mean arterial pressure (MAP)[8, 9] ; however, both approaches seem to perform well for this function.[10] In determining the need for and optimal location of arterial line placement, one must consider the risk and benefits of the procedure for each patient.

Next

Indications

Indications for arterial line placement are as follows:

  • Continuous direct BP monitoring - Arterial catheter MAP measurements are even more accurate than sphygmomanometric BP readings in patients who are morbidly obese, are very thin, have severe extremity burns, or have very low blood pressures [11]
  • Inability to use indirect BP monitoring (eg, in patients with severe burns or morbid obesity)
  • Frequent blood sampling

Placement of an arterial line can also help prevent complications associated with repeated arterial puncture (eg, hematomas and scar tissue formation).

Previous
Next

Contraindications

Absolute contraindications for arterial line placement are as follows[3, 12] :

Relative contraindications are as follows[3, 12] :

  • Anticoagulation
  • Coagulopathy
  • Inadequate collateral flow
  • Infection at the cannulation site
  • Partial-thickness burn at the cannulation site
  • Previous surgery in the area
  • Synthetic vascular graft
Previous
Next

Technical Considerations

Anatomic considerations

The radial artery originates in the cubital fossa from the brachial artery (see the image below). It traverses the lateral aspect of the forearm and gives rise to the palmar arches that provide vascular flow for the hand. At the wrist, the radial artery sits proximal and medial to the radial styloid process and just lateral to the flexor carpi radialis tendon.

Anatomy of radial artery. Anatomy of radial artery.

For the radial artery, the initial puncture site should be as distal as possible. A common location is over the radial pulse at the proximal flexor crease of the wrist. In any case, the puncture site should be at least 1 cm proximal to the styloid process so as to keep from puncturing the retinaculum flexorum and the small superficial branch of the radial artery.

The femoral artery originates at the inguinal ligament from the external iliac artery (see the image below). It passes under the inguinal ligament at approximately the midpoint between the anterior superior iliac spine and the pubic tubercle. It lies medial to the femoral nerve and lateral to the femoral vein and lymphatics.

Anatomy of femoral triangle. Anatomy of femoral triangle.

To facilitate control of bleeding and prevent bleeding into the pelvis, the femoral artery should always be accessed approximately 2.5 cm below the inguinal ligament, where it can be easily compressed. Normally, the femoral arterial pulsation can be palpated midway between the anterior superior iliac spine and the pubic symphysis.

Best practices

The following measures and recommendations may facilitate placement of an arterial line:

  • Always position the patient appropriately and feel arterial pulsation before initiating arterial line placement
  • Before starting the procedure, flush the needle introducer with heparinized flush to facilitate flashback of blood up to the needle hub upon entry into the artery
  • Puncture the radial artery in a slight lateral-to-medial direction; this allows the artery to be stabilized against the flexor carpi radialis tendon
  • After arterial puncture or decannulation, maintain pressure over the puncture site for at least 5 minutes (or possibly longer if the patient is in a hypocoagulable state)
  • Make a small skin incision at the site of needle puncture to allow easier passage of the catheter through the skin and help prevent catheter kinking during advancement [5]
  • When using a catheter-over-needle technique, be sure to advance the needle 2 mm after flash to ensure catheter placement inside the lumen
  • When using a Seldinger technique, do not dilate the artery; to minimize bleeding and vessel injury, dilate only the soft tissue tract
  • If the guide wire cannot be passed into the artery, try rotating the needle 90-180° in an attempt to eliminate an intimal flap blocking passage of the wire [4]
  • To avoid creating false passages, refrain from forcing further advancement if passage of a guide wire or catheter meets with resistance
  • When it proves difficult to advance the catheter into the lumen, consider the “liquid stylet” method; fill a 10-mL syringe with 5 mL of sterile normal saline, attach it to the catheter hub, aspirate 1-2 mL of blood into the syringe, and then slowly inject the syringe contents into the vessel as the catheter is advanced behind the fluid wave [13]
  • If several attempts at cannulation fail, the artery may spasm, making further attempts more difficult; if this occurs, allow the artery to recover for a short time before reattempting cannulation; subcutaneous infiltration of lidocaine or similar anesthetic around the puncture site may reduce vessel spasm [5]
  • Consider adding papaverine 30 mg/250 mL to the arterial line fluid, this may prolong the patency of peripheral arterial catheters in children and neonates [14, 15]
  • Regularly inspect the area for signs of ischemia, and remove the catheter at the first signs of circulatory compromise or clot formation; do not flush the catheter in an attempt to remove clots
  • To reduce the complication rate, remove the catheter as soon as it is no longer necessary [2]
Previous
Next

Outcomes

Common complications of arterial line placement are as follows[2, 6, 16, 17] :

  • Temporary radial artery occlusion (19.7%)
  • Hematoma/bleeding (14.4%)

Less common and rare complications include the following[2, 6, 16, 17] :

  • Localized catheter site infection (0.72%) - The risk increases with the length of time the catheter is in place [18]
  • Hemorrhage (0.53%)
  • Sepsis (0.13%)
  • Permanent ischemic damage (0.09%)
  • Pseudoaneurysm formation (0.09%)
  • Thrombosis
  • Arteriovenous fistula
  • Paralysis of median nerve
  • Nerve injury
  • Femoral artery dissection
  • Suppurative thromboarteritis

A 2014 meta-analysis by O'Horo et al suggested that arterial catheters may be an insufficiently recognized cause of catheter-related bloodstream infection (CRBSI).[19] The risk of arterial CRBSI was found to be higher with the femoral site than with the radial site.

Overall, the more serious complications are exceedingly rare when correct procedural techniques are used.[20]

Previous
 
 
Contributor Information and Disclosures
Author

Alex Koyfman, MD Assistant Professor, Department of Emergency Medicine, University of Texas Southwestern Medical Center, Parkland Memorial Hospital

Alex Koyfman, MD is a member of the following medical societies: American Academy of Emergency Medicine, American College of Emergency Physicians, Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Coauthor(s)

Taylor L Sawyer, DO, MEd, FAAP, FACOP Assistant Professor of Pediatrics, University of Washington School of Medicine; Associate Director, Neonatal-Perinatal Fellowship, Seattle Children's Hospital

Taylor L Sawyer, DO, MEd, FAAP, FACOP is a member of the following medical societies: Academic Pediatric Association, American Academy of Pediatrics, American College of Osteopathic Pediatricians, American Medical Association, American Osteopathic Association, Association of American Medical Colleges, Society for Simulation in Healthcare, International Pediatric Simulation Society

Disclosure: Nothing to disclose.

Zachary Radwine, MD Resident Physician, Division of Emergency Medicine, OSF St Francis Medical Center

Zachary Radwine, MD is a member of the following medical societies: Alpha Omega Alpha, American Academy of Emergency Medicine, American College of Emergency Physicians, Emergency Medicine Residents' Association

Disclosure: Nothing to disclose.

Chief Editor

Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California

Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society

Disclosure: Nothing to disclose.

Acknowledgements

Peter D Canning MD, Physician, Department of Emergency Medicine, Rogue Valley Medical Center

Disclosure: Nothing to disclose.

Andrew R Edwards, MD, FACEP Associate Professor of Emergency Medicine, Vice-Chair for Education and Residency Program Director, Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine; Medical Director, Jefferson County SWAT Team, Jefferson County Sheriff's Department

Andrew R Edwards, MD, FACEP is a member of the following medical societies: American College of Physicians, Society for Academic Emergency Medicine, and Wilderness Medical Society

Disclosure: Nothing to disclose.

Christopher J Freeman, MD, FACEP Assistant Professor, Department of Emergency Medicine, University of Alabama at Birmingham School of Medicine; Medical Staff, UAB University Hospital and UAB Highlands Hospital

Christopher J Freeman, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

M Scott Linscott, MD, FACEP Adjunct Professor of Surgery (Clinical), Division of Emergency Medicine, University of Utah School of Medicine

M Scott Linscott, MD, FACEP is a member of the following medical societies: American College of Emergency Physicians, Society for Academic Emergency Medicine, and Utah Medical Association

Disclosure: Nothing to disclose.

Luis M Lovato, MD Associate Clinical Professor, University of California, Los Angeles, David Geffen School of Medicine; Director of Critical Care, Department of Emergency Medicine, Olive View-UCLA Medical Center

Luis M Lovato, MD is a member of the following medical societies: Alpha Omega Alpha, American College of Emergency Physicians, and Society for Academic Emergency Medicine

Disclosure: Nothing to disclose.

Robert Ridout, MD Neonatologist, Newborn Medicine Service, Department of Pediatrics, Physician Advisor to Quality Services Division for Process Improvement, Tripler Army Medical Center, Hawaii

Robert Ridout, MD is a member of the following medical societies: American Academy of Pediatrics

Disclosure: Nothing to disclose.

Laurie Scudder, DNP, NP Nurse Planner, Medscape; Clinical Assistant Professor, School of Nursing, George Washington University, Washington, DC

Disclosure: Nothing to disclose.

Gil Z Shlamovitz, MD Assistant Professor, Section of Emergency Medicine, Baylor College of Medicine; Director of Medical Informatics, Emergency Center, Ben Taub General Hospital

Gil Z Shlamovitz, MD is a member of the following medical societies: American Academy of Emergency Medicine and American College of Emergency Physicians

Disclosure: Nothing to disclose.

Timothy G Vedder, MD Neonatology Staff, Tripler Army Medical Center; Assistant Clinical Professor of Pediatrics, University of Hawaii, John A Burns School of Medicine; Associate Professor of Pediatrics, Uniformed Services University of the Health Sciences, F Edward Hebert School of Medicine

Timothy G Vedder, MD is a member of the following medical societies: Society of US Army Flight Surgeons

Disclosure: Nothing to disclose.

Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference

Disclosure: Nothing to disclose.

Acknowledgments

The authors wish to thank James Stuart Booth, MD, for his assistance with image capture and processing.

Disclaimer: The views expressed in this manuscript are those of the author(s) and do not reflect the official policy or position of the Department of the Army, the Department of Defense, or the US Government.

References
  1. Cohn JN. Blood pressure measurement in shock. Mechanism of inaccuracy in ausculatory and palpatory methods. JAMA. 1967 Mar 27. 199(13):118-22. [Medline].

  2. Scheer B, Perel A, Pfeiffer UJ. Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine. Crit Care. 2002 Jun. 6(3):199-204. [Medline].

  3. Milzma D, Janchar T. Arterial puncture and cannulation. Roberts JR, Hedges JR. Clinical Procedures in Emergency Medicine. 4th. Philidelphia: W.B. Saunders; 2004. 384-400.

  4. Mitchell JD, Welsby IJ. Techniques of arterial access. Surgery. 2004. 22(1):3-4.

  5. Roberts J, Hedges J. Arterial Puncture and Cannulation. 4. Clinical Procedures in Emergency Medicine. Philadelphia: WB Saunders; 2004. 384-399.

  6. Brzezinski M, Luisetti T, London MJ. Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesth Analg. 2009 Dec. 109(6):1763-81. [Medline].

  7. Lorente L, Brouard MT, Roca I, Jiménez A, Pastor E, Lafuente N, et al. Lesser incidence of accidental catheter removal with femoral versus radial arterial access. Med Intensiva. 2013 Jun-Jul. 37(5):316-9. [Medline].

  8. Soderstrom CA, Wasserman DH, Dunham CM, Caplan ES, Cowley RA. Superiority of the femoral artery of monitoring. A prospective study. Am J Surg. 1982 Sep. 144(3):309-12. [Medline].

  9. Gurman GM, Kriemerman S. Cannulation of big arteries in critically ill patients. Crit Care Med. 1985 Apr. 13(4):217-20. [Medline].

  10. Mignini MA, Piacentini E, Dubin A. Peripheral arterial blood pressure monitoring adequately tracks central arterial blood pressure in critically ill patients: an observational study. Crit Care. 2006. 10(2):R43. [Medline].

  11. Beards SC, Doedens L, Jackson A, Lipman J. A comparison of arterial lines and insertion techniques in critically ill patients. Anaesthesia. 1994 Nov. 49(11):968-73. [Medline].

  12. Stroud S, Rodriguez. Arterial puncture and cannulation. Reichman EH, Simon RR. Emergency Medicine Procedures. 1st. New York: McGraw Hill; 2003. 398-410.

  13. Stirt JA. "Liquid stylet" for percutaneous radial artery cannulation. Can Anaesth Soc J. 1982 Sep. 29(5):492-3. [Medline].

  14. Griffin MP, Siadaty MS. Papaverine prolongs patency of peripheral arterial catheters in neonates. J Pediatr. 2005 Jan. 146(1):62-5. [Medline].

  15. Heulitt MJ, Farrington EA, O'Shea TM, Stoltzman SM, Srubar NB, Levin DL. Double-blind, randomized, controlled trial of papaverine-containing infusions to prevent failure of arterial catheters in pediatric patients. Crit Care Med. 1993 Jun. 21(6):825-9. [Medline].

  16. McEllistrem RF, O'Toole DP, Keane P. Post-cannulation radial artery aneurysm--a rare complication. Can J Anaesth. 1990 Nov. 37(8):907-9. [Medline].

  17. Qvist J, Peterfreund RA, Perlmutter GS. Transient compartment syndrome of the forearm after attempted radial artery cannulation. Anesth Analg. 1996 Jul. 83(1):183-5. [Medline].

  18. Sessler CN, Alford P. Arterial occlusion after femoral artery cannulation. Crit Care Med. 1986 May. 14(5):520-1. [Medline].

  19. O'Horo JC, Maki DG, Krupp AE, Safdar N. Arterial catheters as a source of bloodstream infection: a systematic review and meta-analysis. Crit Care Med. 2014 Jun. 42(6):1334-9. [Medline].

  20. Applegate RJ, Sacrinty MT, Kutcher MA, Kahl FR, Gandhi SK, Santos RM, et al. Trends in vascular complications after diagnostic cardiac catheterization and percutaneous coronary intervention via the femoral artery, 1998 to 2007. JACC Cardiovasc Interv. 2008 Jun. 1(3):317-26. [Medline].

  21. Ruetzler K, Sima B, Mayer L, Golescu A, Dunkler D, Jaeger W, et al. Lidocaine/tetracaine patch (Rapydan) for topical anaesthesia before arterial access: a double-blind, randomized trial. Br J Anaesth. 2012 Nov. 109(5):790-6. [Medline].

  22. Hansen MA, Juhl-Olsen P, Thorn S, Frederiksen CA, Sloth E. Ultrasonography-guided radial artery catheterization is superior compared with the traditional palpation technique: a prospective, randomized, blinded, crossover study. Acta Anaesthesiol Scand. 2014 Apr. 58(4):446-52. [Medline].

  23. Anderson JS. Arterial cannulation: how to do it. Br J Hosp Med. 1997 May 21-Jun 3. 57(10):497-9. [Medline].

  24. Berrizbeitia LD. Placement of an arterial line. N Engl J Med. 2006 Jul 20. 355(3):324; author reply 324-5. [Medline].

  25. Shiver S, Blaivas M, Lyon M. A prospective comparison of ultrasound-guided and blindly placed radial arterial catheters. Acad Emerg Med. 2006 Dec. 13(12):1275-9. [Medline].

  26. Shiloh AL, Savel RH, Paulin LM, Eisen LA. Ultrasound-guided catheterization of the radial artery: a systematic review and meta-analysis of randomized controlled trials. Chest. 2011 Mar. 139(3):524-9. [Medline].

  27. Barber JD, Wright DJ, Ellis RH. Radial artery puncture. A simple screening test of the ulnar anastomotic circulation. Anaesthesia. 1973 May. 28(3):291-2. [Medline].

  28. Slogoff S, Keats AS, Arlund C. On the safety of radial artery cannulation. Anesthesiology. 1983 Jul. 59(1):42-7. [Medline].

  29. Thompson SR, Hirschberg A. Allen’s test re-examined. Crit Care Med. 1988. 16:915.

  30. Wilkins RG. Radial artery cannulation and ischaemic damage: a review. Anaesthesia. 1985 Sep. 40(9):896-9. [Medline].

  31. Mangano DT, Hickey RF. Ischemic injury following uncomplicated radial artery catheterization. Anesth Analg. 1979 Jan-Feb. 58(1):55-7. [Medline].

  32. McGregor AD. The Allen test--an investigation of its accuracy by fluorescein angiography. J Hand Surg Br. 1987 Feb. 12(1):82-5. [Medline].

  33. Stead SW, Stirt JA. Assessment of digital blood flow and palmar collateral circulation. Allen's test vs. photoplethysmography. Int J Clin Monit Comput. 1985. 2(1):29-34. [Medline].

  34. Mangar D, Thrush DN, Connell GR, Downs JB. Direct or modified Seldinger guide wire-directed technique for arterial catheter insertion. Anesth Analg. 1993 Apr. 76(4):714-7. [Medline].

 
Previous
Next
 
Anatomy of radial artery.
Anatomy of femoral triangle.
Wrist position for radial artery line placement.
Modified Allen test. Return of perfusion to hand after release of compression of ulnar artery.
Radial artery cannulation. Positioning of hand.
Radial artery cannulation. Palpation of radial artery.
Radial artery cannulation (catheter over needle). Catheter introduction through skin.
Radial artery cannulation (catheter over needle). Puncture of radial artery.
Radial artery cannulation (catheter over needle). Catheter advanced into radial artery.
Radial artery cannulation (catheter over needle). Arterial line tubing attached to radial artery catheter.
Radial artery cannulation (Seldinger). Catheter-over-wire arterial line kit.
Radial artery cannulation (Seldinger). Palpation of radial artery.
Radial artery cannulation (Seldinger). Puncture of skin with finder needle.
Radial artery cannulation (Seldinger). Puncture of radial artery with return of blood.
Radial artery cannulation (Seldinger). Introduction of guide wire into radial artery.
Radial artery cannulation (Seldinger). Skin incision over needle.
Radial artery cannulation (Seldinger). Advancement of catheter over guide wire.
Radial artery cannulation (Seldinger). Attachment of arterial line tubing to catheter.
Radial artery cannulation (modified Seldinger). Catheter-over-wire arterial line kit.
Radial artery cannulation (modified Seldinger). Catheter and wire assembled.
Radial artery cannulation (modified Seldinger). Wire advancement through catheter.
Allen test. Examiner occludes both radial and ulnar arteries while patient makes fist.
Allen test. Radial and ulnar arteries remain occluded after hand is opened.
Allen test. Pressure on ulnar artery is released, and time to observed return of color to hand is measured.
Radial artery cannulation (modified Seldinger). Radial artery catheter kit.
Radial artery cannulation (modified Seldinger). Radial artery catheter.
Positioning of wrist for radial artery cannulation.
Radial artery cannulation (modified Seldinger). Radial artery prepared and draped in sterile fashion.
Radial artery cannulation (modified Seldinger). Introduction of radial artery catheter.
Radial artery cannulation (modified Seldinger). Angle of introduction of radial artery catheter.
Radial artery cannulation (modified Seldinger). Flashback of blood into radial artery catheter hub.
Radial artery cannulation (modified Seldinger). Radial artery catheter entering artery.
Radial artery cannulation (modified Seldinger). Advancement of guide wire into radial artery.
Radial artery cannulation (modified Seldinger). Advancement of guide wire into radial artery.
Radial artery cannulation (modified Seldinger). Stabilization of catheter while introducer is removed.
Radial artery cannulation (modified Seldinger). Stabilization of catheter while introducer is removed.
Radial artery cannulation (modified Seldinger). Pressure transducer attached to radial artery catheter.
Radial artery cannulation (modified Seldinger). Radial artery cannula sutured in place.
Radial artery cannulation (modified Seldinger). Sterile dressing applied over radial artery cannula.
Radial artery cannulation (modified Seldinger). Inline 3-way stop-cocks attached for blood sampling.
Angiocatheter used for radial artery cannulation in infants and small children.
Radial artery cannulation (catheter over needle). Introduction of angiocatheter into radial artery.
Radial artery cannulation (catheter over needle). Flashback of blood into angiocatheter hub.
Radial artery cannulation (catheter over needle). Needle entering radial artery with bevel facing up.
Radial artery cannulation (catheter over needle). Stabilization of catheter while needle introducer is removed.
Radial artery cannulation (catheter over needle). Pressure transducer attached to radial artery catheter.
Radial artery cannulation (catheter over needle). Radial artery catheter secured in place with Steri-Strips.
Radial artery cannulation (catheter over needle). Sterile dressing applied over radial artery cannula.
Femoral artery cannulation (catheter over needle). Insertion of 20-gauge, 1.75-in. catheter over needle into femoral artery. Note 45° insertion angle.
Femoral artery cannulation (catheter over needle). Removal of needle after artery has been cannulated and catheter has been inserted into lumen of artery.
Femoral artery cannulation (combination technique). Insertion of guide wire through catheter into femoral artery lumen.
Femoral artery cannulation (combination technique). Final placement of 20-gauge, 5-in. catheter into femoral artery (note yellow plastic spring wire insertion adapter).
Femoral artery cannulation (Seldinger). Puncture of femoral artery with 18-gauge, 3-in. hollow introducer needle. Note 45° insertion angle.
Femoral artery cannulation (Seldinger). Guide wire being inserted into femoral artery lumen.
Femoral artery cannulation (Seldinger). 2-mm incision is made next to guide wire with No. 11 scalpel blade.
Femoral artery cannulation (Seldinger). Insertion of 20-gauge, 5-in. catheter over guide wire into femoral artery.
 
 
 
All material on this website is protected by copyright, Copyright © 1994-2016 by WebMD LLC. This website also contains material copyrighted by 3rd parties.