Equipment
Several commercially available kits contain all the supplies necessary for arterial line placement. These include the Arrow UM-04018, for Seldinger-technique femoral lines, and the Arrow AK-04020 with integrated wire, for modified Seldinger-technique radial lines (Arrow International, a division of Teleflex Medical, Research Triangle Park, NC).
Devices and supplies required may include the following:
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Ultrasound probe - 5-13 MHz linear array
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Sterile ultrasound probe kit with sterile lubrication
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Sterile gloves
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Sterile gauze (4 × 4 in.)
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Sterile towels
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Chlorhexidine or povidone-iodine skin preparation solution
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1% Lidocaine without epinephrine in a 3- to 5-mL syringe with a 25- to 27-gauge needle
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5-mL syringe with heparinized flush
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Appropriate-sized cannula for artery
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Scalpel (No. 11 blade)
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Nonabsorbable suture (3-0 to 4-0)
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Adhesive tape or strips
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Sterile nonabsorbable dressing
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Three-way stopcock
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Pressure transducer kit
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Pressure tubing
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Arm board of appropriate size for the patient (eg, neonate, pediatric, adult)
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Needle driver
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Intravenous (IV) tubing T-connector
Radial artery
Equipment for radial artery cannulation may include the following:
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Catheter-over-needle technique - 20-gauge, 1.75-in. (4.45-cm) polyurethane catheter over 22-gauge introducer needle
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Catheter-over-wire technique (Seldinger) - 20-gauge peripheral artery catheter kit with 20-gauge catheter, 22-gauge introducer needle, and compatible soft-tip wire (see the image below)
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Catheter-over-wire technique (modified Seldinger) - 20-gauge peripheral artery catheter kit with integrated wire and catheter
Whereas a 20-gauge peripheral artery catheter kit is suitable for large children and adult patients, a 22- to 24-gauge angiocatheter is preferable for infants and neonates.
Femoral artery
Commercial kits for the Seldinger technique (catheter-over-wire) are not generally available in the United States. Recommended equipment for catheter-over-wire femoral artery cannulation (see the image below) may include the following:
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18-gauge, 3-in. (7.6-cm) introducer needle
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18- or 20-gauge, 1.5-in. (3.8 cm) or 3-in. needle (an 18-gauge spinal needle will usually suffice)
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Guide wire, appropriately sized for the catheter (eg, 45 cm in length and 0.64 mm in diameter); it should have a straight soft tip on one end and a J tip on the other
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Plastic spring wire insertion adapter to straighten the J-tip end of the guide wire for insertion into the plastic catheter
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18- or 20-gauge catheter, 15 cm or longer
Femoral artery cannulation (modified Seldinger). Catheter-over-wire arterial line kit.
Patient Preparation
Preparation of the patient for arterial line placement includes selection of the appropriate site and approach technique for catheter insertion (see Technique), as well as anesthesia, positioning, and creation of a sterile field (see below).
Anesthesia
In an emergency situation or when the patient is unresponsive, anesthesia is not required. In a conscious patient, local anesthesia can be provided by using a small amount of lidocaine 1% at the puncture site to prevent obscuring the site. Lidocaine with epinephrine should be avoided because it can constrict the artery, making cannulation more difficult. A lidocaine-tetracaine patch may also be an option for local anesthesia and obviates the need for subcutaneous infiltration. [15] (See Local Anesthetic Agents, Infiltrative Administration.)
If the patient is combative or if maintaining stability of the extremity is difficult, sedation or general anesthesia may be required. (See Procedural Sedation.)
Positioning
For radial artery cannulation, the patient is placed in the supine position. The arm is placed up on a flat surface in neutral position with the palm up and the wrist adequately exposed. The wrist is dorsiflexed to 30-45° and supported in this position with a towel or gauze under its dorsal aspect (see the image below). Hyperdorsiflexion should be avoided; this maneuver can compress the radial artery, making cannulation more difficult. Positioning is maintained by having an assistant hold the patient’s hand or by taping the hand and fingers to the work surface.
For femoral artery cannulation, the patient is also placed in the supine position, with the hip in mild external rotation. The artery is palpated at the midpoint between the anterior superior iliac spine and the pubic tubercle.
Creation of sterile field
After the target vessel is selected, the area should be prepared with either chlorhexidine gluconate or povidone-iodine ophthalmic solution 5% and draped with sterile towels or drapes. Because arterial catheters can be a source of bloodstream infections (BSIs), sterile technique must not be overlooked. [14] Operators should don sterile gloves, a mask, and hair covering. When the procedure is done under ultrasonographic (US) guidance, a sterile probe cover and gel should also be utilized. After the equipment is inspected, it should be maintained on the sterile field. The vessel should then be reidentified by means of palpation or US after the sterile field has been assembled.
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Anatomy of radial artery.
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Anatomy of femoral triangle.
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Wrist position for radial artery line placement.
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Modified Allen test. Return of perfusion to hand after release of compression of ulnar artery.
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Radial artery cannulation. Positioning of hand.
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Radial artery cannulation. Palpation of radial artery.
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Radial artery cannulation (catheter over needle). Catheter introduction through skin.
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Radial artery cannulation (catheter over needle). Puncture of radial artery.
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Radial artery cannulation (catheter over needle). Catheter advanced into radial artery.
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Radial artery cannulation (catheter over needle). Arterial line tubing attached to radial artery catheter.
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Radial artery cannulation (Seldinger). Catheter-over-wire arterial line kit.
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Radial artery cannulation (Seldinger). Palpation of radial artery.
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Radial artery cannulation (Seldinger). Puncture of skin with finder needle.
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Radial artery cannulation (Seldinger). Puncture of radial artery with return of blood.
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Radial artery cannulation (Seldinger). Introduction of guide wire into radial artery.
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Radial artery cannulation (Seldinger). Skin incision over needle.
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Radial artery cannulation (Seldinger). Advancement of catheter over guide wire.
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Radial artery cannulation (Seldinger). Attachment of arterial line tubing to catheter.
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Femoral artery cannulation (modified Seldinger). Catheter-over-wire arterial line kit.
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Radial artery cannulation (modified Seldinger). Catheter and wire assembled.
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Radial artery cannulation (modified Seldinger). Wire advancement through catheter.
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Allen test. Examiner occludes both radial and ulnar arteries while patient makes fist.
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Allen test. Radial and ulnar arteries remain occluded after hand is opened.
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Allen test. Pressure on ulnar artery is released, and time to observed return of color to hand is measured.
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Radial artery cannulation (modified Seldinger). Radial artery catheter kit.
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Radial artery cannulation (modified Seldinger). Radial artery catheter.
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Positioning of wrist for radial artery cannulation.
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Radial artery cannulation (modified Seldinger). Radial artery prepared and draped in sterile fashion.
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Radial artery cannulation (modified Seldinger). Introduction of radial artery catheter.
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Radial artery cannulation (modified Seldinger). Angle of introduction of radial artery catheter.
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Radial artery cannulation (modified Seldinger). Flashback of blood into radial artery catheter hub.
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Radial artery cannulation (modified Seldinger). Radial artery catheter entering artery.
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Radial artery cannulation (modified Seldinger). Advancement of guide wire into radial artery.
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Radial artery cannulation (modified Seldinger). Advancement of guide wire into radial artery.
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Radial artery cannulation (modified Seldinger). Stabilization of catheter while introducer is removed.
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Radial artery cannulation (modified Seldinger). Stabilization of catheter while introducer is removed.
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Radial artery cannulation (modified Seldinger). Pressure transducer attached to radial artery catheter.
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Radial artery cannulation (modified Seldinger). Radial artery cannula sutured in place.
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Radial artery cannulation (modified Seldinger). Sterile dressing applied over radial artery cannula.
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Radial artery cannulation (modified Seldinger). Inline 3-way stopcocks attached for blood sampling.
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Angiocatheter used for radial artery cannulation in infants and small children.
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Radial artery cannulation (catheter over needle). Introduction of angiocatheter into radial artery.
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Radial artery cannulation (catheter over needle). Flashback of blood into angiocatheter hub.
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Radial artery cannulation (catheter over needle). Needle entering radial artery with bevel facing up.
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Radial artery cannulation (catheter over needle). Stabilization of catheter while needle introducer is removed.
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Radial artery cannulation (catheter over needle). Pressure transducer attached to radial artery catheter.
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Radial artery cannulation (catheter over needle). Radial artery catheter secured in place with Steri-Strips.
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Radial artery cannulation (catheter over needle). Sterile dressing applied over radial artery cannula.
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Femoral artery cannulation (catheter over needle). Insertion of 20-gauge 1.75-in. catheter over needle into femoral artery. Note 45° insertion angle.
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Femoral artery cannulation (catheter over needle). Removal of needle after artery has been cannulated and catheter has been inserted into lumen of artery.
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Femoral artery cannulation (combination technique). Insertion of guide wire through catheter into femoral artery lumen.
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Femoral artery cannulation (combination technique). Final placement of 20-gauge 5-in. catheter into femoral artery (note yellow plastic spring wire insertion adapter).
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Femoral artery cannulation (Seldinger). Puncture of femoral artery with 18-gauge 3-in. hollow introducer needle. Note 45° insertion angle.
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Femoral artery cannulation (Seldinger). Guide wire being inserted into femoral artery lumen.
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Femoral artery cannulation (Seldinger). 2-mm incision is made next to guide wire with No. 11 scalpel blade.
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Femoral artery cannulation (Seldinger). Insertion of 20-gauge 5-in. catheter over guide wire into femoral artery.
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Equipment setup for ultrasound-guided radial arterial line placement.
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Ultrasound probe with sterile sheath.
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External view of ultrasound-guided short-axis view.
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Identification of radial artery in short-axis view. Yellow circle surrounds radial artery.
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Identification of radial artery with color Doppler ultrasonography.
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External view of ultrasound-guided long-axis view.
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Identification of radial artery with long-axis view. Yellow arrows highlight radial artery.
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Short-axis view of needle entering soft tissue and targeting radial artery. Red arrow identifies radiopaque needle near radial artery.
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Long-axis view of needle entering soft tissue and targeting radial artery. Yellow arrows highlight radial artery. Red stars identify radiopaque needle near radial artery.
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Needle within radial artery in short-axis view. Red arrow identifies radiopaque needle within lumen of radial artery.
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Long-axis view of needle within lumen of radial artery. Yellow arrows highlight radial artery. Red stars identify radiopaque needle within lumen of radial artery.
