Continuous, accurate hemodynamic monitoring (e.g. vasopressor titration, BP accuracy)
Need for frequent ABGs
Contraindications
Abnormal Allen's test, thrombosis of selected site, distorted anatomy at selected site (known prior fistulas, grafts, malformations), severe PAD at selected site, Raynaud's of selected limb
Allen Test if placing radial artery access: goal to assess collateral ulnar blood flow to avoid ischemia. Compress both radial and ulnar artery 10-15 sec to allow blanching of palm, then release ulnar artery to assess re-perfusion. If blanching quickly resolves, ulnar artery will allow distal perfusion.
Consent
Bruising, pain, damage to adjacent structures, infection, bleeding (possible extension to RP bleed with femoral placement), hematoma formation, vascular complications (dissection, AV fistula, pseudoaneurysm), thrombosis, rarely distal ischemia
Pre-procedural considerations
Bleeding risk guidelines: no definitive guideline (suggest plts > 50K, INR < 3, PTT < 100)
Allen Test if placing radial artery access to assess collateral ulnar blood flow. Compress both radial and ulnar artery 10-15 sec to allow blanching of palm, then release ulnar artery to assess re-perfusion. If blanching quickly resolves, ulnar artery will allow distal perfusion.
Radial access: ensure wrist is adequately extended; can use towel roll under wrist or tape hand
Discuss with fellow prior to brachial, femoral a-line placement
Ask RN to prepare tubing and waveform monitoring prior to time-out
Procedural considerations
Types of Kits
Arrow kit: all-in-one device that has arterial catheter over introducer needle
A-line kit: individual introducer needle, guidewires, and sutures; multiple steps
Micropuncture kit: atraumatic guidewire, microcatheter and introducer sheath
Reconfirm location with US after lidocaine
Ensure arterial access (pulsatile flow of bright red blood)
Supplies
Ultrasound with linear probe
Ultrasound probe cover
Sterile towels
Sterile gloves
Table for supplies
Small towel to position patient wrist
Tape
Sterile dressing
Pressure tubing (ask nurse to obtain and set up)
1% lidocaine (if not in kit)
Procedure
Clean site with chlorhexidine
Give local lidocaine subcutaneously and deep
Reconfirm location with US after lidocaine
Advance needle at 45-degree ankle with ultrasound guidance until in the target vessel
Depending on kit used, advance catheter over needle (Arrow kit) or insert wire then advance catheter over wire after removing needle (Micropuncture kit)
Attach pressure tubing with nursing and ensure good waveform
Suture into place
Apply sterile dressing
Post- procedural considerations
Immediately connect pressure tubing to catheter while maintaining sterile technique
Observe monitor for arterial waveform to verify appropriate placement
