Table of Contents
Before you start
Indications: continuous blood pressure monitoring; frequent arterial blood gasses
Contraindications: absent pulse, Raynaud syndrome, thromboangiitis obliterans, inadequate circulation to extremity, burns over site, vascular graft/arteriovenous fistula
Sites: radial artery is preferred site and is outlined below; brachial artery may also be used if radial is not possible; ultrasound is not required but usually kept available in case it is needed
Introduction
- Wash hands, Introduce self, Patients name & DOB & wrist band, Explain procedure and get consent if possible
- Risks: infection, bleeding/haematoma, arterial occlusion/permanent ischaemic damage, pseudoaneurysm/fistula formation, nerve damage
- Ensure assistant is available and clinical and non-clinical bins are close by to dispose of waste
Preparation part
- Wash hands and apply apron and face visor
- Clean a trolley
- Gather equipment onto bottom of trolley (think through what you need in order)
Equipment list
- Cleansing snap-sponge (iodine or alcohol/chlorhexidine) x2
- Arterial line kit
- Drape with hole in centre
- 5ml syringe (for local anaesthetic)
- Orange 25G needle (for local infiltration)
- Introducer needle (yellow top)
- Arterial line with guidewire inside in correct orientation (has soft and firm ends – soft end goes into artery)
- 5ml blood gas syringe
- Note equipment in kits varies
- Arterial line extension connector
- Blunt fill 18G drawing-up needle
- Externally sterile syringe of sterile 0.9% saline (or 10ml syringe + drawing up needle) for flush
- Cannula dressing
- Sterile ultrasound probe cover and gel
- Equipment to be kept outside of the sterile field
- Sterile surgical gloves
- Incontinence pad
- Ultrasound machine (in case required)
- 10ml 1% lidocaine (maximum 3mg/kg – note 1ml 1% lidocaine = 10mg)
- 10ml 0.9% saline vial (for drawing up for flush if not using pre-prepared flush)
- Walk to patient
- Wash hands
- Open the arterial line kit to form a large sterile field on the top of the trolley
- Open packets (without touching the instruments themselves) and drop sterile instruments neatly into the sterile field
Patient part
Positioning and exposure
- Position patient so wrist is accessible and hyperextended (use a folded clean towel if available)
- Expose area
- Palpate artery
- Place incontinence pad under arm
Preparation
- Wash hands
- Apply sterile gloves using sterile technique
- Prepare equipment in order in sterile field
- Remove sheath and cap from arterial line, and then remove guidewire (keeping it in the correct orientation)
- Flush arterial line connector with 0.9% saline from non-threaded end, then clamp lumen and replace cap
- If not using pre-prepared flush: ask assistant to snap open 0.9% saline vial and hold open upside-down; then draw up using drawing up needle on 10ml syringe; then remove needle and expel any air
- Sterilize area
- Work from middle outwards in one spiral motion (using cleansing snap-sponge)
- Repeat this with 2nd cleansing snap-sponge
- Discard used snap-sponges as they are no longer sterile, but note all equipment used after this (including all needles) can be returned to the sterile field after use
- Apply the sterile drape over the area, so that the hole is in the correct place to allow access to the insertion site
- Place guidewire in correct orientation in patient’s sterile field so it is readily accessible
- Anaesthetise area
- Ask assistant to snap open lidocaine bottle and hold open upside-down
- Draw up lidocaine using drawing up needle on 5ml syringe and expel any air, then change to the orange 25G needle
- Insert needle at an acute angle to form a large subcutaneous lidocaine bleb around insertion site in order to anaesthetise the skin, ensuring you aspirate before injection to avoid injection into a blood vessel
- Now wait 1 minute for the anaesthetic to work
Seldinger insertion procedure
- Introducer needle insertion
- Insert the bare introducer needle into the radial artery
- Pierce the skin at 15-30⁰
- Advance very slowly into the artery, looking for pulsating blood coming from the end of the needle
- Flatten needle to skin
- If you are unsuccessful, remove and flush the needle with 0.9% saline and try again (consider using ultrasound if needed)
- Insert the bare introducer needle into the radial artery
- Guidewire insertion
- Insert the soft end of the guidewire into the introducer needle, leaving a few centimetres to hold
- From now on, keep hold of the guidewire at all times with one hand
- Withdraw the needle and thread it right the way off the end of the guidewire, ensuring the guidewire remains in place
- Catheter insertion
- Thread the arterial catheter over the guidewire until the tip is near the skin
- Now retract the guidewire slowly until the end comes out of the port
- Holding the end of the guidewire, insert the catheter all the way into the artery
- When the catheter is in place, remove guidewire
- Aspirate blood with the blood gas syringe
- Attach the flushed arterial line connector (with cap on and lumen clamped) – the threaded end attaches to the arterial line
- Flush connector and then clamp and replace bung
Securing catheter
- Dry any blood with gauze
- Apply cannula dressing then film dressing over the top
To complete
- Ask nursing staff to connect arterial line to transducer
- Thank patient and cover them
- Dispose of sharps safely in sharps bin, bin waste and gloves/apron, clean trolley, and wash hands
- Fully document procedure in patients notes