Arterial line insertion [advanced]

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)

• 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 2^nd 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)
• 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