Arterial catheterization techniques for invasive monitoring
- Gilles Clermont, MDCM, MSc
Gilles Clermont, MDCM, MSc
- Associate Professor
- University of Pittsburgh Medical Center
- Arthur C Theodore, MD
Arthur C Theodore, MD
- Associate Professor of Medicine
- Boston University School of Medicine
- Section Editors
- John F Eidt, MD
John F Eidt, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor of Surgery
- University of South Carolina School of Medicine Greenville
- Joseph L Mills, Sr, MD
Joseph L Mills, Sr, MD
- Section Editor — Vascular and Endovascular Surgery
- Professor and Chief
- Division of Vascular Surgery and Endovascular Therapy
- Baylor College of Medicine
Arterial catheters (also called intra-arterial catheters or A-lines) are common in critically ill patients. They can be used to obtain arterial blood for laboratory testing, and for direct measurement of blood pressure and cardiac output. However, insertion of an arterial catheter is an invasive procedure and complications can occur.
This topic will review the indications, insertion techniques, and complications of arterial catheterization. The use of arterial catheters to monitor blood pressure is also reviewed. Percutaneous arterial puncture and arterial blood gases (ABGs) are discussed elsewhere. (See "Arterial blood gases".)
Advantages of an indwelling arterial catheter include continuous access to arterial blood and the ability to continuously measure the blood pressure. As a result, arterial catheterization is indicated when:
●Frequent blood gases are necessary, such as with acute respiratory failure.
●The blood pressure must be monitored closely, such as during shock, major surgery, hypertensive emergency, or vasopressor therapy. This is particularly true if the blood pressure abnormality is acute or the blood pressure is labile.
- McGee WT, Horswell JL, Calderon J, et al. Validation of a continuous, arterial pressure-based cardiac output measurement: a multicenter, prospective clinical trial. Crit Care 2007; 11:R105.
- Shiloh AL, Eisen LA. Ultrasound-guided arterial catheterization: a narrative review. Intensive Care Med 2010; 36:214.
- Maher JJ, Dougherty JM. Radial artery cannulation guided by Doppler ultrasound. Am J Emerg Med 1989; 7:260.
- Levin PD, Sheinin O, Gozal Y. Use of ultrasound guidance in the insertion of radial artery catheters. Crit Care Med 2003; 31:481.
- Shiver S, Blaivas M, Lyon M. A prospective comparison of ultrasound-guided and blindly placed radial arterial catheters. Acad Emerg Med 2006; 13:1275.
- Dudeck O, Teichgraeber U, Podrabsky P, et al. A randomized trial assessing the value of ultrasound-guided puncture of the femoral artery for interventional investigations. Int J Cardiovasc Imaging 2004; 20:363.
- 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; 139:524.
- Tada T, Amagasa S, Horikawa H. Absence of efficacy of ultrasonic two-way Doppler flow detector in routine percutaneous arterial cannulation. J Anesth 2003; 17:206.
- Gu WJ, Wu XD, Wang F, et al. Ultrasound Guidance Facilitates Radial Artery Catheterization: A Meta-analysis With Trial Sequential Analysis of Randomized Controlled Trials. Chest 2016; 149:166.
- Quan Z, Tian M, Chi P, et al. Modified short-axis out-of-plane ultrasound versus conventional long-axis in-plane ultrasound to guide radial artery cannulation: a randomized controlled trial. Anesth Analg 2014; 119:163.
- Guidelines for the measurement of respiratory function. Recommendations of the British Thoracic Society and the Association of Respiratory Technicians and Physiologists. Respir Med 1994; 88:165.
- Lightowler JV, Elliott MW. Local anaesthetic infiltration prior to arterial puncture for blood gas analysis: a survey of current practice and a randomised double blind placebo controlled trial. J R Coll Physicians Lond 1997; 31:645.
- Beards SC, Doedens L, Jackson A, Lipman J. A comparison of arterial lines and insertion techniques in critically ill patients. Anaesthesia 1994; 49:968.
- Mangar D, Thrush DN, Connell GR, Downs JB. Direct or modified Seldinger guide wire-directed technique for arterial catheter insertion. Anesth Analg 1993; 76:714.
- Tegtmeyer, K, Brady, G, Lai, S, et al. Placement of an arterial line. http://content.nejm.org/cgi/video/354/15/e13 (Accessed on April 17, 2007).
- Weiss BM, Gattiker RI. Complications during and following radial artery cannulation: a prospective study. Intensive Care Med 1986; 12:424.
- Davis FM, Stewart JM. Radial artery cannulation. A prospective study in patients undergoing cardiothoracic surgery. Br J Anaesth 1980; 52:41.
- Jones RM, Hill AB, Nahrwold ML, Bolles RE. The effect of method of radial artery cannulation on postcannulation blood flow and thrombus formation. Anesthesiology 1981; 55:76.
- Bedford RF. Radial arterial function following percutaneous cannulation with 18- and 20-gauge catheters. Anesthesiology 1977; 47:37.
- Bedford RF. Long-term radial artery cannulation: effects on subsequent vessel function. Crit Care Med 1978; 6:64.
- Zevola DR, Dioso J, Moggio R. Comparison of heparinized and nonheparinized solutions for maintaining patency of arterial and pulmonary artery catheters. Am J Crit Care 1997; 6:52.
- Kulkarni M, Elsner C, Ouellet D, Zeldin R. Heparinized saline versus normal saline in maintaining patency of the radial artery catheter. Can J Surg 1994; 37:37.
- Clifton GD, Branson P, Kelly HJ, et al. Comparison of normal saline and heparin solutions for maintenance of arterial catheter patency. Heart Lung 1991; 20:115.
- Lapum JL. Patency of arterial catheters with heparinized solutions versus non-heparinized solutions: a review of the literature. Can J Cardiovasc Nurs 2006; 16:64.
- Evaluation of the effects of heparinized and nonheparinized flush solutions on the patency of arterial pressure monitoring lines: the AACN Thunder Project. By the American Association of Critical-Care Nurses. Am J Crit Care 1993; 2:3.
- Robertson-Malt S, Malt GN, Farquhar V, Greer W. Heparin versus normal saline for patency of arterial lines. Cochrane Database Syst Rev 2014; :CD007364.
- Branson PK, McCoy RA, Phillips BA, Clifton GD. Efficacy of 1.4 percent sodium citrate in maintaining arterial catheter patency in patients in a medical ICU. Chest 1993; 103:882.
- Czepizak CA, O'Callaghan JM, Venus B, et al. Vascular access. In: Clinical anesthesia practice, Kirby, RR, Gravenstein, N (Eds), W.B. Saunders Company, Philadelphia 1994. p.542.
- Downs JB, Rackstein AD, Klein EF Jr, Hawkins IF Jr. Hazards of radial-artery catheterization. Anesthesiology 1973; 38:283.
- Singh S, Nelson N, Acosta I, et al. Catheter colonization and bacteremia with pulmonary and arterial catheters. Crit Care Med 1982; 10:736.
- Raad I, Umphrey J, Khan A, et al. The duration of placement as a predictor of peripheral and pulmonary arterial catheter infections. J Hosp Infect 1993; 23:17.
- Band JD, Maki DG. Infections caused by aterial catheters used for hemodynamic monitoring. Am J Med 1979; 67:735.
- Frezza EE, Mezghebe H. Indications and complications of arterial catheter use in surgical or medical intensive care units: analysis of 4932 patients. Am Surg 1998; 64:127.
- Norwood SH, Cormier B, McMahon NG, et al. Prospective study of catheter-related infection during prolonged arterial catheterization. Crit Care Med 1988; 16:836.
- Cobb DK, High KP, Sawyer RG, et al. A controlled trial of scheduled replacement of central venous and pulmonary-artery catheters. N Engl J Med 1992; 327:1062.
- Thomas F, Burke JP, Parker J, et al. The risk of infection related to radial vs femoral sites for arterial catheterization. Crit Care Med 1983; 11:807.
- Lorente L, Santacreu R, Martín MM, et al. Arterial catheter-related infection of 2,949 catheters. Crit Care 2006; 10:R83.
- Mimoz O, Pieroni L, Lawrence C, et al. Prospective, randomized trial of two antiseptic solutions for prevention of central venous or arterial catheter colonization and infection in intensive care unit patients. Crit Care Med 1996; 24:1818.
- Eyer S, Brummitt C, Crossley K, et al. Catheter-related sepsis: prospective, randomized study of three methods of long-term catheter maintenance. Crit Care Med 1990; 18:1073.
- Gillies D, O'Riordan L, Wallen M, et al. Optimal timing for intravenous administration set replacement. Cochrane Database Syst Rev 2005; :CD003588.
- Chang C, Dughi J, Shitabata P, et al. Air embolism and the radial arterial line. Crit Care Med 1988; 16:141.
- Hansen K. Transthoracic echocardiogram and transcranial doppler detection of emboli after foam sclerotherapy of leg veins. J Vasc Ultrasound 2007; 31:213.
- Peruzzi WT, Parker MA, Lichtenthal PR, et al. A clinical evaluation of a blood conservation device in medical intensive care unit patients. Crit Care Med 1993; 21:501.
- Smoller BR, Kruskall MS. Phlebotomy for diagnostic laboratory tests in adults. Pattern of use and effect on transfusion requirements. N Engl J Med 1986; 314:1233.
- Silver MJ, Jubran H, Stein S, et al. Evaluation of a new blood-conserving arterial line system for patients in intensive care units. Crit Care Med 1993; 21:507.
- Shapiro BA, Mahutte CK, Cane RD, Gilmour IJ. Clinical performance of a blood gas monitor: a prospective, multicenter trial. Crit Care Med 1993; 21:487.
- Menzel M, Henze D, Soukup J, et al. Experiences with continuous intra-arterial blood gas monitoring. Minerva Anestesiol 2001; 67:325.
- Russell JA, Joel M, Hudson RJ, et al. Prospective evaluation of radial and femoral artery catheterization sites in critically ill adults. Crit Care Med 1983; 11:936.
- Martin C, Saux P, Papazian L, Gouin F. Long-term arterial cannulation in ICU patients using the radial artery or dorsalis pedis artery. Chest 2001; 119:901.
- Groell R, Schaffler GJ, Rienmueller R. The peripheral intravenous cannula: a cause of venous air embolism. Am J Med Sci 1997; 314:300.
- O'Malley MK, Rhame FS, Cerra FB, McComb RC. Value of routine pressure monitoring system changes after 72 hours of continuous use. Crit Care Med 1994; 22:1424.
- Finnie KJ, Watts DG, Armstrong PW. Biases in the measurement of arterial pressure. Crit Care Med 1984; 12:965.
- Cohn JN. Blood pressure measurement in shock. Mechanism of inaccuracy in ausculatory and palpatory methods. JAMA 1967; 199:118.
- Johnson CJ, Kerr JH. Automatic blood pressure monitors. A clinical evaluation of five models in adults. Anaesthesia 1985; 40:471.
- Lindqvist A. Beat-to-beat agreement of non-invasive finger artery and invasive radial artery blood pressure in hypertensive patients taking cardiovascular medication. Clin Physiol 1995; 15:219.
- Farquhar IK. Continuous direct and indirect blood pressure measurement (Finapres) in the critically ill. Anaesthesia 1991; 46:1050.
- Aitken HA, Todd JG, Kenny GN. Comparison of the Finapres and direct arterial pressure monitoring during profound hypotensive anaesthesia. Br J Anaesth 1991; 67:36.
- Veremakis C, Holloran TH. The technique of monitoring arterial blood pressure. J Crit Illn 1989; 4:82.
- Gardner RM. Direct arterial pressure monitoring. Curr Anaesth Crit Care 1990; 1:239.
- Boutros A, Albert S. Effect of the dynamic response of transducer-tubing system on accuracy of direct blood pressure measurement in patients. Crit Care Med 1983; 11:124.
- Imperial-Perez F, McRae M. Arterial Pressure Monitoring. Crit Care Nurse 2002; 22:70.
- Gardner RM, Hollingsworth KW. Optimizing the electrocardiogram and pressure monitoring. Crit Care Med 1986; 14:651.
- Gardner RM. Accuracy and reliability of disposable pressure transducers coupled with modern pressure monitors. Crit Care Med 1996; 24:879.
- Site selection
- Ultrasound guidance
- - Separate-guidewire
- - Integral-guidewire
- - Direct puncture
- All sites
- - Thrombosis
- - Embolism
- - Infection
- - Air embolism
- - Iatrogenic blood loss
- BLOOD PRESSURE MONITORING
- Sources of error
- - Dynamic response
- - Transducer position
- - Calibration
- SUMMARY AND RECOMMENDATIONS