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Documenti di Professioni
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Bandage
Contraindications
Strict Relative
Inadequate circulation Previous surgery in the area Arterial Cannulation
Raynaud’s syndrome Anticoagulation/coagulopathy
Buerger’s disease Skin infection at the site
Full-thickness burns Atherosclerosis
Inadequate collateral flow Dressing
Local
Partial-thickness burns sponges Electronic
anesthetic
transducer
Antiseptic and cable
Complications
Hematoma formation
Infection Intravenous catheter Pressure
Bleeding transducer
Ischemia and tubing
Guidewire
Thrombosis/embolism
Arteriovenous fistula formation
Pseudoaneurysm formation
Arrow Arterial
Catheterization Kit
Arm board
Review Box 20.1 Arterial puncture and cannulation: indications, contraindications, complications, and equipment.
377
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378 SECTION IV Vascular Techniques and Volume Support
Although acute respiratory decompensation and metabolic arterial blood sampling is still required for accurate analysis
emergencies are the most common reasons for ABG sampling, of oxygen pressure (PO2).11–13
all blood tests performed on venous blood are also possible
on an arterial sample. Cultures performed on blood obtained
from an indwelling arterial line have a sensitivity and specificity
similar to that of cultures performed on blood obtained from EQUIPMENT: ARTERIAL PUNCTURE
a venipuncture site.3,4 Patients with moderate respiratory
decompensation may be managed without arterial puncture
Arterial Puncture With a Needle/Syringe
by using continuous, noninvasive pulse oximetry, end-tidal To obtain a single sample of arterial blood by the percutaneous
or transcutaneous carbon dioxide monitoring, carboxyhemo- method, attach a 3-mL syringe (preferred and most common)
globin and methemoglobin monitoring, or any combination to a needle. Select the needle size based on puncture location
thereof.5 Nonetheless, a role still exists for arterial blood and patient size and age. For an adult, use a 20-gauge, 2.5-inch
sampling. The initial correlation between noninvasive values needle for a femoral sample and a 22-gauge, 1.25-inch needle
and acid-base status via arterial sampling is often important for a radial artery puncture. For pediatric arterial sampling,
in critical illness to set a baseline or verify a trend. Some use a needle with a slightly shorter length in the range of
authors use ABG sampling in the initial evaluation of critically 22- to 24-gauge at the same sites as in adults.
ill trauma patients.6 Vasoactive drugs (e.g., nitroprusside and Precoated blood gas plastic syringes (with dry lithium
norepinephrine) are best administered with continuous monitor- heparin) are commonly used and allow a longer shelf life and
ing of arterial pressure to guide titration. The response of ready use (Fig. 20.1). Such devices are designed to minimize
trauma and post-cardiac arrest patients to acute resuscitative sampling error as a result of heparin.14 If necessary, prepare a
efforts may also be more easily monitored with the use of regular syringe with 1 or 2 mL of a heparinized saline solution
arterial catheterization. (1000 International Units [IU]/mL) drawn into the syringe to
Few contraindications to arterial puncture exist; none coat the barrel and needle. Fully eject the heparin through
are absolute. For example, after thrombolysis, arterial can- the needle immediately before skin puncture to minimize
nulation should be performed only if it will provide essen- heparin-related errors. Although the syringe may appear devoid
tial data that cannot be obtained by any other method. If of heparin, enough heparin remains in the needle and syringe
absolutely necessary, a single arterial puncture of the readily to provide anticoagulation. Even dry heparin may produce
compressible radial artery is preferred. Arterial puncture can abnormalities in ABG results because of a heparin-induced
be performed safely in patients who are anticoagulated or dilutional effect.
who have other coagulopathies, but it should be undertaken The latest blood gas and chemistry analyzers require only
with extreme caution in patients with severe disseminated 0.2 mL of whole blood for accuracy, and some point-of-care
coagulopathies. devices can perform analyses on single drops of blood. However,
There are reports of patients with bleeding complications sample sizes of less than 1.0 mL of blood aspirated into heparin-
who require transfusion. Some patients have suffered compres- coated syringes may result in a heparin-related error on ABG
sion neuropathies secondary to hematomas at the puncture values.
site.7 Repeated arterial sampling in such patients should be Stored heparin solution has higher PO2 and lower PCO2
accomplished by insertion of an indwelling cannula to minimize values than blood does.15 A dilutional effect from heparin would
trauma to the arterial wall. mean that the addition of 0.4 mL of heparin solution to a
The presence of severe arteriosclerosis, with or without 2-mL sample of blood (dilution of 20%) will lower PCO2 by
diminution in flow, is a relative contraindication to arterial 16%.14 Proper technique with dry lithium heparin-prefilled
puncture. In hemodynamically unstable patients with advanced syringes or full ejection of excess heparin will prevent such
cardiovascular disease, the benefits of invasive monitoring may problems if more than 2 mL of blood is collected. A falsely
nonetheless outweigh its risks.2 Consider an alternative site if
an isolated, decreased palpable pulse or bruit is felt over the
site selected. Additionally, consider an alternative site if there
is evidence of decreased or absent collateral flow in areas where
flow normally exists, such as in Raynaud’s syndrome or an
abnormal result on the modified Allen test (discussed later in Vented
plunger
the section on Techniques). Avoid puncturing a specific arterial
site when infection, burn, or other damage to cutaneous defenses
exists in the overlying skin or through or distal to a surgical
shunt. Pre-heparinzed
syringe
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CHAPTER 20 Arterial Puncture and Cannulation 379
A
Preparation for Arterial Cannulation
Box 20.1 lists the usual equipment for arterial cannulation, B
although the majority of prepackaged kits contain the supplies
most needed (see also Review Box 20.1). Shorter catheters are
ideal for peripheral artery cannulation, whereas use of a longer
catheter and the Seldinger technique is preferable for the Actuating
femoral artery. lever
For arterial cannulation in adults, use a 16- to 18-gauge
catheter for the femoral artery and a 20-gauge catheter for
Self-enclosed
the radial artery (Fig. 20.2). Small children and infants require guidewire Reference
a 22- to 24-gauge catheter, which may need to be inserted mark
percutaneously via the Seldinger technique or through a femoral
cutdown. Based on patient size, older pediatric patients usually
require 20- to 22-gauge catheters. Figure 20.2 Catheters for arterial cannulation. A, Standard intravenous
The tubing that connects the catheter to the pressure catheter. Use 20 gauge for the radial artery and 16 or 18 gauge for the
transducer has a significant effect on accuracy of the monitoring femoral artery. B, Arrow Arterial Catheterization Kit. This device has
system. The higher the frequency response of the entire system, a self-enclosed guidewire that is advanced into the artery by moving
the more accurate the determination of systolic and diastolic the actuating lever forward. When the lever reaches the reference
pressure; however, artifact also becomes more of a problem.1,23 mark on the barrel of the device, the tip of the guidewire is at the
Use stiff, low-capacitance plastic tubing for arterial catheteriza- opening of the needle lumen. (Arrow International, Reading, PA.)
tion and monitoring. Place the electronic pressure transducer
connection as close as possible to the patient and zero it
appropriately because the frequency response of a tube is pressure values involves the use of a simple manometer.26 This
inversely related to its length.24,25 system can be assembled quickly if the material is available.
The pressure wave produced with each contraction is A continuous method of flushing the pressure tubing is
transmitted from the artery through the catheter and connecting required to maintain patency of the catheter lumen during
tubing to a measuring device. The arterial fluid wave is received intraarterial pressure monitoring. A three-way stopcock through
by an electromechanical transducer that changes the mechanical which the tubing is intermittently flushed with saline (a
pressure wave into an electrical signal that can be displayed minimum of every 15 to 30 minutes) is a simple, effective
on the monitor. The most basic technique for obtaining blood method. Continuous flush devices push a set amount of fluid
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380 SECTION IV Vascular Techniques and Volume Support
Wire cable
TABLE 20.1 Parameters That Affect Interpretation of
Arterial Blood Gases
To oscilloscope AIR BUBBLE DELAYED
PARAMETER HEPARINa IN SAMPLE ANALYSISb
Normal
Saline Bag PO2 No significant Elevated Variableb
changec
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CHAPTER 20 Arterial Puncture and Cannulation 381
1 2
Position the wrist in slight dorsiflexion, cleanse the skin with Optionally, place a small wheal of local anesthetic (e.g., 1%
antiseptic solution, and palpate the radial pulse. lidocaine without epinephrine) over the entry site. Avoid placing
too large of a wheal, which may obscure the artery.
3 4
Hold the syringe in your hand like a dart, with the bevel up. As soon as blood flows, stop advancing the needle. Allow the
Palpate the artery with the index and middle fingers of your other syringe to fill on its own. If bone is encountered, withdraw slowly
hand. Puncture the skin distal to your finger, and slowly advance because both vessel walls may have been penetrated and the
the needle at a 30° angle toward the pulsating vessel. lumen may be entered as the needle is withdrawn.
5 6
End cap
Remove the needle from the artery after the syringe has filled. Remove all air from the syringe by holding it upward, gently
Apply a bandage and firm pressure to the puncture site for a tapping it, and depressing the plunger. Attach the end cap to the
minimum of 3 to 5 minutes. syringe to maintain anaerobic conditions, and submit the sample
to the laboratory.
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382 SECTION IV Vascular Techniques and Volume Support
pulsating vessel at an approximately 30-degree angle. A larger artery just proximal to the puncture site. An important indication
angle is required to puncture the deeper femoral artery. Once of vessel identification is the loss of audible pulsations with
the needle enters the arterial lumen, allow the syringe plunger compression.
to rise with the arterial pressure on its own to discriminate Proper handling of the sample and rapid analysis are very
between arterial and venous sampling (see Fig. 20.4, step 4). important. When the needle is withdrawn, expel any air bubbles
As soon as blood flows, stop advancing the needle and allow present in the syringe to avoid a false elevation in PO2.31 Remove
the syringe to fill. If no blood flow is obtained or if bone has the air neatly and easily by tapping the inverted syringe (needle
been hit, withdraw the needle slowly because both walls of pointing upward) to force any air to the top; then carefully
the vessel may have been punctured and the lumen may be and slowly depress the syringe plunger to push out the remaining
entered as the needle is withdrawn. Redirect the needle only air (see Fig. 20.4, step 6). A gauze pad or alcohol wipe may
when the needle has been retracted to a location just deep to be used to collect any excess blood expelled with the syringe
the dermis. After at least 1 to 2 mL of blood has been obtained, held upright and the plunger side down. Remove the needle
remove the needle from the artery. Apply firm pressure at the and cap the syringe to ensure anaerobic conditions. Alternatively,
puncture site for a minimum of 3 to 5 minutes (see Fig. 20.4, many of the commercially available ABG kits come with
step 5). If the patient is anticoagulated or has a coagulopathy, an air bubble removal device (Filter-Pro [Smiths Medical,
10 to 15 minutes of pressure is required (Videos 20.2, 20.3, St. Paul, MN]) that allows the clinician to expel air bubbles
and 20.4). from the sample and reduce potential exposure from the blood
Use of ultrasound is rapidly becoming a standard in pro- product.
cedures involving central vascular access. The same ultrasound- Air in the sample will significantly increase PO2 (mean
guided techniques are also being applied to arterial cannulation increase, 11 mm Hg) after 20 minutes of storage, even if kept
(Ultrasound Box 20.1.) Shiloh and colleagues reported 71% at 4°C. pH and PCO2 are not significantly altered by air bubbles
improvement in the likelihood of success at the first attempt if the blood is stored at 4°C for 20 minutes and no significant
when using ultrasound guidance.30 Vascular Doppler can also deterioration has occurred.16,31 If blood is stored at room
be used to improve success rates. Hold the probe over the temperature for longer than 20 minutes, PCO2 will increase
Ultrasound can be used with great success in the placement of the target vessel, multiple means of identification should be used
peripheral and central intravenous lines, and it can also be used for before an attempt at cannulation.
the placement of arterial catheters. Once the vessel has been identified, ultrasound can also be used
First, identify the target vessel with ultrasound. Use a high- to directly guide cannulation. Sterile technique should be maintained,
frequency transducer (10 to 12 mHz) to ensure proper resolution. The particularly when accessing central arteries such as the femoral artery.
target vessel is typically easiest to identify in the transverse plane (with A full description of the technique of ultrasound-guided venous access
the indicator pointing toward the patient’s right side) (Fig. 20.US1). can be found in both the general ultrasound chapter (Chapter 66)
Arteries usually appear as rounded structures with thick walls, as and the central venous access chapter (Chapter 22) in this textbook.
opposed to veins which are ovoid. Depending on the size of the The principles of these procedures also apply to arterial cannulation,
vessel, pulsations may be noted in the arteries. Application of color although a few points should be emphasized. When guiding access to
flow Doppler to a suspected artery will frequently demonstrate a the radial artery, a transverse approach is typically used because the
pattern of pulsatile flow (Fig. 20.US2). Although arteries are usually vessel is small and difficult to visualize in the longitudinal approach.
thought to resist collapse from outside pressure (such as from Additionally, it may be difficult to keep the image of the longitudinal
applying pressure to the overlying transducer), smaller arteries in the vessel centered on the screen, especially when one physician is
periphery may show a degree of collapse. When seeking to identify directing both the ultrasound and the needle.
Figure 20.US1 Placement of the transducer over the distal end of Figure 20.US2 Image of the radial artery with color flow. Applying
the arm in the transverse plane to localize the radial artery. color flow will enable the operator to correctly identify the artery.
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CHAPTER 20 Arterial Puncture and Cannulation 383
and the pH will decrease, probably as a result of leukocyte When successful blood flow into the needle-catheter assembly
metabolism. In a stored sample, PO2 varies to such an extent has ceased, it may have pierced the backside of the arterial
that the change is unpredictable for chemical interpretation wall and may no longer be in the artery. This double-puncture
at 30 minutes, regardless of the storage method. High leukocyte method is useful for cannulating small vessels, yet it is not
or platelet counts, such as those seen in leukemic patients, recommended as a routine procedure for inexperienced clinicians.
may shorten acceptable storage intervals.32,33 If double puncture has occurred and blood has ceased to flow
Thus, ABG samples should always be kept on ice and into the collection reservoir, do not remove the entire needle-
analyzed within 15 to 20 minutes. Samples that cannot catheter assembly. Instead, simply retract the needle slightly
be analyzed within this time frame should be considered to determine whether blood flow into the catheter can be
unreliable. reestablished. If blood flow occurs, gently advance the catheter.
If not, slowly withdraw the catheter until pulsatile blood flow
reappears and then advance the catheter into the artery. It is
important for the clinician to be aware of whether the tip of
PERCUTANEOUS TECHNIQUE the needle or the catheter is the leading edge within the vessel.1
FOR ARTERIAL CANNULATION Once the catheter is fully advanced into the vessel lumen,
maintain occlusive pressure on the proximal end of the artery
Direct Over-the-Needle Catheter Cannulation to limit blood loss, and then remove the needle (see Fig. 20.5,
Placement of an angiocatheter directly into an arterial lumen step 5). Next attach narrow-bore, low-compliance pressure
in a manner similar to placement of an intravenous catheter tubing to the catheter (see Fig. 20.5, step 6). Securely suture
is the most practiced and simplest method, but it is not always the apparatus to the wrist, and then apply an appropriate sterile
successful because of technical difficulties. The only routine dressing. Occasionally, difficulty will be encountered advancing
site for this technique is the radial artery. Use of a catheter the catheter into the lumen. The “liquid stylet” method may
over a guidewire as per the Seldinger technique is strongly aid further passage of the catheter.34 Fill a 10-mL syringe with
advised at most other sites. approximately 5 mL of sterile normal saline. Attach the syringe
Take time to ensure proper alignment of the desired site. to the catheter hub, and aspirate 1 to 2 mL of blood to confirm
Delays, complications, and inability to successfully cannulate intraluminal position. Then slowly inject the fluid from the
an artery often occur as a result of failure to properly prepare syringe and advance the catheter behind the fluid wave.
the desired site and involved limb. An important preparatory Ultrasound guidance is now routinely used for both periph-
step is to ensure that the target limb is secured flat and not eral and central venous access and can also assist with arterial
rotated; any rotation could result in the desired artery being cannulation (see Ultrasound Box 20.1). Ultrasound-guided
shifted from the expected anatomic position and making it radial artery cannulation is associated with an increased first
more difficult to cannulate. For example, to adequately prepare attempt success rate, fewer attempts prior to success, and a
the radial artery, immobilize the wrist and hand in mild lower incidence of hematoma formation compared to the
dorsiflexion with some padding for support underneath the traditional method of palpation.35
wrist (Fig. 20.5, step 1). Prepare the skin with sterile technique. With B-mode ultrasound, visualize the targeted artery in
Inject local anesthetic with a 25-gauge or smaller needle real-time by using a 7.5- to 10-MHz linear-array transducer.
to achieve sufficient infiltration and to ensure a painless Differentiate the target artery from the adjacent vein by its
procedure. Subcutaneous infiltration of lidocaine or a similar pulsatility and noncompressibility under mild pressure by the
anesthetic may also reduce vessel spasm at the time of arterial transducer. Use color Doppler to further distinguish between
puncture. arteries and veins. Either transverse or longitudinal views can
Check the catheter assembly for proper movement and be applied during arterial cannulation, but the transverse view
function. Alternatively, a 3-mL syringe with the plunger is often more useful in smaller arteries. Once the catheter has
removed can be used as a blood reservoir. Advance the catheter entered the artery and it is confirmed by blood flow, place
toward the palpated artery at a comfortable angle for the the ultrasound transducer on the field to free up the nondomi-
operator, generally 30 to 45 degrees from the skin (see Fig. nant hand.36,37
20.5, step 2). Make a small incision with a No. 11 scalpel blade The number of attempts and additional arterial punctures
or a larger-bore needle to eliminate the problem of damage increases the size of the developing hematoma and the real
to the catheter from kinking on the skin. The tip of the needle risk for vessel wall damage, thrombosis, and even loss of arterial
is often perceived to pierce the artery, but successful puncture flow through the vessel. Despite the added trauma, there is
is confirmed by identifying a “flash” of arterial blood flow into no reported increase in complications when both walls, rather
the needle hub and reservoir. As the needle-catheter assembly than one, are punctured in a single cannulation attempt.38–40
advances through the skin toward the artery, the initial flash
of arterial blood is obtained by the needle alone, which protrudes Guidewire Techniques
beyond the catheter. For this reason, the needle-catheter
assembly should be lowered and advanced 2 mm forward to
for Arterial Cannulation
ensure that the tip of the catheter has cannulated the vessel, A modified Seldinger technique can often rescue a failed direct
along with the needle (see Fig. 20.5, step 3). The position of cannulation attempt with an over-the-needle catheter (Fig.
the catheter within the vessel lumen is confirmed by continuous 20.6). If the catheter has been placed in the arterial lumen
return of arterial blood. The catheter alone can now be advanced with successful blood return, pass a properly sized guidewire
with care over the needle and into the artery (see Fig. 20.5, through the catheter and into the artery. Advance the catheter
step 4). If the catheter fails to thread, it has not properly entered over the guidewire and fully into the vessel. Be careful because
the vessel lumen and should not be forced to advance without stiffer guidewires, unlike most prepackaged ones, do not have
confirmation of placement by active blood return. a softer, more flexible end tip and the vessel wall may be
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384 SECTION IV Vascular Techniques and Volume Support
1 2
30°
Immobilize the hand and wrist in mild dorsiflexion on a padded Advance the needle into the artery at a 30° to 45° angle to the
arm board. Prepare the skin with antiseptic, anesthetize, and skin. Confirm arterial puncture by observing a flash into the
apply a sterile drape. needle hub.
3 4
Lower the angiocatheter and advance it 2 mm forward to ensure Carefully advance the catheter over the needle and into the
that the tip has cannulated the vessel. Confirm proper placement artery. Do not force the catheter; if it fails to easily thread, it has
by observing continuous arterial blood return. not properly entered the vessel lumen. (See text for
troubleshooting tips.)
5 6
Tamponade over the artery proximal to the tip of the catheter Attach the tubing from the pressure transducer to the catheter.
(to prevent blood loss), and remove the needle. Suture the catheter hub to the skin and cover with a sterile
dressing, such as Tegaderm.
Figure 20.5 Arterial cannulation: over-the-needle catheter technique. Note that in this example the
angiocatheter does not have a safety mechanism such as a retracting needle. This allows a syringe to
be attached to the back of the hub as a blood reservoir. Such angiocatheters may be difficult to find
in some institutions.
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CHAPTER 20 Arterial Puncture and Cannulation 385
1 2
Prepare the wrist and insert the needle as described in Fig. 20.5. Hold the catheter in place and remove the needle. Pulsatile
Look for pulsatile blood return in the flash chamber. blood should flow from the catheter. If not present, slowly back
the catheter out, and observe for blood return.
3 4
Insert the guidewire through the catheter. It should advance Advance the catheter over the wire and into the artery. Remove
freely and easily into the vessel. Do not force it. the wire, attach the catheter hub to the transducer tubing, and
secure it to the skin.
damaged or even perforated with excessive force. Alternatively, guidewire-directed technique are superior to those with direct
catheter sets are available with an attachable, catheter-contained, arterial cannulation.42 A few available kits are designed specifi-
wire stylet that permits a modified Seldinger technique for cally for cannulation of larger arteries, but single-lumen venous
placement of the catheter. The over-the-needle catheter follows catheters with guidewires may be used if catheter size and
the self-contained guidewire during cannulation. Numerous length are appropriate for specific arteries (see the following
commercially available sets feature styles of guidewire and section for guidelines). The guidewire technique should be
reservoir attachments that are different from an over-the-needle used initially for critical patients.
catheter assembly. Most resemble the Arrow Arterial Catheter- Place the needle percutaneously into the arterial lumen, as
ization Kit (Arrow International, Inc., Reading, PA) (Fig. 20.7; described previously. Then place a guidewire through the needle
see also Fig. 20.2). These kits are extremely practical for smaller into the vessel lumen, and remove the needle. Thread the
vessels, especially the radial, brachial, and axillary arteries, and catheter over the wire, and pull the wire out. Although most
have excellent success rates for first-time placement. Although kits have vessel dilators, especially with larger catheter sizes,
some authors have suggested that guidewire-based techniques caution is advised. Dilate the tract only and not the artery to
will improve arterial cannulation success rates in certain avoid unnecessary blood loss and excessive arterial injury.
patients,41 it appears that success is more a function of operator
experience and personal preference.42
Cutdown Technique for Arterial Cannulation
The cutdown technique is rarely used, but in certain circum-
Seldinger Technique stances it may be performed to obtain arterial access. With
The Seldinger technique for venipuncture is described in the increasing use of ultrasound-assisted catheter placement,
detail in Chapter 22. Overall success rates with the Seldinger, this technique should seldom be required. Perform cannulation
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386 SECTION IV Vascular Techniques and Volume Support
1 2
Ensure that the actuating lever is fully retracted, and then insert Stabilize the needle and advance the guidewire into the vessel by
the needle into the artery. Monitor for blood flashback in the hub using the actuating lever. When the lever reaches the reference
of the needle to confirm intraarterial placement. mark (black arrow) on the device, the wire begins to exit the
needle.
3 4
After the wire is fully inserted, advance the entire assembly 1–2 Remove the needle and guidewire assembly and attach the
mm farther into the vessel. Firmly hold the needle in position, transducer tubing to the catheter hub. Use the wing clip (arrow)
and advance the catheter over the wire and into the vessel. A to suture the catheter to the skin, and then cover with a sterile
slight rotating motion may be helpful. dressing.
after direct visualization of the vessel. A cutdown can be as the kind used in the percutaneous method, and introduce
performed on any artery but is most commonly reserved for it through the skin just distal to the incision. Advance it into
distal lower limb arteries and, rarely, the brachial artery. the surgical site (Fig. 20.8).34 Alternatively, use a modified
After a site has been selected, prepare the overlying skin with Seldinger guidewire setup to catheterize the artery. Puncture
an antiseptic solution. Using sterile technique, inject local the arterial wall with the tip of the needle, and thread the
anesthetic solution subcutaneously in a horizontal line 2 to catheter into the vessel lumen. When this has been accom-
3 cm long and perpendicular to the artery. Omit this step if plished, remove the two silk sutures, which have only been
the patient is unconscious or otherwise anesthetized at the used to control the vessel, and close the skin incision. Do not
cutdown site. tie off the artery the way that a vein is tied off during a venous
Use a No. 10 or 15 scalpel blade to incise the skin along cutdown. Apply firm pressure over the cutdown site, as used
the anesthetic wheal. Spread the underlying tissues parallel to after arterial puncture. If pressure is not applied, separation
the artery with a mosquito hemostat. Palpate the pulse repeat- of the soft tissues during the procedure may allow considerable
edly throughout the procedure to ensure proper positioning. hemorrhage into the tissue.
Once the surrounding soft tissue has been retracted and after
exposing approximately 1 cm of the artery, isolate the artery
by passing two silk sutures underneath it with the hemostat.
Local Puncture Site and Catheter Care
Strip away only enough perivascular tissue to expose the artery. Once the catheter has been placed successfully, advance it until
Perivascular tissue will help limit bleeding at the time of catheter the hub is in contact with the skin. Secure the catheter by
removal. Introduce an over-the-needle catheter device, such fastening it to the skin with suture material. Silk (2-0) or nylon
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CHAPTER 20 Arterial Puncture and Cannulation 387
Distal
Proximal ligature
ligature
Over-the-needle
catheter
Artery Skin
penetration penetration
Superficial
Figure 20.8 Placement of an arterial line using the cutdown technique. palmar arch
Note that the catheter enters the surgical wound percutaneously to
minimize entry of bacteria into the healing wound and permit better
stabilization of the catheter. Entry of the catheter into the vessel is
Deep
more parallel to the vessel than illustrated. Ligatures are only used to palmar arch
temporarily isolate the artery and to control bleeding. The artery should
not be tied off. The catheter is secured by suturing the hub to the skin.
Ulnar
artery Radial
artery
Catheter Square knot
hub
Figure 20.10 Arterial anatomy of the hand and wrist.
Skin surface
Vessel
to maintain patency. Use of a heparinized flush solution in
pressurized arterial lines may result in greater long-term
Surgeon’s knot (3-0/4-0 silk suture)
accuracy of pressure monitoring, but no real difference in
catheter blockage has been reported, and this approach avoids
Figure 20.9 A technique for securing a vascular catheter to adjacent heparin-related complications such as drug incompatibility,
skin.
thrombosis, local tissue damage, and hemorrhage.46–50 For
short-term setups as in the ED, saline is sufficient.
Blood samples are obtained easily from the arterial catheter
(4-0) sutures provide the best anchoring. To accomplish this, system. Attach a syringe to the three-way stopcock and aspirate
take a moderate bite of skin with the needle, and tie a knot in and discard the blood to clear the line. Studies examining
the suture while leaving both tails of the suture long. Avoid the necessary discard volume of flushed blood solution have
pinching the skin too tightly. Tie the loose ends of the suture found considerable variation, depending on the volume of the
around the catheter at its hub. Then, after laying two ties, system.51,52 Short lengths of tubing between the catheter and
place a second set of knots on the back portion without occlud- the aspiration port minimize the necessary discard volume.
ing the lumen by constriction (Fig. 20.9). For a tubing length of 91 cm (36 inches), aspirate 4 to 5 mL52;
Another option to secure these lines is to apply commercially for a tubing length of 213 cm (84 inches), aspirate 8 mL.51
available sutureless securement devices. According to one study, Attach a second syringe that has been heparinized, and aspirate
sutured lines are associated with a 10% rate of catheter-related 3 mL of blood to send for ABG analysis. If the blood is to be
bloodstream infection. In comparison, lines that were secured used for other tests, the second syringe does not need to be
with a sutureless method had an infection rate of less than 1% heparinized. Self-contained, nondetachable, blood sample
and eliminated the potential for accidental needlestick from withdrawing systems allow less blood wasting for sampling.
suturing.43 Flush the stopcock and line to avoid clotting.
After tying the catheter in place, apply a drop of antibiotic
ointment to the puncture site44 and a self-adhesive dressing
over the area. Certain transparent dressings containing
chlorhexadine gluconate can retard the colonization of bacteria.45 SELECTION OF ARTERIES FOR CANNULATION
Further secure the catheter and its connecting tubing with
sterile sponges and adhesive tape. Make sure that all tubing
Radial and Ulnar Arteries
connections are tight and secure. If the tubing becomes discon- The radial artery is most frequently used for prolonged can-
nected inadvertently, the patient can exsanguinate rapidly. nulation. Widespread collateral flow is present in the wrist
because of two major palmar anastomoses known as arches
(Fig. 20.10). The superficial palmar arch lies between the
Fluid-Pressurized Systems aponeurosis palmaris and the tendons of the flexor digitorum
When successful arterial cannulation has been performed, sublimis. The arch is formed mainly by the terminal ulnar
attach the catheter to a pressurized fluid-filled system. A artery and the superficial palmar branch of the radial artery.
three-way stopcock can be interposed between the patient and The other major communication of these two vessels, the deep
the transducer for blood gas sampling and to allow flushing palmar arch, is formed by connections of the terminal radial
of the system. Flushing can be periodic or continuous at a rate artery with the deep palmar branches of the ulnar artery.53
of 3 to 4 mL/hr through a continuous-flow device. Most Some collateral flow is almost always present at the wrist, with
institutions use normal saline in place of heparinized solution the deep arch alone being complete in 97% of 650 hand
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388 SECTION IV Vascular Techniques and Volume Support
dissections at autopsy.54 Despite these findings, Friedman55 puncture for blood gas sampling. Moreover, the utility of the
noted the absence of palpable ulnar pulses in 10 of 290 (3.4%) Allen test is still questioned because of numerous reports of
healthy children and young adults. Interestingly, this was always permanent ischemic sequelae after cannulation even after a
a bilateral finding. Radial pulses were present in all subjects, normal Allen test result.58,61,62 Notably, other studies have found
however. no ischemic complications following radial artery catheterization
Before attempting radial artery cannulation, the adequacy and abnormal results on the Allen test.39,63 Although there are
of collateral flow to the hand may be assessed by performing no guarantees against digital ischemia after radial artery can-
a bedside examination called the Allen test. This examination nulation,64 the finding of an abnormal Allen test result should
was originally described by E. V. Allen in 192956 and is used be documented and lead one to search for an alternative site
to assess arterial stenosis in the hands of patients with throm- for the procedure.
boangiitis obliterans. This test identifies patients at increased At the wrist, the radial artery rests on the flexor digitorum
risk for ischemic complications from radial artery catheteriza- superficialis muscle, the flexor pollicis longus muscle, the
tion. The procedure has undergone many modifications57,58 pronator quadratus muscle, and the radius bone.54 Isolate
since originally being described in a cooperative patient. The the pulsation of the artery on the palmar surface of the wrist.
modified Allen test is performed as follows: occlude both the The radial artery is more superficial as it moves closer to the
radial and ulnar arteries with digital pressure and then ask wrist. In this location, it provides a more consistent site for
the patient to tightly clench the fist repeatedly to exsanguinate cannulation because of its fixation and decreased mobility.
the hand. Then open the hand and release the occlusion Dorsiflexing the wrist at approximately a 45-degree angle over
of the ulnar artery only (Fig. 20.11). After 2 minutes, repeat a towel or sandbag and fixing the wrist to an arm board will
the test in the same manner with release of the radial artery also help isolate the artery.65 This degree of preparation should
only. Rubor should return rapidly to the hand following the be considered standard when time for setup permits (see Fig.
release of pressure from either vessel. 20.5, step 1).38,39
An abnormal (positive) Allen test result, suggestive of Antegrade radial artery cannulation may be accomplished
inadequate collateralization, is defined as the continued presence in infants and children when the radial arteries are obstructed
of pallor 5 to 15 seconds after release of the radial artery.6,19,58,59 and retrograde blood flow is observed during a failed cutdown
If return of color takes longer than 5 to 10 seconds, do not attempt at standard retrograde arterial cannulation.66 In addition,
perform radial artery puncture. Be careful to avoid overextension displacement of perivascular interstitial fluid in neonates and
of the hand with wide separation of the digits, which may bright light make the course of the artery visible. Then, under
compress the palmar arches between fascial planes and yield direct vision, cannulation of the artery becomes as easy as
a false-positive result.60 Time permitting, performance of some venous cannulation.67 Doppler ultrasound on selected patients
variation of the Allen test is desirable before ulnar or radial with poor peripheral pulses may also facilitate percutaneous
puncture, especially for prolonged cannulation. This test is radial artery cannulation and minimize the number of punctures
not considered mandatory or standard for one-time radial artery needed for placement.68
1 2 3
Radial artery Ulnar artery
Compress both the radial and ulnar arteries to Instruct the patient to relax the hand and Release the ulnar artery and observe
occlude arterial flow, and instruct the patient to extend the fingers. Carefully observe the the hand for return of rubor, which
repeatedly make a tight fist to squeeze venous hand—it should be blanched. signifies good flow in the ulnar artery.
blood out of the hand. Alternatively, the hand If filling does not occur within 5 to 10
may be squeezed first and then the arteries seconds, radial artery cannulation
occluded. should not be done. If brisk filling
occurs, repeat the test with release of
the radial artery to assess radial artery
patency. If both the radial and ulnar
arteries demonstrate patency, the wrist
may be used for arterial cannulation.
Figure 20.11 Allen test. Before puncturing the radial artery for cannulation, it is important to identify
a competent ulnar artery should injury to the radial artery occur. This is not generally required, nor
standard, for a single arterial puncture. (Adapted from Schwartz GR, editor: Principles and practice of
emergency medicine, Philadelphia, 1978, Saunders, p 354. Reproduced by permission.)
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CHAPTER 20 Arterial Puncture and Cannulation 389
Femoral Artery
The femoral artery is the second most commonly used vessel
for arterial cannulation. Based on its ease of cannulation and
Biceps
brachii Ulnar
nerve
Brachial Extensor
artery hallicus
Extensor longus
Pronator
teres digitorum
Median
longus
nerve Dorsalis
pedis artery
Figure 20.12 Brachial artery anatomy. Figure 20.13 Dorsalis pedis artery anatomy.
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390 SECTION IV Vascular Techniques and Volume Support
low record of complications, it has been called the vessel of enter the skin with the needle at an angle of approximately
choice for arterial access.75–77 Along with the axillary artery, 45 degrees instead of the usual 15 to 20 degrees.
the femoral artery more closely resembles aortic pressure The extremely large ratio of arterial diameter to catheter
waveforms than those from any other peripheral site. The diameter is thought to reduce the incidence of thrombosis,
femoral artery is the direct continuation of the iliac artery and particularly total occlusion. However, occlusion has been
enters the thigh after passing below the inguinal ligament. reported with femoral cannulation for monitoring purposes.79
Arterial puncture must always occur distal to the ligament to A commonly perceived disadvantage of this site is the increased
prevent uncontrolled hemorrhage into the pelvis or perito- possibility of bacterial contamination because of its proxim-
neum.78 The artery may be palpable easily midway between ity to the warm, moist groin and perineum; however, no
the pubic symphysis and the anterior superior iliac spine. The studies have confirmed this hypothesis.80 The femoral area
advantage of cannulating the artery at a site just distal to the is inconvenient for any patient who is awake and mobile or
inguinal ligament is that the artery can be compressed against for a patient who is able to sit in a chair. If the patient is that
the femoral head. Cannulation becomes more difficult the mobile, reconsider the risk-benefit ratio of invasive monitoring.
more distal the puncture site is from the inguinal ligament Despite theoretical difficulties, some hospitals use femoral
because the femoral artery splits into the superficial femoral arterial lines almost exclusively, and the ICU nursing staff is
and the deep femoral arteries. These arteries, especially the often more comfortable caring for these lines than those at
deep femoral, can be challenging to compress if bleeding needs other sites.
to be controlled. One method of locating an appropriate arterial
puncture site is to place the thumb and fifth finger on the
pubis symphysis and the anterior iliac spine and locate the
Umbilical and Temporal Arteries
artery underneath the middle knuckle. When puncturing this In neonates, arterial access can be accomplished for a short
vessel, be careful to avoid the femoral nerve and vein, which time through the umbilical artery (see Chapter 19). After this
form the lateral and medial borders, respectively (Fig. 20.14). artery closes, the temporal artery provides a safe alternative.
A longer, larger-diameter catheter is required for accurate Prian described the use of the temporal artery and noted its
monitoring of the femoral artery because of its size and the accessibility and lack of clinical sequelae if it undergoes
relatively greater depth at which it lies. Only the Seldinger thrombosis.81 Use the cutdown method with a 22-gauge catheter
technique is recommended for this site, which enables placement after the artery’s course has been traced with an ultrasonic
of a 15- to 20-cm plastic catheter for prolonged monitoring. flow detector. Because of the increasing accuracy of ear
Avoid using catheter-through-the-needle or over-the-needle oximeters and the use of capillary blood gas samples for
devices because of the vessel’s distance beneath the skin. Leakage determination of pH, prolonged arterial cannulation will become
around the catheter can occur with these devices as a result less frequent during infant care.
of the high arterial pressure and the loose fit of the cannula
in the hole in the vessel wall. Regardless of the device used,
COMPLICATIONS OF
ARTERIAL CANNULATION
Arterial cannulation is safe if care is taken to avoid complica-
tions. Most can be avoided by adhering to a few simple
principles. Reported clinical sequelae of arterial puncture and
cannulation range from simple hematomas to life-threatening
infections and exsanguination. In addition, ischemia, arterio-
venous fistula, and pseudoaneurysm formation are possible.
Inguinal
ligament The incidence of complications varies with the site selected,
the method of cannulation, and the clinician’s level of skill and
Sartorius experience. Early detection of complications is greatly aided
muscle by enhanced vigilance.
It is difficult to compare complication rates at various sites
Femoral because most published studies have primarily used only the
nerve radial artery. No studies have compared the approach and
complication rates of arterial catheters in the ED with those
Femoral placed in the ICU or operating room. In a large study spanning
artery 24 months, 2119 ICU patients had arterial catheters placed
at admission: 52% at the radial site and 45% at the femoral
Femoral site. The most common complication was vascular insufficiency
vein (4%), followed by bleeding (2.1%), and infection (0.6%). No
difference was reported in infection rates at femoral versus
Adductor
longus
radial sites.82 There are reports of complications from arterial
muscle puncture for procedures unrelated to cannulation, such as
arteriography or simple puncture for blood sampling as routinely
performed in the ED. In a study of 2400 consecutive cardiac
catheterizations over a 12-month period, complications occurred
in 1.6% of patients, including 17 needing vascular repair and
Figure 20.14 Femoral artery anatomy. 28 requiring transfusion.83
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CHAPTER 20 Arterial Puncture and Cannulation 391
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392 SECTION IV Vascular Techniques and Volume Support
Shinozaki and colleagues98 demonstrated a marked reduction secondary to the poor blood supply in this area and thought
in equipment contamination when the continuous flush device that proper technique would decrease the incidence of necrosis.
was located just distal to the transducer, as opposed to closer One feared complication of indwelling radial and brachial
to the three-way stopcock used for sampling. This setup reduces arterial catheters is the occurrence of a cerebrovascular accident
the length of the static column of fluid between the sampling secondary to embolization from flushing of the catheters.20,102
stopcock and the transducer. As mentioned previously, a drop As little as 3 to 12 mL of flush solution has been shown to
of iodophor or antibiotic ointment applied to the puncture reflux to the junction of the subclavian and vertebral arteries.76
site decreases the incidence of local wound infection.46 This A fatality caused by air embolism from a radial artery catheter
technique has drawn a great deal of criticism, however. The has been reported and was re-created in a primate model.105
current standard is a clean, nonocclusive, dry dressing. An Although these animals were much smaller (7 kg) than an adult
antibiotic- or silver-impregnated catheter is recommended for human, as little as 2.5 mL of air introduced at a relatively low
long-term placement. flush rate was found to embolize in retrograde fashion to the
Thrombosis of the vessel in which the cannula is placed is brain. Cerebral embolization can be prevented with the use
another frequently encountered problem. The incidence of of continuous flush systems (3 mL/hr) and by ensuring the
thrombosis varies with the method used to determine the integrity of the tubing and transducer systems to prevent entry
presence of clots. Bedford and Wollman18 found a greater than of air. In addition, small volumes (<2 mL) of intermittent flush
40% occlusion rate when radial artery catheters were left in solution should be used.
place for longer than 20 hours. All these occluded vessels Complication rates also vary according to the method of
eventually recanalized. Angiographic studies show deposition arterial cannulation. Mortensen106 studied the three main
of fibrin on 100% of catheters left in place for longer than 1 techniques (discussed earlier in the section on Techniques),
day, although clinical evidence of ischemia secondary to occlu- but unfortunately, most of his arterial cannulations were
sion by such thrombi is seen in less than 1% of cases in most for angiographic purposes. The complications associated with
studies.99 Most reports of nonangiographic catheterization prolonged cannulation time are therefore underrepresented.
involve the radial artery. Therefore it is difficult to compare In Mortensen’s series, cutdown arteriotomy exhibited the lowest
the incidence of thrombosis at other sites, although during incidence of complications (7.7%), whereas the Seldinger
the 176 femoral catheterizations reported by Soderstrom and technique had a 17.7% incidence of complications. The
colleagues76 and Ersoz and associates,100 dorsalis pedis pulses complication rate with percutaneous cannulation was 11.3%.
were decreased in only two patients and no clinical signs of False passage of the guidewire, the catheter, or both was
ischemia were noted. Larger catheter sizes, trauma during associated with increased intimal damage and complications.
cannulation, and the presence of atherosclerosis have all been It is imperative that the wire or catheter be advanced only if
postulated to increase the incidence of thrombosis; however, no resistance is met.
conflicting studies abound. Once the monitoring system is set up, manipulate it as little
Arterial spasm after puncture (usually following multiple as possible. Perform any handling with aseptic technique.
attempts) can predispose to thrombus formation and can Change the tubing and other fluid-filled devices every 48 hours,
even lead to ischemic changes without fibrin deposition. and insert catheters into a vessel that provides the largest
Successful reversal of spasm with intraarterial lidocaine, vessel-to-catheter ratio as possible.
reserpine, and phentolamine has been reported, but no reliable If these principles are followed and the patient and system
studies of their efficacy in this clinical situation have been are carefully inspected at frequent intervals, complications of
published.101 arterial puncture and cannulation can be minimized.
Thrombosis can be minimized by decreasing the duration
of catheterization and proper flushing. Surgical embolectomy
or thrombectomy is rarely required because the smaller vessels INTERPRETATION
that are most likely to occlude usually have good collateral
circulation. The larger femoral artery, which has poor col- An indwelling arterial catheter provides continuous blood
lateralization, rarely occludes with catheterization when used pressure monitoring. The trend of a patient’s pressure facilitates
for monitoring purposes. assessment of the effect of various therapeutic interventions.
Thrombosis can result in occlusion of the catheter. Time The absolute systolic and diastolic pressure measured will vary
until occlusion of radial and femoral artery catheters has been at different catheter sites, with higher peak systolic pressures
compared. Radial cannulas became occluded at an average of measured at the periphery. The pressure will also be higher
3.8 days, whereas femoral cannulas became occluded after 7.3 when measured at the distal end of the lower limb.23,76 A wide
days.77 The importance of this comparison is minimal if the variance between direct arterial pressure and the pressure
clinician follows infection prophylaxis guidelines and changes measured with a standard pneumatic cuff will always exist in
arterial catheters after 4 days. some patients. Oscillometric blood pressure measurement can
A few less common complications are easily prevented. One significantly underestimate arterial blood pressure.107 For this
that occurs only with the percutaneous catheter-through-the- reason, regularly compare a cuff pressure with that obtained
needle method is catheter embolization. Once the catheter via invasive monitoring. Moreover, a change in their relationship
has been placed through the needle, it should never be pulled may be the first indication of difficulty with the direct measuring
back because the end of the catheter may be sheared off by system.
the sharp needle bevel. If this complication occurs, surgical Waveform analysis may also provide an early indication of
removal of the tip of the catheter is necessary. thrombosis in the arterial catheter. Many variables affect the
Skin necrosis is a complication of radial artery cannulation waveform, including cardiac valvular disease and arterioscle-
that involves an area of the volar surface of the forearm proximal rosis.108 Waveforms may vary tremendously among patients,
to the cannula.102,103 Wyatt and colleagues104 believed this to be but after an adequate monitoring system has been established,
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CHAPTER 20 Arterial Puncture and Cannulation 393
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CHAPTER 20 Arterial Puncture and Cannulation 393.e1
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