Clinical Procedures - Arterial Line Insertion (Radial Artery) Indications • Continuous beat-to-beat measurement of arterial blood pressure (inotrope therapy, intraoperatively for major surgery, transfer of critically ill) • Repeated blood gas sampling. Contraindications • Infection at insertion site • Working AV fistula • Traumatic injury proximal to the insertion site • Vascular insufficiency in the distribution of the artery to be cannulated • Significant clotting abnormalities. Risks • Non-vascular: superficial bleeding, infection, inadvertent arterial injection . Vascular: vasospasm, thrombosis, thromboembolism, air embolism, blood vessel injury, distal ischaemia Procedure Tips • Good positioning is vital. Make sure both you and the patient are comfortable • © Do not force the guidewire. If there is resistance, try lowering the needle to a shallower angle without removing it from the artery • © Cover the floor with spill sheets as the procedure can be messy! • D The modified Allen's test should be used for assessment of the collateral supply to the hand before the radial artery is punctured but may not be completely reliable in predicting ischaemic injury. Modified Allen's test • Compress the radial and ulnar arteries at the wrist and ask the patient to clench their fist • Ask the patient to open the hand • Release pressure over the ulnar artery • Watch the palm for return of colour: • Return of colour should normally occur in 5-10 seconds • Return of colour taking >15 seconds suggests an inadequate collateral supply by the ulnar artery and radial artery cannulation should not be performed. Equipment • Arterial catheter set: • Arterial catheter (20G), needle, guidewire • Sterile gloves, sterile gown (‡ surgical hat and mask) • Dressing pack including a sterile drape • Sterile preparation solution (e.g. 2% chlorhexidine) • Local anaesthetic (e.g. 1% lidocaine), 22G needle, and 5mL syringe • (Optional) A 3-way tap with a short extension (flushed with normal saline) connected to a 10mL syringe containing normal saline • Suture • Transducer set with pressurized bag of heparinized saline. Procedure (Modified Seldinger Technique) • Introduce yourself, confirm the patient's identity, explain the procedure, and obtain informed consent • Choose a site for arterial line insertion (e.g. radial artery) • Position the forearm so that it is supported from underneath and hyperextend the wrist • Set up a trolley keeping everything sterile: • Open the dressing pack onto the trolley creating a sterile field • Open the arterial catheter set and place onto the sterile field • Wash hands using a surgical scrub technique and put on the sterile gown and gloves • Clean the wrist, hand, and forearm with a sterile preparation solution and create a sterile field with the drape • Palpate the radial artery with your non-dominant hand and infiltrate the skin overlying the pulsation with some local anaesthetic • Insert the arterial needle, directing it towards the radial pulsation at a 30-45° angle. (Do not attach to a syringe.) • You can also use a syringe with the plunger removed. This allows identification of the arterial pulsation without excess spillage • On hitting the artery, blood will spurt out of the hub of the needle • Keeping the needle still, insert the guidewire through the hub of the needle. © Don't force the guidewire • Remove the needle leaving the guidewire in place • Thread the arterial catheter over the guidewire making sure that guidewire is seen at all times through the distal end of the catheter • Holding the distal end of the guidewire with one hand, push the arterial catheter through the skin with the other • Remove the guidewire • Blood should spill out of the end of the catheter if it is within the artery • Connect to the short extension of the 3-way tap, aspirate and flush with normal saline, and close off the tap: • Alternatively, connect immediately to a pressurized transducer set, aspirate, and flush •Do not delay connection to transducer and flush-bag • Take extreme care not to allow any air bubbles to flush into the artery (risk of distal embolization) • Suture in place • Label catheter as arterial and inform relevant staff. Documentation • Time, date, indication and informed consent obtained • Site and side of successful insertion • Site, side, and complications of unsuccessful attempts) • Aseptic technique: gloves, gown, hat, mask, sterile solution • Local anaesthetic: type and amount infiltrated • Technique used: modified Seldinger, cannula over needle • Catheter size used: 20G • Aspirated and flushed • Signature, printed name, and contact details.
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