Arterial Line

An arterial line is a thin catheter inserted into an artery.

Arterial line placement is a common procedure in various
critical care settings. It is most commonly used in intensive
care medicine and anesthesia to monitor blood pressure
directly and in real time (rather than by intermittent and
indirect measurement, like a blood pressure cuff) and to obtain
samples for arterial blood gas analysis. There are specific
insertion sites, trained personnel and procedures for arterial
lines. There are also specific techniques for drawing a blood
sample from an A-Line or arterial line.
An arterial line is usually inserted into the radial artery in
the wrist, but can also be inserted into the brachial artery at the
elbow, into the femoral artery in the groin, into the dorsalis
pedis artery in the foot, or into the ulnar artery in the wrist. In
both adults and children, the most common site of cannulation
is the radial artery, primarily because of the superficial nature
of the vessel and the ease with which the site can be
maintained. Additional advantages of radial artery cannulation
include the consistency of the anatomy and the low rate of
complications.
 After the radial artery, the femoral artery is the second
most common site for arterial cannulation. One advantage of
femoral artery cannulation is that the vessel is larger than the
radial artery and has stronger pulsation. Additional advantages
include decreased risk of thrombosis and of accidental catheter
removal, though the overall complication rate remains
comparable.
There has been considerable debate over whether
radial or femoral arterial line placement more accurately
measures blood pressure and mean arterial pressure, however,
both approaches seem to perform well for this function. In
determining the need for and optimal location of arterial line
placement, one must consider the risk and benefits of the
procedure for each patient. A golden rule is that there has to
be collateral circulation to the area affected by the chosen
artery, so that peripheral circulation is maintained by another
artery even if circulation is disturbed in the cannulated artery.

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 There are multiple people that perform arterial line
insertions. Cardiologists/cardiac surgeons, critical care doctors,
anesthesiologists, emergency doctors, thoracic surgeons,
registered nurses specially trained in arterial lines and certified
nurse anesthetists may all insert arterial lines.

When placing an arterial line, make sure to follow these steps

to successfully facilitate placement of an arterial line:

1. Always position the patient appropriately and feel arterial

pulsation before initiating arterial line placement
2. Before starting the procedure, flush the needle introducer
with heparinized flush to facilitate flashback of blood up
to the needle hub upon entry into the artery
3. Puncture the radial artery in a slight lateral-to-medial
direction; this allows the artery to be stabilized against
the flexor carpi radialis tendon
4. After arterial puncture or decannulation, maintain
pressure over the puncture site for at least 5 minutes (or
possibly longer if the patient is in a hypocoagulable state)
5. Make a small skin incision at the site of needle puncture
to allow easier passage of the catheter through the skin
and help prevent catheter kinking during advancement
6. When using a catheter-over-needle technique, be sure to
advance the needle 2 mm after flash to ensure catheter
placement inside the lumen
7. When using a Seldinger technique, do not dilate the
artery; to minimize bleeding and vessel injury, dilate only
the soft tissue tract
8. If the guide wire cannot be passed into the artery, try
rotating the needle 90-180° in an attempt to eliminate an
intimal flap blocking passage of the wire
9. To avoid creating false passages, refrain from forcing
further advancement if passage of a guidewire or catheter
meets with resistance
10. When it proves difficult to advance the catheter into the
lumen, consider the “liquid stylet” method; fill a 10-mL
syringe with 5 mL of sterile normal saline, attach it to the
catheter hub, aspirate 1-2 mL of blood into the syringe,
and then slowly inject the syringe contents into the vessel
as the catheter is advanced behind the fluid wave
11. If several attempts at cannulation fail, the artery may
spasm, making further attempts more difficult; if this
occurs, allow the artery to recover for a short time before
reattempting cannulation; subcutaneous infiltration of
lidocaine or similar anesthetic around the puncture site
may reduce vessel spasm
12. Consider adding papaverine 30 mg/250 mL to the
arterial line fluid, this may prolong the patency of
peripheral arterial catheters in children and neonates
13. Regularly inspect the area for signs of ischemia, and
remove the catheter at the first signs of circulatory
compromise or clot formation; do not flush the catheter
in an attempt to remove clots
14. To reduce the complication rate, remove the catheter as
soon as it is no longer necessary

15. Arterial lines are generally not used to administer

medication, since many injectable drugs may lead to
serious tissue damage and even require amputation of
the limb if administered into an artery rather than a vein.
Intra-arterial BP management permits the rapid
recognition of BP changes that is vital for patients on
continuous infusions of vasoactive drugs. Arterial
cannulation also allows repeated arterial blood gas
samples to be drawn without injury to the patient. There
are multiple indications for arterial line placement, such
as…
● Cardiovascular conditions including severe
uncontrolled hypertension, heart failure, and
cardiovascular arrest.
● Labile blood pressure (hypotension) including
hypotension due to severe bleeding, sepsis and
shock.
● Major surgery including open-heart surgery, chest
surgery, brain surgery, organ transplants, trauma
surgery, and certain abdominal surgeries.
● Coma including coma due to stroke and head injury
● Drug overdose or poisoning including ingestion of
drugs or exposure to toxins, such as
organophosphates including nerve gas
 ● Anticipation of hemodynamic instability
● Titration of vasoactive drugs
● Frequent blood sampling
● Respiratory failure including respiratory failure due to
severe asthma or pulmonary edema
● Morbid obesity (unable to fit an appropriately sized
NIBP cuff).
Calibrating (zeroing) the arterial line has specific steps.
First, ensure the transducer pressure tubing and flush solution
are correctly assembled and free of air bubbles. Next, place
transducer at level of the right atrium, make sure it is off to
patient (open to air), press zero – this sets atmospheric
pressure as zero reference point and whenever patient position
is altered the transducer height should be altered. There are
multiple conditions that must be met to ensure accuracy. First,
make sure cannula is properly placed within the lumen of an
unobstructed artery (i.e. No spasm, thrombus, atheroma
proximal to cannula). Make sure cannula is not kinked or
obstructed, cannula connected by short, rigid, wide-bore tubing
to the transducer, no air bubbles in tubing or transducer,
interface from fluid to transducer accurately transmits
deflections, transducer has adequate frequency response
(natural frequency >100Hz, transducer is leveled and zeroed to
desired point (i.e. left atrium), no zero drift and monitor
calibrated accurately.
There are multiple common sources of error. Look for
bubbles in catheter-transducer system – decreased resonant
frequency, clotting in arterial catheter, elastic walls causes
increased damping, and cannula won’t flush due to kinked or
clotted line.
An arterial line can measure much more than blood
pressure. Arterial lines can measure pulse rate and rhythm,
effects of dysrhythmias on perfusion, ECG lead disconnection,
continuous cardiac output using pulse contour analysis, specific
wave form morphologies that might be diagnostic, pulse
pressure variation and steeper upstroke of pulse pressure.
There are multiple complications associated with arterial
lines. Insertion is often painful; an anesthetic such as lidocaine
can be used to make the insertion more tolerable and to help
prevent vasospasm, thereby making insertion of the arterial
line somewhat easier. Aside from pain, other complications
include, thrombosis and distal ischaemia, infection, increased
diagnostic blood loss and anemia, retrograde air embolism,
inadvertent drug/air injection, haematoma, retroperitoneal
haematoma (femoral), bowel obstruction (femoral), vessel
damage may lead to stricture and prevent future AV fistula
formation for haemodialysis and pseudo-aneurysm.
Zeroing the arterial line helps to give the most accurate
reading possible. First, close off the line to the patient (so that
no air goes inside while zeroing) and then open the line up to
air. This allows the pressure reading to be set at atmospheric
pressure as your reference point for monitoring blood pressure
or central venous pressure. Having an accurate atmospheric
pressure helps to ensure the accuracy of your reading. Let’s
look at steps for zeroing….
● The spot where the zeroing takes place is at the
transducer. Start by turning the stopcock (white part
of the transducer) off to the patient. This blocks air
from getting into the patient while zeroing.
● Take off the cap on the transducer (the clear cap
behind the stop cock). Some of these already have
holes in them which would mean that you don’t have
to take it off. Make sure that you keep the cap end
sterile. You don’t want to introduce any kind of
bacteria into the pressure line.
● Press the “zero” button on your monitor. Wait for it
to zero the line. This typically takes about five
seconds.
● Place the clear cap back on the transducer.
● Turn the stopcock back upwards (this would be
turning it 90 degrees to the right). This allows the
pressure line to actually monitor the pressure.
How to draw blood sample from an arterial line

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1. Use aseptic technique
2. Remove sterile cap from unused port of the most proximal
of stopcocks to the insertion site. (Place cap in sterile
gauze).
3. Attach sterile syringe (3ml).
4. Turn stopcock off to flush solution and on to patient.
5. Gently withdraw 3 ml of blood (to clear line of heparin
solution and possible clots).
6. Turn stopcock off to all three ports.
7. Remove syringe and discard.
 8. Place a second sterile syringe on stopcock (should be
heparinized if for ABG analysis). To heparinize a syringe
(many syringes are pre-heparinized):
a. Use aseptic technique
b. Withdraw 0.5 ml of 1:1,000 Na heparin with a sterile
syringe.
c. Coat inside of syringe with heparin.
d. Expel excess heparin.
9. Turn stopcock on to patient.
10. Withdraw desired amount of blood.
11. Turn stopcock off to sample port on to patient.
12. Remove syringe (if for ABBG analysis: remove air bubbles,
cap, rotate to mix with heparin, label and place on ice).
13. Flush system for 1-3 seconds.
14. Turn stopcock off to patient and on to sample port.
15. Flush sample port (collect fluid with a sterile gauze).
16. Turn stopcock off to sample port and back on to patient.
17. Replace sterile cap.
18. Resume IV flow.
Note: Newer closed systems allow collection without opening
to the air.

Removing Arterial Line

When removing the arterial line, gather necessary removal
equipment. You will need non-sterile gloves, sterile gauze,
surgical tape, small sterile plaster (if required), stitch
cutter. Loosen all dressings, cut retaining suture if present and
withdraw the line from the artery without applying
pressure. Using the sterile gauze immediately apply pressure
for up to five minutes or until bleeding has stopped. Make sure
to observe the site regularly for bleeding every five minutes for
the first minutes, then every hour. Insure that the patient does
not have any numbness or tingling in the area.

Overall, arterial line placement is considered a safe procedure,

with a rate of major complications that is below 1%. It is not
entirely without risks, however, and it requires appropriate
knowledge of the anatomy and procedural skills.
 References
● Gardner RM. Direct blood pressure measurement-dynamic response
requirements. Anesthesiology. 2015 Mar;54(3):227-36. PubMed PMID:
7469106.
● Gershengorn HB, Wunsch H, Scales DC, Zarychanski R, Rubenfeld G, Garland
A. Association Between Arterial Catheter Use and Hospital Mortality in
Intensive Care Units. JAMA Intern Med.2014 Sep 8.
● McGhee BH, Bridges EJ. Monitoring arterial blood pressure: what you may
not know. Crit Care Nurse. 2002 Apr;22(2):60-4, 66-70, 73 passim. Review.
PubMed PMID:1191944.
● Scheer B, Perel A, Pfeffer UJ. Clinical review: complications and risk factors
of peripheral arterial catheters used for haemodynamic monitoring in
anaesthesia and intensive care medicine. Crit Care. 2002 Jun;6(3):199-204.
Epub 2002 Apr 18. Review. PubMed PMID: 12133178.
● Ward M, Langton JA. Blood pressure management. Contin Educ Anaesth
Crit Pain (2007) 7 (4): 122-126.