ARTERIAL LINE - cont'd info

Indications for arterial catheter placement

• Management of shock states
• Management of hypertension in certain
  circumstances
• Frequent arterial blood gas sampling
• Need for frequent blood draws

• • Severe diabetic ketoacidosis
  • Severe hyponatremia
  • Severe hypernatremia

Contraindications for arterial catheter placement

• Insufficient collateral circulation from the ulnar artery
• Raynaud syndrome
• Thromboangiltis obliterans (Buerger disease)
• Overlying cellulitis or full thickness burns to area
• Major injury to the extremity
• Bleeding diathesis (relative contraindication)
• Coagulopathy (PT or PTT > 2x upper limit of normal)
• Platelets < 20.000

Complications of arterial catheter placement

Major Complications

• Arterial thrombosis
• Catheter embolization
• Pseudoaneurysm
  (especially in femoral
  location)
• Arteriovenous fistula
  (especially in femoral
  location)
• Catheter-related blood stream infection

“Minor Complications”

• Bleeding
• Hematoma

Equipment for arterial catheter placement

• 20 gauge radial artery catheter-over-wire kit or angiocatheter (radial arterial line)
• 18 or 20 guage femoral arterial catheter kit (brachial or femoral arterial line)
• Pressure transducer tubing
• Pressure transducer
• 4-0 silk suture
• Arm board
• Tape
• 1% lidocaine without epinephrine for skin anesthesia
• Ultrasound and sterile probe sheath and gel for ultrasound-guided arterial lines

Proper positioning and technique for arterial catheter placement

• Informed consent
• Perform a “Time out” procedure to confirm correct patient, site and procedure
• Make yourself comfortable
• Use an arm board with wrist extension 45 degrees for radial arterial line placement
• Wear a clean surgeon’s cap and mask and a sterile gown and gloves
• Wide sterile prep of the procedure area with chlorhexidine
• Wide sterile drape of the procedure area
• Consider using an ultrasound with in-plane technique
  – Increase first pass success rate and decrease hematoma rate
• Landmark technique: radial artery is palpated ~2 cm above the wrist crease
• Use lidocaine without epinephrine around artery (minimizes arterial vasospasm)
• Take your time locating the maximal impulse
• Your first shot is your best shot
• Advance needle at a 30-45 degree angle until arterial flash seen
• Decrease the angle of the needle taking care not to displace the needle tip from the artery
• Advance wire through needle (radial arterial line kit) or catheter over needle (angiocatheter)
• Advance catheter over wire if using a radial arterial line kit
• Remove wire and needle leaving catheter in place
• Attach pressure transducer tubing to catheter hub
• Secure catheter in place with suture
• Place a clear, sterile dressing over insertion site

• Use a femoral arterial line kit as the radial arterial catheter is often too short
• Use an ultrasound for brachial artery or femoral arterial line placement
• Real-time ultrasound guidance requires a sterile sheath and ultrasound gel
• Brachial artery typically cannulated about 5 cm above the elbow
• Femoral artery typically cannulated 2-3 cm below the inguinal crease
• Modified Seldinger technique utilized to place brachial or femoral arterial lines
• Secure catheters in place with suture as above
  

Arterial catheter troubleshooting

• Over-damped waveform (Flattened waveform):
  – Check set up for air in tubing (flush line), kinks in tubing or catheter
  – Check to assure pressure bag is fully inflated
  – Check to assure no WHITE caps left in the set up
  – Check to assure all of the connections in the system are screwed on tightly
  – Check to assure the set-up is levelled correctly
  – Check to assure the scale is correct on the monitor
• Under-damped (“fling” in waveform):
  – Check set-up for air and flush all air out of tubing
  – Remove extra tubing or extra stopcocks
• No waveform

– Assure that tubing is connected to the patient

– Assure that proper cables are connected to monitor screen

– Assure that system is able to flush and zero properly

– Assure that the blood can be withdrawn from catheter

Coding for arterial catheter placement

36620 Percutaneous arterial line placement

76937 Vascular ultrasound