ARTERIAL LINE - cont'd info

Indications for arterial catheter placement

Indications for Arterial Lines

  • Management of shock states
  • Management of hypertension in certain
  • Frequent arterial blood gas sampling
  • Need for frequent blood draws
    • Severe diabetic ketoacidosis
    • Severe hyponatremia
    • Severe hypernatremia

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Contraindications for arterial catheter placement

Contraindications to Arterial Line

  • 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

Complications of Arterial Line

Major Complications

  • Arterial thrombosis
  • Catheter embolization
  • Pseudoaneurysm
    (especially in femoral
  • Arteriovenous fistula
    (especially in femoral
  • 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

Technique for Radial Arterial Line

  • 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

Technique for Femoral or Brachial Arterial Lines

  • 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

Coding for Arterial Line Placement

36620 Percutaneous arterial line placement

76937 Vascular ultrasound