Dr Tarun Bhatnagar

 Indications
 Preparation & Equipments
 Positioning
 Insertion
 Complications
 Mechanism of Action
 Troubleshooting
1.Continuous, beat-to-beat blood pressure
measurement.
- Hemodynamically unstable pts /ICU pts
requiring inotropic support
- Patients undergoing major surgery
2.Frequent arterial blood gas analysis
-pts with respiratory failure on ventilator
-severe acid/base disturbance.
Advantages of IBP measurement
 Continuous blood pressure recording
 Accurate blood pressure recording even
when patients are profoundly hypotensive vs
NIBP which is difficult or inaccurate
 Real time Visual Display
Disadvantages of IBP measurement
 Potential complications
 Skilled technique reqd
 Expensive
 The radial artery has low complication
rates compared with other sites.
 It is a superficial artery which aids insertion,
and also makes it compressible for haemostasis
 The ulnar, brachial, axillary, dorsalis
pedis, posterial tibial, femoral arteries are
alternatives.
 Allen’s test is recommended before
the insertion of a radial arterial line.
 This is used to determine collateral
circulation between the ulnar and
radial arteries to the hand
 If ulnar perfusion is poor and a
cannula occludes the radial
artery, blood flow to the hand
may be reduced.
 The test is performed by asking the
patient to clench their hand. The
ulnar and radial arteries are
occluded with digital pressure.
 The hand is unclenched and
pressure over the ulnar artery is
released. If there is good collateral
perfusion, the palm should flush in
less than 6 seconds.

The idea here is to figure out if the ulnar

artery will supply the hand with enough
blood, if the radial artery is blocked with
an a-line.
Arterial cannula
 Made from polytetrafluoroethylene (‘Teflon’) to
minimize the risk of clot formation
 20G (pink) cannula - adult patients
22G (blue)- paediatrics
24G (yellow) - neonates and small babies
 Larger gauge cannulae increase the risk of
thrombosis, smaller cannulae cause damping of the
signal.
 The cannula is connected to an arterial giving set.
 Arterial set.
- Specialized plastic tubing, short and stiff to reduce resonance, connected to a 500 ml
bag of saline.

 Saline bag
-500 ml 0.9% saline pressurized to 300 mmHg using a pressure bag, i.e. a pressure
higher than arterial systolic pressure to prevent backflow from the cannula into the
giving set.
-The arterial set and pressurized saline bag with 2500units Heparin incorporate a
continuous slow flushing system of 3–4 ml per hour to keep the line free from clots.
-The arterial set and arterial line should be free from air bubbles.
- The line is attached to a transducer.
-Do not allow the saline bag to empty
◦ –To maintain patency of arterial cannula.
◦ –To prevent air embolism
◦ –To maintain accuracy of blood pressure reading
◦ –To maintain accuracy of fluid balance chart
◦ –To prevent backflow of blood

 Transducer, amplifier and electrical recording

equipment.
-The transducer is zeroed and placed level with the heart.
 Tape and/or steri-strips
 An arm board or towel roll
 Opsite or Tegaderm cover dressing
 Local anesthetic (1% or 2% lidocaine ,lidocaine
cream)
 Suture material for femoral arterial line placement
(2.0 silk)
 Scissors
 Monitor cable for transducing arterial waveform.
 Benzoin solution
 1. Ensure that all preprocedure steps are
taken
 2. Assure that pressure tubing with
transducer is connected to bedside monitor.
 3. Perform the Allen’s test to assure
adequate collateral blood flow if using the
radial artery.
 4. Wash hands and don gloves
 5. For the radial artery, the arm is
restrained, palm up, with an
armboard to hold the wrist
dorsiflexed
For the radial artery, the most
common insertion, the arm is
restrained, palm up, with an
armboard to hold the wrist
dorsiflexed
 5. Apply anesthetic agent (local lidocaine 1-2% or lidocaine cream).
 6. Locate pulsating artery via palpation.
 7. Cleanse area selected for arterial line placement.
 8. Prepare patient for puncture.
 9. Stabilize artery by pulling skin taut.
 10. Puncture skin at 45-60 degree angle for radial artery; 90
degrees for femoral artery.
 11. Advance catheter when flash of blood is observed in catheter.
 12. Connect to pressure I.V. tubing and check for arterial
waveform on bedside monitor.
 13. Cleanse area of any blood and allow site to dry.
 14. Apply Benzoin to cleansed area and allow to dry and become
“tacky.”
 15. Secure arterial line with tape and cover with a Tegaderm
dressing.
 16. Secure I.V. tubing to prevent it from being caught and
pulling on arterial catheter. If a femoral arterial line is placed, it
should be secured with a suture.
 17. Properly dispose of the I.V. sharps and other used materials.
 1. Direct cannulation

 2. Transfixation

 3. Guidewire (Seldinger)
technique
 Haemorrhage may occur if there are leaks in the system.
Connections must be tightly secured and the giving set and line
closely observed..
 Emboli. Air or thrombo emboli may occur.
Care should be taken to aspirate air bubbles
 Accidental drug injection may cause severe, irreversible damage
to the hand.
-No drugs should be injected via an arterial line
- The line should be labelled (in red) to reduce the likelihood of this
occurring
 Arterial vasospasm
 Partial occlusion due to large cannula width, multiple attempts
at insertion and long duration of use
 Permanent total occlusion
 Sepsis or bacteraemia secondary to infected radial arterial lines is
very rare (0.13%);
-local infection is more common.
-if the area looks inflamed the line site should be changed.
 –Concentration of a
drug into the tissues
served by the
cannulated artery can
result in cell death
 –Skin necrosis, severe
gangrene, limb
ischemia, amputation &
permanent disabilities
 Mechanism of action
 A transducer is a device that
reads the fluctuations in
pressure – it doesn’t matter if it’s
arterial, or central venous, or PA
 The column of saline in the arterial
set transmits the pressure changes
to the diaphragm in the transducer
 The transducer reads the
changing pressure, and changes it
into an electrical signal that goes
up and down as the pressure does
which is displayed as an arterial
waveform
 The transducer connects to the
bedside monitor with a cable, and
the wave shows up on the screen,
going from left to right
 The transducer has to sit in a “transducer holder” – this is the
white plastic plate that screws onto the rolling pole that holds
the whole setup.
 The transducer has to be levelled correctly-to make sure that it’s
at the fourth intercostal space, at the mid-axillary line
(Phlebostatic axis)
 Make sure there’s no air in the line before you hook it up to
the patient – use the flusher to clear bubbles out of the tubing.
 Zero the line to atmospheric pressure properly
 Choose a screen scale that lets you see the waveform clearly.
 To ensure accuracy of readings
 Flush the device & turn it off to patient but
open to atmosphere
 These exert pressure on transducer
 This pressure is called zero
 Zero once per shift or if values are questionable
 Ensure flush bag is pumped up
 Once inserted, an
arterial waveform
trace should be
displayed at all times
 This confirms that
the invasive arterial
BP monitoring is
set up correctly, and
minimizes problems.
:
 The highest point - systolic
pressure,
-the lowest is the diastolic.
Everybody see the little
notch on the diastolic
downslope? – there’s one in
each beat.
 A little after the beginning of
diastole – the start of the
downward wave – the aortic
valve flips closed, generating
a little back-pressure bump:
called the “dicrotic notch”..
 Now we know how the arterial pressure
monitoring system works, we need to be able
to decide whether or not the trace (and
BP in numerical format) is accurate.
 Failure to notice this may lead to unnecessary,
or missed treatments for our patients.
 There are 2 main abnormal tracing problems
that can occur once the monitor gain is set
correctly.
 Dampened trace
 Dampening occurs due to:
◦ air bubbles
◦ overly compliant, distensible tubing
◦ catheter kinks
◦ clots
◦ injection ports
◦ low flush bag pressure or no fluid in the flush bag
◦ Improper scaling
◦ Severe hypotension if everything else is ruled out
 This type of trace Under estimate SBP, over
estimate DBP
 Resonant trace
 Resonance occurs due to:
◦ long tubing
◦ overly stiff, non-compliant tubing
◦ increased vascular resistance
◦ reverberations in tubing causing harmonics that
distort the trace (i.e. high systolic and low diastolic)
◦ non-fully opened stopcock valve
 This type of trace
 Over estimate SBP, under estimate DBP
 Arterial lines measure systolic BP
approximately 5 mmHg higher and the
diastolic BP approximately 8 mmHg lower
compared to non-invasive BP (NIBP)
measurement
Troubleshooting
 “It takes a year just to learn which way to
turn the stopcocks!”
This is really true: some stopcocks point to where
they’re open, and some point to where they’re closed
– it just takes some time to learn which is which.
 The trick is remembering which way to turn the
stopcock, and avoiding a mess.
 Don’t forget to clear the stopcock, recap, and then
flush the line.
 Keep things nice and sterile.
 This probably means that the artery being
monitored or gone into spasm.
 You need to think about things that might make
this happen:
-Is the patient very cold?
-Are his extremities poorly perfused?
-Is he on a “shipload” of pressors, making his
arterial bed tighten up –
- Is he “dry” as well?
 Sometimes arteries become unhappy with catheters
in them, and you just have to convince the team
that the patient needs a new one placed in
another site.
 The first thing to think about is:
1.Is the arterial catheter still in place? Yes? Try
drawing with a 3cc syringe from the stopcock – if it draws
normally, then you’ve got a hardware problem
2.Cables become loose?
3.Did the screen scale get accidentally set to, say,
40, instead of 150 or 200mm of pressure?- you’ll only see
a flat line.

4.Is it a transducer setup Failure – try a new setup.

 If the line doesn’t draw –

-Is there a clot in the hub?
-Try taking the site dressing down – is the catheter
kinked going into the patient?
- Sometimes art-lines just fail – the artery spasms and
won’t open up – time for a new site.
 The routine now is 96 hours – make sure that
you label the line setup when you hang it.
Obviously, change the line setup if it is
contaminated in any way.
 Usually this will be pretty obvious:
the pulse will diminish, or go away altogether. The
hand may look dusky, or be cold, or lose some
sensation – remember to assess for coloring,
sensation, motion, and capillary refill.
 If you think that the a-line is threatening the
patient’s hand, let the team know right away,
and be ready to set up for another insertion
somewhere else if the line is still necessary.
 Compress the site with a sterile 4x4 for at least
5 minutes, or longer if the patient is
anticoagulated.
 Assess the perfusion of the hand.
 Make sure you put the patient on the non-
invasive cuff at meaningful intervals while
you talk to the team about replacing the line
 This is usually pretty obvious – the patient is
hemodynamically stable, needs only one or two
blood draws in a day, no more need for ABGs
 Disconnect the cable from the monitor which will
automatically turn off the alarms.
 Take out the sutures in the usual way with a fresh sterile
kit.
 Have a gauzepiece ready, pull the catheter, and manually
compress the site for at least 3 to 5 minutes.
 Make sure the patient’s hand is still perfused.
 Check for hematoma or bleeding, put a compression
dressing on the site (not too tight!), which you can then
take off after about an hour.
 Recheck the site hourly for a few hours afterwards – a
hematoma could still form, and since there isn’t a whole lot of
room in a wrist, you’d definitely want to know!
Any Questions ????
Thanks