Procedure: Radial Arterial Line

The Procedure

Hello again from the Emergency Procedures team,

Radial Arterial Line Insertion

Today we cover arterial line insertion, with a guide made in partnership with a recent publication in Emergency medicine Australasia. Thanks to Clare Armstrong, Ben Butson and Paul Kwa for their expert input.  

Armstrong C, Butson B, Kwa P. Clinical Procedures: Arterial line insertion. Emergency Medicine Australasia, 2023; 35: 142-7.

Detailed written instructions and explanation are available in our Free App (iOS and Android). This video is hot off the press and we want your help improving it. Drop us a line with any suggestions

So, without further ado…here is the video

The rationale…

Should I use always use ultrasound to place arterial lines?

Yes. Success is increased and complications (including infection) are reduced.

It is being used increasingly and is recommended in newer guidelines. It is certainly advisable in patients with predicted difficulty such as hypotension, absent radial pulse, obesity, previous failed attempts or when only a single site is identified. 

Should I use local anaesthetic?

Yes, always inject 1-2 ml of lignocaine 1%.

Multiple studies show subjective improvement in pain. A more comfortable patient is likely to reduce clinician stress and patient movement improving success rate. Lignocaine may also reduce the incidence of arterial vasospasm improving the size of the target vessel.  

Does it matter which way up I insert my needle?

Yes, probably it does.

Trial evidence suggests that first attempt insertion success in increased (72 – 84%) by inserting the needle bevel down rather than up. This is postulated to reduce posterior wall puncture and haematoma, by keeping the cutting point of the needle away from the vessel wall.

Does it matter which way I hold my ultrasound probe?

Yes, probably.  Trial evidence suggest that in plane ultrasound methods increase first attempt success (51 – 76%). The tip is thought to be more easily lost (puncturing the posterior wall) in the out of plane approach.

Probably the out of plane approach is optimal if you have skill in and out of plane. Otherwise, we recommend the method with which you have most confidence.

Should I suture my line?

We prefer 2 Steri-Strips combined with an adhesive dressing and a wrist splint.

Thers is no clear evidence as to the best option.

6% of arterial lines are accidentally dislodged in the ICU so try to make sure it’s secure and consider your local institution guidelines.to guarantee line position.

Do I need to be Sterile?

“Sterile procedures” do not exist and the term is confusing. The correct term is Aseptic Non-Touch Technique (ANTT). Whether in the ED or the operating room we practise ANTT. We aim to reduce microbes to a level where they will not cause pathology by cleaning and disinfecting skin (“Sterile sites”) and then we only touching disinfected skin with sterile equipment (“Sterile parts”).

For an arterial line with a Seldinger set……..

The arterial line is sterile and may only touch skin that has been cleaned and disinfected (“sterile site”). Your hands need to touch the guide wire and the arterial line (“sterile parts”) so sterile gloves are needed. A guidewire is likely to flop about and might touch something dirty, so a sterile field is needed. If you think you might touch equipment, you should choose to wear a sterile gown.

ANTT is part of standard precautions along with hand hygiene, respiratory hygiene (always wear a mask for invasive procedures), PPE, Sharps injury prevention, cleaning and waste disposal.

How do I remove an arterial line?

Pull the line out and then place pressure on the site for 10 minutes either manually or with an appropriate dressing. Check the removed device is complete and monitor neurovascular observations (pulse, colour, temperature, sensation, and cap refill) for 15 minutes.

Are there any special considerations in paediatric patients?

Ultrasound and a paediatric Seldinger set are recommended to increase the chance of success.

If you don’t have a special set:

• Use a 24G cannula for children < 10 kg
• Use a 22G cannula for children 10 – 40 kg

Be aware that the complication rate in children < 2yrs is much higher (32%). You should only place an arterial line if it is necessary. 

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