Arterial Line

Cindy E. BoomCindy E. BoomNational Cardiovascular CenterNational Cardiovascular CenterHarapan Kita, Jakarta 2007Harapan Kita, Jakarta 2007

IntroductionIntroduction

Performed in 100% of all patients undergo cardiac surgery

Performed in 50-70% of all ICU patients

HistoricHistoricalal

1.Farinas (1941): aorta cannulation with urethral catheter introduced through a surgically exposed femoral artery.

2.Strain gauge manometer introduced (1947).

3.Peterson et al. (1949) described on-line arterial monitoring.

4.Seldinger (1953): percutaneous placement using a guidewire.

Indications for Arterial Indications for Arterial CannulationCannulation

1.Hemodynamic monitoring.2.Frequent arterial blood gas sampling.

3.Arterial administration of drugs.

4.Intraaortic baloon pump use.

Patient will require three or more measurements daily

EquipmentEquipment

1.An appropriate intravascular catheter.

2.Fluid-filled noncompliant tubing with stopcocks.

3.A transducer and dome.4.A constant flush device.5.Electronic monitoring equipment, consisting of a connecting cable, monitor with amplifier, oscilloscope display screen, and recorder.

Intravascular pressure changes are transmitted through

Hydraulic (fluid-filled) element

Transducer

Convert mechanical displacement

Proportional electrical signal

The major problems:

1. Inadequate dynamic response.

2. Improper zeroing and zero drift

3. Improper transducer/ monitor calibration (12-15)

Site Selection

The ideal artery has extensive collateral

circulation that will maintain the

viability of distal tissues of thrombosis occurs

The site should be:1.Comfortable for the patient2.Accessible for nursing care 3.Close to the monitor equipment4.No infection5.No disruption in the epidermal barrier

6.Larger arteries and catheters provide more accurate (central aortic)

Surgical cut down at any site is no longer recommended due to increased risk of complications, especially infection and thrombosis

Radial & femoral artery constitute more than 90% of all arterial catheterizationsFemoral artery is preferred siteLong term

cannulation

Brachial artery is not commonly used because

↓good collateral circulation

↑risk of distal ischemia

Axillary artery has

many attractive features

Radial Artery Radial Artery CannulationCannulation

Understanding of arterial anatomy

Modified Allen’s Test (1929); technique of diagnosing occlusive arterial disease

Fig. Anatomy of the radial artery. Note the collateral circulation to the ulnar artery thought the deep volar arterial arch and dorsal arch.

Fig: Palpation of the brachial artery. The arm Fig: Palpation of the brachial artery. The arm is fully extended at the elbow and the artery is fully extended at the elbow and the artery palpated in the antecubital fossa as palpated in the antecubital fossa as indicated. The brachial artery is then indicated. The brachial artery is then cannulated at this site.cannulated at this site.

Modified Allen’s Test

Compresses both radial & ulnar arteries

Patient clinch & unclinch the fist

Until pallor of the palm

One artery is then released

Time to blushing of palm note

Procedure is repeated with the other artery

Normal < 7 seconds (+ test)Equivocal 8 – 14 secondsAbnormal >= 15 (- test)

Fig: The Allen test is performed before cannulation of the radial artery to ensure adequacy of the ulnar and radial arteries and patency of the deep palmar arch. I. The examiner compresses both arteries while the patient repeatedly makes a tight firs to squeeze blood out of the hand. 2. After the patient relaxes the fingers, the examiner observes the waxen hand. The patient sholud be instructed not to hyperextend the finger and wrist because this may result in a false-positive test. J, Compression of the ulnar artery is released and the hand is observed for a blush or hyperemia. If color does not return within 5 to 10 seconds, radial artery cannulation should not be done. If brisk filling occurs, the test is repeated with the radial artery to test radial artery competency. If both vessels are competent, the radial artery may used for puncture. (From Schwartz GR, editor: Principles and practice of emergency medicine, Philadelpiha, 1978, W.B. Saunders.)

Percutaneous insertion

Modified Allen’s Test

-Hand plated 30º-60º dorsiflexion; with the aid of a roll of gauze and armband.

-Not to hyperabduct the thumb (obliterate the pulse).

Volar aspect of the wrist is steriled

Approximately 0,5 ml of lidocaine is infiltrated (through 25-gauge needle)

20-gauge; 30º-60º angle entry to skin approximately 2-3 inches proximal to the distal wrist crease

20-gauge; 30º-60º angle entry to skin approximately 2-3 inches proximal to the distal wrist crease

Needle & cannulation advanced until blood return is noted (signifying intrarterial placement of the tip of the needle)

A small amount of further advancement for the cannula to enter the artery as well

With this accomplished, needle and cannula are brought flat to the skin and the cannula advanced to its hub with a firm, steady rotary action.

Correct positioning is confirmed by pulsatile blood return on removal of the needle

The catheter can then be advanced into the arterial lumen

Brachial artery cannulation

Infrequently performed

The lack of effective collateral circulationExperience in the

use of brachial artery catheters

Have reported complication rates no higher than with other routes

Doppler studies

Fig: Cannulation of the radial artery. Fig: Cannulation of the radial artery. A. A towel is placed behind the wrist, and the hand is A. A towel is placed behind the wrist, and the hand is immobilized with tape. immobilized with tape. The radial artery is fixated with a 20-gauge angiocath The radial artery is fixated with a 20-gauge angiocath connected to a 5-ml connected to a 5-ml syringe (optional). syringe (optional). B. The angiocath is withdrawn until pulsatile blood return B. The angiocath is withdrawn until pulsatile blood return is noted. is noted. C. The trocar is withdrawn as the Teflon catheter is C. The trocar is withdrawn as the Teflon catheter is simultaneously advancedsimultaneously advanced..

Femoral Femoral Artery Artery

CannulationCannulationFemoral artery catheters are gaining wider clinical use

The femoral artery is large and often palpable when other sites are not

The technique of cannulation is easy to learn

Fig. Anatomy of the femoral artery and adjacent structures. The artery is cannulated below the inguinal ligament.

Complications of Arterial CannulationArterial cannulation

Relatively safe

Estimate of total complication rate range 15% - 40% For infectious and

noninfectious complications have been identified

Complications Associated with Arterial Complications Associated with Arterial CannulationCannulationSiteSite ComplicationComplicationAll siteAll site Pain and swellingPain and swelling

ThrombosisThrombosisAsymptomaticAsymptomaticSymptomaticSymptomatic

EmbolizationEmbolizationHematomaHematomaHemorrhageHemorrhageLimb ischemiaLimb ischemiaCatheter-related infectionCatheter-related infection

LocalLocalSystemicSystemic

Diagnostic blood lossDiagnostic blood lossPseudoaneurysmPseudoaneurysmHeparin-associated thrombocytopeniaHeparin-associated thrombocytopenia

Radial arteryRadial artery Cerebral embolizationCerebral embolizationPeripheral neuropathyPeripheral neuropathy

Femoral arteryFemoral artery Retroperitoneal hemorrhageRetroperitoneal hemorrhageBowel perforationBowel perforationArteriovenous fistulaArteriovenous fistula

Axillary Axillary arteryartery

Cerebral embolizationCerebral embolizationBrachial plexopathyBrachial plexopathy

Brachial Brachial arteryartery

Median nerve damageMedian nerve damageCerebral embolizationCerebral embolization

Factor Predisposing to Complications with Arterial Factor Predisposing to Complications with Arterial CannulationCannulationLarge tapered cannulas Large tapered cannulas (> 20 gauge except at the large artery sites)(> 20 gauge except at the large artery sites)

HypotensionHypotensionCoagulopathyCoagulopathyLow cardiac outputLow cardiac outputMultiple puncture attemptsMultiple puncture attemptsUse of vasopressorsUse of vasopressorsAltherosclerosisAltherosclerosisHypercoagulable stateHypercoagulable statePlacement by surgical cutdownPlacement by surgical cutdownSite inflammationSite inflammationIntermittent flushing systemIntermittent flushing systemBacteremia Bacteremia

Recommendations

Most centers have more experience with radial artery cannulation, but femoral artery catheters are reliable and have a comparable incidence of complication

Thank you