image by: Dr Sandip Mukhopadhyay

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Learning to do Arterial Lines

Arterial Lines are fun. They sometimes can be as easy to do as a canula. Other times they can be very tricky.

The importance of an arterial line can not be overstated. It's one of those things that strictly speaking is never "necessary", but always good to have. No treatment is given via an arterial line, and thus sometimes in ED we skip this out because we're too busy. But it makes looking after critically unwell patients so much easier and more efficient. Learning how to do arterial lines quickly makes a world of difference in a resus.

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 Hemodynamic access for the crashing patient: The dirty double

Currently I begin by placing two catheters in the femoral artery and vein, immediately next to each other. This may be done using a single sterile field. The central venous catheter is placed first because it is generally more important. In highly acute situations, a nurse may attach extension tubing to the central line and start using it immediately (prior to inserting the arterial catheter). This will compromise the sterility of a portion of the sterile field, which can then be covered with a sterile towel. These lines are placed with the intention that they will be “dirty” lines which must be removed within ~24 hours. They are placed using sterile gloves, a mask, and a sterile sheet but without full sterility.

Articles of Interest

A-lines in septic shock: the wrist versus the groin

Intuitively it might seem that the femoral arterial line is a more invasive procedure that should be associated with greater complications. However, available evidence suggests that the femoral A-line is a safe procedure, with a similar complication rate compared to radial A-lines. Furthermore, meticulous placement with full sterility and ultrasound guidance makes the femoral A-line procedure safer today than it has been historically. Instead of running away from this procedure, we need to learn how to perform it safely.

Arterial Line Placement

The radial artery is the most common location for arterial line placement because it is readily accessible and has a low complication rate. The femoral artery is also a common insertion site and is often the vessel of choice for severely hypotensive or coding patients because of its larger caliber.

Arterial Line Placement -Radial (w/out US)

Approach to arterial line placement without ultrasound

Arterial Line Placement: Basics for Medical Students

Arterial puncture and cannulation, also known as arterial line placement or “a-line,” is commonly performed in the ED to allow for continuous blood pressure measurement and frequent arterial blood gas sampling. Generic arterial line kits include separate needle and wire components, as would be used to place a central line. However, the following guide covers fundamental knowledge for the commonly utilized all-in-one (Seldinger type) radial artery kit.

Critical Device Series: Arterial Lines Tips and Tricks

A-line placement can be performed blind or via ultrasound guidance. After learning the basic steps for arterial line placement, this guide will serve as an advanced tips and trick resource to ensure your arterial lines can be placed effectively and efficiently.

Damping and Arterial Lines

So back to our original question how accurate is the arterial pressure on the monitor for our patient? This is an underdamped waveform most likely from catheter whip. This means the pressures we were seeing most likely overestimated the systolic blood pressure and underestimated the diastolic blood pressure.

How To Get An Arterial Line On The First Stick

Often when we really need an arterial line, the radial pulse is hard to palpate due to hypotension. Placement by palpation is technically challenging and time consuming. Yet, arterial line placement is a common ED procedure. Is there a way to increase success, reduce complications, and improve efficiency when placing arterial lines? Ultrasound for the win!

Just-in-Time Training for Emergency Medicine Radial Arterial Line Placement

While this article may be read in entirety, the piece is intended to focus on the specific microskills of arterial line placement. As the teacher or learner, identify specific microskills from the procedure that have proven difficult and focus on these subsections. Success of the entire procedure will come from focused mastery of the individual microskills.

Procedures » Arterial Line

The needle was introduced into the radial(?)femoral artery and appropriate blood return was obtained. The wire was advanced and the catheter was threaded over the wire and needle and wire were removed. The catheter was attached to the BP monitor and good waveform was shown. The catheter was then sutured in place. Blood loss was minimal.

Ultrasound vs Landmark-Guided Palpation for Radial Arterial Line Placement

In this study of novice emergency physicians, ultrasound-guided radial arterial line placement had a better first-pass and overall success, while minimizing attempts and complications compared to a landmark-guided palpation technique. This study shows that ultrasound guided arterial line placement is safe and more efficient approach to radial arterial cannulation.

Unlocking Common ED Procedures – Under Pressure: Arterial Lines in the Emergency Department

Arterial lines are commonly used in the ICU and OR, where patients often require close monitoring. However, adoption of this technique in the ED is far from universal.

“How To Place An Intra-arrest Femoral Arterial Line” From EmCrit 332 With Links To Additional Resources

So you go down the common femoral vessels to where they split into the deep and superficial vessels and then you enter the common femoral vessel two centimeters proximal to the branch point.

Resources

EM Fundamentals

Trainees will demonstrate competence in performing arterial line placement.