Arterial Line

Equipment to obtain:

Nursing staff assist with:
- Setting up tubing with stopcock + transducer + flush.
- Obtaining 1% lidocaine without epinephrine.
Personal equipment: face mask, sterile gloves, sterile gown.
Procedural equipment:
- radial arterial line kit
- chlorhexidine swabs x2
- non-sterile towel (to anchor hand), tape
- surgical sterile towel x2
- sterile probe cover, sterile ultrasound jelly
- 5mL syringe, blunt tip catheter, 25+ gauge needle
- silk suture, needle driver, scissors
- sterile gauze, Tegaderm.

Keep ultrasound machine plugged into wall.
Linear probe: set to ‘procedure mode.’ Add center line.
Align ultrasound screen in position where head rotation not required to visualize arterial cannula and screen.
Place non-sterile jelly on linear probe, keep ready to use.

Perform modified Allen’s test (squeeze radial/ulnar artery + release ulnar = ensure good collateral blood flow to hand via ulnar).
Examine past medical history for contraindications.
Examine overlying skin over insertion site for burns/infection.
Obtain consent for procedure + describe risks/benefits to patient.
Complications to discuss with patient: Infection, hematoma, thrombosis, pseudoaneurysm.

Place patient hand on a side table + have ultrasound set up on same side of patient. Have nursing assistant in room + ensure arterial line tubing is ready.
Dorsiflex the hand to 30-60 degrees with a roll of gauze/towel. Tape hand to table.
Sterilize volar wrist with chlorhexidine swab.
Create a sterile working field on the table (i.e. with surgical towel). Empty supplies onto field (i.e. radial artery catheter kit, 5mL syringe, blunt tip catheter, 25+ gauge needle, suture + needle driver, scissors, gauze, Tegaderm).
Put on sterile gloves.
Obtain lidocaine 1% without epi from nursing colleague and draw up 5mL with blunt tip syringe, then prepare syringe with 25-gauge needle, ready for infiltration.
Apply sterile probe cover to ultrasound + add sterile jelly. Hold ultrasound with non-dominant hand + center artery on screen.

Inject 0.5 mL lidocaine on both sides of artery insertion site. Wait for lidocaine to take effect (i.e. 1-2 minutes).
Needle is inserted at 30–60 degree angle to the skin, insertion is around 3-5cm proximal to wrist crease. Hold needle with thumb + forefinger, bevel up.
Advance needle towards artery, then advance/fan probe to see needle tip. Continue advancing needle/probe to walk the needle towards artery.
Once in the artery + blood is returned in the hub, advance the guidewire through needle the into artery (go all the way past the black marking to the hub).
Drop arterial line angle to 10-15 degrees if having issues with advancing guidewire.
If resistance is felt at the black line of the arrow arterial catheter the tip of the needle may be outside the artery. Consider pulling wire back and ensuring there is still arterial flow in the catheter. If there is not consider adjusting angle of approach, if flow does not return attempt pulling back 1 mm to establish flow.
Advance catheter with firm rotation into the artery. Pause.
Remove wire/needle. Place finger over the catheter to prevent blood escaping.
Connect catheter to transducer (with nursing help) + check waveform.
Secure arterial line with sutures (wrap around hub) + apply dressing.
Regularly assess for extremity perfusion + document procedure.

Prcoedural steps written by: Muraile Vignarajah MD

Staff Reviewed by; Dr. Jason Erb (Anesthesiology, Critical Care).