Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

SOUTHERN HEALTH & SOCIAL CARE TRUST

Guideline for Insertion and

Name of Procedure/Guidelines/
1 management of peripheral arterial
Protocol
cannulas in adult patients

To provide guidance on safe insertion

Purpose of Procedure/ Guidelines/
2 and management of peripheral arterial
Protocol
catheters in adult patients

3 Replaces New

5 Name & title of author Dr. Michael.J.Morrow FRCA MEd

Anaesthetics and Intensive Care

6 Specialty
Medicine

7 Division ATICS

8 Equality Screened by N/A

To all Southern Trust

9 Proposals for dissemination Anaesthetists/Intensivists/Acute sector
nursing staff/Midwives

10 Proposals for implementation With immediate effect

To be included in induction manual for

11 Training Implications
all Anaesthetists in training

Date Procedure/Guideline/ Protocol

12 June 2016
submitted

13 Date of next review June 2017

14 CG ID TAG CG0320

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

SOUTHERN HEALTH & SOCIAL CARE TRUST

Purpose
This Standard Operating Procedure (SOP) was designed for healthcare personnel
who insert and/or care for patients with arterial catheters in theatres, critical care
and high dependency units within the Southern Trust.
Prerequisites for this SOP are a working knowledge of basic cardiovascular anatomy,
physiology, and cardiovascular pharmacology.

Procedure Statement
The National Patient Safety Agency has recommended the development of
guidelines for the management of arterial lines (NPSA Rapid Response report 2008).
Patients may require arterial lines to monitor blood pressure (BP) trends both intra
and perioperatively, titrate drug therapies and obtain blood samples for arterial
blood gas analysis and laboratory studies.

To ensure that a patient receives optimal treatment, it is crucial that staff are aware
of factors that affect the safety and accuracy of arterial monitoring.
In addition, to ensure that the opportunity for blood stream infection is minimised
standard precautions must be followed.

Sections
1. Indications and Documentation
2. Contraindications
3. Insertion of Arterial Line
4. Transducer Set-up
5. Arterial monitoring
6. Calibrating the system
7. Dressing
8. Blood Sampling

General Principles and care

Potential Complications
Troubleshooting
References

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

1. Documentation of Clinical Need for Insertion:

Arterial lines and arterial blood gas sampling can be associated with morbidity and
rarely mortality therefore the clinical indication for the insertion of an arterial line
should be documented. The following situations are not exhaustive and clinical
judgement should be exercised at all times. If in doubt, consult a senior colleague.

Indications Situations Include Threshold for Insertion

Prolonged shock of any type Consider in all patients

Close monitoring of labile blood

Consider in all patients
pressure

Patients with existing or anticipated All ASA 4 and 5 patients.

haemodynamic instability where close
monitoring is required Consider in ASA 3

When vasoactive medications are

indicated and the response to such Consider in all patients
Continuous medications requires monitoring.
arterial
pressure Patients undergoing any major
measurement vascular, thoracic, abdominal or Consider in all patients
neurologic procedures or surgery

At anaesthetist’s
Controlled hypotensive anaesthesia
discretion

Cardiac dysrhythmias (causing/with

potential to cause haemodynamic Consider in all patients
instability)

Patients receiving intra-aortic balloon

Where appropriate
counterpulsation

Patients being transferred to other

Consider in all patients
units

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

Indications (Cont.)

Indications Situations Include Minimum Thresholds

Patients with significant pulmonary

system compromise requiring
Serial blood gas mechanical ventilation, or those
Consider in all patients
measurement who may have severe acid-base
imbalance requiring frequent
monitoring of arterial blood gases
Frequent estimation of other blood
Consider in all patients
chemistry
Patients undergoing thrombolytic
therapy for coronary, cerebral or
vascular occlusions (must be
inserted prior to initiation of
thrombolytic therapy) to allow for
Consider in all patients
continuous blood pressure
monitoring and to permit blood
collection for diagnostic laboratory
studies without the need for
venipuncture

Significant obesity where non-

Miscellaneous invasive methods are unreliable or Consider in all patients
impossible

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

2. Contraindications
There are few absolute contraindications to the use of arterial lines; however,
there are some relative contraindications. This means that the situations listed
below will increase the risk of complications when using an intra-arterial catheter.
This increased risk must be examined relative to the benefit that the patient will
receive in the form of more accurate assessments and interventions.

Absolute contraindications include the following:

 Inadequate circulation to the extremity

 Sepsis at the proposed insertion site
 Thromboangitis obliterans (Buerger disease)
 Reynaud’s phenomenon
 Full thickness burns at proposed insertion site
 Insertion sites where previous vascular surgery has been performed, or that
would involve 
catheter placement through vascular grafts or fistulae.

Relative contraindications include the following:

 Severe peripheral vascular disease in the selected artery

 Uncontrolled coagulopathy or bleeding disorders
 Current or recent use of fibrinolytics or anticoagulants causing an increased
risk of bleeding at the insertion site

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

3. Insertion of Arterial Line

Procedure to be performed only by appropriately experienced personnel.
There are two common techniques for siting arterial lines, the Seldinger technique
(over guide wire) and the cannula-over-needle technique.
Whatever method is chosen, the procedure should be performed in an aseptic
manner.

Equipment:
 Clean and dry dressing trolley
 Sterile dressing trolley drape
 Minor procedure tray
 5x sterile gauze
 Arterial Cannula (usually 20g or 22g for adult patients)
 2% Chlorhexidine in alcohol wipes or Chloraprep applicator
 1% Lignocaine for skin infiltration
 25g needle + 2ml syringe
 1x adhesive dressing
 Fenestrated drape
 Sterile gloves
 Transducer, single-use pressure bag and 500ml of Normal Saline
 Arterial identification labels

Preparation of Patient:
1. Explain procedure to patient.
2. Verbal consent should be obtained by the anaesthetist prior to performing
the procedure.
3. Position patient in bed as comfortably as possible with area to be used
exposed. (NB if a radial artery is to 
be used an appropriate support may be
used to hyperextend wrist to allow easier insertion).
4. The wrist is extended and the radial artery palpated as it runs over the distal
radius where it is most superficial. An absorbent pad should be positioned
underneath the arm, particularly if the Seldinger approach is to be employed.
5. The artery is punctured through the skin, with the needle inclined at an angle
of 15-30 degrees to the skin. Arterial blood should be seen to come out of
the needle. At this point the cannula may be advanced over the needle if
using a cannula-over-needle technique, or the guidewire advanced into the
artery if using the Seldinger technique.
6. The arterial line may then need to be secured with an adhesive dressing.
The ’transfixion technique’ of deliberately advancing the needle/cannula through
both sides of the artery and then withdrawing it again until blood flows up the
cannula runs the risk of causing a false aneurysm or a haematoma around the
artery and is not recommended.

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

Documentation:
The anaesthetist who performs procedure must document it in the anaesthetic chart
and/or medical progress notes. Nursing staff should document the procedure in the
care plan, noting the date and site of insertion, when next dressing and line change
are due and the planned date for removal.
The arterial line can remain in-situ for up to 7 days (unless signs of infection are
evident e.g. inflammation, unexplained pyrexia etc.). The site must be reviewed
regularly and findings must be documented in the patient’s progress notes.

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

4. Transducer Set-up
Rationale:
The arterial catheter is connected to the fluid filled tubing of the monitoring
system. The transducer creates the link between the fluid filled tubing system and
the electronic system converting a mechanical signal into a waveform on the
monitor. The transducer system must be set up correctly to ensure the accuracy of
the monitoring system. Transducers should be changed (minimum) every 3 days.
This change includes the transducer, associated lines and the flush solution bag
(unless empty)

Equipment:
 Hand hygiene must be performed prior to donning clean gloves (i.e. wash
with liquid soap or use alcohol hand rub)
 Gloves
 500 ml bag Normal Saline
 Pressure bag
 Transducer giving set
 Module and cable
 Monitor

Procedure:
 An appropriate red line connection should be used to clearly indicate that
the line is arterial.
 Only 500ml bags of sterile normal saline (0.9%) should be used for the
arterial line pressure transducer.
 Heparin should NOT be added to the saline solution.
 Although infusion bags will not have any additives such as heparin, they
must still be labelled. Labels should clearly identify contents of infusion
bags, even when pressure bags are used. Date and time of preparation and
name/signature of both the person preparing and the person checking the
infusion must be recorded on the label.
 Insert giving set into normal saline bag. (Keeping end sterile).
 Ensure all roller clamps are open.
 Prime line by squeezing fast flush device.
 Check all Luer connections are tightened and 3-way tap is turned off from
giving port.
 Ensure that all air bubbles are removed from system and that all parts are
primed with fluid. Air may cause damping of the system and inaccuracy of
monitoring.
 Place saline bag into the pressure bag and inflate to 300 mmHg.
 When the anaesthetist is ready, connect the transducer to the cannula.
 Connect transducer to cable and watch for trace on monitor.
 The arterial line must be clearly labelled with a red sticker .
 Zero and calibrate system.

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

5. Arterial Monitoring
The arterial pressure wave corresponds with the cardiac cycle.

Arterial systole begins with opening of aortic valve and rapid ejection of blood into the
aorta. This is the upswing on the arterial waveform followed by a downward turn.
A notch (dicrotic notch) is visible on downward stroke, which represents closure of the
aortic valve signifying the beginning of diastole.
The remainder of the downward stroke represents diastolic run off of blood flow into
the arterial tree. The QRS complex of ECG trace comes first and the arterial waveform
follows.

6. Calibrating the system (Levelling and Zeroing)

Rationale:
To ensure consistency and accuracy of the arterial blood pressure monitoring the
transducer must be positioned and calibrated regularly to an anatomically
consistent site.

This site is called the

phlebostatic axis.

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

Zeroing:
Zeroing is the method of calibrating the monitoring system so that the effects of
atmospheric and hydrostatic pressure are eliminated. Zeroing must be carried out
once per shift.
Preparation of patient:
1. Position patient on their back.
2. Patient may be positioned with the head of the bed elevated between 0-
60°.
3. Flush the system
4. Level transducer to phlebostatic axis (may mark this with an x on patient)
5. Turn stop-cock on transducer so that it is ‘off’ to the patient.
6. Remove cap
7. Press zero on the module
8. Ensure that zero appears on screen replace cap and turn stop-cock so that
it is open to monitoring 
and patient. 
NB: If patient is positioned on their
side the reference point will be different. It is difficult to identify true
phlebostatic axis. There may be a discrepancy in readings. If there is a
great variation when positioned on their sides. The patient should be
placed onto their back and a true reading obtained.

7. Dressing
Rationale: 

Infection at the arterial catheter site will be minimised.
Adhesive dressings should generally be left intact for up to 7 days, however if the
dressing is not transparent, then the insertion site should be carefully monitored
for signs of infection.

More frequent dressings should only be undertaken if there is a problem with

kinking of the line, leaking around insertion site or if the dressing is peeling off.

Equipment:
 Dressing Pack
 Sterile Gloves and personal protective equipment
 Transparent occlusive dressing
 Normal Saline (if visibly soiled or crustings are present)
 2% Chlorhexidine

Procedure:
 Wash hands (or use alcohol hand rub)
 Assemble equipment on dressing trolley
 Wash hands (or use alcohol hand rub)
 Carefully remove old dressing

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

 Wash hands and don sterile gloves/PPE

 Cleanse area with normal saline (if visibly soiled or crustings are present)
 Dry site with gauze
 Apply chlorhexidine and alcohol to insertion site and allow to dry
 Apply steri-strips (if necessary) to keep cannula secure
 Apply transparent dressing so that insertion point of cannula is in middle of
dressing 


NB. Transducer only needs to be changed if considered to be giving faulty

readings or if time in-situ is >3 days

8. Blood Sampling

Sampling from arterial lines is potentially risky and should only be carried out by
appropriately trained staff.

Equipment:
• 5ml syringe
• Sterile gauze
• Arterial blood gas sampling syringe
• +/- blood collection tubes
• Personal protective equipment (gloves, mask, goggles)

Procedure:
 Hand hygiene must occur before and after the procedure
 Suspend alarm on monitor
 Don personal protective equipment
 Remove cap from stopcock and attach 5ml syringe. Turn stop cock ‘off’ to flush
bag
 Withdraw 2-3ml of blood to clear line of saline
 Attach ABG syringe and withdraw sample
 Once specimen has been taken, turn stopcock ‘off’ to the patient, remove
syringe, cover 
the port with gauze and using the fast flush device, flush port.
 Replace cap
 Turn stopcock ‘off’ to the port and flush line ensuring that all blood is cleared
 Ensure alarm is turned on

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines
General Principles and Care of Arterial Lines
Procedure
Keep pressure bag inflated to
300mmHg
Flush bags of Normal Saline are
changed every 72 hrs. or as necessary.
All flush bags must be labelled with
time and date of commencement
Infusion bags must be labelled. Labels
should clearly identify contents of
infusion bags, even when pressure bags
are used. Date and time of preparation
and name/signature of both the person
preparing and the person checking the
infusion must be recorded on the label.
Do not add extra tubing or stopcocks to
system
All lines must be have rigid non-
compliant tubing
Periodically flick tubing system and
flush the tubing system
Fast flush solution after opening the
system for blood sampling and/or
zeroing
Immobilise arm and keep sites clearly
visible at all times e.g. On top of sheets.
Do not use a bandage over arterial line
site.
Date for Review: June 2017
January 2014
Rationale
Deflation of bag will result in retrograde
blood flow. Keeps line patent and
infuses 3-5ml /hr. Prevents dampening
of trace. Prevents clots
Infection control, keep bag sterile.
Ensures adequate flushing volume.
ONLY Saline 0.9% is to be used as an
infusion/flush solution. This must be
double checked and signed for on a
label applied to the infusion bag before
administration to prevent the use of
unsuitable solutions.
Extra areas of air entrapment, which
can cause inaccuracy of the arterial
trace.
Increase risk of infection
Eliminates any bubbles escaping the
flush solution.
Helps eliminate air bubbles. Clears the
line of blood
Safety measure to prevent adverse
events e.g. haemorrhage or
disconnection
Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

Troubleshooting

Problem Possible Solution

Difficulty with zeroing Check all equipment and connections

Does not reach ‘0’ waveform
Does not reach baseline
between patient and monitor.
Ensure all rollerclamps are open.
Check system for air bubbles and blood
clots.
Recalibrate.
Replace transducer, cable module,
arterial line

Unable to aspirate cannula Check line for kinks

Apply traction to cannula
Gently try to flush
Replace arterial line

Falsely high readings

Incorrect placement or transducer Check position of transducer


Uncalibrated system
 Re zero

Kinked cannula
 Remove kink

Dampened Remove air bubbles/ blood clots

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

Potential Complications

Problem Prevention Solution

Haemorrhage Keep limb visible at all Apply pressure to limb

times
Assess leak
Ensure alarms are on
If haemorrhage persists
Ensure that arm is contact medical staff
immobile

Ensure all connections are

tight

Infection Assess area regularly for Remove arterial line

redness or swelling
Ensure proper
Avoid interrupting circuit handwashing when
handling arterial line or
Use gloves when handling transducer
arterial line

Blockage Keep pressure bag inflated Attempt to aspirate blood

to 300mmHg to remove clot
Clotting
Attempt to aspirate blood Ensure all connections
are kept secure
Air emboli Use fast flush device to
clear line and to prevent
clot formation

Interruption to peripheral Regularly check distal Notify doctor and

circulation pulses and capillary refill consider removing
arterial line

The most common complications are temporary radial artery occlusion (20%), and
hematoma (14%) followed by infection at the arterial site (<1%), hemorrhage (0.5%) or
bacteremia (0.13%), and very rarely permanent ischemic damage or pseudoaneurysm
(0.09% each).
Local injury (e.g., intimal damage and proliferation) and scarring have been found even
after short-term catheterization.
Long-standing or permanent radial artery occlusion has also been described. In some

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

cases (particularly after vascular procedures) the radial artery occlusion may be
delayed several days of the procedure or removal of catheter.
Rare complications include paralysis of the median nerve, air embolism, compartment
syndrome and carpal tunnel syndrome. Rarely, intravascular catheter fragments have
occurred.
Larger catheter diameter, presence of vasospasm and female sex (probably related to
smaller vessel diameter) increase the risk of ischemic complications.
Inadequate experience placing catheters (high number of attempts, multiple arterial
sticks and hematoma formation) may also influence the complication rate.

Date for Review: June 2017

Standard Operating Procedure: Insertion and Management of Arterial Lines January 2014

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Webb RK, Currie M, Morgan CA, Williamson JA, Mackay P, Russell WJ, Runciman WB.
The Australian Incident Monitoring Study: an analysis of 2000 incident reports.
Anaesth Intensive Care. 1993 Oct;21(5):520-8.
Aherns T, Penick JC & Tucker MK (1995). Frequency requirements for zeroing
transducers in haemodynamic monitoring. American Journal of Critical Care; 4(6):
466-471.

Bridges EJ, Bond EF, Ahrens T, Daly E, Woods SL (1997) Ask the experts. Critical Care
Nurse; 17(6): 1 96-97.

Centre for Disease Control (2002). Guidelines for the prevention of intravascular
catheter-related infections. 51 (RR10): 1-26.

Courtois MA, Fattal PG, Kov·cs SJ, Tiefenbrunn AJ & Ludbrook PA (1995). Anatomically
and physiologically based reference level for measurement of intracardiac pressures.
Circulation; 92: 1.

Hudak CM, Gallo BM & Morton PG (1998) Critical Care Nursing; A Holistic Approach.
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Imperial-Perez F, McRae M (1999) Protocols for practice: Applying research at the

bedside. Critical Care Nurse; 19(2): 105-106.

Scheer BV, Perel A, Pfeiffer UJ. Clinical review: Complications and risk factors of
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intensive care medicine. Critical Care June 2002, Vol6, No3.

Bernsten AD, Soni N, Oh T E, 2003 Oh’s Intensive Care Manual 5th Edition p80-81
Butterworth Heinemann.

Date for Review: June 2017