Arterial Line Insertion and Removal

• Knowing the basics about arterial lines including how to evaluate your
waveforms is a necessary part to the management of a patient who has
one.
• That said, the time will come for you to either place a new one for your
patient, or the time to remove one when it’s no longer needed.
• These are important waypoints in the continuum of care for a patient
with an a-line, so in this lesson, I’m going to cover just that!
• (Intro)
• In this lesson, we are going to focus on some important information
when it comes to placing a new a-line or removing one that’s no longer
needed. I will attempt to cover some important topics in this discussion
that will hopefully give you the knowledge and tools needed when these
situations arise, which they will frequently!
• Sites
o To start off, I want to talk about the different sites that we have
available for use for arterial catheters. This is going to be the most
commonly used.
o Radial artery
§ This is going to be the most common and often preferred site
for placement.
• This is primarily because of the maximum amount of
mobility that is available for a patient with a line placed
here.
o The only real restriction to movement is going to
be of the hand and wrist on the side where the
line is placed.
• It does also provide the best location for bleeding
control, except for maybe 1 other.
 • We also have the benefit of collateral circulation to the
hand via the ulnar artery.
o It is important to check this collateral circulation
prior to placing a radial a-line, which I will talk
about in just a minute here.
o The benefit here, is that if a thrombus or
hematoma develops that impacts blood flow
distal, or if the catheter size itself impedes flow in
this vessel, we have the collateral circulation to
continue to provide needed blood to the hand.
• Another benefit comes from the distal pulse
amplification that I talked about in the previous lesson.
o We will still see some effect from this, but
compared to most of the other sites, we will have
pretty minimal changes to our waveform giving us
more accurate SBP and DBP numbers.
§ Despite these advantages, there are some risks with this
location.
• There are a few nerves in the area that are at risk for
damage.
• Because of the smaller size compared to others,
vasospasm during insertion can come up.
o Femoral artery
§ This location is probably the 2nd most common location.
§ The femoral artery is our go to during and emergency.
• It is a big artery close to the surface.
• It is easily palpable.
• Given these facts, it makes it very easy to place quickly
and/or when the patient’s blood pressure (or lack
thereof) would make the other locations next to
impossible.
• It does unfortunately have some problems.
o First has to do with mobility.

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 § These patients will not be able to sit up and
will have to remain flat and cannot move or
bend that leg.
• Reverse trendelenburg will need to be
used for VAP prevention.
o Second would be bleeding control.
§ It is not easy to get control of bleeding in
this area.
§ It requires firm direct pressure for an
extended time (usually at least 15 mins, if
not longer)
§ It is also not easy to know if the bleeding
has stopped as they could develop a RP
bleed which is often not visually noticeable
externally.
§ As mentioned in the first video in this
series, because these are often placed in an
emergency, transection of the artery can
happen, leading to either hematoma and/or
RP bleed.
o Third, these lines are the highest risk for
thrombosis.
o Finally, infection is a greater risk for these lines.
§ They are very close to the perinium which
can lead to contamination and infection.
§ Again, because these are often placed in an
emergency, the cleanliness of the insertion
and site and subsequent dressing may be at
risk.
• In these cases, we really want to get a
new “clean” line placed within 24
hours.

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 o This is not always possible, but
usually can be done.
§ Brachial/Axillary artery
• There are a few benefits to choosing this location.
o First is it being a pretty large artery, making it
pretty easy to place.
o Also, given its location, it still remains relatively
easy to control bleeding, much like with a radial
line.
o Lastly, the arterial line waveform that we see is
going to have the least effect of distal pulse
amplification seen, making it the closest to our
central aortic pressure.
• As you would guess, this does have some risks.
o This location is the next greatest risk for
thrombosis behind the femoral site.
o We also have limited collateral circulation here,
so if a major thrombus forms, we potentially
compromise blood flow to the whole arm.
o Lastly, because of its location, mobility for the
patient’s entire arm is going to be restricted.
§ Although they would be able to freely move
their wrist and hand.
§ Dorsalis pedis artery
• A pedal a-line is certainly the least common on these
sites.
• It is often a last resort when placing a non-emergent a-
line, although usually used before a femoral especially
in more awake patients.
• In practice, I have not found these lines to last very long
though, making trying to keep them going a key goal.
• There are some advantages to them.

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 o Just as with radial lines, they are pretty easy to
control bleeding from.
o They sometimes are less susceptible to
movement in the foot but can contribute to the
line not lasting as long.
§ Once you start having trouble with them
though, they can become very positional
and need the “perfect” foot placement to
get a good reading.
o They also have good collateral circulation.
o Limited mobility restrictions as we tend to restrict
movement of just the foot and ankle.
• Some of the risks are
o The limited time that it may remain functional,
requiring close care of the site.
o Due to their location, they experience the
greatest impact to our pressure wave and thus
SBP and DBP readings.
§ Again, due to distal pulse amplification.
o In older adults, PAD is often a concern and most
often effects the arteries of the distal legs,
leading to inaccuracies in our readings.
o Diabetic patients we would really try to avoid
using this location as well.
§ Finally, there ARE other locations, but in practice, this are the
most commonly used ones.
• Allen test
o When I was talking about the collateral circulation of the radial
artery, I mentioned that it is important to check for this.
o The way that we do this is with the “Allen test”
o This test is a quick easy way to check for collateral circulation in the
hand.

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 o We often will just preform what is called the modified Allen test,
where we will just check the circulation of the collateral artery.
§ In most cases, this is the ulnar artery, as most often we will
cannulate the radial artery.
o This test works best, when the patient can participate, but can also
be done for the unconscious patient.
o Steps (*video*)
§ Occlude both the radial and ulnar arteries.
§ Wait until blanching of the hand is present.
• This can be sped up and improved if the patient can
repeatedly clench and open their fist.
§ Once blanched, release pressure on the collateral artery
(again usually the ulnar)
§ We should see flushing of the hand fully in 5-15 seconds.
• If its longer than this, then they would fail the test.
o This would mean that adequate collateral
circulation does not exist, and we should test the
other hand.
§ Make sure the hand isn’t hyperextended which can give a
false negative.
• Insertion
o I am going to quickly review this section as this is not intended to
cover “how” to insert a catheter.
o What catheter to use?
§ When it comes to choosing which arterial catheter, this is
going to vary based on the insertion site.
§ Size
• We typically use either 20g or 18g catheters
o 18g is often reserved for larger arteries
o The average radial artery has a cross-sectional
area of 3.8mm2
§ 18g has a cross-section area of 1.26mm2
taking up 33% of the lumen.

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 § 20g only has a cross-section area of
0.63mm2 making it only 16% of the space
• Length
o When cannulating either the brachial/subclavian
or femoral, we want to use a longer catheter.
o Usually, we want one that is 15cm or longer.
o The direction of the cannula will be inserted against the blood flow,
so pointing more proximal to the insertion site.
o Ultrasound guidance can be helpful in placement in some locations.
§ Typically for femoral access, there are very clear palpable
landmarks.
§ Have this easily available if needed
o Sometimes a local numbing agent such as 1% lidocaine is used prior
to insertion.
o Ensure that you have a primed and ready pressure tubing set, a
dressing, biopatch, and additional tape.
o Sterile procedure.
§ Do we treat arterial line insertion like a central line?
• The is much debate on this topic.
§ At a minimum, CHG scrub, sterile gloves, and masks should be
used.
§ Some hospitals and providers treat this the same as central
lines, using gowns, drapes, and caps as well.
o Once the cannula has been inserted be prepared to quickly attach
the prepared tubing and ensure we have a good reading and
waveform.
o Securement
§ Oftentimes, our arterial catheter will be secured with sutures.
§ We do also have stat-lock devices that can be used.
§ We want to be extra secure in our setup and tubing.
• If a radial line is used, it helps to wrap the tubing down
and around the thumb, using additional tape to secure
it.

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 • For other lines, make sure that you have tape securing
the tubing more distal from the catheter.
o The point of this is so that if something happens
and the tubing is pulled, this will pull on the tape,
or break free first, before pulling on the line itself.
§ This obviously can end up bad.
• Removal
o Alright, now that we have talked about insertion, let’s talk about
removal.
o There are a few reasons that we would remove an arterial line
§ First and most commonly, is that it’s no longer needed.
• If you remember from the first lesson, I talked about
the reasons why we would use an arterial line.
• Well, if those reasons no longer exist, we should
discontinue the line.
§ Neurovascular compromise
• There can be multiple causes here, but if our patient’s
circulation is compromised, we need to remove the line
quickly.
§ Bleeding at site/hematoma
§ Infection/sepsis
§ Failure (broken system, lost waveform)
o Steps to remove
§ First, make sure you have an order to discontinue the
catheter.
§ Prior to removal, make sure and check coags and platelets.
• This is especially true for femoral lines but should be
done before any removal.
• For any abnormal values, discuss with the provider.
• We don’t necessarily need normal coagulation, but we
may need to apply pressure longer as well as ensure
more frequent monitoring a little longer.

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 o This all varies by facility so make sure you know
your policies and discuss with the provider.
• You may need to give blood products, reversal
medications, or hold anticoagulants.
§ The removal of the catheter is simple and straight forward.
• Remove the dressing
• Remove any sutures if present, otherwise disconnect
from stat-lock.
• Place a stack of folded 2x2s or 4x4s over the insertion
site and apply slight pressure.
• Smoothly remove the catheter.
o Remember the longer lengths used for femoral
and brachial lines
o Stop if any resistance is met and contact provider.
• As the end of the catheter is removed apply more
forceful direct pressure.
o For femoral lines, due to the angle of insertion,
the hole in the artery will be 1-2” above
(proximal) the skin insertion site.
o Hold direct pressure for at least 5 minutes for the
radial/pedal and 15 minutes for brachial/femoral
§ Longer times may be needed if
coags/platelets are not normal.
§ Once direct pressure is released, stay in the room and over
the next couple minutes make sure that no bleeding occurs.
• If it does, repeat holding direct pressure.
§ After removal, we will want to ensure frequent monitoring
for a period of time.
• Your hospital policy will govern this.
• A good example would be Q5min x 3, Q15m x3, then
hourly.
• We want to be checking for bleeding, hematoma,
bruising, and distal pulse/blood flow.