DIRECT ARTERIAL PRESSURE MONITORING
Direct arterial pressure monitoring is preferred whenever haemodynamic instability exists or is
expected to occur perioperatively. In such situations, invasive measurement enables beat to beat
monitoring of arterial pressure. A cannula is inserted into an artery and connected to a pressure
transducer.
The monitor displays beat to beat blood pressure both numerically as well as graphically.
Sites
• Radial artery: Most common
• Dorsalis pedis artery: When radial arteries are inaccessible or they have already been used.
Femoral artery: If the peripheral circulation is sluggish, blood pressures are too low and the radial
arteries are not felt, cannulation of brachial or femoral arteries may be considered. However, these
sites should be changed to more peripherally placed catheters as early as possible to avoid
complications such as distal ischaemia.
• The distal circulation must be assessed periodically by capillary refill time, colour of the digit, nail
bed, pulse oximetry, etc.
What information is obtained?
The invasive arterial pressure monitoring provides the following information
• Systolic, diastolic and mean blood pressures
• Heart rate and rhythm
• Contractility: The upstroke of the arterial waveform is steep if the heart has good contractility.
• Preload: The systolic variation in arterial pressure > 10% with respiration indicates hypovolaemia
Afterload: The dicrotic notch is lower on the downstroke, of arterial waveform when afterload is
reduced.
What size cannula?
• A 20-gauge cannula may be used for the radial, brachial Or dorsalis pedis arteries in adults.
• A long 18 gauge non kinking cannula is preferred for femoral arterial lines in adults.
• A 22-gauge cannula in children.
Complications
• Ischaemia distal to cannula: Normally collateral circulation is adequate to maintain perfusion distal
to the arterial cannulation site. Occasionally ischaemia may occur when associated with low cardiac
output, sepsis, shock, high-dose vasopressors or vasculitis.
• Exsanguination: In case of accidental disconnection, blood loss of up to 500 ml/min can occur
(through 18 G cannula)
• Spurious result: Wrong position or calibration of transducers
• Infection
Arterial line insertion, also known as an arterial catheter, is commonly used in various clinical settings
for continuous blood pressure monitoring and frequent blood sampling. The primary indications for
arterial line insertion include:
1. Continuous Blood Pressure Monitoring:
o Critically ill patients, especially those in shock or with unstable hemodynamics.
o Patients undergoing major surgery, particularly cardiac or vascular surgeries.
o Patients receiving medications that affect blood pressure, such as vasopressors or
inotropes.
2. Frequent Blood Sampling:
o Patients requiring frequent arterial blood gas analysis (ABG) to monitor respiratory
status and acid-base balance.
o Patients with conditions requiring frequent blood tests, such as severe sepsis or
multi-organ failure.
3. Severe Cardiopulmonary Conditions:
o Patients with acute respiratory distress syndrome (ARDS), chronic obstructive
pulmonary disease (COPD), or other severe respiratory conditions.
o Patients with significant cardiac conditions, such as acute myocardial infarction or
congestive heart failure.
4. Monitoring During Critical Procedures:
o During high-risk surgeries or procedures where rapid changes in blood pressure are
anticipated.
o During procedures requiring precise hemodynamic monitoring, such as neurosurgery
or transplant surgery.
5. Hemodynamic Instability:
o Patients in the intensive care unit (ICU) with unstable blood pressure requiring close
monitoring.
o Patients in shock from various causes, including septic shock, hypovolemic shock, or
cardiogenic shock.
6. Patients with Poor Peripheral Venous Access:
o When peripheral venous access is challenging, an arterial line may be used to obtain
blood samples and monitor arterial blood gases
