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Arterial Lines

Editor: Michael Keenaghan Updated: 1/19/2024 5:36:46 PM


Arterial catheterization is a routine and standard procedure in intensive care settings, emergency rooms, and the operating room. This procedure entails the insertion of a catheter into the peripheral artery lumen to facilitate a one-time or frequent arterial blood sampling to assess oxygenation and acid-base status, as well as for hemodynamic monitoring through the evaluation of various patterns of arterial waveforms. The German physiologist Carl Ludwig initially identified this type of waveform in 1847. The Seldinger technique, which employs a guidewire to facilitate the catheterization procedure, was introduced and has proven more efficient.

An arterial catheterization can be achieved via multiple anatomical sites with unique risks and benefits. However, practitioners must be mindful of procedural indications and contraindications, the proper preparation of equipment and personnel, and be skilled in insertion techniques. As with all invasive procedures, arterial catheterization may present complications, and personnel must be ready to intervene promptly to prevent unnecessary harm to the patient.[1][2]

Anatomy and Physiology

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Anatomy and Physiology

Arterial lines may be inserted into various arteries, with the radial and femoral arteries being commonly preferred due to their accessibility, enabling a thorough evaluation of surrounding anatomy and landmarks before the procedure. Alternatively, arterial lines can be placed in the brachial artery at the elbow, the dorsalis pedis artery in the foot, or the ulnar artery in the wrist. Palpation or ultrasound can aid in locating the artery accurately. Before arterial catheterization, confirming the presence of collateral circulation to the affected area is crucial, ensuring peripheral circulation is maintained by an alternate artery in case of disruption in the cannulated artery. The Allen test, performed at the wrist, is one such method to assess collateral flow in the hand.[3][4]

Upper Extremity Vasculature

  • Radial artery
    • The radial artery is the preferred and most common catheterization site. The radial artery originates in the cubital fossa, branching off the brachial artery. It courses along the lateral aspect of the forearm, generating the palmar arches that supply blood to the hand. Positioned at the wrist, the radial artery is proximal and medial to the radial styloid process, just lateral to the flexor carpi radialis (FCR) tendon. The radial artery is palpated superficially in the thenar area of the wrist at the radiocarpal joint. The radial pulse is best felt slightly medial to the extensor tendons of the thumb.
    • The optimal initial puncture for radial arterial cannulation is at the distal-most part of the wrist, commonly over the radial pulse at the proximal flexor crease. To avoid puncturing the retinaculum flexorum and the small superficial branch of the radial artery, the puncture site should be at least 1 cm proximal to the styloid process.
  • Ulnar artery
    • The ulnar artery is situated on the volar aspect of the wrist, opposite to the radial pulse, specifically at the ulnocarpal joint. It undergoes division into two branches, which then join a corresponding division of the radial artery, creating an extensive collateral network recognized as the deep and superficial palmar arch.
    • Comparatively smaller and less easily palpable than the radial artery, the ulnar artery is less frequently employed for catheterization. However, it may be considered when other options have been explored or exhausted.
  • Axillary artery
    • The axillary artery ascends to the superficial axilla, coursing through the pectoralis minor muscle, and is best delineated when the arm is abducted. Palpation of this large vessel is achievable slightly lateral to the belly of the pectoralis major muscle. Aligned with the cords of the brachial plexus, the axillary artery and vein together form a neurovascular bundle.
    • Catheterization of the axillary artery necessitates arm abduction and is typically a secondary option when peripheral alternatives prove ineffective. Successful catheter advancement into the subclavian artery yields a central pressure arterial waveform.
  • Brachial artery
    • The brachial artery, an extension of the axillary artery, initiates at the lower margin of the teres major muscle and stands as the principal artery of the upper extremity. Its trajectory runs along the ventral surface of the arm, giving rise to various smaller branching arteries before arriving at the cubital fossa. Among these branches are the deep brachial artery, the superior ulnar collateral artery, and the inferior ulnar collateral artery. Upon reaching the cubital fossa, the brachial artery undergoes division into its terminal branches: the radial and ulnar arteries of the forearm.
    • Catheterization of the brachial artery is not usually performed as there is a lack of collateral arterial flow, which increases the risk of ischemic injury to the distal upper extremity. If used, it is done in complex surgical cases and patients with multiple complex medical conditions.

Lower Extremity Vasculature

  • Femoral artery
    • The femoral artery originates at the inguinal ligament from the external iliac artery. It traverses under the inguinal ligament at approximately the midpoint between the anterior superior iliac spine and the pubic tubercle. It is medial to the femoral nerve and lateral to the femoral vein and lymphatics. The femoral artery is the main blood vessel that supplies the lower extremity. Complete femoral artery obstruction can cause lower limb ischemia without other major collateral vessels with severe consequences.
    • The femoral artery should be accessed around 2.5 cm below the inguinal ligament to facilitate bleeding control and prevent pelvic bleeding. This location offers easier palpation and enables compression of the artery.
  • Dosalis pedis artery
    • The dorsalis pedis artery originates at the distal tibia, between the medial and lateral malleoli, extending from the anterior tibial artery. Its course is superficial on the dorsal surface of the forefoot, passing over the talus and navicular towards the first dorsal interosseous space, where it transforms into the first dorsal metatarsal artery.
    • The dorsalis pedis artery can be palpated laterally to the extensor hallucis longus tendon (or medially to the extensor digitorum longus tendon) on the dorsal surface of the foot, distal to the dorsal prominence of the navicular bone, which serves as a reliable landmark for palpation.
    • The dorsalis pedis artery has ample collateral circulation, making it a preferred access site for the lower extremity, especially in children. This site is often avoided in adults as they likely have other comorbidities, such as diabetes and peripheral artery disease, which can lead to complications. 
  • Posterior tibial artery
    • The posterior tibial artery is the other significant arterial supply to the foot. It courses posteriorly to the popliteus muscle, penetrating the soleus muscle, and descends between the tibialis posterior and flexor digitorum longus muscles. It is responsible for supplying blood to the rear crural compartment. At the level of the talus, the artery bifurcates into the medial and lateral plantar arteries. 
    • The posterior tibial artery can be palpated behind the medial malleolus in a groove bordered by the Achilles tendon posteriorly. The posterior tibial artery is smaller in caliber than the dorsalis pedis artery and is at greater risk of occlusion.

Other Vessels

The superficial temporal artery is a branch of the external carotid artery. It may be palpated in the temporal area of the head anterosuperior to the ear. It has been rarely used in settings like cardiac stenting in those with severe iliac disease.[5]

The umbilical cord traditionally contains 2 umbilical arteries and 1 umbilical vein at birth. The umbilical stump typically involutes within the first few days of life. Before involution, however, the umbilical arteries are accessible; they are branches of the internal iliac arteries.


The benefits of an indwelling arterial catheter are manifold, providing continuous access to arterial blood and blood pressure values. It enables the identification of abnormal arterial waveform patterns and the evaluation of respirophasic variations to predict fluid responsiveness. It facilitates frequent blood sampling to measure oxygen and carbon dioxide levels and serum pH. Arterial catheters are most useful in the intensive care setting and operating room, where the clinical scenarios call for such invasive monitoring. However, routine arterial catheterization without a valid indication is discouraged due to potential complications and challenges in subsequent cannulation.

In cases of hypoxemic respiratory failure, arterial lines enable the calculation of the oxygenation index (OI), a crucial metric for assessing lung disease severity. OI is computed as mean airway pressure divided by the product of arterial oxygen partial pressure and fractional inspired oxygen concentration (FiO2). An OI exceeding 8 indicates moderate acute respiratory distress syndrome (ARDS), while an OI surpassing 16 signifies severe ARDS.

Arterial catheterization allows continuous systolic, diastolic, and mean arterial blood pressure monitoring through a transducer device connected to a non-compliant tubing system. This method offers significant advantages over automated cuff measurements, which estimate systolic and diastolic pressures based on mean arterial pressure, potentially leading to inaccuracies influenced by an individual's physique and underlying medical conditions. This monitoring becomes crucial when administering vasoactive medications, necessitating real-time assessments for effective titration.

Additional indications for arterial catheterization include cardiac and radiological interventions, manual or automated exchange transfusions, plasmapheresis, continuous arterio-venous perfusion, hemodialysis, and extracorporeal membrane oxygenation. However, it is crucial to emphasize that arterial lines should never be used for medication administration, as doing so can result in severe complications, including paresthesias, intense pain, motor dysfunction, compartment syndrome, gangrene, and limb loss.[6][7][8][9][10]


Arterial catheterization is a procedure that has the risk of site-specific serious complications. Prevention of adverse events is facilitated by understanding the underlying anatomy and contraindications of the procedure. These contraindications include but are not limited to:

  • Peripheral or distal arterial insufficiency
  • Peripheral arterial vascular diseases, including the small-to-medium vasculitides
  • A lack of collateral circulation due to anatomical anomalies, such as the congenital absence of the ulnar artery
  • Infection at the catheter insertion site (less risk with the more peripheral locations)

Various clinical conditions are not necessarily absolute contraindications to arterial catheterization but require special consideration. Collateral circulation should be assessed in most scenarios, including those at high risk, with simple tests like the Allen test when the radial artery is used. If, for some reason, the operator has uncertainty with the exam despite the Allen test, color Doppler ultrasound or photoplethysmography can be used to assess arterial patency and ensure adequate circulation. Other relative contraindications include hypercoagulable and anticoagulated states, overlying burns, and surgical interventions at the insertion site.[11][12]


Most of the materials needed for the placement of an arterial catheter usually come in pre-packaged kits that are commercially available. These bundled kits minimize procedure time and facilitate adherence to evidence-based best practices that minimize insertional catheter-related infections. 

Supplies that are generally required

  • Sterile gloves
  • Sterile gown
  • Sterile fenestrated drape
  • Mask with eye shield
  • Sterile gauze 
  • Sterile towels
  • Chlorhexidine or povidone-iodine skin preparation solution
  • 1% Lidocaine without epinephrine in a 3- to 5-mL syringe with a 25- to 27-gauge needle
  • Scalpel (No. 11 blade preferred)
  • Needle driver
  • Nonabsorbable suture 
  • Sterile nonabsorbable dressing
  • Three-way stopcock
  • Pressure transducer kit
  • Pressure tubing
  • Intravenous (IV) tubing T-connector
  • Appropriate-sized catheter for the artery (see below)
  • Finder needle with attached syringe (see below)
  • Guidewire (see below)

Equipment for radial artery cannulation

  • Catheter-over-needle technique - 20-gauge, 1.75-in. (4.45-cm) catheter over 22-gauge introducer needle
  • Catheter-over-wire technique (Seldinger) - 20-gauge peripheral artery catheter kit with a 20-gauge catheter, 22-gauge introducer needle, and compatible soft-tip wire 
  • Catheter-over-wire technique (modified Seldinger) - 20-gauge peripheral artery catheter kit with integrated wire and catheter

For infants and neonates, a 22- to 24-gauge angiocatheter is preferred over a 20-gauge peripheral artery catheter kit, more suitable for large children and adult patients.

Equipment for catheter-over-wire femoral artery cannulation

  • 18-gauge, 3-in. (7.6-cm) introducer needle
  • 18- or 20-gauge, 1.5-in. (3.8 cm) or 3-in. needle (an 18-gauge spinal needle will usually suffice)
  • Guidewire, appropriately sized for the catheter (eg, 45 cm in length and 0.64 mm in diameter); has a straight soft tip on one end and a J tip on the other 
  • Plastic spring wire insertion adapter to straighten the J-tip end of the guide wire for insertion into the plastic catheter
  • 18- or 20-gauge catheter, 15 cm or longer

The use of an ultrasound machine is recommended as it improves the accuracy of the procedure, reduces complications, and better identifies the proper vessel being canulated. If using an ultrasound, the probe should have a 5-13 MHz linear array, and a sterile ultrasound probe kit with sterile lubrication should be used.

The transducer, connecting tubing, and monitor cable system must be set up and available before placing the catheter. The waveform obtained after connecting the arterial catheter to the monitor confirms successful placement in the lumen of the artery. 

It is recommended that all equipment, including an infection control bundle, must be assembled at the bedside before initiating arterial catheterization. 


Placing an arterial catheter requires an additional assistant, apart from the operator, for non-sterile elements of the procedure and general circulating tasks. Additionally, if the patient needs sedation during the process, another practitioner must administer and monitor it.


Arterial catheterization, an invasive procedure, demands meticulous planning for risk mitigation. Therefore, it is strongly recommended that the team adhere to a checklist before commencing the procedure to ensure the availability of necessary equipment. A "time-out" procedure should also be observed to confirm the patient's identity, the intended procedure, and the correct catheterization site.

The aseptic preparatory technique involves essential steps such as thorough handwashing, sterile gloves, cleansing the insertion area with chlorhexidine, and securing the insertion site with a bio-occlusive tape. Following these protocols, the puncture site can be determined through palpation, doppler auditory assistance, or ultrasound imaging guidance.

Technique or Treatment

Sterile Technique

Arterial catheterization demands strict adherence to standard sterile precautions. All necessary equipment, including monitoring devices and the ultrasound machine, should be meticulously prepared, with the transducer zeroed and ready for use. The access site is readied using standard techniques. In the case of peripheral arterial access sites (eg, radial, dorsalis pedis), a skin antiseptic solution is applied and allowed to dry, followed by the use of sterile gloves. When employing a fenestrated drape, it should be positioned after the antiseptic skin solution is dry. For central arterial access sites (eg, femoral, axillary), comprehensive barrier precautions, including masks, caps, and eye protection, can diminish the risk of catheter site infection and potential disease transmission associated with blood splatter.

Vessel Identification

Before arterial catheterization, the operator must identify the vessel. This can be done via 1 or a combination of these methods. 

  • Palpation
    • Identify anatomic landmarks and use fingers to feel the arterial pulsation.
  • Ultrasound guidance
    • Ultrasound-guided arterial cannulation has now become the standard of care. Using ultrasound guidance during the catheterization of the radial artery has been associated with a high success rate, fewer mean attempts, shorter procedure time, less hematoma formation, distal embolization, pseudoaneurysm, and arteriovenous formation. The number of attempts needed to achieve successful catheterization is significantly reduced using ultrasound guidance.[13] This is particularly true in the infant and pediatric age groups, where repeated catheterization attempts increase the complication rate. In addition, the ultrasound-guided measurement of the internal arterial diameter may inform the choice of catheter size. This measurement may be particularly important in pediatric patients because of the different artery caliber expected in this population. The mode of visualization using transverse or longitudinal axis views each has its benefits and limitations when compared to each other. However, as long as the user can use dynamic needle tip positioning, there is an associated improved success rate.[14][15]
  • Doppler auditory assistance
    • In addition to palpating the arterial pulse, an auditory Doppler device can be used if an ultrasound is unavailable. This device can aid the operator in refining the access needle's entry point. This device may be beneficial in situations of low blood pressure when feeble pulsations make arterial pulse localization difficult.

The Allen Test

The Allen test is traditionally performed before catheterization of the radial artery. This test ensures sufficient collateral ulnar arterial blood flow to avoid distal ischemic injury. To perform this test, the radial and ulnar pulses are simultaneously occluded by manual palpation for 10 to 15 seconds or until blanching of the palm is noted. Then, the ulnar arterial occlusion is released. If the blanching resolves quickly, the patency of the ulnar artery is enough to perfuse the hand despite a complete or partial occlusion of the radial artery.

Local Anesthetic Injection

Local anesthesia is usually administered at the insertion site for conscious patients. This approach ensures patient comfort and may mitigate the risk of vasospasm. It is especially crucial in awake patients with tough skin, as a minor dermatotomy or "skin nick" might be necessary. This precaution prevents potential issues such as the insertion needle becoming obstructed by a skin plug or damage to the plastic catheter.

Insertion Techniques

  • Catheter-over-wire technique
    • This is the primary approach for arterial catheterization and includes the Seldinger and modified Seldinger techniques. Both the Seldinger and modified Seldinger techniques allow the operator to gain access to the arterial lumen with the help of a guidewire. While the Seldinger technique uses separate components, the modified Seldinger technique employs an integrated needle-catheter-wire system.
      • Seldinger
        • The artery is punctured with an introducer needle at a 30- to 45-degree angle. Once pulsatile blood flow is detected, the guidewire is inserted into the needle's hub to access the artery. Once sufficiently advanced, the introducer needle is removed. The opposite end of the guidewire is threaded into the arterial catheter, sliding it until it is completely flush with the skin. The guidewire is removed and inspected for complete integrity of the tip.
        • The Seldinger technique is particularly useful for the access of central vessels that run deeper into the extremity.
      • Modified Seldinger
        • The artery is punctured at a 30- to 45-degree angle with an introducer needle that has a fine catheter over it. Once the artery is accessed, the needle is removed, and the fine catheter is pushed flush to the skin. The guidewire is then passed through the fine catheter into the artery, and the fine catheter is removed, allowing the arterial catheter to be placed over the guidewire into the vessel. The guidewire is then removed. 
  • Catheter-over-needle technique
    • This is similar to the traditional technique of peripheral venous catheterization. After localization, the artery is directly punctured at a 30- to 45-degree angle with the catheter-over-the-needle device. Once arterial blood flow is detected, the operator slides the catheter over the needle forward before removing the needle. This method is most effective when dealing with a superficially located artery, as observed in the radial artery. It is particularly favored for radial artery cannulation in neonates and infants, where the small vessel diameter poses challenges in threading a guidewire into the vessel lumen.
  • Arterial cutdown
    • Arterial cutdown for arterial access is strongly discouraged and should only be contemplated as a last resort. This procedure should be exclusively carried out by physicians possessing adequate training and proficiency to execute the intervention and effectively address any potential complications. As such, it will not be discussed in this review. 

Securing the Arterial Catheter

Following the successful placement of the catheter and establishment of a connection to the transducer apparatus, the procedural team must ensure the catheter's secure fixation. This precautionary measure aims to prevent inadvertent dislodgement, reduce the risk of infection, and minimize excessive motion around the adjacent joint, which could potentially interfere with precise monitoring. This procedure serves the dual purpose of safeguarding the catheter and extending its longevity, thereby obviating the need for a repeat intervention. Transparent adhesive dressings are the preferred choice, allowing for direct visualization of the insertion site.

If the wrist is the site of insertion, if possible, the hand is kept slightly extended and immobilized with a soft roll fixated between the dorsum of the wrist and a rigid board where the hand and forearm will be affixed. The connection tubing takes a loop around the thumb and undergoes a second securement to the forearm. To obtain an accurate blood pressure reading, the monitoring device must be set to "zero" while the transducer hub is leveled at the height of the atrium.[16]

Arterial Catheter Monitoring

The accuracy of data obtained from arterial catheterization is contingent upon the transducer's precise positioning and the monitoring system's effective dampening. Establishing the correct system configuration to measure arterial blood pressure accurately is crucial. For patients in a prone position, the transducer is typically placed at the level of the right atrium or the midaxillary line in the fourth intercostal space. Conversely, for seated patients, considering the lower cerebral pressure compared to the heart level, the transducer should be positioned at the level of the brain. Proper transducer alignment minimizes hydrostatic pressure's impact, ensuring measurement accuracy. Additionally, specific steps must be meticulously followed to guarantee precise readings. They are as follows:

  • Prepare a 500 ml bag of normal saline without heparin, spike it with the transducer administration set, and meticulously remove all air from the tubing, paying close attention to the transducer and flush port.
  • Pressurize the bag to 300 mmHg and set it at a flow rate of 1 to 3 ml/hr, as the elevated pressure counteracts systemic arterial pressure, preventing blood contamination of the transducer. Subsequently, invert the bag and fast flush to eliminate any remaining air bubbles.
  • Connect the transducer to the monitor and conduct a square wave test by fast-flushing the line to observe changes in the waveform.
  • Zero the transducer and monitor, close the line off to the patient, open it to air, and press the "zero" button on the monitor.
  • Before monitoring pressure, close the port to the air and open it to the patient. Connect the patient's catheter and flush it to clear any blood.
  • Check the monitor for a good arterial waveform with prominently displayed arterial blood pressure and mean values.

In addition to ensuring the proper positioning of the transducer, it's essential to consider the influence of dampening on the monitoring system. Dampening can lead to inaccurate systolic and diastolic pressure readings, which become evident in the arterial line waveforms. For instance, if the transducer is situated too low in relation to the catheter, it results in abnormally elevated pressure values. Conversely, the pressure data may be unusually low if the transducer is placed too high relative to the catheter.

To evaluate and address dampening issues, a square wave test is frequently employed for interpretation. This test involves a rapid saline flush, creating elevated pressure and generating vibrations in the transducer. The speed at which these oscillations cease, referred to as the dampening coefficient, is carefully assessed. One typically observes 1 to 2 oscillations in a standard square wave test. However, if the arterial line exhibits inadequate dampening, multiple oscillations persist following the fast saline flush, leading to an underestimation of diastolic pressure and an overestimation of systolic pressure.

However, when the arterial line is overdampened, no oscillations occur after the fast saline flush. While this results in an accurate diastolic pressure reading, it may falsely depict a lower systolic pressure. It's worth noting that an overdampened system can also be caused by a clot or fibrin in the catheter tip.[17] 


The incidence of complications in arterial catheterization among adult patients typically falls within 10% to 13%, with variations depending on the placement site. Ultrasound-guided techniques and stringent adherence to sterile procedures can significantly mitigate many clinically significant complications. Commonly reported complications encompass pain, bruising, hematoma formation, thrombosis, pseudoaneurysm formation, vasospasm, dissection, AV fistula formation, air embolism, and particulate embolism.

Vasospasm, identified in up to 57% of patients in some older reports, presents with symptoms such as pain, decreased blood pressure, waveform dampening, blanching of the fingers or hand, or loss of pulse or O2 saturation signal in the affected limb. While studies from the 1970s suggested premedication with nitroglycerin, calcium channel blockers (eg, verapamil), phentolamine, and heparin could mitigate vasospasm risk in trans-radial coronary catheterization, these interventions are not routinely employed during arterial line placements or for managing vasospasm complications.[18][19]

Among various complications, catheter-related infection and inflammation are the most prevalent (61.8%), followed by mechanical issues (14.1%), embolic or thrombotic events (7.5%), and amputation due to ischemic injury (0.6%). Higher complication rates are associated with critical illness, cardiac surgery, bone marrow transplantation, and hemodialysis.[20] 

The shift towards a trans-radial approach in percutaneous coronary interventions and diagnostic coronary angiography has been linked to a reduced overall risk of thrombosis. In this approach, complication events include a reported incidence of 0.09% of permanent hand ischemic damage, with other adverse events like temporary radial occlusion occurring at a mean rate of 19%. Post-procedure at the 30-day mark, complications may include digital embolization and arterial dissection. These rates, already significant in non-scleroderma patients, pose additional challenges for those with scleroderma, impaired fibrinolysis, or other underlying vasculopathies, potentially amplifying complication risks.[21] 

In pediatric patients, arterial catheterization presents unique challenges due to vessel diameters of only 2 to 3 mm. While studies on complication rates in this population are limited, the largest retrospective analysis of over 10,000 pediatric patients reported a complication rate of 10.3%. Factors such as age (1-4 months), late catheter placement in the hospital course, and systemic infections further contribute to complication risks in the pediatric population.[22][23]

Clinical Significance

Arterial line placement and monitoring represent widely accepted standards of care for critically ill patients. This medical intervention is frequently applied in medical and surgical intensive care units and operating rooms, catering to adult and pediatric populations. A key advantage of arterial lines is their ability to continuously monitor blood pressure and mean arterial pressure while facilitating regular blood gas sampling to assess arterial oxygenation, carbon dioxide levels, and pH status.

Despite these advantages, arterial catheterization has risks, including potential complications such as catheter-related infections and a chance of distal blood flow compromise. Moreover, the landscape of hemodynamic monitoring has evolved, introducing alternative techniques that have led to a decreased frequency of arterial catheterization. Consequently, the routine placement of arterial catheters in managing critically ill pediatric patients should be approached with caution and not considered standard practice.

Enhancing Healthcare Team Outcomes

Ensuring optimal patient outcomes and safety in arterial line management necessitates a collaborative and multidisciplinary approach involving various healthcare professionals. Each healthcare team member has unique skills, expertise, and responsibilities. As leaders in patient care, physicians must possess the technical skills for precise arterial line placement and removal. They play a crucial role in devising a comprehensive strategy for patient management, including determining the necessity of arterial lines, selecting appropriate monitoring techniques, and deciding on the optimal duration of catheterization. Ethics in this context involves a commitment to patient autonomy, informed consent, and considering the risks and benefits associated with arterial catheterization.

Advanced practitioners, including nurse practitioners and physician assistants, contribute to patient-centered care by actively participating in arterial line placement, monitoring, and addressing complications. Nurses, at the forefront of patient care, play a pivotal role in maintaining catheter patency, monitoring for complications, and ensuring patient comfort. Pharmacists contribute through medication management, especially regarding heparin infusions and preventing complications associated with medication errors. Interprofessional communication is critical, as it facilitates a seamless exchange of information and fosters a shared understanding of patient needs. Effective care coordination involves regular team meetings, clear communication channels, and a shared commitment to patient safety. Through the collaborative efforts of physicians, advanced practitioners, nurses, pharmacists, and other healthcare professionals, a patient-centered approach to arterial line management is achieved, leading to improved outcomes, enhanced patient safety, and optimized team performance.

Nursing, Allied Health, and Interprofessional Team Interventions

Maintaining catheter patency is of utmost importance, achieved through continuous infusion at a rate of 1 to 3 mL/hour, either with or without a pressurized bag system. Commonly employed infusate fluids include normal saline or normal saline with 1 to 2 units/mL of heparin. Studies have indicated that using heparinized solutions does not diminish the risk of catheter thrombosis.[24] Consequently, when drawing blood from the arterial line for laboratory analysis, discarding an initial portion of the blood is imperative to prevent potential laboratory errors. Typically, a waste of 1 to 3 mL suffices, the specific amount dependent on the patient's age and circulating blood volume.

Historical accounts of hyperglycemia have been linked to the infusion of glucose-containing fluids through arterial lines. Moreover, reports of limb ischemia and skin and tissue necrosis resulting from inadvertent medication infusion through arterial catheters emphasize the need for rigorous precautions. Proper labeling of the arterial line is essential to avoid these complications, with the added safeguard of dual nursing verification for infusing fluids.

Regular monitoring of perfusion distal to the catheter is assigned to nursing staff. If any concerns arise regarding ongoing perfusion impairment, prompt catheter removal is warranted to avert potential complications.



Valgardsson AS, Karason S, Laxdal E, Haraldsdottir KH. [Finger necrosis following arterial cannulation - a case report]. Laeknabladid. 2018 Dec:104(12):551-553. doi: 10.17992/lbl.2018.12.208. Epub     [PubMed PMID: 30511646]

Level 3 (low-level) evidence


Kaki A, Blank N, Alraies MC, Kajy M, Grines CL, Hasan R, Htun WW, Glazier J, Mohamad T, Elder M, Schreiber T. Access and closure management of large bore femoral arterial access. Journal of interventional cardiology. 2018 Dec:31(6):969-977. doi: 10.1111/joic.12571. Epub 2018 Nov 19     [PubMed PMID: 30456854]


Greer MR, Carney S, McPheeters RA, Aguiniga P, Rubio S, Lee J. Radial Arterial Lines Have a Higher Failure Rate than Femoral. The western journal of emergency medicine. 2018 Mar:19(2):364-371. doi: 10.5811/westjem.2017.11.34727. Epub 2018 Feb 20     [PubMed PMID: 29560067]


Paik JJ, Hirpara R, Heller JA, Hummers LK, Wigley FM, Shah AA. Thrombotic complications after radial arterial line placement in systemic sclerosis: A case series. Seminars in arthritis and rheumatism. 2016 Oct:46(2):196-199. doi: 10.1016/j.semarthrit.2016.03.015. Epub 2016 Mar 31     [PubMed PMID: 27139167]

Level 2 (mid-level) evidence


Csavajda Á, Bertrand OF, Merkely B, Ruzsa Z. Superficial temporal artery access for percutaneous coronary artery stenting during the COVID-19 pandemic: a case report. European heart journal. Case reports. 2021 Feb:5(2):ytaa520. doi: 10.1093/ehjcr/ytaa520. Epub 2020 Dec 27     [PubMed PMID: 33594345]

Level 3 (low-level) evidence


Nuttall G, Burckhardt J, Hadley A, Kane S, Kor D, Marienau MS, Schroeder DR, Handlogten K, Wilson G, Oliver WC. Surgical and Patient Risk Factors for Severe Arterial Line Complications in Adults. Anesthesiology. 2016 Mar:124(3):590-7. doi: 10.1097/ALN.0000000000000967. Epub     [PubMed PMID: 26640979]


Chim H, Bakri K, Moran SL. Complications related to radial artery occlusion, radial artery harvest, and arterial lines. Hand clinics. 2015 Feb:31(1):93-100. doi: 10.1016/j.hcl.2014.09.010. Epub 2014 Nov 25     [PubMed PMID: 25455360]


Chee BC, Baldwin IC, Shahwan-Akl L, Fealy NG, Heland MJ, Rogan JJ. Evaluation of a radial artery cannulation training program for intensive care nurses: a descriptive, explorative study. Australian critical care : official journal of the Confederation of Australian Critical Care Nurses. 2011 May:24(2):117-25. doi: 10.1016/j.aucc.2010.12.003. Epub 2011 Jan 5     [PubMed PMID: 21211987]


Jozwiak M, Monnet X, Teboul JL. Pressure Waveform Analysis. Anesthesia and analgesia. 2018 Jun:126(6):1930-1933. doi: 10.1213/ANE.0000000000002527. Epub     [PubMed PMID: 29077613]


Sen S, Chini EN, Brown MJ. Complications after unintentional intra-arterial injection of drugs: risks, outcomes, and management strategies. Mayo Clinic proceedings. 2005 Jun:80(6):783-95     [PubMed PMID: 15945530]

Level 2 (mid-level) evidence


Habib J, Baetz L, Satiani B. Assessment of collateral circulation to the hand prior to radial artery harvest. Vascular medicine (London, England). 2012 Oct:17(5):352-61. doi: 10.1177/1358863X12451514. Epub 2012 Jul 19     [PubMed PMID: 22814998]


Di Santo P, Harnett DT, Simard T, Ramirez FD, Pourdjabbar A, Yousef A, Moreland R, Bernick J, Wells G, Dick A, Le May M, Labinaz M, So D, Motazedian P, Jung RG, Chandrasekhar J, Mehran R, Chong AY, Hibbert B. Photoplethysmography using a smartphone application for assessment of ulnar artery patency: a randomized clinical trial. CMAJ : Canadian Medical Association journal = journal de l'Association medicale canadienne. 2018 Apr 3:190(13):E380-E388. doi: 10.1503/cmaj.170432. Epub     [PubMed PMID: 29615421]

Level 1 (high-level) evidence


Zhao W, Peng H, Li H, Yi Y, Ma Y, He Y, Zhang H, Li T. Effects of ultrasound-guided techniques for radial arterial catheterization: A meta-analysis of randomized controlled trials. The American journal of emergency medicine. 2021 Aug:46():1-9. doi: 10.1016/j.ajem.2020.04.064. Epub 2020 May 6     [PubMed PMID: 33684726]

Level 1 (high-level) evidence


Dudeck O, Teichgraeber U, Podrabsky P, Lopez Haenninen E, Soerensen R, Ricke J. A randomized trial assessing the value of ultrasound-guided puncture of the femoral artery for interventional investigations. The international journal of cardiovascular imaging. 2004 Oct:20(5):363-8     [PubMed PMID: 15765858]

Level 1 (high-level) evidence


Cho SA, Jang YE, Ji SH, Kim EH, Lee JH, Kim HS, Kim JT. Ultrasound-guided arterial catheterization. Anesthesia and pain medicine. 2021 Apr:16(2):119-132. doi: 10.17085/apm.21012. Epub 2021 Apr 15     [PubMed PMID: 33866769]


Saugel B, Kouz K, Meidert AS, Schulte-Uentrop L, Romagnoli S. How to measure blood pressure using an arterial catheter: a systematic 5-step approach. Critical care (London, England). 2020 Apr 24:24(1):172. doi: 10.1186/s13054-020-02859-w. Epub 2020 Apr 24     [PubMed PMID: 32331527]

Level 1 (high-level) evidence


Nguyen Y, Bora V. Arterial Pressure Monitoring. StatPearls. 2023 Jan:():     [PubMed PMID: 32310587]


Kim JM, Arakawa K, Bliss J. Arterial cannulation: factors in the development of occlusion. Anesthesia and analgesia. 1975 Nov-Dec:54(6):836-41     [PubMed PMID: 1239224]


Coppola J, Patel T, Kwan T, Sanghvi K, Srivastava S, Shah S, Staniloae C. Nitroglycerin, nitroprusside, or both, in preventing radial artery spasm during transradial artery catheterization. The Journal of invasive cardiology. 2006 Apr:18(4):155-8     [PubMed PMID: 16729400]

Level 1 (high-level) evidence


Costa F, Daemen J, Diletti R, Kauer F, Geuns RJ, Ligthart J, Witberg K, Zijlstra F, Valgimigli M, Van Mieghem NM, van Leeuwen MA. Response by Costa et al to Letter Regarding Article, "The Rotterdam Radial Access Research: Ultrasound-Based Radial Artery Evaluation for Diagnostic and Therapeutic Coronary Procedures". Circulation. Cardiovascular interventions. 2016 Jul:9(7):. pii: e003990. doi: 10.1161/CIRCINTERVENTIONS.116.003990. Epub     [PubMed PMID: 27406990]

Level 3 (low-level) evidence


Brzezinski M, Luisetti T, London MJ. Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesthesia and analgesia. 2009 Dec:109(6):1763-81. doi: 10.1213/ANE.0b013e3181bbd416. Epub     [PubMed PMID: 19923502]


Hignett R, Stephens R. Radial arterial lines. British journal of hospital medicine (London, England : 2005). 2006 May:67(5):M86-8     [PubMed PMID: 16729631]


Evans N, Skowno J, Hodgson E. The anaesthesiologist in the intensive care unit. Current opinion in anaesthesiology. 2003 Aug:16(4):401-7     [PubMed PMID: 17021489]

Level 3 (low-level) evidence


López-Briz E, Ruiz Garcia V, Cabello JB, Bort-Martí S, Carbonell Sanchis R, Burls A. Heparin versus 0.9% sodium chloride locking for prevention of occlusion in central venous catheters in adults. The Cochrane database of systematic reviews. 2018 Jul 30:7(7):CD008462. doi: 10.1002/14651858.CD008462.pub3. Epub 2018 Jul 30     [PubMed PMID: 30058070]

Level 1 (high-level) evidence