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Intra-arterial catheterization for invasive monitoring:

Indications, insertion techniques, and interpretation
Authors: Arthur C Theodore, MD, Gilles Clermont, MDCM, MSc, Allison Dalton, MD
Section Editors: Michael F O'Connor, MD, FCCM, Girish P Joshi, MB, BS, MD, FFARCSI
Deputy Editors: Nancy A Nussmeier, MD, FAHA, Geraldine Finlay, MD

All topics are updated as new evidence becomes available and our peer review process is complete.

Literature review current through: Mar 2021. | This topic last updated: Aug 18, 2020.

INTRODUCTION

Intra-arterial catheters (also called arterial cannulas or A-lines) are often inserted for invasive
blood pressure (BP) monitoring and intravascular access for blood sampling in high-risk
surgical and critically ill patients. This topic will review techniques, complications,
advantages, and uses of intra-arterial catheterization, as well as sources of error that may
occur during monitoring and interpretation of the arterial pressure waveform. Pulmonary
artery catheterization is discussed separately. (See "Pulmonary artery catheterization:
Indications, contraindications, and complications in adults" and "Pulmonary artery catheters:
Insertion technique in adults" and "Pulmonary artery catheterization: Interpretation of
hemodynamic values and waveforms in adults".)

USES

Advantages of an indwelling arterial catheter include continuous access to arterial blood and
blood pressure (BP) values. Indications include the need for:

● Continuous monitoring of arterial BP – Intra-arterial BP monitoring is often employed

during the intraoperative period when major surgery is planned, significant
comorbidities are present, or difficult intravascular access is anticipated, and when
 patients are critically ill and require titrated vasoactive medications. (See "Monitoring
during anesthesia", section on 'Invasive blood pressure monitoring'.)

● Identification of abnormal arterial waveform patterns – (See 'Interpretation of the

arterial waveform tracing' below.)

● Evaluation of respirophasic variations in the arterial pressure waveform to predict

fluid responsiveness - Visual estimates or manual calculations of systolic pressure
variation (SPV) or pulse pressure variation (PPV) are possible ( figure 1 and figure 2),
or commercially available devices that provide automated calculation of SPV, PPV, or
stroke volume variation (SVV) may be employed ( table 1). (See "Intraoperative fluid
management", section on 'Dynamic hemodynamic parameters' and "Novel tools for
hemodynamic monitoring in critically ill patients with shock", section on 'Arterial pulse
waveform analysis'.)

● Frequent blood sampling – Occasionally, an arterial catheter is placed for intermittent

blood sampling for laboratory testing, including point-of-care tests such as arterial blood
gases with pH, hemoglobin, electrolytes, glucose, lactate, and tests of hemostasis [1].
Intra-arterial access is particularly useful in patients who do not have intravascular
access via a central venous catheter (CVC). (See "Arterial blood gases" and "Clinical use of
coagulation tests", section on 'Point-of-care testing'.)

Routine arterial catheterization in the absence of a reasonable indication is not

recommended since complications may occur (see 'Complications' below), and thrombosis or
stenosis may render future cannulation of previously used arteries more difficult [2].

CONTRAINDICATIONS

There are several contraindications to arterial line placement, some of which are site-specific
and other that are general. These contraindications are similar to those described for arterial
blood gas sampling and are discussed separately. (See "Arterial blood gases", section on
'Indications and contraindications'.)

SITE SELECTION

The initial step in selection of a catheterization site is the location of a palpable arterial pulse.
Common sites include peripheral arteries (radial [most common], brachial, or dorsalis pedis
sites) and central arteries (femoral [most common] or axillary sites). The peripheral arteries
are typically located more easily, and have a lower infection risk compared with central
arterial sites. In most institutions, the radial, axillary, and femoral sites are most commonly
accessed, while the brachial site is accessed only rarely for selected cardiac surgical or
medically complex patients [3-5]. While frequently used in children, the dorsalis pedis site is
often avoided in adult patients with diabetic complications or significant peripheral arterial
disease of the lower extremities. Anatomical landmarks for these sites are described
separately. (See "Arterial blood gases", section on 'Site selection'.)

● Checking for collateral flow – Prior to radial arterial catheterization, a check for
collateral flow to the hand is performed to identify possible risks for an ischemic
complication [6]. Variable blood supply to the deep and superficial palmar arches
occasionally causes inadequate perfusion and ischemia following placement of an
arterial catheter.

A physical examination that includes the Allen test or modified Allen test is often
employed, although there is significant interobserver variability, and the test lacks
predictive accuracy for subsequent hand ischemia [6-9]. Although the best method for
assessing radial arterial patency and collateral competency is color Doppler
ultrasonography, equipment is not always immediately available [10]. Alternative
methods are being developed (eg, photoplethysmography) [11,12]. (See "Arterial blood
gases", section on 'Ensure collateral circulation'.)

● Immobilization – If the radial artery is selected, the wrist is often immobilized on a

padded arm board. At the brachial or femoral site, positioning to straighten the
extremity is helpful for initial catheter insertion and maintenance of catheter integrity.

INSERTION TECHNIQUE

Arterial catheterization should be performed using standard sterile precautions. All

equipment including equipment for monitoring and the ultrasonography device should be
prepared and the transducer zeroed and ready for use. The equipment necessary is listed in
the table ( table 2).

Sterile technique — The access site is prepared with standard techniques. For peripheral
arterial access sites (ie, radial, brachial, dorsalis pedis), a chlorhexidine-alcohol skin antiseptic
solution is applied to the access site and allowed to dry, and sterile gloves are worn. If a
fenestrated drape is used, it should be positioned after the antiseptic solution is dry on the
skin [2]. For central arterial access sites (ie, femoral, axillary), full barrier precautions
including masks, caps, and eye protection can be used to reduce the potential for catheter
site infection and minimize risk for disease transmission associated with blood splatter [2].
(See "Overview of central venous access in adults", section on 'Sterile technique'.)

Local anesthetic injection — We use local anesthesia at the site of insertion in conscious
patients. Injection of local anesthetic does not adversely impact the success of the procedure
and may reduce vasospasm [13]. In particular, local anesthesia is necessary in awake patients
with tough skin if a small dermatotomy (ie, "skin nick") is made in order to prevent occlusion
of the insertion needle with a skin plug and/or damage to the plastic catheter.

Use of a guidewire — We suggest using a guidewire during arterial catheter insertion,

unless the operator is experienced and more comfortable with a direct puncture approach.
Furthermore, we suggest changing to a guidewire approach if difficulties are encountered
with the direct puncture approach. In one trial in 69 critically ill patients, the direct puncture
approach was less likely to be successful, took longer to perform, used more catheters, and
required more punctures compared with using a separate-guidewire or integral-guidewire
approach [14]. Similarly, first attempt success rates were higher using a guidewire rather
than the direct puncture approach in a prospective cohort study of 138 patients (82 versus 65
percent overall), particularly in 42 female patients (57 versus 14 percent) [15].

For all approaches to arterial catheterization, the operator's nondominant hand gently
palpates the artery, while the dominant hand manipulates the intravascular catheter (an
outer catheter over a needle). Specific approaches include:

● Separate-guidewire approach – During the separate-guidewire approach, the

intravascular catheter with an inner needle is inserted at a 30 to 45 degree angle and
advanced slowly until pulsatile blood return is observed ( figure 3) [16]. The
intravascular catheter is then advanced slightly, assuring that the catheter tip is now
within the lumen, or until the blood return ceases. This step acknowledges that initial
blood return begins as soon as the needle enters the lumen, but before the outer
catheter also enters the artery's lumen. Advancing the intravascular catheter ensures
that the outer catheter has advanced into the lumen.
 While stabilizing the intravascular catheter with the nondominant hand, the dominant
hand removes the needle from the intravascular catheter. If pulsatile blood return is
observed after the needle is removed, the separate-guidewire is advanced through the
outer catheter. If pulsatile blood is not observed after the needle is removed, the outer
catheter is gently withdrawn until pulsatile blood return is obtained, and only then is the
guidewire advanced through the outer catheter. Then the guidewire is advanced further,
until its distal end is well beyond the distal end of the outer catheter. Finally, the outer
catheter is advanced over the guidewire into the artery, then the guidewire is removed.

● Integral-guidewire – The most common approach uses an integral-guidewire that is

inseparable from the prepackaged intravascular catheter ( figure 3). This approach is
similar to that for a separate guidewire. While the nondominant hand gently palpates
the artery, the dominant hand manipulates the catheter, inserting it at a 30 to 45 degree
angle and advancing it slowly until pulsatile blood return is obtained. Then the angle of
the needle-guidewire-catheter unit is decreased, so that the needle-guidewire-catheter
unit is more parallel to the skin. If blood flow is still observed, the guidewire tab is
advanced with the dominant hand pushing the wire into and through the needle and
catheter. However, if decreasing the angle of the needle-guidewire-catheter unit results
in loss of blood return, the unit is advanced slowly until blood flow is observed again.
Then the catheter is advanced into the artery over the needle and guidewire, and the
needle-guidewire component of the unit is removed.

● Direct puncture – For the direct puncture approach, while the nondominant hand gently
palpates the artery, the intravascular needle-catheter unit is inserted by the dominant
hand at a 30 to 45 degree angle and advanced slowly until pulsatile blood return is
obtained. Then the angle of the needle-catheter unit is decreased, so that the needle-
catheter unit is more parallel to the skin. The needle-catheter unit is then slowly
advanced another millimeter or two, assuring that blood return continues and that not
only the inner needle tip, but also the catheter tip is now within the arterial lumen. The
outer catheter is then advanced into the artery directly from the needle without the aid
of a guidewire, and the needle is removed.

When using the direct puncture technique, it is important to recognize that the needle
tip extends beyond the catheter tip by approximately 1 to 2 mm. When puncturing the
artery with the needle-catheter unit, the initial, "flash," of arterial blood comes from the
leading needle tip, and if the needle-catheter unit is not advanced slightly into the
 arterial lumen, the catheter tip may remain outside of the vessel wall. Attempts to
advance the catheter tip will then be unsuccessful, because the catheter will displace the
vessel wall rather than enter the vessel lumen.

Similarly, when advancing the needle-catheter unit at a shallow angle to assure that the
catheter is intraluminal, blood return may cease. Again, since the leading tip is the
needle rather than the catheter, the needle alone should be slowly withdrawn. Often, the
catheter tip will still be in the arterial lumen, blood return now resumes, and the catheter
may be advanced into the artery. Alternatively, the catheter may also need to be
withdrawn slightly if along with the needle, the catheter tip has also penetrated the back
wall of the artery and there is no blood return. Slight catheter withdrawal will then
restore blood return as the catheter re-enters the arterial lumen. The catheter is then
advanced within the artery.

Catheter stabilization — All equipment should be prepared in advance, including syringes

with flush solution and the tubing that will be connected to the arterial catheter. Once the
catheter is advanced into the artery, the needle is removed. The artery should be
compressed proximal to the catheter to prevent bleeding after removing the needle and
during connection of the pre-flushed arterial tubing. Finally, the catheter should be secured
via sutures or with a transparent adhesive dressing.

Use of ultrasound guidance — We often use ultrasonography to identify a patent arterial

vessel and guide catheter placement [17-19].

In a 2018 meta-analysis, use of ultrasound guidance was associated with higher first attempt
success rate (risk ratio [RR] 1.35, 95% CI 1.16-1.57) and decreased failure rate compared with
digital palpation without ultrasound (RR 0.52, 95% CI 0.32-0.87), but time required for
insertion and the overall success rate were not improved [19]. Other meta-analyses have
noted similar results [20,21]. Transverse (ie, short axis) and/or longitudinal (ie, long axis)
views may be used to locate and cannulate the artery. In one trial in 164 patients undergoing
radial artery catheterization, the first attempt success rate was higher with transverse axis
views than with longitudinal axis views, but the overall incidence of failure to cannulate was
similar [22]. Either B-mode or color duplex ultrasound imaging can be employed, although
visualization of the needle is typically better with B-mode imaging due to fewer artifacts.
Individual clinician preferences depend in part on the selected arterial site.

The presumed benefit of ultrasound is to allow visualization of the needle entering the vessel
in real time. Efficacy has not been demonstrated in studies employing ultrasound to simply
locate or map an arterial vessel without dynamic real-time visualization of needle placement
[17,23]. A 2018 meta-analysis reported that the highest first attempt success rates were
achieved by employing both long and short axis views with dynamic needle tip positioning (a
technique that requires real-time ultrasonographic confirmation of the needle tip in the
vessel prior to advancement of the catheter) [19]. Short axis visualization without dynamic
needle tip positioning was associated with lower first attempt success rates that were similar
to palpation techniques without ultrasound guidance.

Use of ultrasound during arterial catheterization may decrease risk of complications such as
hematoma formation by identifying an evolving hematoma or presence of a
pseudoaneurysm or arteriovenous fistula [24-26]. Also, ultrasound guidance may decrease
risk of embolism since the operator can avoid catheter insertion at the site of an atheroma or
calcified area along the arterial wall [27]. During axillary artery catheterization,
ultrasonography may prevent injury to surrounding structures including the brachial plexus
[27].

MONITORING BLOOD PRESSURE

Direct continuous measurement with an intra-arterial catheter is the gold standard for
determining arterial blood pressure (BP). The mean arterial pressure (MAP) determined by
direct measurement generally correlates well with pressures from manual
sphygmomanometry and automated non-invasive BP cuffs in healthy adults. Non-invasive
cuff pressure measurements are less accurate in patients with shock, cardiac arrhythmias,
severely increased systemic vascular resistance (SVR; eg, due to administration of
vasoconstrictor drugs) [28], or severely decreased SVR (eg, distributive shock) [29,30] (see
"Monitoring during anesthesia", section on 'Noninvasive blood pressure monitoring').
Furthermore, non-invasive BP measurements appear to show the greatest discrepancies at
the extremes of BP values compared with invasive measurements, such that actual BP is
overestimated during severe hypotension and underestimated during severe hypertension
[31].

Interpretation of the arterial waveform tracing — The arterial waveform results from
ejection of blood from the left ventricle into the aorta during systole, followed by peripheral
runoff during diastole [32]. The normal arterial waveform is shown in the figure ( figure 4).
Unusual radial arterial pressure waveforms may occur due to pathology in the ascending
aorta or aortic valve (eg, aortic dissection, aortic valve replacement) [33,34], or with
decreases in systemic BP or systemic vascular resistance. Examples of abnormal arterial
waveforms that are associated with clinical pathology include pulsus alternans in left
ventricular failure, pulsus paradoxus in cardiac tamponade, pulsus bisferiens or water
hammer pulse in aortic regurgitation, or an anacrotic pulse, pulsus parvus or pulsus tardus
in aortic stenosis. These and other examples are described in detail in a separate topic. (See
"Examination of the arterial pulse".)

The systolic upstroke represents the systolic ventricular ejection. The peak systolic pressure
is followed by a rapid decrease in pressure as ventricular contraction ends (ie, the systolic
decline). The dicrotic notch (ie, the incisura) represents the closure of the aortic valve, which
indicates the start of diastole. The pressure throughout diastole is the primary determinant
of left ventricular blood flow. The lowest pressure at the end of the diastolic cycle occurs
immediately before the next arterial upstroke.

In addition to providing absolute numerical data for peak systolic and nadir diastolic BP
values, other useful hemodynamic information that can be derived from the arterial pressure
waveform include:

● Mean arterial pressure

• MAP is the mean pressure averaged over several cardiac cycles at the measurement
site. It represents the area under the curve during a single beat. Most monitors
average this number electronically over a period of time.

• MAP may be estimated mathematically as the sum of diastolic BP plus one-third of

the pulse pressure, although this formula is valid only at a heart rate of
approximately 60 beats per minute [35].

● Pulse pressure

• Pulse pressure is the difference between systolic and diastolic pressures. Generally,
elevated pulse pressure indicates age-associated vascular stiffness, particularly in
hypertensive older patients [36]. Decreases in a patient's pulse pressure relative to
baseline are typically caused by hypovolemia, decreases in stroke volume (SV), or
increases in systemic vascular resistance (SVR). Increases in a patient's pulse
 pressure relative to baseline are caused by increases in SV and/or decreases in SVR
(eg, during exercise).

• Pulse pressure variation (PPV) may be used to assess intravascular volume status.
(See "Intraoperative fluid management", section on 'Dynamic hemodynamic
parameters' and "Monitoring during anesthesia", section on 'Other monitors of
circulation'.)

● Additional systolic and diastolic pressure parameters

• The slope of the systolic upstroke is generally related to left ventricular contractility,
although other hemodynamic variables affect this relationship [37]. For example,
this slope becomes steeper as the waveform is measured further from the aorta
[38]. (See 'Site of arterial catheterization' below.)

• The slope of the diastolic decline in pressure (ie, diastolic runoff) varies with
resistance in the arterial tree. If stroke volume is constant, diastolic runoff decreases
sharply if SVR is low (eg, vasodilator therapy, septic shock), but is more gradual if
SVR is high (eg, vasoconstrictor therapy, severe heart failure).

Factors affecting measurement of blood pressure — Despite the superiority of direct

intra-arterial BP measurement compared with noninvasive techniques, misinterpretation of
data or technical problems may introduce errors [39].

Site of arterial catheterization — Arterial pressure waveforms change as the pressure

wave moves from the aorta to the periphery. Peripheral arterial waveforms have a higher
systolic BP, steeper systolic upstroke, lower diastolic BP, lower and later dicrotic notch, and
wider pulse pressure compared with measurements obtained at the aortic root [38,40]. For
example, the systolic BP in the radial artery can be 10 to 35 mmHg higher than the systolic
BP in the aorta, while measurements of diastolic pressure and MAP are less affected in a
peripheral site [41,42]. These changes are the result of the decreased diameter of peripheral
blood vessels, their elasticity, and wave reflections off the peripheral vessel branch points
and walls [43].

Transducer level — The pressure transducer should be leveled to a point that

corresponds with the level of the heart, aiming for 5 cm behind the sternum in a supine
patient [44,45], which best approximates the location of the aortic root in an adult.
Alternatively, the mid-axillary line is used as an appropriate reference level, particularly when
direct arterial pressure is simultaneously being monitored along with pulmonary arterial or
central venous pressures [46-48]. In either right or left lateral decubitus position, the
transducer should be leveled at the mid-sternum (see "Patient positioning for surgery and
anesthesia in adults", section on 'Lateral decubitus'). In some cases (eg, the sitting position),
the anesthesiologist may decide to level the transducer with the external auditory meatus to
reflect the pressure at the Circle of Willis and therefore brain perfusion pressure. (See
"Patient positioning for surgery and anesthesia in adults", section on 'Physiologic effects of
sitting position'.)

Regardless of the level chosen for the transducer, it should be recognized that transducer
position is a critical determinant of all directly monitored intravascular pressures. If the
position of the patient relative to the transducer is changed, the level of the transducer
should also be adjusted to avoid erroneous BP readings [49]. The hydrostatic pressure
difference between various vertical locations of the transducer is easily calculated (10 cm
water height = 7.4 mmHg), and subsequent transducer height adjustments will always
produce these exact differences in measured pressures (see below, transducer calibration).

In addition to assuring the appropriate transducer level, the transducer must also be,
"zeroed," prior to monitoring. To do this, the stopcock adjacent to the transducer is turned
off to the patient, then opened to air to be exposed to ambient atmospheric pressure. The
bedside monitor pressure zero button is then selected, which assigns atmospheric pressure
to be zero. The stopcock is then closed to air and adjusted to the height that will best align it
with the level of the heart as described above. Note that the pressure transducer need not be
re-zeroed when transducer height is adjusted slightly to align it appropriately with the
patient. However, the transducer must always be zeroed before monitoring begins,
whenever the electronic pressure monitoring cable is disconnected, and when BP accuracy is
in question [50].

Over-damping or under-damping of the pressure tracing — The arterial catheter,

noncompliant tubing, and three-way stopcocks used for invasive monitoring each change
the degree of damping of the pressure waveform between the artery and the transducer
that measures it [51]. Thus, unnecessary length of tubing and extra stopcocks should be
avoided. Also, the arterial pressure waveform may become damped by air bubbles or clot in
the arterial catheter, causing a characteristic (though sometimes subtle) change in the
waveform, with a decrease in the displayed systolic pressure, and a falsely narrowed pulse
pressure. However, MAP often remains accurate in these circumstances. Removal of air or
flushing the catheter often resolves such overdamping. If a clot on the catheter tip is
suspected, then the catheter should be replaced.

Whether the degree of damping (ie, dynamic response) in a monitoring system is

appropriate can be assessed at the bedside by the rapid-flush test ( figure 5) [52,53]. This
test is performed by briefly opening and closing the valve in the continuous flush device
(rapid flushing), which produces a square wave on the monitor. The square wave is followed
by, "ringing" (rapid oscillations in pressure), then a return to baseline. Over- or under-
damping may be present:

● Over-damping – No ringing is observed after a rapid flush of an over-damped system.

Common causes of over-damping include air bubbles or clots in the connecting tubing,
loose connections, kinks, or arterial spasm.

● Under-damping – Excess ringing is observed after a rapid flush in an under-damped

system. Common causes of under-damping include excessive tubing length, tubing
connected with stopcocks, and patient factors such as tachycardia, high cardiac output,
or hypothermia. In general, most arterial pressure monitoring systems in clinical use are
slightly under-damped, resulting in systolic pressure, "overshoot," that is commonly
observed [51,54].

Calibration — Routine calibration of the monitor and transducer is no longer necessary

since modern disposable transducers are standardized [55]. However, if a calibration error is
suspected, it is easy to perform a simple test at the bedside by creating a, "water column," of
standard height with the saline-filled monitoring tubing. For example, a 30 cm height should
display a pressure of approximately 22 mmHg [56].

MONITORING INTRAVASCULAR VOLUME STATUS

Interpretation of respiratory variation — Arterial waveform analysis can be used to

determine fluid responsiveness. Variations in the waveform that occur during respiration (eg,
pulse pressure variation [PPV] or systolic blood pressure variation [SPV], stroke volume
variation [SVV]) can be observed or measured to assess responses to fluid challenges (
figure 1 and figure 2) [57-61]. Each of the dynamic indices based on respiratory
variation has advantages and disadvantages, with limitations in sensitivity and specificity (
 table 1) [57,62-64]. Although hemodynamic indices of respiratory variation can be
computed (manually or automatically), visual estimation may be adequate to guide fluid
therapy. (See "Intraoperative fluid management", section on 'Indices based on respiratory
variation (arterial pressure waveform)' and "Novel tools for hemodynamic monitoring in
critically ill patients with shock", section on 'Volume tolerance and fluid responsiveness'.)

Cardiac output measurement — Although the gold standard for cardiac output
measurements is use of thermodilution techniques with a pulmonary artery catheter (PAC),
the risks of central venous catheterization and introduction and maintenance of a PAC have
led to development of alternative methods such as arterial waveform-based devices, lithium
dilution-based devices, and thermodilution-based devices [57,65]. Information regarding the
accuracy and utility of these technologies is discussed elsewhere. (See "Novel tools for
hemodynamic monitoring in critically ill patients with shock", section on 'Arterial pulse
waveform analysis'.)

COMPLICATIONS

Clinically significant complications of arterial catheterization are uncommon. Most

complications can occur at any insertion site, although a few are site-specific ( table 3).
Proper site selection, sterile technique, and ultrasound guidance during catheterization
minimize complications.

All sites — Complications of indwelling arterial catheters include bruising, pain, swelling,
hematoma or bleeding at the insertion site, damage to adjacent structures, local or systemic
infection, and iatrogenic blood loss due to sampling. In addition, specific vascular
complications include vasospasm, thromboembolism, dissection, pseudoaneurysm, or
arteriovenous fistula formation. These vascular complications may cause local or distal
ischemia that can progress to necrosis in rare instances.

Vasospasm — Vasospasm is a common complication following arterial catheterization,

occurring in 57 percent of patients in one study, and is typically an initial sign in arteries that
develop thrombosis [66] (see 'Thrombosis' below). Vasospasm is identified by pain in the
extremity, decrease in arterial blood pressure (BP), severe damping of the arterial waveform,
loss of the arterial pulse or significant decrease in the oximetry plethysmogram signal quality
index distal to the arterial cannulation site [67]. Risk factors may include female sex, diabetes
mellitus, and/or the ratio of catheter size to radial artery size [68].
We do not employ intra-arterial injection of any agent to reduce the incidence of vasospasm.
Studies to decrease vasospasm risk have included intra-arterial injection of heparin,
nitroglycerin, nitroprusside, verapamil, and phentolamine, as well as administration of
systemic sedative agents [69-72]. Systemic sedatives can decrease sympathetic output to the
predominantly alpha-1 receptors of the distal arteries, which may decrease the risk of
vasospasm. However, results in these studies were not consistent, and most were conducted
in patients undergoing percutaneous coronary interventions with a large catheter-to-radial
artery size ratio.

Thrombosis — Arterial thrombosis can be suspected in patients with decreased distal

pulses, dampened or lost arterial waveform, or cyanotic digits. In rare cases, gangrene may
occur [73]. Thrombosis can be detected by Doppler ultrasound in up to 25 percent of patients
who have an arterial catheter, although clinically significant thrombosis occurs in less than 1
percent of such patients [74,75]. Risk factors for thrombosis include [75-78]:

● Increased duration of catheterization (ie, >72 hours)

● Larger catheters
● Smaller blood vessels
● Low flow states (eg, low cardiac output)
● Peripheral artery disease
● Vasospastic disorders (eg, Raynaud phenomenon)

We do not routinely use heparin or sodium citrate to maintain patency of intra-arterial

catheters but rather use saline for flushing and maintenance of catheter patency. A 2014
meta-analysis noted no significant differences in catheter patency or functionality in
individual studies with or without use of heparinized solution flushed with continuous
pressure at a heparin dose of 1 to 2 international units/mL (seven trials; 505 patients) [79]. As
an alternative to heparin flushing, sodium citrate is used by some centers to maintain
catheter patency when heparin is contraindicated (ie, heparin-induced thrombocytopenia).
However, in one small randomized trial in 40 critically ill patients, no differences in catheter
patency were noted for flush solution containing either sodium citrate 1.4% or heparin 4
international units/mL [80].

Particulate embolism — Extremity ischemia as a consequence of embolization may occur

if intra-arterial catheter insertion or manipulation causes dislodgement or fragmentation of
thrombus or atheromatous debris. Arterial catheters in proximity to the origin of the carotid
artery (eg, axillary artery) can cause cerebral emboli.

Distal pulses should be monitored regularly in all patients with an arterial catheter for early
detection of embolization. Caution is advised during flushing of the catheter (ie, manual
catheter flushing performed gently with the lowest pressure needed). Prolonged high
pressure flushing using the system flush valve should be avoided to minimize the potential
for retrograde embolization of particulate matter or air [81,82]. (See 'Air embolism' below.)

Signs and symptoms of ischemia due to embolization depend on the presence (or absence)
of collateral circulation and the size of the embolized particles. Distal embolization and
ischemia (ie, in the digits) is more typical for an indwelling arterial catheter. However,
proximal limb ischemia may occur if the access site itself thromboses.

Air embolism — Air bubbles in the flush solution of an arterial catheter monitoring
system can embolize antegrade or retrograde and may cause ischemic damage to the brain,
spinal cord, heart, or skin. In a primate model, 2 mL of air injected into the radial artery with
a standard pressurized infusion apparatus results in clinically significant cerebral air emboli
[83]. Such emboli are more likely in patients who are small in size or sitting upright. (See "Air
embolism", section on 'Etiology'.)

It is important to realize that air introduced into the arterial circulation via an arterial
catheter is more likely to have adverse sequelae than air introduced via intravenous
catheters because venous air will travel to the pulmonary capillaries and not pass to the left
side of the heart. (See "Air embolism", section on 'Arterial air embolism'.)

Accidental intra-arterial injection of medications — Unintentional intra-arterial

injection of a medication may lead to limb or other end-organ ischemia or damage. The
mechanism of injury may be related to cytotoxicity of the agent itself or to obstruction of
blood flow caused by formation of drug crystals, hemolysis and platelet aggregation due to
vessel intima damage, or profound vasoconstriction and subsequent thrombosis (eg, due to
norepinephrine injection) [84,85]. Specific adverse reactions caused by various agents after
intra-arterial injection are shown in the table ( table 4).

Dissection, pseudoaneurysm, arteriovenous fistula — Arterial dissection,

pseudoaneurysm, and arteriovenous fistula formation are uncommon complications of
arterial cannulation. Dissection occurs in approximately 1 percent of patients undergoing
radial artery catheterization for coronary angiography [86]. Prompt identification by strict
monitoring of the arterial waveform is important since acute dissection may lead to arterial
occlusion and distal ischemia.

Pseudoaneurysm formation is a very rare complication of arterial cannulation, occurring with

an incidence of <0.1 percent after radial artery access for coronary angiography [87]. It
presents as a pulsatile mass and typically occurring after local site bleeding and/or
hematoma formation. Such damage to the arterial wall is associated with multiple
cannulation attempts, larger sheath size, anticoagulation, and catheter infection [88]. This
can be an early or late complication.

Very rarely, an arteriovenous fistula may develop after arterial catheterization [89].

Local or systemic infection — Compared with central venous catheters (CVCs), it is

generally accepted that the risk of infection is lower with arterial catheters. Most arterial
catheter-related infections develop due to local (eg, insertion site) infection, approximately
10 percent by colonization, and only rarely due to bacteremia or sepsis [90-97].

The overall incidence of infection is difficult to estimate due to variable definitions for
infection among studies, and inclusion of both arterial and venous catheters in many studies.
A 2013 meta-analysis that included 49 studies and nearly 31,000 arterial catheters noted an
incidence of 3.4 arterial catheter-related bloodstream infections per 1000 catheters, with
0.96 infections per 1000 catheter days [97]. A higher incidence of infections was noted for the
femoral arterial site (1.5 per 100 catheters) compared with the radial site (0.3 per 100
catheters). One prospective cohort study in more than 2500 patients also noted a higher
incidence of catheter-related infection after femoral compared with radial arterial
catheterization, both for bloodstream infections (1.92 versus 0.25 infections per 1000
catheter-days) and for local infections (3.02 versus 0.75 infections per 1000 catheter-days)
[95]. Other smaller studies found no association between the site of arterial catheterization
and infection [93,98]. (See "Intravascular catheter-related infection: Epidemiology,
pathogenesis, and microbiology".)

Risk factors for catheter-related infection include poor aseptic technique during insertion,
insertion by surgical cut-down, and longer duration of use (≥4 days) [2,91,92,94,99].
Preventive measures are based on studies of prevention of catheter-related infection in
patients with a CVC or a pulmonary artery catheter (PAC) ( table 5). (See "Intravascular
catheter-related infection: Prevention".)
 Iatrogenic blood loss — Laboratory tests not only require withdrawal of the blood
sample to be tested, but an additional 3 to 12 mL of blood may be wasted (ie, to avoid
sample contamination with saline or heparin). Substantial blood loss can result if frequent
testing is necessary [100,101]. Strategies to help minimize iatrogenic blood loss include:

● Sampling from the port nearest to the catheter insertion, or using a closed blood draw
system that allows re-infusion of unused blood [102].

● Use of intra-arterial blood gas monitoring if withdrawal of blood for blood gases is the
major reason for blood sampling. This technique uses a fluorescent optode to measure
arterial pH, partial pressure of arterial carbon dioxide (PaCO2), and partial pressure of
arterial oxygen (PaO2) measurements as needed without removing blood from the
patient [103]. Fiberoptic continuous sensor systems are also available, and may be
advantageous if a prolonged period monitoring is anticipated [104].

Site-specific complications — Each arterial catheterization site is associated with a unique

set of potential complications ( table 3) [77,93,105,106]. As examples, radial artery
insertion is associated with peripheral neuropathy, femoral artery insertion with
retroperitoneal hematoma, axillary artery insertion with brachial plexopathy, and brachial
artery insertion with injury to the median nerve.

Although many sites share the same possible complications (eg, bleeding), the frequency of
these complications varies among the different insertion sites. As examples:

● The most common complications associated with radial artery catheterization are
occlusion (2 to 35 percent) and hematoma (up to 15 percent). Permanent injury rarely
results from either complication [107].

● A common complication associated with femoral artery catheterization is hematoma (6

percent), which can be large and difficult to detect if extension to the retroperitoneum
occurs [107].

MAINTENANCE OF AN INDWELLING ARTERIAL CATHETER

We employ the following measures to maintain intra-arterial catheter integrity and prevent
local or systemic infection (see 'Local or systemic infection' above):
 ● Arterial catheters are not routinely changed to a new site after any interval [2,108].
Instead, vigilant clinical assessment of the insertion site and of the patient is employed
to determine whether an arterial catheter should be replaced. However, any catheter
inserted under emergency conditions (ie, placed without standard sterile precautions)
should be replaced as soon as is feasible. Arterial catheters should be discontinued
when their use is not critical to patient care. It is preferable not to leave femoral
catheters in place for longer than five days due to a higher risk of infection, and not
longer than seven days for other sites.

● Disposable or reusable transducers are replaced at 96-hour intervals. The associated

tubing, continuous flush device, and flush solutions are also replaced [2].

● The catheter site dressing is replaced when it becomes damp, loose, or soiled, and when
the arterial catheter is removed or replaced.

● Antimicrobial prophylaxis is used in selected settings. (See "Antimicrobial prophylaxis for

prevention of surgical site infection in adults".)

REMOVAL OF AN ARTERIAL CATHETER

Before removing any arterial catheter, international normalized ratio, partial thromboplastin
time, and platelet counts should be checked and administration of medications that affect
coagulation and platelet function noted. If any of these are abnormal, or if the patient is on
antiplatelet therapy, extended compression times will be needed. Unlike venous catheter
removal, it is not necessary to maintain a Trendelenburg position to avoid air embolism,
although the supine position is preferred in patients with a femoral catheter so that
adequate pressure can be maintained after removal.

Aseptic technique is used during removal of arterial catheters, and care must be taken to
avoid splashing blood. After hand washing, nonsterile gloves, a protective gown, and face
mask with shield should be donned for any arterial catheter removal regardless of catheter
location. The catheter should be flushed prior to removal, or alternatively, blood can be
drawn back into the catheter to prepare it for removal.

To remove the catheter, clean the catheter site with chlorhexidine, place a 4x4 dressing and
apply pressure overlying the arterial puncture site, then slowly pull the catheter out
maintaining pressure at both the artery and skin puncture sites. Generally, pressure should
be held for five minutes over the radial artery and for ten minutes over the femoral artery.

In addition to the cannulation site, the optimal duration for pressure application depends on
the catheter size, with longer compression times for larger diameter devices or sheaths. For
patients with known coagulopathy, compression times should be increased to ten minutes
over the radial artery and 15 to 20 minutes over the femoral artery. If oozing continues, the
artery should be compressed for five additional minutes and rechecked. Once bleeding has
stopped, a dressing can be placed.

After removal, the catheter should be inspected to ensure that it is intact. If the catheter is
fragmented, pressure should be applied above the site of catheter entry into the skin. Since
embolization of catheter fragments can occlude the distal extremity circulation, urgent
surgical referral should be obtained. (See 'Particulate embolism' above.)

After removal from a femoral puncture site, the hip should remain without flexion for up to
two hours following removal. The pulse at the puncture site and pulses distal to it should be
rechecked in 15 minutes for signs of hematoma or extremity ischemia.

SUMMARY AND RECOMMENDATIONS

● Indwelling arterial catheters are used for continuous monitoring of systemic blood
pressure (BP), evaluation of respirophasic variations in the arterial pressure waveform to
determine intravascular volume status, and intermittent blood sampling for laboratory
testing. (See 'Uses' above.)

● A catheterization site is selected by locating a palpable arterial pulse in a peripheral

(radial, brachial, dorsalis pedis) or central (eg, femoral, axillary) arterial site. (See 'Site
selection' above.)

● Peripheral arterial catheters are placed with standard sterile techniques including sterile
gloves and drape, whereas full barrier precautions including masks, caps, and eye
protection can be used for insertion of central arterial catheters to minimize the
potential for infection or disease transmission. Equipment necessary for arterial
catheterization is listed in the table ( table 2). (See 'Sterile technique' above.)

● In conscious patients we use local anesthesia at the insertion site to avoid pain
 (particularly if a skin incision is needed). (See 'Local anesthetic injection' above.)

● A guidewire is typically used during arterial catheter insertion, unless the operator is
experienced and more comfortable with a direct puncture approach. If difficulties are
encountered with the direct puncture approach, it is prudent to change to a guidewire
approach. (See 'Use of a guidewire' above.)

● Despite the superiority of direct intra-arterial BP measurement compared with

noninvasive techniques, factors such as the site of arterial cannulation, transducer level,
or damping of the pressure tracing may cause misinterpretation of the arterial pressure
waveform or introduce errors. (See 'Monitoring blood pressure' above.)

● Arterial waveform analysis can be used to determine fluid responsiveness. Variations in

the waveform that occur during respiration (eg, pulse pressure variation [PPV] or systolic
blood pressure variation [SPV], stroke volume variation [SVV]) can be observed or
measured to assess responses to fluid challenges ( figure 1 and figure 2). (See
'Cardiac output measurement' above and "Novel tools for hemodynamic monitoring in
critically ill patients with shock".)

● Complications of indwelling arterial catheters include vasospasm, thrombosis,

particulate or air embolism, accidental intra-arterial injection of medications, dissection
or pseudoaneurysm formation, iatrogenic blood loss, and local or systemic infection.
(See 'Complications' above.)

● We suggest that arterial catheters not be replaced routinely (Grade 2C). Instead, we use
vigilant clinical assessment of the insertion site and of the patient to determine the need
to remove or replace an arterial catheter. It is preferable not to leave femoral catheters
in place for longer than five days and arterial catheters at other sites for more than
seven days. Arterial catheters should be discontinued when their use is not critical to
patient care.

● We typically replace disposable or reusable transducers at 96-hour intervals, with

replacement of the associated tubing, continuous flush device, and flush solutions at the
same time. (See 'Maintenance of an indwelling arterial catheter' above.)

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Topic 8174 Version 19.0
GRAPHICS

Volume responsiveness to guide fluid therapy

Frank-Starling relationship with corresponding respiratory variations in the arterial pressure waveform. Large
respiratory variations in the arterial pressure or in the plethysmographic waveforms indicate that the patient is on
the steep portion of the Frank-Starling relationship. Small variations indicate that the patient is on the plateau.
Cardiac output maximization concepts aim at increasing cardiac output until it reaches the plateau of the Frank-
Starling relationship. This goal, as demonstrated on this figure, could be achieved by minimizing respiratory variation
in arterial pressure or plethysmographic waveform.

* Arterial waveform obtained from invasive arterial monitoring.

Modified with permission from: Rinehart J, Liu N, Alexander B, Cannesson M. Closed-Loop Systems in Anesthesia: Is There a Potential for
Closed-Loop Fluid Management and Hemodynamic Optimization? Anesth Analg 2012; 114:130. Copyright © 2012 Lippincott Williams &
Wilkins.

Graphic 86275 Version 7.0

Systolic pressure variation and pulse pressure variation

Respiratory variations in arterial pressure.

SPV: systolic pressure variation; PP MAX : pulse pressure maximal; PP MIN : pulse pressure minimal.

Graphic 85848 Version 4.0

Dynamic parameters for intraoperative fluid therapy

Advantage Disadvantage

Systolic pressure variations Easy to manually calculate Depends on diastolic pressure and on
changes in pleural pressure
(Has not been studied in the prone
position)

Pulse pressure variations Directly related to stroke volume Not easy to manually calculate
variations
Need specific device for continuous
display

Stroke volume variations Accurate analysis despite multiple Need specific device
extrasystoles

Modified with permission from: Biais M, Ouattara A, Janvier G, Sztark F. Case scenario: Respiratory variations in arterial pressure for
guiding fluid management in mechanically ventilated patients. Anesthesiology 2012; 116:1354. Copyright © 2012 Lippincott Williams &
Wilkins.

Graphic 85850 Version 9.0

Equipment for arterial line insertion

Cannulation
Intravascular catheter

Guidewire appropriate for arterial site

Lidocaine solution (1 percent) and syringe

Suture material or transparent adhesive dressing

Maximal sterile-barrier precautions (drape, gown, mask, gloves, and cap; antiseptic handwash)

Materials to securely immobilize and expose the arterial site (eg, armboard, tape)

Monitoring
Fluid filled noncompliant tubing with stopcocks

Transducer and dome

Constant flush device

Electronic monitoring equipment

Connecting cable

Bedside monitor and display screen

Recorder

Graphic 78590 Version 5.0

Radial artery catheterization techniques

Separate-guidewire approach*: The nondominant hand palpates the artery while the
dominant hand manipulates the catheter, which is inserted and advanced slowly until
pulsatile blood return is observed. The catheter is advanced slightly, ensuring the outer
catheter has also entered the lumen. Care must be taken to avoid puncturing the posterior
wall of the vessel when advancing the catheter. The nondominant hand then stabilizes the
catheter while the dominant hand removes the needle from the intravascular catheter. If
pulsatile blood return is observed after the needle is removed, the guidewire is advanced
until its tip is beyond the distal end of the catheter. Finally, the catheter is advanced into the
artery over the guidewire and the guidewire is removed.
Integral-guidewire approach*: The guidewire of this specialized device is integrated with
the needle and catheter. The nondominant hand palpates the artery, while the dominant
hand manipulates the needle-guidewire-catheter unit, which is inserted and advanced
slowly until pulsatile blood return is observed. The nondominant hand then stabilizes the
needle-guidewire-catheter unit, while the dominant hand advances the guidewire tab to
push the wire into and through the needle and catheter. The outer catheter is advanced
over the needle and wire into the artery. Finally, the needle-guidewire unit is removed.

* For illustration purposes, full barrier precautions are not pictured.

Graphic 74903 Version 6.0

Arterial pressure waveform

Graphic 114459 Version 1.0

Arterial catheter rapid flush test

Intravascular pressure tracings obtained during the rapid flushing of a monitoring

catheter. A. Optimal damping in which rapid flushing produces a rapid upstroke in
pressure followed by recovery characterized by a fall in pressure to below baseline
with less than three beats of ringing. B. Overdamped system in which no ringing is
seen. C. Underdamped system in which there is excessive ringing.

Redrawn from Rippe, JM, Irwin, RS, Alpert, JS, Fink, MP (Eds), Intensive Care Medicine, 3rd ed,
Little Brown, Boston, 1996.

Graphic 56073 Version 2.0

Complications of arterial catheters

All sites
Pain and swelling

Thrombosis

Embolization

Hematoma

Limb ischemia

Pseudoaneurysm

Diagnostic blood loss

Arteriovenous fistula

Infection

Radial artery
Cerebral embolization

Peripheral neuropathy

Femoral artery
Retroperitoneal hematoma

Axillary artery
Cerebral embolization

Brachial plexopathy

Brachial artery
Cerebral embolization

Median nerve damage

Graphic 63291 Version 4.0

Adverse reactions to intra-arterial injection of various agents [1-6]

Drug Effect

Aminophylline Tissue damage

Amiodarone Ischemia

Amphetamines Ischemia, tissue damage

Amphotericin Tissue damage

Atracurium Ischemia

Barbiturates (thiopental) Ischemia, necrosis, tissue damage

Benzodiazepines Tissue damage

Buprenorphine Cyanosis

Calcium chloride/gluconate Tissue damage

Chlordiazepoxide Vasospasm

Chlorpromazine Ischemia, necrosis

Erythromycin Tissue damage

Ketamine Necrosis

Mannitol (10% and 20%) Tissue damage

Metoclopramide Ischemia, necrosis

Opiates Ischemia, tissue damage

Parenteral nutrition Tissue damage

Penicillin Tissue damage

Phenytoin Ischemia, necrosis, tissue damage

Potassium chloride Tissue damage

Promethazine Ischemia, necrosis

Propofol Hyperemia, distal "blanching"

Prostaglandins Tissue damage

Non-depolarizing muscle antagonists (atracurium, Ischemia

rocuronium)

Sodium bicarbonate Tissue damage

Sodium chloride >0.9% Tissue damage

Vancomycin Tissue damage

Vasoconstrictors (epinephrine, dopamine, norepinephrine, Tissue damage

vasopressin)

References:​
1. Arquilla B, Gupta R, Gernshiemer J, et al. Acute arterial spasm in an extremity caused by inadvertent intra-arterial injection
successfully treated in the emergency department. J Emerg Med 2000; 192:139.
2. Devulapalli C, Han KD, Bello RJ, et al. Inadvertant intra-arterial drug injection in the upper extremity: systematic review. J Hand
Surg Am 2015; 40:2262.
3. Foret AL, Bozeman AP, Floyd III WE. Necrosis caused by intra-arterial injection of promethazine: case report. J Hand Surg 2009;
34:919.
4. Ghouri AF, Mading W, Prabaker K. Accidental intraarterial drug injections via intravascular catheters placed on the dorsum of the
 hand. Anesth Analg 2002; 95:487.
5. Lake C, Beecroft CL. Extravasation injuries and accidental intra-arterial injection. Continuing Education in Anaesthesia Critical
Care & Pain 2010; 10:109.
6. Righini M, Angelli, lo-Scherrer A, Gueddi S, et al. Management of severe ischemia of the hand following intra-arterial injection.
Thromb Haemost 2005; 4:219.

Graphic 120700 Version 1.0

Prevention of infection with arterial catheters

Replacement and relocation of catheter

Do not routinely replace peripheral arterial catheters.

Perform inspection of site daily for signs of infection, distal ischemia, or embolization.

Replace disposable or reusable transducers at 96-hours intervals. Replace other components of the system, including
tubing, continuous flush device, and flush solutions at the time the transducer is changed.

Replacement of catheter-site dressing

Replace dressing when the catheter is removed or replaced, or when the dressing becomes damp, loosened, or soiled.
Replace dressings more frequently in diaphoretic patients.

There is no need to remove a gauze or opaque dressing if the patient has no clinical signs of infection.

Replacement of administration sets

Replace the intravenous tubing, continuous flush device at the time the transducer is replaced (ie, 96-hour intervals).

Hang time for parenteral fluids

Replace the flush solution at the time the transducer is replaced (ie, 96-hour intervals).

Graphic 65076 Version 4.0

Contributor Disclosures
Arthur C Theodore, MD Nothing to disclose Gilles Clermont, MDCM, MSc Nothing to disclose Allison
Dalton, MD Nothing to disclose Michael F O'Connor, MD, FCCM Consultant/Advisory Boards:
Intensix/CLEW [Predictive analytics in medicine]. Girish P Joshi, MB, BS, MD, FFARCSI Consultant/Advisory
Boards: Pacira Pharmaceuticals [pain management]. Speaker's Bureau: Baxter [anesthesia]. Nancy A
Nussmeier, MD, FAHA Nothing to disclose Geraldine Finlay, MD Consultant/Advisory Boards: LAM Board
of directors, LAM scientific grant review committee for The LAM Foundation.

Contributor disclosures are reviewed for conflicts of interest by the editorial group. When found, these are
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