PROCEDURE 61 • Knowledge of anatomy and physiology of the vasculature and adjacent structures is needed. • Nurses must be adequately prepared to insert arterial catheters. This preparation should include specific educational content about arterial catheter insertion and opportunities to demonstrate clinical competency. • Understanding of the principles of hemodynamic monitoring is necessary. • Clinical competence in suturing is needed. • Conditions that warrant the use of arterial pressure monitoring include patients with the following: • Noninvasive indirect blood pressure measurements determined with auscultation of Korotkoff sounds distal to an occluding cuff consistently average 10 to 20 mm Hg lower than simultaneous direct measurement.13 • Arterial waveform inspection can help with rapid diagnosis of the presence of valvular disorders, and determine the effects of dysrhythmias on perfusion, the effects of the respiratory cycle on blood pressure, and the effects of intraaortic balloon pump therapy or ventricular assist device therapy on blood pressure. • The preferred artery for arterial catheter insertion is the radial artery (see Fig. 80-1). Although this artery is smaller than the ulnar artery, it is more superficial and can be more easily stabilized during the procedure.9 The brachial artery is a safe and reliable alternative site for arterial puncture and line placement.18 • At times, the femoral artery may be used for arterial catheter insertion. The use of this artery can be technically difficult because of the proximity of the femoral artery to the femoral vein (see Fig. 80-2). • The most common complications associated with arterial puncture include pain, vasospasm, hematoma formation, infection, hemorrhage, and neurovascular compromise.3,8,19 • Causes of failure to cannulate the artery include a tangential approach to the artery, tortuosity of the artery or arterial spasm, or impingement of the needle tip on the posterior wall.20 • Site selection is as follows:
Arterial Catheter Insertion (Perform)
PREREQUISITE NURSING KNOWLEDGE
Acute hypotension or hypertension (hypertensive crisis)
Hemodynamic instability or circulatory collapse
Continuous infusion of vasoactive medications
Frequent arterial blood gas measurements
Intraaortic balloon pump therapy
Coronary interventional procedures
Use the radial artery as the first choice. Conduct a modified Allen’s test before performing an arterial puncture on the radial artery (see Fig. 80-3). Normal palmar blushing is complete before 7 seconds, indicating a positive result; 8 to 14 seconds is considered equivocal; and 15 or more seconds indicates a negative test result. Doppler flow studies or plethysmography can also be performed to ensure the presence of collateral flow. Research shows these studies to be more reliable than the modified Allen’s test.1,20 Thrombosis of the arterial cannula is a common complication. Ensuring collateral flow distal to the puncture site is important for prevention of ischemia. Puncture of both the radial and ulnar arteries on the same hand is never recommended, to prevent compromising blood supply to the hand.4,10,14,16
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