JoVE Science Education
Emergency Medicine and Critical Care
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JoVE Science Education Emergency Medicine and Critical Care
Arterial Line Placement
  • 00:00Overview
  • 01:04Preparatory Steps and Positioning
  • 03:35Two Techniques for ALP: Over-the-Wire and Over-the-Needle
  • 06:30Summary

동맥 선 배치

English

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Overview

출처: 샤론 보드, MD, 응급 의학의 학과, 존스 홉킨스 의과 대학, 메릴랜드, 미국

환자를 모니터링할 때 정확하고 신뢰할 수 있는 값을 얻는 것이 중요합니다. 혈압 모니터링은 필수적인 활력 징후 중 하나이며, 대부분의 환자에게 비침습적 기술을 활용하여 측정하는 것은 정확한 값을 제공합니다. 그러나 혈압에 더 정확하고 구체적이며 신뢰할 수 있는 측정이 필요한 상황이 있습니다. 이것은 동맥 내 혈압 감시에 의해 달성될 수 있고 동맥 선 배치를 요구합니다. 동맥 선 배치는 주요 동맥 중 하나에 혈압을 변환 할 수있는 카테터의 삽입을 말합니다 (예 : 방사형 또는 대퇴동맥). 잠재적으로 동맥 선 배치를 필요로 하는 환자는 극단적인 낮은 (패혈증 또는 심장 유발 충격에서 와 같은) 또는 높은 (뇌혈관 사고 또는 고혈압 응급) 혈압 측정을 포함합니다. 이 환자의 대부분은 혈압을 증가하거나 감소시키기 위하여 혈관 활성 약물에 두습니다. 목표는 환자의 혈압을 감소 하는 경우, 그것은 점차적으로 수행 해야 합니다., 더 가까운 혈압 모니터링을 필요로. 동맥 라인 배치는 또한 빈번한 동맥 혈액 가스 감시를 필요로 하는 환자를 위해 이상적입니다.

Procedure

1. 절차 준비 필요한 소모품을 구하십시오. 여기에는 다음이 포함됩니다. 클로르페시딘 패드와 같은 살균 피부 준비 패드 주사기 (리도카인 1%) 바늘이 부착된 동맥 라인 소개자 키트. 키트에는 오버-더-니들 카테터 키트와 가이드 와이어가 있는 키트의 두 가지 유형이 있습니다. 바늘 드라이버, 픽업 및 홍채 가위를 가진 적절한 봉합재료(일반적으로 #0 실크).</…

Applications and Summary

Placement of an arterial line is a core procedure when caring for critically ill patients. It is important to note that the procedure might not be successful on the initial attempt. If multiple attempts are made for placement in the same vessel, spasm may develop. In this situation, an alternative site should be identified for arterial access. Arterial line placement provides accurate and timely blood pressure monitoring and affords a clinician with the ability to closely titrate medications and pressors.

Transcript

Arterial line placement refers to the insertion of a catheter, which is able to transduce blood pressure, into one of the major arteries, like radial or femoral.

Blood pressure monitoring is one of the essential vital signs and, for a majority of patients, measuring it utilizing non-invasive techniques-discussed in a video in the Essential of Physical Examinations 1 collection-provides accurate values.nHowever, there are situations in which the blood pressure requires more exact, specific, and reliable measurements. In such cases, one can perform arterial line placement, or ALP, which allows intra-arterial blood pressure monitoring in real time.

Here, we will demonstrate the essential steps required to successfully place an arterial line in a patient’s radial artery.

Now let’s review the steps for performing a successful arterial line placement in the radial artery.

The necessary supplies include: antiseptic skin prep pads, such as chlorhexidine pads; a 1% lidocaine syringe with a needle attached-this is optional; an arterial line introducer kit-there are two different types: over-the-needle and with a guide wire; proper suture material-which is generally zero silk-with a needle driver, pickups, and iris scissors; tape for patient positioning, gauze, sterile dressing to further secure the line and, lastly, an arm board-only necessary for some patients.

Don personal protective equipment, this includes appropriately sized sterile gloves and a mask with an attached face shield. It is imperative to keep the eyes shielded from possible exposure.

Upon entering the room, verify that the arterial line setup is attached to the monitor correctly. Before starting the procedure, assess the patient for procedure contraindications. Inspect the insertion site for cellulitis or severe burns, would be a contraindication to the procedure. Assess for adequate collateral blood flow to the hand, by using the Modified Allen’s test.

Ask the patient make a fist, and then occlude their ulnar and radial artery. Next, have the patient releases their fist. The hand should be pale. Release the pressure on the ulnar artery. The patient’s hand should turn pink in the next 1-3 seconds. This indicates the ulnar artery is functioning properly, and one can proceed with the arterial line placement in the radial artery of that arm. After confirming the absence of any contraindication, place the patient’s arm on a flat surface in supine position, with the wrist adequately exposed. Then place the patient’s hand in dorsiflexion and support it in this position with a gauze roll under the dorsal aspect. Placing the patient’s hand in this position brings the radial artery closer to the skin’s surface and aids in cannulation. To maintain the hand in this position, tape it with the gauze roll, and once properly secured, one can begin with line placement can begin.

Now let’s discus the two different techniques commonly utilized for line placement – the over-the-wire technique and the over-the-needle technique.

First, prep the insertion area with a chlorhexidine swab. Be sure to allow the area to dry prior to the line insertion. Locate the radial artery by feeling for the pulse with your non-dominant hand, approximately 1-2 cm proximal to the wrist.

To prevent discomfort from the procedure, anesthetize the insertion site with an intradermal injection of 1-2 milliliters of lidocaine 1%.

At the location of the pulse, using your dominant hand, insert the needle at a 30 – 45° angle and when advancing the needle, look at the hub for a flash of blood. It is important to identify the first flash of patient’s blood, as the radial vessel is small and the flash can be easily missed. Failure in identifying this first flash may lead to a vessel puncture. Note, that the initial blood flash is bright red in appearance, as opposed to the darker colored blood from a vein. Once the flash is observed, advance the needle a few more millimeters.

For the “over-the-wire technique”, advance the wire gently into the vessel, while removing the needle. It should not meet much resistance and should easily thread. If experiencing difficulty, gradually rotate the needle tip and attempt the wire placement again. After the wire is inserted, advance the catheter over the wire and remove the wire. Be sure to never let go of the wire during the procedure.

If the over-the-needle technique is being utilized, advance the needle a few millimeters more when the initial flash of blood is observed, and then gradually advance the catheter as the needle angle is reduced to approximately 10°. The catheter should advance easily into the vessel. When removing either the needle or the wire, be careful to hold pressure on the proximal portion of the catheter. You will know the catheter is in the correct location if there is pulsatile blood flow from the catheter.

Promptly connect the hub of the catheter to the arterial line setup. At this time, blood pressure monitoring can begin. Secure the line with sutures, usually zero silk, and place a sterile dressing over the line. Be sure to discard the sharps appropriately. Lastly, assess perfusion by performing the capillary refill in the patient’s hand. Capillary refill should be normal- fingers should turn pink in 1-3 seconds.

You have just watched a JoVE video detailing the steps for arterial line placement. This is a core procedure when caring for critically ill patients, as it provides accurate and timely blood pressure monitoring, which in turn allows the clinician to closely titrate medications and pressors. As always, thanks for watching!

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JoVE Science Education Database. JoVE Science Education. Arterial Line Placement. JoVE, Cambridge, MA, (2023).