Atlas of Procedures in Neonatology, 4th Edition

Vascular Access

30

Peripheral Arterial Cannulation

An N. Massaro

Khodayar Rais-Bahrami

Martin R. Eichelberger

Arterial access is often needed in the care of the sick neonate. For various technical or clinical reasons, catheterization of the umbilical artery is not always possible. Therefore, peripheral arterial cannulation may be required. Although cannulation of the axillary (1,2) and temporal arteries (3,4) has been reported in neonates, these sites are not recommended because of the difficulty of access and potential adverse neurologic sequelae, respectively (5,6,7 and 8). Similarly, cannulation of the brachial artery should be avoided because of the poor collateral blood flow. As a general rule, the most peripheral available artery should be used, to reduce the potential sequelae from any associated vascular compromise or thromboembolic event. The artery chosen should be large enough to measure blood pressure without occlusion, have adequate collateral circulation, be at a site with low infection risk, and be in an area that can be easily monitored and cared for by nursing staff. Common sites for peripheral arterial cannulation include the radial, ulnar, dorsalis pedis, and posterior tibial arteries.

  1. Indications
  2. Monitoring of arterial blood pressure
  3. Frequent monitoring of blood gases or laboratory tests (e.g., sick ventilated neonates or extremely low-birthweight premature infants)
  4. When preductal measurement is required (e.g., with persistent pulmonary hypertension) in the case of right-upper-extremity cannulation
  5. Contraindications
  6. Bleeding disorder that cannot be corrected
  7. Pre-existing evidence of circulatory insufficiency in limb being used for cannulation
  8. Evidence of inadequate collateral flow (i.e., occlusion of the vessel to be catheterized may compromise perfusion of extremity)
  9. Local skin infection
  10. Malformation of the extremity being used for cannulation
  11. Previous surgery in the area (especially cutdown)
  12. Equipment

Sterile

  1. Gloves
  2. Antiseptic solution (e.g., an iodophor)
  3. 4- x 4- in gauze squares
  4. 0.5 to 0.95 N saline with 1 to 2 U/mL heparin

Although hypernatremia has been reported in very small premature infants who received excess sodium in flush solution (9), in our experience 0.5 N saline has been used without complications at infusion rates of 0.5 to 1 mL/hr. Using heparinized saline has been shown to maintain line patency longer than hypotonic solutions such as heparinized 5% dextrose water (10) or unheparinized normal saline (11).

  1. 3- or 5-mL syringe
  2. 20-gauge venipuncture needle (if using larger-size 22-gauge cannula)
  3. Appropriate-size cannula: 22-gauge x 1- in (2.5-cm), 24-gauge x 0.75-in, or 24-gauge x 0.56-in tapered or nontapered cannula with stylet for larger to smaller neonates, respectively
  4. Antiseptic ointment (optional)
  5. Arterial pressure transducer and extension tubing (see Chapter 8)
  6. 5-0 nylon suture with curved needle (optional)
  7. Needle holder (optional)
  8. Suture scissors (optional)
  9. T connector primed with heparinized flush solution
  10. Transparent, semipermeable dressing

Nonsterile

  1. Equipment for transillumination (see Chapter 12) or Doppler ultrasound

Use of Doppler ultrasound for localization of the artery (12,13 and 14) and assessment of the adequacy of the palmar circulation has been described (15,16).

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  1. ½-in, water-resistant adhesive tape
  2. Materials for forearm restraint (see Chapter 3) for radial or ulnar cannulation
  3. A constant-infusion pump capable of delivering flush solution at rate of 0.5 to 1 mL/hr against back pressure

Additional Equipment Required for Cutdown Procedure

  1. All equipment except mask must be sterile.
  2. Gown and mask
  3. 0.5% lidocaine hydrochloride in labeled 3-mL syringe
  4. 11 scalpel and holder
  5. Two curved mosquito hemostats
  6. Nerve hook
  7. 5-0 nylon suture
  8. Precautions
  9. When performing radial artery cannulation, always check ulnar collateral circulation using the Allen test (see Chapter 14) (17) or Doppler ultrasound (15,16) prior to undertaking procedure.
  10. When performing dorsalis pedis or posterior tibial cannulation, a modified Allen test can be performed by raising the foot, occluding the dorsalis pedis and posterior tibial arteries, releasing pressure over one, and monitoring for tissue perfusion within 10 seconds, although this technique is less reliable than testing in the hand (18).
  11. When performing radial or ulnar cannulation, avoid excessive hyperextension of wrist, because this may result in occlusion of artery and a false-positive Allen test (19) and has been associated with median nerve conduction block (20).
  12. Leave all fingertips/toes exposed so that circulatory status may be monitored. Examine limb frequently for changes in perfusion.
  13. Never ligate artery.
  14. Take care not to introduce air bubbles into cannula while assembling infusion system or taking blood samples.
  15. Make sure that a continuous pressure waveform tracing is displayed on a monitor screen at all times.
  16. Be aware that the blood pressure measured in the lower extremity may be 5 to 20 mm Hg higher than in the upper extremity, and may be delayed by one tenth of a second (18).
  17. Do not administer a rapid bolus injection of fluid via line, because there is a danger of retrograde embolization of clot or air (21). Flush infusion after sampling should be:
  18. Minimal volume (0.3 to 0.5 mL)
  19. Injected slowly
  20. To reverse arteriospasm, see Chapter 33.
  21. Use cannula for sampling only; no fluids other than heparinized saline flush solution should be administered via cannula.
  22. Remove cannula at first indication of clot formation or circulatory compromise (e.g., dampening of waveform on monitor). Do not flush to remove clots.
  23. Inspect cannula insertion site at least daily.
  24. If signs of cellulitis are present, remove the cannula and send the cannula tip for culture. Also, send a wound culture if there is inflammation at the cutdown site.
  25. Obtain a blood culture from a peripheral site if signs of sepsis are present.
  26. Inspect the area distal and proximal to the insertion site for blanching, redness, cyanosis, or changes in temperature or capillary refill time.
  27. Remove cannula as soon as indications no longer exist.
  28. Technique

Standard technique for percutaneous arterial cannulation

  1. Choose a site for cannulation and secure the appropriate limb.
  2. Radial artery:This is the most routine site for cannulation. The infant's forearm and hand can be transilluminated with the wrist in extension 45 to 60 degrees (Fig. 30.1), making sure that fingers are visible to monitor distal perfusion. The artery can be palpated proximally to the transverse crease on

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the palmar surface of the wrist, medial to the styloid process of the radius, and lateral to the flexor carpi radialis (Fig. 30.2).

 

FIG. 30.1. Transillumination of the radial artery.

  1. Ulnar artery:In a small number of infants, the ulnar artery may be more easily located than the radial artery (22). If an Allen test indicates that the collateral blood supply is adequate, the ulnar artery may be cannulated using the same method as for a radial artery. The ulnar artery runs along the palmar margin of the flexor carpi ulnaris, radial to the pisiform bone. Caution is necessary when cannulating the ulnar artery because it runs next to the ulnar nerve and is smaller in caliber than the radial artery (Fig. 30.2).
  2. Dorsalis pedis artery:The dorsalis pedis artery can be found in the dorsal midfoot between the first and second toes with the foot held in plantar flexion (Fig. 30.3). It should be noted that the vascular anatomy of the foot is variable and the dorsalis pedis artery may be absent in some patients (23), whereas it may provide the main blood supply to the toes in others (24).
 

FIG. 30.2. Anatomic relations of the major arteries of the wrist and hand.

  1. Posterior tibial artery:The posterior tibial artery runs posterior to the medial malleolus with the foot held in dorsiflexion (Fig. 30.4).
  2. Identify artery by
  3. Palpation (see anatomic landmarks as described above or individual arterial sites)
  4. Transillumination (Fig. 12.1 and Chapter 12) (25)
  5. Doppler ultrasound (12,13 and 14)
  6. Scrub and put on gloves.
  7. Prepare skin over site with antiseptic (e.g., an iodophor).
  8. Make small skin puncture with venipuncture needle over site (to ease passage of cannula through skin and reduce chances of penetrating the posterior wall of the vessel, especially when using a larger-gauge cannula).
  9. Accomplish cannulation of artery (Fig. 30.5).
  10. Method A (preferred for small premature neonates) (Fig. 30.6)
  11. Puncture artery directly at an angle of 10 to 15 degrees to the skin, with the needle bevel down.
  12. Advance slowly. There will be arteriospasm when the vessel is touched, and blood return may be delayed.

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FIG 30.3. A: Anatomic relations of dorsalis pedis artery. B: White arrow shows anatomic location of dorsalis pedis artery.

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FIG. 30.4. A: Anatomic relations of posterior tibial artery, showing site of incision for cutdown. B: Cannulation of posterior tibial artery; cannula is attached to a transducer for continuous blood pressure monitoring.

 

FIG. 30.5. A: Cannulation of artery using Method A (see text). B: Cannulation of artery using Method B (see text). (Redrawn from 

Filston HC, Johnson DG. Percutaneous venous cannulation in neonates and infants: a method for catheter insertion without “cutdown.” Pediatrics. 1971;48:896

, with permission of American Academy of Pediatrics.)

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  2. Withdraw needle stylet (blood should appear in the cannula) and advance cannula into artery as far as possible.

Method B (Fig. 30-5b)

  1. Pass needle stylet (with bevel up) and cannula through artery at 30- to 40-degree angle to skin.
  2. Remove stylet and withdraw cannula slowly until arterial flow is established.
  3. Advance cannula into artery.

Inability to insert the cannula into the lumen usually indicates failure to puncture the artery centrally. This often results in laceration of the lateral wall of the artery with formation of a hematoma, which can be seen on transillumination.

 

FIG. 30.6. A: Puncture artery directly at angle of 10 to 15 degrees to skin, with needle bevel down. B: Advance slowly. C:Withdraw needle stylet, allow for blood return, and advance cannula into artery. D: Attach cannula firmly to T connector.

  1. Attach cannula firmly to T connector and gently flush with 0.5 mL of heparinized solution, observing for evidence of blanching or cyanosis.
  2. Apply iodophor ointment (optional) to puncture site.
  3. Suture cannula to skin with 5-0 nylon suture if desired.

This step may be omitted as long as cannula is securely taped (Fig. 26.4); use of sutures may produce a more unsightly scar.

  1. Secure cannula as done with peripheral intravenous line, shown in Fig. 26.4. Transparent semipermeable dressing may be used in place of tape to allow continuous visualization of skin entry site. Guarantee that all digits are visible for frequent inspection.

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  1. Maintain patency by attaching T connector to extension tubing or arterial pressure line to run 0.5 to 1 mL/hr of heparinized flush solution by constant infusion pump.
  2. Change intravenous (IV) tubing and flushing solution every 24 hours.

Radial artery cutdown

  1. Cutdown technique is better for the very small neonate, because trauma to the artery causes vasospasm, which makes percutaneous cannulation of a small vessel very difficult.
  2. Technique I: Cutdown at wrist
  3. The artery is initially exposed by cutdown, and a catheter is inserted under direct vision.
  4. Prepare as for percutaneous procedure (Standard Technique, Steps 1 to 3).
  5. Scrub and prepare as for major procedure (see Chapter 4).
  6. Infiltrate site of incision (point of maximum pulsation just proximal to proximal wrist crease) with 0.5 to 1 mL of lidocaine.
  7. Wait 5 minutes for anesthesia.
  8. Make a 0.5-cm transverse skin incision (Fig. 30.7A).
  9. Deepen incision into subcutaneous tissue by blunt longitudinal dissection with curved mosquito hemostat (Fig. 30.7B).
  10. Use curved mosquito hemostat to dissect artery free.

Be gentle, to avoid arteriospasm.

  1. Elevate artery with hemostat or nerve hook (Fig. 30.7C).
  2. Loop ligature (5-0 silk) around artery for traction purposes (Fig. 30.7D). Do not tie ligature.
  3. Advance cannula stylet into artery with bevel down, until cannula is clearly within vessel lumen (Fig. 30.7E).
  4. Remove stylet and advance cannula to hub (Fig. 30.7F).
  5. Remove ligature.
  6. See percutaneous method under E (Standard Technique, Steps 7 to 11) for fixation and care of cannula.

The incision can usually be kept small enough so that the hub of the cannula fills it and no closing suture is needed.

  1. Technique II: Cannulation at anatomic snuff box
  2. Described by Amato et al. (26)
  3. May be used in infants who have undergone previous arterial cutdown at wrist
  4. Should not be a primary approach to radial artery (particularly if cannulation is achieved by cutdown)
  5. Site is not easy to expose.
  6. Scar tends to be more disfiguring than at wrist.
  7. The radial artery passes dorsally at the wrist and traverses the anatomic snuff box, which is bounded medially by the extensor pollicus longus and extensor pollicus brevis muscles (Fig. 30.8A).
  8. The artery becomes superficial immediately after passing the extensor pollicus longus and before passing beneath the first dorsal interosseous muscle.
  9. The point for cannulation is located at the junction of a line drawn along the medial aspect of the extended thumb and another line drawn along the lateral aspect of the extended index finger (Fig. 30.8).

Posterior tibial artery cannulation by a cutdown procedure

  1. Prepare as for percutaneous method.
  2. Put on mask.
  3. Tape foot to footboard in equinovarus position (see Chapter 3).
  4. Scrub and prepare as for major procedure (see Chapter 4).
  5. Infiltrate incision site with 0.5 to 1 mL of 0.5% lidocaine (Fig. 30.4).
  6. Wait 5 minutes for anesthesia.
  7. Make transverse incision (0.5 cm) posteroinferior to medial malleolus (see Fig. 30.4).

A vertical, rather than a transverse, incision is optional. The former has the advantage that it offers the opportunity to extend the incision cephalad, should the posterior wall of the vein be perforated on the initial attempt at cannulation. However, it has the disadvantage that it may be made too far lateral or medial to the artery.

  1. Identify artery by longitudinal dissection with mosquito hemostat. The artery is usually found just anterior to the Achilles tendon and adjacent to the tibial nerve.
  2. Place mosquito hemostat behind artery, and loop 5-0 nylon suture loosely around it.

Be gentle, to avoid arteriospasm.

  1. Elevate artery in wound with suture. Do not ligate artery.
  2. While stabilizing artery with suture, insert needle and cannula, with bevel down.
  3. Withdraw stylet and advance cannula to hub.
  4. Remove nylon suture.
  5. Close wound with 5-0 nylon suture (usually requires only one suture).

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FIG. 30.7. Radial artery cannulation by cutdown. A: Making transverse skin incision. B: Blunt dissection with mosquito hemostat.C: Elevating artery with artery hook. D: Looping ligature around artery. E: Introducing cannula into artery while gentle “back traction” is applied to suture. F: Cannula advanced to hub.

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FIG. 30.8. A: Anatomic relations of the radial artery on the volar aspect of the wrist. B: Point for cannulation of the radial artery is indicated by the junction of the dotted lines. (Redrawn from 

Amato JJ, Solod E, Cleveland RJ. A “second” radial artery for monitoring the perioperative pediatric cardiac patient. J Pediatr Surg. 1977;12:715

, with permission.)

  1. See percutaneous method under E (Standard Technique, Steps 7 to 11) for fixation and care of cannula.
  2. Obtaining Arterial Samples

Equipment

  1. Gloves
  2. Alcohol swabs
  3. Sterile 2- x 2-in gauze squares (for three-drop method)
  4. 25-gauge straight needle (for three-drop method)
  5. Appropriate-sized syringe for sample (heparinized if sample is not processed on site)
  6. Syringe with flush (for stopcock method)
  7. Ice if necessary for sample preservation
  8. Specimen labels and requisition slips

Technique I: Three-drop method

  1. Wash hands and put on gloves.
  2. Clean diaphragm of T connector with antiseptic solution and allow to dry.
  3. Clamp T-connector tubing close to hub.
  4. Place sterile gauze squares beneath hub.
  5. Introduce 25-gauge needle through diaphragm and allow 3 to 4 drops of fluid/blood to drip onto gauze.
  6. Attach syringe to needle and withdraw sample.
  7. Remove needle from diaphragm.
  8. Unclamp T connector and allow residual pump pressure to flush catheter (27,28).

Technique II: Stopcock method (a three-way stopcock needs to be interposed between the patient and the transducer)

  1. Wash hands and put on gloves.
  2. Clean hub of stopcock with antiseptic solution.
  3. Attach syringe to stopcock.
  4. Turn stopcock off toward infusion pump side.
  5. Aspirate waste (volume depends on length of tubing).
  6. Using second syringe, withdraw sample.
  7. Flush cannula slowly over 30 to 60 seconds with 0.5 mL of flush solution.
  8. Open stopcock to pump to allow for continued infusion of heparinized saline.
  9. Removal of the Cannula

Indications

  1. Stabilization or resolution of the indications for cannulation of the artery
  2. Cannula-related infection
  3. Evidence of thrombosis or mechanical occlusion of the artery

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FIG. 30.9. Complication of cannulation of the radial artery. Arrow indicates necrotic area on forearm.

Technique

  1. Remove tape/dressing and cut stitch (if present) securing cannula to skin.
  2. Remove cannula gently.
  3. Apply local pressure for 5 to 10 minutes.
  4. Complications of Peripheral Arterial Cannulation
  5. Thromboembolism/vasospasm/thrombosis
  6. Blanching of hand and partial loss of digits (29,30 and 31)
  7. Gangrene of fingertips and hemiplegia (32)
  8. Necrosis of forearm and hand (Fig. 30.9) (33,34 and 35)
  9. Skin ulcers (34,36)
  10. Ischemia/necrosis of toes (Fig. 30.10)(22,37)
  11. Cerebral emboli (5,7,21,39)
  12. Reversible occlusion of artery (39,40)
  13. Infiltration of infusate (37)
  14. Infection (27,41,42,43,44,45 and 46)
  15. Hematoma (47,48)
  16. Damage to peripheral nerves, for example:
  17. Median nerve above medial epicondyle of humerus (Fig. 30.11A) may affect the following:
  18. Pronation of forearm
  19. Abduction of wrist
  20. Flexion of wrist and distal phalanges of middle and index fingers
 

FIG. 30.10. Complication of cannulation of dorsalis pedis artery. Healing areas of sloughed skin are seen at site of skin puncture on dorsum of foot and also on anterior aspect of lower leg. Tips of toes 1, 3, 4, and 5 are necrotic.

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FIG. 30.11. A: Muscles supplied by the median nerve in the forearm. B: Muscles supplied by the median nerve in the hand.C: Muscles supplied by the ulnar nerve in the hand. D: Muscles supplied by the posterior tibial nerve in the ankle and foot.

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  2. Opposition, abduction, and flexion of thumb (atrophy of thenar eminence)
  3. Sensation—maximally over volar aspect index and middle fingers
  4. Vasomotor control in limb
  5. Median nerve at wrist (Fig. 30.11B) causes carpal tunnel syndrome (20,49).
  6. Ulnar nerve at wrist causes (Fig. 30.11C):
  7. Atrophy of small hand muscles
  8. Sensory loss over dorsal and palmar surfaces of ring and little fingers and ulnar portion of hand and wrist
  9. Peripheral portion of deep peroneal nerve—anesthesia of the lateral aspect of the dorsum of the hand, which results in no significant disability
  10. Posterior tibial nerve at medial malleolus (Fig. 30.11D) may affect:
  11. Flexor hallucis brevis muscle
  12. Flexor of proximal phalanx of big toe
  13. Muscles of foot that spread and close toes and flex proximal phalanx of toes
  14. Sensation on plantar surface of foot

Lesions of posterior tibial nerve may be difficult to detect on examination but may lead to significant discomfort in later life owing to loss of plantar arches on weight bearing.

  1. False cortical thumbs (50)
  2. Burns from transilluminator (51,52)
  3. Hemorrhage (including accidental dislodgement of cannula) (37,39,53,54)
  4. Hypernatremia caused by heparinized saline infusion through cannula (9)
  5. Hypervolemia related to continuous flush device (55)
  6. Air embolism (38,52)
  7. Pseudoaneurysm (44)
  8. Acquired bone dysplasia (56)

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