Chapter 32 ■ Central Venous Catheterization 199

care. Do not clamp or suture; stretch or apply tension

to catheter.

j. Utilizing sterile technique and a 3- to 5-mL syringe,

flush catheter with heparinized saline solution, leaving syringe attached. A small-barreled syringe (such

as a 1-mL syringe) may generate too much pressure,

resulting in catheter rupture (12).

k. Prepare sterile field: Holding the extremity with sterile gauze prepare a large area at and around the

insertion site, working outward in concentric circles.

Allow the prep solution to dry. Repeat process with

new gauze/prep solution. Place a large sterile drape

under and above the extremity, leaving only the

insertion site exposed. A large drape or multiple sterile towels should be used to cover an area well

beyond the extremity to decrease the risk of accidental contamination (2).

3. Catheter insertion using a break-away needle

(Fig. 32.2) or a peel-away introducer (Figs. 32.3, 32.5)

a. Apply tourniquet above insertion site on extremity

(optional).

b. Providing slight skin traction, insert needle about

0.5 to 1 cm below the intended vein, at a low angle

(approximately 15 to 30 degrees).

c. When a flashback is obtained, advance the needle

about 5 to 6 mm at a lower angle to ensure that the

whole bevel of the needle is within the vein. If a

peel-away introducer with a needle is used, remove

the needle at this time and advance the introducer

sheath slightly. If the introducer (needle or sheath)

is well within the vein, there will be continued

blood flow through it.

d. Remove the tourniquet.

e. Using nontoothed iris forceps, gently grasp the catheter about 1 cm from its distal end and thread it

slowly into the introducer, a few millimeters at a

time.

 

198 Section V ■ Vascular Access

b. Gather supplies. Wash hands thoroughly.

c. Identify appropriate vein for insertion (see D).

d. Position infant to facilitate insertion (Table 32.3).

Restrain infant; provide comfort measures.

e. Measure approximate distance from the insertion

site to the point where the catheter tip will be placed

(Table 32.3).

f. Don mask and head cover.

g. Set up/open sterile equipment tray.

h. Perform hand hygiene as for a major procedure and

wear sterile surgical gown and gloves.

i. Trim catheter to appropriate size (trimming is based

on unit policy and manufacturer recommendations).

The catheter is fragile and should be handled with

A B

C D

E F

Fig. 32.3. PICC using a peel-away cannula introducer. A: Perform venipuncture. When flashback of

blood is noted, reduce angle and advance introducer sheath farther to ensure placement in the vein.

B: Withdraw the introducer needle from the sheath. Note that the introducer sheath is supported to avoid

displacement. C: Insert the catheter into the introducer sheath using fine nontoothed forceps. D: Withdraw

the introducer sheath. Note that the catheter is stabilized by applying digital pressure to the vein distal to

the introducer sheath. E: Remove the introducer sheath by splitting and peeling it away from the catheter.

Complete catheter advancement to premeasured length. F: Aspirate catheter to check for blood return

and flush with heparinized saline to ensure patency. (From Klein C. NeoPicc: The Neonatal and Pediatric

Workshop Manual. San Antonio, TX: Klein Baker Medical, 1998, with permission.)

Fig. 32.4. Use of a blunt scalp vein needle to form a hub for a

silicone catheter. The plastic needle cover is used to stabilize the

needle–catheter junction. A commercially available blunt needle

adapter may be inserted and fixed in a similar manner.

 

Chapter 32 ■ Central Venous Catheterization 197

removed. Disadvantage: There is a potential for shearing or severing the catheter if it is retracted while the

needle is in the vein.

2. Peel-away introducer (Fig. 32.3): A needle introducer is

used to place a small cannula or sheath into the vein.

The needle is then removed and the catheter is

threaded through the cannula. The introducer cannula

or sheath is then retracted from the vein, split or

“peeled” apart, and removed from the catheter.

3. Intact cannula (Fig. 32.4): This technique is now rarely

used because most commercially available catheters

have a hub and introducer needles. A regular IV cannula is used to obtain venous access. The needle is

removed. The silicone catheter is threaded through the

cannula to its final position. The cannula is then

retracted and slipped off the end of the “hubless” catheter. A blunt needle with hub is connected to the end

of the catheter. Disadvantage: The blunt needle attachment must be secured well, otherwise leakage can

occur.

C. Placement of PICC

1. Equipment

All equipment used, except the mask, head cover,

and tape measure, must be sterile. Commercial kits

contain many of the necessary items. Assemble all supplies before starting procedure.

a. Radio-opaque central venous catheter

b. Break-away or peel-away needle introducer

c. Device for trimming the catheter ( based on manufacturer recommendations)

d. Tourniquet (optional)

e. Drapes

f. Smooth iris forceps

g. Gauze pads

h. Skin prep: 10% povidone–iodine or 0.5% chlorhexidine solution (as per institutional policy)

i. Transparent dressing

j. Sterile tape strips

k. Sterile heparinized saline solution (0.5 to 1 U/mL

heparin or per institutional policy)

l. 5- to 10-mL syringe with needle

m.Tape measure

n. Sterile surgical gown, sterile gloves, mask, and head

cover

2. Preparation

a. Although anesthesia is not required, nonpharmacologic comfort measures and pain medication should

be provided as needed. A small dose of sedative or

narcotic analgesic may be useful.

A B

C

Fig. 32.2. PICC using break-away needle technique. (From

Gesco International, San Antonio, Texas, with permission.)

 

196 Section V ■ Vascular Access

2. Cutdown or open surgical technique

a. Advantages

(1) Allows for insertion of larger silicone catheter

(3 or 4.2 French [Fr])

(2) The catheters can be tunneled under the skin

away from the venotomy site, so they can remain

in place longer with a lower risk of infection.

b. Disadvantages

(1) Requires general anesthesia or IV sedation

(2) Requires surgical incision

(3) Vein is often ligated, so it cannot be reused in

the future.

(4) Potential for injury to adjacent anatomical structures

(5) Increased potential for wound infection

(6) An operating room is the ideal setting for the

procedure, so risks of transport of critically ill

neonates need to be taken into consideration.

G. Types of Central Venous Catheters

1. Catheter materials: See Table 32.2.

2. Types of catheters

a. Percutaneous (PICC) catheters/introducers

PICC catheters and kits are available commercially. PICCs are generally made of silicone or polyurethane. Sizes include 1.2, 1.9, 2, and 3 Fr. Larger

sizes are generally not used in the neonatal population. Most catheters are single-lumen. Double-lumen

catheters can decrease the need for maintaining concurrent IV access when more than one site is

required. PICC introducers/needles are available in

20 to 28 gauge. Choice will depend on the size of the

vein to be cannulated.

b. Surgically placed central venous catheters

Surgically placed central venous catheters for

neonates are available in sizes 2.5, 2.7, 3, 4.2, and

5 Fr. Catheters are usually silicone or polyurethane,

with tissue in-growth cuffs that adhere to the subcutaneous tract, anchoring the catheter. Recently,

antimicrobial cuffs have become available. Most

catheters are single-lumen, but a few manufacturers

make double-lumen catheters.

Percutaneous Central Venous

Catheterization (See Procedures

Website for video)

A. Insertion Sites (Fig. 14.1)(Table 32.1)

The veins used, in order of preference are

1. Antecubital veins: Basilic and cephalic veins

2. Saphenous veins

3. Scalp veins: Temporal and posterior auricular veins

4. Axillary vein

5. External jugular vein

Right-sided and basilic veins are preferred because

of the shorter and more direct route to the central vein.

The cephalic vein may be more difficult to thread to

the central position because of narrowing of the vessel

as it enters the deltopectoral groove and the acute angle

at which it joins the subclavian vein. The axillary and

external jugular veins are the last choices because they

are close to arteries and nerves.

B. Insertion Variations

1. Break-away needle (Fig. 32.2): Needle is inserted into

the vein. Next, the catheter is advanced through the

needle. The needle is then retracted, split, and

Table 32.2 Catheter Materials

Type of Catheter Advantages Disadvantages

Silicone Soft, pliable

Lower risk of vessel perforation

Reported to be thromboresistant

May be more difficult to insert percutaneously

Thrombosis reported

Fragile material: Less tolerance to pressure

Poor tensile strength: Can tear or rupture

May be less radio-opaque

Polyurethane Easier to insert percutaneously

Stiffer on insertion but softens within body

Some catheters are more radio-opaque

Tensile strength: More tolerant to pressure

Reported to be thromboresistant

Increased risk of vessel perforation during insertion

Thrombosis reported

Polyethylene Easier to insert

Very high tensile strength

High degree of stiffness may increase vessel perforation during insertion or

throughout catheter dwell

Polyvinyl chloride (PVC) Easier to insert percutaneously

Stiff on insertion but softens within body

May leach plasticizers into body

High incidence of thrombosis

 

6. Maintain strict aseptic technique for the insertion

and care of central catheter. Hand hygiene (with soap

and water or with alcohol based hand rub) should be

performed before and after palpating catheter insertion sites, as well as before and after inserting, replacing, accessing, repairing or dressing an intravascular

catheter (2).

7. Never leave a catheter in a position where it does not

easily and repeatedly withdraw blood during the insertion procedure, to ensure that the tip is not lodged

against a blood vessel or cardiac wall.

8. Always confirm (both AP and lateral radiographs are

recommended) the position of the catheter tip by radiography or echocardiography prior to using it.

9. If possible, the line should be inserted and cared for by

specifically trained personnel. Central line teams and

the use of insertion and maintenance checklists and

bundles have been shown to decrease the frequency of

catheter-related infections (3).

10. Do not submerge the catheter or catheter site in water.

Chapter 32 ■ Central Venous Catheterization 195

Table 32.1 Vessels Amenable to Central Venous Access

Blood Vessel Recommended Technique

Upper extremity: Cephalic, basilic, median cubital,

or axillary vein

Percutaneous or surgical

Lower extremity: Saphenous vein or femoral vein Percutaneous or surgical

Scalp vein Percutaneous technique, amenable only to PICC lines

External jugular vein Percutaneous or surgical

Internal jugular vein or common facial vein Surgical technique

D. Vessels Amenable to

Central Venous Access

Table 32.1 lists the sites usually used for central venous

catheterization in the newborn.

E. Position of Catheter Tip (Fig. 32.1)

1. The catheter should be placed in as large a vein as possible, ideally outside the heart, and parallel with the

long axis of the vein such that the tip does not abut the

vein or heart wall. The recommendations for appropriate position of a central venous catheter tip vary, but

there is general agreement that the tip should not be

within the right atrium (4–6). However, one large retrospective audit of 2,186 catheters showed that catheters

with their tips in the right atrium and not coiled were

not associated with pericardial effusions (7).

a. When inserted from the upper extremity, the catheter tip should be in the superior vena cava (SVC),

outside the cardiac reflection, or at the junction of

the SVC and right atrium.

b. When inserted from the lower extremity, the catheter tip should be above the L4–L5 vertebrae or the

iliac crest, but not in the heart.

2. Confirmation of catheter tip placement

a. The tip of the radio-opaque catheter is usually seen

on a routine chest radiograph (Fig. 32.1), but there

can be significant interobserver variability in assessing the position, even with digital enhancement (8).

b. Two radiographic views (anteroposterior and lateral)

help to confirm that the catheter is in a central vein.

This is particularly important for catheters placed in a

lower extremity, where the catheter may inadvertently

be in an ascending lumbar vein and may appear to be

in good position on an anteroposterior view (9).

c. The use of radio-opaque contrast improves localization of the catheter tip, particularly when the

catheter is difficult to see on a standard radiograph.

A 0.5-mL aliquot of 0.9% saline is instilled into the

catheter to check patency, followed by 0.5 mL of

iohexol. The radiograph is taken, and the line is

flushed again with 0.5 mL of 0.9% saline. With this

technique, there is no need to inject the contrast

material while the radiograph is being taken (10).

d. Ultrasonography may also be useful in localizing

the catheter tip (11).

e. Chest radiographs obtained for any reason should be

scrutinized for appropriate catheter position. Routine

weekly radiographs taken for this purpose do not

appear to reduce the risk of complications (6).

F. Methods of Vascular Access

1. Percutaneous technique

a. Advantages

(1) Simpler to perform and relatively rapid procedure

(2) Vessel is not ligated as in open cutdown methods

(3) Decreased potential for wound infection/

dehiscence complications

b. Disadvantages

(1) Beyond the initial insertion into the peripheral

vein, further passage of the catheter into its final

position is essentially a blind technique, although

there is increasing experience with ultrasound

imaging (11).

(2) A smaller-caliber catheter may preclude use for

blood transfusions

Fig. 32.1. Chest radiograph with PICC tip in appropriate position, just above junction of superior vena cava and right atrium.

 

Jeanne M. Rorke

Jayashree Ramasethu

A. Alfred Chahine

32 Central Venous Catheterization

Central venous catheters provide stable IV access to sick or

low-birthweight infants who need long-term IV nutrition or

medications (1).

A percutaneous central venous catheter, also known as

a peripherally inserted central catheter (PICC), is a soft,

flexible catheter that is inserted into a peripheral vein and

threaded into the central venous system. Central venous

lines may be placed by surgical cutdown when percutaneous access is not possible. Totally implantable vascular

access devices (ports) are rarely used in neonates and are

thus not included in this chapter.

Regardless of the method employed to obtain secure

and reliable venous access, the clinician should be familiar

with the technique and anatomic considerations unique to

the approach. Some form of analgesia and sedation is generally required, with general anesthesia being reserved for

more complex access cases. The majority of venous access

procedures in the critically ill neonate are performed at the

bedside rather than in the operating room.

A. Common Indications

1. Total parenteral nutrition

2. Long-term IV medication administration

3. Administration of hyperosmolar IV fluids or irritating

medications that cannot be administered through

peripheral IV cannulas.

4. Fluid resuscitation

5. Repetitive blood draws (catheters are not usually

inserted primarily for this indication in neonates; only

larger-lumen catheters may be used for blood draws

without risk of clotting).

B. Relative Contraindications

There are no absolute contraindications, as the clinical situation dictates the need for venous access.

1. Skin infection at insertion site

2. Uncorrected bleeding diathesis (not a contraindication

for percutaneous catheters inserted in distal peripheral

venous sites)

3. Ongoing bacteremia or fungal infection (which may

cause catheter colonization and infection)

4. The patient can be treated adequately with peripheral IV access. Central venous catheters have significant risks of complications and must not be used

when peripheral venous access is possible and

adequate.

C. General Precautions

1. Central venous catheterization must be performed by

trained individuals who are familiar with the venous

anatomy of the proposed catheter route.

2. Obtain informed consent prior to performing the procedure.

3. Plan ahead: Success with PICC placement is higher if

the catheter is inserted electively before peripheral

veins are “used up” by frequent cannulations.

4. Infant should be on a cardiorespiratory monitor during

the procedure.

5. Follow the manufacturer’s instructions for catheter

use.

 

Chapter 31 ■ Peripheral Arterial Cannulation 193

34. Miyasaka K, Edmonds JF, Conn AW. Complications of radial

artery lines in the paediatric patient. Can Anaesth Soc J. 1976;

23:9.

35. Adams JM, Speer ME, Rudolph AJ. Bacterial colonization of

radial artery catheters. Pediatrics. 1980;65:94.

36. Skoglund RR, Giles EE. The false cortical thumb. Am J Dis Child.

1986;140:375.

37. Uy J, Kuhns LR, Wall PM, et al. Light filtration during transillumination of the neonate: a method to reduce heat buildup in the

skin.Pediatrics. 1977;60:308.

38. Morray J, Todd S. A hazard of continuous flush systems for vascular pressure monitoring in infants. Anesthesiology. 1983;58:187.

39. Chang C, Dughi J, Shitabata P, et al. Air embolism and the radial

arterial line. Crit Care Med. 1988;6:141.

40. Dzepina I, Unusic J, Mijatovic D, et al. Pseudoaneurysms of the

brachial artery following venipuncture in infants. Pediatr Surg Int.

2004;20:594.

41. Seibert JJ, McCarthy RE, Alexander JE, et al. Acquired bone dysplasia secondary to catheter-related complications in the neonate.

Pediatr Radiol. 1986;16:43.

194

6. Hayden WR. Hypernatremia due to heparinized saline infusion

through a radial artery catheter in a very low-birth-weight infant.

J Pediatr. 1978;92:1025.

7. Rais-Bahrami K, Karna P, Dolanski EA. Effect of fluids on life

span of peripheral arterial lines. Am J Perinatol. 1990;7:122.

8. Clifton GD, Branson P, Kelly HJ, et al. Comparison of normal

saline and heparin solutions for maintenance of arterial catheter

patency. Heart Lung. 1991;20:115.

9. Maher JJ, Dougherty JM. Radial artery cannulation guided by

Doppler ultrasound. Am J Emerg Med. 1989;7:260.

10. Schwemmer U, Arzet HA, Trautner H, et al. Ultrasound-guided

arterial cannulation in infants improves success rate. Eur J

Anaesthesiol. 2006;23:476.

11. Morray JP, Brandford HG, Barnes LF, et al. Doppler-assisted

radial artery cannulation in infants and children. Anesth Analg.

1984;63:346.

12. Mozersky DJ, Buckley CJ, Hagood CO Jr, et al. Ultrasonic evaluation of the palmar circulation. A useful adjunct to radial artery

cannulation. Am J Surg. 1973;126:810.

13. Allen EV. Thromboangiitis obliterans: methods of diagnosis of

chronic occlusive arterial lesions distal to the wrist with illustrative cases. Am J Med Sci. 1929;178:237.

14. Hack WW, Vos A, van der Lei J, et al. Incidence and duration of

total occlusion of the radial artery in newborn infants after catheter removal. Eur J Pediatr. 1990;149:275.

15. Wallach SG. Cannulation injury of the radial artery: diagnosis

and treatment algorithm. Am J Crit Care. 2004;13:315.

16. Barone JE, Madlinger RV. Should an Allen test be performed

before radial artery cannulation? J Trauma. 2006;61:468.

17. Johnstone RE, Greenhow DE. Catheterization of the dorsalis

pedis artery. Anesthesiology. 1973;39:654.

18. Greenhow DE. Incorrect performance of Allen’s test:-ulnar-artery

flow erroneously presumed inadequate. Anesthesiology. 1972;

37:356.

19. Chowet AL, Lopez JR, Brock-Utne JG, et al. Wrist hyperextension leads to median nerve conduction block: implications

for intra-arterial catheter placement. Anesthesiology. 2004;100:

287.

20. Lowenstein E, Little JW 3rd, Lo HH. Prevention of cerebral

embolization from flushing radial-artery cannulas. N Engl J Med.

1971;285:1414.

21. Adams JM, Rudolph AJ. The use of indwelling radial artery catheters in neonates. Pediatrics. 1975;55:261.

22. Kahler AC, Mirza F. Alternative arterial catheterization site using

the ulnar artery in critically ill pediatric patients. Pediatr Crit Care

Med. 2002;3:370.

23. Huber JF. The arterial network supplying the dorsum of the foot.

Anat Rec. 1941;80:373.

24. Spoerel WE, Deimling P, Aitken R. Direct arterial pressure monitoring from the dorsalis pedis artery. Can Anaesth Soc J. 1975;

22:91.

25. Pearse RG. Percutaneous catheterisation of the radial artery in

newborn babies using transillumination. Arch Dis Child. 1978;

53:549.

26. Amato JJ, Solod E, Cleveland RJ. A “second” radial artery for

monitoring the perioperative pediatric cardiac patient. J Pediatr

Surg. 1977;12:715.

27. Hack WW, Vos A, Okken A. Incidence of forearm and hand ischaemia related to radial artery cannulation in newborn infants.

Intensive Care Med. 1990;16:50.

28. Vasquez P, Burd A, Mehta R, et al. Resolution of peripheral artery

catheter-induced ischemic injury following prolonged treatment

with topical nitroglycerin ointment in a newborn: a case report.

J Perinatol. 2003;23:348.

29. Baserga MC, Puri A, Sola A. The use of topical nitroglycerin ointment to treat peripheral tissue ischemia secondary to arterial line

complications in neonates.J Perinatol. 2002;22:416.

30. Detaille T, Pirotte T, Veyckemans F. Vascular access in the neonate. Best Pract Res Clin Anaesthesiol. 2010;24:403.

31. Wyatt R, Glaves I, Cooper DJ. Proximal skin necrosis after radialartery cannulation. Lancet. 1974;1:1135.

32. Spahr RC, MacDonald HM, Holzman IR. Catheterization of the

posterior tibial artery in the neonate. Am J Dis Child. 1979;133:

945.

33. Abrahamson EL, Scott RC, Jurges E, et al. Catheterization of posterior tibial artery leading to limb amputation. Acta Paediatr.

1993;82:618.

 

Chapter 31 ■ Peripheral Arterial Cannulation 191

A

C

B

D

Fig. 31.11. 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.

192 Section V ■ Vascular Access

(5) Sensation—maximally over volar aspect index

and middle fingers

(6) Vasomotor control in limb

b. Median nerve at wrist (Fig. 31.11B) causes carpal

tunnel syndrome (19).

c. Ulnar nerve at wrist causes (Fig. 31.11C)

(1) Atrophy of small hand muscles

(2) Sensory loss over dorsal and palmar surfaces of

ring and little fingers and ulnar portion of hand

and wrist

d. Peripheral portion of deep peroneal nerve—

anesthesia of the lateral aspect of the dorsum of the

hand, which results in no significant disability

e. Posterior tibial nerve at medial malleolus (Fig.

31.11D) may affect

(1) Flexor hallucis brevis muscle

(2) Flexor of proximal phalanx of big toe

(3) Muscles of foot that spread and close toes and

flex proximal phalanx of toes

(4) 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.

6. False cortical thumbs (36)

7. Burns from transilluminator (37)

8. Hemorrhage (including accidental dislodgement of

cannula) (32,34)

9. Hypernatremia caused by heparinized saline infusion

through cannula (6)

10. Hypervolemia related to continuous flush device (38)

11. Air embolism (39)

12. Pseudoaneurysm (40)

13. Acquired bone dysplasia (41)

References

1. Greenwald BM, Notterman DA, DeBruin WJ, et al. Percutaneous

axillary artery catheterization in critically ill infants and children.

J Pediatr. 1990;117:442.

2. Piotrowski A, Kawczynski P. Cannulation of the axillary artery in

critically ill newborn infants. Eur J Pediatr. 1995;154:57.

3. Schindler E, Kowald B, Suess H, et al. Catheterization of the

radial or brachial artery in neonates and infants. Paediatr Anaesth.

2005;15:677.

4. Prian GW, Wright GB, Rumack CM, et al. Apparent cerebral

embolization after temporal artery catheterization. J Pediatr. 1978;

93:115.

5. Bull MJ, Schreiner RL, Garg BP, et al. Neurologic complications

following temporal artery catheterization. J Pediatr. 1980;96:

1071.

190 Section V ■ Vascular Access

Fig. 31.9. Complication of cannulation of the radial

artery. Arrow indicates necrotic area on forearm.

Fig. 31.10. 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.

G. 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

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.

H. Complications of Peripheral Arterial

Cannulation

1. Thromboembolism/vasospasm/thrombosis

a. Blanching of hand, gangrene of fingertips, partial

loss of digits (14,21,22,27) Topical nitroglycerine

has been reported to restore perfusion in some cases.

(28,29) Warming of the contralateral limb, to produce reflex vasodilation, can also be used. (30)

b. Necrosis of forearm and hand (Fig. 31.9) (27,31)

c. Skin ulcers (31)

d. Ischemia/necrosis of toes (Fig. 31.10) (32,33)

e. Cerebral emboli (4,20,34)

f. Reversible occlusion of artery (14,34)

2. Infiltration of infusate (32)

3. Infection (35)

4. Hematoma (21)

5. Damage to peripheral nerves

a. Median nerve above medial epicondyle of humerus

(Fig. 31.11A) may affect the following

(1) Pronation of forearm

 

 

188 Section V ■ Vascular Access

A B

C D

E F

Fig. 31.7. 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.

Chapter 31 ■ Peripheral Arterial Cannulation 189

6. Wait 5 minutes for anesthesia.

7. Make transverse incision (0.5 cm) posteroinferior to

medial malleolus (see Fig. 31.4).

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.

8. 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.

9. Place mosquito hemostat behind artery, and loop 5-0

nylon suture loosely around it.

Be gentle, to avoid arteriospasm.

10. Elevate artery in wound with suture. Do not ligate

artery.

11. While stabilizing artery with suture, insert needle and

cannula, with bevel down.

12. Withdraw stylet and advance cannula to hub.

13. Remove nylon suture.

14. Close wound with 5-0 nylon suture (usually requires

only one suture).

15. See percutaneous method under E (Standard Technique,

steps 7 to 11) for fixation and care of cannula.

F. Obtaining Arterial Samples

Equipment

1. Gloves

2. Alcohol swabs

3. Sterile 2- × 2-inch gauze squares (for three-drop method)

A B

Fig. 31.8. 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.)

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.

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 to infusion pump.

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.