Percutaneous Arterial Cannulation - Guideline for Undertaking

Publication: 01/09/2004  --
Last review: 20/07/2017  
Next review: 01/07/2020  
Clinical Guideline
CURRENT 
ID: 537 
Approved By:  
Copyright© Leeds Teaching Hospitals NHS Trust 2017  

 

This Clinical Guideline is intended for use by healthcare professionals within Leeds unless otherwise stated.
For healthcare professionals in other trusts, please ensure that you consult relevant local and national guidance.

Please check the patients allergy status, as they may be allergic to Chlorhexidine, and alternative ( Providine iodine) solution will be required.
Be aware: Chlorhexidine is considered an environmental allergen.
Refer to the asepsis guidance.

Guideline for Undertaking Percutaneous Arterial Cannulation

  1. Introduction and background
  2. Scope
  3. Evidence review
  4. Requisites for clinical practitioners undertaking percutaneous arterial cannulation
  5. Training and supervision
  6. Consent
  7. Contraindications for percutaneous arterial cannulation
  8. The procedure

1. Introduction and background

The main indications for percutaneous arterial cannulation are:

  • Blood pressure measurement
  • Arterial blood sampling
  • Radiological procedures requiring arterial access

In the acute/critical care environment, arterial cannulation allows for continuous blood pressure monitoring (the displayed waveform may be a useful diagnostic tool) and repeated blood sampling, particularly for arterial blood gas analysis of PaO2, PaCO2 and acid-base status.

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2. Scope

These guidelines are aimed at clinical practitioners who are required, as part of their role, to undertake percutaneous arterial cannulation in acutely/critically ill adult patients. The term clinical practitioners refer to registered nurses, operating department practitioners/assistants and allied health professionals. Registered nurses must adhere to the recommendations set out in The Code: Professional standards of practice and behaviour for nurses and midwives (Nursing and Midwifery Council 2015) and the Policy for Advancing Clinical Practice Beyond Initial Registration for Registered Nurses and Midwives (Leeds Teaching Hospitals Trust 2016). Operating department assistants/practitioners and allied health professionals must work in accordance with their relevant codes of practice. 

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3. Evidence review

These guidelines should be read in conjunction with the guidance set out in Latto et al.'s (2000) text entitled Percutaneous Central Venous and Arterial Catheterisation, which provides the evidence base for both radial and dorsalis pedis artery cannulation, general considerations and associated complications.

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4. Requisites for clinical practitioners undertaking percutaneous arterial cannulation

Before undertaking percutaneous arterial cannulation training clinical practitioners must:

  • Be assessed and deemed competent to perform aseptic technique
  • Demonstrate competence in venepuncture and venous cannulation
  • Demonstrate competence in the care and management of arterial catheters, arterial waveform interpretation, arterial blood sampling from an indwelling arterial cannula, and arterial blood gas analysis.
  • Work in clinical areas where the adjustment of practice is agreed by the line manager/matron.
  • Discuss their intentions to undertake arterial cannulation with their line manager/matron in order to determine appropriateness and suitability for training.

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5. Training and supervision

The following apply:

  • A clinical supervisor, who is competent in percutaneous arterial cannulation, must supervise overall development and training.
  • Supervised practice must be provided by an anaesthetist, surgeon or a clinical practitioner who is competent in percutaneous arterial cannulation.
  • A record of each arterial cannulation procedure must be maintained for audit purposes
  • Competence must be assessed against the competency standard statements set out in the Learning Guide and Competency Standard Statements (LTHT 2009) by either a consultant anaesthetist or an Advanced Critical Care Practitioner, before unsupervised practice is undertaken.
  • A copy of the witness statement and competency standard statements, thus verifying competence, must be retained in the clinical practitioner's personal portfolio and by the line manager/matron.
  • Advanced Critical Care Practitioners will be assessed using Direct Observation of Procedural Skills (DOPS) from a Consultant or ST5 or above in grade.  In accordance with the Faculty of Intensive Care Medicine (FICM) standards for Advanced Critical Care Practitioners (FICM, 2015).

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6. Consent

Percutaneous arterial cannulation may be associated with complications that could result in severe injury. Wherever possible, informed consent should be obtained from the patient or the procedure explained to a close relative before arterial cannulation is carried out. However, this is not always practicable in critical care units. When consent cannot be obtained, implied consent is assumed because the procedure is regarded as necessary for the patient's continued well-being in accordance with Mental Capacity Act (OPSI 2005)

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7. Contraindications for percutaneous arterial cannulation

  • Patients with severe peripheral vascular disease
  • Patients receiving warfarin or intravenous heparin where the PT>72 seconds or INR > 2.2
  • Patients receiving thrombolytic therapy, for example, streptokinase
  • Platelet counts of < 50 x109/L
  • History of a clotting disorder such as haemophilia
  • Profound hypotension with weak or absent radial/dorsalis pedis pulse
  • Previous surgical treatment of the artery, especially if a synthetic graft has been used.
  • Arteriovenous fistulae that have been fashioned for haemodialysis (may become thrombosed or infected from arterial cannulae on the same limb).
  • Conditions that affect the patency and reactivity of small arteries such as Buerger's disease and Raynaud's disease.
  • Presence of infection near the puncture site.

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8. The procedure

Clinical practitioners who have undergone supervised training and have been assessed as competent may undertake percutaneous artery cannulation and must adhere to the following:

  • Confirm the need for percutaneous arterial cannulation with a member of the patient's clinical team.
  • Undertake a maximum of three attempts at each site at a maximum of two sites, while being mindful of earlier attempts by senior medical colleagues.
  • Seek guidance from senior medical staff if there are concerns about the adequacy of the collateral flow.
  • Limit the procedure to adults in the designated areas in which scope of practice is to be adjusted
  • Make a record in the medical case notes of the date, time, technique used, site of cannulation, number of attempts, the use of lignocaine, and any untoward incidents.
  • An untoward incident must be documented in accordance with Trust policy.
  • Lignocaine 1% 1 -2 ml (3mg/kg), if required, must be either prescribed by a doctor or non-medical prescriber or administered according to a patient group direction.
  • Undertake only radial or dorsalis pedis artery cannulation in accordance with the Learning Guide and Competency Standard Statements (LTHT 2009).
  • Problems/complications occurring during the procedure must be reported directly to senior medical staff so that a decision for further intervention/referral can be made.
  • Observe for any contraindications set out in section seven.

Asepsis

All practitioners must have current, up to date hand hygiene and asepsis training

  • Hands must be decontaminated according the Hand Hygiene Policy (LTHT 2017).
  • The procedure should be carried out following the Trust Asepsis Guidelines (LTHT 2017)
  • A sterile dressing pack should be opened onto a clean trolley and all sterile equipment assembled on the sterile field. The sterile towel from the pack should be placed under the area where the arterial line will be inserted.  
  • Visibly soiled skin should be cleaned with soap and water prior to decontamination. 
  • The patient’s skin should be decontaminated using 2% chlorhexidine in 70% alcohol isopropyl solution.
  • Sterile examination gloves should be worn and the arterial line should be inserted using an aseptic technique. 
  • The arterial line should be secured with a statlock device whenever possible
  • A transparent semi-permeable dressing is the recommended dressing of choice.
  • Three way taps and transducer equipment should be connected using as aseptic non touch technique.   
  • Standard infection prevention and control precautions should be followed (LTHT 2017)
  • All sharps should be disposed of at point of use.

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Provenance

Record: 537
Policy/Guideline number (Nursing, Midwifery and Health Visitors only) 01 10 04
Objective:

These guidelines are aimed at clinical practitioners who are required, as part of their role, to undertake percutaneous arterial cannulation in acutely/critically ill adult patients.

Clinical condition:
Target patient group:
Target professional group(s): Secondary Care Doctors
Secondary Care Nurses
Allied Health Professionals
Adapted from:

N/A


Evidence base

  • FICM (2015) Curriculum for Training for Advanced Critical Care Practitioners.  Faculty of Intensive Care Medicine.
  • Latto, I.P., Ng, W.S., Jones, P.L., Jenkins, B.J. Percutaneous Central Venous and Arterial Catheterisation. Third Edition. pp 297-333. W.B. Saunders, London.
  • The Leeds Teaching Hospitals NHS Trust (2016) Policy for Advancing Clinical Practice beyond initial Registration for Registered Nurses and Midwives
  • The Leeds Teaching Hospitals NHS Trust (2017) Hand Hygiene Policy
  • The Leeds Teaching Hospitals NHS Trust (2017) Standard Prevention of Infection Control Precautions Policy  
  • The Leeds Teaching Hospitals NHS Trust (2017) Asepsis Guideline
  • The Leeds Teaching Hospitals NHS Trust (2009) Percutaneous Arterial Cannulation and Radial Artery Puncture: Learning Guide and Competency Standard Statements 
  • Nursing and Midwifery Council (2015) The Code: Professional standards of practice and behaviour for nurses and midwives
  • Office of Public Sector Information (2005) The Mental Capacity Act

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Document history

LHP version 1.0

Related information

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