Pre‐procedure

ActionRationale

1. 1.Show
   Introduce yourself to the patient, explain and discuss the procedure with them, and gain their consent to proceed.
   To ensure that the patient feels at ease, understands the procedure and gives their valid consent (NMC [356], C). Note: many patients are anaesthetized when arterial devices are inserted.
2. 2.Show
   Wash hands with soap and water, or an alcohol‐based handrub, and dry.
   To minimize the risk of infection (DH [117], E; NHS England and NHSI [348], C).
3. 3.Show
   Prepare the infusion and transducer sets using aseptic technique.
   To minimize the risk of infection (DH [117], E; Loveday et al. [278], C).
4. 4.Show
   Check that all Luer‐Lok connections are secure.
   To prevent disconnection, as equipment is often loose when taken straight from the packaging. E

Procedure

1. 5.Show
   Connect the transducer to a 500 mL bag of 0.9% sodium chloride, which must be prescribed.
   To prepare the infusion; saline is more effective than heparinized flush (Gamby and Bennett [167], R; Kulkarni et al. [250], R; O'Grady et al. [362], C). Only 0.9% sodium chloride must be used as flush (NPSA [360], C).

   To prime the administration set and three‐way tap ports. E
2. 6.Show
   Open the roller clamp fully and squeeze the flush device actuator (see instructions with set).
   To reduce the risk of air embolism, although retrograde air embolism is a rare event after routine radial artery cannula flushing. E
3. 7.Show
   Check thoroughly for air bubbles in the circuit.
   To reduce the risk of inaccurate pressure readings caused by bubbles in the set (Daily and Schroeder [99], R).
4. 8.Show
   Insert the bag into the pressure infuser, and inflate the pressure bag to 300 mmHg. An automatic flush mode is activated within the system, which delivers 3 mL per hour, which maintains the patency of the cannula.
   To prevent backpressure of blood into the transducer set by ensuring the pressure is higher than the arterial blood pressure (Morton and Fontaine [326], R).
5. 9.Show
   Wash hands with soap and water, or an alcohol‐based handrub, and dry.
   To reduce the risk of cross‐infection (DH [117], C; NHS England and NHSI [348], C).
6. 10.Show
   Prepare a trolley near the patient.
   To reduce the risk of cross‐infection (DH [117], C; Loveday et al. [278], E).
7. 11.Show
   Complete the Allen test (see Figure 17.44) if the radial artery is to be used.
   To assess whether palmar arch circulation is adequate, although this assessment is not entirely reliable (Valgimigli et al. [450], Wallach [460], R).
8. 12.Show
   Prepare the insertion site with a 2% chlorhexidine in 70% alcohol swab and place a sterile towel under the appropriate area.
   To maintain asepsis. To provide a clean working area (DH [117], C). To minimize the risk of infection (Loveday et al. [278], E).
9. 13.Show
   Administer adequate local anaesthetic.
   To minimize pain during the procedure; this may reduce sudden movements by the patient, which could result in through‐puncture (Lipsitz [272], R; Zinchenko et al. [483], R). Local vasodilation effects of the local anaesthetic may reduce vasospasm, making a successful cannulation more likely (Lipsitz [272], R).
10. 14.Show
    Put on gloves.
    To prevent contamination of hands if blood spillage occurs (Loveday et al. [278], C).
11. 15.Show
    Another nurse may act as an assistant and hold the patient's foot or arm. If the radial artery is cannulated, the wrist must be hyperextended. Promptly return the wrist to the neutral position following cannulation.
    To prevent movement and to flex the hand or foot slightly to facilitate insertion. E

    Prolonged hyperextension may be associated with changes in median nerve conduction (Chowet et al. [79], R).
12. 16.Show
    Insert the cannula and observe for blood flashback.
    To ascertain that the cannula is in the artery. E
13. 17.Show
    Attach the transducer set and fully open the roller clamp.
    To commence the flush infusion system and prevent backflow of blood. E
14. 18.Show
    Apply a transparent dressing over the cannula and tape the tubing securely.
    To leave the site visible and secure, and to allow observers to immediately recognize any dislodgement, inflammation or disconnection (Healy et al. [205], E).
15. 19.Show
    Clearly label the device as arterial, on the dressing as well as on the tubing.
    To ensure the device is not mistaken for a venous cannula, preventing accidental intra‐arterial injection of drugs (E), particularly if the tubing is disconnected and the cannula capped off in the event of a transfer (NPSA [360], C), although this practice should be discouraged.
16. 20.Show
    Loop the tubing around the thumb, ensuring this is not too tight (Action figure 20).
    To minimize movement of the cannula and damage to the vessel, and to prevent ulcer formation. E
17. 21.Show
    Connect the transducer to the monitoring equipment.
    To allow the arterial waveform to be checked and to obtain continuous blood pressure measurements. E
18. 22.Show
    Calibrate the arterial device (the transducer will read an arterial pressure calibrated to atmospheric air, which offsets the extraneous atmospheric and hydrostatic pressures).
    To make sure that readings are accurate. E

Post‐procedure

1. 23.Show
   Remove gloves and dispose of equipment and clinical waste appropriately.
   To prevent sharps injury (NHS Employers [347], C).
2. 24.Show
   Clearly document the date of insertion and the placement of the arterial cannula in the patient's records.
   To maintain accurate records and provide appropriate reference (NMC [356], C).