Arterial line cannulation in children: Is it time for guidelines?
To the Editor,
Arterial catheters are routinely used during major surgeries and in
critically ill patients for continuous hemodynamic monitoring and
blood samplings. With approximately 8 millions of catheters inserted
in Europe and USA each year, this procedure is relatively common,
although technically not devoid of risk, especially in pediatrics.
Complications are often minor (ie, local hematoma) and mostly gen-
erated by repeated puncture attempts. However, more serious com-
plications have been described, ranging from damage of adjacent
anatomical structures (nerves) to occlusion of the artery potentially
leading to permanent ischemic events and debilitating consequences.
To date, specific recommendations regarding sites of insertion,
techniques, line maintenance, and complication management are
lacking. In 2014, we conducted an anonymous, web-based survey
(details available upon request), among members of the CPAS
(Canada), SPA (USA), APAGBI (UK), and SARNePI (Italy).
Among various questions on participants’ background, clinical,
and technical preferences regarding arterial cannulation, and use of
2D ultrasound (2D-US), we addressed specific neonatal issues (pri-
mary site of insertion, size of radial, and femoral catheters). From a
pool of 4254 members, the questionnaire was started by 1171 and
completed by 899.
The majority of the responders (90%) were staff, university-
affiliated (81%), with exclusive pediatric activity (54%) or combined
adult/pediatric population (27%). The remaining responders worked
either in a general hospital with mixed activity (12%), in private
clinic, or did not specify (7%).
Most of the participants had more than 5 years of experience as
pediatric anesthesiologist (78%), performed pediatric anesthesia at
least 3 days per week (85%), and placed more than 25 arterial lines
per year (51%).
A summary of the data is reported in Figure 1. Few responders
had institutional guidelines for arterial cannulation, which often
endorsed a full sterile preparation for the cannulation. Interestingly,
the majority does not assess collateral perfusion of the hand. The
Allen’s test or its modifications are still recommended in major pedi-
atric textbooks, but their utility has been recently questioned.
The radial artery represents the preferred primary site of cannula-
tion, followed by the femoral. Tibialis posterior seemed to be used more
often than the axillary and the brachial arteries (data not shown). It may
be a valid alternative to the radial artery, as recently demonstrated.
Regarding 1-month old full-term babies, the radial artery was the
preferred vessel and cannulated with either 24G or 22G intravenous
catheters (69% and 21%, respectively), whereas femoral catheters
were often 2.5F 5 cm, 22 G, or 3 Fr 5 cm (38%, 29% and 15%,
respectively). Those data were of particular interest, since the size of
a 22G cannula may be too big as it may occupy more than 15%-
20% of the arterial lumen.
2.5 Fr 5 cm
Going through and draw back
Puncturing and threading
3 fFr 5 cm
Arterial cannulation techniques (% of responders)
Local written guidelines
Allen’s test or similar
Full sterile preparation
Preferred site - 1 month term baby
Choice in case of failure
Radial catheter - 1 month term baby
Femoral catheter - 1 month term baby
FIGURE 1 Arterial cannulation techniques. N/A, data not available
© 2018 John Wiley & Sons Ltd wileyonlinelibrary.com/journal/pan Pediatric Anesthesia. 2018;28:564–572.