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Application of Ultrasonography: Vascular

Cannulation - Radial Artery

Pre-scenario Preparation:
Make sure to knock on the door, introduce yourself, and wash your hands.
Always make good eye contact, listen carefully, and communicate in terms the
standardized patient will understand (if you have to give them instructions).

Make sure to pay attention to laterality (i.e. perform the task on the correct
extremity). In practice you address this by reviewing consents, confirming with
the patient, performing a time out, and marking the extremity.

Obtain the ultrasound image as requested. You can ask the patient to position
themselves as appropriate. You will be able to manipulate the ultrasound
probe but you can request that the examiner change the depth or gain to
enhance image acquisition. The outline doesn’t indicate that you will be
required to ask for doppler placement over an image of interest but you should
ask for doppler ultrasound placement over an image if you feel it is applicable.
Once you are satisfied with the image, you will ask the examiner to freeze the
image.

You will be asked to generate an in-plane or out-of-plane view (Note: Vascular

access ultrasound is most commonly performed out-of-plane).

You will be asked to identify laterality and the radial artery.

You will be asked to identify optimal needle positioning for vascular access.

Patients should remain supine for all vascular access tasks. This will help
identify the vessels and can help reduce the risk of venous air embolism.
General Description:

Ultrasound guidance can help expedite the cannulation of the radial artery at the
wrist. It is performed in the out-of-plane approach.

Ultrasound Placement:

A linear array probe is the probe of choice for the radial artery. Apply ultrasound gel
to the probe or the requested extremity. Then place the probe over the radial (i.e.
lateral) aspect of the distal forearm at the wrist. The ultrasound is placed such that
needle insertion will be out-of-plane (Note: This ultrasound probe has a center line
indicator. The probe is currently located in the center of the wrist. However, it will be
moved laterally to center over the radial artery when it is time to simulate
cannulation).
Radial Artery Ultrasound Image:

Adjust the ultrasound probe laterally until the image includes the radial artery as
shown in the image below (A = Radial Artery). The artery is medial to the vein
(which obliterates easy with probe pressure) and just lateral to the flexor carpi
radialis tendon. It is important to note how superficial the artery is located (i.e. about
0.5 cm depth in this image). You will likely need to set the image depth to a
shallower depth as this is a superficial structure (Note: The ultrasound depth is set
to 1.5 cm in the right lower corner of the image). The artery will be pulsatile and
difficult to collapse when pressure is applied to the probe (Note: Doppler could be
requested to verify pulsatility of the artery if there is uncertainty.).
Needle Placement:

You should center the ultrasound on the artery. The simulated needle placement will
be an out-of-plane placement (i.e. The needle is inserted in the middle of the probe
and it crosses the width, but not length, of the probe).
The image below indicates the direction that the out-of-plane needle (i.e. see arrow
above the artery) will take to the artery. The needle is imaged as an echogenic dot
but it takes careful probe manipulation to image the needle. This approach provides
a shorter needle path to the target but the extent of the unimaged needle is a
definite limitation (i.e. the needle tip can be beyond the probe). In practice, the probe
is usually adjusted by slight cephalad or caudad movement to bring the needle into
view. It is best to use a catheter-over-needle approach. The angle of the needle
should be shallow (i.e. close to the skin) to better facilitate threading of the catheter.
You could verify catheter insertion by turning the probe in-plane with the catheter
length. Arterial catheter placement can be verified by pulsatility of blood and
transduction of arterial waveform on the monitor.
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