Ultrasound-Guided Radial Artery Catheterization in a Four-Month-Old Boy

CHAPTER 1

Arterial catheterization in pediatric patients can be exceedingly challenging when performed using traditional landmark-based technique. Some that rely on visual or tactical cues. Moreover, once an initial attempt fails, subsequent punctures become substantially more difficult due to bleeding, hematoma formation, or vasospasm, making first-pass success highly desirable. Mastery of ultrasound-guided vascular access markedly improves the likelihood of successful cannulation on the first attempt. The procedure is performed using the short-axis, out-of-plane approach, although dynamic needle tip positioning is now commonly incorporated. This method entails alternatively advancing the needle and the transducer in small increments while continually visualizing the exact position of the needle tip. Even after the inner needle punctures the anterior arterial wall and blood flashback is confirmed, the outer catheter must be advanced until it is fully positioned within the lumen before completing cannulation. Now, we will present a real-time video of the procedure. The patient is a four-month-old male weighing 5.5 kilogram who was scheduled to undergo a systemic-to-pulmonary shunt procedure for tetralogy of Fallot.

CHAPTER 2

For radial artery access, place an appropriately-sized roll of gauze beneath the wrist to achieve dorsiflexion. CDC guidelines recommend skin disinfection with over 0.5% chlorhexidine in alcohol or povidone-iodine, the use of sterile gauze, and a sterile drape. When ultrasound guidance is used, the probe must be covered with a sterile sheath and maximal barrier precautions should be observed.

CHAPTER 3

Apply sterile gel and visualize the radial artery in the short-axis view.

CHAPTER 4

Initiate the puncture using a 24-gauge catheter with a short-axis, out-of-plane approach. Once the needle tip is visualized as a bright dot between the skin and the anterior wall of the artery, we advance the ultrasound probe and the puncture needle alternatively until the needle penetrates the anterior wall of the artery and the blood return is confirmed. This technique of advancing the ultrasound probe and the puncture needle alternately forward is called dynamic needle tip positioning. After confirming blood return, repeat the dynamic needle tip positioning technique approximately three more times while ensuring that the needle tip is located within the artery.

CHAPTER 5

Finally, the outer catheter is inserted into the radial artery.

CHAPTER 6

Wipe away excess sterile jelly, and carefully peel off the sterile drape, taking care not to destroy the catheter. Withdraw the inner needle while maintaining pressure on the artery, then have an assistant connect the line. Apply a dressing and complete the procedure.