This chapter is vaguely relevant to Section G7(iii) of the 2017 CICM Primary Syllabus, which asks the exam candidate to "describe the invasive and non-invasive measurement of blood pressure, including
limitations and potential sources of error". It is also vaguely related to Section X(ii), "describe the anatomy relevant to the insertion of an arterial line into a brachial, axillary, posterior tibial, dorsalis pedis, radial or femoral artery". None of the Part I or Part II questions have so far tested the candidate's ability to wisely select a correct insertion site, perhaps recognising that there are many different ways to skin a cat.
There is no specific literature to guide decisionmaking in this area. Most of the material presented here is derived from "Chapter 3: Arterial line placement and care" from Irwin and Rippe's Intensive Care Medicine (7th Ed), by Lee-Llacer and Seneff. Site selection is guided as much by the effects we don't want as by the desired effects, and valuable reading about site-specific complications should include the excellent reviews by (Scheer et al, 2002; Frank et al,1983).
In short:
The ideal site for arterial catheter placement would have the following characteristics:
- Large
- Proximal
- Extensive collateral circulation
- Comfortable for the patient
- Accessible for nursing care and insertion
- Unaffected by infection or trauma
- Not in the way of any other planned procedure (eg. a radial artery harvest for CABG)
- Close to the monitoring equipment (if it cannot be repositioned)
Potential sites typically used in adults include:
- Radial artery
- Femoral artery
- Axillary artery
- Dorsalis pedis artery
- Brachial artery
Less typical sites can include:
- Ulnar artery
- Axillary artery
- Superficial temporal artery
However, everyone still ends up getting a radial arterial line. This is because the balance of risk and benefit favours the radial artery as the first choice for arterial catheterisation. Each site has its advantages and disadvantages, with respect to ease of nursing access, patient comfort, accuracy of measurement and difficulty of cannulation; and rates of serious complications are similar for all sites.
In the neonatal setting, the umbilical artery is a unique access point which also needs to be mentioned. Theoretically, any peripheral artery can be accessed for arterial pressure measurement.
Nuclear hormone receptors
- 1A. Thyroid hormone receptors
- 1B. Retinoic acid receptors
- 1C. Peroxisome proliferator-activated receptors
- 1D. Rev-Erb receptors
- 1F. Retinoic acid-related orphans
- 1H. Liver X receptor-like receptors
- 1I. Vitamin D receptor-like receptors
- 2A. Hepatocyte nuclear factor-4 receptors
- 2B. Retinoid X receptors
- 2C. Testicular receptors
- 2E. Tailless-like receptors
- 2F. COUP-TF-like receptors
- 3B. Estrogen-related receptors
- 4A. Nerve growth factor IB-like receptors
- 5A. Fushi tarazu F1-like receptors
- 6A. Germ cell nuclear factor receptors
- 0B. DAX-like receptors
- Steroid hormone receptors
Ion channels
- Voltage-gated ion channels
- Ligand-gated ion channels
- Other ion channels
- Aquaporins
- Chloride channels
- Connexins and Pannexins
- Piezo channels
- Sodium leak channel, non-selective
- Store-operated ion channels
G-protein-coupled receptors
- Orphan and other 7TM receptors
- 5-Hydroxytryptamine receptors
- Acetylcholine receptors (muscarinic)
- Adenosine receptors
- Adhesion Class GPCRs
- Adrenoceptors
- Angiotensin receptors
- Apelin receptor
- Bile acid receptor
- Bombesin receptors
- Bradykinin receptors
- Calcitonin receptors
- Calcium-sensing receptor
- Cannabinoid receptors
- Chemerin receptor
- Chemokine receptors
- Cholecystokinin receptors
- Class Frizzled GPCRs
- Complement peptide receptors
- Corticotropin-releasing factor receptors
- Dopamine receptors
- Endothelin receptors
- G protein-coupled estrogen receptor
- Formylpeptide receptors
- Free fatty acid receptors
- GABAB receptors
- Galanin receptors
- Ghrelin receptor
- Glucagon receptor family
- Glycoprotein hormone receptors
- Gonadotrophin-releasing hormone receptors
- GPR18, GPR55 and GPR119
- Histamine receptors
- Hydroxycarboxylic acid receptors
- Kisspeptin receptor
- Leukotriene receptors
- Lysophospholipid (LPA) receptors
- Lysophospholipid (S1P) receptors
- Melanin-concentrating hormone receptors
- Melanocortin receptors
- Melatonin receptors
- Metabotropic glutamate receptors
- Motilin receptor
- Neuromedin U receptors
- Neuropeptide FF/neuropeptide AF receptors
- Neuropeptide S receptor
- Neuropeptide W/neuropeptide B receptors
- Neuropeptide Y receptors
- Neurotensin receptors
- Opioid receptors
- Orexin receptors
- Oxoglutarate receptor
- P2Y receptors
- Parathyroid hormone receptors
- Platelet-activating factor receptor
- Prokineticin receptors
- Prolactin-releasing peptide receptor
- Prostanoid receptors
- Proteinase-activated receptors
- QRFP receptor
- Relaxin family peptide receptors
- Somatostatin receptors
- Succinate receptor
- Tachykinin receptors
- Thyrotropin-releasing hormone receptors
- Trace amine receptor
- Urotensin receptor
- Vasopressin and oxytocin receptors
- VIP and PACAP receptors
Enzymes
- Kinases (EC 2.7.x.x)
- AGC: Containing PKA, PKG, PKC families
- DMPK family
- G protein-coupled receptor kinases (GRKs)
- MAST family
- NDR family
- PDK1 family
- Protein kinase A
- Akt (Protein kinase B)
- Protein kinase C (PKC)
- Protein kinase G (PKG)
- Protein kinase N (PKN) family
- RSK family
- RSKL family
- SGK family
- YANK family
- Atypical
- ABC1 family
- Alpha kinase family
- BCR family
- Bromodomain kinase (BRDK) family
- G11 family
- Phosphatidyl inositol 3' kinase-related kinases (PIKK) family
- RIO family
- PDHK family
- Pyruvate dehydrogenase kinase (PDHK) family
- TAF1 family
- TIF1 family
- CAMK: Calcium/calmodulin-dependent protein kinases
- CAMK1 family
- CAMK2 family
- CAMK-like (CAMKL) family
- CAMK-unique family
- CASK family
- DCAMKL family
- Death-associated kinase (DAPK) family
- MAPK-Activated Protein Kinase (MAPKAPK) family
- Myosin Light Chain Kinase (MLCK) family
- Phosphorylase kinase (PHK) family
- PIM family
- Protein kinase D (PKD) family
- PSK family
- RAD53 family
- Testis specific kinase (TSSK) family
- Trbl family
- Trio family
- CK1: Casein kinase 1
- CMGC: Containing CDK, MAPK, GSK3, CLK families
- CLK family
- Cyclin-dependent kinase (CDK) family
- Cyclin-dependent kinase-like (CDKL) family
- Dual-specificity tyrosine-(Y)-phosphorylation regulated kinase (DYRK) family
- Glycogen synthase kinase (GSK) family
- Mitogen-activated protein kinases (MAP kinases)
- RCK family
- SRPK family
- Lipid modifying kinases
- 1-phosphatidylinositol 4-kinase family
- Phosphatidylinositol-4-phosphate 3-kinase family
- Phosphatidylinositol 3-kinase family
- Phosphatidylinositol-4,5-bisphosphate 3-kinase family
- 1-phosphatidylinositol-3-phosphate 5-kinase family
- Type I PIP kinases (1-phosphatidylinositol-4-phosphate 5-kinase family)
- Type II PIP kinases (1-phosphatidylinositol-5-phosphate 4-kinase family)
- Sphingosine kinase
- Other protein kinases
- CAMKK family
- Aurora kinase (Aur) family
- Bub family
- Bud32 family
- Casein kinase 2 (CK2) family
- CDC7 family
- Haspin family
- IKK family
- IRE family
- MOS family
- NAK family
- NIMA (never in mitosis gene a)- related kinase (NEK) family
- NKF1 family
- NKF2 family
- NKF4 family
- NKF5 family
- NRBP family
- Numb-associated kinase (NAK) family
- Other-unique family
- Polo-like kinase (PLK) family
- PEK family
- SgK493 family
- Slob family
- TBCK family
- TOPK family
- Tousled-like kinase (TLK) family
- TTK family
- Unc-51-like kinase (ULK) family
- VPS15 family
- WEE family
- Wnk family
- Miscellaneous protein kinases
- actin-binding proteins ADF family
- SCY1 family
- Hexokinases
- STE: Homologs of yeast Sterile 7, Sterile 11, Sterile 20 kinases
- TK: Tyrosine kinase
- Receptor tyrosine kinases (RTKs)
- Type I RTKs: ErbB (epidermal growth factor) receptor family
- Type II RTKs: Insulin receptor family
- Type III RTKs: PDGFR, CSFR, Kit, FLT3 receptor family
- Type IV RTKs: VEGF (vascular endothelial growth factor) receptor family
- Type V RTKs: FGF (fibroblast growth factor) receptor family
- Type VI RTKs: PTK7/CCK4
- Type VII RTKs: Neurotrophin receptor/Trk family
- Type VIII RTKs: ROR family
- Type IX RTKs: MuSK
- Type X RTKs: HGF (hepatocyte growth factor) receptor family
- Type XI RTKs: TAM (TYRO3-, AXL- and MER-TK) receptor family
- Type XII RTKs: TIE family of angiopoietin receptors
- Type XIII RTKs: Ephrin receptor family
- Type XIV RTKs: RET
- Type XV RTKs: RYK
- Type XVI RTKs: DDR (collagen receptor) family
- Type XVII RTKs: ROS receptors
- Type XVIII RTKs: LMR family
- Type XIX RTKs: Leukocyte tyrosine kinase (LTK) receptor family
- Type XX RTKs: STYK1
- Non-receptor tyrosine kinases (nRTKs)
- Receptor tyrosine kinases (RTKs)
- TKL: Tyrosine kinase-like
- Interleukin-1 receptor-associated kinase (IRAK) family
- Leucine-rich repeat kinase (LRRK) family
- LIM domain kinase (LISK) family
- Mixed Lineage Kinase (MLK) family
- RAF family
- Receptor interacting protein kinase (RIPK) family
- Receptor serine/threonine kinase (RSTK) family
- TKL-unique family
- AGC: Containing PKA, PKG, PKC families
- Peptidases and proteinases
- AA: Aspartic (A) Peptidases
- AD: Aspartic (A) Peptidases
- CA: Cysteine (C) Peptidases
- CD: Cysteine (C) Peptidases
- CE: Cysteine (C) Peptidases
- M-: Metallo (M) Peptidases
- MA: Metallo (M) Peptidases
- MC: Metallo (M) Peptidases
- ME: Metallo (M) Peptidases
- MF: Metallo (M) Peptidases
- MG: Metallo (M) Peptidases
- MH: Metallo (M) Peptidases
- MJ: Metallo (M) Peptidases
- MP: Metallo (M) Peptidases
- PA: Serine (S) Peptidases
- PB: Threonine (T) Peptidases
- PC: Cysteine (C) Peptidases
- SB: Serine (S) Peptidases
- SC: Serine (S) Peptidases
- AAA ATPases
- Acetylcholine turnover
- Adenosine turnover
- Amino acid hydroxylases
- L-Arginine turnover
- Carboxylases and decarboxylases
- Catecholamine turnover
- Ceramide turnover
- Serine palmitoyltransferase
- 3-ketodihydrosphingosine reductase
- Ceramide synthase
- Sphingolipid Δ4-desaturase
- Sphingomyelin synthase
- Sphingomyelin phosphodiesterase
- Neutral sphingomyelinase coupling factors
- Ceramide glucosyltransferase
- Acid ceramidase
- Neutral ceramidases
- Alkaline ceramidases
- Ceramide kinase
- Chromatin modifying enzymes
- Cyclic nucleotide turnover/signalling
- Cytochrome P450
- Endocannabinoid turnover
- Eicosanoid turnover
- GABA turnover
- Glycerophospholipid turnover
- Haem oxygenase
- Hydrogen sulphide synthesis
- Hydrolases
- Inositol phosphate turnover
- Lanosterol biosynthesis pathway
- LPA synthesis
- Nucleoside synthesis and metabolism
- Phosphatases
- Sphingosine 1-phosphate turnover
- Thyroid hormone turnover
- 1.-.-.- Oxidoreductases
- 1.1.1.42 Isocitrate dehydrogenases
- 1.4.3.13 Lysyl oxidases
- 1.13.11.- Dioxygenases
- 1.14.11.29 2-oxoglutarate oxygenases
- 1.14.13.9 kynurenine 3-monooxygenase
- 1.17.4.1 Ribonucleoside-diphosphate reductases
- 2.1.1.- Methyltransferases
- 2.1.2.- Hydroxymethyl-, formyl- and related transferases
- 2.3.1.- Acyltransferases
- 2.3.2.- Aminoacyltransferases
- 2.4.2.1 Purine-nucleoside phosphorylase
- 2.4.2.30 poly(ADP-ribose)polymerases
- 2.5.1.58 Protein farnesyltransferase
- 2.6.1.42 Branched-chain-amino-acid transaminase
- 3.1.-.- Ester bond enzymes
- 3.1.1.- Carboxylic Ester Hydrolases
- 3.2.1.- Glycosidases
- 3.4.21.46 Complement factor D
- 3.5.1.- Histone deacetylases (HDACs)
- 3.5.1.2 Glutaminases
- 3.5.3.15 Peptidyl arginine deiminases (PADI)
- 3.6.5.2 Small monomeric GTPases
- 4.2.1.1 Carbonate dehydratases
- 5.-.-.- Isomerases
- 5.2.-.- Cis-trans-isomerases
- 5.99.1.2 DNA Topoisomerases
- 6.3.3.- Cyclo-ligases
Catalytic receptors
- Cytokine receptor family
- GDNF receptor family
- Immune checkpoint catalytic receptors
- Integrins
- Natriuretic peptide receptor family
- Pattern recognition receptors
- Receptor kinases
- TK: Tyrosine kinase
- Receptor tyrosine kinases (RTKs)
- Type I RTKs: ErbB (epidermal growth factor) receptor family
- Type II RTKs: Insulin receptor family
- Type III RTKs: PDGFR, CSFR, Kit, FLT3 receptor family
- Type IV RTKs: VEGF (vascular endothelial growth factor) receptor family
- Type V RTKs: FGF (fibroblast growth factor) receptor family
- Type VI RTKs: PTK7/CCK4
- Type VII RTKs: Neurotrophin receptor/Trk family
- Type VIII RTKs: ROR family
- Type IX RTKs: MuSK
- Type X RTKs: HGF (hepatocyte growth factor) receptor family
- Type XI RTKs: TAM (TYRO3-, AXL- and MER-TK) receptor family
- Type XII RTKs: TIE family of angiopoietin receptors
- Type XIII RTKs: Ephrin receptor family
- Type XIV RTKs: RET
- Type XV RTKs: RYK
- Type XVI RTKs: DDR (collagen receptor) family
- Type XVII RTKs: ROS receptors
- Type XVIII RTKs: LMR family
- Type XIX RTKs: Leukocyte tyrosine kinase (LTK) receptor family
- Type XX RTKs: STYK1
- Receptor tyrosine kinases (RTKs)
- TKL: Tyrosine kinase-like
- Receptor serine/threonine kinase (RSTK) family
- TK: Tyrosine kinase
- Receptor Guanylyl Cyclase (RGC) family
- Receptor tyrosine phosphatase (RTP) family
- Tumour necrosis factor (TNF) receptor family
Transporters
- ATP-binding cassette transporter family
- F-type and V-type ATPases
- P-type ATPases
- Major facilitator superfamily (MFS) of transporters
- SLC superfamily of solute carriers
- SLC1 family of amino acid transporters
- SLC2 family of hexose and sugar alcohol transporters
- SLC3 and SLC7 families of heteromeric amino acid transporters (HATs)
- SLC4 family of bicarbonate transporters
- SLC5 family of sodium-dependent glucose transporters
- SLC6 neurotransmitter transporter family
- SLC8 family of sodium/calcium exchangers
- SLC9 family of sodium/hydrogen exchangers
- SLC10 family of sodium-bile acid co-transporters
- SLC11 family of proton-coupled metal ion transporters
- SLC12 family of cation-coupled chloride transporters
- SLC13 family of sodium-dependent sulphate/carboxylate transporters
- SLC14 family of facilitative urea transporters
- SLC15 family of peptide transporters
- SLC16 family of monocarboxylate transporters
- SLC17 phosphate and organic anion transporter family
- SLC18 family of vesicular amine transporters
- SLC19 family of vitamin transporters
- SLC20 family of sodium-dependent phosphate transporters
- SLC22 family of organic cation and anion transporters
- SLC23 family of ascorbic acid transporters
- SLC24 family of sodium/potassium/calcium exchangers
- SLC25 family of mitochondrial transporters
- SLC26 family of anion exchangers
- SLC27 family of fatty acid transporters
- SLC28 and SLC29 families of nucleoside transporters
- SLC30 zinc transporter family
- SLC31 family of copper transporters
- SLC32 vesicular inhibitory amino acid transporter
- SLC33 acetylCoA transporter
- SLC34 family of sodium phosphate co-transporters
- SLC35 family of nucleotide sugar transporters
- SLC36 family of proton-coupled amino acid transporters
- SLC37 family of phosphosugar/phosphate exchangers
- SLC38 family of sodium-dependent neutral amino acid transporters
- SLC39 family of metal ion transporters
- SLC40 iron transporter
- SLC41 family of divalent cation transporters
- SLC42 family of Rhesus glycoprotein ammonium transporters
- SLC43 family of large neutral amino acid transporters
- SLC44 choline transporter-like family
- SLC45 family of putative sugar transporters
- SLC46 family of folate transporters
- SLC47 family of multidrug and toxin extrusion transporters
- SLC48 heme transporter
- SLC49 family of FLVCR-related heme transporters
- SLC50 sugar transporter
- SLC51 family of steroid-derived molecule transporters
- SLC52 family of riboflavin transporters
- SLCO family of organic anion transporting polypeptides
- Patched family
Other protein targets
- Adiponectin receptors
- Anti-infective targets
- Aryl hydrocarbon receptor complex
- B-cell lymphoma 2 (Bcl-2) protein family
- Blood coagulation components
- Bromodomain-containing proteins
- Enzymatic bromodomain-containing proteins
- Non-enzymatic BRD containing proteins
- Butyrophilin and butyrophilin-like proteins
- Carrier proteins
- CD molecules
- Chromatin-interacting transcriptional repressors
- Circadian clock proteins
- Claudins
- EF-hand domain containing
- Fatty acid-binding proteins
- Fc epsilon receptors
- G-alpha family G(q) subfamily
- Heat shock proteins
- Immune checkpoint proteins
- Immunoglobulins
- Inhibitors of apoptosis (IAP) protein family
- Kelch-like proteins
- Kinesins
- Leucine-rich repeat proteins
- Lymphocyte antigens
- Mitochondrial-associated proteins
- Myosin binding proteins
- Non-catalytic pattern recognition receptors
- Notch receptors
- Pentaxins
- Regulators of G protein Signaling (RGS) proteins
- Repulsive guidance molecules
- Reticulons and associated proteins
- Ribosomal factors
- Sigma receptors
- Transcription factors
- Tubulins
- Tumour-associated proteins
- WD repeat-containing proteins
References
Lee-Llacer J, Seneff, M. "Chapter 3: Arterial line placement and care." In: Irwin and Rippe's Intensive Care Medicine, 7th Edition. New York: Little, Brown (2007): 36-47.
Pauca, Alfredo L., et al. "Does radial artery pressure accurately reflect aortic pressure?." Chest 102.4 (1992): 1193-1198.
Russell, James A., et al. "Prospective evaluation of radial and femoral artery catheterization sites in critically ill adults." Critical care medicine 11.12 (1983): 936-939.
Scheer, Bernd Volker, Azriel Perel, and Ulrich J. Pfeiffer. "Clinical review: complications and risk factors of peripheral arterial catheters used for haemodynamic monitoring in anaesthesia and intensive care medicine." Critical Care 6.3 (2002): 199.
Thomas, Frank, et al. "The risk of infection related to radial vs femoral sites for arterial catheterization." Critical care medicine 11.10 (1983): 807-812.