When Should ICU Patients Get an Arterial Line? Building Appropriateness Criteria for Safer, Smarter Use

Study Overview

Arterial catheters are a staple in adult intensive care, used for continuous blood pressure monitoring and frequent blood sampling. But they also carry real risks, including thrombosis/occlusion, infection, and unnecessary blood loss from repeated sampling. This paper sets out to solve a common ICU gap: clear, scenario-based guidance on when arterial lines are appropriate, uncertain, or inappropriate.

Using the RAND/UCLA Appropriateness Method, the team developed a structured process to create appropriateness criteria for arterial catheter use in adult ICU patients. The work focused on the development phase of the criteria, including how the clinical scenarios were built and how expert ratings were run.

Key Findings

• The study used a structured, reproducible approach that combines evidence + expert judgement, rather than relying on habit or local culture.
• Evidence was synthesised first using a literature review and a national survey to ground the work in both research and real-world practice.
• A multidisciplinary expert panel rated clinical scenarios across two rounds, using a 9-point scale to classify indications as appropriate, uncertain, or inappropriate.
• The final set included 3 domains, 10 chapters, and 254 clinical indications, designed to reflect how arterial line decisions actually happen in ICU (why insert, how to insert, when to remove).
• The process explicitly managed disagreement, making differences in expert opinion visible rather than hidden.

Implications

This paper is a behind-the-scenes look at how “appropriate use” guidance gets built when perfect trial evidence doesn’t exist for every scenario. The biggest value is the framework: it creates a transparent way to support ICU decision-making so arterial lines are used when benefits outweigh harms, and avoided when they don’t.

The practical takeaway is that arterial line decisions can be standardised without oversimplifying ICU complexity. Once the final ratings and recommendations are reported, these criteria can support consistent practice, reduce unnecessary arterial lines, and strengthen quality improvement and education.

Read more:https://doi.org/10.1016/j.aucc.2026.101568

Authors: Annabel Levido; Steven J. Bernstein; Kevin B. Laupland; Felicity Edwards; Roohallah Alizadehsani; Jennifer K. Horowitz; Amanda J. Ullman; Samantha Keogh