Challenging the default use of arterial catheters in critical care

We read with interest the systematic review and meta-analysis by Levido et al. [1], showing that the rates of failure or complications of arterial catheters in ICU are higher than thought previously. The authors highlight the heterogeneity of reporting between the individual studies, and it is also worth noting the lack of data on the duration of arterial catheter use. These factors limit the clinical utility of the reported incidences in the review, precluding a risk assessment at critical care admission and beyond. Previous studies have highlighted the risks associated with arterial catheters [2] and alternatives have been proposed [3]. Although arterial catheters are associated with increased risks of catheter-related complications, it will be difficult to persuade clinicians that similar outcomes in critical care populations are achievable without their use. For example, although frequent arterial blood sampling might cause iatrogenic anaemia in the ICU, some might argue that it is over testing that is the issue and not the use of arterial catheters from which samples are drawn. We suggest that it is time to challenge the default use of arterial catheters in critical care patients and propose reserving invasive arterial monitoring for more carefully selected patients. A culture shift towards a more conservative approach has the potential for preventing patient harm from non-infective and infective complications, lowering financial and environmental costs and reducing iatrogenic blood loss and blood transfusions in individual patients. Future research should focus on refining patient selection for arterial catheters, establishing a more evidence-based timing of insertion and evaluating bundles of care that allow earlier removal of existing arterial catheters once clinical stability allows.