Evidence Summary for Ultrasound‐Guided Peripheral Arterial Catheter Placement in Adult Critical Care Patients

ABSTRACT

Background and Aims

Ultrasound guidance can improve the success and safety of peripheral arterial catheter placement in critically ill adult patients; however, existing evidence is scattered and lacks a graded, clinically actionable synthesis. This evidence summary aimed to systematically retrieve, evaluate, and synthesize evidence on ultrasound‐guided peripheral arterial catheter placement in critically ill adult patients, in order to inform evidence‐based nursing practice.

Methods

This evidence summary was conducted following the methodological framework recommended by the Joanna Briggs Institute (JBI) for evidence synthesis. A top‐down search was performed based on the “6S” evidence pyramid model to identify relevant clinical guidelines, systematic reviews, and randomized controlled trials. Twenty databases and resources including UpToDate, Embase, and PubMed were systematically searched from inception until August 31, 2025.

Results

A total of 20 publications were included: 3 clinical guidelines, 12 systematic reviews, and 5 randomized controlled trials. From these, 29 discrete evidence recommendations were extracted and synthesized, covering six key aspects: puncture site selection, catheterization procedures and recommendations, comparison of puncture approaches, ultrasound imaging and probe techniques, ultrasound equipment and auxiliary tools, and training.

Conclusion

This evidence summary provides 29 graded recommendations for ultrasound‐guided peripheral arterial catheter placement in critically ill adult patients. Implementing these recommendations can increase first‐attempt success, decrease complications, and improve patient safety. Adoption should be tailored to local equipment availability and clinical context, while adhering to core evidence‐based principles.

Trial and Protocol Registration

This study was registered with the Center for Evidence‐Based Nursing at Fudan University (Registration No. ES20245973). URL: http://ebn.nursing.fudan.edu.cn/home.

1. Introduction

The peripheral arterial catheter functions as a core tool for hemodynamic monitoring in the intensive care unit (ICU), and plays a pivotal role in circulatory support for critically ill adult patients through continuous arterial pressure monitoring and convenient blood sampling [1]. For the purpose of this evidence summary, “critically ill adult patients” refers to adult patients (≥ 18 years) requiring ICU admission for monitoring and/or treatment of life‐threatening conditions. Studies indicate that invasive arterial catheter placement is one of the most frequently performed procedures in intensive care settings [2, 3, 4], underscoring its indispensable role in critical care management. With the growing severity of illness among ICU patients and the increasing demand for precise hemodynamic monitoring, the frequency of peripheral arterial catheter placement has continued to rise. However, traditional palpation‐guided techniques exhibit significant limitations in clinical practice. These methods demonstrate lower success rates in patients with obesity, weak arterial pulses, or aberrant vascular anatomy [5] and are associated with increased risks of complications, including catheter‐related bloodstream infection and local hematoma [6]. These technical limitations and safety concerns can directly undermine the timeliness and reliability of hemodynamic monitoring in critically ill adult patients.

In response, ultrasound‐guided vascular access has emerged as a transformative approach. Compared with conventional landmark techniques, ultrasound guidance significantly improves first‐attempt success rates, reduces the number of required attempts, shortens procedural time, and decreases complication rates [7, 8]. Current evidence‐based guidelines strongly advocate for the routine implementation of ultrasound guidance during vascular access procedures, emphasizing its crucial roles in pre‐cannulation vessel assessment, real‐time needle visualization, and early identification of procedural complications [9].

Despite the availability of clinical guidelines, translating these broad recommendations into actionable practice remains challenging for bedside nurses in critical care settings [10]. Existing guidelines typically address vascular access for heterogeneous patient populations across multiple clinical contexts (e.g., operating rooms, interventional suites, and general wards) [9, 11], and do not specifically focus on the unique clinical demands of critically ill adult patients in the ICU. These patients often present with hemodynamic instability, peripheral vasoconstriction, edema, or altered vascular anatomy, which may render standard procedural recommendations insufficient or inapplicable [7]. Furthermore, primary evidence and systematic reviews on this topic are dispersed across multiple sources with varying levels of recommendation grades, and clinical practitioners may find it difficult to rapidly identify graded, directly applicable practice recommendations during busy ICU workflows. A consolidated, critically appraised evidence summary that is specifically oriented to ICU nursing practice—extracting, grading, and synthesizing recommendations from existing high‐quality sources into clearly actionable items—would therefore facilitate the implementation of evidence‐based practice in this setting.

This evidence summary aimed to: (1) systematically retrieve, evaluate, and synthesize available evidence on ultrasound‐guided peripheral arterial catheter placement in critically ill adult patients; (2) provide a reference for clinical nursing practice to improve procedural safety and success; and (3) support the standardization of evidence‐based ultrasound‐guided techniques in critical care settings.

2. Methods

Currently, reporting specifications for evidence summary is still lacking. This evidence summary was conducted following the methodological framework recommended by the Joanna Briggs Institute (JBI) for best evidence summaries and the Evidence Summary Reporting Standards of the Fudan University Center for Evidence‐Based Nursing [12]. The reporting specifications include problem establishment, literature retrieval, literature screening, literature evaluation, the summary and grading of evidence and the formation of practical suggestions. The study was registered with the Fudan University Center for Evidence‐Based Nursing (Registration No. ES20245973; URL: http://ebn.nursing.fudan.edu.cn/home).

2.1. Establishment of the Problem

The evidence‐based question was structured according to the PIPOST model [13], with the following components: P (target population for evidence application): Critically ill adult patients; I (intervention): Ultrasound‐guided peripheral arterial catheter placement; P (professionals applying the evidence): Physicians and nurses; O (outcome): Peripheral arterial catheter placement success rate, incidence of catheter‐related complications, etc.; S (place of applying the evidence): ICU; T (type of evidence): Guidelines, clinical decision‐making tools, evidence summaries, expert consensus statements, systematic reviews, and randomized controlled trials (RCTs).

2.2. Evidence Sources and Retrieval Strategies

Following the “6S” evidence pyramid model [14], we systematically searched the literature from top‐tier evidence sources downward. Twenty databases and official websites were comprehensively searched, including UpToDate, BMJ Best Practice, Cochrane Library, Guidelines International Network (GIN), Registered Nurses' Association of Ontario (RNAO), Society of Critical Care Medicine (SCCM), Scottish Intercollegiate Guidelines Network (SIGN), Centers for Disease Control and Prevention (CDC), German Medical Society (GMS), National Institute for Health and Care Excellence (NICE), Embase, PubMed, Web of Science, CINAHL, Yimaitong Guidelines Network, China National Knowledge Infrastructure (CNKI), Chinese Biomedical Literature Database (CBM), Wanfang Database, VIP Database, and Chinese Medical Association journals.

The search was conducted using subject terms and free‐text words, with the search terms being “Ultrasonography/Echotomography/Ultrasonic Imaging/Imaging, Ultrasonic/Sonography, Medical/Medical Sonography/Ultrasound Imaging/Imaging*, Ultrasound/Ultrasonographic Imaging*/Imaging*, Ultrasonographic/Diagnostic Ultrasound*/Ultrasound*, Diagnostic/Tomography, Ultrasonic/Ultrasonic Tomography/Diagnosis, Ultrasonic/Diagnoses, Ultrasonic/Ultrasonic Diagnoses/Ultrasonic Diagnosis/B‐mode ultrasonography/Ultrasound guidance/Ultrasound‐guided/Ultrasonic examination/Color Doppler ultrasound/Ultrasonography, Doppler” and “Catheterization, Peripheral/peripheral arterial catheterization/Peripheral Catheterization*/Catheterization*, Peripheral Arterial/Peripheral Arterial Catheterization*/Arterial Catheterization*, Peripheral/arterial cannulation/Arterial catheter*/indwelling arterial catheter*/Peripheral arterial duct/Peripheral artery/arterial cannula/Invasive arterial conduit.” The search period was from the establishment of each database to August 31, 2025. Figure 1 shows the PubMed search strategy.

Figure 1.

PubMed search strategy.

2.3. Study Inclusion and Exclusion Criteria

The study inclusion criteria were as follows: (1) Guidelines, clinical decision tools, evidence summaries, expert consensus statements, systematic reviews and RCTs related to ultrasound‐guided peripheral arterial catheter placement in critically ill adult patients. (2) Publications limited to the Chinese and English languages.

The study exclusion criteria were as follows: (1) Incomplete literature (e.g., conference abstracts, protocols without results, or retracted articles). (2) Full‐text studies lacking extractable data for evidence synthesis, even after attempting to contact the corresponding authors. (3) Non‐evidence‐based personal monographs. (4) Studies deemed to be of low quality based on methodological quality assessment (e.g., guidelines scoring < 30% in three or more AGREE II domains, or original studies meeting less than 60% of JBI checklist criteria).

2.4. Data Extraction

The retrieved literature was imported into Zotero and duplicates were removed. Two researchers trained in evidence‐based methods independently screened the literature. Initial screening was conducted by reviewing titles, abstracts, and keywords, followed by full‐text review for re‐screening. The quality of the included literature was assessed. During the screening process, if multiple articles with identical titles by the same author were identified, only the most recent publication was retained. Similarly, for studies with closely related titles by the same author, the most recent and relevant publication was selected. Any discrepancies between the researchers were resolved through discussion, with arbitration by a third reviewer when necessary. The literature screening process was summarized in a PRISMA 2020 flow diagram (Figure 2).

Figure 2.

PRISMA 2020 flow diagram of literature screening.

2.5. Literature Quality Evaluation

2.5.1. Literature Quality Evaluation Process

The quality evaluation utilizing the aforementioned instruments (AGREE II for guidelines and JBI critical appraisal checklists for individual studies) was independently conducted by three researchers trained in evidence‐based methodology. All researchers had completed systematic training in evidence‐based research methods. In case of disagreement, discrepancies were resolved through group discussion until consensus was reached.

2.5.2. Literature Quality Evaluation Method

Evaluation of guidelines: Guidelines were assessed using the updated AGREE II instrument [15]. The tool comprises six domains and 23 items, with each item rated on a 7‐point scale (1 = strongly disagree to 7 = strongly agree). Domain scores were standardized using the formula: (obtained score − minimum possible score)/(maximum possible score − minimum possible score) × 100%. Recommendations were classified into three levels: Grade A (all six domains ≥ 60%), Grade B (at least three domains ≥ 30% and at least one domain < 60%), and Grade C (three or more domains < 30%). Literature rated as Grade C was excluded from this study.

Evaluation of systematic reviews: Systematic reviews were evaluated using the JBI Critical Appraisal Checklist for Systematic Reviews [16], which consists of 11 items rated as “Yes,” “No,” “Unclear,” or “Not applicable.”

Evaluation of randomized controlled trials: RCTs were appraised using the JBI Critical Appraisal Checklist for RCTs [16], comprising 13 items with the same response options: “Yes,” “No,” “Unclear,” or “Not applicable.”

Evaluation of expert consensus articles: Expert consensus articles were assessed using the JBI Critical Appraisal Checklist for Text and Opinion Papers [16], which consists of six items rated as “Yes,” “No,” “Unclear,” or “Not applicable.”

Evaluation of evidence summaries and clinical decision support tools: Evidence summaries and clinical decision support tools were not directly evaluated due to the lack of standardized appraisal tools [17]. Instead, their original source evidence was traced and assessed according to the relevant study type. In cases of conflicting evidence, priority was given to higher‐quality, more recent, and better‐supported evidence.

2.6. Evidence Summaries, Classifications and Recommendation Levels

Literature meeting the inclusion criteria was subjected to evidence extraction, translation, back‐translation, synthesis, and classification in accordance with standardized methodological principles: (1) Identical evidence from multiple sources was consolidated; (2) In cases of conflicting evidence, priority was given to the higher‐quality evidence; (3) For contemporaneous publications, the most authoritative and earliest published source was chosen. Discrepancies were resolved through researcher discussion, with arbitration by a third independent reviewer when necessary.

According to the 2014 edition of the JBI Levels of Evidence and Grades of Recommendation from the JBI [16], the evidence was categorized into five levels, with the strength of evidence decreasing from Level 1 to Level 5. Level 1 represents the highest quality of evidence, while Level 5 indicates the lowest. Based on the JBI FAME framework (Feasibility, Appropriateness, Meaningfulness, and Effectiveness) [16], two researchers trained in evidence‐based nursing independently rated the strength of the recommendations. This process was conducted in strict accordance with JBI guidelines for grading recommendation strength, taking into account the validity, feasibility, appropriateness, and clinical significance of the evidence. Any disagreements between the reviewers were resolved through arbitration by a third researcher. Expert consensus meetings were held to evaluate the evidence, resulting in a final classification of recommendations as either Grade A (strong recommendation) or Grade B (weak recommendation).

3. Results

3.1. Search Studies

The initial search retrieved 8797 records. After importing into Zotero and removing duplicates, 5927 articles remained. Two researchers independently screened the titles and abstracts of each article, resulting in 466 potentially eligible articles. Following full‐text review, 20 studies were ultimately included: 3 clinical practice guidelines [9, 11, 18], 12 systematic reviews [19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30], and 5 randomized controlled trials [31, 32, 33, 34, 35]. The detailed selection process is depicted in the PRISMA 2020 flow diagram (Figure 2), while Table 1 presents the general characteristics of the included studies.

Table 1.

Basic characteristics of included literature (n = 20).

Included literature	Year of publication (year)	Literature reference	Type of literature	The literature theme
Lamperti et al. [11]	2020	PubMed	Guideline	European Society of Anesthesiology guidelines on peri‐operative use of ultrasound‐guided for vascular access (PERSEUS vascular access)
Lamperti et al. [18]	2012	PubMed	Guideline	International evidence‐based recommendations on ultrasound‐guided vascular access
Vegas et al. [9]	2025	Yimaitong	Guideline	Guidelines for performing ultrasound‐guided vascular cannulation: recommendations of the American Society of Echocardiography
Liu et al. [27]	2022	CNKI	Systematic review	Safety and efficacy of ultrasound‐guided arterial puncture and catheterization: a meta‐analysis
Xue et al. [28]	2024	CNKI	Systematic review	Comparison of ultrasound‐guided technique and palpation method for radial artery puncture in adult critically ill patients: a meta‐analysis
Bhattacharjee et al. [25]	2018	Embase	Systematic review	Comparison between ultrasound‐guided technique and digital palpation technique for radial artery cannulation in adult patients: an updated meta‐analysis of randomized controlled trials
Cao et al. [29]	2023	PubMed	Systematic review	Comparison between the long‐axis in‐plane and short‐axis out‐of‐plane approaches for ultrasound‐guided arterial cannulation: a meta‐analysis and systematic review
Flumignan et al. [30]	2021	Cochrane Library	Systematic review	Ultrasound guidance for arterial (other than femoral) catheterization in adults
Lv et al. [19]	2019	PubMed	Systematic review	Evaluating the long‐, short‐, and oblique‐axis approaches for ultrasound‐guided vascular access cannulation
Mishra et al. [20]	2024	PubMed	Systematic review	Acoustic shadowing to facilitate ultrasound‐guided arterial cannulation: a systematic review and meta‐analysis of randomized controlled trials
Moussa Pacha et al. [21]	2018	PubMed	Systematic review	Ultrasound‐guided versus palpation‐guided radial artery catheterization in adult population: a systematic review and meta‐analysis of randomized controlled trials
Shiloh et al. [22]	2011	Embase	Systematic review	Ultrasound‐guided catheterization of the radial artery: a systematic review and meta‐analysis of randomized controlled trials
Sun et al. [23]	2022	PubMed	Systematic review	Comparison of out‐of‐plane short axis with in‐plane long axis for ultrasound‐guided radial arterial cannulation: a systematic review with trial sequential analysis of randomized controlled trials
Tang et al. [24]	2014	PubMed	Systematic review	Ultrasound guidance for radial artery catheterization: an updated meta‐analysis of randomized controlled trials
Wu et al. [26]	2022	PubMed	Systematic review	Ultrasound‐guided dynamic needle‐tip positioning method is superior to conventional palpation and ultrasound method in arterial catheterization
Hao et al. [34]	2020	Wanfang Database	Randomized controlled trial	Application of ultrasound‐guided double‐line positioning technique in radial artery puncture
Kumar et al. [35]	2024	PubMed	Randomized controlled trial	Longitudinal axis approach versus longitudinal oblique axis approach for ultrasound‐guided radial artery cannulation in adult patients: a comparative study
Min et al. [31]	2016	PubMed	Randomized controlled trial	Effect of bevel direction on the success rate of ultrasound‐guided radial arterial catheterization
Sun et al. [32]	2025	PubMed	Randomized controlled trial	Optimal insertion site for ultrasound‐guided radial artery catheterization utilizing the dynamic needle tip positioning technique: a prospective randomized controlled study
Zhang et al. [33]	2022	PubMed	Randomized controlled trial	Effect of ultrasound angle for radial artery cannulation in adults: a randomized controlled trial

3.2. Evaluation of Publication Quality

3.2.1. Quality Evaluation of Guidelines

This study included a total of three guidelines [9, 11, 18], all of which were independently evaluated by three researchers. All three guidelines were rated as Level A (with all domain standardized scores exceeding 60%), indicating an overall high quality of the included guidelines. Detailed evaluation results are presented in Table 2.

Table 2.

Quality evaluation results of clinical guidelines (n = 3).

Included literature	Standardized scores in various domains (%)						≥ 60%	≥ 30%	Recommendation level
	Scope and purpose	Stakeholder involvement	Rigor of development	Clarity of presentation	Applicability	Editorial independence
Lamperti et al. [11]	85.19	62.96	82.64	88.89	63.89	69.44	6	6	A
Vegas et al. [9]	88.89	62.96	88.89	88.89	62.50	88.89	6	6	A
Lamperti et al. [18]	85.19	61.11	75.69	88.89	63.89	69.44	6	6	A

3.2.2. Quality Evaluation of Systematic Reviews

A total of 12 systematic reviews [19, 20, 21, 22, 23, 24, 25, 26, 27, 28, 29, 30] were included in this study. All evaluated items met the “Yes” criteria, and all studies were included. The quality assessment results are presented in Table 3.

Table 3.

Quality evaluation results of systematic review (n = 12).

Included literature	Q1	Q2	Q3	Q4	Q5	Q6	Q7	Q8	Q9	Q10	Q11
Liu et al. [27]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Xue et al. [28]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Mishra et al. [20]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Cao et al. [29]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Bhattacharjee et al. [25]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Sun et al. [23]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Lv et al. [19]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Flumignan et al. [30]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Tang et al. [24]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Shiloh et al. [22]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Wu et al. [26]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes
Moussa Pacha et al. [21]	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes	Yes

Note: Q1: Whether the evidence‐based questions raised are clear and unambiguous? Q2: Whether the literature inclusion criteria were appropriate for this evidence‐based question? Q3: Is the search strategy appropriate? Q4: The adequacy of databases or resources for searching literature? Q5: Whether the literature quality evaluation criteria used are appropriate? Q6: Whether two or more reviewers independently complete the quality evaluation of the literature? Q7: Whether to take certain measures to reduce errors when extracting data? Q8: Whether the methods of pooling studies were appropriate? Q9: Whether the possibility of publication bias was assessed? Q10: Whether the proposed policy or practice recommendations are based on the results of systematic reviews? Q11: Whether the proposed directions for further research are appropriate?

3.2.3. Quality Evaluation of RCT

This study included five RCTs [31, 32, 33, 34, 35]. The overall quality was satisfactory, and all were included. The quality assessment results are presented in Table 4.

Table 4.

Quality evaluation results of randomized controlled trial (n = 5).

Items	Hao et al. [34]	Min et al. [31]	Zhang et al. [33]	Kumar et al. [35]	Sun et al. [32]
1. Was true randomization used for assignment of participants to treatment groups?	Yes	Yes	Yes	Yes	Yes
2. Was allocation to groups concealed?	Unclear	Yes	Yes	Yes	Yes
3. Were treatment groups similar at the baseline?	Yes	Yes	Yes	Yes	Yes
4. Were participants blind to treatment assignment?	Unclear	Yes	Unclear	Unclear	Yes
5. Were those delivering treatment blind to treatment assignment?	No	No	No	No	No
6. Were outcomes assessors blind to treatment assignment?	Yes	Yes	Yes	Yes	Yes
7. Were treatment groups treated identically other than the intervention of interest?	Unclear	Yes	Yes	Yes	Yes
8. Was follow up complete and if not, were differences between groups in terms of their follow up adequately described and analyzed?	Yes	Yes	Yes	Yes	Yes
9. Were participants analyzed in the groups to which they were randomized?	Yes	Yes	Yes	Yes	Yes
10. Were outcomes measured in the same way for treatment groups?	Yes	Yes	Yes	Yes	Yes
11. Were outcomes measured in a reliable way?	Yes	Yes	Yes	Yes	Yes
12. Was appropriate statistical analysis used?	Yes	Yes	Yes	Yes	Yes
13. Was the trial design appropriate, and any deviations from the standard RCT design (individual randomization, parallel groups) accounted for in the conduct and analysis of the trial?	Yes	Yes	Yes	Yes	Yes

3.3. Evidence Description and Summary

The synthesized evidence regarding ultrasound‐guided peripheral arterial catheter placement in critically ill adult patients encompasses six key aspects: puncture site selection, catheterization procedures and recommendations, comparison of puncture approaches, ultrasound imaging and probe techniques, ultrasound equipment and auxiliary tools, and training. A total of 29 evidence‐based recommendations were synthesized and are presented in Table 5.

Table 5.

Evidence summary for ultrasound‐guided peripheral arterial catheter placement in adult critical care patients.

Category	Content of evidence	Level	Recommendation level
Puncture site selection	1. Peripheral arterial catheter placement sites may include the radial artery, dorsalis pedis artery, brachial artery, axillary artery, femoral artery, posterior tibial artery, and ulnar artery [29].	5b	A
	2. Peripheral arterial puncture preferentially targets the radial artery. When the radial artery diameter is less than 1.7 mm (in adults) or when anatomic variations (such as abnormal branching) are present, the brachial artery may be selected as an alternative site [9].	5b	A
	3. The area between the radial styloid process and the distal one‐third of the forearm is the preferred site for radial artery catheter placement, which are associated with higher success rates of cannulation, lower rates of catheter removal, and longer catheter indwelling times [32].	1c	A
Catheterization procedures and recommendations	4. Pre‐puncture scanning of two arteries should be performed to select the one with the largest diameter; real‐time ultrasound guidance is superior to static imaging techniques for catheter placement [9].	5b	A
	5. During radial artery cannulation, stabilizing the ultrasound probe‐holding hand on the bed surface helps maintain operational stability. This technique facilitates precise alignment of the probe axis, radial artery axis, and catheter axis, thereby improving puncture success rates [35].	1c	A
	6. Sterile technique must always be used when placing a vascular access device, including hand hygiene, wearing a surgical gown, gloves, cap, and mask, and using sterile gel or a sterile probe cover [11].	5b	A
	7. Confirming a suitable target artery before establishing the sterile field allows for optimal site selection while minimizing procedural delays [9].	5b	A
	8. Ultrasound‐guided peripheral arterial catheter placement involves: preprocedural ultrasound assessment of the vessel and identification of local pathology; real‐time ultrasound‐guided puncture; verification of correct catheter tip placement; evaluation for potential complications [11].	5b	A
	9. Prior to radial artery puncture, a modified Allen's test using duplex ultrasound with color Doppler is recommended to assess collateral flow via the ulnar artery [11].	1a	A
	10. A “move‐the‐probe→advance‐the‐needle→redirect‐the‐needle” sequence is recommended to reduce puncture‐related complications [27].	1a	A
Comparison of puncture approaches	11. When visualizing vessels in the transverse (short‐axis) view, the out‐of‐plane approach is typically used for puncture. Conversely, the in‐plane approach is generally employed when vessels are visualized in the longitudinal (long‐axis) view [18].	5b	A
	12. Both short‐axis (SAX) and long‐axis (LAX) views have distinct advantages: SAX allows faster puncture, while LAX provides better visualization of the needle [9].	5b	A
	13. Compared with the long‐axis in‐plane technique, the short‐axis out‐of‐plane technique demonstrated higher rates of posterior wall puncture and hematoma formation, although both techniques showed comparable catheterization times [29].	1a	A
	14. A modified short‐axis out‐of‐plane approach incorporating dynamic needle tip positioning significantly improves first‐attempt and overall cannulation success rates compared to the conventional short‐axis out‐of‐plane technique, particularly in patients with difficult vascular access [21, 23, 26].	1a	A
	15. For radial artery cannulation, the oblique‐axis approach provides enhanced visualization of the needle, vessel, and surrounding structures compared to the long‐axis or short‐axis approaches. It achieves higher cannulation success rates and requires less time for catheter placement [19].	1a	A
	16. In ultrasound‐guided radial artery puncture using the short‐axis view, the bevel‐down needle approach yields higher success rates and fewer complications than the bevel‐up approach [31].	1c	B
Ultrasound imaging and probe techniques	17. The visualization of two hypoechoic lines in the ultrasound image improves first‐attempt success rates for radial artery puncture while reducing procedure‐related complications [34].	1c	A
	18. Compared to an ultrasound probe perpendicular to the artery, orienting the probe perpendicular to the needle trajectory significantly reduces total puncture time for radial artery access. The needle should be inserted at a 45°angle to the skin while maintaining perpendicular alignment with the transducer [33].	1c	B
	19. For radial artery catheterization, we recommend using a small linear‐array transducer with a high‐frequency probe to achieve high‐resolution near‐field imaging. The imaging depth should be adjusted to clearly display the radial artery and adjacent structures [24].	1a	A
Ultrasound equipment and auxiliary tools	20. A linear ultrasound transducer with a frequency range of 8–12 MHz is recommended. If the target artery is located deeper than 5 mm, a 5–8 MHz microconvex probe may be used to balance imaging resolution and penetration depth [9].	5b	A
	21. Real‐time two‐dimensional ultrasound (2D USG) provides clear visualization of the radial artery in the forearm, enabling real‐time needle guidance and arterial catheter visualization while improving first‐attempt success rates [22, 25].	1a	A
	22. Real‐time B‐mode ultrasound increases first‐attempt success rates for radial artery catheterization [30].	1a	A
	23. For ultrasound novices, needle guides can be utilized to improve cannulation success rates [18].	5b	A
	24. The ultrasound monitor should be positioned within the operator's direct line of sight during needle insertion [18].	5b	A
	25. Long‐axis imaging is particularly effective for identifying vascular tortuosity, atherosclerotic plaques, and difficult catheter insertion scenarios. The oblique‐axis approach combines the advantages of both short‐ and long‐axis imaging, providing clearer visualization of the needle shaft and tip while simultaneously displaying surrounding structures in a single view, thereby enhancing procedural safety [9].	5b	B
	26. Single‐echo and double‐echo line‐assisted ultrasound guidance facilitates precise puncture point localization, while 2D ultrasound guidance helps determine puncture depth. These complementary techniques work synergistically to optimize the procedure [20].	1a	A
Training	27. It is recommended that the puncture procedure be performed by senior nurses, specialty nurses, or nurses who have obtained qualified certification through critical care ultrasound training [28].	1a	A
	28. It is recommended that practitioners complete at least 10 ultrasound‐guided vascular puncture and cannulation procedures before performing the technique independently [9].	5b	A
	29. The training curriculum should include didactic sessions, hands‐on laboratory practice, and clinical implementation phases [11].	5b	A

Note: MHz stands for megahertz.

4. Discussion

4.1. Anatomical and Procedural Rationale for Technical Optimization

Based on Evidence 1–9, a thorough analysis was conducted regarding puncture site selection and standardized catheterization procedures. The area between the radial styloid process and the distal one‐third of the forearm is the preferred site for radial artery catheter placement [32], offering significant anatomical advantages: consistent arterial diameter and thin subcutaneous tissue, which effectively reduce the risk of vessel perforation. The guideline [9] recommends thoroughly assessing vascular status before catheterization, selecting the artery with the largest diameter for puncture, and employing real‐time ultrasound guidance. This aligns with the findings of Li et al. [36], who reported a positive correlation between vessel diameter and successful puncture rates. A guideline [11] emphasizes that a complete ultrasound‐guided peripheral arterial catheter placement procedure should include four key steps: pre‐procedural ultrasound assessment, real‐time guided puncture, confirmation of catheter position, and complication assessment. Strict adherence to aseptic technique and precise puncture site selection are critical prerequisites for ensuring procedural safety [11, 18].

For pre‐procedural evaluation, the guideline [11] recommends using duplex ultrasound with color Doppler to perform a modified Allen's test, assessing collateral flow through the ulnar artery. During radial artery puncture, stabilizing the hand holding the ultrasound probe on the bed surface can improve operational stability [35]. An operational sequence of “moving the probe → advancing the needle → adjusting needle direction” is suggested [27], which helps reduce the incidence of complications.

Regarding puncture approach selection, Evidence 10–15 provides important guidance. Although the long‐axis in‐plane (LAIP) technique yields superior overall performance [11], studies [19, 21, 23, 26] indicate that for patients with difficult catheterizations, a modified short‐axis out‐of‐plane approach combined with dynamic needle tip positioning or an oblique‐axis approach may be more suitable. This study also found that in dorsal pedal artery catheterization, the short‐axis out‐of‐plane technique can reduce evaluation time [37]. This discrepancy may be attributed to the thick subcutaneous tissue and anatomical variations of the dorsal pedal artery, underscoring the need to tailor the guidance strategy according to the specific anatomical site. Furthermore, a study [31] reported that a bevel‐down approach under short‐axis view guidance resulted in higher success rates. These findings offer diverse technical options for clinical practice, further highlighting the importance of individualized operational approaches.

4.2. Clinical Value of Ultrasound Technology and Equipment Selection

The core clinical value of ultrasound‐guided techniques in peripheral arterial catheter placement for critically ill adult patients lies in the simultaneous improvement of procedural precision and safety. Evidence 16–25 systematically delineate the clinical application value of ultrasound technology and further reveals the complex interactive relationship among the device, the operator, and the patient. Regarding image optimization, ultrasound guidance with a double‐line marker combined with two‐dimensional (2D) ultrasound can significantly improve puncture accuracy [20, 34]. The guideline [9] indicates that long‐axis imaging is particularly effective for identifying vascular abnormalities, while oblique‐axis imaging can provide more comprehensive structural information. Concerning probe technique, maintaining a 45° probe insertion angle is recommended [33], and the use of a high‐frequency linear array probe is advised for optimal imaging quality [24].

In terms of equipment selection, Evidence 19–21 [18, 22, 25, 30] confirm that high‐frequency probes (5–15 MHz) used with real‐time 2D ultrasound or B‐mode ultrasound can significantly increase the first‐attempt success rate. The study by Mesa et al. [38] shows that novices performing peripheral vascular access procedures under ultrasound guidance achieved higher success rates and accuracy when using real‐time ultrasound‐guided catheterization techniques. It is also recommended that novices may use needle guides to assist the procedure and should position the ultrasound screen within their direct line of sight [18].

However, the relatively slow equipment upgrade rate in primary hospitals may lead to technological disparities that hinder the widespread adoption of these techniques. Regarding resource allocation, we propose a “Four‐Tier Technical Promotion Model”: ① Basic Tier (Portable ultrasound + Out‐of‐plane technique), ② Standard Tier (High‐frequency probe + In‐plane technique), ③ Advanced Tier (Double‐line marker + Dynamic needle tracking), ④ Intelligent Tier (AI‐assisted puncture). Medical institutions should select appropriate ultrasound devices and auxiliary tools based on their specific conditions and strengthen technical training for healthcare staff to enhance the application effectiveness of ultrasound technology. The evidence synthesis provided here aligns with established guidelines [9, 11] while bridging the gap between high‐level recommendations and practical ICU execution. Our proposed “Four‐Tier Technical Promotion Model” is intended as a clinical implementation framework rather than a replacement for primary evidence.

4.3. Training System and the “Three‐Dimensional Competency Enhancement Model”

Evidence 26–28 defines the specific components of the training curriculum. Operators should possess professional qualifications, and the procedure is recommended to be performed by senior nurses or practitioners with specialized training [28]. It is emphasized that training in ultrasound‐guided peripheral arterial catheter placement must integrate both cognitive and technical competencies, and should include group lectures, laboratory sessions, and a clinical practicum phase [11, 39].

Based on this, we propose the establishment of a “Three‐Dimensional Competency Enhancement Model”: ① Cognitive Training: Implement a progressive training structure of micro‐lectures → case libraries → workshops for the systematic study of ultrasound principles and operational protocols; ② Technical Skill Practicum: Leverage high‐fidelity vascular phantoms for plane conversion training, with a focus on probe manipulation, puncture approach selection, and strict adherence to aseptic technique; ③ Behavioral Reinforcement: Optimize the operational workflow through PDCA (Plan‐Do‐Check‐Act) cycles, with a cycle duration of ≤ 8 weeks, involving practice on real patient cases and continuous quality improvement. Research [40] has shown that Virtual Reality (VR) and Augmented Reality (AR) technologies can provide healthcare professionals with a more realistic and immersive training experience, thereby improving training outcomes and opening new pathways for the widespread adoption of this technique.

5. Limitations

While this evidence summary provides a comprehensive synthesis of the evidence regarding ultrasound‐guided peripheral arterial catheter placement in critically ill adult patients, certain limitations should be acknowledged. Regarding the inclusion of non‐English/Chinese literature, while our search focus remained on these two languages to ensure accuracy in appraisal, we acknowledge this as a limitation that may overlook regional practices in other language‐dominant systems. Second, the high proportion of evidence derived from international studies necessitates caution when generalizing findings, due to potential differences in healthcare settings, resource availability, and patient characteristics across regions. Third, there remains a relative paucity of high‐quality evidence specifically targeting ultrasound‐guided peripheral arterial catheter placement. Future research should aim to continuously update this evidence base and prioritize the selection and implementation of recommendations based on their feasibility, appropriateness, meaningfulness, and effectiveness to facilitate translation into clinical practice.

6. Conclusions

This study systematically summarizes 29 evidence‐based recommendations for ultrasound‐guided peripheral arterial catheter placement in critically ill adult patients, covering six key aspects: puncture site selection, catheterization procedures and recommendations, comparison of puncture approaches, ultrasound imaging and probe techniques, ultrasound equipment and auxiliary tools, and training. These findings offer an evidence base for the standardization of clinical practice. However, notable variations exist in infrastructure and the extent of evidence implementation across different healthcare institutions. Therefore, in clinical practice, it is recommended to carefully evaluate the feasibility of evidence recommendations by considering departmental equipment levels, individualized patient needs, and the local clinical context. Corresponding targeted optimization of operational protocols should be conducted to enhance catheterization safety and nursing quality. Future research should be grounded in evidence‐translation methodologies, integrating specific clinical settings and patient population characteristics to promote the precise translation and contextual application of evidence into practice.

Author Contributions

Ting Shi: conceptualization, investigation, data curation, methodology, writing – original draft, writing – review and editing. Suqin Han: visualization, funding acquisition. Jiali Huang: investigation, data curation. Shuting Hong: visualization, validation. Jing Su: formal analysis, supervision. Hong Zhang: formal analysis, supervision. Xueqin Huang: formal analysis, supervision. Jinhua Wu: project administration, supervision, writing – review and editing, funding acquisition, resources.

Ethics Statement

Ethical approval was not required for this study as it is an evidence summary (evidence synthesis) based on previously published literature and does not involve direct interaction with human participants or animals. All included primary studies were conducted in accordance with ethical standards.

Conflicts of Interest

The authors declare no conflicts of interest.

Transparency Statement

The lead author (Ting SHI) affirms that this manuscript is an honest, accurate, and transparent account of the study being reported; that no important aspects of the study have been omitted; and that any discrepancies from the study as planned (and, if relevant, registered) have been explained.

Data Availability Statement

Nursing Open (NOP2). All data included in this study are available upon request by contacting the corresponding author.