Vascular access is one of the most pervasive and yet least standardized elements of modern neonatal care. Every day, in intensive care units across Europe and beyond, clinicians thread slender catheters into the arteries of the smallest and sickest newborns to monitor blood pressure continuously, sample blood gases repeatedly, and guide life-sustaining decisions. Despite how routine these procedures have become, practices vary enormously between hospitals and even between individual clinicians, and many long-held habits have never been tested against solid evidence. A new recommendation published in Pediatric Research by the Neonatal European Vascular Access Team (NEVAT) and the Pediatric and Neonatal Vascular Access Special Interest Group of the European Society for Pediatric Research (ESPR) aims to close that gap. As the sixth installment in a ten-part series of recommendations, the document provides evidence-based guidance for the safe insertion, securement, and ongoing management of intra-arterial catheters in neonates, a population in which millimeters and minutes can make the difference between a working line and a devastating complication.
Intra-arterial catheters, or IACs, are thin tubes placed directly into peripheral arteries, most commonly the radial artery at the wrist or the posterior tibial artery at the ankle. Once in place, they allow beat-to-beat blood pressure monitoring and painless blood sampling, sparing fragile infants the repeated needle punctures that would otherwise be required. The new recommendation emphasizes that the value of these devices comes with real risks: arterial lines can cause ischemia, infection, bleeding, and injury to delicate neonatal vessels and surrounding nerves. Because premature infants may weigh less than a kilogram and have arteries with internal diameters of well under a millimeter, the technical margin for error is extraordinarily narrow. The authors argue that this combination of high stakes and high variability is precisely why a standardized, evidence-based approach is overdue.
A central technical theme of the recommendation is the use of ultrasound guidance during insertion. Traditional arterial cannulation relies on palpation, feeling the pulse and advancing the needle blindly toward it. In neonates, whose vessels are tiny, mobile, and easily compressed by the palpating finger, this approach frequently fails and can traumatize the vessel. Recent studies cited by the panel, including retrospective observational work on real-time ultrasound-guided peripheral arterial cannulation in infants and case series demonstrating success even in very low birth weight infants who are conventionally considered difficult to cannulate, show that ultrasound dramatically improves first-pass success. A 2023 Cochrane systematic review of ultrasound-guided arterial cannulation in children supports the technique’s advantages, and dedicated protocols such as the Safe Insertion of Arterial Catheters approach have been developed specifically to minimize complications by combining ultrasound imaging with structured technique.
The recommendation also addresses the choice of insertion site, which is far from trivial. The radial artery of the forearm remains the most common target, but the panel reviews the vascular anatomy of the limb in detail, noting that collateral circulation, the backup blood supply that keeps tissue alive if the cannulated artery occludes, must be adequate before a line is placed. The ulnar artery has been proposed as an alternative cannulation site in neonates, and the posterior tibial artery offers another option for lower-limb access. Femoral artery catheterization, by contrast, is treated with considerable caution. Although some cohort studies have reported acceptable outcomes, published cases of limb length shortening associated with femoral arterial lines in the neonatal period highlight the potential for long-term harm when a major vessel supplying a growing leg is compromised. The guidance therefore steers clinicians toward peripheral sites with robust collateral flow whenever clinically feasible.
Catheter selection itself receives technical attention. Ultrasound can be used not only to guide the needle but also to measure the cross-sectional internal diameter of the target artery before cannulation, allowing clinicians to match catheter size to vessel size. Oversized catheters are thought to increase the risk of flow obstruction and ischemic injury, while undersized catheters may kink or fail to transmit accurate pressure waveforms. The recommendation draws on studies of distal radial artery diameter in neonates and infants to support this measurement-based approach, embedding it within the broader vessel health and preservation framework that underpins the whole series: choose the right device, for the right patient, at the right time, and preserve the vasculature for future needs.
Once the catheter is in place, securement becomes the next battleground for standardization. The panel reviews the evidence on transparent semipermeable membranes, including comparative studies of their moisture-vapor transmission properties, and on medical adhesive-related skin injuries, which are a documented hazard in neonatology where the stratum corneum of premature skin is paper-thin. Tissue adhesives such as octyl-butyl-cyanoacrylate glue, already studied for securing peripheral intravenous catheters in neonates, and dialkylcarbamoylchloride-impregnated dressings used at catheter exit sites are discussed as part of a modern securement toolkit. Limb fixation technique is another practical focus: the recommendation describes positioning and splinting methods for both upper and lower limbs that keep the catheter functional without immobilizing the joint so rigidly that circulation or skin integrity is compromised. The goal is a line that stays put, stays patent, and does not injure the skin it crosses.
Perhaps the most striking pharmacological element of the guidance concerns topical nitroglycerin. Arterial spasm is a common reason that cannulation attempts fail and a suspected contributor to ischemic complications after lines are placed. A systematic review and meta-analysis published in Archives of Disease in Childhood found that local nitroglycerin facilitates peripheral arterial cannulation in children, and separate systematic reviews in neonates have examined topical nitroglycerin for treating ischemic injuries, including analyses of nitroglycerin patch application in premature babies with peripheral arterial ischemia. By synthesizing this evidence, the recommendation gives clinicians a rational, evidence-based adjunct: a vasodilator applied to the skin to relax the vessel, improve the odds of a successful first attempt, and potentially rescue compromised perfusion, all while acknowledging the need to monitor for hypotension in infants whose blood pressure is already precarious.
The management phase of an arterial line’s life, from flushing regimens to pressure monitoring to the decision to remove the device, is also covered. Direct arterial pressure measurement differs systematically from indirect cuff-based techniques, and the panel points to comparative studies in pediatric intensive care to remind clinicians that the two are not interchangeable. Infusion therapy standards, most recently the ninth edition of the Infusion Nurses Society standards of practice, provide the backbone for aseptic technique, dressing changes, and surveillance, consistent with national evidence-based guidelines for preventing healthcare-associated infections. The recommendation frames all of this within a patient-centered structure built on the 7-Rights framework and the standardized nomenclature developed through the NAVIGATE project, so that a catheter described in one hospital means the same thing in another, a prerequisite for meaningful quality improvement and research.
What makes this document notable is not a single dramatic discovery but the quiet rigor of consensus built on evidence. The work was not externally funded, the authors declare no competing interests, and the writing team spans neonatologists, nurses, and vascular access specialists from institutions across the Netherlands, France, Austria, Belgium, Italy, the United Kingdom, Bulgaria, Portugal, Spain, and beyond, with input from foundations representing parents of newborn infants. For a field in which some practices, as the authors bluntly state, lack supporting evidence, the recommendation represents a deliberate turn from tradition toward accountability. If the remaining installments in the ten-part series match this one, neonatal units across Europe may soon share a common technical language for the lines that keep their smallest patients alive, and the infants hooked to those lines may face fewer failed attempts, fewer injured vessels, and safer first days of life.
Subject of Research: Evidence-based management of intra-arterial catheters in neonates
Article Title: Management of intra-arterial catheters: neonatal european vascular access team—ESPR recommendation 6
Article References: van der Lee, R., Yousef, N., Schwaberger, B., De Bisschop, B., Piersigilli, F., Ouwehand, T., Van Eenoo, S., Hugill, K., van Rens, M., on behalf of the Pediatric and Neonatal Vascular Access Special Interest Group (SIG) of the European Society for Pediatric Research (ESPR) and Neonatal European Vascular Access Team (NEVAT), Van der Lee, R., De Bisschop, B., Van Eenoo, S., van Rens, M., Debuf, M.-J., Milan, A., Barone, G., Pittiruti, M., Werther, T., … Tuna, M. L. (2026). Management of intra-arterial catheters: neonatal european vascular access team—ESPR recommendation 6. Pediatric Research. https://doi.org/10.1038/s41390-026-05470-x
Image Credits: AI Generated
DOI: 10.1038/s41390-026-05470-x
Keywords: neonatology, intra-arterial catheters, vascular access, ultrasound guidance, radial artery, nitroglycerin, catheter securement, preterm infants, ESPR, NEVAT, blood pressure monitoring, ischemia
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Harold Sullivan. (October 3, 2026). European Experts Issue First Standardized Rules for Tiny Arterial Lines in Newborns. Scienmag. https://scienmag.com/european-experts-issue-first-standardized-rules-for-tiny-arterial-lines-in-newborns/
Harold Sullivan. “European Experts Issue First Standardized Rules for Tiny Arterial Lines in Newborns.” Scienmag, 3 October 2026, https://scienmag.com/european-experts-issue-first-standardized-rules-for-tiny-arterial-lines-in-newborns/. Accessed 3 October 2026.
Harold Sullivan. “European Experts Issue First Standardized Rules for Tiny Arterial Lines in Newborns.” Scienmag. October 3, 2026. https://scienmag.com/european-experts-issue-first-standardized-rules-for-tiny-arterial-lines-in-newborns/
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Tags: blood pressure monitoringcatheter securementcomplications of neonatal arterial catheterizationESPREuropean guidelines for neonatal arterial linesEuropean Society for Pediatric Research vascular access guidelinesevidence-based neonatal intensive care protocolsimproving neonatal arterial line safetyintra-arterial catheterization in newbornsintra-arterial cathetersischemianeonatal blood gas sampling proceduresneonatal blood pressure monitoringneonatal vascular access standardsneonatal vascular access team recommendationsneonatologyNEVATnitroglycerinpreterm infantsradial arterysafe insertion and management of arterial lines in neonatesstandardized neonatal vascular access practicesultrasound guidancevascular access
