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Arterial Puncture ProceduresArterial Puncture Procedures

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Ali Nawaz Qadri

(RN, DCHN, BSCN 1ST SEMESTER)

Subject: Advanced Concept Nursing

Topic: Arterial Puncture Procedure

Faculty: Sir Sarfaraz Masih

Collage: KKCON (LUMHS)

Dated: 14-06-2013

Email: alinawazqri@hotmail.com

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ObjectivesObjectives1.1. Define the key terms and abbreviations listed Define the key terms and abbreviations listed

at the beginning of this chapter.at the beginning of this chapter.

2.2. State the primary reason for performing State the primary reason for performing arterial punctures and identify the personnel arterial punctures and identify the personnel who may be required to perform them.who may be required to perform them.

3.3. Explain the purpose of collecting arterial blood Explain the purpose of collecting arterial blood gas (ABG) specimens and identify and describe gas (ABG) specimens and identify and describe commonly measured ABG parameters.commonly measured ABG parameters.

4.4. Identify the sites that can be used for arterial Identify the sites that can be used for arterial puncture, the criteria used for selection of the puncture, the criteria used for selection of the site, and the advantages and disadvantages of site, and the advantages and disadvantages of each site.each site.

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Objectives (contObjectives (cont’’d)d)5.5. List equipment and supplies needed for List equipment and supplies needed for

arterial puncture.arterial puncture.

6.6. Identify typical required and supplemental Identify typical required and supplemental requisition information and describe patient requisition information and describe patient assessment and preparation procedures, assessment and preparation procedures, including the administration of local including the administration of local anesthetic, prior to performing arterial blood anesthetic, prior to performing arterial blood gases.gases.

7.7. Explain the purpose of the modified Allen test, Explain the purpose of the modified Allen test, describe how it is performed, define what describe how it is performed, define what constitutes a positive or negative result, and constitutes a positive or negative result, and give the procedure to follow for either result.give the procedure to follow for either result.

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Objectives (contObjectives (cont’’d)d)8.8. Describe the procedure for Describe the procedure for

collecting radial arterial blood gases collecting radial arterial blood gases and the role of the phlebotomist in and the role of the phlebotomist in other site collections.other site collections.

9.9. List hazards and complications of List hazards and complications of arterial puncture, identify sampling arterial puncture, identify sampling errors that may affect the integrity errors that may affect the integrity of an arterial sample, and describe of an arterial sample, and describe the criteria for specimen rejection.the criteria for specimen rejection.

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OverviewOverview Disadvantages of Arterial PunctureDisadvantages of Arterial Puncture

Technically difficultTechnically difficult Potentially more painful & hazardous than Potentially more painful & hazardous than

venipuncturevenipuncture Thus, not normally used for routine blood testsThus, not normally used for routine blood tests

Reason for Arterial PunctureReason for Arterial Puncture To obtain blood for arterial blood gas (ABG) To obtain blood for arterial blood gas (ABG)

teststests Arterial blood:Arterial blood:

Best specimen for evaluating respiratory functionBest specimen for evaluating respiratory function Has high oxygen content & consistency of compositionHas high oxygen content & consistency of composition

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ABGsABGs Used in diagnosis & management of Used in diagnosis & management of

respiratory disordersrespiratory disorders Provide valuable info. about patientProvide valuable info. about patient’’s:s:

OxygenationOxygenation VentilationVentilation Acid-base balanceAcid-base balance

Used in management of electrolyte & acid-Used in management of electrolyte & acid-base balance in patients w. diabetes & base balance in patients w. diabetes & other metabolic disordersother metabolic disorders

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Commonly Measured ABG Commonly Measured ABG AnalytesAnalytes

AnalyAnalytete

NormNormal al RangeRange

DescriptionDescription

pHpH 7.35– 7.35– 7.457.45

A measure of acidity or A measure of acidity or alkalinity of blood (acidosis alkalinity of blood (acidosis or alkalosis)or alkalosis)

PaOPaO22 80–80–100 100 mm mm HgHg

Partial pressure of OPartial pressure of O22 dissolved in arterial blooddissolved in arterial blood

PaCOPaCO22 35–45 35–45 mm mm HgHg

Partial pressure of COPartial pressure of CO22 dissolved in arterial blooddissolved in arterial blood

HCOHCO22 22–26 22–26 mEq/LmEq/L

A measure of bicarbonate A measure of bicarbonate in bloodin blood

OO22 sat sat 97%– 97%– 100%100%

Percent OPercent O22 bound to bound to hemoglobinhemoglobin

Base Base excesexcesss

-2–+2 -2–+2 mEq/LmEq/L

A calculation of non A calculation of non respiratory part of acid-respiratory part of acid-base balancebase balance

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Personnel Who Perform Personnel Who Perform Arterial PunctureArterial Puncture

NursesNurses Medical technologists & techniciansMedical technologists & technicians Respiratory therapistsRespiratory therapists Emergency medical techniciansEmergency medical technicians

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Site-Selection CriteriaSite-Selection Criteria Presence of collateral circulationPresence of collateral circulation

Blood supply from more than one arteryBlood supply from more than one artery

Artery accessibility & sizeArtery accessibility & size Type of tissue surrounding puncture siteType of tissue surrounding puncture site

Low risk of injuring adjacent structures or tissue during Low risk of injuring adjacent structures or tissue during puncturepuncture

Ability to fix or secure artery to prevent rollingAbility to fix or secure artery to prevent rolling Adequate pressure can be applied to artery after Adequate pressure can be applied to artery after

collectioncollection Absence of inflammation, irritation, edema, hematoma, Absence of inflammation, irritation, edema, hematoma,

lesion, wound, AV shunt in close proximity, or recent lesion, wound, AV shunt in close proximity, or recent arterial puncturearterial puncture

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Arterial Puncture SitesArterial Puncture SitesThe Radial ArteryThe Radial Artery

AdvantagesAdvantages Good collateral circulation (radial & ulnar arteries)Good collateral circulation (radial & ulnar arteries) Easy to palpate (close to surface of skin)Easy to palpate (close to surface of skin) Less chance of hematoma formation after collectionLess chance of hematoma formation after collection

DisadvantagesDisadvantages Requires considerable skill to puncture it Requires considerable skill to puncture it

successfully due to small sizesuccessfully due to small size Difficult to locate on patients w. hypovolemia or low Difficult to locate on patients w. hypovolemia or low

cardiac outputcardiac output

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Arterial Puncture Sites Arterial Puncture Sites (cont(cont’’d)d)

• Arteries of the arm and hand

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Arterial Puncture Sites Arterial Puncture Sites (cont(cont’’d)d)

The Brachial ArteryThe Brachial Artery AdvantagesAdvantages

Large & relatively easy to palpate & punctureLarge & relatively easy to palpate & puncture Sometimes the preferred artery for a large volume of Sometimes the preferred artery for a large volume of

bloodblood Adequate collateral circulation (but not as good as radial)Adequate collateral circulation (but not as good as radial)

DisadvantagesDisadvantages Deeper & can be harder to palpate than radial arteryDeeper & can be harder to palpate than radial artery Lies close to basilic vein; risk of mistakenly puncturing itLies close to basilic vein; risk of mistakenly puncturing it Lies close to median nerve; risk of pain & nerve damageLies close to median nerve; risk of pain & nerve damage Increased risk of hematoma formationIncreased risk of hematoma formation

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Arterial Puncture Sites Arterial Puncture Sites (cont(cont’’d)d)

The Femoral ArteryThe Femoral Artery Largest artery used for arterial punctureLargest artery used for arterial puncture Located superficially in groin, lateral to Located superficially in groin, lateral to

pubis bonepubis bone Performed primarily by physicians & Performed primarily by physicians &

specially trained emergency room specially trained emergency room personnelpersonnel

Generally used only in emergency Generally used only in emergency situations or when no other site is situations or when no other site is availableavailable

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Arterial Puncture Sites Arterial Puncture Sites (cont(cont’’d)d)

• Arteries of the leg

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Arterial Puncture Sites Arterial Puncture Sites (cont(cont’’d)d)

Other SitesOther Sites In infants:In infants:

ScalpScalp Umbilical arteriesUmbilical arteries

In adults:In adults: Dorsalis Pedis ArteriesDorsalis Pedis Arteries

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ABG Specimen CollectionABG Specimen Collection Test RequisitionTest Requisition

Info. concerning conditions at time Info. concerning conditions at time of collection is needed:of collection is needed: Current body temperatureCurrent body temperature Respiratory rateRespiratory rate Ventilation statusVentilation status Fraction of inspired oxygen (FIOFraction of inspired oxygen (FIO22)) Prescribed flow rate in liters per minutePrescribed flow rate in liters per minute

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

Equipment and SuppliesEquipment and Supplies Personal protective equipmentPersonal protective equipment

Fluid-resistant lab coat, gown, or apronFluid-resistant lab coat, gown, or apron GlovesGloves Face protectionFace protection

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

Equipment & Equipment & SuppliesSupplies

AntisepticAntiseptic Local anesthetic Local anesthetic

(optional)(optional) Sharp, short-bevel Sharp, short-bevel

hypodermic needlehypodermic needle 1- to 5-mL self-filling 1- to 5-mL self-filling

syringesyringe Luer-tip normal or Luer-tip normal or

bubble removal capbubble removal cap CoolantCoolant

2- by 2-in. gauze 2- by 2-in. gauze squaressquares

Self-adhering gauze Self-adhering gauze bandagebandage

ID & labeling ID & labeling materialsmaterials

Puncture-resistant Puncture-resistant sharps containersharps container

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

• ABG equipment

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

Patient PreparationPatient Preparation Identification & explanation of proceduresIdentification & explanation of procedures Patient preparation & assessmentPatient preparation & assessment Modified Allen testModified Allen test Administration of local anesthetic Administration of local anesthetic

(optional)(optional)

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

Modified Allen test procedureModified Allen test procedure1.1. Have patient make a tight fistHave patient make a tight fist

2.2. Compress patientCompress patient’’s radial & ulnar arteries at s radial & ulnar arteries at same timesame time

3.3. Maintaining pressure, have patient open hand Maintaining pressure, have patient open hand slowlyslowly

4.4. Lower patientLower patient’’s hand & release pressure on s hand & release pressure on ulnar artery onlyulnar artery only

5.5. Assess results: +hand flushes pink; -hand Assess results: +hand flushes pink; -hand does not flush pinkdoes not flush pink

6.6. Record results on requisitionRecord results on requisition

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

• Left: using middle & index fingers to apply pressure to patient’s wrist. Middle: patient opens hand. Right: positive result—hand flushes pink within 15 seconds.

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

Preparing and Administering Local Preparing and Administering Local AnestheticAnesthetic1.1. Verify absence of allergy to anesthetic or its Verify absence of allergy to anesthetic or its

derivativesderivatives

2.2. Sanitize hands & don glovesSanitize hands & don gloves

3.3. Attach needle to syringeAttach needle to syringe

4.4. Clean stopper of anesthetic bottle w. alcohol wipeClean stopper of anesthetic bottle w. alcohol wipe

5.5. Insert needle through bottle stopper & withdraw Insert needle through bottle stopper & withdraw anestheticanesthetic

6.6. Carefully replace needle cap & put syringe in Carefully replace needle cap & put syringe in horizontal positionhorizontal position

7.7. Clean & air-dry siteClean & air-dry site

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

Preparing and Administering Local Preparing and Administering Local AnestheticAnesthetic8.8. Insert needle into skin at site at angle of Insert needle into skin at site at angle of

10 degrees10 degrees

9.9. Pull back slightly on plungerPull back slightly on plunger

10.10. Slowly expel contents into skin, forming a Slowly expel contents into skin, forming a raised whealraised wheal

11.11. Wait 1 to 2 min. before proceeding w. Wait 1 to 2 min. before proceeding w. arterial puncturearterial puncture

12.12. Note anesthetic application on requisitionNote anesthetic application on requisition

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

Radial ABG ProcedureRadial ABG Procedure1.1. Review & accession test requestReview & accession test request

2.2. Approach, identify, & prepare patientApproach, identify, & prepare patient

3.3. Check for sensitivities to latex & other Check for sensitivities to latex & other substancessubstances

4.4. Access steady state, verify collection Access steady state, verify collection requirements, & record inforequirements, & record info

5.5. Sanitize hands & don glovesSanitize hands & don gloves

6.6. Assess collateral circulationAssess collateral circulation

7.7. Position arm & ask patient to extend wristPosition arm & ask patient to extend wrist

8.8. Locate radial artery & clean siteLocate radial artery & clean site

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

• Assess collateral circulation

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

Radial ABG ProcedureRadial ABG Procedure9.9. Administer local anesthetic (optional)Administer local anesthetic (optional)

10.10. Prepare equipment & clean gloved Prepare equipment & clean gloved nondominant fingernondominant finger

11.11. Pick up equipment & uncap & inspect needlePick up equipment & uncap & inspect needle

12.12. Relocate radial artery & warn patient of Relocate radial artery & warn patient of imminent punctureimminent puncture

13.13. Insert needle at a 30- to 45-degree angle, Insert needle at a 30- to 45-degree angle, slowly direct it toward pulse, & stop when a slowly direct it toward pulse, & stop when a flash of blood appearsflash of blood appears

14.14. Allow syringe to fill to proper levelAllow syringe to fill to proper level

15.15. Place gauze, remove needle, activate safety Place gauze, remove needle, activate safety feature, & apply pressurefeature, & apply pressure

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

• Insert needle at a 30- to 45-degree angle, slowly direct it toward pulse, & stop when a flash of blood appears

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

Radial ABG ProcedureRadial ABG Procedure16.16. Remove & discard syringeRemove & discard syringe

17.17. Expel air bubbles, cap syringe, mix, & Expel air bubbles, cap syringe, mix, & label specimenlabel specimen

18.18. Check patientCheck patient’’s arm & apply bandages arm & apply bandage

19.19. Dispose of used & contaminated Dispose of used & contaminated materials, remove gloves, & sanitize materials, remove gloves, & sanitize handshands

20.20. Thank patient & transport specimen to lab Thank patient & transport specimen to lab ASAPASAP

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ABG Specimen Collection ABG Specimen Collection (cont(cont’’d)d)

• Expel air bubbles, cap syringe, mix, & label specimen

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Hazards and Complications Hazards and Complications of Arterial Puncture and of Arterial Puncture and

Sampling ErrorsSampling Errors

Hazards & Hazards & ComplicationsComplications ArteriospasmArteriospasm Artery damageArtery damage DiscomfortDiscomfort InfectionInfection NumbnessNumbness Thrombus formationThrombus formation Vasovagal responseVasovagal response

Sampling ErrorsSampling Errors Air bubblesAir bubbles Delay in analysisDelay in analysis Improper mixingImproper mixing Improper syringeImproper syringe Obtaining venous Obtaining venous

blood by mistakeblood by mistake Use of improper Use of improper

anticoagulantanticoagulant Use of too much or too Use of too much or too

little heparinlittle heparin

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