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Arterial Puncture and Line Placement

Introduction

Arterial puncture is a commonly employed

procedure to obtain arterial blood for analysis. For most single-time

samples in emergent and urgent situations, the single arterial puncture

(stick) is adequate. Intra-arterial line placement is often used in

situations that require access for frequent blood sampling and for

real-time blood pressure monitoring.

Arterial puncture is usually done using

the radial artery and is performed by physicians and physician

extenders, respiratory therapists, and other trained personnel. Arterial

blood samples can be used for blood gas analysis, including measurement

of the partial pressures of oxygen (PaO2) and carbon dioxide

(PaCO2) and the pH of arterial blood. These values help

the physician assess pulmonary function, establish diagnoses, direct

further interventions, and determine the required intensity of

monitoring in critically ill patients.

Intra-arterial lines (arterial line,

art-line, or a-line) are used as an invasive blood pressure monitoring

method and for continuous access to blood vessels for frequent blood

sampling. Blood pressure must be monitored closely when the patient is

in shock, during a hypertensive emergency, and during vasopressor use.

No data exist to support a specific site, but arterial lines are most

commonly placed in the radial, brachial, or femoral arteries (a radial

insertion is illustrated). A guidewire may be used during placement of

an arterial line, or a direct puncture approach may be taken.

Prior to radial artery puncture or

arterial line insertion, an Allen test should be performed to assess

collateral blood flow of the hand. To perform the Allen test, wrap your

fingers around the patient 's wrist and compress both the ulnar

and radial arteries. As you are doing this, have the patient elevate and

then open and close his or her hand several times to allow blood to

drain from the hand. Afterward, open the patient 's hand and see

that it has blanched white. Release pressure from the ulnar artery,

keeping the radial artery occluded. Within 2 to 3 seconds, normal skin

color should return to first the ulnar side of the palm and then the

entire palm shortly thereafter. If the hand remains white, collateral

circulation is inadequate and radial artery puncture or arterial line is

contraindicated.

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Equipment

  • Arterial line kit
  • Arterial line monitoring equipment (as needed)
  • Pulse Doppler (as needed)

See Appendix E for skin cleansing

recommendations and Appendix F for local anesthetic recommendations.

Indications

  • Close monitoring of blood pressure (e.g., intensive care unit setting)
  • Access to arterial blood (frequent arterial blood gasses)
  • Frequent blood draws for laboratory tests
  • Continuous monitoring of oxygen saturation

Contraindications (Relative)

  • Dermatitis or cellulitis at insertion site
  • Absence of palpable pulse at chosen arterial site
  • Severe coagulopathy or platelet count <50,000
  • Uncooperative patient
  • Poor collateral circulation at proposed site (absolute contraindication)

The Procedure

Step 1

Obtain informed consent from

the patient or proxy (see Appendix A). Perform the Allen

test to assess adequate collateral arterial flow. Flush the arterial

line tubing with normal saline to reduce risk of an air embolus.

Check the kit to make sure all of the necessary components are

present. Place the patient 's hand in anatomical position

(palm up) and secure the wrist at a gentle extension (approximately

30 to 45 degrees).

Step 1 View Original Step 1 View Original

Step 2

Prep the skin over the

proposed puncture site. Arterial line kits usually will come with

skin cleaning supplies, but a separate chlorhexidine swab can be

used instead (see Appendix E).

Step 2 View Original Step 2 View Original

Step 3

Drape the area per proper

aseptic technique. Again, arterial line kits will usually provide a

paper drape, but some practitioners prefer to use sterile towels or

cloths.

Step 3 View Original Step 3 View Original

Step 4

Anesthetize the skin over the

site with 3 to 5 mL of 1% to 2% " lidocaine. (Be aware

that excess fluid can diminish the pulse strength and/or distort

anatomy.)

Step 4 View Original Step 4 View Original

Step 5

With the nondominant hand,

gently palpate the artery. With the dominant hand, hold the

intravascular catheter (an outer guidewire over a needle) with the

needle bevel up and at a 30- to 45-degree angle.

Step 5 View Original Step 5 View Original

Step 6

Puncture the skin and advance

the needle slowly at the site of arterial pulsation.

  • PEARL: At this point, some physicians like to make a superficial nick in the skin at the site of insertion to ease the passage of the intravascular catheter, but this is not necessary.

Step 6 View Original Step 6 View Original

Step 7

Advance until a flash of blood

appears in the syringe. Once this flash is obtained, slowly advance

the outer catheter into the artery, simultaneously removing the

needle. If the arterial puncture was for a one-time arterial blood

draw, the needle and catheter would be removed at this point, with a

dressing placed on the site after appropriate pressure is held at

the site for approximately 5 minutes.

  • PEARL: The arterial line kit will come with a guidewire that can be used to assist in placement, especially in arterial lines not placed in the radial artery.

Step 7 View Original Step 7 View Original

Step 8

Upon removing the needle,

pulsatile blood return should be observed. At this point, connect

the arterial line transducer tubing to the tip of the catheter.

After ensuring the line is in a good place and a good waveform is

seen on the arterial line monitors, secure your line to the skin

with the suture provided. Once it is secure, place an occlusive

dressing at the site.

Complications

  • Local infection, pain, and bleeding
  • Blood clotting in the catheter
  • Nerve injury
  • Ischemic changes to the hand and wrist

Pediatric Considerations

In the pediatric population, the ulnar

artery may be used as a primary site as long as the Allen test for good

radial collateral circulation is checked first. The patient 's

ability to cooperate also should be considered before deciding to

attempt any procedure.

Postprocedure Instructions

Arterial line catheters are not changed

on a routine basis; rather, the site is monitored closely for signs of

infection and changed based on clinical judgment. However, all arterial

lines placed in emergent situations should be replaced. The dressing

should be kept clean, dry, and intact and be changed as necessary.

Coding Information and Supply Sources

View Large CPT Code Description 2008 Average 50th Percentile Fee Global Period 36600 Arterial puncture, withdrawal of blood for diagnosis $84.00 0 36620 Arterial catherization or cannulation for sampling,

monitoring, or transfusion (separate procedure);

percutaneous $307.00 0 CPT is a registered trademark of the American

Medical Association.2008 average 50th Percentile Fees are provided courtesy of 2008

MMH-SI 's copyrighted Physicians ' Fees and

Coding Guide.

Supplies may be purchased from these

companies:

  • Arrow Medical Products Ltd., 2400 Bernville Road, Reading, PA 19605. Phone: 1-800-233-3187. Web site: http://www.arrowintl.com/.
  • Baxter, 1 Baxter Pkwy., Deerfield, IL, 60015-4625. Phone: 847-948-2000. Fax: 847 948-3642. Web site: http://www.baxter.com.
  • American Hospital Supply. Phone: 407-475-1168. Web site: http://www.americanhospitalsupply.com/.
  • Cardinal Health, Inc., 7000 Cardinal Place, Dublin, OH 43017. Phone: 800-234-8701. Web site: http://www.cardinal.com/.
  • Owens and Minor, 4800 Cox Road, Glen Allen, VA 23060-6292. Phone: 804-747-9794. Fax: 804-270-7281.

Bibliography

1Beards SC, Doedens L, Jackson A, Lipman J.

A comparison of arterial lines and insertion

techniques in critically ill patients.

Anaesthesia 1994;49:968. [View Abstract] 2Gabel-Hughes KS, Geelhoed GW.

Methods of arterial site skin preparation and

dressing.Critical Care

Nurse 1990;10(5):90 " 96. [View Abstract] 3Lightowler JV, Elliot MW.

Local anaesthetic infiltration prior to

arterial puncture for blood gas analysis: a survey of

current practice and a randomised double blind placebo

controlled trial. J R Coll

Physicians

Lond. 1997;31:645. [View Abstract] 4Shiver S, Blaivas M, Lyon M.

A prospective comparison of ultrasound-guided

and blindly placed radial arterial

catheters. Acad Emerg

Med. 2006;13(12):1275 " 1279. [View Abstract] 5Ventriglia WJ.

Arterial blood gases.

Emerg Med Clin N

Am. 1986;4:235 " 251. [View Abstract] 6Weiss BM, Galtiker RI.

Complications during and following radial

artery cannulation: a prospective study.

Intensive Care Med.

1986;14:424. 72008 MAG Mutual Healthcare

Solutions,

Inc. 'sPhysicians '

Fee and Coding Guide. Duluth,

Georgia. MAG Mutual

Healthcare Solutions,

Inc.2007.