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.