CHAPTER 208 Arterial Puncture and Percutaneous Arterial Line Placement
Arterial Puncture
An arterial puncture can be useful in certain urgent, acute, or chronic conditions, basically whenever an arterial blood sample is needed. If frequent sampling or (intra)arterial blood pressure monitoring is necessary, placement of an arterial line should be considered. With proper technique and equipment, an arterial puncture is a safe and simple procedure. However, advancements in technology for noninvasive monitoring may eventually make this procedure obsolete. Use of pulse oxymetry (arterial oxygen saturation) and end-tidal CO2 (ETCO2) monitoring has already markedly decreased the need for arterial puncture. In most cases, an arterial puncture is used now only to assess and confirm hypoxia or hypercapnia when indicated by pulse oxymetry or ETCO2 monitoring. Although venous sampling may occasionally be used to monitor pH (e.g., diabetic ketoacidosis), venous blood pH is much less reliable as a surrogate marker for arterial pH in patients with shock and other critical illnesses; therefore, arterial puncture is still necessary in these patients.
Indications
Contraindications
note: If drawing of frequent arterial specimens or continuous pressure monitoring is necessary, placement of an arterial line should be considered.
Equipment



Arterial Site Selection
Each site for arterial puncture has its own risks and benefits. Because of its proximity to the skin surface, the radial artery in the patient’s nondominant hand is the preferred site. It is an excellent location if there is adequate ulnar artery collateral circulation (see the following section) and if the clinical situation is stable. In severely hypotensive patients or during cardiopulmonary resuscitation, the femoral artery is usually the most readily palpable and most conveniently located artery, in spite of its higher risk of complications with puncture. Alternative sites, in decreasing order of preference, include the brachial, dorsalis pedis, and superficial temporal arteries. The brachial artery should be reserved for use when radial artery puncture cannot be performed or is contraindicated. Although the dorsalis pedis artery is absent, usually bilaterally, in 12% of the population, it is another option for puncture. Before dorsalis pedis artery puncture is performed, collateral flow should be demonstrated in a manner similar to the Allen test (see the following section). Superficial temporal artery puncture will not be discussed. Ultimately, clinician experience and local anatomy are the deciding factors in choice of site. If possible, the clinician should avoid an artery where the overlying cutaneous defenses are disrupted because of infection, burn, severe dermatitis, or other skin damage.
Assessment of Ulnar Collateral Circulation
Radial artery puncture can lead to thrombosis of the distal artery. Because 12% of hands have inadequate collateral flow because of an incomplete palmar arch (Fig. 208-1), to minimize the risk of permanent ischemic damage to the hand, many experts suggest confirming adequate collateral circulation before puncture. Even if there is excellent collateral flow, the nondominant hand should be used, if possible. However, other experts have questioned the value of testing for collateral circulation. At least one large case series of patients demonstrated the safety of radial artery cannulation without testing for collateral circulation with the modified Allen test in patients without major peripheral arterial disease (Slogoff and colleagues, 1983).
Modified Allen Test
The Allen test, used to evaluate ulnar collateral flow, was first described in 1929. To minimize falsely abnormal results, the modified Allen test can be used:


Figure 208-2 Modified Allen test. A, Hand is elevated and fist clenched while radial and ulnar arteries are occluded for 1 minute. B, Hand is lowered and fist is unclenched. Hand is cadaveric. C, Ulnar artery compression is released while radial artery compression is continued. In a negative test, the entire hand regains color within 6 seconds. D, Positive test. With inadequate collateral perfusion from the ulnar artery, the hand remains cadaveric as long as radial artery compression is maintained. When inadequate collateral perfusion is demonstrated, another puncture or cannulation site should be considered.
An abnormal or equivocal modified Allen test result, although it may not preclude arterial puncture or cannulation, should alert the clinician to potential complications, a need for caution when performing the procedure, and a need to monitor the patient closely postprocedure. Various types of noninvasive studies are also useful for further patient evaluation. Hand-held Doppler ultrasonography or pulse oximetry can be used to rapidly assess perfusion with techniques more sensitive and specific than the modified Allen test. If time allows, formal arterial Doppler ultrasonography, either portable or in the radiology department, can be used to further evaluate the collateral circulation or direct the puncture.
Hand-Held Doppler Evaluation
Assessment of Dorsalis Pedis Collateral Circulation
To minimize the risk of permanent ischemic damage to the distal foot, some experts suggest confirming adequate collateral circulation before dorsalis pedis artery puncture is attempted.
note: In most persons, collateral circulation of the foot is provided by a branch of the posterior tibial artery. Hand-held Doppler ultrasonography can be used to assess collateral flow between the dorsalis pedis and posterior tibial arteries in a manner similar to that used in the palmar arch.
Preprocedure Patient Preparation
The clinician and patient should be in a comfortable position that can be maintained for 10 to 15 minutes. The procedure, its necessity, alternatives (if there are any), and possible complications should be explained to the alert patient. In nonemergent situations, informed consent should be obtained (see the sample patient consent form online at www.expertconsult.com). The patient should be prepared for some discomfort.
Technique
note: Certain kits contain syringes that are already heparinized (often containing a pellet of lyophilized heparin) and the plunger should not be moved.


Figure 208-5 This patient is left-hand dominant. Palpate the patient’s radial pulse with your left hand. While holding the heparinized syringe with your right hand (reverse hands if left-handed), puncture the skin at approximately a 60-degree angle to the skin, directing the needle toward the radial pulsation.
note: Avoid “spearing” (going through) the artery. Osteomyelitis and large hematomas can result from “spearing” the artery.


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