Arterial Puncture
Amber M. Dave
1. Sampling for arterial blood gas determination
2. Sampling for routine laboratory test when venous and capillary sampling are not suitable or unobtainable
3. Sampling for ammonia, lactate, or pyruvate level
4. To obtain a large quantity (≥1.5 mL) of blood from an infant
B. Contraindications
1. Coagulation defects, thrombocytopenia
2. Circulatory compromise in the extremity
3. Inappropriate artery
a. Femoral artery
b. Use of radial artery if collaterals are inadequate (see Allen test described under Radial Artery Puncture)
c. Ulnar artery (poor collaterals)
4. Infection and/or inflammation in sampling area
5. When cannulation of that vessel is anticipated
6. Use of peripheral arteries on the ipsilateral arm in an infant with congenital heart disease requiring a shunt via the subclavian artery
C. Precautions
1. Perform arterial sampling only when venous or capillary sampling is inappropriate or unobtainable.
2. Use smallest possible (23- to 27-gauge) needle to minimize trauma to vessel and to prevent hematoma formation.
3. Avoid laceration of the artery caused by puncturing both sides of arterial wall in exactly opposite locations.
4. Remove excess heparin and air bubble from the blood gas syringe. If a small bubble gets into the sample, point the tip of the syringe up, expel the air bubble immediately, and cap syringe.
5. Guarantee hemostasis at the end of the procedure. Pressure must be applied even if an attempt is unsuccessful or results in an inadequate sample.
6. Check distal circulation after puncture.
a. Arterial pulse
b. Capillary refill time
c. Color and temperature
7. Take action to reverse arteriospasm, if necessary. (See Chapter 36.)
D. Selection of Arterial Site
1. Peripheral site preferred.
2. Radial artery preferred if ulnar collateral intact (see Allen test below).
3. Posterior tibial artery satisfactory.
4. Dorsalis pedis artery is often small or absent, but may be accessible in some infants.
5. Brachial artery only if indication is urgent and peripheral arterial or umbilical artery access is not available because of risk of injury to the adjacent median nerve, and the risk of ischemia due to the absence of collaterals at this site (3).
7. Ulnar artery should be avoided because of the risk of impaired circulation to the hand due to poor collateral circulation or damage to the ulnar or the median nerve.
E. Equipment
1. Sterile gloves
2. Sterile needle
a. A 23- to 25-gauge venipuncture needle, preferably a safety-engineered needle
b. A butterfly needle with extension tubing is often easier to use
3. Appropriate syringes, including a preheparinized blood gas syringe
4. Antiseptic for skin preparation: Povidone-iodine solution or 0.5% chlorhexidine in 70% alcohol (for infants >2 months old); sterile water or sterile saline wipe to remove antiseptic at end of procedure
5. Gauze pads
6. High-intensity fiberoptic light for transillumination (optional) and a sterile glove to cover (see Chapter 15)
7. Bedside ultrasound, if available
F. Technique (
Video 17.1: Radial Artery Blood Sampling)
Video 17.1: Radial Artery Blood Sampling)1. Transillumination may assist location of vessel (see Fig. 15.5) (8). Use of ultrasound guidance may decrease the number of attempts, increase success when performed by an experienced practitioner, and decrease the risk of hematoma formation or ischemia (9, 10).
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