Arterial Puncture

The arterial puncture is used to collect blood specimen for arterial blood gas (ABG)
analysis to manage cardiopulmonary disorders and maintain the acid-base balance of
the body. The arterial blood is the ideal specimen for respiratory function evaluation due
to the consistency of its composition and high oxygen content. The phlebotomist should
have a thorough understanding of the collection procedure to minimize pain and
maintain the açcuracy of the results since it is more technically challenging and
hazardous than venipuncture.

Arterial blood collection

Arterial blood is collected to determine the level of oxygen and carbon dioxide in the
blood and measure the pH. Arterial collection is more dangerous than venous collection
to the patient, and it requires in-depth training beyond routine phlebotomy skills.

Composition of Arterial Blood

Arterial blood is rich in both oxygen and electrolytes; this is different from venous blood,
in which the levels of these substances vary, depending on the metabolic activities of
surrounding tissues. In addition, arterial blood is uniform in composition throughout the
body. This makes arterial blood monitoring ideal for managing oxygen, electrolytes, and
acid-base balance. Arterial collection is most often used for testing arterial blood gases
(ABGs), ammonia, and lactic acid.

Arterial Blood Gas (ABG)

ABG testing determines the concentrations of oxygen and carbon dioxide dissolved in
the blood and measures the pH. The evaluation of the arterial blood gas is performed to
diagnose respiratory disorders. The testing provides information about (1) oxygenation,
(2) ventilation, and (3) acid-base balance, which help in the management of diseases.
Patients with diabetes or other disorders also use ABG to manage the electrolyte and
acid-base balance.

Commonly Measured ABG

Equipments for Arterial Puncture

1. Heparinized syringe and needle

- Arterial blood is collected in a syringe that has been pretreated with
heparin to prevent coagulation.
- Note: Prepackaged syringes are available. But we may be required to
prepare a heparinized syringe when no commercial prepackaged product
is available. To do this, follow these steps:

1. Use a solution of sodium heparin with a concentration of 1000 U/mL.

2. Calculate the volume of heparin to draw up. Use 0.05 mL of heparin
solution for each milliliter of blood to be drawn.
3. Attach a 20-gauge needle to the syringe, and draw up the heparin by
slowly pulling back on the plunger.
4. Rotate the liquid in the syringe to coat the barrel.
5. Remove the 20-gauge needle and replace it with the needle you will
use for collection.
6. Expel the excess heparin and any air by depressing the plunger fully
with the needle pointed down.

2. Antiseptic
- The risk of serious infection is greater with arterial puncture than with
venipuncture. For this reason, both alcohol and povidone–iodine or
chlorhexidine are used to clean the site.
3. Lidocaine Anesthetic
- Arterial collection can be painful. To lessen pain, 0.5 mL of lidocaine, a
local anesthetic, may be injected subcutaneously, using a 25- to 26-gauge
needle on a 1-mL syringe. Note that not all hospitals use lidocaine before
the puncture.
4. Safety Equipment
- Arterial blood is under pressure and may spray out of the puncture. You
need a fluid-resistant gown, face protection, and gloves. You also need a
puncture-resistant container for sharps.
5. Luer Tip
- This plastic tip covers the syringe top after you have removed the needle.
This keeps air from reaching the specimen and altering gas
concentrations.
 6. Other Equipment
- Other equipment needed for arterial puncture includes the following:
• Crushed ice
• Ice and water
• Gauze pads
• Pressure bandages
• Thermometer (to take the patient’s temperature)
• Transport container
- No tourniquet is needed because arterial blood is under pressure.

Sites and Criteria Used for Arterial Puncture

The following criteria are used in selecting the site for an arterial
puncture:

1. There is collateral circulation, or the site gets its blood supply from more than one
artery. The potential site can be evaluated by using a portable ultrasound instrument or
by modified Allen test.
2. The artery should be accessible and large in size so that the puncture is easy.
3. The surrounding tissue of the puncture site should have little risk of being injured
during the procedure. The area should also help in keeping the artery from rolling and
the pressure can be applied easily in the area after the procedure.
4. The area should be free from inflammation, irritation, edema, hematoma, lesion, and
wound. There should be no arteriovenous (AV) shunt near the site or there is no recent
arterial puncture.

Arterial Puncture Site

(insert lang picture for each artery sites, Rawan)
Radial Artery - the most commonly used site located in the thumb side of the wrist.
Although it is smaller than either the brachial or the femoral artery, it has good collateral
circulation and is easily accessible along the thumb side of the wrist.

Brachial Artery - located in the medial anterior of the antecubital fossa. It has adequate
collateral circulation, although not as much as the radial artery.

Femoral Artery - located in the groin lateral to the pubic bone. The femoral is used when
the previously mentioned sites are not available for puncture. Its large size and high
volume make it useful when cardiac output is low. However, it has poor collateral
circulation.
Alternative sites for adults
- Dorsalis pedis artery in the foot.
Alternative sites for infants
- Umbilical artery and scalp artery are used.

Testing Collateral Circulation

- The modified Allen test is the most common method used to assess the
adequacy of collateral circulation in the radial artery.

Modified Allen Test

1. Extend the patient’s wrist over a towel, and have the patient make a fist.

2. Locate pulses of both the ulnar and the radial arteries, and compress both
arteries.

3. Have the patient open and close the fist repeatedly. This squeezes blood out of
the hand. The patient’s palm should blanch (become lighter).
 4. Release the pressure from the ulnar artery. Observe the color of the patient’s
palm within 5 to 10 seconds.
5. Negative result: If no color appears during the 5 to 10 seconds, there is
inadequate collateral circulation and the artery should not be used.
Positive result: If color appears within 5 to 10 seconds, there is adequate
collateral circulation and you may proceed with the radial puncture.

Patient Preparation

1. As part of the standard procedure, the identity of the patient is confirmed before
the start of the test. The blood drawer should also explain the procedure to the
patient and get his/her expressed consent to proceed.

2. The patient should be resting in a comfortable position (lying in bed or seated on

a chair) for at least 5 minutes or until the breathing of the patient becomes stable.
The collection conditions must be documented in the test requisition.

3. The patient should be stable or in steady state for 20 to 30 minutes before the
test is performed.

4. To determine if the patient has collateral circulation, the modified Allen test is
performed prior to collection.

5. Administering a local anesthetic.

Preparing and Administering Local Anesthetic
1. Ask the patient for history of allergic reactions to anesthetic or its derivatives
2. Follow hand hygiene and wear gloves
3. Attach the safety needle to the syringe
4. Clean stopper of the anesthetic bottle using isopropyl alcohol wipes
5. Insert needle through the bottle stopper to withdraw the anesthetic
6. Replace needle caps and keep the syringe in a horizontal position
7. Clean the site and air-dry
8. Insert needle into the puncture site at 1o-degree angle
9. Pull back the plunger slightly
10. Slowly expel contents into the skin. It should form a raised wheel
11. Wait for about 2 minutes before continuing with the arterial puncture
12. Note the anesthetic application on the test requisition.

Radial Artery Puncture

1. Prepare the patient, and examine and complete the requisition form.
- Take the patient’s temperature and respiration rate and record them on
the requisition form if required by your facility’s protocol.
- The patient should be in a respiratory steady state, meaning that he or she
has received the specified amount of oxygen and has refrained from
exercise for at least 30 minutes.
2. Choose and prepare the site.
- Perform the modified Allen test to assess collateral circulation in the hand.
If the result is positive, proceed. Position the patient comfortably.
- Clean the site with the antiseptic required by your institution.
- Inject the local anesthetic. Wait 1 to 2 minutes for the anesthetic to begin
working.
3. Perform the puncture
- Cleanse the fingers of your nondominant hand and place them over the
area where the needle should enter the artery.
- Hold the syringe like a dart with your dominant hand, with the needle tip
pointed bevel up toward the upper arm. Insert the needle 5 to 10 mm
distal to the finger you placed on the artery. Insert it at an angle 45 to 60
degrees above the plane of the skin.
- As the needle is inserted into the artery, blood should appear in the hub.
 4. Withdraw the needle, apply pressure, and ice the syringe.
- Withdraw the needle with your dominant hand. With your nondominant
hand, apply direct pressure to the site with a folded gauze square.
- Place the syringe in the ice.
5. Examine the puncture site.
- After 5 minutes (or 15 minutes for patients on anticoagulant therapy),
check the site to ensure that the bleeding has stopped.
- Once the bleeding has stopped, clean the site with alcohol to remove the
iodine, and apply a bandage.
- Check for a pulse distal to the site. If the pulse is absent or weak, contact
the nurse immediately
6. Label and ice the specimen.
- Dispose of the needle in the sharps container.
- Label the specimen with a waterproof pen, and return the syringe to the
ice.
- Deliver the specimen to the laboratory immediately. Ice the specimen if
you are unable to deliver to the lab within 30 minutes.

Arterial Puncture Complications

Complications from arterial puncture may include the following:

● Arteriospasm - the spontaneous constriction of an artery in response to pain.

Arteriospasm may close the artery, preventing oxygen from reaching tissue.
● Embolism - or blood vessel obstruction, is due to an air bubble or dislodged clot
in the artery. This can cause arterial occlusion (blockage), leading to loss of
blood flow.
● Hematoma - resulting from inadequate pressure on the site. This is more likely in
elderly patients, whose artery walls are not as elastic and thus not as likely to
close spontaneously.
● Hemorrhage - this is more likely in patients who have coagulation disorders or
are receiving anticoagulant therapy (heparin or warfarin).
● Infection - from skin contaminants. Contaminants are easily carried to the rest of
the body without encountering the immune system.
● Lightheadedness, nausea, or fainting.
● Nerve damage, caused by inadvertent contact with a nerve. This is more likely
during arterial puncture than venipuncture because the needle passes more
deeply into tissue.
● Severe pain.
● Thrombosis, or clot formation, within the artery.
Sampling errors
The integrity of the blood sample and the accuracy of the test are
compromised when:

1. air bubbles were not expelled from the sample

2. processing exceeded optimal time, which is within 10 minutes from collection
3. the sample was not mixed properly or immediately
4. syringe was used improperly
5. venous blood was obtained by mistake
6. improper anticoagulant was used
7. incorrect volume of heparin was used.

Criteria for Rejection of ABG Specimen

The laboratory personnel will reject the ABG specimen that has been
submitted for analysis using the following criteria:

1. Air bubbles are found in the specimen.

2. The specimen has clotted.
3. The specimen has hemolyzed.
4. The submitted specimen did not comply with the proper labeling requirement.
5. The prescribed transportation temperature for the specimen was not met.
6. The specimen did not meet the required volume or QNS.
7. It took so much time for the specimen to reach the laboratory.
8. The wrong type of syringe was used.
Capillary Blood Gas Testing
- Capillary blood gas (CBG) testing is an alternative to ABG testing when arterial
collection is not possible or is not recommended. Capillary blood is not as
desirable a specimen for blood gas testing because it is a mixture of blood from
the capillaries, venules, and arterioles and is mixed with tissue fluid.
The collection is done using a normal heel-stick procedure. Important points in
the procedure are as follows:

1. Warm the site to 40° C to 42° C for 5 to 10 minutes before the stick to
maximize the arterial character of the capillary blood.
2. Clean the site with the appropriate antiseptic swab, using the antiseptic
required by your institution. Allow the site to dry for the appropriate time.
3. Collect the sample in a heparinized glass pipet. Before collection, insert a
metal filing, called a flea, into the tube. After collection, a magnet is used
to draw the flea back and forth across the length of the tube to mix the
contents with the heparin.
4. Fill the tube completely with blood so that no air bubbles remain.
5. Seal both ends of the tube with clay or plastic caps to prevent air
contamination.