Atlas of Procedures in Neonatology, 4th Edition
Dawn M. Walton
Billie Lou Short
- Indications (1, 2)
- Sampling for arterial blood gas determination
- Sampling for routine laboratory test when venous and capillary sampling not suitable or unobtainable
- Coagulation defects, thrombocytopenia
- Circulatory compromise in the extremity
- Inappropriate artery
- Femoral artery
- Use of radial artery if inadequate collaterals (see Allen's test below)
- Infection in sampling area
- When cannulation of that vessel is anticipated
- Use of peripheral arteries on the ipsilateral arm in an infant with congenital heart disease requiring a shunt via the subclavian artery
- Perform arterial sampling only when venous or capillary sampling is inappropriate.
- Arterial blood gas analyses prior to placement of indwelling access.
- Ammonia levels
- Large quantities of blood to be obtained
- Very low-birthweight infants with poor venous access
- Use smallest possible needle to minimize trauma to vessel (23 to 27 gauge).
- Avoid laceration of the artery caused by puncturing both sides of arterial wall in exactly opposite locations.
- Guarantee hemostasis at end of procedure.
- Check distal circulation after puncture.
- Arterial pulse
- Capillary refill time
- Color, temperature
- Take action to reverse arteriospasm, if necessary (see Chapter 33).
- Selection of Arterial Site
- Peripheral site preferred
- Radial artery preferred if ulnar collateral intact
- Dorsalis pedis, posterior tibial arteries satisfactory
- Brachial artery onlyif urgent indication and no more peripheral arterial or umbilical artery access is available(3)
- Temporal artery should be avoided because of risk of neurologic damage (4, 5).
- A 23- to 25-gauge venipuncture needle
- Safety-engineered needle should be used
- Appropriate syringes
- Materials for minor skin preparation; povidone–iodine solution preparation preferred for blood culture
- Gauze pads
- Sterile glove to cover transilluminator
- High-intensity fiber-optic light for transillumination (see Chapter 12)
- Oral sucrose solution (24% to 25%) for pain control, if indicated (6, 7)
General Principles (1, 2)
- Transillumination may assist location of vessel (Fig. 12.1) (8).
- Position needle for arterial puncture against direction of blood flow.
- Keep angle of entry shallow for superficial vessels.
- 15 to 25 degrees for superficial artery, bevel down
- 5 degrees for deep artery, bevel up
- Penetrate skin first, and then puncture artery to minimize trauma to vessel.
- Use fresh needle and repeat skin preparation if withdrawal from skin is necessary.
- Apply firm, local pressure for 5 minutes to achieve complete hemostasis.
FIG. 14.1. Position of wrist for puncture of radial artery. (1) distal wrist crease; (2) proximal wrist crease.
Radial Artery Puncture (2)
- Extend wrist, supine, not hyperextended (Fig. 14.1), which may occlude vessel.
- Locate radial and ulnar arteries at proximal wrist crease (Fig. 14.2).
- Radial artery is lateral to flexor carpi radialis tendon.
- Ulnar artery is medial to flexor carpi ulnarius tendon.
- Transillumination may be helpful.
- Perform modified Allen's test for collateral supply (9).
- Elevate infant's hand.
- Occlude both radial and ulnar arteries at wrist.
- Massage palm toward wrist.
- Release occlusion of ulnar artery only.
- Look for color to return to hand in less than 10 seconds, indicating adequate collateral supply.
- Do not puncture radial artery if color return takes more than 15 seconds.
FIG. 14.2. Anatomy of the major arteries of the wrist and hand.
FIG. 14.3. A: Penetration of artery at angle of 15 to 25 degrees with bevel down. Preferred method for small premature infants. B:Penetration of artery at angle of 45 degrees with bevel up.
- Locate artery by palpation and/or transillumination.
- Prepare area with antiseptic, as for minor procedure.
- Check function of syringe.
- Puncture skin and penetrate artery at 45 degrees with bevel up. For very small infants, use angle of 15 to 25 degrees with bevel down (Fig. 14.3).
- While maintaining gentle suction, advance until there is blood return or resistance from bone.
- If no blood obtained prior to encountering resistance, withdraw needle cautiously until blood returns. Artery may spasm when needle is introduced. Be patient; change angle of needle as necessary.
- Collect sample and remove needle.
- Compress site for 5 minutes or until hemostasis is complete.
- Verify satisfactory peripheral blood flow (10, 11).
Dorsalis Pedis Puncture
- Locate artery by palpation and transillumination on dorsum of foot between extensor hallucis longus and extensor digitorum longus tendons (Fig. 14.4).
- Choose an angle of 15 to 25 degrees.
- See F, “General Principles.”
Posterior Tibial Puncture
- Locate artery by palpation and transillumination between Achilles tendon and medial malleolus (Fig. 14.5).
- Choose an angle of 45 degrees.
- See F, “General Principles.”
FIG. 14.4. Anatomic relations of the dorsalis pedis artery.
FIG. 14.5. Anatomic relations of the posterior tibial artery.
- Complications (10)
See Chapter 30 for complications of arterial cannulation.
- Distal ischemia from arteriospasm, hematoma, thrombosis, or embolism
- Osteomyelitis (12)
- Infected hip joint after femoral puncture (12)
- Hemorrhage or hematoma
- Nerve damage (13)
- Median nerve (brachial artery puncture)
- Posterior tibial nerve
- Femoral nerve
- Extensor tendon sheath injury, resulting in “false cortical thumb” (14)
- Forearm compartment syndrome following brachial artery puncture (15)
- Inaccuracy of blood gas estimated (16, 17)
- Excessive heparinization of syringe (falsely low PCO2and pH)
- Hypothermic or hyperthermic infant
- Gas bubbles in syringe
- Spuriously high PO2
- Spuriously low PCO2
- Excessive delay in processing
- Clot in syringe
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- Shaw JC.Arterial sampling from the radial artery in premature and full-term infants. Lancet. 1968;2:389.
- Okeson GC, Wulbrecht PH.The safety of brachial artery puncture for arterial blood sampling. Chest. 1998;114:748.
- Bull MJ, Schreiner RL, Garg BP, et al. Neurologic complications following temporal artery catheterization. J Pediatr. 1980;96:1071.
- Simmons MA, Levine RL, Lubchenco LO, et al. Warning: serious sequelae of temporal artery catheterization. J Pediatr. 1978;92:284.
- Acharya AB, Annamali S, Taub NA, Field D.Oral sucrose analgesia for preterm infant venipuncture. Arch Dis Childhood Fetal Neonatal Ed. 2004;89:F17.
- Stevens B, Yamada J, Ohlsson A.Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database Syst Rev. 2004;(3):CD001069.
- Wall PM, Kuhns LR.Percutaneous arterial sampling using transillumination. Pediatrics. 1977;59:1032.
- Cable DG, Mullany CJ, Schaff HV.The Allen test. Ann Thorac Surg. 1999;67:876.
- Gillies ID, Morgan M, Sykes MK, et al. The nature and incidence of complications of peripheral artery puncture. Anaesthesia. 1979;34:506.
- Noreng MF.Blood flow in the radial artery before and after arterial puncture. Acta Anaesthesiol Scand. 1986;30:281.
- Nelson DL, Hable KA, Matsen JM.Proteus mirabilis osteomyelitis in two neonates following needle puncture. Successful treatment with ampicillin. Am J Dis Child. 1973;125:109.
- Pape KE, Armstrong DL, Fitzhardinge PM.Peripheral median nerve damage secondary to brachial arterial blood gas sampling. J Pediatr. 1978;93:852.
- Skogland RR, Giles EJ.The false cortical thumb. Am J Dis Child. 1986;140:375.
- Safran MR, Bernstein A, Lesavoy MA.Forearm compartment syndrome following brachial arterial puncture in uremia. Ann Plast Surg. 1994;32:535.
- Fan LL, Dellinger KT, Mills AL.Potential errors in neonatal blood gas measurements. J Pediatr. 1980;97:650.
- Goldsmith JP.Error in blood gas sampling results in spurious interpretation of compensated metabolic acidosis. J Perinatol. 1993;13:165.