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Arterial puncture and cannulation Dr Karl Jones, primary care physician, Liverpool.

Reviewed by Dr Sean Neil, anaesthetic SpR, West Sussex Region. Thursday, 3 June 2010

Key learning points With increasingly sophisticated non-invasive investigations, arterial puncture is becoming less used, particularly outside the operating theatre and the intensive care unit, but still has a role to play. It is largely safe and has few contraindications. The radial artery is the most commonly used site. For cannulation, apart from radial artery cannulation, the Seldinger over-the-wire technique is preferred. 1,2 Serious complications are rare but include haemorrhage, thrombosis, ischaemia, nerve damage, infection, pseudoaneurysm, and accidental intra-arterial drug injection. The incidence of complications can be reduced by careful selection of patients and consideration of other means of gathering the required information.

Introduction With the increased availability and reliability of non-invasive alternatives, arterial puncture is becoming less important. It does have a role to play in the management of the severely ill, haemodynamically unstable patient, and in severe metabolic disorders, such as diabetic ketoacidosis, though there is a trend in the latter case to use arterial acid-base analysis as a baseline, and to monitor trends with venous sampling. 3,4 Pulse oximetry offers a safe, non-invasive alternative to serial arterial gas analysis in the majority of clinical situations, including in A&E, out-patient departments and for the assessment of COPD in the community. Arterial cannulation is a simple technique which, none-the-less, requires a certain degree of skill in order to be regularly successful. Though usually safe, 5 it can be very uncomfortable (without local anaesthetic), and complications can be disastrous. In certain situations its use is essential. Indications Arterial puncture Diagnosis of O2 and CO2 gas exchange disorders Diagnosis and monitoring of acid-base disorders Monitoring haemoglobin and haematocrit Monitoring blood glucose Monitoring electrolytes To obtain blood when venous access is difficult Arterial cannulation Monitor BP where repeated cuff measurements are impracticable Continuous measurement of BP in shock, haemodynamic instability, during inotropic or vasoactive therapy, and for maintenance of cerebral perfusion pressure Repeated blood gas sampling Cardiac output measurement Repeated blood sampling Angiography Systolic pressure variation as a guide to fluid therapy Contraindications There are no absolute contraindications to arterial puncture or cannulation, but the presence of local infection, scarring or third-degree burns should prompt a search for an alternative site for the procedure, or even a re-evaluation of the indications for arterial puncture. Similarly, other sites should be considered if there is a positive Allens test, a decreased pulse or a bruit over the chosen artery. The decision to perform arterial puncture should be taken with great care in patients with Raynauds disease or thomboangiitis obliterans (Buergers disease) because of the risk of jeopardising the distal circulation. 6-8 The risk of thrombus formation in thrombophilic states or of plaque displacement with embolisation or vessel occlusion in arteriosclerosis should also be considered as risk factors arguing against arterial puncture.

Patients with bleeding disorders or on anticoagulant regimes are at risk of haemorrhage. If arterial puncture is considered necessary, great care should be taken to minimise bleeding by applying adequate pressure over the puncture site for at least ten minutes. Single puncture is preferable to an indwelling cannula if there is an increased risk of bleeding. Arterial puncture should, if at all possible, be avoided in patients with disseminated intravascular coagulation or those undergoing thrombolysis. As with many decisions in medicine, it is a matter of weighing potential benefits against risk. Site selection Radial artery The radial artery is the most commonly used for arterial puncture. It has the advantages that the artery is easily identified and palpated, is easily accessible for puncture, is easily compressed for haemostasis, has a widespread collateral flow, and is associated with a lower incidence of complications. In order to cannulate the radial artery, the forearm is placed in full supination with the wrist dorsiflexed to about 60 o . The artery is identified by feeling for its pulsation at two positions along the artery at just proximal to the wrist, fixing these two points with the index and middle fingers of the non-dominant hand, and a puncture point is selected between these two points. An approach angle of between 15 o and 30 o is recommended. Before the artery is cannulated, the collateral circulation is usually assessed using a modified Allens test, though some doubt its value. 5 Figure 1: Anatomy of radial artery (image used with permission from Wikipedia).

Brachial artery The brachial artery can be identified towards the medial border of the arm, and is suitable for puncture or cannulation as it passes from above, through the antecubital fossa. It is usually cannulated in or proximal to the antecubital fossa. As the elbow joint has a great mobility, it is usual to splint the arm and to use a longer cannula. The proximity of the median nerve makes nerve damage a particular risk, and the absence of effective collateral circulation increases the risk of ischaemia. Because of this, the brachial artery is not a preferred site for arterial cannulation Femoral artery The femoral artery can be cannulated as it traverses the femoral triangle below the inguinal ligament. It should never be cannulated above the ligament (where it becomes the external iliac artery and is intraabdominal) as it is very difficult to apply adequate pressure to the artery. The artery passes from the mid-point of the inguinal ligament to the apex of the femoral triangle and is accompanied by the femoral nerve laterally and the femoral artery medially. The usual approach is to

cannulate the artery about 2.5cm or so below the ligament where it can be easily compressed against the femoral head, and to use a relatively steep angle of approach of between 45-60 o , owing to the arterys greater depth. A Seldinger technique is advised for cannulation of the femoral artery. Dorsalis pedis artery 9 The dorsalis pedis artery runs approximately midway between the malleoli on the dorsal surface of the forefoot. It can usually be palpated, but is often difficult to find and is absent in up to 12% of people. It is also more affected by vascular disease than is the radial artery. If palpated, it is best approached at the midpoint of its course down the forefoot, at an angle of 25-30 o . Cannulation of the dorsalis pedis artery is technically more difficult than using the radial artery, and monitoring is hampered by the pressure wave in the foot being 5-20 mmHg higher than in the radial artery, as well as being delayed by 0.1-0.2 seconds. The pressure wave is higher in the supine position, compared to that of the standing position. Testing the collateral circulation in the foot To test the collateral circulation in the foot before dorsalis pedis cannulation, occlude the artery by applying pressure and then blanch a nail bed by applying pressure to the nail with the thumb of the other hand. Following release of the pressure on the nail bed, the capillary circulation should refill within 4-5 seconds. A test similar to Allens test at the wrist is possible using the anterior and posterior tibial arteries, but is difficult to perform. It is particularly difficult to occlude the anterior tibial artery and this is rarely done in practice. Equipment Arterial puncture Limb support Skin prep Drapes Gloves and goggles 5ml syringe, 25G or 27G needle and local anaesthetic (1% lidocaine without adrenalin) Arterial puncture set or 3ml syringe with needle (22G for radial, 20G for femoral) and heparin or heparinised saline (preferred) Syringe cap Ice Dressings Arterial cannulation As for arterial puncture Scalpel or wide-bore needle 2-0 or 3-0 silk on a suture needle Catheter-needle assembly or cannula/needle/guide-wire pack with spare guide-wire (20G for radial and 16G-18G for femoral the femoral cannula needs to be significantly longer) Dressings Pressure tubing Three-way stopcocks

Bag of normal saline Pressure infusion set with continuous flush device Antibiotic ointment Technique Arterial puncture Positioning is extremely important in increasing the success rate of arterial puncture. If using the radial artery, the arm should be supported in supination with the wrist dorsiflexed to about 60 o , a position more stable and comfortable for the patient if a soft cloth roll is placed under the wrist. For femoral puncture, the leg should be placed in slight external rotation, brachial artery puncture requires the arm to be slightly hyperextended at the elbow and supported by an arm-board in full supination, while for dorsalis pedis puncture the foot is simply plantar-flexed. Once the target artery is appropriately identified, the skin is cleaned using alcohol or povidone iodine, draped, and a small amount of local anaesthetic infiltrated at the intended puncture site. Arterial puncture is usually performed using a heparinised 3ml syringe with a 22G needle for radial puncture or a 20G needle for femoral puncture. If using an arterial puncture pack, the enclosed syringe is already coated with heparin; otherwise a normal syringe can be coated by drawing up and expelling as completely as possible heparin or heparinised saline. It is important to leave as little heparin as possible in the syringe in order to reduce assay inaccuracies (heparin lowers pCO2 in the sample). Holding the syringe barrel comfortably (in a similar fashion to holding a dart), the operator punctures the skin through the anaesthetised area at the point of maximal pulsation at an angle of about 30 o to the skin (45 o -60 o for femoral puncture), along the axis of the artery, and the needle is advanced slowly until blood appears in the syringe. 2-3mls of blood is then taken and the needle and syringe withdrawn while applying firm pressure to the artery. The syringe should then be tapped to dislodge any air, securely capped and placed on ice and sent immediately for analysis (results are unreliable if there is a delay exceeding 20 minutes). If there is no flash-back of blood, withdraw the needle very slowly, a millimetre at a time, and check for flash-back. When the needle tip is just below the skin surface and puncture has been unsuccessful, the aim of the needle can be altered to 1mm or so to one side of the original approach. If repeatedly unsuccessful, try another site (or operator). Repeated attempts increase the likelihood of complications and are distressing for the patient. The technique of transfixing the artery, introducing the needle tip until it hits bone and then withdrawing until flash-back of blood occurs, is not recommended as it is likely to be more uncomfortable, and is associated with a higher complication rate. Following arterial puncture, pressure on the artery should be maintained for at least five minutes. and sent immediately for analysis (results are unreliable if there is a delay exceeding 20 minutes). If there is no flash-back of blood, withdraw the needle very slowly, a millimetre at a time, and check for flash-back. When the needle tip is just below the skin surface and puncture has been unsuccessful, the aim of the needle can be altered to 1mm or so to one side of the original approach. If repeatedly

unsuccessful, try another site (or operator). Repeated attempts increase the likelihood of complications and are distressing for the patient. The technique of transfixing the artery, introducing the needle tip until it hits bone and then withdrawing until flash-back of blood occurs, is not recommended as it is likely to be more uncomfortable, and is associated with a higher complication rate. Following arterial puncture, pressure on the artery should be maintained for at least five minutes.