Radial Artery Puncture

Author: Carlos Eduardo Reis, MD

Most commonly radial artery puncture is performed in order to obtain arterial blood
sampling for gas analysis. The partial pressures of oxygen (PaO2) and carbon dioxide
(PaCO2) and the pH of arterial blood are important in assessing pulmonary function,
since these data indicate the status of gas exchange between the lungs and the blood.

Contraindications

 Cellulitis or other infections over the radial artery

 Absence of palpable radial artery pulse
 Positive Allen test (see below), indicating that only one artery supplies the hand
 Coagulation defects (relative)

Allen Test

It is very important to perform Allen Test to confirm the patency of the ulnar artery,
because in case there is no collateral flow through the ulnar artery, radial artery
puncture is contraindicated since it can result in a gangrenous finger or loss of the
hand from spasm or clotting of the radial artery. The Allen Test is performed with the
patient sit with her hands supinated on her knees. Then stand at the patient's side with
your fingers around her wrist; compress the tissue over both radial and ulnar arteries.
Allow a few minutes for the blood to drain from the hand while the patient opens and
closes her hands several times. Release the pressure on the ulnar artery while keeping
the radial artery occluded. normal skin color should return to the ulnar side of the
palm in 1-2 seconds, followed by quick restoration of normal color to the entire palm.
A hand that remains white indicates either absence or occlusion of the ulnar artery,
and radial artery puncture is contraindicated.

Anatomical Review

The radial artery runs along the lateral aspect of the volar forearm deep to the
superficial fascia. The artery runs between the styloid process of the radius and the
flexor carpi radialis tendon. The point of maximum pulsation of the radial artery can
usuall be palpated just proximal to the wrist. See figure 1 for anatomical relations.
 Figure 1. Anatomy of the wrist

Necessary Equipment

1) Materials for skin cleansing ( Alcohol and cotton )

2) Syringe with 3 to 5 mL of Lidocaine 1% and a 23- to 25-gauge neddle.
3) Preheparinised 3 to 5 mL syringe with 23 to 25 gauge neddle. To heparinize the
syringe, aspirate 0.5 mL of heparin into the syringe, hold the syringe upright, pull the
plunger all the way out to the end, and then return all of the heparin to the original
container. This can be done with buttrfly wings.
4) Gloves
5) Ice for transport.

Procedure

1)Wash your hands and put on disposable gloves.

2)Locate the approximate position of the artery by slowly rolling your index finger
from side to side. See figure 2

Figure 2.

3)Clean the skin over the proposed site of puncture.

4)Anesthetize the skin over the proposed site of puncture with the the 1% lidocaine 3
to 5 mL
5)Identify again the point of maximal pulsation of the radial artery.

6)With your dominant hand hold the syringe and needle puncture ( preheparinised )
and insert the needle into the anesthetized area at 45 degrees to the skin with needle's
bevel uppermost.

7)Guide the needle slowly toward the point of maximum pulsation. When you hit the
artery there will be a sudden gush of arterial blood into the hub of the needle. Then
you need to make a small amount of suction to obtain an adequate blood sample
( only 1-2 mL ). If no blood is obtained with these maneuvers, withdraw the needle to
a position just under the skin and try again. Make at least 3 attempts before giving up
and trying another site. This can be done with butterfly wings if you prefer, like the
illustration in figure 3.

Figure 3.

8)Once you have taken blood sample remove the needle from the artery and apply
direct pressure over the site for 5 minutes.

9)Expel all air bubbles from the sample holding the syringe upright and allowing the
bubbles to collect near the needle hub. Then evacuate it by pushing on the plunger.

10)Carefully cap the needle with a rubber stopper. Don't forget to label the tube with
patient's name. Place the sample in the bag containing ice and send it to tha lab.

It is very important to return about 20 minutes later to check for adequated perfusion
of the hand and for possible hematoma formation.

If you have suggestions or comments send an e-mail to Carlos Eduardo Reis

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Arterial blood gas (ABG) analysis is used to measure the partial pressures of oxygen
(PaO2) and carbon dioxide (pacO2)' and the pH of an arterial sample. Oxygen content
(O2CT), oxygen saturation (SaO2) and bicarbonate (RCO3 -) values are also
measured. A blood sample for ABG analysis may be drawn by percutaneous arterial
puncture or from an arterial line.

Purpose

• To evaluate gas exchange in the lungs.

• To assess integrity of the ventilatory control system.
• To determine the acid-base level of the blood.
• To monitor respiratory therapy.

Patient preparation

• Explain to the patient that this test is used to evaluate

how well the lungs are delivering oxygen to blood and
eliminating carbon dioxide.
• Tell him that the test requires a blood sample. Explain
who will perform the arterial puncture and when and which
site - radial, brachial, or femoral artery - has been selected
for the puncture.
• Inform him that he needn't restrict food or fluids.
• Instruct the patient to breathe normally during the test,
and warn him that he may experience a brief cramping or
throbbing pain at the puncture site.

Procedure and posttest care

• Perform an arterial puncture.

• After applying pressure to the puncture site for 3 to 5
minutes, tape a gauze pad firmly over it. (If the puncture site
is on the arm, don't tape the entire circumference; this may
restrict circulation.)
• If the patient is receiving anticoagulants or has a
coagulopathy, hold the puncture site longer than 5 minutes if
necessary.
• Monitor vital signs, and observe for signs of circulatory
impairment, such as swelling, discoloration, pain, numbness,
and tingling in the bandaged arm or leg.
• Watch for bleeding from the puncture site.

Precautions

• Wait at least 15 minutes before drawing arterial blood

when starting, changing, or discontinuing oxygen therapy.
 • Before sending the sample to the laboratory, note on
the laboratory slip whether the patient was breathing room air
or receiving oxygen therapy when the sample was collected.
• If the patient was receiving oxygen therapy, note the
flow rate. If he is on a ventilator, note the fraction of inspired
oxygen and tidal volume.
• Note the patient's rectal temperature and respiratory
rate.

Reference values

Normal ABG values fall within the following ranges:

• PaO2: 75 to 100 mm Hg
• PacO2: 35 to 45 mm Hg
• pH: 7.35 to 7.45
• O2CT: 15% to 22%
• SaO2: 95% to 100%
• HCO3 -: 24 to 28 mEq/L.

Abnormal findings

Low PaO2, O2CT, and SaO2 levels and a high PacO2 may result from conditions that
impair respiratory function, such as respiratory muscle weakness or paralysis,
respiratory center inhibition (from head injury, brain tumor, or drug abuse, for
example), and airway obstruction (possibly from mucus plugs or a tumor). Similarly,
low readings may result from bronchiole obstruction caused by asthma or
emphysema, from an abnormal ventilation-perfusion ratio due to partially blocked
alveoli or pulmonary capillaries, or from alveoli that are damaged or filled with fluid
because of disease, hemorrhage, or near-drowning.

When inspired air contains insufficient oxygen, PaO2, O2CT, and SaO2 decrease, but
PacO2 may be normal. Such findings are common in pneumothorax, impaired
diffusion between alveoli and blood (due to interstitial fibrosis, for example), or an
arteriovenous shunt that permits blood to bypass the lungs.

Low O2CT - with normal PaO2, Sa02 and, possibly, PacO2 values may result from
severe anemia, decreased blood volume, and reduced hemoglobin oxygen-carrying
capacity.

Interfering factors

• Failure to heparinize syringe, place Rumple in an iced

bag, or send the sample to the laboratory immediately
(possible altered PaO2 and PacO2 because metabolic
processes continue after sample is drawn)
• Exposing the sample to air (increase or decrease in
PaO2 and PacO2)
• Venous blood in the sample (possible decrease in Pa02
and increase in PII(02)
• Bicarbonate, ethacrynic acid hydrocortisone,
metolazone, prednisone, and Ihlllzides (possible increase in
PacO2) . Acetazolamide, methicillin, nitrofurantoin, and
tetracycline (possible decrease in PacO2)
• Fever (possible false-high PaO2 and PacO2).