Arterial blood is obtained anaerobically by inserting a short-beveled, sharp needle into an artery. An arterialized blood specimen may also be obtained from properly warmed capillary puncture sites.
II. Clinical Significance: N.A.
Sites of arterial puncture:
1. Radial artery:
The radial artery is easily accessible at the wrist in most patients.
A warmed capillary specimen approximates an arterial specimen. Heel punctures are recommended in infants less than one year. Skin punctures for arterial blood gases must NOT be performed on the fingers of newborns.
1. Marquest Quik ABG Kit with Needle Protection (Vital Signs #4023LTRU)
2. 2 x 2 gauze (Fisher #22362178)
3. Alcohol wipes (CardinalHealth #KC5150A)
4. Paper tape (CardinalHealth #M1535-1)
5. Cup of ice water or Cold/Hot Pack (CardinalHealth #M1570)
6. Approved glove, labcoat and safety glasses (In accordance with the Personal Protective Equipment (PPE) section of the UCL Exposure Control Plan)
7. Endure 300 (EcoLab #E300)
V. Reagents: N.A.
VI. Standardization: N.A.
1. Obtain a cup of ice water or a cold/hot pack from the refrigerator only if the specimen is to be transported to the laboratory for analysis.
2. Positively identify the patient according to the UCL “Patient Identification” policy.
Note: Outpatients only: If the patient is receiving Oxygen, and the physician has requested ABGs on room air, we must have an order indicating the length of time that the patient should be breathing room air before obtaining the specimen. If the time is not indicated on the order, we must contact the physician before obtaining the specimen. Note the length of time specified under comments on the requisition. Ordinarily 20 - 30 minutes off Oxygen is required. There must be someone to monitor the patient while he or she is on room air. The companion or laboratory staff must be instructed to restart the oxygen or call a 'code' if the patient is in distress. If the patient is not accompanied by anyone, someone from the laboratory staff must stay with the patient. If during the period off Oxygen the patient indicates acute distress, such as increasing shortness of breath, chest pain or faintness, resume Oxygen therapy immediately and notify a supervisor, pathologist or attending physician.
Note: Inpatients only: If the ordering physician has requested ABGs on room air and has not specified the amount of time the patient is to be on room air we ordinarily require 20 - 30 minutes off Oxygen. The patient’s nurse will turn the Oxygen off and will monitor the patient.
Note: If patients are receiving room air breathing treatments it is acceptable to obtain the specimen during or immediately after the treatment. If the treatments are with oxygen then follow the previous notes instructions.
3. Explain the procedure to the patient, so he/she is at ease.
4. Prepare the syringe: Open the Marquest Quik ABG Kit. Preset the plunger to desired sample volume before performing the arterial puncture.
Note: During the collection procedure, the plunger can be pulled back manually if more blood is desired. In some cases, the syringe may automatically continue to fill when it reaches the preset mark.
Attach the gel-filled sheath to the base stand. Place this stand on a safe and secure surface.
5. The minimum PPE required to perform this procedure is designated labcoat, gloves and safety glasses. Put a fresh pair of gloves on in view of the patient.
6. The radial artery is the artery used. (Refer to Diagram.)
Note: Laboratory staff does not perform arterial punctures using any other site.
Perform the Allen Test:
The hand is closed tightly to form a fist. Pressure is then applied at the wrist, compressing and obstructing both the radial and ulnar arteries. The hand is then opened (but not fully extended), revealing a blanched palm and fingers. The obstructing pressure is next removed from only the ulnar artery while the palm and fingers, including the thumb, are observed; they should become flushed within 15 seconds as the blood from the ulnar artery refills the empty capillary bed. If the ulnar artery does not adequately supply the entire hand (a negative Allen Test), do not perform the arterial puncture. Have the appropriate personnel (nurse, supervisor, pathologist) notify the patient's physician. Record the results of the Allen Test on the requisition.
A. If the Allen Test is positive, the radial artery may be punctured. The arm should be abducted with the palm facing up and the wrist extended about 30° to stretch and fix the soft tissue over the firm ligaments and bone.
B. If the Allen Test is negative on the right and left wrist, the patient's physician is notified and laboratory staff does NOT perform the arterial puncture.
7. Use two fingers to palpate the artery. If the artery can be palpated with each finger, the artery will lie directly between the two fingers. Make the puncture between the fingers at about a 45 to 65 degree angle, toward the direction of blood flow.
8. Clean the puncture site with an alcohol wipe. Allow to dry.
9. The skin is punctured, then the artery. Do not probe from side to side. If the artery is missed, bring the needle almost to the surface and redirect it toward the anticipated arterial location. If the technique doesn't work within a few attempts, withdraw the needle and apply firm pressure. If it appears that the artery has been punctured, firm pressure must be applied to the site for five minutes.
10. When the artery is punctured, blood will automatically fill the syringe. (If the patient is in shock, the preset syringe may not self-fill. If so, manually pull back the plunger.)
Note: Air will vent automatically from the syringe barrel.
11. Allow blood to fill the syringe completely. If blood flow stops before blood contacts the green plunger tip, terminate the puncture.
12. Apply firm pressure to the puncture site for a minimum of 3 - 5 minutes. After 3 - 5 minutes, observe the puncture site. Bleeding should have stopped and there should be no swelling around the puncture site. If bleeding cannot be stopped, ask for nursing assistance (for an outpatient, notify a pathologist or supervisor).
13. Keeping the syringe upright, needle pointed down; insert the needle into the gel-filled sheath until the needle is completely embedded in gel. The needle hub must firmly engage the sheath.
14. Remove the needle and needle protection device as one unit by twisting the needle hub. Discard into a sharps container.
15. Immediately stopper the syringe with the black syringe stopper, provided in the kit, while keeping the syringe pointed down.
16. Depress the plunger downward to expel any air from the sample.
Note: When blood makes contact with the green plunger tip, it will seal and not allow air to be expelled. If this occurs, hold the syringe upright, stoppered tip pointed upward and tap the syringe barrel to move air bubbles toward the black syringe stopper. Remove the stopper and push the air bubbles out with the plunger. Replace the black syringe stopper.
17. Agitate the sample for 20-30 seconds by rolling the sampler between palms of both hands to ensure heparin mixing.
18. Analyze the specimen immediately. Refer to the “i-Stat1; Operate” procedure. If the specimen must be returned to the laboratory for analysis, place the syringe in a cup of ice water or wrap it in a cold pack.
19. Record the date and time of specimen collection, site of collection, results of the Allen Test, the concentration of O2 being administered and phlebotomist initials on the test requisition.
20. Properly remove gloves and wash hands. If gloves have not been visibly contaminated with blood and/or body fluids, hands may be washed using Endure 300. If during the blood collection procedure gloves have become visibly contaminated with blood or body fluids, hands are washed using soap and water.
21. If a client appears abusive, uncooperative or in any way threatening follow the guidelines in the “Clients, Handling Abusive/Threatening; General Policy”.
VIII. Limitations: N.A.
IX. Results Derivation: N.A.
X. Expected Result(s) and/or Critical Values: N.A.
XI. Quality Control:
1. Qualifications for performing arterial punctures are based upon completion of the following criteria:
A. During new staff orientation documentation is noted in the new staff members orientation packet.
B. Annual Competency Validation is done through the Laboratory Annual Competency program. Documentation is noted in the Employees Annual Competency packet.
2. A list of personnel qualified to perform an arterial puncture follows this procedure. The list will be updated annually in June following the completion of the annual competency cycle.
1. The Simplicity and Safety of Arterial Puncture; Thomas L. Petty, M.D., D. Boyd Bigelow, M.D., and Bernard E. Levin, M.D.; JAMA Feb. 21, 1966, vol. 195, No. 8.
2. NCCLS Approved Standard: H11-A2; Percutaneous Collection of Arterial Blood for Laboratory Analysis, 2nd Ed., May 1992.
3. Morbidity and Mortality Weekly Report, Vol:51, No. RR-16, pp 1-44, October 25, 2002.
4. NCCLS H11-A3; Procedures for the Collection of Arterial Blood Specimens; Approved Standard. Vol:17, No. 18, 3rd Ed., May 1999.
5. Quik ABG™ package insert. Vital Signs, Inc. Englewood, Co.
i. February 1981 G. Drinkwater
ii. February 1996 J. Mueller (Revised: deleted use of brachial artery)
iii. July 2000 J. Mueller (Revised: IV., VII.2-16. for Marquest Quik syringe kit & i-Stat analysis)
iv. February 2003 R. Schaefer/J. Mueller (Revised: I.; III.; IV.6-7; VII.5-8,15,17-19.; XII.3-4.)
v. November 2008 R. Stoffel (Revised: XI.1.)
vi. June 2009 S. Hosch (Revised: VII.11-12.; XII.5)
May 2010 S. Hosch (Revised: VII.17.added)
June 2011 S. Hosch (Revised: IV.3.; VII.18.; list of qualified staff)
Arterial Punctures 6/1/2011