University of Colorado Hospital Nursing Practice Guideline Neonatal Intensive Care Unit: Radial Arterial Puncture

Related Policies and Procedures: M-9-NN, P-10-NN, P-12-NN, S-1-NN, S-4NN, W-1-NN, Approved by: NICU Guidelines Committee, NICU Clinical Nurse Manager, NICU Medical Director Effective: April 2012 Description: This guideline describes the practices to safely perform radial arterial puncture on an infant. Accountability: RNs with documented competency in venipuncture and IV insertion will be trained in performing radial arterial punctures. Only trained RNs, NNPs, and MDs may perform radial arterial puncture in the NICU.

Definitions:
Modified Allens test: assessment performed prior to arterial puncture to ensure adequate collateral circulation. Arterial puncture: the puncture of an artery by means of a needle. ChloraPrep: Chlorhexidine gluconate 2% with isopropyl alcohol 70%

A.

Indications
1. Venous puncture and/or capillary attempts are unsuccessful. a. Inability to obtain adequate sample. b. No access sites available related to infant condition. 2. Venous and/or capillary samples are not satisfactory. 3. Arterial access (UAC, PAL) is not available. 4. Arterial blood specimen is ordered in the absence of a UAC/PAL.

B.

Precautions
1. Venous puncture and/or heel stick will be attempted prior to arterial puncture, unless otherwise indicated by guidelines and/or orders. 2. Avoid area of infection or loss of skin integrity near selected puncture site. 3. Use caution in infants with coagulation defects. 4. Avoid puncture in extremities with inadequate or impaired circulation. 5. Consider the need to preserve arterial site for possible cannulation. 6. Avoid extremities with inadequate collateral circulation distal to the selected puncture site.

7. Use of small-gauge needle reduces potential complication (25- gauge).

C.

Equipment and supplies

1. Antiseptic supplies a. ChloraPrep is used for patients 27 weeks or greater AND greater than 1000 grams (may begin using ChloraPrep when 2 weeks of age on any patient). Povidone-iodine is used for all other patients. b. ChloraPrep is a gentle friction scrub with back/forth motion x 30 seconds and allow to dry (minimum of 30 seconds). Only remove from skin with Sali-Wipe if skin appears irritated/ reddened. c. Povidone-Iodine is a gentle friction scrub with circular motion, moving outward for full 30 seconds. Must remain on skin a minimum of 2 minutes or longer to dry. Remove all povidoneiodine with Sali-wipe after procedure. 2. 3. 4. 5. 25-gauge butterfly needle or 25-gauge needle. TB syringes or 3 mL syringes. Sterile gauze pad. Arterial blood gas syringe and/or other applicable specimen containers.

D.

Procedure
1. Perform appropriate hand hygiene and don clean gloves. 2. Determine radial artery puncture site. a. Extend wrist, do not hyperextend, which may occlude vessel. b. Palpate artery at distal crease of wrist. 3. Perform modified Allen test to assess collateral circulation. a. Elevate hand. b. Apply pressure to occlude both radial and ulnar arteries. c. Massage the palm to blanch hand. d. Release pressure on ulnar artery. e. If color returns to hand in less than 10 seconds, adequate collateral circulation is suggested. If color returns in greater than 15 seconds, do not puncture artery because of poor collateral circulation. 4. Provide pain management such as pacifier for nonnutritive sucking, sucrose, and/or developmental care methods. See NICU nursing practice guideline D-1-NN. 5. Position and stabilize extended wrist to allow puncture against direction of arterial flow.

6. Prepare area with antiseptic for skin puncture (middle to outer third of wrist). 7. Puncture skin with needle (bevel up) at a 15- to 45-degree angle, using shallower angle for smaller infants or more superficial arteries.

8. Advance needle slowly to puncture artery. a. If resistance is met or blood is not obtained, withdraw needle slowly to just below skin level, palpate artery, and advance needle again in the direction of the artery. b. If hematoma or bleeding develops, apply pressure with gauze to occlude artery just proximal to the puncture site, withdraw needle, and apply pressure until hemostasis has occurred (approximately 5 minutes of direct pressure). 9. If arterial cannulation is successful, when blood enters the butterfly tubing, attach syringe and aspirate gently to obtain sample. 10. Apply firm, but not occlusive, pressure to the artery and puncture site and withdraw needle. Apply pressure to site for at least 5 minutes or until hemostasis has occurred. 11. Ensure distal circulation after puncture. a. Evaluate color and temperature of hand. b. Check capillary refill time. c. Palpate arterial pulse. 12. Document the procedure in patients electronic record. (Date, time, site location, Allen test result, pain management interventions, tolerance to procedure, specimen obtained, amount of blood drawn, hemostasis, distal circulation, and any complications.)

E.

Complications
1. 2. 3. 4. Hematoma. Hemorrhage. Infection. Thrombosis, embolism.

5. 6. 7. 8.

Arteriospasm Tissue necrosis, possibly leading to loss of hand. Needle injury to adjacent structures. Pain

References:
Milazzo, W., Fielder, J., Bittel, A., Coil, J., McClure, M., Tobin, P., and Vande Kamp, V. (2011). Oral sucrose to decrease pain associated with arterial puncture in infants 30 to 36 weeks gestation: a randomized clinical trial. Advances in Neonatal Care: Offical Journal of the National Association of Neonatal Nurses, 11 (6), 406-411. (level of evidence II) Verklan, Terese. M, Walden, Marlene. Core Curriculum for Neonatal Intensive Care Nursing. (4rd ed.). St. Louis, 2010, Elsevier Saunders. 322-324. (level of evidence VI) Gaspardo, C.M., Chimello, J.T., Cugler, T.S., Martinez, F.E., and Linhares, M.B.M. (2008). Pain and tactile stimuli during arterial puncture in preterm neonates. Pain, 140(1), 58-64. Retrieved February 6, 2012, from http://dx.doi.org/10.1016/j.pain.2008.07.004. (level of evidence - IV)