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Arterial Punctures By Nurses

1971; Elsevier BV; Volume: 59; Issue: 1 Linguagem: Inglês

10.1378/chest.59.1.97

1931-3543

Marvin A. Sackner, Wilbur G. Avery, J. W. SOKOLOWSKI,

Hemodynamic Monitoring and Therapy

Arterial blood gas analysis is the single most useful laboratory test in the management of patients with respiratory and metabolic disorders. In recent years, requests for such studies have overburdened house officers who in most institutions have been trained to perform arterial punctures. We have trained two registered nurses to perform radial arterial punctures and found that they have become more proficient in this technic than most of the house staff. In a five month period, 1,541 punctures were performed by these nurses without morbidity. Arterial blood gas analysis is the single most useful laboratory test in the management of patients with respiratory and metabolic disorders. In recent years, requests for such studies have overburdened house officers who in most institutions have been trained to perform arterial punctures. We have trained two registered nurses to perform radial arterial punctures and found that they have become more proficient in this technic than most of the house staff. In a five month period, 1,541 punctures were performed by these nurses without morbidity. In 1965, we began using a simple technic for obtaining arterial blood from the radial artery for analysis of blood pH, oxygen tension and carbon dioxide tension. For editorial comment, see page 3 We reported on the safety and utility of this method based upon over 2,000 arterial punctures in an 18-month period.1Sackner MA Arterial blood gas analysis.Med Times. 1967; 95: 79-87PubMed Google Scholar We stressed the importance of arterial blood gas analysis as the single most useful laboratory test in the management of patients with respiratory and metabolic disorders. Accordingly, requests for arterial blood gas studies in our institution have risen to a level which overtaxed our house staff who we trained to draw the arterial bloods. In 1966, there were 1,980 arterial blood gas analyses done in our laboratory. In 1969, this number had risen to 11,555. Furthermore, physicians in smaller hospitals in our community have expressed disappointment in not being able to obtain arterial blood gas analyses readily since interns and residents are often unavailable. For this reason, we decided to train registered nurses to take over the task of arterial punctures during the day shift. Since November, 1969, two nurses have performed 1,541 arterial punctures without morbidity or complications. The success of this plan has been so gratifying that we believe it should be possible to train paramedical personnel such as respiratory therapy, pulmonary and cardiac laboratory technicians, reserving the nurses for a supervisory role and for procedures such as placing percutaneous indwelling arterial catheters for repeated sampling. The material includes 5ml glass syringe wetted with heparin solution, 1,000 units per ml, attached to a 22 gauge 1” needle; 2 ml plastic disposable syringe filled with 2 percent lidocaine (Xylocaine) solution attached to a 25 gauge 1/2” needle; alcohol sponges; round tooth pick. The patient is preferably supine or semirecumbent and the wrist extended to about 45°. The area over the radial artery one-half to one inch above the wrist crease is cleansed with alcohol and infiltrated with 1 to 2 ml of 2 percent Xylocaine solution to make a skin wheal. The radial artery is palpated with the fingers of one hand and the 5 ml syringe and needle advanced gently with the other hand, entering the artery at a 45° angle. Occasionally, penetration into the artery can be sensed by the operator, but often the puncture of the artery is detected by blood slowly entering the syringe as a result of the arterial pressure. Because of the small size of the puncturing needle, pulsations generally are damped. The syringe barrel will be forced backwards by arterial but not venous pressure. Plastic syringes should not be used for arterial punctures since the greater friction (compared to glass) may prevent or hinder spontaneous movement of the syringe barrel under influence of arterial pressure. Generally there is a paucity of veins in the vicinity of the radial artery, and no large nerve. After 3 to 5 ml of blood are withdrawn from the artery, firm pressure is applied at the site of puncture for about two minutes. If any bubbles are seen in the syringe, they are flushed out, holding the syringe vertically. The needle is taken off the syringe and a round toothpick is inserted in its place so that the blood is not exposed to the atmosphere. The blood is immediately transported to the laboratory for analysis. If radial arterial blood cannot be obtained, similar technics can be employed for the brachial and femoral arteries. However, the radial artery is the preferred site because of the absence of significant morbidity. The nurses were given one week of instruction on technics of arterial puncture, the recognition and treatment of vasovagal reactions, interpretation of usual acid-base abnormalities, and recognition of possible venous samples. Although occasionally a member of the pulmonary disease service had to perform the radial arterial puncture during the nurses’ first month on the job, it has not been found necessary since then except in rare instances. This is in part because the nurses rapidly became proficient in radial arterial punctures and because they do not hesitate to puncture the brachial or femoral arteries. Under ordinary circumstances the blood can be obtained in less than two minutes. From November, 1969 to April, 1970, 1,541 arterial punctures were carried out by nursing personnel. These included: 1,347 radial artery, 127 brachial and 67 femoral. During an episode of respiratory failure, 24 serial arterial blood samples were drawn from one patient without morbidity. There has not been a single vasovagal reaction or morbidity except for occasional minimal superficial hematomas over the puncture site. The performance of arterial punctures by nurses is a safe and useful technic. It becomes another procedure which can be performed competently by nurses and ultimately by paramedical personnel. This is an advantage since they are available for immediate requests while the house staff is often busy with other duties. We strongly believe that local anesthesia should be employed prior to arterial puncture for two reasons: 1) it lessens the tendency of patients either to hold their breath or hyperventilate because of pain, thereby interfering with a steady state and acutely affecting the blood gas tensions, and 2) it diminishes the frequency of vasovagal reactions. However, it is important that individuals performing the puncture be trained in recognizing and treating the rare sensitivity reactions following the use of these drugs. They must also be trained to ask, prior to administration of the anesthetic, about previous reactions to “caine” type drugs, especially past reactions to dental anesthesia. Our opinion is not shared by Petty and his coworkers2Petty TL Bigelow DB Levine BE The simplicity and safety of arterial puncture.JAMA. 1966; 195: 181-183Crossref Scopus (14) Google Scholar who reported that local anesthesia was unnecessary.