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|Source: Phlebotomy Standardization Origination Date: 09/01/97 |

|Revision Date(s) w/ Initials:01/05; 02/07; 04/07; 05/08; 04/09, 05/10, 08/18/11 DZS |

| | |Signature |Date |

|X |Technical Consultant/Supervisor: | | |

|X | | | |

| |PRMC Medical Director (Dr. C. McBride) | | |

|X |PHH Medical Director (Dr. C. McBride) | | |

| | | | |

| |PWH Medical Director (Dr. C. McBride) | | |

| |PVH Medical Director (Dr. S. Lee) | | |

| | | | |

| |PLH Medical Director (Dr. Y. Zhuang) | | |

| |PNH Medical Director (Dr. B. Cobanov) | | |

I. PRINCIPLE

Arterial puncture will be done only to obtain specimens that require arterial blood, or if specific orders for an arterial puncture are requested by a physician.

II. SPECIMEN REQUIREMENTS AND COLLECTION METHOD

A. CRITERIA FOR SITE OF ARTERIAL PUNCTURE:

Arterial puncture may cause vessel spasm, intraluminal clotting, bleeding with the formation of a periarterial clot (hematoma). Important consideration in choosing arterial puncture sites should be the potential collateral (alternative) blood flow available in the event the artery becomes obstructed. It is easier to palpate, stabilize, and puncture a superficial artery than a relatively deep one. Superficial arteries are found at the distal ends of the extremities. Laboratory personnel are strictly limited to radial artery puncture.

B. RADIAL ARTERY PUNCTURE:

The radial artery at the wrist meets the above criteria as being the safest and most accessible site for arterial puncture. The vessel is located superficially at the wrist and not adjacent to large veins. The collateral circulation is usually adequate via the ulnar artery.

C. THE ALLEN’S TEST:

This is a simple, clinically reliable maneuver for assessing collateral circulation in the hand. The hand is closed tightly to form a fist, which will force as much blood from the hand as possible. Pressure is then applied directly at the wrist, compressing and obstructing both the radial and ulnar arteries. The hand is then relaxed (but not fully extended), revealing a blanched palm and fingers. Release pressure from the ulnar artery while the palm, fingers and thumb are observed. They should become flushed within 15 seconds as the blood from the ulnar artery refills the empty capillary beds. The flushing of the entire hand confirms that the ulnar artery alone is capable of supplying the entire hand with blood since the radial artery is still occluded. This result constitutes a positive Allen’s Test. If the test is not positive, try the other arm. Do not proceed unless the Allen’s Test is positive.

1. Modified Allen's Test:

If the patient is unconscious or uncooperative the Allen's test should be performed as follows:

a. Compress both the ulnar and radial at the wrist to obliterate pulses.

b. Squeeze the patient’s hand until blanching occurs.

c. With the radial artery still compressed, release pressure on the ulnar artery, and watch for the return of color to the hand within 15 seconds.

D. PATIENTS WHO FAIL THE ALLEN’S TEST:

1. Supervisor is to verify that a patient has failed the Allen’s Test.

2. The nurse in charge of the patient is to be notified that the gases will not be drawn by lab personnel because the patient has failed the Allen’s Test, and that respiratory will be called to obtain the specimen.

3. Label should be canceled in the lab's computer system.

E. MISSED ARTERIAL BLOOD GASES:

When arterial blood gases are ordered on a patient, any one phlebotomist or technologist may make no more than two attempts, and no more than three attempts may be made by laboratory personnel. In the event that the patient is missed three times by laboratory personnel, the Respiratory Therapy Department should be contacted to obtain the specimen. Labels should be cancelled in lab's computer system.

III. EQUIPMENT AND MATERIALS

Pre-heparinized plastic syringe that fills with arterial blood pressures (kit).

1 ½ Inch number 22-gauge needle (kit).

1-inch number 23-gauge needle (kit).

Betadine or iodophor prep pad.

Alcohol prep pad.

2”’X 2” Gauze pad.

Cap or rubber stopper.

Procedure gloves.

Plastic biohazard bag.

Patient label.

Soft label or a requisition

Ice.

Needle safety Device

IV. PROCEDURE

A. ARTERIAL BLOOD GAS

1. Prior to entering the room, obtain ice and place in plastic biohazard bag.

2. Identify the patient and introduce yourself to the patient. Explain the procedure.

3. Wash hands.

4. Apply gloves.

5. Check radial pulses and determine site for puncture.

6. Perform the Allen’s Test on the hand with best pulse to ensure adequate collateral circulation.

7. Assemble syringe with needle, and safety device.

8. Lubricate barrel of syringe with heparin.

9. Eject all heparin such that only the dead space of the syringe and the needle contains heparin (0.2cc). NOTE: Absolute minimum volumes are 0.5 cc when using an adult syringe and 0.2 cc when using a pediatric (tuberculin) syringe.

10. Position patient comfortably. The patient’s arm should be abducted with the palm facing up and the wrist extended to about 30 degrees to stretch and fix the soft tissues over the firm ligaments and bone. If needed, a rolled bath towel may be placed under the backside of the patient’s wrist.

11. Prep the site for puncture.

a. Scrub puncture with iodophor prep and continue in concentric circles around the site. Note: For allergies to iodine, replace with ChloraPrep.

b. Scrub the site with alcohol prep in the same manner.

c. Be certain that after cleansing, the puncture site is not touched again except with gloved fingers.

12. Palpate artery to be punctured to determine lateral borders and exact position.

13. Anchor artery by placing a finger over the artery at the point where the needle will enter the artery.

14. Holding the syringe like a dart, the skin is punctured about 5mm to 10mm distal to the finger directly over the artery using approximately a 45-degree angle of insertion with the bevel of the needle up.

15. After the needle penetrates the skin, it should be advanced slowly, aiming for the artery just beneath the finger. Observe hub of needle for blood as the needle enters the artery.

16. Allow blood to fill syringe until the plunger stops (3cc).

17. Withdraw the needle and immediately apply pressure with a gauze pad for a minimum of three to five minutes measured by the clock. (If a patient is on anticoagulants or has evidence of bleeding, ecchymosis or edema: continue pressure an additional five minutes if any of these signs are present.

18. Lock the needle protection device in place and remove needle from syringe.

19. The vent cap should then be placed over the end of the syringe. Check for air bubbles. If present, dislodge by holding syringe with vent cap upward and carefully push the air out of the syringe through the vent cap.

20. Rotate syringe gently for a few seconds to mix heparin with blood, and then place on ice. This stabilizes the specimen and minimizes the oxygen consumption that causes metabolic changes in the sample.

21. Check puncture site, apply bandage, taking care not to occlude the radial artery.

22. Label specimen according to the Patient Identification, Specimen Collection, Labeling and Testing procedure (#4213), including oxygen level and patient’s current temperature, if it is greater than 99.6 or if less than 97.6.

23. Documentation should be made of: Allen's Test - positive or negative, length of time pressure held, and the site of collection. This label should be placed in the ledger located in phlebotomy and is stored for 2 years.

24. Deliver the specimen to the laboratory.

B. CAPILLARY BLOOD GAS

1. Perform a capillary puncture according to the Specimen Collection by Skin Puncture procedure (#3632).

2. The site must be properly warmed prior to puncture. This increases arterial blood flow to the site up to sevenfold reducing the difference between the arterial and venous gas pressures. Inadequate warming of the site prior to the puncture will result in unreliable values.

3. Fill two Radiometer safeCLINITUBES without allowing air bubbles to enter tube.

4. Place one small magnetic stirring bar (flea) in each of the safeCLINITUBES.

5. Place capillary caps (red caps) on both ends of each safeCLINITUBE.

6. Slowly rotate each safeCLINITUBE allowing the small magnetic stirring bar (flea) to fall to each end approximately five times. This ensures proper mixing of the blood with the heparized safeCLINITUBES.

7. Place safeCLINITUBES in a red top vacuum tube and label according to the Patient Identification, Specimen Collection, Labeling and Testing procedure (#4213). NOTE: Labeling should include the patient’s oxygen level and temperature.

8. Place specimen on ice and transport to lab immediately.

C. VENOUS BLOOD GAS

1. Prior to entering the room, obtain ice and place in plastic biohazard bag.

2. Identify the patient and introduce yourself to the patient. Explain the procedure.

3. Wash hands.

4. Apply gloves.

5. Assemble syringe with needle:

6. Lubricate barrel of syringe with heparin.

7. Eject all heparin such that only the dead space of the syringe and the needle contains heparin (0.2cc).

8. Perform venipuncture according to the Blood Collection procedure.

9. Allow blood to fill syringe until the plunger stops (3cc). NOTE: Absolute minimum volumes are 0.5 cc when using an adult syringe and 0.2 cc when using a pediatric (tuberculin) syringe.

10. Withdraw the needle and immediately apply pressure with a gauze pad or cotton ball until bleeding has ceased. (If a patient is on anticoagulants or has a site for evidence of bleeding, ecchymosis or edema: continue pressure an additional five minutes if any of these signs are present.

11. Lock the needle protection device in place and remove needle from syringe.

12. The vent cap should then be placed over the end of the syringe. Check for air bubbles. If present, dislodge by holding syringe with vent cap upward and carefully push the air out of the syringe through the vent cap.

13. Rotate syringe gently for a few seconds to mix heparin with blood, and then place on ice. This stabilizes the specimen and minimizes the oxygen consumption that causes metabolic changes in the sample.

14. Check puncture site, apply bandage.

15. Label specimen according to the specimen labeling procedure, including oxygen level and patient’s current temperature, if it is greater than 99.6 if it is greater than 99.6 or if less than 97.6.

16. Deliver the specimen to the laboratory.

V. LIMITATIONS OF PROCEDURE:

A. Laboratory personnel should not draw children under the age of three; Respiratory Care should be called to obtain the specimen.

B. Artery may be inaccessible due to periarterial tissues (overlying muscle, connective tissue, or fat).

C. Arteriopspasm may preclude collection despite successful introduction of needle into artery.

D. Arterial blood specimens withdrawn from the body only reflect the physiologic condition at the moment of sampling (e.g. Pain from the puncture, itself may lead to hyperventilation with consequent changes in values).

E. Patients who have had changes in the Fio2 should wait at least 20 to 30 minutes to achieve a steady state, before taking a blood specimen.

F. Specimens should be iced immediately and analyzed within 1-2 hours after collection. However, due to the potential affects from subjects with elevated white cell counts, samples should be sent to the lab as soon as possible to ensure the integrity of the sample.

G. Pulse may not be palpable.

H. The phlebotomist should check with the nurse to assure the patient should be drawn with or without oxygen. (Many times, the doctor will request the patient have their oxygen removed for a specified amount of time to evaluate their blood gas on room air or at a specific oxygen level.)

I. Patient's in ICU, CCU, or with Trauma/Medical team activates, that require multiple tubes be drawn, are permitted to be drawn with a single stick from the artery using vacuum tubes. The rest of the hospital should be drawn twice, with a single ABG syringe and venipucture for the vacuum tubes. NOTE: Drawing a green tube as the specimen type when using vacuum tubes for an ABG is only permissible during Medical/Trauma Team activates and should only be considered as a last resort.

J. Patient’s experiencing adverse reactions such as fainting, nausea, vomiting, seizures or cardiac arrest should refer to Procedure #3652, Patient Adverse Reactions.

VI. REFERENCES

Procedures for the Collection of Arterial Blood Specimens; Approved Standard-Fourth Edition. CLSI (Clinical Laboratory Standards Institute). September 2004.

Procedures for the Collection of Diagnostic Blood Specimens by Venipuncture; Approved Standard – Sixth Edition. CLSI (Clinical Laboratory Standards Institute). 2007.

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