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Chapter 15 ■ Arterial Puncture 97

Fig. 15.3. Anatomic relations of the posterior

tibial artery.

Fig. 15.4. Anatomic relations of the

dorsalis pedis artery.

3. The effectiveness of the modified Allen test (described

below) for assessing the adequacy of collateral supply

to the hand has not been adequately studied in neonates and suffers from poor interobserver reliability.

Transillumination is a valuable adjunct and use of

ultrasound has also been reported (11).

a. Elevate infant’s hand.

b. Occlude both radial and ulnar arteries at wrist.

c. Massage palm toward wrist.

d. Release occlusion of ulnar artery only.

e. Look for color to return to hand in <10 seconds,

indicating adequate collateral supply.

f. Do not puncture radial artery if color return takes

more than 15 seconds.

4. Puncture the skin at the level of proximal crease and

penetrate artery at 15 to 30 degrees with bevel up.

5. See F, “General Principles.”

Posterior Tibial Puncture

1. Locate artery by palpation or transillumination between

Achilles tendon and medial malleolus (Fig. 15.3; see

also Fig. 13.5). Puncture the artery just posterior to

medial malleolus.

2. See F, “General Principles.”

98 Section III ■ Blood Sampling

Dorsalis Pedis Puncture

1. Locate artery by palpation or transillumination on dorsum of foot between extensor hallucis longus and extensor digitorum longus tendons (Fig. 15.4). It can be

located between the first and second metatarsal in the

dorsal midfoot between the first and second toes.

2. See F, “General Principles.”

Brachial Artery Puncture

1. Locate the artery by palpation or transillumination

along the medial margin of the biceps muscle at the

bend of elbow and enter the artery at or above the level

of anterior cubital fossa.

2. See F, “General Principles.”

G. Complications (10)

See Chapter 34 for complications of arterial cannulation.

1. Distal ischemia from arteriospasm, thrombosis, or

embolism

2. Infection (rare)

a. Osteomyelitis (12)

b. Infected hip joint after femoral puncture (12)

3. Hemorrhage or hematoma

4. Nerve damage (13)

a. Median nerve (brachial artery puncture)

b. Posterior tibial nerve

c. Femoral nerve

5. Extensor tendon sheath injury, resulting in “false cortical thumb” (14)

6. Pseudoaneurysm following brachial artery puncture (15)

References

1. Smith AD. Arterial blood sampling in neonates. Lancet. 1975;

1:254.

2. Shaw JC. Arterial sampling from the radial artery in premature

and full-term infants. Lancet. 1968;2:389.

3. Okeson GC, Wulbrecht PH. The safety of brachial artery puncture for arterial blood sampling. Chest. 1998;114:748.

4. Bull MJ, Schreiner RL, Garg BP, et al. Neurologic complications

following temporal artery catheterization. J Pediatr. 1980;96:1071.

5. Simmons MA, Levine RL, Lubchenco LO, et al. Warning: serious sequelae of temporal artery catheterization. J Pediatr. 1978;

92:284.

6. Acharya AB, Annamali S, Taub NA, et al. Oral sucrose analgesia

for preterm infant venipuncture. Arch Dis Childhood Fetal

Neonatal Ed. 2004;89:F17.

7. Stevens B, Yamada J, Ohlsson A. Sucrose for analgesia in newborn infants undergoing painful procedures. Cochrane Database

Syst Rev. 2004;(3):CD001069.

8. Wall PM, Kuhns LR. Percutaneous arterial sampling using transillumination. Pediatrics. 1977;59:1032.

9. Noreng MF. Blood flow in the radial artery before and after arterial puncture. Acta Anaesthesiol Scand. 1986;30:281.

10. Gillies ID, Morgan M, Sykes MK, et al. The nature and incidence of complications of peripheral artery puncture. Anaesthesia.

1979;34:506.

11. Barone JE, Madlinger RV. Should an Allen test be performed

before radial artery cannulation? J Trauma. 2006;61:468.