sitioned for puncture of external jugular vein. b. Pneumothorax/subcutaneous emphysema

94 Section III ■ Blood Sampling

c. Interference with ventilation due to positioning

d. Raised intracranial pressure to head-down position

aggravating intraventricular hemorrhage

6. During scalp vein puncture

a. Laceration of artery

b. Corneal abrasion or other eye damage if rubber

band used improperly

References

1. Baral J. Use of a simple technique for the collection of blood from

premature and full-term babies. Med J Aust. 1968;1:97.

2. Kayiran SM, Ozbek N, Turan M, et al. Significant differences

between capillary and venous complete blood counts in the neonatal period. Clin Lab Haematol. 2003;25:9.

3. Shah VS, Ohlsson A. Venepuncture versus heel lance for blood

sampling in term neonate. Cochrane Database Syst Rev. 2011;

(10):CD001452.

4. Biran V, Gourrier E, Cimerman P, et al. Analgesic effects of

EMLA cream and oral sucrose during venepuncture in preterm

infants. Pediatrics. 2011;128(1):e63.

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

Syst Rev. 2004;(3):CD001069.

6. Ogawa S, Ogihara T, Fujiwara E, et al. Venepuncture is preferable to heel lance for blood sampling in term neonate. Arch Dis

Child Fetal Neonatal Ed. 2005;90(5):F432.

7. Plaxico DT, Bucciarelli RL. Greater saphenous vein venipuncture in the neonate. J Pediatr. 1978;93:1025.

8. Ramasethu J. Complications of vascular catheters in the neonatal

intensive care unit. Clin Perinatol. 2008;35:199.

9. Gamba P, Tchaprassian Z, Verlato F, et al. Iatrogenic vascular

lesions in extremely low birth weight and low birth weight neonates. J Vasc Surg. 1997;26(4):643.

10. Kantr RK, Gorton JM, Palmieri K, et al. Anatomy of femoral vessels in infants and guidelines for venous catheterizations.

Pediatrics. 1989;33:1020.

11. Asnes RS, Arendar GM. Septic arthritis of the hip: a complication

of venipuncture. Pediatrics. 1966;38:837.

95

Ashish O. Gupta

15 Arterial Puncture

A. Indications (1,2)

1. Sampling for arterial blood gas determination

2. Sampling for routine laboratory test when venous and

capillary sampling are not suitable or unobtainable

3. Sampling for ammonia, lactate, or pyruvate level

4. To obtain a large quantity of blood

B. Contraindications

1. Coagulation defects, thrombocytopenia

2. Circulatory compromise in the extremity

3. Inappropriate artery

a. Femoral artery

b. Use of radial artery if collaterals are inadequate (see

Allen test below)

c. Ulnar artery (poor collaterals)

4. Infection and/or inflammation in sampling area

5. When cannulation of that vessel is anticipated

6. Use of peripheral arteries on the ipsilateral arm in an

infant with congenital heart disease requiring a shunt

via the subclavian artery

C. Precautions

1. Perform arterial sampling only when venous or capillary sampling is inappropriate or unobtainable.

2. Use smallest possible (23- to 27-gauge) needle to

minimize trauma to vessel and to prevent hematoma

formation.

3. Avoid laceration of the artery caused by puncturing

both sides of arterial wall in exactly opposite locations.

4. Remove excess heparin and air bubble from the blood

gas syringe. If a small bubble gets into the sample, point

the top of the syringe up, expel the air bubble immediately, and cap syringe.

5. Guarantee hemostasis at the end of the procedure.

Pressure must be applied even if an attempt is unsuccessful or results in an inadequate sample.

6. Check distal circulation after puncture.

a. Arterial pulse

b. Capillary refill time

c. Color and temperature

7. Take action to reverse arteriospasm, if necessary. (See

Chapter 34.)

D. Selection of Arterial Site

1. Peripheral site preferred.

2. Radial artery preferred if ulnar collateral intact.

3. Posterior tibial artery satisfactory.

4. Dorsalis pedis artery is often small or absent, but may

be accessible in some infants.

5. Brachial artery only if indication is urgent and peripheral arterial or umbilical artery access is not available

because of risk of injury to the adjacent median nerve,

and the risk of ischemia due to the absence of collaterals at this site (3).

6. Temporal artery should be avoided because of risk of

neurologic damage (4,5).

7. Ulnar artery should be avoided because of the risk of

impaired circulation to the hand due to poor collateral

circulation or damage to the ulnar or the median nerve.

E. Equipment

1. Sterile gloves

2. Sterile needle

a. A 23- to 25-gauge venipuncture needle, preferably a

safety-engineered needle

b. A butterfly needle with extension tubing is often

easier to use

3. Appropriate syringes, including a preheparinized blood

gas syringe

4. Povidone–iodine solution and alcohol prep pads or

wipes for minor skin preparation

5. Gauze pads

6. High-intensity fiberoptic light for transillumination

(optional) and a sterile glove to cover (see Chapter 13)

7. Oral sucrose solution (24% to 25%) or eutectic mixture

of local anesthetics for pain control, if possible (6,7).