Guidelines for Undertaking Radial Artery Puncture

See also - Percutaneous Arterial Cannulation and Radial Artery Puncture Learning guide and Competency standard statements for registered nurses and clinical practitioners

1. Introduction and background
2. Scope
3. Evidence review
4. Requisites for clinical practitioners undertaking radial artery puncture
5. Training and supervision
6. Consent
7. Contraindications for radial artery puncture
8. The Procedure

1. Introduction and background

The main indication for radial artery puncture is to investigate arterial blood gas and acid-base balance. It is usually carried out in an emergency situation as an aid to diagnosis or to evaluate response to oxygen therapy/ventilation in patients with acute respiratory failure.
The radial artery is the most commonly used site for puncture and sampling because it is almost always superficial, readily palpable, associated with a low incidence of complications, and usually has good collateral circulation.

Back to top

2. Scope

These guidelines are aimed at clinical practitioners who are required, as part of their role, to undertake radial artery puncture in acutely/critically ill adult patients. The term clinical practitioners refer to registered nurses, operating department practitioners/assistants and allied health professionals. Registered nurses must adhere to the recommendations set out in The Code: Professional standards of practice and behaviour for nurses and midwives (Nursing and Midwifery Council, 2018).  Operating department assistants/practitioners and allied health professionals must work in accordance with their relevant codes of practice.

Back to top

3. Evidence review

These guidelines should be read in conjunction with the guidance set out in Latto et al’s (2000) text entitled Percutaneous Central Venous and Arterial Catheterisation, which provides the evidence base for the procedure, general considerations and potential complications.

Back to top

4. Requisites for clinical practitioners undertaking radial artery puncture

Before undertaking radial artery puncture training clinical practitioners must:

• Be assessed and deemed competent to perform aseptic technique.
• Demonstrate competence in venepuncture and venous cannulation.
• Demonstrate knowledge of arterial blood gas analysis and implications for individual patient management.
• Work in clinical areas where the adjustment of practice is agreed by the line manager/matron.
• Discuss their intentions to undertake arterial cannulation with their line manager/matron in order to determine appropriateness and suitability for training.

Back to top

5. Training and supervision

The following apply:

• A clinical supervisor, who is competent in radial artery puncture, must supervise overall development and training.
• Supervised practice must be provided by a doctor or a clinical practitioner competent in radial artery puncture.
• A training log of each radial artery puncture must be maintained for audit purposes.
• Competence must be assessed against the competency standard statements set out in the Percutaneous Arterial Cannulation and Radial Artery Puncture Learning Guide and Competency Standard Statements (LTHT 2020) either by a doctor or a clinical practitioner competent to perform radial arterial puncture and who also has a recognised teaching and assessing qualification, before unsupervised practice is undertaken.
• A copy of the witness statement and competency standard statements, thus verifying competence, must be retained in the clinical practitioner’s personal portfolio and by the line manager/matron

Back to top

6. Consent

Wherever possible, informed consent should be obtained from the patient or the procedure explained to a close relative before undertaking radial artery puncture.  However, this is not always practicable in critical care units. When consent cannot be obtained, implied consent is assumed because the procedure is regarded as necessary for the patient’s continued well-being, in accordance with The Mental Capacity Act (OPSI 2005).

Back to top

7. Contraindications for radial artery puncture

• Patients with severe peripheral vascular disease
• Patients receiving warfarin or intravenous heparin where PT>72 seconds or INR >2.2
• Patients receiving thrombolytic therapy, for example, streptokinase
• Platelet counts of <50 x 10⁹ /L
• History of coagulation disorder such as haemophilia
• Profound hypotension with weak or absent radial pulse
• Previous surgical treatment of the artery, especially if a synthetic graft has been used.
• Arteriovenous fistulae that have been fashioned for haemodialysis (may become thrombosed or infected from arterial cannulae on the same limb).
• Conditions that affect the patency and reactivity of small arteries such as Buerger’s disease and Raynaud’s disease.
• Presence of infection near the puncture site.

Back to top

8. The Procedure

Clinical practitioners who have undergone supervised training and have been assessed as competent may undertake radial artery cannulation and must adhere to the following:

• Confirm the need for radial artery puncture with a member of the patient’s clinical team.
• Undertake a maximum of three attempts at each site
• Seek guidance from senior medical staff if there are concerns about the adequacy of the collateral flow.
• Limit the procedure to adults in the designated areas in which scope of practice is to be adjusted.
• Make a record in the medical case notes of the date, time, technique used, site of puncture, number of attempts, the use of lignocaine, and any untoward incidents (that must also be documented in accordance with Trust policy) and the blood gas results
• Lignocaine 1% 1-2 ml (3mg/kg), if required, must be prescribed or administered according to a patient group direction.
• Undertake only radial artery puncture
• Undertake the procedure in accordance with The Leeds Teaching Hospitals Percutaneous Arterial Cannulation and Radial Artery Puncture Learning Guide and Competency Standard Statements (LTHT 2020)

Asepsis
All practitioners must have current up to date hand hygiene and asepsis training

• Hands must be decontaminated according the LTHT Hand Hygiene Policy (2019).
• The procedure must be carried out following the Trust Asepsis Policy (LTHT 2019)
• Appropriate PPE should be worn at all times
• A sterile dressing pack should be opened onto a clean trolley and all sterile equipment assembled on the sterile field. The sterile towel from the pack should be placed under the area where the arterial line will be inserted.  
• Visibly soiled skin should be cleaned with soap and water prior to decontamination. 
• The patient’s skin should be decontaminated using a 2% chlorhexidine in 70% alcohol isopropyl solution.
  Sterile gloves should be worn and a sterile dressing pack used.
  An aseptic technique must be adopted throughout the procedure.  
• Standard infection prevention and control precautions should be followed (2019). 
• All sharps should be disposed of at point of use.