Microsoft word - arterial ta.doc

Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. Arterial Puncture
Basic procedure for any diagnostic angiogram Gowned up – trolley prepared – patient ready (both femoral pulses checked). Patient’s Equipment required
Angiographic catheter wire (which selected depends on procedure) in container 20ml syringe (saline) (see saline prep. algorithm) Two 2ml syringes (heparin 1000 units per ml) – used to anticoagulate the blood, not used in this part of procedure but would be on trolley Sponge holder forceps (used to check positioning using image intensifier and to hold Green needle (longer and larger calibre than orange needle) 3 silver fluid containers (1 contrast, 1 antiseptic and then waste, 1 for saline) Clip (to attach wire container to sheet) Sterile green sheets (two small, one large, one split sheet). Sterile cover for intensifier (shower cap) Saline (500ml normal saline) – see saline prep. algorithm Sharps pad (for sharps safety; blade placed into pad) Dressing (an adherent, transparent film) or towel clip Paper bag (for used surgical tools which are returned for sterilisation If there is an assistant for the procedure some of these steps can be completed by the Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement.
Steps included in the Arterial Puncture Task Analysis
1. Pre-procedure
2. Cleaning Incision site
3. Sterile sheets
4. Preparing Image Intensifier
5. Select syringe
6. Preparation of syringe
7. Draw up local
8. Ensure there are no bubbles in the syringe
9. Wire preparation
10. Locating femoral artery
11. Injecting local anaesthetic
12. Incising skin
13. Preparing for Puncture
14. Puncturing artery
15. Inserting wire
Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. 1. Pre-procedure
Yes go to next step
Yes (consider using this side if
No (reduced or absent pulse may
indicate a different procedure is required for imaging, or intervention or that it is a artery as a tube and go blindly or go to upstream lesion suspected if there is bear Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. 2. Cleaning Incision site
2.2. Fold swab over so it is small enough to be placed in forceps 2.5. Using forceps soak swab in antiseptic by placing it in pot holding antiseptic 2.6. Pick up pot and take pot, forceps (with swab) over to the patient 2.7. Clean the planned incision site with antiseptic soaked swab 2.8. If necessary, place a clean swab in the patient’s groin area (this prevents the antiseptic running into this area which is very painful) 2.9. Pour small amount of antiseptic from pot onto patient and dab / wipe with Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. 3. Sterile sheets
3.1. Position sterile sheets and sterile split sheet over patient so incision site is 3.2. Is the split sheet in a secure position for the procedure? Yes – go to next step
No – Secure sheets using a towel clip or adherent dressing from trolley:
remove backing and use to fasten green split sheet in position Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. 4. Preparing Image Intensifier
4.1. With help from assistant place sterile cover (shower cap) over image 5. Select Syringe
6. Preparation of syringe
Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. 7. Draw up Local Anaesthetic
7.1. Attach green needle to local syringe (a green needle is used to draw up local as it is a larger calibre than the orange needles and fluid flow is more rapid) 7.2. Request local anaesthetic from assistant 7.3. With an assistant both read out the contents of the vial and the use by date (to 7.4. Request assistant take the top off the vial 7.5. Request assistant hold the vial almost horizontal with the top of the vial 7.7. Move the neck of the vial downwards with the needle so the neck of the vial 7.8. Draw up local (pull back on syringe). Is there enough local in the syringe? Yes (go to step 8.1)
No (repeat steps 7.2 to 7.8)
Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. 8. Ensure there are no bubbles in the syringe
NOTE - Air can be dangerous if injected into a vessel 8.1. Tap and oscillate the syringe to allow bubbles to float to the surface of the 8.2. Hold syringe with needle pointing up 8.3. Press plunger on syringe until all air is evacuated (surface of the liquid reaches top of syringe or liquid comes out of syringe.) 8.4. Remove green needle from syringe and place on sharps pad 8.5. Select orange needle and place on syringe (this needle is thinner and therefore Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement.
9. Wire Preparation

NOTE - this step is included for illustration purposes since wire preparation will often
depend on the type of wire selected for use in the procedure 9.1. Select angiographic catheter wire from trolley 9.2. Does the wire need flushing through? Yes – flush wire through with saline (to ensure there is no air in it, and to put
saline in the wire to reduce the risk of clotting) No –go to step 9.3
9.3. Ensure wire is easily accessible by either coiling the wire (if not already coiled in a case) and replacing on the trolley or laying the wire out on the green sheet covering the patient. Take care to keep wire sterile. Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. 10. Locating femoral artery
Pick up 5ml local anaesthetic syringe and place on sheet covering patient (to ensure it is easily accessible when required) Palpate patient to locate anterior superior iliac spine and pubic tubercle (to find inguinal ligament to mark the mid point where the external iliac artery becomes the common femoral artery. The common femoral artery must be located initially by palpation to do the puncture). Feel carefully for pulsations in artery. Is it located ok? Yes (go to step 10.9) No (go to step 10.4)
Place metal marker in region of proposed incision site Ask radiographer to move the image intensifier into position over Screen using foot pedal (see exposing fluoroscopy algorithm) Use picture on screen to relate marker to anterior superior iliac spine, pubic tubercle, femoral head and any vascular calcification. Feel in correct anatomical location for pulsation of the femoral artery. Yes (go to step 10.9)
No – possible reasons are; (a) calcification (b) obese patient (c)
scarring of groin (d) upstream obstruction. (repeat step 10.4, other possibilities include ultrasound, blind puncture, feel the artery as a tube, use x-ray image to identify calcium deposits in artery – cross over methods with contrast and roadmap). If unable to locate artery this is a complex case Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. Feel more proximal and distal to the strongest palpable arterial pulsation to ascertain the direction of the artery Locate the centre line of the artery by feeling both the medial and Position fingers to fix artery with fingers on either side of vessel (the aim is to puncture into mid line of artery). Complications of not puncturing the mid line of the artery; (a) guide wire entering into wall of artery rather than travelling along the artery (b) occlusion of artery (c) damage of artery Press down with fingers (especially in large / obese patients in order to displace fat and get closer to the artery, pressing too hard may result in occluding (blocking) the artery and loss of the pulse) Yes (go to step 11.1)
No (complex case)
Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. 11. Injecting local anaesthetic
NOTE - use palpation of the pulse to identify the location. Local anaesthetic should be injected approx 2cms below where you plan to puncture artery (this ensures you can get approximately a 45 degree angle when doing arterial puncture). (This varies with physical size of patient - in obese patients the needle is inserted further away from the planned arterial puncture site to ensure the artery can be reached with the needle still at approx. a 45 degree angle – i.e. need to gauge the entry point of the needle to ensure the mid third of the artery is reached. The distance the needle has to travel from the skin to the artery will determine the site of the entry point). Great care must be taken in choosing entry site as if you overshoot with the arterial needle the back wall of the artery may be punctured above the inguinal ligament which can lead to very serious complications / retroperitoneal haemorrhage. Pick up local syringe (with orange, i.e. short 23g needle) Position needle over planned incision site Insert needle of syringe very superficially (intra-epidermal injection) Aspirate with needle (if you get blood this indicates the needle is in a vessel, do not inject local into vessel). Is there blood? Yes (pull back and adjust needle slightly and repeat step 11.4)
No (go to step 11.5)
Inject local (this produces a bleb on skin which looks like a nettle sting Insert needle at a shallow angle a little further into skin Aspirate with needle (if you get blood this indicates the needle is in a vessel, do not inject local into vessel). Is there blood? Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. Yes (pull back and adjust needle slightly and repeat step 11.7)
No (go to step 11.8)
Inject local (forms a larger weal on the skin) Slowly advance needle into subcutaneous tissue Aspirate with needle (if you get blood this indicates the needle is in a vessel, do not inject local into vessel). Is there blood? Yes (pull back and adjust needle slightly and repeat step 11.11)
No (go to step 11.12)
Repeat steps 11.9 to 11.12 until required amount of local has been injected or you reach the extreme of the needle Remove syringe (needle remains in skin, as a marker for site of local Yes - select longer needle (green) from trolley and place on syringe
No – go to next section
Insert green needle next to orange needle (which is marking position) Repeat steps 11.9 to 11.12 until required amount of anaesthetic has Remove syringe (with green needle attached) Place green needle with syringe attached into sharps pad. Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. 12. Incising Skin
NOTE – 2 to 3mm nick, made by putting blade in skin and then moving the blade upwards (this prevents the risk of puncturing the artery with the blade). The orange needle is still in position to provide a marker. This nick reduces the friction of the skin Wait for the local to work (approx 2 minutes) Select blade and sharps pad from trolley Remove orange needle from skin and place on sharps pad Press gently on skin with blade at planned incision site to check no Yes (inject more local, subjective decision, Section 11)
No (go to step 12.5)
Is there a risk of damaging a vein or artery whilst making incision? Yes - keeping blade resting on site of planned entry site retract skin
laterally by 1 to 2cms (moves skin away from vein or artery while nicking to reduce the risk of cutting into the vein or artery) No – go to next step
If skin was retracted allow it to fall back Pick up swab from the trolley and wipe the incision site to clean away Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. 13. Preparing for Puncture
Move wire container close to incision site to allow early location and insertion once artery has been punctured Remove 12-15 cms of wire and place the tip of the wire near the incision site, if a j wire has been selected for the procedure move the torpedo to the end of the j wire thus straightening the j out prior to insertion in needle Hold in place in hand near incision site Ensure incision site is clean. Is it clean? Yes (go to step 14.1)
No (clean incision site with swab and go to step 14.1)
Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. 14. Puncturing artery
Position vascular access needle on incision site – between 2 fingers pressing down (see step 10.11), Bevel uppermost (see holding a vascular Insert needle through the nick in the skin at a 45 degree angle towards artery (with the orifice on the bevel of the needle pointing upwards and Feel the artery pulsation using non needle holding hand and align the Is there any indication from patient that more local anaesthetic is Yes (inject more local through arterial puncture needle and go to step 14.6)
No (continue to step 14.6)
Feel for the artery pulsating through the needle. Can you feel Yes (indicates near artery, go to step 14.7)
No (reposition needle and repeat step 14.6)
(a) A sharp stab (but taking care not to travel too far with the needle and puncturing both walls of the artery) to ensure artery is penetrated and (b) Gently increase pressure until the artery wall is pierced. Does blood spurt out – i.e. a jet of blood travelling 0.5 to 2 feet from needle? (note - how far a jet of blood will travel is determined by calibre of needle, Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. also the jet of blood may be reduced if there is low blood pressure or Yes (artery punctured go to step 14.8)
No – is there darker, slow
Yes – vein puncture,
No – complex case
Immediately but gently decrease angle between needle and patient (the needle will therefore be pointing up the artery and more aligned with the blood flow). Is there still a jet of blood? Yes – indicates still in artery (go to step 15.1)
No (Incorrect
Yes – indicates in artery
Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. No – withdraw the needle
Yes – indicates in
No – withdraw
Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. 15. Inserting wire
Hold needle in place tilted downwards (i.e. reducing angle between patient and needle to ensure wire travels down artery and does not hit Begin to insert wire into hub of needle. Is there any resistance? If you are unsure, consider screening during insertion to ensure wire is following Yes = complex case (indicates a potential complication, (a) atheroma
plaque: angle needle medial / lateral to avoid (b) only part wall thickness traversed: advance needle until flow increases (c) needle has passed through both walls due to low pressure: withdraw slowly and inspect for jet), consider using fluoroscopy to assist procedure No (insert sufficient wire, checking for any
resistance throughout the procedure, – remove the wire from the container prior to insertion to prevent the friction of the wire in the container being confused with any friction / resistance in the artery. This can be achieved by either (a) removing all wire from the container prior to insertion – taking care to ensure the wire remains on sterile surface (b) taking wire out of Increase pressure on incision site with palpating hand to prevent Hold wire to prevent any movement in wire Arterial Puncture TA, Sheena Johnson, University of Liverpool The authors give permission for this work to be used by others with appropriate acknowledgement. Move torpedo (scud) and needle along wire away from the patient Wipe wire with wet swab to ensure no micro bubbles / thrombus (clots) on wire (to keep the wire clean) Coil the wire up near the incision site to enable the full length of the wire to be cleaned and the needle and torpedo be fully removed Place needle on sharps pad and discard the torpedo Is a sheath or a catheter to be inserted? Catheter (go to inserting a catheter algorithm)
Sheath (go to
inserting a sheath into an artery algorithm)

Source: http://www.hpv.cs.bangor.ac.uk/CRaIVE/arterial%20puncture%20task%20analysis.pdf