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Three Part Question

In [patients requiring an arterial blood sample] is [brachial artery puncture] a [safe procedure]?

Clinical Scenario

A 75-year-old man with a known history of chronic obstructive pulmonary disease and type 2 respiratory failure presents to the emergency department with a 2 day history of productive cough and shortness of breath. There are no signs of cardiovascular shock. He refuses radial arterial blood gas sampling due to pain and discomfort from previous attempts and asks whether an alternative site for sampling can be used. You ask a colleague who recommends the brachial artery—a vessel you have avoided in the past having been told that distal ischaemia can result. You wonder whether your worries are evidence based.

Search Strategy

Ovid MEDLINE(R) 1946 to July Week 1 2013:
(brachial artery puncture.af. or brachial artery sampling.af. or brachial artery blood gas.af). limit to humans and English language 30 records.

Using multi-file searching via the NHS Evidence interface: Embase 1980—date of searching 13 July 2013, Cinahl 1981—date of searching 13 July 2013: ‘brachial artery puncture’.af. or ‘brachial artery sampling’.af. or ‘brachial artery blood gas’.af

Search Outcome

Forty-seven unique papers were found across the three databases. Only one paper conducted a comprehensive study on the safety of the procedure. Eight further relevant papers provided case reports only.

Relevant Paper(s)

Author, date and country	Patient group	Study type (level of evidence)	Outcomes	Key results	Study Weaknesses
G.C.Okeson and P.H.Wulbrecht September 1998 U.S.A	6185 adults. 49% female, 51% male. Age range 18–94 years. 75% were outpatients, 21% were from general inpatient wards and 4% from the intensive care unit	Prospective Cohort Study.	Overall number of complications	127 (Incidence = 0.2%)	The study does not identify whether complications were more associated with those with signs of cardiovascular shock. The technicians who performed arterial punctures are more experienced than most at performing this technique
			Immediate pain or parasthesia	66 (0.11%)
			Delayed pain or parasthesias	57 (0.09%)
			Haematoma formation	4 (0.0006%)

Comment(s)

It is a commonly held belief that the anatomy of the brachial artery precludes its use for arterial blood gas sampling due to the possible risk of median nerve damage and peripheral ischaemia of the hand. However, it is sometimes preferred over radial artery sampling as it may be both technically easier to perform and associated with less patient discomfort. The study above was associated with a low incidence of complications with this procedure and all complications resolved spontaneously and with no permanent deficit. Case reports in the literature do however cite the following serious complications: a false aneurysm of the artery or haematoma of the forearm causing median nerve compression; direct damage to the median nerve itself; acute peripheral ischaemia of the hand; and forearm compartment syndrome. However, a number of these reports also identify both concurrent anticoagulant use and the presence of cardiovascular shock as possible contributing factors. A further study exploring complications of brachial artery puncture, inclusive of patients on anticoagulants and/or with signs of shock, would provide a clearer picture of the overall safety profile of this procedure.

Clinical Bottom Line

Brachial artery puncture is likely to be safe in the non-shocked patient who is not on concurrent anticoagulant therapy.

References

1. Okeson GC, Wulbrecht PH. The Safety of Brachial Artery Puncture for Arterial Blood Sampling Chest Journal 1998; 114:748-751