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Arterial Punctures by Inhalation Therapy Personnel
83
ARTERIAL PUNCTURES BY INHALATION THERAPY PERSONNEL pulmonary function."·'·"·!' Samson's" patient who underwent repair 15 years after rupture had pulmonary function studies done three years after repair and these showed that the vital capacity of the reimplanted lung was only 50 percent of the opposite lung and the oxygen consumption 20 percent of the opposite lung." These studies would suggest that repair of the lesion as soon as it is feasible is best, not only to ensure more complete recovery of function, hut also to prevent irreversible fibrosis or pulmonary infection. The latter is more likely to occur when the bronchial rupture has been incomplete, as complete rupture seems to protect the atelectatic lung from infection, probably by excluding it from communication with the proximal airway. Since incomplete rupture very frequently leads to an intractable stricture," its early detection and repair are equally urgent, primarily to prevent pulmonary suppuration-the only indication for removal of the lung. Thus, in the absence of pulmonary suppuration, repair of the bronelms, even 15 years after the injury, will always be rewarded by some, albeit incomplete, return of lung function. ~lr. R. F. Irvine, Supervisor, Medical Photography, Queen's University for photographic prints.
ACKNOWLEDG~IENT:
REFERE:'\CES
Ballenger FP, Watkins TK, Brisbin HL: Bronchial [raetun': a case report with review of the literature. Military \led 132:993, 1967 2 Paulson DL: Traumatic hronchial rupture with plastic repair. J Thorac Surg 22:636, 19.'51 3 Mahaffey DE, Creech 0, Borden HG, et al: Traumatic rupture of left main bronchus successfully repaired eleven years after injury. J Thorac Surg 32:312, 19.'56 4 Wiesel \V, Jake RJ: Anastomosis of right bronchus to trachea forty-six days following complete bronchial rupture from external injury. Ann Surg 137:220, 19.'53 .'5 Katz RI, Briggs IN: Traumatic ruptured bronchus and injury of major thoracic vessels. Ann Thor Surg 3:23.'5, W67 6 Samson PC: Discussion Ref. 3 J Thorac Sun; 32:312, 19.'56 7 Criffith JL: Fracture of the bronchus. Thorax 4: 10.5, Hl49 8 [ones F\V, Vinson PP: Xonfatal rupture of left main bronchus from external trauma. Surgery .'5:228, 1939 9 Stre-vey TE, Park BS, Thomas PA: Delayed repair of the ruptured left bronchus. J Thorac and Cardiovas Surg .'59:6.'38, W70 lO Hood H\I, Sloan HE: Injuries of the trachea and major bronchi. J Thorac Sunr 38:4.'58, 19.'59 II Campbell DC, Swindell HV, Dominy DE: Delayed repair of rupture of the bronchus. J Thorac and Cardiovas Surg 4:3::320. H-l62
CHEST, VOL. 61, NO.1, JANUARY 1972
Arterial Punctures by Inhalation Therapy Personnel
*
Larry A. Litulesmith, .\I.D.;"" Edu-ard R. Willga, ,\1.0.;"" Dacid E. Cooduouuh, .\f.D., F.C.C.P.;t and Richard A. Paradise, A.A./.T.t
Arterial blood gas analysis in the management of patients with respiratory and metabolic disease is most useful in relationship to its availability, accuracy and correlation with ventilation data. Inhalation therapists and technicians trained to perform arterial punctures were found to be proficient, careful, and available. Six thousand nine hundred arterial punctures were performed by the technicians without morbidity.
A
safe, simple method of arterial puncture to obtain blood for gas analysis was reported in 1966. 1 Simplicity of this technique was confirmed in 1967" and it has been adopted by many physicians. The need for personnel other than the physician to perform arterial punctures rapidly became apparent. Xurses have been used to perform arterial punctures safely," but the justifiable use of nurses to do a technical task has been challenged by the nursing profession" In 1969 we began training our inhalation therapy personnel, both technicians and therapists, to draw arterial blood samples. They seem to be a logical choice of manpower', are interested in the technique, are often associated with the patients requiring arterial blood gas analysis and can be easily trained to perform the task. Utilization of these paramedical personnel to draw arterial blood gas samples has been suggested by others," but its successful implementation has not been previously reported. MATERIALS A:\'D METHODS
A .'5 ml glass syringe, wetted with heparin solution (1,000 units per ml) and attached to a 21 or 22 gauge one-inch needle, is used for drawing the blood samples. A 2 ml plastic disposable syringe, filled with 1 percent lidocaine solution and attached to a 2.5 gauge J2 inch needle, is used to provide local anesthesia. Alcohol sponges, a sealed metal cap for the blood syringe and a cup of ice complete the material used. The blood is drawn with the patient in the position requested by the physician and the wrist extended 4.'5°. The radial artery area approximately one inch above the wrist crease is cleansed with alcohol and infiltrated with 1-2 ml of 1 percent lidocaine solution, beginning with a skin wheal. The remaining amount is injected subcutaneously along the site of the artery after withdrawing the plunger to he sure the artery has not been penetrated. The radial artery is palpated with the fingers of one hand. The .'5 ml syringe and needle, held as "From the Division of Pulmonary Physiology, Department of Internal Medicine and the Department of Anesthesiology, La Crosse Lutheran Hospital and Gundersen Clinic. Ltd., La Crosse, Wisconsin. e e Meclical Co-director, Department of Inhalation Therapy and Division of Pulmonary Physiology. tChairman, Department of Anesthesiology. 1Chief, Department of Inhalation Therapy. Reprillf requests: Dr. Lindesmith, 183.5 South AVCIlUC, LaCrosse, \Viscollsin .54601
84
L1NDESMITH ET AL Table I
Data recorded 11/ lillie of arterial puncture (helpful in interpret ation of arterial blood l!:aS('s) Temperature of patient
Inspired oxygen r-onr-entrat ion or liter flow Rr-spirutorv rate Method of administration of oxygen Ventilator
Mask Cannula, etc, Tidal volume or minute venrilarion (if on respirator) Position of pat ir-nt a pencil, is advanced with the other hand through the area of the skin wheal, entering the artery at a 45° angle. Puncture of the artery is usually detected by observing the pulsatile flow of hlood entering the syringe hecause of arterial pressure. Although pulsations may he damped, the syringe harrel will usually he moved by arterial pressure. Four to 6 ml of hlood is drawn from the artery and firm pressure is applied to the site of the puncture for three minutes. Any hubbies in the syringe are immediately expressed and the syringe is capped, rotated and placed immediately in ice for transportation to the laboratory along with the laboratory form properly filled out with ventilation information (Table 1). When radial artery blood cannot be obtained, similar techniques are used for obtaining blood from brachial, ulnar, or femoral arteries. However, the radial artery site is preferred because of least morbidity. RESULTS
The technicians were instructed in: (1) techniques of arterial puncture as described; (2) the recognition and first aid of vasovagal reactions or anaphylactic reactions to lidocaine; (3) the recognition of possible venous samples, and (4) interpretation of acid-base abnormalities. They routinely asked the patient to identify any known reaction to local anesthetic drugs. They asked the patient and checked the chart regarding anticoagulant use or platelet deficiency which necessitates holding pressure on the artery for 10 to 15 minutes. Rarely did a physician have to perform the arterial puncture. The technicians rapidly showed proficiency and had no trouble obtaining blood within two to three minutes. They accurately recorded ventilation information applicable to the time they drew the blood. After instruction, supervised practice, development of self-confidence and satisfactory demonstration of ability by deed and by examination, each individual technician was certified by the instructing physician as to his or her proficiency in arterial puncture technique. The certification was recorded in the technician's personnel records. Two trained therapists and 17 technicians and trainees who have had on-the-job training for at least three months have been satisfactorily trained and certified. The average number of practice sessions required to
develop the technician's self-confidence was seven, with a range of five to 12. Only one technician, who had a sensory deficit in one hand due to a nerve injury, could not learn to perform punctures sa tisfactorily. During 1969, 1900 arterial punctures were performed by these personnel. 1'\inety-nine percent of these (1880 samples) were from the radial artery. During 1970, .')O()() arterial punctures were performed. Over this two-year period, no vasovagal reactions occurred. There were no anaphylactic reactions to lidocaine. In two patients, identified as having had previous local anesthetic reactions, punctures were performed without the use of lidocaine. Minimal superficial hematomas occurred in a few patients. DISCUSSIOX
The proper interpretation of arterial blood gases depends upon knowledge of clinical data such as amount and type of ventilation, method of administration of oxygen and amount of inspired oxygen received by the patient at the time the blood sample is drawn. Inhalation technicians are not only available and capable of performing the arterial puncture, but also are easily trained to record pertinent ventilatory and oxygenation information at the time the blood gas samples are drawn. Table 1 shows the data recorded by the technicians each time a sample is drawn. The use of inhalation therapy technicians to perform arterial punctures obviously leaves physicians and nurses free from this technical duty, but raises a question of legal liability. Exact legal guidelines are not available and, where present, may vary from state to state. Until better guidelines are established defining the roles and liability of paramedical personnel, responsibility must be assumed by hospital administrators, medical directors of inhalation therapy departments and attending physicians. Our state hospital association, on advice of its legal counsel, approved our use of paramedical personnel in this manner after appropriate instruction and certification of such personnel. Our hospital administration then assumed, with the physicians involved, responsibility for using inhalation therapy personnel to draw arterial blood samples. REFERENCES
Petty TL, Bigelow DB, Levine BE: The simplicity and safety of arterial puncture. JA\IA 195:181-183, 1966 2 Sackner \IA: Arterial hlood gas analysis. Medical Times 95:79-87, 1967 3 Sackner \IA, Avery \Ve, Sokolowski J: Arterial punctures by nurses. Chest 59:97-98,1971 4 Mclntyre H\I: The nurse-technical assistant or professional assoeiate? (editorial) C!wst SD:3-4, H>71
CHEST, VOL. 61, NO.1, JANUARY 1972
ARTERIAL PUNCTURES BY INHALATION THERAPY PERSONNEL pulmonary function."·'·"·!' Samson's" patient who underwent repair 15 years after rupture had pulmonary function studies done three years after repair and these showed that the vital capacity of the reimplanted lung was only 50 percent of the opposite lung and the oxygen consumption 20 percent of the opposite lung." These studies would suggest that repair of the lesion as soon as it is feasible is best, not only to ensure more complete recovery of function, hut also to prevent irreversible fibrosis or pulmonary infection. The latter is more likely to occur when the bronchial rupture has been incomplete, as complete rupture seems to protect the atelectatic lung from infection, probably by excluding it from communication with the proximal airway. Since incomplete rupture very frequently leads to an intractable stricture," its early detection and repair are equally urgent, primarily to prevent pulmonary suppuration-the only indication for removal of the lung. Thus, in the absence of pulmonary suppuration, repair of the bronelms, even 15 years after the injury, will always be rewarded by some, albeit incomplete, return of lung function. ~lr. R. F. Irvine, Supervisor, Medical Photography, Queen's University for photographic prints.
ACKNOWLEDG~IENT:
REFERE:'\CES
Ballenger FP, Watkins TK, Brisbin HL: Bronchial [raetun': a case report with review of the literature. Military \led 132:993, 1967 2 Paulson DL: Traumatic hronchial rupture with plastic repair. J Thorac Surg 22:636, 19.'51 3 Mahaffey DE, Creech 0, Borden HG, et al: Traumatic rupture of left main bronchus successfully repaired eleven years after injury. J Thorac Surg 32:312, 19.'56 4 Wiesel \V, Jake RJ: Anastomosis of right bronchus to trachea forty-six days following complete bronchial rupture from external injury. Ann Surg 137:220, 19.'53 .'5 Katz RI, Briggs IN: Traumatic ruptured bronchus and injury of major thoracic vessels. Ann Thor Surg 3:23.'5, W67 6 Samson PC: Discussion Ref. 3 J Thorac Sun; 32:312, 19.'56 7 Criffith JL: Fracture of the bronchus. Thorax 4: 10.5, Hl49 8 [ones F\V, Vinson PP: Xonfatal rupture of left main bronchus from external trauma. Surgery .'5:228, 1939 9 Stre-vey TE, Park BS, Thomas PA: Delayed repair of the ruptured left bronchus. J Thorac and Cardiovas Surg .'59:6.'38, W70 lO Hood H\I, Sloan HE: Injuries of the trachea and major bronchi. J Thorac Sunr 38:4.'58, 19.'59 II Campbell DC, Swindell HV, Dominy DE: Delayed repair of rupture of the bronchus. J Thorac and Cardiovas Surg 4:3::320. H-l62
CHEST, VOL. 61, NO.1, JANUARY 1972
Arterial Punctures by Inhalation Therapy Personnel
*
Larry A. Litulesmith, .\I.D.;"" Edu-ard R. Willga, ,\1.0.;"" Dacid E. Cooduouuh, .\f.D., F.C.C.P.;t and Richard A. Paradise, A.A./.T.t
Arterial blood gas analysis in the management of patients with respiratory and metabolic disease is most useful in relationship to its availability, accuracy and correlation with ventilation data. Inhalation therapists and technicians trained to perform arterial punctures were found to be proficient, careful, and available. Six thousand nine hundred arterial punctures were performed by the technicians without morbidity.
A
safe, simple method of arterial puncture to obtain blood for gas analysis was reported in 1966. 1 Simplicity of this technique was confirmed in 1967" and it has been adopted by many physicians. The need for personnel other than the physician to perform arterial punctures rapidly became apparent. Xurses have been used to perform arterial punctures safely," but the justifiable use of nurses to do a technical task has been challenged by the nursing profession" In 1969 we began training our inhalation therapy personnel, both technicians and therapists, to draw arterial blood samples. They seem to be a logical choice of manpower', are interested in the technique, are often associated with the patients requiring arterial blood gas analysis and can be easily trained to perform the task. Utilization of these paramedical personnel to draw arterial blood gas samples has been suggested by others," but its successful implementation has not been previously reported. MATERIALS A:\'D METHODS
A .'5 ml glass syringe, wetted with heparin solution (1,000 units per ml) and attached to a 21 or 22 gauge one-inch needle, is used for drawing the blood samples. A 2 ml plastic disposable syringe, filled with 1 percent lidocaine solution and attached to a 2.5 gauge J2 inch needle, is used to provide local anesthesia. Alcohol sponges, a sealed metal cap for the blood syringe and a cup of ice complete the material used. The blood is drawn with the patient in the position requested by the physician and the wrist extended 4.'5°. The radial artery area approximately one inch above the wrist crease is cleansed with alcohol and infiltrated with 1-2 ml of 1 percent lidocaine solution, beginning with a skin wheal. The remaining amount is injected subcutaneously along the site of the artery after withdrawing the plunger to he sure the artery has not been penetrated. The radial artery is palpated with the fingers of one hand. The .'5 ml syringe and needle, held as "From the Division of Pulmonary Physiology, Department of Internal Medicine and the Department of Anesthesiology, La Crosse Lutheran Hospital and Gundersen Clinic. Ltd., La Crosse, Wisconsin. e e Meclical Co-director, Department of Inhalation Therapy and Division of Pulmonary Physiology. tChairman, Department of Anesthesiology. 1Chief, Department of Inhalation Therapy. Reprillf requests: Dr. Lindesmith, 183.5 South AVCIlUC, LaCrosse, \Viscollsin .54601
84
L1NDESMITH ET AL Table I
Data recorded 11/ lillie of arterial puncture (helpful in interpret ation of arterial blood l!:aS('s) Temperature of patient
Inspired oxygen r-onr-entrat ion or liter flow Rr-spirutorv rate Method of administration of oxygen Ventilator
Mask Cannula, etc, Tidal volume or minute venrilarion (if on respirator) Position of pat ir-nt a pencil, is advanced with the other hand through the area of the skin wheal, entering the artery at a 45° angle. Puncture of the artery is usually detected by observing the pulsatile flow of hlood entering the syringe hecause of arterial pressure. Although pulsations may he damped, the syringe harrel will usually he moved by arterial pressure. Four to 6 ml of hlood is drawn from the artery and firm pressure is applied to the site of the puncture for three minutes. Any hubbies in the syringe are immediately expressed and the syringe is capped, rotated and placed immediately in ice for transportation to the laboratory along with the laboratory form properly filled out with ventilation information (Table 1). When radial artery blood cannot be obtained, similar techniques are used for obtaining blood from brachial, ulnar, or femoral arteries. However, the radial artery site is preferred because of least morbidity. RESULTS
The technicians were instructed in: (1) techniques of arterial puncture as described; (2) the recognition and first aid of vasovagal reactions or anaphylactic reactions to lidocaine; (3) the recognition of possible venous samples, and (4) interpretation of acid-base abnormalities. They routinely asked the patient to identify any known reaction to local anesthetic drugs. They asked the patient and checked the chart regarding anticoagulant use or platelet deficiency which necessitates holding pressure on the artery for 10 to 15 minutes. Rarely did a physician have to perform the arterial puncture. The technicians rapidly showed proficiency and had no trouble obtaining blood within two to three minutes. They accurately recorded ventilation information applicable to the time they drew the blood. After instruction, supervised practice, development of self-confidence and satisfactory demonstration of ability by deed and by examination, each individual technician was certified by the instructing physician as to his or her proficiency in arterial puncture technique. The certification was recorded in the technician's personnel records. Two trained therapists and 17 technicians and trainees who have had on-the-job training for at least three months have been satisfactorily trained and certified. The average number of practice sessions required to
develop the technician's self-confidence was seven, with a range of five to 12. Only one technician, who had a sensory deficit in one hand due to a nerve injury, could not learn to perform punctures sa tisfactorily. During 1969, 1900 arterial punctures were performed by these personnel. 1'\inety-nine percent of these (1880 samples) were from the radial artery. During 1970, .')O()() arterial punctures were performed. Over this two-year period, no vasovagal reactions occurred. There were no anaphylactic reactions to lidocaine. In two patients, identified as having had previous local anesthetic reactions, punctures were performed without the use of lidocaine. Minimal superficial hematomas occurred in a few patients. DISCUSSIOX
The proper interpretation of arterial blood gases depends upon knowledge of clinical data such as amount and type of ventilation, method of administration of oxygen and amount of inspired oxygen received by the patient at the time the blood sample is drawn. Inhalation technicians are not only available and capable of performing the arterial puncture, but also are easily trained to record pertinent ventilatory and oxygenation information at the time the blood gas samples are drawn. Table 1 shows the data recorded by the technicians each time a sample is drawn. The use of inhalation therapy technicians to perform arterial punctures obviously leaves physicians and nurses free from this technical duty, but raises a question of legal liability. Exact legal guidelines are not available and, where present, may vary from state to state. Until better guidelines are established defining the roles and liability of paramedical personnel, responsibility must be assumed by hospital administrators, medical directors of inhalation therapy departments and attending physicians. Our state hospital association, on advice of its legal counsel, approved our use of paramedical personnel in this manner after appropriate instruction and certification of such personnel. Our hospital administration then assumed, with the physicians involved, responsibility for using inhalation therapy personnel to draw arterial blood samples. REFERENCES
Petty TL, Bigelow DB, Levine BE: The simplicity and safety of arterial puncture. JA\IA 195:181-183, 1966 2 Sackner \IA: Arterial hlood gas analysis. Medical Times 95:79-87, 1967 3 Sackner \IA, Avery \Ve, Sokolowski J: Arterial punctures by nurses. Chest 59:97-98,1971 4 Mclntyre H\I: The nurse-technical assistant or professional assoeiate? (editorial) C!wst SD:3-4, H>71
CHEST, VOL. 61, NO.1, JANUARY 1972