What are the risks of an arterial blood draw to the brachial (Brachial artery) artery in the upper arm and how can they be minimized?

From the Guidelines

Arterial blood draws from the brachial artery should be performed with caution and consideration of alternative sites due to the significant risks of complications, and the use of ultrasound guidance is recommended to minimize these risks. The brachial artery is associated with a higher risk of complications, including hematoma formation, arterial occlusion, nerve damage, and infection, compared to other sites like the radial artery 1. To minimize these risks, it is essential to consider alternative sites like the radial artery, which is safer and more accessible. If the brachial artery must be used, proper patient positioning with the arm extended and supinated is crucial.

Key Considerations for Brachial Artery Puncture

• Use strict aseptic technique with chlorhexidine or alcohol preparation to reduce the risk of infection 1.
• Select the smallest gauge needle appropriate for the procedure (typically 20-22G) to minimize tissue damage.
• Approach the artery at a 45-degree angle to reduce the risk of complications.
• Apply direct pressure for at least 5 minutes after the draw, extending to 10-15 minutes for patients on anticoagulants, to minimize bleeding and hematoma formation.
• Monitor the puncture site for bleeding, swelling, or discoloration, and be aware of the potential for nerve damage due to the proximity of the median nerve 1.

Role of Ultrasound Guidance

The use of ultrasound guidance for vascular access, including arterial puncture, has been shown to be cost-effective and associated with reduced complications and improved outcomes 1. Ultrasound guidance can help identify the artery and surrounding structures, reducing the risk of complications, and is particularly useful in difficult cases or when the pulsation of the artery is not evident. Therefore, ultrasound guidance should be used routinely for brachial artery punctures when trained operators are available 1.

From the Research

Risks of Arterial Blood Draw to the Brachial Artery

The risks of an arterial blood draw to the brachial artery in the upper arm include:

• Hematoma formation
• Compression of the median nerve
• Vascular complications, such as access site stenosis or occlusion
• Infection
• Peripheral nerve injury
• Thrombosis or upper extremity ischemia (although no cases were reported in the study by 2)

Minimizing Risks

To minimize the risks associated with brachial artery access, the following strategies can be employed:

• Using ultrasound (US) guidance, as it has been shown to reduce the risk of access site complications 2
• Performing an arterial cutdown, as it is associated with lower complication rates compared to percutaneous access 3
• Using smaller sheath sizes, as larger sheath sizes (>5F) are associated with increased risk of complications 3
• Avoiding the use of anticoagulants, as they can increase the risk of hematoma formation 4
• Considering alternative access sites, such as the radial artery, if possible 4

Factors Associated with Complications

The following factors are associated with an increased risk of complications after brachial access:

• Age
• Female gender
• Larger sheath sizes (>5F)
• Peripheral arterial disease 5
• Lack of experience with brachial access (although this was not a significant predictor in the study by 3)