Algorithm for the management of suspected arterial puncture during central venous access

CVC: central venous catheter; pO₂: partial pressure of oxygen.
* Depending on the access site, any hematoma causing symptoms or generally larger than 3 cm.
¶ For persistent bleeding, obtain coagulation parameters and consider correction prior to additional access attempts. Ultrasound evaluation can help determine the size and rule out pseudoaneurysm or arteriovenous fistula.
Δ Arterial blood may not appear pulsatile if blood pressure is low, and color may be dark with low oxygen tension.
◊ The arterial pressure waveform is characterized by a sharp upstroke in systole, reduced pressure in late systole with a secondary upstroke (incisura), and reduced pressure during diastole. The venous pressure waveform is characterized by low amplitude with two rounded upstrokes, the first of which is greater than the second.
§ The arterial blood gas is typically characterized by a high oxygen tension (pO₂ >80 mmHg) compared with the venous blood gas (pO₂ <50 mmHg).
¥ The ability to compress a vascular access site depends on the anatomic site and the condition of the vessel. Arteries with significant atherosclerotic disease may not compress effectively.