Diagnostic Use, Interpretation, & Specimen Collection

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1 Diagnostic Use, Interpretation, & Specimen Collection COURSE DESCRIPTION The measurement of arterial blood gases is vital in the identification, diagnosis, and treatment of many life-threatening situations. The collection of arterial blood is not only technically difficult, but it can be painful and hazardous for the patient. In addition, arterial blood is one of the specimens that is most sensitive to pre-analytic errors. Therefore, policies and procedures relating to arterial blood specimen collection must be strictly followed. This continuing education course will provide general information about arterial specimen collection and diagnostic use of blood gas test results. Rev 4.0 May 2014 Page 1 of 26

2 COURSE TITLE: Arterial Blood Gases Author: Ramazi Mitaishvili, MD Chief Executive Officer Ramazi Mitaishvili Global Health, Inc. Glendale, CA Editor: Lucia Johnson, MA Ed, CLS(NCA), MT(ASCP)SBB Director, Continuing Education NCCT Overland Park, KS Number of Clock Hours Credit: 6.0 Course # P.A.C.E. Approved: Yes X No OBJECTIVES Upon completion of this continuing education course, the professional should be able to: 1. List the analytes included in arterial blood gas (ABG) measurements. 2. List the abbreviations for each analyte. 3. Describe patient symptoms that can lead to orders for ABG analysis. 4. State the typical reference ranges for the ABG analytes. 5. Recognize abnormal arterial blood gas results. 6. Identify causes of abnormal ABG test results. 7. List credentials of individuals recommended for ABG specimen collection training. 8. State the potential puncture sites for ABG specimen collection. 9. Identify the ideal site recommended for ABG specimen collection. 10. Locate the radial, brachial, and common femoral arteries. 11. Describe the use of local anesthesia for ABG specimen collection. 12. List equipment and supplies used for arterial puncture. 13. List the steps for arterial puncture. 14. Describe the need for and performance of the Modified Allen test. 15. Recognize positive and negative results of the Modified Allen test. 16. Describe pre-analytical errors that can affect ABG test results. 17. Describe complications that can follow ABG specimen collection. 18. Identify transportation requirements for ABG specimens. 19. Discuss complications that can follow ABG specimen collection and methods to avoid their occurrence or minimize their effects. 20. List reasons for ABG specimen rejection. 21. List documentation requirements for ABG specimen collection. Disclaimer The writers for NCCT continuing education courses attempt to provide factual information based on literature review and current professional practice. However, NCCT does not guarantee that the information contained in the continuing education courses is free from all errors and omissions. Page 2 of 26

3 NOTE: This continuing education course introduces arterial blood gas specimen collection and diagnostic use. Successful completion of this course does not provide the individual with the skills necessary to perform arterial blood gas specimen collection. INTRODUCTION Arterial blood gases, abbreviated ABG, are blood tests that determine the concentrations of carbon dioxide, oxygen, bicarbonate, and ph in arterial blood. Blood specimens are collected from an artery, which is a more difficult and problemprone procedure than that of venipuncture. Venous blood does not provide an accurate picture of oxygen and carbon dioxide status as the blood has already moved through the body s tissues. Therefore, oxygen has been used up and carbon dioxide produced. The specific substances measured by a blood gas analyzer are: hydrogen ion activity (ph) partial pressure of carbon dioxide (PaCO 2 or pco 2 ), and partial pressure of oxygen (PaO 2 or po 2 ). From the above blood gas test results, the blood gas analyzer calculates bicarbonate (HCO 3 ) concentration. NOTES Other analytes can be measured or calculated. For the purposes of this CE course, only the four analytes listed are discussed. This CE course will discuss adult ABG specimen collection only. DIAGNOSTIC USE OF ABG TESTS As blood passes through the lungs, oxygen moves from the lungs into the blood. At the same time, carbon dioxide moves out of the blood into the lungs. ABG test results determine how well a patient s lungs move oxygen into the blood and remove carbon dioxide from the blood. ph is a measure of the level of hydrogen ion (H+), which indicates the acid/base balance of the blood. The ph of the blood decreases (becomes more acidic) with increased amounts of pco 2 and other acids, and the ph of the blood increases (becomes more alkaline) with decreased pco 2 or increased amounts of bases like bicarbonate (HCO 3 ). pco 2 is a measure of the amount of carbon dioxide gas dissolved in the blood. As pco 2 levels increase in the blood, ph levels decrease and the blood becomes more acidic. As pco 2 levels decrease, ph levels increase, making the blood more alkaline. po 2 is a measure of the amount of oxygen gas (O 2 ) dissolved in the blood. Page 3 of 26

4 HCO 3 is the main form of carbon dioxide (CO 2 ) in the blood. It is calculated from the ph and pco 2 values. It measures the metabolic component of the acid-base balance. As HCO 3 is excreted and reabsorbed by the kidneys in response to ph imbalances. As the amount of HCO 3 rises, so does the ph. Abnormal ABG test results can mean that the patient is not getting enough oxygen, is not eliminating sufficient carbon dioxide, or that there is a problem with kidney function. If left untreated, life-threatening consequences can occur. The respiratory and metabolic systems are interrelated and, when imbalances occur, one system will compensate for the other to bring the ph back into balance. With the ph balanced, other blood gas analytes will move back into normal values. When ph is imbalanced, the blood is either too acidic (a state of acidosis) or alkaline (a state of alkalosis). Acidosis and alkalosis can be either metabolic or respiratory in origin. Respiratory acidosis is characterized by a decreased ph and an increased pco 2. o It is due to respiratory depression with not enough O 2 coming in and a build-up of CO 2 in the blood. o This is caused by many things including, but not limited to, pneumonia, chronic obstructive pulmonary disease (COPD), and over-sedation from narcotics. Respiratory alkalosis is characterized by an increased ph and a decreased pco 2. o It is due to hyperventilation when too much O 2 is entering and quantities of CO 2 are being lost. o Causes of hyperventilation include, but are not limited to, anxiety, panic, over-breathing, and pain. Metabolic acidosis is characterized by a decreased ph and a decreased HCO 3. o It results from an increased accumulation of metabolic acids, usually from the inability of the kidneys to excrete acid. o It can be caused by an accumulation of ketoacids (as seen in starvation and diabetes), poisoning, and kidney failure, among other things. Metabolic alkalosis is characterized by an increased ph and an increased HCO 3. o It occurs with hyperventilation, resulting in a loss of CO 2. o It can be caused by prolonged vomiting (resulting in a loss of acid with the stomach content), severe dehydration, and the consumption of alkaline substances. ABG are generally ordered when the patient has difficulty breathing, has shortness of breath, is on oxygen therapy, Page 4 of 26

5 is known to have a respiratory, metabolic, or kidney disease and is experiencing respiratory distress, has head or neck trauma, or has prolonged anesthesia, especially for cardiac bypass or brain surgery. ABG test results can help establish a diagnosis, determine severity of illness, monitor therapy, and identify disease progress and prognosis. REFERENCE RANGES There is no one set of ABG reference ranges, also called normal values. Reference ranges depend on the type of ABG analyzer used, the age of the patient, altitude, and room temperature. Typical reference ranges are listed below. Analyte Reference Range HCO meq/l* pco mmhg** ph po mmhg *milliequivalents per liter **millimeters mercury CAUSES OF ABNORMAL TEST RESULTS The following table lists medical causes of abnormal ABG test results. Abnormal Test Result Causes Increased ph Vomiting Early congestive heart failure Anxiety (resulting in hyperventilation) Drugs causing alkalosis Hyperaldosteronism Volume contraction (conditions where red blood cell volume decreases and hyperosmolar plasma concentrations increase) Decreased ph Ketoacidosis Lactic acidosis Renal failure Respiratory failure Chronic obstructive pulmonary disease (COPD) Drugs causing acidosis (iron, isoniazid, salicylates) Ethylene glycol Increased pco 2 Respiratory failure Hypoventilation COPD Central Nervous System (CNS) depression Drugs depressing respiration (alcohol, barbiturates, opiates, benzodiazepines) Page 5 of 26

6 Abnormal Test Result Causes Decreased pco 2 Hyperventilation Anxiety Interstitial lung disease Cirrhosis Hyperthyroidism Pulmonary embolism Aspirin Air bubbles in the specimen Increased po 2 Oxygen therapy Hyperventilation Aspirin Decreased po 2 COPD Pneumonia Interstitial lung disease Pulmonary embolism Congestive heart failure Shock CNS depression Right-to-left cardiac shunts Drugs that depress respiration (alcohol, barbiturates, opioids, narcotics, tramadol, nalmefene, flumazenil) Increased HCO 3 Vomiting Cushing s syndrome Blood volume depletion Diuretics Glucocorticoids Decreased HCO 3 Metabolic acidosis Ketoacidosis Lactic acidosis Renal failure Diarrhea Carbonic anhydrase inhibitors Ethylene glycol Methanol Aspirin Pregnancy SPECIMEN COLLECTION Settings ABG specimen collection is performed by trained healthcare personnel in a variety of settings including hospitals, clinics, physician offices, extended care facilities, and the home, when appropriate. Personnel Only individuals who are appropriately qualified and who have documented competency in the procedure should perform ABG specimen collection. The credentials listed on the next page are strongly recommended for ABG specimen collection training. Page 6 of 26

7 MD (Doctor of Medicine), DO (Doctor of Osteopathy), CRT (Certified Respiratory Therapist, National Board for Respiratory Care), RRT (Registered Respiratory Therapist, National Board of Respiratory Care), RN (Registered Nurse, National Counsel of State Boards of Nursing) RPFT (Registered Pulmonary Function Therapist, National Board of Respiratory Care), CPFT (Certified Pulmonary Function Technologist, National Board of Respiratory Care), MT/CLS (Medical Technologist, ASCP/Clinical Laboratory Scientist, NCA) MLT/CLT (Medical Laboratory Technician, ASCP/Clinical Laboratory Technician, NCA) RCVT (Registered Cardiovascular Technologist, Cardiovascular Credentialing International), and CPT II (Certified Phlebotomy Technician II, state of California license). State law can be more stringent and limit the collection of ABG to specific credentials. In addition, healthcare facilities can have specific policies identifying the healthcare professionals who are permitted to collect ABG specimens. Per the federal Clinical Laboratory Improvement Act of 1988 (CLIA 88), ABG specimen collection and analysis should be performed under the direction of a physician specifically trained in laboratory medicine, pulmonary medicine, anesthesia, or critical care. Frequency The frequency with which sampling is performed depends on the clinical status of the patient and the indication for performing the procedure. The quantity of blood collected is dependent on the requirements of the ABG analyzer. Care should be taken to keep the blood sample size as small as possible to limit blood loss, especially in neonates. Sufficient volume is generally 1.0 ml or less. Repeated puncture of a single site increases the likelihood of hematoma, scarring, or laceration of the artery. Care should be exercised to use alternate sites for patients requiring multiple punctures. Critically ill patients who require many ABG tests often have an indwelling catheter, i.e., arterial line, inserted to eliminate the need for repeated punctures. Puncture sites Recommended arterial puncture sites for ABG specimen collection include the: radial artery (preferred), brachial artery, dorsalis pedis, and femoral (may be contraindicated in some patient populations) Page 7 of 26

8 The radial artery is the ideal site for an arterial puncture for the following reasons. It is small and stabilized, but superficial and easily accessible. It is easily compressed with better control of bleeding. There is no nerve nearby to worry about causing injury. The collateral arch with ulnar artery minimizes the risk of occlusion. NOTES The femoral artery should be reserved as the last option due to the risk of complications. Indwelling arterial lines can be inserted for use. Many critically ill patients have indwelling lines inserted for ease of specimen collection. Healthcare facilities can set specific policies regarding which arteries are used for ABG specimen collection. Healthcare workers must be trained in the removal of blood from indwelling arterial lines before they perform this procedure. Anatomical Review of Puncture Sites Line drawings are from the 20th U.S. edition of Gray's Anatomy of the Human Body, originally published in 1918 and therefore lapsed into the public domain. Radial Artery The radial artery runs along the lateral aspect of the volar forearm deep to the superficial fascia. The artery runs between the styloid process of the radius and the flexor carpi radialis tendon. The radial artery pulse can usually be palpated just proximal to the wrist. Palm Side Top Side Page 8 of 26

9 Brachial Artery The brachial artery is the major artery of the upper arm. The pulse is palpable on the anterior aspect of the elbow and, with the use of a stethoscope and sphygmomanometer (blood pressure cuff), it is commonly used to measure the blood pressure. Femoral Artery The femoral artery is a large artery in the muscles of the thigh. The pulse can be palpated in the upper inner thigh. Collecting blood from the femoral artery is generally limited to physicians and specially trained emergency personnel due to complications that can arise unique to the artery s location. Therefore, this site is considered only as a last resort. Page 9 of 26

10 Dorsalis Pedis Artery The dorsalis pedis is the artery in the lower limb that carriers blood to the dorsal surface of the foot. It divides into two branches, the first dorsal metatarsal artery and the deep plantar artery. The dorsalis pedis artery pulse can be palpated on the topside of the foot. Contraindications/Concerns for Arterial Puncture Contraindications are absolute unless specified otherwise. Risk to the patient must be considered as relative to the importance of specimen collection. ABG specimens should not be collected in the following situations. Cellulitis or infection at the puncture site Absence of palpable pulse Negative results of a Modified Allen test (if using the radial artery) Coagulopathies or medium-to-high-dose anticoagulation therapy (e.g., heparin or Coumadin (warfarin), streptokinase, tissue plasminogen activator), or aspirin can be a contraindication Platelet count 10,000 per mm 3 History of arterial spasms following previous punctures Severe peripheral vascular disease Abnormal or infectious skin processes at or near the puncture site Arterial grafts Evidence of infection or peripheral vascular disease in the selected limb Presence of lesion or surgical shunt distal to the puncture site Page 10 of 26

11 Local Anesthesia The use of local anesthetic prior to arterial puncture is not universal. The reason for the use of local anesthetic is to avoid pain. The concern has been that without local anesthetic, the pain would cause a patient to hyperventilate or stop breathing, both of which could alter the results of the ABG test. This issue has been studied and the results indicate that a non-anesthetized arterial puncture provides an accurate measurement of resting ph and pco 2. The use of local anesthetic can be useful for individuals performing their first arterial punctures but proficient individuals can most likely perform the puncture with a minimum of pain. Equipment Heparinized Syringe Syringes for ABG collection are coated with heparin to prevent clotting of the blood. Usually 1- to 5-mL self-filling syringes are used. The blood is analyzed directly from the syringe. Therefore, evacuated tubes are not needed. Numerous manufacturers offer for sale syringes pre-coated with heparin specific for ABG specimens. Healthcare facilities should no longer purchase plain syringes and coat them with heparin in-house. Too much or too little heparin will affect ABG test results. The syringe (or the needle) should be equipped with an approved safety device to prevent accidental needlestick injury. Alternately, the syringe can be used with an approved safety needle removal device. Personal Protective Equipment Needles Personal protective equipment including eye wear, gloves (non-latex if patient has latex allergy), fluid-resistant laboratory coat, and mask (if indicated) should be worn. 22- to 25-gauge hypodermic needles that are ⅝ to 1½ inches in length are used for arterial puncture. The gauge and length used are determined by the artery location and the amount of blood needed. Generally speaking, a 1" 22-gauge needle is used. The needle should have a safety feature to prevent accidental needlestick injury. Alternately, the needle can be removed from the syringe using an approved safety needle removal device. Winged infusion sets ( butterflies ) can also be used. Safe Needle Removal Device (unless the needle or syringe has an approved safety feature to prevent accidental needlesticks) Page 11 of 26

12 Luer Tip Cap: A regular or specially designed bubble removal cap or other suitable device to cover the tip of the syringe after needle removal is needed to keep the specimen in anaerobic conditions. Antiseptic for Site Preparation: 70% isopropyl alcohol and povidone-iodine or chlorhexidine gluconate swab are recommended. Gauze Squares Adhesive Bandage, Adhesive Tape, or Coban Wrap Container with crushed ice and water sufficient to completely submerge the syringe barrel: Specimens for blood gas analysis are iced for transport to the laboratory. The cold temperature slows down the metabolic processes of the red cells; therefore, the test results reflect what is occurring in the patient s body. Patient Identification Labels Laboratory Requisitions Optional Local anesthetic and syringe/needle Transilluminator, a strong LED light designed to assist with finding veins/arteries in neonates and infants The Modified Allen Test Before using the radial artery for specimen collection, it is important to determine if the patient has collateral circulation in the hand. Both the radial and ulnar arteries supply blood to the hand. In the event the radial artery becomes thrombosed due to arterial puncture, it must be known that the ulnar artery could supply blood to the hand. The recommended procedure to determine collateral circulation is the Modified Allen Test. The following describes the Modified Allen Test. 1. Seat the patient comfortably. 2. Rest the patient s arm, palm facing up, on a flat surface with the wrist supported on a rolled towel. 3. Compress both the radial and ulnar arteries on the inside of the wrist with the index and middle fingers of both hands for several second to occlude both arteries. 4. Ask the patient to tightly clench his/her hand. Alternately, the patient can clench and unclench his/her hand. Refer to the following page for a picture of this technique. Page 12 of 26

13 5. Ask the patient to release his/her hand. The hand should have a blanched (lightened) appearance. 6. Remove pressure from the ulnar artery. 7. The hand should fill with blood within 5 to 10 seconds, as indicated by a reddening of the palm. This is a positive Modified Allen Test, meaning collateral circulation exists and the radial artery can be used for ABG specimen collection. 8. If color returns to the hand after 10 seconds, the Modified Allen Test is negative and the radial artery should not be used for ABG specimen collection. a. A negative Modified Allen Test indicates the inability of the ulnar artery to supply blood to the hand and a lack of collateral circulation. b. If the Modified Allen Test is negative, the other hand or another artery must be considered for use. 9. Release the pressure from the radial artery. 10. Document the results of the Modified Allen Test on the patient s chart. Procedure for Radial Artery Puncture 1. Review physician order for ABG tests. 2. Use the appropriate Universal Precautions. 3. Identify the patient following approved policy and procedures. 4. Explain the procedure and its purpose. Try to ease the patient s fears as much as possible. 5. Document the patient s temperature, respiratory rate, ventilation status, and FiO 2 (fraction of inspired oxygen). If the patient is breathing room air the FiO 2 is If the patient is on oxygen (via nasal cannula or mask) or on a respirator, the respiratory therapist should have this information written on the equipment. 6. If using radial artery for specimen collection, perform and document the results of the Modified Allen test. If the Modified Allen Test is positive, continue with specimen collection. 7. Place a rolled towel under the patient wrist to help stabilize the site. Page 13 of 26

14 8. Clean the puncture site first with chlorhexidine gluconate swab or with 70% isopropyl alcohol followed by povidone iodine. Allow to dry. a. Chlorhexidine gluconate cannot be used on children less than 2 months of age. b. The puncture site should be cleaned in concentric circular motions from the inside to outside. 9. Clean your gloved non-dominant index finger so that is does not contaminate the puncture site when relocating the pulse before needle entry. 10.If a local anesthetic is used, fill a 1-cc syringe with attached 25- to 26- gauge needle with lidocaine. NOTE: Before injecting lidocaine, always check the patient s medical record to assure there are no allergies to lidocaine. a. With the needle at about a 10 angle, enter the skin around the anticipated puncture site. Pull back slightly on the syringe to see if a vein has been punctured. b. If a vein has been punctured, the needle should be removed, and the procedure repeated. c. If a vein has not been punctured, expel the anesthetic into the skin forming a raised wheal. Wait 1-2 minutes for the lidocaine to take effect. d. Alternately, EMLA topical anesthetic cream can be applied to the anticipated puncture site one hour prior to specimen collection. 11. Attach a safe needle device to the heparinized syringe or use a pre-assembled syringe-needle set. 12. Remove the needle cover. Hold the needle like a dart or a pencil. Direct the needle away from the patient s hand with the bevel facing the flow of blood. 13. With the cleansed gloved index finger, relocate the arterial pulse about 5 10 mm distal to the anticipated puncture site. 14. Pull the skin taut and pierce the pulsating artery at a angle. 15. Advance the needle slightly. When the artery is punctured, a flash of blood will appear in the hub of the needle. At this point, the needle does not need further advancing. Bright red blood will flow in a pulsating manner into the needle. Generally speaking, it is not necessary to pull on the plunger unless you are using a 25-gauge needle. a. If there is no pulsation and the blood is dark red in color, a vein most likely has been punctured. Withdraw the needle and begin the procedure again. b. If the artery is missed, slowly withdraw the needle to just under the skin to redirect it into the artery. Do not probe. 16. When sufficient blood (usually 1 ml) has been collected, carefully remove the needle from the skin. NOTE: Some blood gas analyzers can use specimens as small as µl. 17. Immediately place a sterile dry gauze square over the puncture site with one hand. Apply direct manual pressure to the site for at least 5 minutes. Do not allow the patient to hold pressure on an arterial puncture site. 18. While applying pressure to the puncture site, with your other hand a. Activate the safe needle device to protect yourself from an accidental needlestick. b. Gently rotate the syringe to mix the blood with the anticoagulant. c. Remove the needle from the syringe using a safe needle removal device. d. Gently eject any air bubbles from the syringe into clean dry gauze squares. NOTE: If the equipment has a cap to assist with removal of air bubbles, follow the manufacturer instructions to apply and use the cap. Page 14 of 26

15 e. Cap the syringe, if not previously done. f. Label the specimen following approved policies and procedures. g. Place the syringe into the ice water container. NOTE: The Clinical Laboratory Institute Standards (CLSI) state that ABG specimens collected in plastic syringes can be kept at room temperature if analysis will occur within 30 minutes. However, the healthcare facility s procedures should be followed regarding specimen transport. 19. When the patient has stopped bleeding, apply a pressure bandage. a. Never leave a patient who is bleeding. b. If bleeding does not stop within 5 minutes, continue to hold pressure and obtain assistance from the patient s primary nurse. 21. Per the healthcare facility policy, document all required information on the patient chart and/or patient specimen requisition. 20. Transport the specimen immediately to the laboratory. Complications The most common complication from an arterial puncture is the development of a hematoma at the site. Less common but important complications are thrombus in the artery and infection at the site. Descriptions of complications follow. Hematoma Leakage of blood into tissue due to lack of sufficient elastic tissue to seal puncture site can occur, especially in the elderly. Because the blood is under considerable pressure in the arteries, blood is initially more apt to leak from an arterial puncture than from a venipuncture site. However, arterial puncture sites tend to close more rapidly due to the elastic nature of the arterial wall. This elasticity tends to decrease with age; therefore, the probability of a hematoma formation is greater in older patients or in patients receiving anticoagulants. Bruising can be minimized by using the smallest gauge needle possible and by holding the puncture site for at least 5 minutes post-puncture. A pressure bandage should always be applied. Bruising is the most frequently observed complication occurring in 30% of puncture sites. The bruising is more common at the radial site. The formation of hematomas in the antecubital fossa can result in median nerve compression and ischemic changes resulting from compression of the artery. Infection Inadequate or improper cleansing of the puncture site can lead to bacterial infection in the patient. To prevent infection, the site must be thoroughly cleansed and not repalpated at the site of the puncture. Punctures should not be made in areas that appear to be infected or inflamed. Thrombus Injury to the intima, the innermost layer of an artery or vein, can lead to formation of a thrombus (clot). A large thrombus can obstruct the flow of blood and impair circulation. Page 15 of 26

16 Hemorrhage Hemorrhage can occur in patients receiving anticoagulant therapy or with blood coagulation disorders such as hemophilia and von Willebrand disease. To minimize the risk of hemorrhage, the puncture site of patients known to be on anticoagulant therapy or known to have coagulation disorders should be held at least 10 minutes postpuncture. The pressure should then be released and inspected for bleeding or oozing of blood for at least 2 additional minutes. If bleeding or oozing occurs, continue pressure until bleeding ceases. When bleeding ceases, a pressure bandage should always be applied. NOTE: Blood gas analysis should occur within 10 minutes of specimen collection. If a patient s puncture site continues to bleed, it may be necessary to have another individual deliver the blood specimen to the laboratory or hold pressure on the puncture site. Compression Neuropathy A hematoma formation in the antecubital fossa area can mechanically compress a nerve leading to a compression neuropathy. In the antecubital fossa area, the brachial artery and the median nerve pass underneath the bicipital aponeurosis, a strong triangular band of connective tissue that protects the underlying nerves and vessels. Hematoma formation here can result in compression of the median nerve and brachial artery. Compression neuropathy can also occur when ABG specimens are collected in the inguinal area using the femoral artery. Aneurysm Aneurysm, a ballooning of a portion of an artery, caused by arterial puncture has rarely been reported. This is most likely to occur when repeated punctures are performed in the same area. In some instances, the aneurysm can need surgical resection and repair. Arteriospasm Arteriospasm, a sudden constriction of an artery, can occur secondary to pain from the needle entry or anxiety following an arterial puncture. An arteriospasm can temporarily decrease the pulse and cause pain. The arteriospasm can temporarily stop blood flow and make it difficult to obtain a blood specimen. Arteriovenous (AV) Fistula Because of multiple arterial punctures, especially in neonatal patients, an arteriovenous fistula, an abnormal connection between a vein and an artery, can rarely occur. This occurs most frequently when the brachial or femoral arteries are used for specimen collection. Page 16 of 26

17 Pain Pain during and following the procedure is a frequent complaint and is reported to occur in 10% of the patient population. Pain can occur even when a local anesthetic is used. When systemically looked for, tenderness at the puncture site was observed in 15% of patients. Pain can be felt proximal or distal to the puncture site and this type of pain could be secondary to arterial spasm. Pain can also result from probing for an artery when the puncture missed the artery. In most cases, the discomfort following an arterial puncture is temporary and minor. Specimen Integrity Inaccurate and/or unreliable ABG test results can occur from the following pre-analytical errors. Air bubbles If air bubbles are not removed immediately, oxygen from the bubbles can diffuse into the sample and CO 2 can escape, changing the results (po 2 increases and pco 2 decreases). Delay in Analysis Blood cells outside of the body continue to consume oxygen and nutrients, and produce acids and carbon dioxide at room temperature. Analysis of samples left on ice for 60 minutes or more, or specimens not iced for more than 10 minutes will yield inaccurate test results. Presence of Venous Blood in Specimen A vein can lie over or be very close to an artery and venous blood can accidentally be collected. While arterial blood should be bright red, as opposed to the dark red of venous blood, it can be difficult to differentiate in patients with compromised oxygen content. Arterial blood should pulse into the syringe and this can be used as the criteria for identifying the specimen type. Actual analysis of the specimen can determine the presence of arterial blood. Incorrect Sample Volume Insufficient amounts of blood can yield inaccurate test results. Too much blood for the amount of heparin in the syringe can lead to blood clots. A clotted blood specimen cannot be used for testing. Specimen Rejection As described in the previous section, ABG test results are only as good as the specimen that is collected. Therefore, specimens can be rejected for the following reasons. Page 17 of 26

18 Missing, incorrect, or inadequate patient identification and specimen labeling Presence of clots Too small a volume for analysis (QNS or quantity not sufficient) Presence of air bubbles Not placed in ice Delay in delivery Documentation The following items need to be documented on the patient chart (or test requisition) immediately after ABG specimen collection. Number of unsuccessful and successful punctures Site of puncture Results of the Modified Allen s Test, if radial artery was used for puncture The patient s tolerance of the procedure Adverse side effects of the puncture such as development of a hematoma, length of time necessary for bleeding to stop (if more than 5 minutes) Any other information required by a healthcare facility such as patient temperature and FiO 2 (the percent of oxygen entering the patient s lung via cannula or ventilator). This information can be used to interpret the blood gas test results and to direct further patient care. CONCLUSION This continuing education course has discussed the basics of arterial blood gas specimen collection and the diagnostic use of four analytes: ph, pco 2, po 2, and HCO 3. The maintenance of the body s metabolic and respiratory processes is of utmost importance in sustaining life. Blood gas analysis usually involves the measurement of other analytes but, for simplicity in comprehension, the discussion was limited to four. The reader should have gained a respect for the importance and difficulty of specimen collection as well as the hazards that exist for the patient when arterial puncture is performed. Arterial puncture takes practice, patience, and strict adherence to policies and procedures to assure the patient is not endangered and the test results are accurate and reliable. Page 18 of 26

19 REFERENCES 1. Armstrong PW, Parker JO: The complications of brachial arteriotomy. J Thorac Cardiovasc Surg 1971; 61: Browning JA, Kaiser DL, Durbin CG. The effect of guidelines on the appropriate use of arterial blood gas analysis in the intensive care unit. Respir Care 1989; 34: Bruck E, Eichhorn JH, Ray-Meredith S. Shanahan JK, Slockbower JM. Percutaneous collection of arterial blood for laboratory analysis. National Committee for Clinical Laboratory Standards 1985;H11A;5(3): Bucher, L. (2001). Arterial Puncture. In D.J. Lynn-McHale & K.K. Carlson (Eds.), AACN procedure manual for critical care (pp ). Philadelphia, PA: W.B. Saunders Company. 5. Centers for Disease Control. Update: Universal Precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other blood-borne pathogens in health care settings. MMWR 1988; 37: Colley DP Vertebral arteriovenous fistula: an unusual complication of Swan-Ganz catheter insertion. Am J Neuroradiol 1985 Jan-Feb;6(1): Department of Labor, Occupational Safety and Health Administration. Occupational exposure to bloodborne pathogens. 29 CFRR Part Federal Register, Friday December 06, Depierraz B; Essinger A; Morin D; Goy JJ; Buchser E Isolated phrenic nerve injury after apparently atraumatic puncture of the internal jugular vein. Intensive Care Med, 15:132-4, DuBose Jr TD. Acidosis and alkalosis. Chapter 50. Section 7. Alteration in urinary function and electrolytes. In Fauci et al. Harrison's Principles of Internal Medicine 14th edition. 1998; Fleisher M, et al. Two whole-blood multi-analyte analyzers evaluated. Clin Chem 1989;35: Frye M, DiBenedetto R. Lain D, Morgan K. Single arterial puncture vs arterial cannula for arterial gas analysis after exercise. Chest 1986;93: Gardner RM, Clausen JL, Epler G. Hankinson JL, Permutt S. Plummer AL. Pulmonary function laboratory personnel qualifications. American Thoracic Society Position Paper, ATS News, November Gluck SL. Acid-base. Electrolyte quintet. The Lancet 1998; 352: Hansen JE, Simmons DH. A systematic error in the determination of blood PCO2- Am Rev Respir Dis 1977; 115: Harsten A, Berg B. Inerot S. Muth L. Importance of correct handling of samples for the results of blood gas analysis. Acta Anaesthesiol Scand 1988;32: Hess D. Detection and monitoring of hypoxemia and oxygen therapy. Resp Care 2000;45: Hess D, Good C, Didyoung R. Agarwal NN, Rexrode WO. The validity of assessing arterial blood gases 10 minutes after an Flo2 change in mechanically ventilated patients without chronic pulmonary disease. Respir Care 1985;30: Luce EL, Futrell JW, Wilgis EFS, et al: Compression neuropathy following brachial artery puncture in anticoagulated patients. J Trauma 1976; 16: Macon WL, Futrell JW: Median-nerve neuropathy after percutaneous puncture of the brachial artery in patients receiving anticoagulants. N Engl J Med 1973: 288: McCready RA, Hyde GL, Bivins BA, Hagihara PF: Brachial arterial puncture: A definite risk to the hand. South Med J 1984; 77:6 21. Mitaishvili R, ABG Sampling Mitaishvili R, Arterial Puncture Mitaishvili R, Radial artery Puncture Moran RF, Van Kessel A. Blood gas quality assurance. NSCPT Analyzer 1981;11(I): National Committee for Clinical Laboratory Standards. Procedures for the collection of diagnostic blood specimens by skin puncture, 3rd ed. Villanova PA: NCCLS, Neviaser RJ, Adams JP, Can GI: Complications of arterial puncture in anticoagulant patients. J Bone Joint Surg 1976; 58A: Raffin TA. Indications for arterial blood gas analysis. Ann Intern Med 1986;105: Ries, AL, Fedullo PF, Clausen JL. Rapid changes in arterial blood gas levels after exercise in pulmonary patients. Chest 1983; 83: Shapiro BA, Harrison RA, Cane RD, Templin R. Clinical application of blood gases, 4th ed. St Louis: Year Book Medical Publishers Inc Sharzer LA, Baker WH: Nonthrombotic arterial occlusion. Arch Surg 1973; 106: Thorson SH, Marini JJ, Pierson DJ, Hudson LD. Variability of arterial blood gas values in stable patients in the ICU. Chest 1983;84(1): Page 19 of 26

20 32. Weibley RE, Riggs CD. Evaluation of an improved sampling method for blood gas analysis from indwelling arterial catheters. Crit Care Med 1989; 17(8): Williams AJ. ABCs of oxygen. Assessing and interpreting arterial blood gases and acid-base balance. B M J 1998;317: TEST QUESTIONS Arterial Blood Gases Course Directions: Before taking this test, read the instructions on how to complete the answer sheets correctly. If taking the test online, log in to your User Account on the NCCT website Select the response that best completes each sentence or answers each question from the information presented in the module. If you are having difficulty answering a question, go to and select Forms/Documents. Then select CE Updates and Revisions to see if course content and/or a test questions have been revised. If you do not have access to the internet, call Customer Service at Which one of the following abbreviations is for partial pressure of oxygen? a. HCO 3 b. ph c. po 2 d. pco 2 2. Arterial blood gas specimen collection is used. a. because it is easier than venipuncture in elderly patients with fragile veins b. only in patients with pulmonary disease c. only in patients with renal disease d. to assess the ability of the patient s lungs to move oxygen into the blood 3. Which patient below would warrant ABG analysis? a. Patient 1: short of breath b. Patient 2: undergoing appendectomy c. Patient 3: broken arm d. Patient 4: pregnant with urinary tract infection 4. Which one of the following test results is outside of the reference range? a. HCO 3 = 24 meq/l b. ph = 7.33 c. po 2 = 97 mmhg d. pco 2 = 38 mmhg Page 20 of 26

21 5. Which one of the ph values below is within the reference range? a b c d Which one of the values below is within the reference range for pco 2? a. 26 mmhg b. 38 mmhg c. 48 mmhg d. 80 mmhg 7. The reference range listed for HCO 3 is. a meq/l b meq/l c meq/l d meq/l 8. Acidosis would be indicated by a/an. a. ph less than 7.35 b. pco2 less than 35 c. HCO3- greater than 28 d. ph greater than Alkalosis would be indicated by a/an. a. HCO3- less than 21 b. ph less than 7.35 c. pco2 greater than 45 d. ph greater than An accumulation of ketoacids in the blood can result in. a. metabolic acidosis b. ph greater than 7.45 c. metabolic depression d. respiratory acidosis 11. Which one of the following is seen in respiratory acidosis? a. Increased ph and increased HCO 3 b. Decreased ph and decreased HCO 3 c. Increased ph and decreased pco 2 d. Decreased ph and increased pco 2 Page 21 of 26

22 12. Prolonged vomiting can result in. a. respiratory acidosis b. respiratory alkalosis c. metabolic alkalosis d. metabolic acidosis 13. Which one of the following is NOT a cause of increased ph? a. Anxiety b. Hyperaldosteronism c. Renal failure d. Vomiting 14. Decreased pco 2 can be caused by. a. COPD b. ketoacidosis c. pulmonary embolism d. respiratory failure 15. Increased HCO 3 can be caused by. a. aspirin b. ethylene glycol c. glucocorticoids d. shock 16. Sites for adult ABG specimen collection include all of the following EXCEPT. a. brachial artery b. femoral artery c. radial artery d. radial temporal artery 17. The radial artery is considered an ideal site for an arterial puncture for which one of the following reasons? a. It is a deep artery that is well-anchored. b. It cannot be easily compressed. c. There is no nearby nerve to potentially damage. d. Arterial blood flows the quickest from this artery. 18. The radial artery is located. a. between ulna bone and radius bone b. in the superficial subcutaneous tissues on the ulnar side of the wrist c. between the styloid process and flexor carpi radialis d. in the midline of the wrist Page 22 of 26

23 19. Which of the following is a true statement about the brachial artery? a. It is commonly used to measure blood pressure. b. It is located on the top of the foot. c. The pulse is felt in the upper inner thigh area. d. It is the major artery of the thigh. 20. Which artery is used only when using other sites is not possible? a. Brachial b. Dorsalis pedis c. Femoral d. Radial 21. Arterial puncture of the radial artery would be contraindicated in which one of the following patients? a. Patient with a platelet count of 21,000 per mm 3 b. Patient with cellulitis in left leg c. Patient with gangrene on three toes d. Patient with severe peripheral vascular disease 22. What needle gauge below is commonly used to obtain an arterial blood gas sample? a. 16 b. 18 c. 22 d Which two arteries listed below are used in the performance of the Modified Allen test? a. Brachial and radial b. Dorsalis pedis and femoral c. Femoral and ulna d. Ulnar and radial 24. When using the radial artery for ABG specimen collection, where is the pulse felt? a. Anterior aspect of the elbow b. Proximal to the wrist c. Top of the foot d. Upper inner thigh Page 23 of 26

24 25. Which local anesthetic listed below is sometimes used prior to collection of ABG specimens? a. Cocaine b. Lidocaine c. Novocaine d. Prilocain 26. Why is heparin coated on the inside of the syringes used for ABG specimen collection? a. To make the blood gas analyzer work properly b. To make the syringe easier to clean c. To preserve the ph d. To prevent the blood from clotting 27. Which of the following describes a negative Modified Allen test? a. The patient s hand remains blanched at 10 seconds b. The patient s hand remains blanched at 3 seconds c. The patient s hand fills with blood at 10 seconds d. The patient s hand fills with blood immediately 28. Why is the Modified Allen test performed? a. To ensure the radial artery can supply blood to the hand in case the ulnar artery develops a clot as a result of arterial puncture b. To ensure the ulnar artery can supply blood to the hand in case the radial artery develops a clot as a result of arterial puncture c. To ensure the brachial artery can supply blood to the hand in case the radial artery develops a clot as a result of arterial puncture d. To ensure the radial artery can supply blood to the hand in case the brachial artery develops a clot as a result of arterial puncture 29. At what angle should the needle enter the skin at the site of an arterial puncture? a b c d The syringe is filled during sampling by. a. drawing up on the plunger once in the artery b. allowing arterial pressure to fill the syringe c. squeezing the forearm d. applying pressure to the artery Page 24 of 26

25 31. Which one of the following would lead you to believe you have punctured a vein and not an artery? a. Blood fills the syringe without pulling on the plunger b. Blood pulsates into the syringe c. Blood is dark red in color d. Blood is bright red in color 32. In a patient without coagulation issues, for what period should you hold firm pressure on the arterial puncture site? a. 1 minute b. 10 minutes c. 5 minutes d. 15 minutes 33. What should be done after the patient has stopped bleeding? a. Label the syringe with patient information b. Place a pressure bandage on the patient c. Put the syringe in ice water d. Thank the patient and leave the room 34. Specimens for blood gas analysis are placed in ice water for transport to the laboratory because. a. chilling the specimen provides more accurate test results b. chilling the specimen prevents the clotting of the blood c. chilled specimens are required for the blood gas analyzer d. chilled specimens are easier to expel from the syringe 35. How much blood is usually required for blood gas analysis? a. 1 ml b. 3 ml c. 5 ml d. 10 ml 36. Which blood gas analytes are affected by excessive air bubbles in the specimen? a. pco 2, HCO 3 b. ph, pco 2, c. po 2, pco 2 d. HCO 3, ph 37. Which of the following is the most common complication of arterial puncture? a. Compression neuropathy b. Hematoma c. Hemorrhage Page 25 of 26

26 d. Infection 38. Pain from needle entry and/or anxiety can lead to the development of a/an. a. arteriospasm b. arteriovenous (AV) fistula c. compression neuropathy d. infection 39. Which one of the following can cause inaccurate and/or unreliable ABG test results? a. Adequate sample volume b. Prompt analysis of iced specimen c. Specimen containing arterial blood only d. Delay in transport to lab 40. While healthcare facility policy may vary, which of the following information is usually documented on the patient chart or requisition following an arterial puncture for ABG testing? a. FiO 2 b. Patient temperature c. Site of the puncture d. All of the above. *end of test* Page 26 of 26

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