MADURAI MEDICAL COLLEGE

MADURAI - 625 020

Name : V.BALASARASWATHY

Programme : M.Sc.(N) I Year.

Subject : ADVANCED NURSING PRACTICE

Topic : ARTERIAL BLOOD GASES ANALYSIS

Faculty : Mrs.J.ALAMELU MANGAI, M.Sc.(N), MBA(H.M).,

Mrs N .RAJA LAKSHMI,M.Sc(N)
NURSING TUTOR GR-II
COLLEGE OF NURSING.
MMC, MADURAI-20

CENTRAL OBJECTIVES:
 Help the student to acquire knowledge and understanding about central venous pressure monitoring and to develop desirable attitude and skills
to apply the gained knowledge in taking care of the clients in all health care settings.

SPECIFIC OBJECTIVES:

At the end of the class the Students will be able to,

1. Define the term Arterial blood gas analysis

2. state the purposes of Arterial blood gas analysis

3. list out the indication and contra indication of Arterial blood gas analysis

4. explaining how to perform Arterial blood gas analysis

5. mention the articles needed to Arterial blood gas analysis

6. describing about the procedure

7. explaining the interpretation of the blood gases

8. list out the complication arise due to Arterial blood gas analysis

Time Content Teachers Learners Evaluation

 activity activity
2mts Arterial Blood Gases Defining Listening What do u
1 An arterial blood gas (ABG) test measures the acidity (pH) and the levels of with the mean by
roller board arterial blood
oxygen and carbon dioxide in the blood from an artery. This test is used to gas analysis
check how well your lungs are able to move oxygen into the blood and
remove carbon dioxide from the blood.
An ABG measures
 Partial pressure of oxygen (PaO2).This measures the pressure of
oxygen dissolved in the blood and how well oxygen is able to move
from the airspace of the lungs into the blood.
 Partial pressure of carbon dioxide (PaCO2).This measures the pressure
of carbon dioxide dissolved in the blood and how well carbon dioxide
is able to move out of the body.
 pH. The pH measures hydrogen ions (H+) in blood. The pH of blood is
usually between 7.35 and 7.45. A pH of less than 7.0 is called acid and
a pH greater than 7.0 is called basic (alkaline). So blood is slightly
basic.
 Bicarbonate (HCO3). Bicarbonate is a chemical (buffer) that keeps the
pH of blood from becoming too acidic or too basic.
Oxygen content (O2CT) and oxygen saturation (O2Sat) values. O2 content
3mts measures the amount of oxygen in the blood. Oxygen saturation measures Explaining
how much of the hemoglobin in the red blood cells is carrying oxygen (O2) wth the Listening What are all
chart the purpose
to do ABG
PURPOSES analysis?
An arterial blood gas (ABG) test is done to:
 Check for severe breathing problems and lung diseases, such as
 asthma, cystic fibrosis, or chronic obstructive pulmonary disease
(COPD).
 See how well treatment for lung diseases is working.
 Find out if you need extra oxygen or help with breathing (mechanical
ventilation).
 Find out if you are receiving the right amount of oxygen when you are
5mts using oxygen in the hospital.
Measure the acid-base level in the blood of people who have heart failure, Explaining Listening
kidney failure, uncontrolled diabetes, sleep disorders, severe infections, or Mention the
indication and
after a drug overdose
contra
indication of
INDICATIONS the ABG
Indications for ABG sampling include the following: analysis?
 Identification of respiratory, metabolic, and mixed acid-base
disorders, with or without physiologic compensation, by means of pH
([H +]) and CO 2 levels (partial pressure of CO 2)
 Measurement of the partial pressures of respiratory gases involved in
oxygenation and ventilation
 Monitoring of acid-base status, as in patient with diabetic
ketoacidosis (DKA) on insulin infusion; ABG and venous blood gas
(VBG) could be obtained simultaneously for comparison, with VBG
sampling subsequently used for further monitoring
 Assessment of the response to therapeutic interventions such as
mechanical ventilation in a patient with respiratory failure
 Determination of arterial respiratory gases during diagnostic
evaluations (eg, assessment of the need for home oxygen therapy in
 patients with advanced chronic pulmonary disease)
 Quantification of oxyhemoglobin, which, combined with
measurement of arterial oxygen tension (PaO 2), provides useful
information about the oxygen-carrying capacity of the patient
 Quantification of the levels of dyshemoglobins (eg,
carboxyhemoglobin and methemoglobin)
 Procurement of a blood sample in an acute emergency setting when
venous sampling is not feasible (many blood chemistry tests could be
performed from an arterial sample )

CONTRAINDICATIONS

Absolute contraindications for ABG sampling include the following:

 An abnormal modified Allen test (see below), in which case
consideration should be given to attempting puncture at a different
site
 Local infection or distorted anatomy at the potential puncture site
(eg, from previous surgical interventions, congenital or acquired
malformations, or burns)
 The presence of arteriovenous fistulas or vascular grafts, in which
case arterial vascular puncture should not be attempted
 Known or suspected severe peripheral vascular disease of the limb
involved
Relative contraindications include the following:
 Severe coagulopathy
 Anticoagulation therapy with warfarin, heparin and derivatives, direct
 thrombin inhibitors, or factor X inhibitors; aspirin is not a
contraindication for arterial vascular sampling in most cases
 Use of thrombolytic agents, such as streptokinase or tissue Explaining Listening What are all
plasminogen activator the articles
3mts  Needed?
Equipment
The materials needed for ABG sampling (see the image below) include the
following:
Arterial blood gas sampling equipment.
See the list below:
 Gloves – Non sterile gloves may be used, but care must be taken not
to touch the puncture site after cleaning the area
 Syringe for sampling - A standard syringe with a 25-gauge needle and
a 3-mL capacity (a higher-capacity syringe may be difficult to
maneuver, and smaller needle sizes may increase the risk of traumatic
hemolysis, decreasing the accuracy of hemoglobin and potassium
measurements)
 Lithium heparin - 1-2 mL lithium heparin (1000 U/mL) should be
aspirated into the syringe through the needle and then pushed out;
the plunger should be left depressed to allow the arterial blood flow
to fill up the syringe
 ABG syringe (alternative) - Some ABG kits contain a prefilled
heparinized syringe along with a protective needle sleeve and a
syringe cap (see the image below); the sleeve, while still attached to
the syringe, locks the needle within itself to prevent direct contact
between operator and needle; some syringe models have a vented
 plunger that allows the operator to preset a specific amount of blood
to be withdrawn, and with these models, the plunger is placed
midway through the syringe and is not pulled back while the puncture
is performed; before the procedure, the prefilled heparin is expelled,
and the vented plunger is then repositioned at the 2 mL mark
Arterial blood gas syringe kit.
 Antiseptic skin solution - Chlorhexidine and povidone-iodine are
solutions commonly used

 Syringe cap - Usually included in the ABG syringe kit

 2 × 2 in. piece of sterile gauze
 Adhesive bandage
 Bag with ice
 Sharp object container
 LidocaineHCl 1% without epinephrine (optional)
 25-gauge needle with syringe for local anesthetic (optional) Explaining
10mts What are all
 the pre
Procedural planning procedure
planning?
Planning for the procedure focuses on the choice of a puncture site and
accurate delineation of the vascular anatomy. If radial artery sampling is to
be performed, the adequacy of the ulnar collateral circulation must be
confirmed.

Selection of puncture site

 Puncture of the radial artery is usually preferred because of the
accessibility of the vessel, the presence of collateral circulation, and the
artery's superficial course proximal to the wrist, which makes it easier for the
clinician to identify the vascular structure and hold local pressure after the
procedure is finished.
If radial artery sampling is not feasible, femoral artery puncture is a
possible alternative. When femoral artery puncture is being considered, the
potential risk of infection at the entry site and the artery's proximity to the
femoral vein and nerve must be taken into account. The deeper the vascular
structure, the higher the risk of damage to adjacent structures.
Femoral artery puncture necessitates prolonged monitoring and therefore
is recommended only in the inpatient setting.Some physicians recommend
that femoral artery puncture be avoided whenever possible. This
consideration may play a bigger role for patients who will be undergoing an
intervention that involves femoral access (eg, cardiac catheterization or intra-
aortic balloon pump placement) in the near future.
The brachial artery runs deeper in the arm than the radial artery does.
Consequently, its structures are typically harder to identify, and achieving
hemostasis when necessary is more difficult. Furthermore, the brachial artery
is a relatively small-caliber vessel and does not have extensive collateral
circulation. For these reasons, the brachial artery is the least preferred site
for puncture.
Repeated arterial blood sampling at the same site increases the risk of
hematoma, laceration of the artery, and scarring.[2] It also increases the
chances of inadvertent venous blood sampling. If recurrent sampling is
required, health care personnel should alternate puncture sites. If more
frequent sampling is necessary, the health care provider should consider
placing an indwelling arterial catheter through arterial cannulation.

Confirmation of vascular anatomy

ABG sampling can be difficult in patients with feeble pulses or distorted
anatomic landmarks or in situations where sampling of a deep vascular
structure (eg, the femoral or brachial artery) is required. In these scenarios,
ultrasound-guided ABG sampling should be considered, especially when
sampling by the standard approach has been unsuccessful or is not feasible.
Ultrasonography is a noninvasive technique with an excellent safety profile. It
is an important option in cases where vascular sampling proves difficult. The
use of ultrasonography enables more accurate recognition, delineation, and
targeting of the chosen vascular structure. It minimizes the risk of vascular
laceration and damage to surrounding structures.
Although ultrasound guidance is a safe and effective tool for patients
with weak pulses, a better option for patients in profound shock or in the
midst of cardiopulmonary resuscitation is to obtain arterial blood from the
femoral artery using bony landmarks alone. When the tip of the fifth finger is
placed on the symphysis pubis and the tip of the thumb on the anterior
superior iliac spine, the femoral artery always lies beneath the middle finger.
Assessment of collateral circulation (modified Allen test)
If puncture of the radial artery is planned, a modified Allen test should be
performed beforehand when feasible to assess the collateral circulation.
Although the anatomy of the radial artery in the forearm and the hand is
variable, most patients have adequate collateral flow should radial artery
thrombosis occur .The modified Allen test is performed as follows.
Firm occlusive pressure is held on both the radial artery and the ulnar artery
(see the first image below). The patient is asked to clench the frist several
times until the palmar skin is blanched (see the second image below), then to
unclench the fist. Overextension of the hand or wide spreading of the fingers
should be avoided, because it may cause false-normal results.The pressure
on the ulnar artery is released while occlusion of the radial artery is
maintained (see the third image below). The time required for palmar
capillary refill is noted
Patient Preparation
Appropriate positioning of the patient and knowledge of the vascular
anatomy increase the chances of a successful arterial vascular sampling and
diminish the risk of complications.
Anesthesia
Local anesthesia with a subcutaneous injection of lidocaineHCl 1% without
epinephrine may be used. Local anesthesia is not frequently employed,
however, because the administration of the anesthetic is as painful as the
procedure itself.
If local anesthesia is employed, 0.5-1 mL of the anesthetic is injected so as to
create a small dermal papule at the site of puncture; using larger amounts or
injecting the anesthetic into deeper planes may distort the anatomy and
hinder identification of the vessel. After the skin is punctured but just before
the anesthetic is injected, the clinician should pull back the plunger to
confirm that the needle is not inside a blood vessel; intravascular placement
will be signaled by blood filling up the anesthetic syringe.
Positioning
For radial artery blood sampling, the patient should be in the supine position,
 with the arm lying at his or her on a hard surface. The forearm should be
supinated and the wrist dorsiflexed at 40º. A gauze roll may be placed under
the wrist to make the patient more comfortable and to bring the radial artery
to a more superficial plane. Overextension of the wrist is discouraged,
because interposition of flexor tendons may make the pulse difficult to
detect.
For femoral artery blood sampling, the patient is supine on a stretcher, and
the patient's leg is placed in neutral anatomic position.
For brachial artery blood sampling, the arm is placed on a firm surface with
the shoulder slightly abducted. The elbow is extended, with the forearm in
full supination.
15mts Procedure observing
 Arterial blood can be obtained by direct arterial puncture most
usually at the wrist (radial artery). Alternatives to the radial artery
include the femoral and brachial artery - both of which are usually
used in emergency settings. The dorsalispedis artery and ulnar artery
may also be used. It is important to ensure good collateral circulation
(see below), as there is a theoretical risk of thrombus occlusion.
 If multiple samples are required then an indwelling arterial cannula
can be placed.
 Allow the patient to titrate with the oxygen for 5-10 minutes (30
minutes if they have chronic obstructive pulmonary disease (COPD))
before taking a sample.
 If the radial artery is to be used, perform Allen's test to confirm
collateral blood flow to the hand.

Demonstrati
 Allen's test ng the How do you
2mts Elevate the hand and make a fist for approximately 30 seconds. procedure performeallen
test?
Apply pressure over the ulnar and the radial arteries occluding both (keep the
hand elevated).
Open the hand which will be blanched.
Release pressure on the ulnar artery and look for perfusion of the hand (this
takes under eight seconds).
If there is any delay then it may not be safe to perform radial artery
puncture.
Explain the procedure to the patient - it is painful.
If there is time then local anaesthesia can be used.
ABG syringes usually come prepacked and are heparinised. Some contain a
vacuum and thus the plunger does not always need to be pulled. (Check with
your department as to which they use).
 The wrist is extended - a pillow under the hand may improve comfort.
 Palpate the artery and hold fingers firmly over the pulsation.
 Then introduce the needle at a 45° angle slowly with the bevel facing
upwards, aiming for the point of maximum pulsation.
 Once you hit the artery, try to obtain at least a 1 ml sample.
 Once you have taken your sample and withdrawn the needle, apply
firm pressure for a minimum of two minutes (longer if the patient is
on any antiplatelet medication or anticoagulants).
Listening
Monitoring and Follow-up
After the blood sampling procedure, health care personnel should monitor
the patient for early and late signs and symptoms of potential complications.
Active profuse bleeding at the puncture site might raise suspicion of vessel
 laceration. Femoral artery bleeding carries an increased risk of circulatory
compromise because of the large caliber and deep location of the vessel,
which allow larger amounts of blood to accumulate without initially giving
rise to clinical findings.
A rapidly expanding hematoma may compromise regional circulation and
increase the risk of compartment syndrome, especially in the forearm. This
manifests as pain, paresthesias, pallor, and absence of pulses. Paresis and
persistent pain may indicate a nerve lesion. Limb skin color changes, absent
pulses, and distal coldness may be seen in ischemic injury from artery
occlusion caused by thrombus formation or vasospasm. Infection at the
Explaining
puncture site should be considered in the presence of regional erythema and
fever.
2mts How to interpret arterial blood gases Listening
The following indices should be looked at in the following order (see local
laboratory for reference ranges):
 Blood pH - high indicates alkalosis, low indicates acidosis and normal
indicates either normal, mixed defect or a compensated defect.
 PaCO2 level - is it a respiratory problem? If not, look at the
bicarbonate level. High PaCO2 with an acidosis indicates a respiratory
problem. If the PaCO2 is normal or low it indicates compensation.
 Bicarbonate - if the bicarbonate fits with the pH it suggests a primary
metabolic problem. If not, it indicates compensatory changes.
 Look for any compensation - eg, low PaCO2 in severe metabolic
acidosis.
 Anion gap in metabolic acidosis - see below under 'Other useful
information from arterial blood gases'.
  O2 level - is hypoxaemia present? Explaining
Other useful information from arterial blood gases with OHP

 Alveolar-arterial oxygen gradient - (A-a)pO2; difference in oxygen

partial pressures between the alveolar and arterial side. It provides a
measure of oxygen diffusion across the alveoli into the blood. Thus,
will be impaired in lung disease such as COPD Raised (A-a)pO2 may
also represent the presence of an intrapulmonary provides a list of
some of the causes in which (A-a)pO2 change: lung that is perfused
but not ventilated - for example, pneumonia. The shunt, ie a following
table
(A-a) pO2
Normal (A-a)pO2 in type 2 respiratory failure Raised (A-a)pO2
Central nervous system (CNS) depression.
Neuromuscular disorders.
 Anion gap - this is useful in any cause of metabolic acidosis. In plasma,
the sum of the cations (sodium plus potassium) is normally greater
than that of the anions (chloride plus bicarbonate) by approximately
14 mmol/L (normal range 10-18 mmol/L). This is known as the anion
gap. In some disorders, either the positive or negative ions may
increase, leading to a change in the anion gap. The following table
lists the causes of an abnormal anion gap:
Causes of changes in anion gap
Raised anion gap metabolic acidosis
Accumulation of acids, for example:
Ketoacids in diabetic
ketoacidosis (DKA).
o Lactic acid - eg, shock,
 Causes of changes in anion gap
infection.
o Drugs/toxins - eg,
salicylates, ethylene glycol,
methanol.
Causes of a raised anion gap metabolic acidosis can be recalled using the
'MUDPILES' mnemonic (methanol, uraemia, DKA, paraldehyde,
infection/ischaemia/isoniazid, lactic acidosis, ethylene glycol/ethanol,
salicylates/starvation).
Primary acid-base disturbances
 Respiratory acidosis: low pH, high PaCO2, normal or high normal
bicarbonate.
Causes: neuromuscular weakness, intrinsic lung disease - eg, COPD.
 Respiratory alkalosis: high pH, low PaCO2, normal or high normal
bicarbonate.
Causes: any cause of hyperventilation - eg, anxiety, pain.
 Metabolic acidosis: low pH, normal or low normal PaCO2, low
bicarbonate.
Causes: see anion gap table, above.
 Metabolic alkalosis: high pH, normal PaCO2, high bicarbonate.
Causes: vomiting, burns, ingestion of base.
Mixed disorders
Mixed acid-base disorders occur when there is a combination of primary
acid-base disturbances (but not combined respiratory acidosis and alkalosis).
Usually the ABG result does not fit into one of the above four clinical pictures
easily. The therapy is directed towards correction of each primary acid-base
disturbance
 Complication
 Pain
2mts Explaining
 Haematoma And Haemorrhage Mention the
 Trauma To Vessel Listening complications
 Arteriospasm
 Air Or Clotted Blood Emboli
 Vaso Vagal Response
 Arterial Occlusion
 Infection
Summary:

So far we have discussed about definition ofArterial blood gas analysis,itspurposes,indication,contraindication,procedure .interpretation of
blood gases ,complication,monitoring and follow up.

Conclusion:

Arterial gas analysis to analyse the blood cases and its abnormalities.I hope that from this demonstration you would have acquired
knowledge about the arterial blood gas analysis thoroughly.I thank our Madams for giving this opportunity.
Bibliography

1. Annamma Jacob, “Clinical Procedures the Art of Nursing Practice”, 1 st edition (2007). Jaypee Brothers Medical Publishers, New Delhi. PP 396 to 410.

2. Lisa Dougherty, “Clinical Nursing Procedure”, 6th Edition (2004). The Royal Marsden , Blackwell Publishing Oxford, UK 688 to 693.

3. Jean Smith, “Nurse Guide to Clinical Procedure”, 3 rd edition 1998. Lippincott Philadelphia, Page Nos.137-154.