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2aono ‘Arterial Blood Gas Sampling: Backerour, Indications, Cenrsinccations Medscape This site is intended for healthcare professionals Arterial Blood Gas Sampling Updated: May 19, 2016 Author: Mauricio Danckers, MD; Chief Editor: Vincent Lopez Rowe, MD mor OVERVIEW Background Arteries are the large vessels that carry oxygenated blood away from the heart. The distribution of the systemic arteries is like a ramified tree, the common trunk of which, formed by the aorta, commences at the left ventricle, while the smallest ramifications extend to the peripheral parts of the body and the contained organs. For more information about the relevant anatomy, see Arterial Supply Anatomy. Arterial blood gas (ABG) sampling by direct vascular puncture is a procedure often practiced in the hospital setting. The relatively low incidence of major complications, '" its ability to be performed at the patient's bedside, and its rapid analysis make it an important tool used by physicians to direct and redirect the treatment of their patients, especially in patients who are critically ill, to determine gas exchange levels in the blood related to respiratory, metabolic, and renal function. ABG sampling is usually performed on the radial artery because the superficial anatomic presentation of this vessel makes it easily accessible. However, this should be done only after it has been demonstrated that there is sufficient collateral blood supply to the hand. In cases where distal Perfusion is compromised and distal pulses are diminished, femoral or brachial artery puncture can be performed instead. The brachial artery commences at the lower margin of the tendon of the teres major. Passing down the arm, it ends about 1 cm below the bend of the elbow, where it branches into the radial and ulnar arteries. The radial artery commences at the bifurcation of the brachial artery and passes along the radial side of the forearm to the wrist. ABG sampling provides valuable information on the acid-base balance at a specific point in the course of a patient's illness. It is the only reliable determination of ventilation success as evidenced by CO content. It constitutes a more precise measure of successful gas exchange and oxygenation. ABG sampling is the only way of accurately determining the alveolar-arterial oxygen gradient (see the A-a Gradient calculator). Because the results of ABG sampling only reflect the physiologic state of the patient at the time of the sampling, it is important that they be carefully correlated with the evolving clinical scenario and with any changes in the patient's treatment. Indications i f Indications for ABG sampling include the following [2 3. 41 ; hip/lemeticine medscape.convartce/1902703-cverview ats 16 muons ‘ter loo Gas Sampling Beckford deans, Conrinceaions * Identification of respiratory, metabolic, and mixed acid-base disorders, with or without Physiologic compensation, by means of pH ((H *]) and CO » levels (partial pressure of CO ») * 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 (Pa0 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) The American Association for Respiratory Care (AARC) has published a clinical practice guideline on blood gas analysis and hemoximetry, [51 Contraindications z foe Absolute contraindications for ABG sampling include the following '2 : + An abnormal modified Allen test (see Periprocedural Care, Preprocedural Planning), 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 [1 * 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 plasminogen activator Technical Considerations BG sampling may be difficult to perform in patients who are uncooperative or in whom pulses cannot be easily identified. Challenges arise when health care personnel are unable to position the patient properly for the procedure. This situation is commonly seen in patients with cognitive impairment, advanced degenerative joint disease, or essential tremor. The amount of subcutaneous fat in overweight and obese patients may limit access to the vascular area and obscure anatomic landmarks. Arteriosclerosis of peripheral arteries, as is seen in elderly patients and patients with end-stage kidney disease, may cause increased rigidity in the vessel wall hipllemeticine medscape-comvarcle/1902703-overviewtatS aor? ‘Atrial Stood Gos Sampling: Backgreu, ications, Cerrzindcatons Best practices The following suggestions may enhance the performance of ABG sampling: + Patients with poor distal perfusion (eg, those in hypovolemic states, with advanced heart failure, or on vasopressor therapy) may not exhibit a strong arterial pulsation; the operator may need to pull back the ABG syringe plunger to get a blood sample, though this increases the risk of venous blood sampiing + Ifarterial blood flow is not obtained, the operator might slowly pull back the needle; it is possible that the needle has gone through the vessel * Initial arterial flow may subsequently be lost if the needle moves outside the vessel lumen; reidentification of the arterial pulse, using the nondominant middle and index finger, and repositioning the needle in the direction of the vessel could be attempted; avoid blind movement of the needle while it is inserted deeply in the patient's body—pull it back to a point just below the skin, and redirect it to the arterial pulse felt with the other hand * Puncture of venous structures can be identified by lack of pulsatile flow or dark-colored blood, though, arterial blood in severely hypoxemic patients can also have a dark appearance; if venous blood is obtained, removal of the needle from the patient might be necessary to expel the venous blood from the syringe + Excessive skin and abundant soft tissue may obstruct the puncture site; the operator can use the nondominant hand to smooth the skin, or an assistant can remove the subcutaneous tissue from the puncture site field * Incomplete dismissal of heparin solution from the syringe could cause falsely low values for the partial pressure of CO 9; to avoid this, the operator should expel all heparin solution from the syringe before arterial puncture * Incomplete removal of air bubbles can cause falsely elevated values for the partial pressure of oxygen; to avoid this, the operator should be sure to completely remove air bubbles from the syringe (vented plungers have an advantage over standard syringes in this regard) * Avoid puncture of the brachial artery or femoral artery in patients with diminished or absent distal pulses; the absence of distal pulses may signal severe peripheral vascular disease + When femoral or brachial artery puncture is being considered, the use of ultrasound guidance during passage of the needle aids in providing an accurate roadmap to the vessel and helps minimize inadvertent arterial injuries Complication prevention Although patients with severe coagulopathy are at higher risk for bleeding complications, no clear evidence on the safety of arterial puncture in the setting of coagulopathy exists. In patients with coagulopathy, careful evaluation of the need for ABG sampling is recommended. Periprocedure References 1. Brzezinski M, Luisetti T, London MJ. Radial artery cannulation: a comprehensive review of recent anatomic and physiologic investigations. Anesth Analg. 2009 Dec. 109(6):1763-81. {Medline}. 2. AARC clinical practice guideline. Sampling for arterial blood gas analysis. American Association for Respiratory Care. Respir Care. 1992 Aug. 37(8):913-7. [Medline] 3, Raffin TA. Indications for arterial blood gas analysis. Ann Intern Med. 1986 Sep. 105(3):390-8. [Medline] hitpdlemedicine medscepe.conartle/1902705-over views 36 2aonor ‘Arteria Blood Gas Sampling: Backgrcunandctons, Containers 4, Baker WJ. Arterial puncture and cannulation. Roberts JR, Hedges JR, eds. Clinical Procedures in Emergency Medicine. 3rd ed. Philadelphia: WB Saunders Co; 1998. Chap 19 5. [Guideline] Davis MD, Walsh BK, Sittig SE, Restrepo RD. AARC clinical practice guideline: blood gas analysis and hemoximetry: 2013. Respir Care. 2013 Oct. 58 (10):1694-703. [Medline]. [Full Text. 6. Asif M, Sarkar PK. Three-digit Allen's test. Ann Thorac Surg. 2007 Aug. 84(2):686-7. [Medline]. 7. Barone JE, Madlinger RV. Should an Allen test be performed before radial artery cannulation?. J Trauma. 2006 Aug. 61(2):468-70. [Medline] 8, Ruengsakulrach P, Brooks M, Hare DL, Gordon I, Buxton BF. Preoperative assessment of hand circulation by means of Doppler ultrasonography and the modified Allen test. J Thorac Cardiovasc Surg. 2001 Mar. 121(3):526-31. [Medline]. 9. Gilbert HC, Vender JS. Arterial blood gas monitoring, Crit Care Clin. 1995 Jan. 11(1):233-48. [Medline]. 10. Zimmerman JL, Dellinger RP. Blood gas monitoring. Crit Care Clin. 1996 Oct. 12(4):865-74. [Medline]. 11. Baillie JK. Simple, easily memorised "rules of thumb" for the rapid assessment of physiological compensation for respiratory acid-base disorders. Thorax. 2008 Mar. 63(3):289-90. [Medline]. 12. Dzierba AL, Abraham P. A practical approach to understanding acid-base abnormalities in critical illness. J Pharm Pract. 2011 Feb. 24(1):17-26. [Medline]. 13. Sagy M, Barzilay Z, Boichis H. The diagnosis and management of acid-base imbalance. Pediatr Emerg Care. 1988 Dec. 4(4):259-65. [Medline]. Media Gallery Arterial blood gas sampling equipment. Arterial blood gas syringe kit. Modified Allen test: digital occlusion of radial and ulnar artery. Modified Allen test: clenching of hand. Modified Allen test: ulnar artery occlusion released. Modified Allen test: radial artery occlusion released. ‘Anatomic location of radial artery. Identification of radial pulse. Cleaning of desired radial artery puncture site. Insertion of needle at radial artery puncture site. Radial artery puncture. Removal of needle from radial artery puncture site and application of local pressure for hemostasis, Application of needle protective sleeve. Disposal of needle. Removal of air bubbles from syringe. Capping of syringe. Anatomy of femoral triangle. Identification of femoral artery. Cleaning of desired femoral artery puncture site. Insertion of needle at femoral artery puncture site. Femoral artery puncture itpdlemeicine medscape.convarcle/1902703-cverviewitatS 46 2wono7 ‘tori Blood Gas Somping: Backers ceations, Coniainicatens + Removal of needle from femoral artery puncture site and application of local pressure for hemostasis. Anatomic location of brachial artery. Identification of brachial artery. Cleaning of desired brachial artery puncture site. Insertion of needle at brachial artery puncture site. Brachial artery puncture. Removal of needle from brachial artery puncture site and application of local pressure for hemostasis. Back to List Contributor Information and Disclosures Author Mauricio Danckers, MD Pulmonary and Critical Care Physician, Aventura Medical Center Mauricio Danckers, MD is a member of the following medical societies: American College of Chest Physicians, American Medical Association Disclosure: Nothing to disclose. Coauthor(s) Ethan D Fried, MD, MS Associate Professor of Medicine, Hofstra North Shore-LlJ School of Medicine; Associate Designated Institutional Official, Associate Chair for Education, Department of Medicine, Member, Division of Pulmonary/Critical Care Medicine, Lenox Hill Hospital Ethan D Fried, MD, MS is a member of the following medical societies: American College of Physicians, Association of Program Directors in Intemal Medicine Disclosure: Nothing to disclose. Specialty Editor Board Mary L Windle, PharmD Adjunct Associate Professor, University of Nebraska Medical Center College of Pharmacy; Editor-in-Chief, Medscape Drug Reference Disclosure: Nothing to disclose. Chief Editor Vincent Lopez Rowe, MD Professor of Surgery, Program Director, Vascular Surgery Residency, Department of Surgery, Division of Vascular Surgery, Keck School of Medicine of the University of Southern California nigtiemedicine medscape.comfarticl!1902703-overviewta15 86 earn ‘Atrial Blood Gas Sampling: Background, Ieioaons, Cntraindications Vincent Lopez Rowe, MD is a member of the following medical societies: American College of Surgeons, American Heart Association, Society for Vascular Surgery, Vascular and Endovascular Surgery Society, Society for Clinical Vascular Surgery, Pacific Coast Surgical Association, Western Vascular Society Disclosure: Nothing to disclose. Acknowledgements A special thank-you to Dr Susan Nathan and Mr Kyle Pursell for their contributions to the realization of this article, nipitemedcine medscape.comarticle!1802703-overviewa5