clinical perspectives
CORE COMPETENCY
Arterial Blood Gas
A
rterial blood
gases (ABGs) are a core compe-
tency for respiratory therapists.
The AARC and the National
Committee for Clinical Labora-
tory Standards (NCCLS) have
published multiple guidance
and standard documents
addressing each facet of the
subject. The interest, research,
and knowledge about all the
issues surrounding ABGs con-
tinue to grow. The majority of
the 1997 AARC Open Forum
session Monitors, Devices, &
Components: As Advertised
was devoted to the equipment
for analyzing ABGs and the
devices used to collect arterial
specimens.
A thorough and careful evalu-
ation is required for each type of
device introduced. Traditionally,
bias and error on the new instru-
ment is compared to the bias
and error on a conventional
Analysis
by Susan Blonshine, BS, RRT, RPFT
bench analyzer. Cost analysis
studies must also be completed
to compare the feasibility of
newer technologies such as
point of care devices or
patient-attached analyzers.
Importance of
outcome assessment
Outcome assessment is also
an integral part of the evalua-
tion phase. The introduction
of the Clinical Laborator y
Improvement Act of 1988 chal-
lenged the respirator y care
community to document our
role in this procedure. A survey
conducted by the AARC
revealed that in the United
States, respiratory therapists
perform approximately 80 per-
cent of ABGs. The challenge
continues as we move into a
combination of central labora-
tories and point-of-care test-
ing (POCT).
Technology is pro viding
smaller devices with a wider
range of anal ytes to select
f rom for inclusion on the
de vice. Anal ytes reach far
beyond pH, carbon dioxide
tension (PCO 2 ), oxygen ten-
sion (PO2), and hemoximetry.
Other selected analytes may
include electrolytes, glucose,
lactate, prothrombin time,
and activated partial throm-
boplastin time. Each service
location or application may
require a different combina-
tion of analytes.
Other important issues to
raise are the impact of POCT
on cost, training, and out-
comes. Quality control
requirements must be met
regardless of the ty pe of
device. Each regulatory group
or accrediting a gency may
have slightly different require-
ments.
A ARC Tm e s F e b r u a r y 19 9 9 55
 clinical perspectives
Controlling variances in
pre-analytical stage
An area of primary concern in
arterial blood collection is the
pre-analytical stage, the stage
where the greatest variance is
likely to occur. It is critical to
understand and control these
variances. Examples of potential
areas for error include the type
of syringe, anticoagulant, stor-
age method, and transport
method. A required analysis
time for each specimen under
specific conditions must be
defined.
At minimum, the following
should be considered in speci-
men preservation, transport,
and analysis:
removal of air contamination,
high PO2s,
elevated leukocyte or platelet
counts,
capping the specimen,
icing the specimen,
patients metabolic status,
use of plastic or glass syringes,
and
specific analytes required.
The simultaneous measure-
ment of blood gases,
56 AARC Tmes Fe b rua ry 1999
electrolytes, and other analytes
in whole blood expands the
knowledge requirements each
respiratory therapist must pos-
sess to fully understand the pre-
analytical effects on the speci-
men. The anticoagulant
selected must have little to no
effect on the analytes measured.
Heparin salt is the only antico-
agulant acceptable for the mea-
surement of the aforemen-
tioned analytes. Lithium
heparin is commonly used.
Icing a specimen
Generally, it is considered
acceptable to leave a sample at
room temperature if the analysis
will occur in 10 to 15 minutes.
Very high leukocyte values, as
seen in leukemic patients, can
cause a significant drop in the
PO2 over a short period. In this
case, the specimen should be
placed in an ice slurry or ana-
lyzed immediately.
The effect of lower tempera-
tures on red blood cell perme-
ability also applies to the icing
issue. Elevated potassium levels
have been observed in healthy
individuals, even when the spec-
imen was only iced for a few min-
utes. When potassium is mea-
sured, the specimen should be
analyzed in 10 to 15 minutes and
not iced. Ionized calcium con-
centration and pH are stable for
at least 10 to 15 minutes at room
temperature. If a delay in analy-
sis is anticipated, the specimen
should be placed in an ice slurry.
additional
reading
National Committee
for Clinical Labora-
tory Standards
(NCCLS). (1993). Simultane-
ous measurement of blood gases,
electrolytes, and related analytes in
whole blood: Patient, collection and
reporting considerations; proposed
guideline. (NCCLS Document C32-P).
NCCLS. (1992) Percutaneous collec-
tion of arterial blood for laboratory
analysis (2nd Ed.). (NCCLS Docu-
ment H11-A2).
NCCLS. (1991) Collection, transport,
and processing of blood specimens for
coagulation testing and general perfor-
mance of coagulation assays; approved
guideline (2nd Ed.). (NCCLS Docu-
ment H21-A2).
Peruzzi, W.T., & Shapiro, B.A. (1995,
September). Blood gas measurements.
Respiratory Care Clinics of North Amer-
ica, 1(1), 133-142.
Evaluating the
collection device
The specific collection device
should always be evaluated to
determine the effects on the
specimen and possible effects on
the equipment during analysis.
Information should also be avail-
able from the manufacturer.
Inadequate mixing of settled
specimens is also a commonly
overlooked pre-analytical error.
The sample must be mixed thor-
oughly for two to three minutes
immediately before measuring
 clinical perspectives
hemoglobin/hematocrit and
oxygen content.
If coagulation testing or assays
are to be performed, a different set
of procedures must be followed.
Anticoagulants such as oxalate,
heparin, and EDTAare unaccept-
able. The anticoagulant should be
10.9 mmol/L (3.2 percent) of the
dihydrate form of trisodium cit-
rate, buffered or nonbuffered. The
blood-to-anticoagulant ratio is
9:1. If this ratio is not maintained,
it may lead to inaccurate results.
An acceptable specimen is free
from clots and fills greater than
90 percent of the collection tube.
Gentle inversion and observation
of the whole-blood specimen
should reveal clot formation. If
visible hemolysis is present, the
specimen should not be used.
NCCLS guidelines for
specimen storage
NCCLS documents provide
further guidelines for storage of
specimens. Application of the
results to patient care is a part
of the day-to-day functions for
respiratory therapists.
Previous articles ha ve
demonstrated the value of the
respiratory therapist in appro-
priate ordering practices for
ABGs using clinical practice
guidelines. The control of ser-
vice utilization as testing
moves to the bedside is an
essential function for respira-
tory therapists.
Bedside testing
The critical care setting is a
primary location for bedside
testing. Frequent testing is per-
formed in these areas, offering
an opportunity to have a posi-
tive effect on turnaround
times, length of stay, and out-
comes through POCT. This fre-
quent testing creates a greater
concern of blood loss in the
neonatal intensive care unit.
The ability to measure multi-
ple analytes on small volumes is a
significant advantage of POCT.
Traditionally, the blood volumes
required are 2.7 to 3.0 mL. This
may account for as much as 10
percent of the blood loss in
neonates. The respiratory thera-
pist is the only professional inti-
mately involved in all steps of the
process, from assessing the need
for ABGs and related analytes to
appropriately applying results.
This unique role creates an
opportunity for respirator y
therapists as the measurement
of multiple analytes on whole
blood expands and technology
moves testing out of the tradi-
tional settings. b
Susan Blonshine is the director of
TechEd, a diagnostics consulting ser-
vice in Michigan. She is the AARCs
official representative to the National
Committee for Clinical Laboratory
Standards, and she chaired the Associ-
ations Diagnostics Section from 1995
to 1997.
A ARC Tmes F e bru a r y 19 99 57