PRAKTIKUM CLIN PATH DI BLOCK FMS 3 :

1.Do take arterial blood in mannequin

2. Handle syringe and specimen arterial blood after puncture

3.How to interpretation blood gas analysis result

1.Do take arterial blood in mannequin

OBTAINING ARTERIAL BLOOD SAMPLE
Prior to Obtaining Sample

 Check patients chart for

o The order (with or without oxygen?)
o What is the current oxygen order?
o Is the patient a COPD?
 If a recent FIO2 change has occurred, you must wait 5-10 minutes before performing
the puncture. With COPD patients wait 20-30 minutes!
 Is the patient receiving anti-coagulants or thrombolytics? Bleeding disorders? Shunt?
 Prepare the syringe ---- wet with heparin and no air space in syringe.

Ways to Obtain Arterial Blood

 Radial Puncture
 Brachial Puncture
 Femoral Puncture
 Arterial Line Draws

Radial Site

 Near the surface

 Best chance of collateral circulation
 No large veins nearby
 Not too painful
Perform the Allen’s Test Prior to Radial Puncture

 Tests for adequate collateral circulation

 Results can assist in determining which radial artery to use - left versus right
 Have patient make a fist while you tightly squeeze both the radial and ulnar arteries;
Let go of the ulnar and watch to see if hand is uniformly re-perfused (pinks up). If
large areas remain pale - check the other hand.

WHO Guidelines on Drawing Blood: Best Practices in Phlebotomy.

Release the occlusive pressure on the ulnar artery only to determine whether the modified
Allen test is positive or negative.
* Positive modified Allen test – If the hand flushes within 5-15 seconds it indicates that the
ulnar artery has good blood flow; this normal flushing of the hand is considered to be a
positive test.
* Negative modified Allen test – If the hand does not flush within 5-15 seconds, it indicates
that ulnar circulation is inadequate or nonexistent; in this situation, the radial artery
supplying arterial blood to that hand should not be punctured.

Steps in Performing Arterial Puncture

 Choose site - Radial is first site of choice

 Don gloves & clean site using Betadine &/or alcohol pad
 Prepare syringe - position gauze for holding the site after puncture is completed
 Palpate site; make sure bevel of needle is pointing up & needle is parallel to artery.
 Insert needle slowly at a 45 degree until blood enters the hub of the needle

Issues in Arterial Puncture

 Blood will enter syringe automatically because it is under pressure

 Arterial blood is generally brighter red than venous blood
 It is best to obtain a 1 - 2 ml of arterial blood. (Most blood gas machines can give
accurate blood gas values with a sample of low as 0.2 ml of arterial blood.)
 Use supplied 1 inch 22 gauge needle for radial
 Use larger and longer for brachial (can continue to use 22 gauge for brachial)
  Definitely hand brachial needle ( 1 and half inch 20guage) to ER doctor for femoral
draw
 Use smaller gauge needle for infants and smaller volume sample of blood

Helpful Hints for better technique

 Elevate the wrist for better success – Positioning one of the keys
 Quickly enter the skin and then slowly advance to ‘flash in the hub’
 If advance too quickly, can flash and stop – Slowly withdraw – blood may restart
 If miss the artery on first angle of attack, then withdraw to the bevel and redirect
medially or laterally
 Second key is keep palpating the pulse after first direction unsuccessful
 You will need to decide on which side you missed the artery on
 Some protocols dictate only two redirects
Post-puncture Issues

 Upon needle removal, immediately hold site with pressure using gauze for 5 minutes.
Inspect site to assure bleeding has stopped. Band-aid is optional
 Ice sample unless it is to be run immediately
 Note patient’s FIO2 and temperature
 If you have time, return after running sample and check for hematoma or occlusion of
vessel

Complications of Arterial Puncture

 Arteriospasm Air or clotted blood emboli

 Hematoma at site Hemorrhage
 Pain Trauma to artery or nerve
 Inadvertent needle stick Loss of feeling below puncture site

2. Handle syringe and specimen arterial blood

after puncture
 Expel any air present using care not to splatter blood
 Insert exposed needle into “rubber block” or “wax cap”. DANGER! Do NOT re-cap
needle! (In old days - Scoop with a one-hand-technique)
o Prevents contact with oxygen in air and inadvertent needle sticks
  Mix blood (with heparin) by rolling syringe between fingers and turning it upside
down
 DELIVER THE SPECIMEN TO THE LABORATORY WITHIN 15 MINUTES OF COLLECTION

3.How to interpretation blood gas analysis

result
Characteristics of Arterial Blood Gas Values

 A standard blood gas machine actually measures only the following values
o PO2; PCO2; pH
 The following values are calculated by the machine;
o SO2% (saturation); HCO3; Base Excess
 A special blood gas machine called a CO-oximeter actually measures oxygen
saturation; carbon monoxide saturation and hemoglobin levels

PURPOSE TO EXAMINE ARTERIAL BLOOD GAS ANALIZE

1.Evaluates how effectively the lungs are delivering oxygen to
the blood and how efficiently they are eliminating carbon
dioxide from it.
2.Evaluates how well the lungs and kidneys are interacting to
maintain normal blood pH (acid-base balance).

NORMAL ABG VALUES

pH 7.40 (7.35 – 7.45)

PaCO2 40 (35 – 45) mmHg

PaO2 80 – 100 mmHg

HCO3 : 22 – 26 m eq /L

O2 saturation : 95 – 100 %

Base excess : + or - 2

THE'6'EASY'STEPS'TO'ABG'ANALYSIS:
1. Is"the"pH"normal?
Analyze pH The"first"step"in"analyzing"ABGs"is"to"look"at"the"pH.""
Normal"blood"pH"is 7.35"to"7.45.
If"blood"pH"falls"below"7.35"it"is"acidotic.""
If" blood"pH"rises above"7.45,"it"is"alkalotic
2. Is"the"CO2"normal?
Step2: Analyze CO2
The"second"step"is"to"examine"the"pCO2.""Normal"pCO2"levels"are"35-
45mmHg.""
Below" 35"is"alkalotic,"above"45"is"acidotic.
3. Is"the"HCO3"normal?
Analyze the HCO3
The"third"step"is"to"look"at"the"HCO3"level.""A"normal"HCO3"level"is"22 -26
"mEq/L.
If"theHCO3"is"below"22,"the"patient"is"acidotic
If"the"HCO3"is"above"26,"the"patient"is" alkalotic
4. Match"the"CO2"or"the"HCO3"with"the"pH
Next"match"either"the"pCO2"or"the"HCO3"with"the"pH"to"determine"the"acid
base" disorder.
For"example,
IF THE PH IS ACIDOTIC ( < 7,35) :
a) IF "the"CO2"is"acidotic, ( > 45 ) the"acid base"
disturbance"is"being"caused"by"the"respiratory"system.""
Therefore,"we"call"it"a" respiratory acidosis.
b) If the HCO3 is acidotic ( < 22 ) the"acid base"
disturbance"is"being"caused"by"the"metabolic system.
Therefore,"we"call"it"a" metabolic acidosis.
IF"THE"PH"IS"ALKALOTIC ( > 7,45 )
a) IF "the"CO2"is"alkalotic ( < 35 ) the"acid base"
disturbance"is"being"caused"by"the"respiratory"system.""
Therefore,"we"call"it"a" respiratory"alkalosis.
b) If the HCO3 is alkalotic ( > 26 ) the"acid base"
disturbance"is"being"caused"by"the"metabolic system.
Therefore,"we"call"it"a" metabolic alkalosis.

5. Does"the"CO2"or"the"HCO3"go"the"opposite"direction of"the pH?

Fifth,"does"either"the"CO2"or"HCO3"go"in"the"opposite"direction"of"the"pH?
If"so,"there"is"compensation"by"that"system.
 For"example,"the"pH"is"acidotic,"the"CO2"is"acidotic,"and"
the"HCO3"is"alkalotic.
The"CO2"matches"the"pH"making"the"primary"acid base"disorder :
respiratory"acidosis.
The"HCO3"is"opposite"of"the"pH"and"would"be"evidence"of"
compensation"from"the"metabolic"system.
6. Are"the"pO2"and"the"O2"saturation"normal?
Step$6:$Analyze$the$pO2$and$the$O2$saturation.
Finally,"evaluate"the"PaO2"and"O2"sat.""If"they"are"below"normal"there"is"evi
dence"of" hypoxemia.

Case Example :

Tono 30 years old male , brought into ER unconcious.A friend found him. No other
history is available. Phy Exam is unremarkable except rapid and shallow breathing
. Arterial blood gas :
pH : 7,2 ( N : 7,35 – 7,45)
p CO 2 : 37 mm Hg ( N : 35 – 45 )
p O2 : 77 mm Hg ( N ; 75 – 100 )
p HCO3 : 17 mmol/L (N : 22 – 26 )
O2 sat : 95 % ( 95 – 100 )
O2 content : 18 ml / 100 ml blood ( 17 – 22 )
ACYDOSIS METAB

pH : 7,33 ( N : 7,35 – 7,45)

p CO 2 : 32 mm Hg ( N : 35 – 45 )
p O2 : 77 mm Hg ( N ; 75 – 100 )
p HCO3 : 17 mmol/L (N : 22 - 26 )
O2 sat : 95 % ( 95 – 100 )
O2 content : 18 ml / 100 ml blood ( 17 – 22 )
ACIDOSIS METAB TERKOMPENSASI ( HAMPIR PENUH)

pH : 7,50 ( N : 7,35 – 7,45)

p CO 2 : 31 mm Hg ( N : 35 – 45 )
p O2 : 77 mm Hg ( N ; 75 – 100 )
p HCO3 : 25 mmol/L (N : 22 – 26 )
O2 sat : 95 % ( 95 – 100 )
 O2 content : 18 ml / 100 ml blood ( 17 – 22 )
Alkalosis Respiratoric

References :
1.Shelly P. Dev, M.D., Melinda D. Hillmer, M.D., BSc.Phm., and Mauricio Ferri, M.D.
N Engl J Med 2011
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].