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Arterial Puncture for Blood

Gas Analysis
Mira Puspita

BLOOD GAS ANALYSIS


Identify acid base disturbance
Quantification of oxyhemoglobin and saturation
O2
Quick assesment of electrolytes and Hb
Some machines will measure lactate (a
by product of anaerobic respiration).

Indications
Respiratory Failure in acute and chronic states
Any severe illness which may lead to a metabolic
acidosis - for example:
Cardiac failure
Liver failure
Renal failure
Hyperglycaemic states associated with diabetes mellitus
Multiorgan failure
Sepsis
Burns
Poisons/toxins

Evaluation Therapy

Contraindications
Absolute
A possitive Allen Test
Local infection or
distorted anatomy at
the potential puncture
The presence of
arteriovenous
fistulasor vascular
grafts
Known or suspected
severe peripheral
vascular disease of
the limb involved

Relative
Severe coagulopathy
Use of thrombolytic
agents, such as
streptokinase or
tissue plasminogen
activator

Arterial Puncture sites


Radial artery ,
Brachial artery

Femoral artery

Which Artery to Choose?


The radial artery is superficial, has
collaterals and is easily compressed. It
should almost always be the first choice.

COMPLICATION

Local hematoma
Artery vasospasm
Arterial occlusion
Air or thrombus embolism
Local anesthetic anaphylactic reaction
Infection at the puncture site
Vessel laceration
Hemorrhage
Local pain

ALLEN TEST
To assess the arterial blood flow to the hand

Periprocedural Care
Informed Consent
Equipment

Preparing to perform the Procedure:


Make sure you and the patient are
comfortable.
Cleansing Hands
Barrier Protection

1. Radial Artery Blood Sampling

Allen test first


The radial artery is most
easily accessible medial to
the radial styloid process
and lateral to the flexor carpi
radialis tendon, 2-3 cm
proximal to the ventral
surface of the wrist crease

1. Radial Artery Blood


Sampling

2. Brachial Artery Blood


Sampling

The brachial artery is best


identified
between
the
medial epicondyle of the
humerus and the tendon of
the biceps brachii in the
antecubital fossa.

2. Femoral Artery Blood


Sampling

The femoral artery is best


identified in the midline
between the symphysis
pubis and the anterior
superior iliac crest, 2-4 cm
distal to the inguinal
ligament.

INTERPRETATION OF
ARTERIAL BLOOD GASES

COMPONENTS OF THE ABG

pH: Measurement of acidity or alkalinity, based on the hydrogen (H+

7.35 7.45
Pao2: The partial pressure oxygen that is dissolved in arterial blood.
80-100 mm Hg.
PCO2: The amount of carbon dioxide dissolved in arterial blood.
35 45 mmHg
HCO3: The calculated value of the amount of bicarbonate in the blood
22 26 mmol/L

B.E:
The base excess indicates the amount of excess or
insufficient
level of bicarbonate. -2 to +2mEq/L

SaO2:The arterial oxygen saturation. >95%

Stepwise approach to ABG


Step 1: Acidosis or Alkalosis?
Step 2: Is the primary disturbance respiratory or metabolic?
Step 3. Assess to Pa O2.
Step 4. For a metabolic acidosis, determine whether an anion
gap is present.
Step 5. Assess the normal compensation by the respiratory
system for a metabolic disturbance

Step 1. Acidosis or
Alkalosis?
pH??
If pH <7.35 primary disorder is
acidosis
If pH > 7.45 primary disorder is
alkalosis

Step 2. Is the primary disturbance


respiratory or metabolic?
PaCO2
Searah dengan PH : Kompensasi respirasi
dengan komponen metabolik sebagai
penyebab utama
Berlawanan dengan PH : Murni komponen
respirasi sebagai penyebab

HCO3
Searah dengan PH : Murni komponen metabolik
sebagai penyebab
Berlawanan dgn PH : Kompensasi metabolik
dengan komponen respirasi sebagai penyebab
utama

Step 2. Is the primary disturbance


respiratory or metabolic?
PaCO2
Searah dengan PH : Kompensasi respirasi dengan
komponen metabolik sebagai penyebab utama
Berlawanan dengan PH : Murni komponen
respirasi sebagai penyebab

HCO3
Searah dengan PH : Murni komponen metabolik
sebagai penyebab
Berlawanan dgn PH : Kompensasi metabolik
dengan komponen respirasi sebagai penyebab
utama

pH

PaCo2

HC03
normal

Respiratory
acidosis
Respiratory
Alkalosis
Metabolic
Acidosis
Metabolic
Alkalosis

normal
normal
normal

Step 3. Assess to PaO2


Assess pao2 < 80 mm Hg - Hypoxemia
If the change in paco2 is associated with
the change in pH, the disorder is acute.
In chronic process the compensatory
process brings the pH to within the
clinically acceptable range ( 7.30 7.50)

Step 4. Anion Gap

Calculation of AG is useful approach to


analyse metabolic acidosis
AG = (Na+) (cl- + Hco3-)
Normal 8-16 mmol/L

STEP 5. COMPENSATION
A patient can be uncompensated or
partially compensated or fully
compensated
pH has returned within normal rangefully compensated though other
values may be still abnormal

TERIMA KASIH

LOCATIONS
Arteri Radialis, merupakan pilihan pertama yang paling
aman dipakai untuk pungsi arteri kecuali terdapat banyak
bekas tusukan atau haematom juga apabila Allen test
negatif.
Arteri Brachialis, merupakan pilihan kedua karena lebih
banyak resikonya bila terjadi obstruksi pembuluh darah.
Arteri Femoralis, merupakan pilihan terakhir apabila pada
semua arteri diatas tidak dapat diambil. Bila terdapat
obstruksi pembuluh darah akan menghambat aliran darah
ke seluruh tubuh/ tungkai bawah dan bila yang dapat
mengakibatkan berlangsung lama dapat menyebabkan
kematian jaringan. Arteri femoralis berdekatan dengan vena
besar, sehingga dapat terjadi percampuran antara darah
vena dan arteri.

Contraindications
bsolute 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[2]
Local infection or distorted anatomy at the potential puncture site (eg, from
previous surgical interventions, congenital or acquired malformations, or
burns)
The presence ofarteriovenous fistulasor vascular grafts, in which case
arterial vascular puncture should not be attempted
Known or suspected severe peripheral vascular disease of the limb involved [2]
Relative contraindications include the following:
Severe coagulopathy[2]
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[2]
Use of thrombolytic agents, such as streptokinase or tissue plasminogen
activator[2]

Indications
Identification of respiratory, metabolic, and mixed acid-base disorders, with or without
physiologic compensation
Respiratory failure- in acute and chronic states.
Any severe illness which may lead to a metabolic acidosis - for example:
Cardiac failure.
Liver failure.
Renal failure.
Hyperglycaemic states associated withdiabetes mellitus.
Multiorgan failure.
Sepsis.
Burns.
Poisons/toxins.

Ventilated patients.
Sleep studies.
Severely unwell patients from any cause - affects prognosis.

Indications

Identification of respiratory, metabolic, and mixed acid-base disorders, with or without


physiologic compensation

Monitoring of acid-base status, as in patient with diabetic ketoacidosis (DKA) on insulin


infusion

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 [2, 3](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 (PaO2), 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 [4] )