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ArterialBloodGasSampling:Overview,PeriproceduralCare,Technique

ArterialBloodGasSampling
Author:MauricioDanckers,MDChiefEditor:VincentLopezRowe,MDmore...
Updated:Sep08,2014

Overview
Background
Arteriesarethelargevesselsthatcarryoxygenatedbloodawayfromtheheart.The
distributionofthesystemicarteriesislikearamifiedtree,thecommontrunkof
which,formedbytheaorta,commencesattheleftventricle,whilethesmallest
ramificationsextendtotheperipheralpartsofthebodyandthecontainedorgans.
Formoreinformationabouttherelevantanatomy,seeArterialSupplyAnatomy.
Arterialbloodgas(ABG)samplingbydirectvascularpunctureisaprocedureoften
practicedinthehospitalsetting.Therelativelylowincidenceofmajorcomplications,
[1]itsabilitytobeperformedatthepatientsbedside,anditsrapidanalysismakeit
animportanttoolusedbyphysicianstodirectandredirectthetreatmentoftheir
patients,especiallyinpatientswhoarecriticallyill,todeterminegasexchange
levelsinthebloodrelatedtorespiratory,metabolic,andrenalfunction.
ABGsamplingisusuallyperformedontheradialarterybecausethesuperficial
anatomicpresentationofthisvesselmakesiteasilyaccessible.However,this
shouldbedoneonlyafterithasbeendemonstratedthatthereissufficientcollateral
bloodsupplytothehand.Incaseswheredistalperfusioniscompromisedanddistal
pulsesarediminished,femoralorbrachialarterypuncturecanbeperformed
instead.
Thebrachialarterycommencesatthelowermarginofthetendonoftheteres
major.Passingdownthearm,itendsabout1cmbelowthebendoftheelbow,
whereitbranchesintotheradialandulnararteries.Theradialarterycommencesat
thebifurcationofthebrachial,andpassesalongtheradialsideoftheforearmto
thewrist.
ABGsamplingprovidesvaluableinformationontheacidbasebalanceataspecific
pointinthecourseofapatient'sillness.Itistheonlyreliabledeterminationof
ventilationsuccessasevidencedbyCO2content.Itconstitutesamoreprecise
measureofsuccessfulgasexchangeandoxygenation.ABGsamplingistheonly
wayofaccuratelydeterminingthealveolararterialoxygengradient(seetheAa
Gradientcalculator).
BecausetheresultsofABGsamplingonlyreflectthephysiologicstateofthe
patientatthetimeofthesampling,itisimportantthattheybecarefullycorrelated
withtheevolvingclinicalscenarioandwithanychangesinthepatientstreatment.

Indications
IndicationsforABGsamplingincludethefollowing:
Identificationofrespiratory,metabolic,andmixedacidbasedisorders,with
orwithoutphysiologiccompensation,bymeansofpH([H +])andCO 2levels
(partialpressureofCO 2) [2,3]
Measurementofthepartialpressuresofrespiratorygasesinvolvedin
oxygenationandventilation
Monitoringofacidbasestatus,asinpatientwithdiabeticketoacidosis(DKA)
oninsulininfusionABGandvenousbloodgas(VBG)couldbeobtained
simultaneouslyforcomparison,withVBGsamplingsubsequentlyusedfor
furthermonitoring
Assessmentoftheresponsetotherapeuticinterventionssuchasmechanical
ventilationinapatientwithrespiratoryfailure
Determinationofarterialrespiratorygasesduringdiagnosticevaluations [2,3]
(eg,assessmentoftheneedforhomeoxygentherapyinpatientswith
advancedchronicpulmonarydisease)
Quantificationofoxyhemoglobin,which,combinedwithmeasurementof
arterialoxygentension(PaO 2),providesusefulinformationaboutthe
oxygencarryingcapacityofthepatient
Quantificationofthelevelsofdyshemoglobins(eg,carboxyhemoglobinand
methemoglobin)
Procurementofabloodsampleinanacuteemergencysettingwhenvenous
samplingisnotfeasible(manybloodchemistrytestscouldbeperformed
fromanarterialsample [4])

Contraindications
AbsolutecontraindicationsforABGsamplingincludethefollowing:
AnabnormalmodifiedAllentest(seebelow),inwhichcaseconsideration

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shouldbegiventoattemptingpunctureatadifferentsite [2]
Localinfectionordistortedanatomyatthepotentialpuncturesite(eg,from
previoussurgicalinterventions,congenitaloracquiredmalformations,or
burns)
Thepresenceofarteriovenousfistulasorvasculargrafts,inwhichcase
arterialvascularpunctureshouldnotbeattempted
Knownorsuspectedsevereperipheralvasculardiseaseofthelimbinvolved
[2]

Relativecontraindicationsincludethefollowing:
Severecoagulopathy [2]
Anticoagulationtherapywithwarfarin,heparinandderivatives,direct
thrombininhibitors,orfactorXinhibitorsaspirinisnotacontraindicationfor
arterialvascularsamplinginmostcases [2]
Useofthrombolyticagents,suchasstreptokinaseortissueplasminogen
activator [2]

TechnicalConsiderations
ABGsamplingmaybedifficulttoperforminpatientswhoareuncooperativeorin
whompulsescannotbeeasilyidentified.Challengesarisewhenhealthcare
personnelareunabletopositionthepatientproperlyfortheprocedure.This
situationiscommonlyseeninpatientswithcognitiveimpairment,advanced
degenerativejointdisease,oressentialtremor.
Theamountofsubcutaneousfatinoverweightandobesepatientsmaylimitaccess
tothevascularareaandobscureanatomiclandmarks.
Arteriosclerosisofperipheralarteries,asisseeninelderlypatientsandpatientswith
endstagekidneydisease,maycauseincreasedrigidityinthevesselwall.

Bestpractices
ThefollowingsuggestionsmayenhancetheperformanceofABGsampling:
Patientswithpoordistalperfusion(eg,thoseinhypovolemicstates,with
advancedheartfailure,oronvasopressortherapy)maynotexhibitastrong
arterialpulsationtheoperatormayneedtopullbacktheABGsyringe
plungertogetabloodsample,althoughthisincreasestheriskofvenous
bloodsampling
Ifarterialbloodflowisnotobtained,theoperatormightslowlypullbackthe
needleitispossiblethattheneedlehasgonethroughthevessel
Initialarterialflowmaysubsequentlybelostiftheneedlemovesoutsidethe
vessellumenreidentificationofthearterialpulse,usingthenondominant
middleandindexfinger,andrepositioningtheneedleinthedirectionofthe
vesselcouldbeattemptedavoidblindmovementoftheneedlewhileitis
inserteddeeplyinthepatientsbodypullitbacktoapointjustbelowthe
skin,andredirectittothearterialpulsefeltwiththeotherhand
Punctureofvenousstructurescanbeidentifiedbylackofpulsatileflowor
darkcoloredblood,though,arterialbloodinseverelyhypoxemicpatientscan
alsohaveadarkappearanceifvenousbloodisobtained,removalofthe
needlefromthepatientmightbenecessarytoexpelthevenousbloodfrom
thesyringe
Excessiveskinandabundantsofttissuemayobstructthepuncturesitethe
operatorcanusethenondominanthandtosmooththeskin,oranassistant
canremovethesubcutaneoustissuefromthepuncturesitefield
Incompletedismissalofheparinsolutionfromthesyringecouldcausefalsely
lowvaluesforthepartialpressureofCO 2toavoidthis,theoperatorshould
expelallheparinsolutionfromthesyringebeforearterialpuncture
Incompleteremovalofairbubblescancausefalselyelevatedvaluesforthe
partialpressureofoxygentoavoidthis,theoperatorshouldbesureto
completelyremoveairbubblesfromthesyringe(ventedplungershavean
advantageoverstandardsyringesinthisregard)
Avoidpunctureofthebrachialarteryorfemoralarteryinpatientswith
diminishedorabsentdistalpulsestheabsenceofdistalpulsesmaysignal
severeperipheralvasculardisease
Whenfemoralorbrachialarterypunctureisbeingconsidered,theuseofthe
ultrasoundguidanceduringpassageoftheneedleaidsinprovidingan
accurateroadmaptothevesselandhelpsminimizeinadvertentarterial
injuries

Proceduralplanning
Planningfortheprocedurefocusesonthechoiceofapuncturesiteandaccurate
delineationofthevascularanatomy.Ifradialarterysamplingistobeperformed,the
adequacyoftheulnarcollateralcirculationmustbeconfirmed.
Selectionofpuncturesite
Punctureoftheradialarteryisusuallypreferredbecauseoftheaccessibilityofthe
vessel,thepresenceofcollateralcirculation,andtheartery'ssuperficialcourse
proximaltothewrist,whichmakesiteasierforthecliniciantoidentifythevascular
structureandholdlocalpressureaftertheprocedureisfinished.
Ifradialarterysamplingisnotfeasible,femoralarterypunctureisapossible

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alternative.Whenfemoralarterypunctureisbeingconsidered,thepotentialriskof
infectionattheentrysiteandtheartery'sproximitytothefemoralveinandnerve
mustbetakenintoaccount.Thedeeperthevascularstructure,thehighertheriskof
damagetoadjacentstructures.
Femoralarterypuncturenecessitatesprolongedmonitoringandthereforeis
recommendedonlyintheinpatientsetting. [2]Somephysiciansrecommendthat
femoralarterypuncturebeavoidedwheneverpossible.Thisconsiderationmayplay
abiggerroleforpatientswhowillbeundergoinganinterventionthatinvolves
femoralaccess(eg,cardiaccatheterizationorintraaorticballoonpumpplacement)
inthenearfuture.
Thebrachialarteryrunsdeeperinthearmthantheradialarterydoes.
Consequently,itsstructuresaretypicallyhardertoidentify,andachieving
hemostasiswhennecessaryismoredifficult.Furthermore,thebrachialarteryisa
relativelysmallcalibervesselanddoesnothaveextensivecollateralcirculation.For
thesereasons,thebrachialarteryistheleastpreferredsiteforpuncture.
Repeatedarterialbloodsamplingatthesamesiteincreasestheriskofhematoma,
lacerationoftheartery,andscarring. [2]Italsoincreasesthechancesofinadvertent
venousbloodsampling.Ifrecurrentsamplingisrequired,healthcarepersonnel
shouldalternatepuncturesites.Ifmorefrequentsamplingisnecessary,thehealth
careprovidershouldconsiderplacinganindwellingarterialcatheterthrougharterial
cannulation.
Confirmationofvascularanatomy
ABGsamplingcanbedifficultinpatientswithfeeblepulsesordistortedanatomic
landmarksorinsituationswheresamplingofadeepvascularstructure(eg,the
femoralorbrachialartery)isrequired.Inthesescenarios,ultrasoundguidedABG
samplingshouldbeconsidered,especiallywhensamplingbythestandardapproach
hasbeenunsuccessfulorisnotfeasible.
Ultrasonographyisanoninvasivetechniquewithanexcellentsafetyprofile.Itisan
importantoptionincaseswherevascularsamplingprovesdifficult.Theuseof
ultrasonographyenablesmoreaccuraterecognition,delineation,andtargetingof
thechosenvascularstructure.Itminimizestheriskofvascularlacerationand
damagetosurroundingstructures.
Althoughultrasoundguidanceisasafeandeffectivetoolforpatientswithweak
pulses,abetteroptionforpatientsinprofoundshockorinthemidstof
cardiopulmonaryresuscitationistoobtainarterialbloodfromthefemoralartery
usingbonylandmarksalone.Whenthetipofthefifthfingerisplacedonthe
symphysispubisandthetipofthethumbontheanteriorsuperioriliacspine,the
femoralarteryalwaysliesbeneaththemiddlefinger.
Assessmentofcollateralcirculation(modifiedAllentest)
Ifpunctureoftheradialarteryisplanned,amodifiedAllentestshouldbeperformed
beforehandwhenfeasibletoassessthecollateralcirculation.Althoughtheanatomy
oftheradialarteryintheforearmandthehandisvariable,mostpatientshave
adequatecollateralflowshouldradialarterythrombosisoccur. [1]ThemodifiedAllen
testisperformedasfollows. [1]
Firmocclusivepressureisheldonboththeradialarteryandtheulnarartery(see
thefirstimagebelow).Thepatientisaskedtoclenchthefistseveraltimesuntilthe
palmarskinisblanched(seethesecondimagebelow),thentounclenchthefist.
Overextensionofthehandorwidespreadingofthefingersshouldbeavoided,
becauseitmaycausefalsenormalresults. [5]Thepressureontheulnararteryis
releasedwhileocclusionoftheradialarteryismaintained(seethethirdimage
below).Thetimerequiredforpalmarcapillaryrefillisnoted.

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ModifiedAllentest:digitalocclusionofradialandulnarartery.

ModifiedAllentest:clenchingofhand.

ModifiedAllentest:ulnararteryocclusionreleased.

Thetestisthenrepeated,butthistimetheradialarteryisreleasedwhiletheulnar
arteryremainscompressed(inversemodifiedAllentestseetheimagebelow).

ModifiedAllentest:radialarteryocclusionreleased.

ThemodifiedAllenstesthasbeenthemethodmostfrequentlyusedforclinical

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assessmentoftheadequacyofulnararterycollateralcirculationandthepatencyof
thepalmararchesofthehand.However,thereissomecontroversialevidence
suggestingthatitcanpredictischemiccomplicationsinthesettingofradialartery
occlusion. [1]
GiventhelowpositivepredictivevalueofthemodifiedAllentest,theexaminer
shouldconsiderfurthertestingtoassesspatencyofcirculation,suchasfingerpulse
plethysmography,Dopplerflowmeasurements,andmeasurementofthearterial
systolicpressureofthethumb. [5]
WhetherthemodifiedAllentestisclinicallyreliableasascreeningtestforadequate
collateralcirculationofthehandiscontroversial.Awiderangeofvaluesforhand
reperfusionhavebeennoted,andnormalvaluesarenotconsistent(rangingfrom3
to15seconds)[1,5,6]furthermore,thereisconflictingevidenceregardingthe
validityofthemodifiedAllentestasastandardofcare. [6,7]

Complicationprevention
Althoughpatientswithseverecoagulopathyareathigherriskforbleeding
complications,noclearevidenceonthesafetyofarterialpunctureinthesettingof
coagulopathyexists.Inpatientswithcoagulopathy,carefulevaluationoftheneed
forABGsamplingisrecommended.

PeriproceduralCare
PatientEducation/InformedConsent
Healthcarepersonnelshouldexplainthearterialbloodgas(ABG)sampling
proceduretothepatient,withparticularattentiontotheassociatedrisksand
benefits.However,thismaynotbepossibleincertainclinicalscenarios,suchasa
criticallyillpatientwithrapiddecompensationorapatientwithanalteredlevelof
consciousness(eg,fromencephalopathyoradvanceddementia).Writtenconsentis
notnecessary.
Patientsshouldbeaskednottomanipulatetheareainvolvedintheprocedureand
shouldbeinstructedtoalerthealthcarepersonnelifnewsymptomsdevelop,such
asskincolorchanges,persistentorworseningpain,activebleeding,impaired
movement,orsensationofthelimb.

Equipment
ThematerialsneededforABGsampling(seetheimagebelow)includethe
following:

Arterialbloodgassamplingequipment.

Seethelistbelow:
GlovesNonsterileglovesmaybeused,butcaremustbetakennottotouch
thepuncturesiteaftercleaningthearea
SyringeforsamplingAstandardsyringewitha25gaugeneedleanda3
mLcapacity(ahighercapacitysyringemaybedifficulttomaneuver,and
smallerneedlesizesmayincreasetheriskoftraumatichemolysis,
decreasingtheaccuracyofhemoglobinandpotassiummeasurements)
Lithiumheparin12mLlithiumheparin(1000U/mL)shouldbeaspirated
intothesyringethroughtheneedleandthenpushedouttheplungershould
beleftdepressedtoallowthearterialbloodflowtofillupthesyringe
ABGsyringe(alternative)SomeABGkitscontainaprefilledheparinized
syringealongwithaprotectiveneedlesleeveandasyringecap(seethe
imagebelow)thesleeve,whilestillattachedtothesyringe,lockstheneedle
withinitselftopreventdirectcontactbetweenoperatorandneedlesome
syringemodelshaveaventedplungerthatallowstheoperatortopreseta
specificamountofbloodtobewithdrawn,andwiththesemodels,the
plungerisplacedmidwaythroughthesyringeandisnotpulledbackwhile
thepunctureisperformedbeforetheprocedure,theprefilledheparinis
expelled,andtheventedplungeristhenrepositionedatthe2mLmark

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Arterialbloodgassyringekit.

AntisepticskinsolutionChlorhexidineandpovidoneiodinearesolutions
commonlyused
SyringecapUsuallyincludedintheABGsyringekit
22in.pieceofsterilegauze
Adhesivebandage
Bagwithice
Sharpobjectcontainer
LidocaineHCl1%withoutepinephrine(optional)
25gaugeneedlewithsyringeforlocalanesthetic(optional)

PatientPreparation
Appropriatepositioningofthepatientandknowledgeofthevascularanatomy
increasethechancesofasuccessfularterialvascularsamplinganddiminishtherisk
ofcomplications.

Anesthesia
LocalanesthesiawithasubcutaneousinjectionoflidocaineHCl1%without
epinephrinemaybeused.Localanesthesiaisnotfrequentlyemployed,however,
becausetheadministrationoftheanestheticisaspainfulastheprocedureitself.
Iflocalanesthesiaisemployed,0.51mLoftheanestheticisinjectedsoasto
createasmalldermalpapuleatthesiteofpunctureusinglargeramountsor
injectingtheanestheticintodeeperplanesmaydistorttheanatomyandhinder
identificationofthevessel.Aftertheskinispuncturedbutjustbeforetheanesthetic
isinjected,theclinicianshouldpullbacktheplungertoconfirmthattheneedleis
notinsideabloodvesselintravascularplacementwillbesignaledbybloodfillingup
theanestheticsyringe.

Positioning
Forradialarterybloodsampling,thepatientshouldbeinthesupineposition,with
thearmlyingathisorheronahardsurface.Theforearmshouldbesupinatedand
thewristdorsiflexedat40.Agauzerollmaybeplacedunderthewristtomakethe
patientmorecomfortableandtobringtheradialarterytoamoresuperficialplane.
Overextensionofthewristisdiscouraged,becauseinterpositionofflexortendons
maymakethepulsedifficulttodetect.
Forfemoralarterybloodsampling,thepatientissupineonastretcher,andthe
patient'slegisplacedinneutralanatomicposition.
Forbrachialarterybloodsampling,thearmisplacedonafirmsurfacewiththe
shoulderslightlyabducted.Theelbowisextended,withtheforearminfull
supination.

MonitoringandFollowup
Afterthebloodsamplingprocedure,healthcarepersonnelshouldmonitorthe
patientforearlyandlatesignsandsymptomsofpotentialcomplications.Active
profusebleedingatthepuncturesitemightraisesuspicionofvessellaceration.
Femoralarterybleedingcarriesanincreasedriskofcirculatorycompromisebecause
ofthelargecaliberanddeeplocationofthevessel,whichallowlargeramountsof
bloodtoaccumulatewithoutinitiallygivingrisetoclinicalfindings.
Arapidlyexpandinghematomamaycompromiseregionalcirculationandincrease
theriskofcompartmentsyndrome,especiallyintheforearm.Thismanifestsas
pain,paresthesias,pallor,andabsenceofpulses.Paresisandpersistentpainmay
indicateanervelesion.Limbskincolorchanges,absentpulses,anddistalcoldness

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maybeseeninischemicinjuryfromarteryocclusioncausedbythrombusformation
orvasospasm.Infectionatthepuncturesiteshouldbeconsideredinthepresence
ofregionalerythemaandfever.

Technique
ApproachConsiderations
Healthcarepersonnelshouldwearglovesandeyeprotectionforthedurationofthe
arterialbloodgas(ABG)samplingprocedureandshouldfollowhospitalpolicies
regardingmanagementofbodyfluidsamples.Theoperatorshouldhaveallthe
requiredequipmentatthebedsidebeforebeginningtheprocedure.
Thearterialpulseisfeltwiththemiddleandindexfingersofthenondominanthand.
Bothfingersshouldbeproximaltothedesiredpuncturesiteplacingthe
nondominantmiddlefingerdistallyandthenondominantindexfingerproximally,
withtheneedleinsertionsiteinbetween,isstronglydiscouraged,becauseofthe
increasedriskofneedlestickinjury.
IftheABGsyringeistobeused,theprotectiveneedlesleeveandneedleshouldbe
placedontothesyringe,theprefilledheparinexpelled,andtheventedplunger
repositionedtothe2mLmark.
Arterialbloodsamplesshouldbeobtainedinstrictanaerobicconditionsandshould
beplacedoniceandheldat0Cuntilanalysis. [8]Anyairbubblesintroducedduring
thesamplingprocedurewillleadtooverestimationofarterialoxygentension(PaO2)
andunderestimationofarterialcarbondioxidetension(PaCO2). [8]
Keepingthesampleatlowertemperaturesslowscellularmetabolismandreduces
ongoingconsumptionofoxygen. [8]Thisisespeciallyimportantinpatientswith
leukocytosis. [9]

RadialArteryBloodSampling
Theradialarteryismosteasilyaccessiblemedialtotheradialstyloidprocessand
lateraltotheflexorcarpiradialistendon,23cmproximaltotheventralsurfaceof
thewristcrease(seetheimagebelow).

Anatomiclocationofradialartery.

Theprocedureisperformedasfollows.First,performamodifiedAllentestinthe
limbselectedfortheprocedure(seeIntroduction).
Palpatethepatient'sradialpulsewiththeindexandmiddlefingerpadsofthe
nondominanthand(seethefirstimagebelow).Visualizethedirectionoftheartery,
andcleanthedesiredpuncturesiteinanoutwardcircularmotionwithanantiseptic
solution(seethesecondimagebelow).

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Identificationofradialpulse.

Cleaningofdesiredradialarterypuncturesite.

UncaptheABGsyringe,andholditwith2fingersofthedominanthand.The
needlebevelshouldbefacingupward.Inserttheneedlejustundertheskinata45
angle,aiminginthedirectionoftheartery,whilepalpatingtheradialpulseproximal
tothepuncturesitewiththenondominanthand(seetheimagebelow).Anglingthe
needleinthisfashionminimizestraumatothevesselandallowssmoothmuscle
fiberstooccludethepuncturesiteaftertheprocedure.

Insertionofneedleatradialarterypuncturesite.

Advancetheneedleslowly.Oncetheneedleentersthelumenoftheradialartery,
thearterialbloodflowstartstofillthesyringe(seetheimagebelow).Atthispoint,
removethenondominanthandfromthefield.Itisnotnecessarytopullbackthe
plunger,unlessanunventedplungerwithasmall(25gauge)needleisbeingused
orthepatienthasaweakpulse.

Radialarterypuncture.

After23mLofarterialbloodhasbeenobtained,removetheneedle.Atthesame
time,useasmallpieceofgauze,heldinthenondominanthand,toapplyfirm
occlusivelocalpressureatthepuncturesitefor5minutes(seetheimagebelow).
Avoidcheckingthepuncturesiteuntillocalpressurehasbeenmaintainedforat
least5minutes.Inpatientswhohaveacoagulopathyorareonanticoagulation

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therapy,itmaybenecessarytoapplylocalpressureforalongertime.Checkfor
hemostasis,andapplyanadhesivebandageoverthepuncturesite.

Removalofneedlefromradialarterypuncturesiteandapplicationoflocalpressurefor
hemostasis.

Applytheneedleprotectivesleeve(seethefirstimagebelow),thenuntwistthe
sleeveandplaceitinthesharpobjectcontainer(seethesecondimagebelow).

Applicationofneedleprotectivesleeve.

Disposalofneedle.

Removetheexcessairinthesyringebyholdingituprightandgentlytappingit,
allowinganyairbubblespresenttoreachthetopofthesyringe,fromwherethey
canthenbeexpelled(seethefirstimagebelow).Capthesyringe,placeitintheice
bag,andsenditforanalysis(seethesecondimagebelow).

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Removalofairbubblesfromsyringe.

Cappingofsyringe.

FemoralArteryBloodSampling
Thefemoralarteryisbestidentifiedinthemidlinebetweenthesymphysispubisand
theanteriorsuperioriliaccrest,24cmdistaltotheinguinalligament.Thefemoral
arteryismedialtothefemoralnerveandlateraltothefemoralvein(seetheimage
below).

Anatomyoffemoraltriangle.

Itisimportanttoassessthedistalpulsesofthelowerlimbbeforeattempting
femoralpuncture.Diminishedorabsentpedalpulsescouldbeindicativeof
peripheralarterialdisease(PAD).IfPADisasignificantpossibility,strong
considerationshouldbegiventousinganalternativearterialpuncturesite.

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Theprocedureisperformedasfollows.
Palpatethepatient'sfemoralpulsewiththeindexandmiddlefingerpadsofthe
nondominanthand(seethefirstimagebelow).Visualizethedirectionoftheartery,
andcleanthedesiredpuncturesiteinanoutwardcircularmotionwithanantiseptic
solution(seethesecondimagebelow).

Identificationoffemoralartery.

Cleaningofdesiredfemoralarterypuncturesite.

UncaptheABGsyringe,andholditwith2fingersofthedominanthand.The
needlebevelshouldbefacingupward.Inserttheneedlejustundertheskinata60
90angle,aiminginthedirectionoftheartery,whilepalpatingthefemoralpulse
proximaltothepuncturesitewiththenondominanthand(seetheimagebelow).

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Insertionofneedleatfemoralarterypuncturesite.

Advancetheneedleslowly.Oncetheneedleentersthelumenofthefemoralartery,
thearterialbloodflowstartstofillthesyringe(seetheimagebelow).Atthispoint,
removethenondominanthandfromthefield.Itisnotnecessarytopullbackthe
plunger,unlessanunventedplungerwithasmall(25gauge)needleisbeingused
orthepatienthasaweakpulse.

Femoralarterypuncture.

After23mLofarterialbloodhasbeenobtained,removetheneedle.Atthesame
time,useasmallpieceofgauze,heldinthenondominanthand,toapplyfirm
occlusivelocalpressureatthepuncturesitefor5minutes(seetheimagebelow).In
patientswhohaveacoagulopathyorareonanticoagulationtherapy,itmaybe
necessarytoapplylocalpressureforalongertime.Checkforhemostasis,andapply
anadhesivebandageoverthepuncturesite.Recheckthedistalpulses.

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Removalofneedlefromfemoralarterypuncturesiteandapplicationoflocalpressurefor
hemostasis.

Applytheneedleprotectivesleeve,thenuntwistthesleeveandplaceitinthesharp
objectcontainer.
Removetheexcessairinthesyringebyholdingituprightandgentlytappingit,
allowinganyairbubblespresenttoreachthetopofthesyringe,fromwherethey
canthenbeexpelled.Capthesyringe,placeitintheicebag,andsenditfor
analysis.

BrachialArteryBloodSampling
Thebrachialarteryisbestidentifiedbetweenthemedialepicondyleofthehumerus
andthetendonofthebicepsbrachiiintheantecubitalfossa.Itcanbefelthigherin
thearminthegroovebetweenthebicepsandtricepstendons.Thebasilicveinand
thebrachialnervearelocatedincloseproximity(seetheimagebelow).

Anatomiclocationofbrachialartery.

Aswithfemoralarteryaccess,thepulsesdistaltothebrachialarterymustbe
assessedbeforetheprocedure.Inpatientswithabsentpulsesatthewrist(ie,inthe
radialandulnararteries),analternativesiteforarterialsamplingshouldbe
considered.
Theprocedureisperformedasfollows.
Palpatethepatient'sbrachialpulsewiththeindexandmiddlefingerpadsofthe
nondominanthand(seethefirstimagebelow).Visualizethedirectionoftheartery,
andcleanthedesiredpuncturesiteinanoutwardcircularmotionwithanantiseptic
solution(seethesecondimagebelow).

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Identificationofbrachialartery.

Cleaningofdesiredbrachialarterypuncturesite.

UncaptheABGsyringe,andholditwith2fingersofthedominanthand.The
needlebevelshouldbefacingupward.Inserttheneedlejustundertheskinata45
60angle,aiminginthedirectionoftheartery,whilepalpatingthebrachialpulse
proximaltothepuncturesitewiththenondominanthand(seetheimagebelow).

Insertionofneedleatbrachialarterypuncturesite.

Advancetheneedleslowly.Oncetheneedleentersthelumenofthebrachialartery,
thearterialbloodflowstartstofillthesyringe(seetheimagebelow).Atthispoint,
removethenondominanthandfromthefield.Itisnotnecessarytopullbackthe
plunger,unlessanunventedplungerwithasmall(25gauge)needleisbeingused
orthepatienthasaweakpulse.

Brachialarterypuncture.

After23mLofarterialbloodhasbeenobtained,removetheneedle.Atthesame
time,useasmallpieceofgauze,heldinthenondominanthand,toapplyfirm
occlusivelocalpressureatthepuncturesitefor5minutes(seetheimagebelow).In

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patientswhohaveacoagulopathyorareonanticoagulationtherapy,itmaybe
necessarytoapplylocalpressureforalongertime.Checkforhemostasis,andapply
anadhesivebandageoverthepuncturesite.Recheckthepulsesatthewrist.

Removalofneedlefrombrachialarterypuncturesiteandapplicationoflocalpressurefor
hemostasis.

Applytheneedleprotectivesleeve,thenuntwistthesleeveandplaceitinthesharp
objectcontainer.
Removetheexcessairinthesyringebyholdingituprightandgentlytappingit,
allowinganyairbubblespresenttoreachthetopofthesyringe,fromwherethey
canthenbeexpelled.Capthesyringe,placeitintheicebag,andsenditfor
analysis.

ComplicationsofProcedure
ComplicationsofABGsamplingincludethefollowing:
Localhematoma [3]
Arteryvasospasm [3]
Arterialocclusion [3]
Airorthrombusembolism [3]
Localanestheticanaphylacticreaction
Infectionatthepuncturesite [3]
Needlestickinjurytohealthcarepersonnel [3]
Vessellaceration [2]
Vasovagalresponse [2]
Hemorrhage [3]
Localpain [2]

Results
Resultsareusuallyavailablewithin515minutes.Aberrantresultsmayresultfrom
contaminationwithroomair,resultinginabnormallylowcarbondioxideandnear
normaloxygenlevels.Delaysinanalysisofthebloodtubeallowforongoingcellular
respirationandmayleadtoerrorswithinaccuratelylowoxygenandhighcarbon
dioxidelevelsreportedintheresults.
Thearterialbloodgas(ABG)testmaydetermineconcentrationsoflactate,
hemoglobin,electrolytes,oxyhemoglobin,carboxyhemoglobin,andmethemoglobin.
Valuesatsealevelincludethefollowing:
Partialpressureofoxygen(PO 2)75100mmHg
Partialpressureofcarbondioxide(PCO 2)3545mmHg
ArterialbloodpH7.387.42
Oxygensaturation(SaO 2)94%100%
Bicarbonate(HCO 3)2226mEq/L
ABGtestingisthecriterionstandardfordeterminingtheadequacyofventilatory
supportandtherelationshipbetweenpH,pO2,pCO2,andHCO3inthehuman
body. [10,11,12]Theseresultshelptodetermineifthepatientisin
metabolic/respiratoryalkalosis/acidosiswithorwithoutananiongap.SeetheAnion
Gapcalculator.
ThepHlevelindicateswhetherapatientisacidemic(pH<7.35)oralkalemic(pH
>7.45).Thepartialpressureofoxygen(pO2)showsthelevelofoxygenationinthe
body.Thepartialpressureofcarbondioxide(pCO2)indicatesthedegreeofCO2
productionoreliminationviatherespiratorycycle.AnelevatedordecreasedpCO2
(ie,respiratoryacidosisorrespiratoryalkalosis,respectively)isanindicationofthe
appropriatenessofventilation.
Thebicarbonateion(HCO3)demonstratesthedegreeofametabolicdisturbancein
apatient.Forexample,alowHCO3levelsuggestsametabolicacidosis,whereasa
highHCO3levelsuggestsametabolicalkalosis.Abaseexcessmaythenbe
determinedtofurtherdelineatetheunderlyingrespiratoryormetabolicdisturbance
viathefollowingequation:

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Baseexcess=0.93X([HCO3]24.4+14.8X[pH7.4])
Abaseexcessofmorethan+2mEq/Lindicatesmetabolicalkalosis(excess
bicarbonate).Lessthan2mEq/Lindicatesametabolicacidosis(typicallyeither
excretionofbicarbonateorneutralizationofbicarbonatebyexcessacid).
Theserumaniongap(AG)isthenusedtodeterminetheunderlyingcauseofa
metabolicacidosis.Theequationusedcommonlyisasfollows:
AG=(Na)(Cl+HCO3)
Normalrangeis816mEq/L.

ContributorInformationandDisclosures
Author
MauricioDanckers,MDPulmonaryandCriticalCarePhysician,AventuraMedicalCenter
MauricioDanckers,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofChestPhysicians,
AmericanMedicalAssociation
Disclosure:Nothingtodisclose.
Coauthor(s)
EthanDFried,MD,MSAssociateProfessorofMedicine,HofstraNorthShoreLIJSchoolofMedicine
AssociateDesignatedInstitutionalOfficial,AssociateChairforEducation,DepartmentofMedicine,Member,
DivisionofPulmonary/CriticalCareMedicine,LenoxHillHospital
EthanDFried,MD,MSisamemberofthefollowingmedicalsocieties:AmericanCollegeofPhysicians,
AssociationofProgramDirectorsinInternalMedicine
Disclosure:Nothingtodisclose.
SpecialtyEditorBoard
MaryLWindle,PharmDAdjunctAssociateProfessor,UniversityofNebraskaMedicalCenterCollegeof
PharmacyEditorinChief,MedscapeDrugReference
Disclosure:Nothingtodisclose.
ChiefEditor
VincentLopezRowe,MDProfessorofSurgery,ProgramDirector,VascularSurgeryResidency,Departmentof
Surgery,DivisionofVascularSurgery,KeckSchoolofMedicineoftheUniversityofSouthernCalifornia
VincentLopezRowe,MDisamemberofthefollowingmedicalsocieties:AmericanCollegeofSurgeons,
AmericanHeartAssociation,SocietyforVascularSurgery,VascularandEndovascularSurgerySociety,Society
forClinicalVascularSurgery,PacificCoastSurgicalAssociation,WesternVascularSociety
Disclosure:Nothingtodisclose.
Acknowledgements
AspecialthankyoutoDrSusanNathanandMrKylePursellfortheircontributionstotherealizationofthis
article.

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