Professional Documents
Culture Documents
Simon Giles
Consultant Nurse
Critical Care
Aims and Objectives
Cyanosis
Systemic sepsis (Acid/base status Hypoxaemia
Confusion
and Lactate)
Visual hallucinations
Metabolic / electrolyte problem (DKA
/ Status epilepticus/ severe D&V)
Indications for sampling
Monitoring of the Critically ill patient
Peri-arrest / post-arrest
assessment
Easily accessible
Easily compressible
Femoral
Larger artery - collapsed
patient looses radial pulse
Femoral
Artery
Disadvantages (NAVY)
More structures
Dirty area
Accessibility
Femoral Artery
Clean area with a N A V Y
suitable antiseptic
Needle at 90 degrees
to skin
NAVY
Anatomical basis
The hand is normally supplied by blood from the ulnar
and radial arteries. The arteries undergo
anastamosis in the hand. Thus, if the blood
supply from one of the arteries is cut off, the other
artery can supply adequate blood to the hand. A
minority of people lack this dual blood supply.
Procedure
Position patient
Radial, slight wrist
extension (IV bag /
towel)
Femoral, abduct legs
(genitals and abdomen)
Palpate artery
Advance needle
Radial - 45 degrees to
skin
Femoral - 90 degrees to
skin
Storing directly on ice can haemolyse sample (lower pH and PaO2 / increase
PaCO2 and K+)
Dont shake the samples affects potassium calibration and causes haemolysis
Recheck patient
further bleeding
Sensory defecit
Caution!
Negative Allens test (collateral circulation test)
Record of competency
trust audit
Individual audit record / case records
Blood Gas Analysis
The 5 step approach
The Easy 5 Step Approach
5-Step approach to arterial blood gas interpretation
1. Assess oxygenation
Is the patient hypoxic?
Is there a significant alveolar-arterial gradient?
2. Determine status of the pH or H+ concentration
pH > 7.45 (H+ < 35 nmol l-1) alkalaemia
< 7.35 (H+ > 45 nmol l-1) acidaemia
3. Determine respiratory component
PaCO2 > 6.0 kPa (45 mmHg) respiratory acidosis
< 4.7 kPa (35 mmHg) respiratory alkalosis
4. Determine metabolic component
HCO3- < 22 mmol l-1 metabolic acidosis
> 26 mmol l-1 metabolic alkalosis
0.1333kPa is 1mmHg
mmHg /7.5 approximates to kPa
5-Step approach to arterial blood gas interpretation
(continued)
5. Combine the information from the pH, PaCO2 and the bicarbonate -
determine the primary disturbance - is there any metabolic or respiratory
compensation?
Mixed Picture
Adjustments in both the respiratory and
metabolic components
Acidosis Alkalosis
Respiratory CO2 CO2
Metabolic HCO3- or base excess HCO3- or base excess
Respiratory Failure
Type 1 Low O2
Normal / Low PaCO2
Asthmatics / LVF
Type 2 Low O2
Elevated PaCO2
Elevated HCO3
COPD
Summary of changes in pH, PaCO2 and HCO3-
in acid-base disorders
Increase the minute ventilation to reduce the PaCO2 this will quickly
increase the pH
The significant acidaemia (low pH) and very high PaCO2 indicate an
additional acute respiratory acidosis (occurring around the time of the
respiratory arrest) in the presence of a fully compensated chronic
respiratory acidosis the pH would be near normal.
RR 28 HR 116 BP 128/60
Scenario 3
Arterial blood gas analysis reveals:
Paper Bag
Observe
Scenario 4
Initial Information
An 23 year old insulin dependent diabetic is brought to
the Emergency Department.
He has been unwell with the man-flu for 3/7, has
vomited several times and not taken his insulin.
On arrival:
HR 130 min-1 BP 90/65 mmHg.
Spontaneous breathing, RR 35 min-1
Oxygen 4 l min-1 via Hudson mask
GCS 14 (E3, M6, V5)
Scenario 4 (continued)
Arterial blood gas analysis reveals:
These blood gas values are consistent with severe diabetic ketoacidosis.
- Insulin
www.the-abg-site.com
www.en.wikipedia.org/wiki/Main_Page
Beaumont T (1997) How to guides: arterial blood gas sampling. Care of the Critically Ill.
13, 1,
Coombs M (2001) Making sense of arterial blood gases. Nursing Times.97, 27, 36-38.
References
Dellinger, R.P. et al (2008) Surviving Sepsis Campaign: International guidelines for
management of severe sepsis and septic shock. Critical Care Medicine; 36: 1, 296327. Giner
J, Casan P, Belda J, et al. Pain during arterial puncture Chest 1996;110:1443-5.
Lightowler JV, Elliott MW. Local anaesthetic infiltration prior to arterial puncture for blood gas
analysis: a survey of current practice and a randomised double blind placebo controlled trial. J
R Coll Physicians Lond 1997;31:645-6.
Jarvis MA, Jarvis CL, Jones PR, Spyt TJ (October 2000). "Reliability of Allen's test in selection
of patients for radial artery harvest". Ann. Thorac. Surg. 70 (4): 13625.
NICE (2007) Acutely Ill Patients in Hospital: Recognition of and Response to Acute Illness in
Adults in Hospital. www.nice.org.uk
Pagana, K.D., Pagana T.J. (2006) In: Ruholl, L. (2006) Arterial blood gases: analysis and
nursing responses. Medsurg Nursing: Official Journal of the Academy of Medical-surgical
Nurses; 15: 6, 343349.
Woodrow, P. (2004) Arterial blood gas analysis. Nursing Standard; 18: 21, 4552.
Oxygenation
Normal Range 10 - 14 kPa
1% 02 is approximately 1kPa.
Normal drop inspired to alveolar is approximately 10.0 kPa
Thus on an inspired oxygen concentration of 50% should give an approximate PaO2 of 40
kPa
5 Step
pH
1 2 3 4 5 6 7 8 9 10 11 12 13 14
Acid Neutral
Alkaline
5 Step
Bicarbonate / Metabolic
Bicarbonate is an alkaline and acts as a buffer,
Bicarbonate takes several hours to adjust
therefore elevated or lowered levels normally
indicate sub-acute / chronic changes.
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Venous versus arterial results
PH
Hb / electrolytes / COHb
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