DR. JORGE P. ROYECA HOSPITAL Document No.

:
Page 1 of 11
LABORATORY POLICY & PROCEDURE MANUAL DJPRH.LAB.1

ARTERIAL BLOOD GAS ANALYSIS POLICIES & Version: Effective Date:

1.0 04-01-2017
PROCEDURE

Title: ARTERIAL BLOOD GAS ANALYSIS POLICIES & PROCEDURE

Name, Title Signature Date

Prepared by: APRIL MAE D. VILLANUEVA, RMT

CLINICAL CHEMISTRY SECTION IN-CHARGE

CLINICAL CHEMISTRY ASSISTANT SECTION IN-CHARGE

Name, Title Signature Date

SANTIAGO N. MARTINEZ, RMT

QUALITY ASSURANCE OFFICER
Approved by:

ELSIE R. DACUA, RMT

CHIEF MEDICAL TECHNOLOGIST

EDWIN C. ALCONCEL, MD, FPSP, BBM-MBA

PATHOLOGIST

Version [0.0] Revision Date Description (notes)

[ddmmyyyy]

Revision History

Name (or Location) # of copies Name (or Location) # of copies

Distributed to:

Name, Title Signature Date

SOP Annual
Review

I. PURPOSE

DR. JORGE P. ROYECA HOSPITAL GENERAL SANTOS CITY, LABORATORY DEPARTMENT

NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red “MASTER
COPY” are not controlled and should be checked against the document (titled as above) prior to use.
 DR. JORGE P. ROYECA HOSPITAL Document No.:
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LABORATORY POLICY & PROCEDURE MANUAL DJPRH.LAB.1

ARTERIAL BLOOD GAS ANALYSIS POLICIES & Version: Effective Date:

1.0 04-01-2017
PROCEDURE

To perform accurate and precise ABG Analysis laboratory test.

II. SCOPE

The SOP defines the handling of a specimen from the time it is received until the time a
report is released from the Clinical Chemistry Section aiming to provide accurate and precise
laboratory results harmoniously.

Pre – Examination Phase

Receiving of request
Charging of tests
Blood collection
Transport of specimen

Examination Phase

Automated method

Post – Examination Phase

Validating of results
Retesting specimens
Reporting results
Referring results
Releasing reports
Retention of specimens and documents

III. PERFORMANCE INDICATOR

Zero error zero delay

IV. RESPONSIBILITY

Laboratory Office Clerk – perform the various office tasks required with receiving and
delivering laboratory test results and other lab reports as they are completed in the
department. Upon receiving written orders from physicians or their designees, the Lab
Office Clerk will help coordinate efficient and timely patient specimen collection by
phlebotomists. All testing orders are directed to the phlebotomists in order of priority. The
Lab Office Clerk will field questions from various sources regarding information about the
Laboratory and lab test requirements or specifics and lab test results. The Lab Office
Clerk will prepare charges for billing.

Medical Technologist – provides information for diagnosis, treatment, and prevention of

disease by conducting medical laboratory tests, procedures, experiments, and analyses.

V. DEFINITION OF TERMS

List of Synonyms

Examination Phase – Analytical Phase

Pre-Examination – Pre-Analytic
Post-Examination – Post-Analytic

List of Acronyms/Abbreviations

ABG – Arterial Blood Gas

NOD – Nurse on Duty
MTOD- Medical Technologist on Duty
DR. JORGE P. ROYECA HOSPITAL GENERAL SANTOS CITY, LABORATORY DEPARTMENT
NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red “MASTER
COPY” are not controlled and should be checked against the document (titled as above) prior to use.
 DR. JORGE P. ROYECA HOSPITAL Document No.:
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LABORATORY POLICY & PROCEDURE MANUAL DJPRH.LAB.1

ARTERIAL BLOOD GAS ANALYSIS POLICIES & Version: Effective Date:

1.0 04-01-2017
PROCEDURE
PPE – Personal Protective Equipment
QA – Quality Assurance
QC – Quality Control
QNS – Quality Not Sufficient
SOP –Standard Operating Procedure
TAT – Turn Around Time
STAT (Statim) – Immediately or Now
pH - potential of Hydrogen
pO2 – Partial Oxygen
PCO2 – Partial Carbon Dioxide
SO2 – Oxygen Saturation
HCO-3 - Bicarbonate
ctCO2 – Total Carbon dioxide
RR – Reference Range
MTOD – Medical Technologist on Duty
RT – Room Temperature
BE (B)-BE (ecf)-Blood and extra-cellular fluid base excess
(O2SAT)- Estimated oxygen saturation
(O2CT)-Estimated oxygen content
AnGap- Anion Gap
(pO2 (a/A))- Arterial alveolar oxygen tension ratio
(pO2 (A/a))- Arterial Alveolar oxygen tension difference
ctHB- Estimated total haemoglobin
PO2/FiO2- Arterial Oxygen tension- inspired oxygen fraction ratio
Ca++ (7.4) - Calcium oin concentration adjusted to pH 7.4

VI. WORK PROCESS

DR. JORGE P. ROYECA HOSPITAL GENERAL SANTOS CITY, LABORATORY DEPARTMENT

NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red “MASTER
COPY” are not controlled and should be checked against the document (titled as above) prior to use.
 DR. JORGE P. ROYECA HOSPITAL Document No.:
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LABORATORY POLICY & PROCEDURE MANUAL DJPRH.LAB.1

ARTERIAL BLOOD GAS ANALYSIS POLICIES & Version: Effective Date:

1.0 04-01-2017
PROCEDURE

ARTERIAL BLOOD GAS ANALYSIS – AUTOMATED

Narrative Workflow Person Responsible

Start

Receiving of request
Receptionist/Clerk

Charging of request
Receptionist/Clerk

Specimen collection
Phlebotomist/
Med. Tech.
Specimen transport
Phlebotomist/
Med. Tech.
Receiving of specimen

Med. Tech.

Log on accession logbook Accession

Logbook Med. Tech.

Check label and specimen Med. Tech.

Specimen Preparation Med. Tech.

Med. Tech.
Load the sample at the machine

Pathologic? yes Med. Tech.

no Refer to verification
of critical values Med. Tech.

Check the clinical impression Med. Tech.

Print

DR. JORGE P. ROYECA HOSPITAL GENERAL SANTOS CITY, LABORATORY DEPARTMENT

NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red “MASTER
COPY” are not controlled and should be checked against the document (titled as above) prior to use.
 DR. JORGE P. ROYECA HOSPITAL Document No.:
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LABORATORY POLICY & PROCEDURE MANUAL DJPRH.LAB.1

ARTERIAL BLOOD GAS ANALYSIS POLICIES & Version: Effective Date:

1.0 04-01-2017
PROCEDURE

ARTERIAL BLOOD GAS ANALYSIS – AUTOMATED

Narrative Workflow Person Responsible

Sign Med. Tech.

Forward the result together with the

Med. Tech.
result at the validator’s table

Releasing of results
Med. Tech.

End

PRE ANALYTICAL PHASE

DR. JORGE P. ROYECA HOSPITAL GENERAL SANTOS CITY, LABORATORY DEPARTMENT

NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red “MASTER
COPY” are not controlled and should be checked against the document (titled as above) prior to use.
 DR. JORGE P. ROYECA HOSPITAL Document No.:
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LABORATORY POLICY & PROCEDURE MANUAL DJPRH.LAB.1

ARTERIAL BLOOD GAS ANALYSIS POLICIES & Version: Effective Date:

1.0 04-01-2017
PROCEDURE
VI. POLICY STATEMENT/WORK INSTRUCTIONS

RECEIVING OF REQUESTS

POLICY

1. ABG test request shall be filled out legibly.

2. Request form for ABG Analysis shall include:
 Full Name of the patient with Middle Name
 Age
 Sex
 Date of Birth
 Hospital Number
 Working Impression or Clinical Diagnosis
 Address
 Name of Requestor/Physician
 Indicate as OPD if Out- Patient and the Ward/Room number if admitted
 Date the test is requested
3. STAT requests are always on top priority. STAT requests may be requested thru
telephone call; hence the NOD shall provide a completely filled laboratory request
afterwards. STAT requests are to be followed up after 30 minutes by the NOD once
tests are delayed.
4. For timed requests, schedule of collection shall be indicated on the request form. The
NOD shall inform the laboratory in any changes made on the scheduled date of
collection. A new laboratory request shall be provided by the NOD if any changes are
to be done.
5. Receiving of requests shall only be done by authorized and trained Laboratory
Personnel (Medical Technologists/Laboratory Clerks)

WORK INSTRUCTION

OPD

1. The receptionist/clerk receives the request form.

2. Requested tests shall be charged by the receptionists/clerk.
3. Charged request shall be paid on the cashier
4. Paid requests shall be brought back to the laboratory for extraction of sample.

IPD

1. The NOD shall deliver the request form in the laboratory and shall log the test
request/s on the receiving logbook or encode on the IHOMIS
2. The receptionist/clerk shall charge the test request/s
3. Test request/s are placed on the designated areas

SAMPLE COLLECTION

POLICY

1. A completely filled out request form shall come with every sample collection
2. PPEs shall be worn at all times
3. Specimen for ABG Analysis is performed by using a heparinized syringe.
4. The phlebotomist/medical technologist shall refer to the NOD or the resident
physician on duty for a more appropriate site in cases like:
 Edematous or swollen, tender or painful extremeties
 Areas with infection or hematoma
 Extensive scars from burns and surgery

DR. JORGE P. ROYECA HOSPITAL GENERAL SANTOS CITY, LABORATORY DEPARTMENT

NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red “MASTER
COPY” are not controlled and should be checked against the document (titled as above) prior to use.
 DR. JORGE P. ROYECA HOSPITAL Document No.:
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LABORATORY POLICY & PROCEDURE MANUAL DJPRH.LAB.1

ARTERIAL BLOOD GAS ANALYSIS POLICIES & Version: Effective Date:

1.0 04-01-2017
PROCEDURE
 Extremities with intravenous [IV] line, arterio-venous [A-V] fistula or
vascular graft, and transfusion line
 Arms on the side of modified radical mastectomy
5. The sample syringe shall be filled according to the intended volume indicated on the
tube. Over-filled and under-filled tubes are criteria for rejection.
6. The sample tube shall be filled out with the patient’s complete name, and collection
date.
7. The phlebotomist/medical technologist shall correct any transcription error on the
standard request form regarding the patient’s data.
8. Collection time, Hemoglobin, Temperature and flow of oxygen therapy of the
patient must be noted on the request form.
9. The phlebotomist/medical technologist shall fill up the collecting tube up to the
required mark only. Over or under collection is a criterion for rejection.
10. In cases of different problematic situations encountered in the collection of blood
specimen for ABG Analysis:

PROBLEM SOLUTION
Apprehensive Patients Reassure the patient. Ask the patient to lie
down if there is a bed in the room
Difficult to identify arterial sites; Difficult to In case when blood is difficult to obtain, only
obtain blood three (3) attempts is allowed. If the third
attempt is a failure, the Medical Technologist
shall inform the nurse on duty and/or the
attending physician.
Fainting or syncope Stabilize patient on a flat surface
Refer IMMEDIATELY to a Physician
Infants Follow institutional protocol on blood extraction
Refusal of blood collection A refusal form shall be filled-up in cases of
specimen collection refusal. NOD shall be
informed.

WORK INSTRUCTION

 Older children and adults

Arterial blood gas (ABG) sampling by direct vascular puncture is a procedure often
practiced in the hospital setting. Under strict aseptic techniques, superficial arteries
such as radial, and brachial artery is punctured with a sterile hypodermic needle and
blood is collected into a syringe.

The phlebotomist/medical technologist shall:

 Identify the patient by asking for full name.

 Wear disposable gloves
 Palpate and locate the artery.
 Disinfect the site with 70% isopropyl alcohol. Let the disinfectant evaporate.
Do not repalpate the puncture site.
 Perform ABG sampling.
 Collect the specimen into the appropriate container up to the required test
tube marking.
 Withdraw the needle from the puncture site.
 Apply dry cotton ball over the puncture site and press the site for three
minutes or until the bleeding stops, then apply the adhesive tape over the
puncture site.
 Expel any air present in the syringe immediately after collection and before
the sample is mixed.

DR. JORGE P. ROYECA HOSPITAL GENERAL SANTOS CITY, LABORATORY DEPARTMENT

NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red “MASTER
COPY” are not controlled and should be checked against the document (titled as above) prior to use.
 DR. JORGE P. ROYECA HOSPITAL Document No.:
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LABORATORY POLICY & PROCEDURE MANUAL DJPRH.LAB.1

ARTERIAL BLOOD GAS ANALYSIS POLICIES & Version: Effective Date:

1.0 04-01-2017
PROCEDURE
 If a portion of the sample must be separated for other testing, do not
expose sample to air.
 Assess for specimen acceptance or rejection. Identify the need to repeat
specimen collection, if necessary.
 Label the collection tubes at the bedside or collection area with the full
name, date and time of collection, and initials of phlebotomist.
 Dispose of contaminated materials into appropriate waste receptacles
 Remove and properly discard used gloves. Wash and dry hands after
collection.
 Promptly send the arterial blood specimen in an ice pack with the
completely filled-out request form to the main laboratory.
 Sample must be tested as soon as possible, or within 15 minutes.

ENDORSEMENT OF REQUESTS AND SAMPLE

POLICY

1. A completely filled out standard request form together with the sample shall be
transported to the working station after sample preparation.
2. For STAT requests, the MTOD shall be informed by the phlebotomist or medical
technologist who collected the sample.

WORK INSTRUCTION

 The phlebotomist/medical technologist shall transport the specimen together with

the request form to the rack/basket provided at the Clinical Chemistry area.
 The phlebotomist/medical technologist shall inform the medical technologist on duty
of the transported specimen.

RECEIVING OF REQUESTS AND SAMPLE

POLICY

1. The medical technologist shall check if the label of the sample matches with the
completely filled out request forms
The following conditions shall need completion of required data:
 Incompletely labelled container – Make sure to complete missing data.
 Incompletely filled out request form – Return to the requisitioner for
completion of all the necessary data. The accompanying specimen shall be
properly labelled and temporarily kept at refrigerated temperature while
awaiting the properly and completely filled out request.
 For STAT request/s, sample/s shall be processed immediately and charges
shall be sorted out while running the test/s.

2. Acceptance Criteria
The blood specimen shall be:

 Collected in a heparinised syringe. No other anti-coagulant is acceptable.

 Properly collected up to the required sample volume mark (minimum of 2cc).
If less volume of blood was collected due to difficult extraction such as from
pediatric and geriatric patients, proper notation must be indicated on the
request form by the phlebotomist.
 Mixed gently after collection.
 Labelled with complete name of the patient with the date of extraction.
 Accompanied by a patient request form that is properly and completely filled
out with all the necessary data.

DR. JORGE P. ROYECA HOSPITAL GENERAL SANTOS CITY, LABORATORY DEPARTMENT

NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red “MASTER
COPY” are not controlled and should be checked against the document (titled as above) prior to use.
 DR. JORGE P. ROYECA HOSPITAL Document No.:
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LABORATORY POLICY & PROCEDURE MANUAL DJPRH.LAB.1

ARTERIAL BLOOD GAS ANALYSIS POLICIES & Version: Effective Date:

1.0 04-01-2017
PROCEDURE
 Submitted within 15 minutes of collection in an ice slurry.

3. Rejection Criteria
The blood specimen shall be rejected and another sample collected, for any
one of the following conditions:
 When name on specimen does not match that on the request
 Improperly labelled sample
 Either broken or leaking container
 Clotted and samples with air bubbles
 Inadequate volume for the quantity of preservative
 Insufficient quantity for the test requested
 Improper sample handling and transport

4. The medical technologist shall report all rejected or returned specimens

indicating a note for the reason on the rejected and returned specimens’ logbook.
Rejection of specimen shall only be done by the medical technologist.
5. The medical technologist shall record all laboratory requests and results for ABG
Analysis on the designated accession and utilization logbook.

WORK INSTRUCTION

 The medical technologist shall check the label on the sample container, and the
quantity and quality of the specimen. Completeness of the request form shall also be
checked appropriately.
 ABG Analysis request/s shall be recorded on the accession and utilization logbook.

ANALYTICAL PHASE

Performance Check before running sample

Policy
1.Check the Calibration status
2.Check the maintenance action
3.Perform Quality Control before running of sample

Calibration Occur
1. Automatic Calibrations:
 1pt @ 30 min or 60 minutes
 2pt@ 2 hours or 4 hours

2. Manually initiated
Maintenance Actions
• Deproteinization to prevent protein buildup scheduled running every
two weeks
• Conditioning is done right after deproteinization, during pH drift or
newly refilled sensor.
• Prime 5x upon replacement with new buffer and wash pack
• Disinfection is perform only when a known pathogenic sample
(HIV/ HBSAG +) is tested.

Analyzing QC Samples

DR. JORGE P. ROYECA HOSPITAL GENERAL SANTOS CITY, LABORATORY DEPARTMENT

NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red “MASTER
COPY” are not controlled and should be checked against the document (titled as above) prior to use.
 DR. JORGE P. ROYECA HOSPITAL Document No.:
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LABORATORY POLICY & PROCEDURE MANUAL DJPRH.LAB.1

ARTERIAL BLOOD GAS ANALYSIS POLICIES & Version: Effective Date:

1.0 04-01-2017
PROCEDURE
If QC Prompts have been set, the system prompts you via the Action List to
analyze a QC sample. You can also run QC samples at any time from the
 Ready screen.
 Select Ready > QC
 Lift the probe lever to the first position
 The measurement block light comes on and the touch screen displays the
probe open screen.
Quality Control
 Normal Controls
 Low Control
 Pathologic Control
 Accepted
 Not accepted

Work Instruction
1. Make sure that the calibration status is accepted.
2. Medical Technologist assigned in CC should be responsible in checking if the
Quality Control of the day is in range before running batches of sample.
3. Make sure that the Medical technologist records all the performance data in
calibration, Quality Control and maintenance for documentation proof.
1. Medical Technologist shall be perform daily and weekly maintenance and record
for documentation

Running of Sample

1. Data Entry for Patient

2. Use on-screen keypad or bar-code scanner for operator and patient ID.
3. Up to 16 digits may be entered for both operator and patient ID.
4. Enter patient temperature, hemoglobin, and FIO2 , or default values will apply
then press ENTER
5. Before running check the sample if short ,clotted or bubbles in sample.

6. From Ready Screen select or press Syringe Icon or Whole Blood and Lift
probe to analyze syringe sample

 Viewing of Results
Patient Results
• Measurement is complete when the = sign for each parameter stops
flashing.
• Results are automatically printed.
• Wash cycle is performed to clean the sample pathway.
• When the wash is complete, the measurement chamber light goes off
and the display returns to the Ready screen. Results are available in
approximately 30 seconds

Work Instruction
In case of stat result NOD will inform immediately.

POST ANALYTICAL PHASE

TRANSLATION, RECORDING AND PRINTING OF RESULTS

POLICY

 MTOD shall check and correlate results with the patient’s diagnosis and previous
results.

DR. JORGE P. ROYECA HOSPITAL GENERAL SANTOS CITY, LABORATORY DEPARTMENT

NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red “MASTER
COPY” are not controlled and should be checked against the document (titled as above) prior to use.
 DR. JORGE P. ROYECA HOSPITAL Document No.:
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LABORATORY POLICY & PROCEDURE MANUAL DJPRH.LAB.1

ARTERIAL BLOOD GAS ANALYSIS POLICIES & Version: Effective Date:

1.0 04-01-2017
PROCEDURE
 MTOD shall check if all the tests requested are performed.
 Date and Time of collection must be noted on the Official Test results.

WORK INSTRUCTION

 Results shall be written by the MTOD on the designated logbooks for each nursing
stations.
 Results shall be placed on the validator’s table for double checking. [for ISO]

ENDORSING OR RELEASING OF OFFICIAL RESULT

POLICY

Turnaround Time [TAT] in the Laboratory is defined as the time from receipt of the specimen
with accompanying request to the release of report from the laboratory.

 Release of routine ABG test report shall be in accordance to the Laboratory’s

policy. In instances when the result is delayed [e.g., retesting, referral] the
concerned physician/healthcare worker shall be informed of the delay.
 All reports of STAT requests shall be released to the concerned patient/personnel
as soon as the result is verified.
 All critical values shall be released/reported as soon as detected.

WORK INSTRUCTION

 Clerks or Laboratory Aid shall endorse results on designated nursing stations.

 STAT results shall be endorsed immediately by the clerk or Laboratory Aid as soon
as the test is verified.
 Critical values shall be endorsed to the physician ONLY as soon as detected.

VII. RECORDS GENERATED

LOGBOOKS

 Accession and Utilization Logbook

 Reagent Monitoring Logbook
 Errors and Events Logbook
 Maintenance Logbook

VIII. REFERENCE

RL348 EX Technical Product Training Guide

DR. JORGE P. ROYECA HOSPITAL GENERAL SANTOS CITY, LABORATORY DEPARTMENT

NOTE: This is a CONTROLLED document. Any documents appearing in paper form that are not stamped in red “MASTER
COPY” are not controlled and should be checked against the document (titled as above) prior to use.