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Performing Arterial Blood Gas Sampling

Full Title of Guideline: Performing Arterial Blood Gases by Direct Arterial


Puncture. A Nursing Practice Guideline for Designated
Practitioners
Author (include email and role): LA Jennings, CCOT Deputy sister,
liseanne.jennings@nuh.nhs.uk
B Jenkinson, CCOT Physiotherapist,
bronwen.jenkinson@nuh.nhs.uk
Division & Speciality: Clinical Support, Critical Care
Version: Version 3
Critical Care Governance
Ratified by:
Acute Care Pathway Governance
Scope (Target audience, state if Trust Critical Care Outreach Team (CCOT) and Nurses
wide): working in Respiratory medicine for assessment of NIV
only.
Review date (when this version goes out October 2020
of date):
Explicit definition of patient group All critically ill adult inpatients with; inappropriate
to which it applies (e.g. inclusion and hypoxaemia, deteriorating oxygen saturations or
exclusion criteria, diagnosis): increasing breathlessness, patients with risk factors for
hypercapnic respiratory failure, breathless patients
thought to be at risk of metabolic conditions, patients with
any other evidence from their medical condition that
would indicate that a blood gas result would be useful in
the management of their care.
Patients receiving acute NIV.

Changes from previous version (not Insertion of rationale for informed consent.
applicable if this is a new guideline, enter
Advice re the avoidance of potential hazards related to
below if extensive): the procedure.
Minimal changes to procedure guideline.
Summary of evidence base this British Thoracic Society (2017) Guideline for emergency
guideline has been created from: oxygen use in adults in healthcare and emergency
settings. Danckers, M & Fried, ED (2013) Arterial Blood
Gas Sampling.
This guideline has been registered with the trust. However, clinical guidelines are
guidelines only. The interpretation and application of clinical guidelines will remain the
responsibility of the individual clinician. If in doubt contact a senior colleague or expert.
Caution is advised when using guidelines after the review date or outside of the Trust.

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Contents

Page
Number
Acknowledgments 3
Introduction & Rationale for Guideline 3
Best Practice 3
Indications for ABG Sampling 4
Role Specific ABG Sampling 5
Contraindications 5
Technical Considerations 5
Procedure for Radial Artery Puncture 6
Modified Allen’s Test 6
Practitioners who can undertake this Guideline 7
Accountability 7
Informed Consent 7
Hazards/Cautions 8
Infection Control 9
Equipment List 9
Documentation 9
Performing an Arterial Blood Gas 10-13
References 14

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Acknowledgements

Written with information from ‘Taking Arterial Blood Gases’ Competency


Package – Last reviewed in 2011 by Donna Emuss, Bronwen Jenkinson,
Sarah Dow, Jo Love, Sue Haines, Holly Scothern & Alison Dinning.

Introduction & Rationale for Guideline

Practitioners who have specialist responsibilities for respiratory


assessment and management currently receive referrals or requests for
advice about the respiratory management of individual patients.

Management of respiratory problems frequently necessitates Arterial


Blood Gas (ABG) analysis - traditionally this has been performed by
medical staff within the trust. ABG sampling is performed at the patient’s
bedside and with fast analysis enables practitioners to direct the
treatment of their patients, especially those that are critically ill to
determine respiratory, metabolic and renal function (Danckers & Fried,
2013).

Best Practice
Arterial blood gases should be used for assessing respiratory failure in
Critically Ill Patients or those with Shock or Hypotension (Systolic blood
pressure <90mmHg) (British Thoracic Society, 2017).

Expanding the role of designated practitioners to perform arterial blood


gas sampling will enable them to offer a more complete service to
patients and to provide timely respiratory intervention or referral to a
more senior healthcare professional/ Critical Care.

For the purposes of this guideline and competency document, site


selection for ABGs is limited to the radial artery only. If the radial artery
is not suitable, the procedure should be carried out by a medical
practitioner.

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Indications for ABG Sampling

British Thoracic Society Guidelines (2017) suggest that ABGs should be


checked in the following situations:

 All critically ill patients.

 Unexpected or inappropriate hypoxaemia (SpO2 <94%) or any


patient requiring oxygen to achieve this target range.

 Deteriorating oxygen saturation or increasing breathlessness in a


patient with previously stable chronic hypoxaemia. (e.g. COPD)

 Any previously stable patient who deteriorates and requires a


significantly increased fraction of inspired oxygen to maintain
constant oxygen saturation.

 Any patient with risk factors for hypercapnic respiratory failure who
develops acute breathlessness, deteriorating oxygen saturation or
drowsiness or other symptoms of CO2 retention.

 Breathless patients who are thought to be at risk of metabolic


conditions such as diabetic ketoacidosis or metabolic acidosis due
to renal failure.

 Any other evidence from the patient’s medical condition that would
indicate that blood gas results would be useful in the patient’s
management (e.g. an unexpected change in EWS)

The results of ABG sampling only reflect the physiological state of the
patient at the time of sampling – it is important they are correlated with
the evolving clinical scenario and changes in a patient’s treatment
(Danckers & Fried, 2013).

It is essential that the contra-indications and hazards to ABG


sampling are weighed up and the reasoning/appropriateness of
performing the procedure is clearly documented by the
practitioner.

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Role specific ABG sampling

Nurses working in respiratory medicine may undertake this role for


assessment of patients requiring NIV Only. This can only be
undertaken when competent in the set-up and management of patients
on acute Non-Invasive Ventilation (NIV) evidenced by completion and
verification of the Working in New Ways package for NIV.

Contra-Indications

 Absent ulnar circulation – as demonstrated by Modified Allen’s Test.

 Impaired circulation e.g. Raynaud’s Disease

 Arteriovenous fistula

 Distorted anatomy/ trauma/burns to the limb - at or proximal to the


attempted arterial puncture site

 Medium or high dose anticoagulation therapy, or history of clotting


disorder

 Severe coagulopathy

 History of arterial spasms

 Abnormal or infectious skin processes at/or near puncture site

Technical Considerations
ABG sampling may be difficult to perform in patients who are un-cooperative
or where pulses cannot be easily identified e.g. cognitive impairment/tremors.

The amount of subcutaneous fat in obese patients may limit access to the
sample area & obscure anatomical landmarks (Danckers & Fried, 2013)

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Procedure for Radial Artery Puncture
The radial artery is the one most often used in practice in the acute care
setting because of easy access and the fact that the artery is superficial
and easily palpated. Prior to any attempt at arterial puncture the
practitioner must perform the Modified Allen’s Test (WHO, 2010)

Modified Allen’s Test


To determine that collateral circulation is present from the ulnar artery in
the event of thrombosis of the radial artery.
 Position the patient’s arm on a firm flat surface with the wrist
extended (Hyperextension of the wrist should be avoided, as it will
obliterate a palpable pulse)
 Compress both the radial and ulnar arteries with the index and
middle fingers of both hands
 Ask the patient to clench and unclench fist until blanching of distal
skin occurs
 Release your pressure over the ulnar artery and assess skin
colour and refill – approximately 5 seconds after release of the artery,
the extended hand should blush owing to capillary refilling. If blanching
occurs, palmar arch circulation is inadequate and sampling could lead
to ischaemia of the hand
 Document poor filling in the patient’s notes. DO NOT proceed in
the tested arm.

(The Royal Marsden NHS Trust, 2015)

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Practitioners who can undertake this Guideline

This package is for senior registered nurses and senior physiotherapists


working in the Critical Care Outreach Team (CCOT) and Respiratory
Medicine.

Nurses working in respiratory medicine may undertake this role only


when competent in the set-up and management of patients on
acute Non-Invasive Ventilation (NIV), evidenced by completion and
verification of the Working in New Ways package for NIV. Before
undertaking this package, it is essential to discuss this with your ward
manager.

Accountability
Designated practitioners should ensure that in fulfilling this role they are
working within the guidance set out by their regulatory body.eg. The
Code of Members' Professional Values and Behaviour (CSP 2011) or
The Code for nurses and midwives (NMC, 2015).

Informed Consent
Consent is valid if given voluntarily and by an appropriately informed
person who has the capacity to consent to the intervention in question.

Consent is a patient’s agreement for a healthcare professional to provide


care.

For consent to be valid the patient must:

• Be competent to make the particular decision


• Understand information relevant to the decision and be able to
retain that information and use and weigh that information in the
balance as part of the process of making the decision
• Have received sufficient information to make the decision
• Not be acting under duress
• Be able to communicate their decision
(NUH, 2012)

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Hazards / Cautions

Complication Cause Avoidance

Haematoma Leaking of blood Use a small diameter needle


into surrounding Apply adequate pressure to the
tissue puncture and observe site for 3-5
minutes.

Haemorrhage Patient receiving Observe puncture site for


anti-coagulant bleeding / oozing for 2 minutes
therapy after you have removed
pressure. A much longer
compression time may be
required.

Distal Ischaemia No collateral Proceed with puncture only if


circulation Allen’s Test performed.
Check site, if ischaemia
suspected inform Dr.

Parasthesia & Nerve Damage Utilise correct technique. If the


Numbness patient reports pain in the
distribution of the nerve, withdraw
the needle. Do not redirect
needle when it lies deep within
tissues.

Sepsis Poor Asepsis Avoid sites where there is an


active infection. Ensure asepsis

Infection of the Contact with Universal precautions throughout


Practitioner body fluids the procedure. Ensure sharps
policy is adhered to.

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Infection Control

Whilst performing arterial blood gases, practitioners should adhere to the


Nottingham University Hospitals NHS Trust Infection Prevention and
Control Policy (2013) & Blood Borne Virus Policy (Including
Management of Inoculation, Sharps and Contamination Incidents)
(2015). This should be covered in detail in the Working in New Ways
competency document.

Equipment List

 Sterile dressing pack


 Sterile gloves and apron
 Trolley
 Clean tray or receiver
 Sterile gauze & tape
 Sharps container
 2% Chlorhexidine in 70% alcohol wipe.
 Pre‐heparinized arterial blood gas syringe (some syringes are vented or
self‐filling, others require user to draw back to fill – check manufacturer's
instructions) currently ‘safe PICO Aspirator’ syringes at NUH.
 23 G needle for sampling with safety device.

Documentation

Any attempt at performing an arterial blood gas must be documented in


the medical notes including:

 Reason for sample


 Assessment of patient & Allens test
 Site used and number of attempts
 ABG result and interpretation

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Performing an Arterial Blood Gas

Adapted from The Royal Marsden Manual of Clinical Nursing


Procedures, 9th Ed (2015)

ACTION RATIONALE

1 Explain and discuss the procedure To ensure the patient understands


with the patient. Obtain valid the procedure and gives their valid
consent in all cases except in consent.
emergencies when the patient is
Consent may not be possible in
unable to consent.
certain clinical scenarios, such as a
critically ill patient with rapid
decompensation or a patient with
an altered level of consciousness
(Danckers and Fried, 2013). This
should be clearly documented.

2 Check the concentration of oxygen Inspired oxygen concentration and


the patient is breathing and body temperature parameters are
temperature at time of sampling. required to interpret arterial blood
gases accurately.

3 Check the patient's current To identify possible risk of bleeding


coagulation screen, platelet count, and haematoma formation post
medical history and prescription procedure and, where appropriate,
chart for anticoagulation therapy. to prevent puncture until
coagulation is corrected (Danckers
and Fried, 2013).

4 Prepare trolley and take to bedside

5 Wash hands with soap and water.

6 Assume a stable and comfortable


position.

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7 Inspect and assess the tissues and To identify any areas of
anatomical structures surrounding excoriation/infection, poor perfusion
the intended sampling site or other puncture sites. If any of
these are present the site should
not be used (Weinstein and Plumer,
2007).

8 Locate and palpate the radial artery To assess maximum pulsation to


with the middle and index fingers of ensure radial artery is optimum site
the non‐dominant hand. for successful puncture. The
dominant hand will be used to
perform puncture (Weinstein and
Plumer, 2007).

9 Perform the modified Allen test To confirm patency of ulnar artery


circulation and assess collateral
circulation to the hand in the event
of radial artery damage. See above
section for procedure.

10 Prepare the patient in supine To bring the radial artery to a more


position: with forearm supinated at superficial plane (Danckers and
the wrist, gently extend the wrist - Fried, 2013).
avoiding overextension (ask for
assistance if required).

11 Clean hands and open the pack


and place equipment onto it.

Withdraw the plunger of the ABG


syringe before the puncture.

12 Place a sterile field under the


patient's wrist and maintain aseptic
technique throughout the
procedure.

13 Clean hands and then clean site


with 2% chlorhexidine in 70%
alcohol wipe and allow to dry.

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14 Apply sterile gloves, take care not
to touch the puncture site after
cleaning

15 Uncap the ABG syringe, attach the


23 G needle and hold it with two
fingers of the dominant hand.

16 Angle the needle at 30–45°, with Minimise trauma to the artery.


the bevel of the needle up just
Pulsatile flow indicates access to
distal to the planned puncture site.
radial artery. Arterial pressure
Whilst palpating the radial pulse
causes blood to pulsate
proximal to the planned puncture
spontaneously back into the syringe
site, advance the needle slowly,
(Weinstein and Plumer, 2007).
aiming in the direction of the artery
until a flashing pulsation is seen in
the hub of the needle.

17 Slowly aspirate by gently pulling the


plunger of the arterial gas syringe
to a minimum of 1mL of blood for
the sample (check recommended
amount of blood as directed by
manufacturer's guidelines). If using
a vented sample syringe, aspiration
is not required as the syringe will fill
automatically

18 Withdraw the needle, immediately Apply pressure for a minimum of 5


followed by application of pressure minutes or until no signs of
using a gauze swab. bleeding are observed. Ask for
assistance if necessary.

19 Discard the sharp into a sharps


container. Promptly return the wrist
to the neutral position following
sampling.

20 Dispose of equipment safely.

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21 Expel any air bubbles from the
syringe, and cap the arterial
syringe.

22 Label with patient's demographics To provide accurate information for


at the patient's bedside. analysis.

23 Send sample immediately to area ABG samples can be processed


of ABG analysis machines such as immediately and a result can be
ICU, HDU, RAU etc. obtained within minutes.

24 Check puncture site and apply a


clean, sterile gauze dressing.
Secure with tape

25 Clearly document rationale for To acknowledge accountability for


procedure in patient's notes and actions and ensure effective
verbally communicate arterial communication. To ensure prompt
analysis findings to relevant and appropriate treatment
medical and nursing teams

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References

British Thoracic Society (2017) Guideline for emergency oxygen use


in adults in healthcare and emergency settings [Online] Available at:
https://www.brit-thoracic.org.uk/standards-of-care/guidelines/bts-
guideline-for-emergency-oxygen-use-in-adult-patients/ Accessed
04.08.17.

Chartered Society of Physiotherapy (2011) Code of Members'


Professional Values and Behaviour. London: CSP.

Danckers, M. & Fried, E.D. (2013) Arterial Blood Gas Sampling.


[Online] Available at: http://emedicine.medscape.com/article/1902703‐
overview Accessed: 08.07.17

Nottingham University Hospitals NHS Trust (2015) Blood Borne Virus


Policy (Including Management of Inoculation, Sharps and
Contamination Incidents). Nottingham: NUH.

Nottingham University Hospitals NHS Trust (2013) Infection Prevention


and Control Policy. Nottingham: NUH.

Nottingham University Hospitals NHS Trust (2012) Consent to


examination or treatment policy. Nottingham: NUH.

Nursing & Midwifery Council (2015) The Code. Professional standards


of practice and behaviour for nurses and midwives. London: NMC.

The Royal Marsden NHS Trust (2015) The Royal Marsden Manual of
Clinical Nursing Procedures. 9th Ed. [Online] Available at:
http://www.rmmonline.co.uk/manual/c10-fea-0054 Accessed 15.10.15

Weinstein, S. & Plumer, A.L. (2007) Plumer's Principles & Practice of


Intravenous Therapy. 8th Ed. Philadelphia: Lippincott Williams &
Wilkins.

White, G.C. (2003) Basic Clinical Lab Competencies for Respiratory


Care: An Integrated Approach. 4th Ed. London: Delmar Publishing.

World Health Organisation (2010) WHO guidelines on drawing blood:


best practices in phlebotomy. Geneva, Switzerland: WHO Document
Production Services.

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