INTERN SURVIVAL GUIDE

Arterial Blood Gas

Tutorial Overview

• Equipment Selection

• Equipment & Patient Preparation & Allen’s Test

• Procedure Steps

• Indications

• Reminders & FAQs

Equipment Selection1. Phlebotomy tray and sharps Bucket

1. Phlebotomy tray and sharps Bucket

2. Non-sterile gloves 2. Non-sterile gloves 3. Alcohol swabs

6. Rolled up towel

3. Alcohol swabs

6. Rolled up towel4. Blood gas syringes4. Blood gas syringes 5. Cotton buds and tape5. Cotton buds and tape

At Bedside: Equipment Preparation

• Hand hygiene• Open the alcohol swab

by tearing along the top of it

• Open the ABG bottle packaging and assemble the syringe

• Do not throw away the black cap

At Bedside: Patient PreparationAllen’s Test

• To assess adequacy of ulnar collateral flow

1. Patient elevates their hand2. Patient clenches fist several

times to blanch palmar skin3. Firm occlusive pressure applied

on both radial and ulnar artery4. Release ulnar artery while the

radial artery is compressed5. Observe for palmar reperfusion6. Repeat the test with radial artery

release first

At Bedside: Patient Preparation

1. Perform hand hygiene

2. Position hand on a firm surface with wrist in 40°extension

3. Place rolled towel under wrist for comfort

4. Palpate brachial artery with middle and index finger. Make sure you can palpate it with a gloved hand

5. Mark point where you can feel the pulse in between your 2 fingers with a skin marker and clean with alcohol swab

Procedure Steps1. Open and uncap ABG needle

2. Palpate the vessel again between your 2 fingers

3. Face bevel towards heart, insert between 60°and 90°between fingers

4. Advance needle until arterial blood starts to fill syringe. There is no need to withdraw plunger. This should be very superficial

5. Fill 2 - 2.5ml

6. Simultaneously withdraw needs and place cotton bud over puncture site. Apply pressure immediately

7. Instruct patient to apply pressure for 5 minutes

Procedure Steps8. Dispose of needle

9. Expel air from syringe and apply black safety cap

10. Mix sample by rolling between hands

11. Label bottles and confirm patient identity at bedside

12. Check and redress puncture site after 5 minutes

13. Dispose of clinical waste and perform hand hygiene

14. Record procedure in patient notes

ABG Indications• Identification of acid-base disorders

• Monitoring of acid-base status

• Measurement of arterial CO2

• Monitoring of ventilated patients

• Assessment of respiratory failure

• Remember that you can get additional information:electrolytes, haemoglobin, lactate

Reminders• Haematoma

– To avoid this puncture only the uppermost wall of the artery by advancing the needle slowly into the artery

– Do not perform on patients with a severe coagulopathy and caution should be exercised in patients on warfarin or heparin

– Apply pressure to the site immediately after puncture and advise the patient to maintain pressure for 5 minutes

• Vessel Damage / Occlusion – Perform Allen’s test to ensure patency of ulnar artery. To avoid artery

damage, insert needle as close to 90°as possible

• Pain– ABG sampling can be painful if the needle penetrates deep and touches the

periosteum of the radial styloid– To avoid this, remember that the radial artery is superficial at the wrist and

advance the needle slowly and wait for the syringe to fill

Frequently Asked Questions

• What happens if I can not palpate the radial artery?– Try the other wrist. You may have to use the brachial

artery or the femoral artery. As an intern you should only do this under supervision and knowing the anatomy of the regions

• Is aspirin a contraindication to ABG?– No. Remember to apply pressure and observe for bleeding

• Is severe peripheral vascular disease a contraindication to ABG– Yes

Frequently Asked Questions• What to do if Allen’s test is abnormal?

– Document your findings in the patient’s chart and try the other radial artery. Otherwise get senior help

• Does the syringe need to be fully filled?– No. 2 -2.5mls is sufficient. The ABG machine requires between

0.5 and 1 ml to process a sample. Remember that you will have to expel air from the sample and you may need to reprocess the sample so it is a good idea to keep the sample until the machine has printed the result

• Do I need to remove supplemental oxygen from a patient to perform an ABG?– No, do not remove the oxygen. Remember to record the

patient’s name, ID and percentage O2 on the result

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