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OutlinesDefinition

Arterial puncture site

Indication

Contraindication

Equipment

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Allen Test for collateral flow

Steps for Allen Test

Procedure

Complication

Expected ABG out come

ABG Interpretation

DefinitionABG is an invasive diagnostic procedure

in which a blood is obtained from anartery directly by an arterial puncture orby drawing blood sample from anindwelling arterial catheter, to measureO2 and CO2 in the blood as well as (PH)acidity of the blood.

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Sites of obtaining blood sample for ABG analysis ABG sampling is usually performed on the radial

artery because the superficial anatomic

presentation of this artery makes it easily

accessible. In cases where distal perfusion is

compromised and distal pulses are diminished,

femoral or brachial artery puncture can be

performed instead.

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Indications Respiratory disorders .

kidney disorders .

Cardiovascular disorders .

Uncontrolled diabetes .

Patients on supplemental oxygen to monitor the

effectiveness of treatment .

. Hemorrhage

Chemical poisoning & a drug overdose

Shock

Metabolic disorders

Head or neck injuries that affect breathing

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ABG testfor Contraindication 1. An abnormal Allen ( in this case attempt puncture

at a different site) .

2. Local infection at the potential puncture site.

3. Previous surgical interventions, congenital or

acquired malformations, or burns at the site

required.

Cont.4. The presence of Arteriovenous fistulas or vascular

grafts at a limb.

5. peripheral vascular disease of the limb involved.

6. Anticoagulation therapy with warfarin, heparin

and derivatives.

7. Use of thrombolytic agents, such as streptokinase .

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Possible side effects associated with the blood gas test include:

Bleeding or bruising at the puncture site

Blood accumulating under the skin

Infection at the puncture site

Sampling errors

Reasons for an inaccurate blood result include:

presence of air in the sample;

collection of venous rather than arterial blood;

an improper quantity of heparin in the

syringe, or improper mixing after blood is

drawn;

a delay in specimen transportation.

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-Explain procedure

-Perform Allen test to the upper arm

Should always be performed before using the radial artery

to determine whether the ulnar artery delivers sufficient

blood to the hand and fingers.

-Inspect potential areas of arterial puncture assess for signs

of infection, skin breakdown, the presence of pulse,

previous surgery..

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-Assess the patient before arterial puncture :-

Patient who has just awakened.

Immediately after suctioning.

Less than 20 to 30 minutes after oxygen therapy or ventilatorsetting.

-Body temperature disturbances

Perform physical assessment of thorax and lungs

Identify medications that may influence ABG measurement (e.g.anticoagulants).

Assess the selected site for puncture.

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Individualized ABG kit (heparinized self-filling 3-mL syringe with 22-G needle attached)

Airtight cap for hub of syringe

Gauze pad 2 _ 2

Band-Aid

Antimicrobial swab, such as chlorhexidine

Biohazard bag for delivery of specimen to laboratory

Appropriate label for specimen, based on facility policy and

procedure

Cup or bag of ice

Clean gloves

Rolled towel

Protective eyewear to protect the eye from splashes

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1-Palpate selected radial, femoral, or brachial site to evaluate

the pulse.

2-Stabilize the hand with the wrist extended over the rolled

towel,

3-Asks the patient to extend the fingers downward and

stabilize artery by slight hyperextension of wrist.

4-Disinfect the area of maximal impulse with alcohol swab or

antiseptic swab, wiping in circular motion and allow to dry.

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5- Hold 2×2 inch gauze pad with the fingers of the other

hand. 0.25

6- Palpate the artery above the puncture site with the

index and middle fingers of your non-dominant hand

while holding the syringe over the puncture site with

your dominant hand. Do not directly touch the area to be

punctured.

7- Hold needle bevel up and insert at 45- 60 degree

angle to the radial or brachial artery & 90 degree

angle to the femoral artery.

8-Stop advancing needle when blood is noted

returning into hub of needle or syringe

9-Aspirate 2 to 3 mL of blood into hepranized

syringe slowly.

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10- Once sample is taken apply sterile cotton pad

over puncture site, withdraw syringe and needle, and

activate safety guard over needle

11-Apply pressure continuous over site for 3 to 5

minutes (15 minutes if patient is undergoing

anticoagulant therapy or has bleeding disorder).

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Pressure may need to be held longer (> 5 mins) if the patient is

on anticoagulant therapy

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After obtaining ABG sample

1-Inspect the puncture site for signs of bleeding or

hematoma formation.

2-Palpate artery below or distal to puncture site.

3-Remove gloves and performs hand hygiene.

4-Take syringe, remove safety needle, and attach a

filter cap to expel air, or cover tip of syringe with 2×2

inch sterile gauze to expel air.

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Prepare syringe for laboratory analysis according to

agency policy. Common principles include:

Removal of air bubbles

Label the sample

Place syringe in cup of crushed ice.Attach properly labeled requisition to blood gas

sample. Send sample to laboratory immediately Review results of sample as soon as possible.

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Documentation1 •Record results of Allen's test.

2.Record puncture site.

3 .Report patient's any ventilator setting (e.g. Tidal

volume, respiratory frequency, mode of ventilation

4.Record and report the results of blood gases test

in nurse's notes and to health care providers as

soon as possible.

5.Record patient's tolerance of the procedure

6. Ask the patient to record and report numbness,

burning, and/or tingling during and after obtaining

the sample at the puncture sits

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PH :- hydrogen ion concentration of blood and is an

indicator of Acid – Base status.

PH 7.35- 7.45

PH Acidosis

PH Alkalosis

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PaCo2:- The partial pressure of carbon dioxide in

the arterial blood

PaCo2 35-45

PaCo2 Respiratory alkalosis

PaCo2 Respiratory acidosis

HCO3:- the serum bicarbonate, which is the majorcomponent of the renal compensatory mechanism.

HCO3 22-26 mEq/L

HCO3 Metabolic acidosis

HCO3 Metabolic alkalosis

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BE:- base excess reflects an increase or decrease in

total buffer base .

BE -2 to +2

BE Metabolic acidosis

BE Metabolic alkalosis

PaO2:- the partial pressure of oxygen in the arterial

blood

PaO2 80-100 mmHg

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ABG interpretation

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Respiratory acidosis

Respiratory Alkalosis

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Metabolic acidosis

Metabolic alkalosis

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Arterial Line Insertion

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Arterial catheter

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Definition

It mean a thin catheter (cannula) inserted

into an artery. It is most commonly used to

provide continuous blood pressure (BP)

monitoring and arterial blood sampling for

analysis. Arterial catheter changes every 7-8

days.

NB Arterial lines are generally not used to administer

medication, injectable drugs may lead to serious tissue

damage, necrosis, gangrene and even amputation of

extremity if administered into an artery rather than a

vein.

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Sites of arterial cannula Arterial lines can be placed in multiple arteries,

including the radial, ulnar, brachial, axillary,

posterior tibial, femoral, and dorsalis pedis

arteries. In both adults and children, the most

common site of cannulation is the radial artery

because of the superficial nature of the vessel.

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Indications

1) Direct Blood pressure monitoring when

noninvasive (indirect) methods have failed

2) Continual arterial access for arterial blood

sampling.

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Contraindications

Absent pulsation Burns over the cannulation site Inadequate circulation to the extremity Infection at the cannulation site Previous surgery in the area Synthetic vascular graft, Arteriovenous fistula

Common complications of arterial cannulation

1- Hemorrhage2- Hematoma3- Air embolism4- Local infection at site of insertion5- Sepsis or bacteremia secondary to infected arterial line6- Risks of thrombosis7- Accidental catheter removal8- Accidental drug injection cause irreversible damage to tissues.9- Nerve damage

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Preparation for procedure Preparation for procedure (Allen's Test)

Allen test is recommended to be performed before radialartery cannulation is initiated. This procedure is asimple bedside test designed to evaluate for adequatecollateral circulation to the palmer arches of the hand. Inmost patients, the palmer arches are supplied by boththe radial artery and the ulnar artery. This collateralcirculation allows perfusion of the hand should either ofthese vessels be injured .

To perform Allen test:

1- the examiner elevates the hand and asks the patient

to make a fist for 30 seconds.

2- With the patient's hand in a fist, the examiner

applies simultaneous pressure to the ulnar and radial

arteries so as to occlude them. (both radial and ulnar

arteries occluded by the examiner while patient

makes fist)

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3- The patient is then asked to open the hand, which

should appear blanched as a consequence of the

occlusion of the radial and ulnar.

(Radial and ulnar arteries remain occluded by the

examiner after patient's hand is opened)

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4-Release the pressure over the ulnar artery and the

time it takes for color to return to the hand is

measured (in seconds). If there is good collateral

perfusion the palm should be return flush in less than

6 second.

5-if the hands did not returned to the flushing color

within 6 seconds this means low perfusion and you

should not use the site for arterial puncture.

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Equipment:

1. Arterial cannula with suitable size:

2. ( 20 G for adults and 22 G for pediatrics and 24 for

neonates)

3. Disinfectant solution

4. Sterile gloves, Sterile drape

5. Face mask, gown, and over head

6. Adhesive tab7. anesthetic such as lidocaine can be used

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The idea here is to figure out if there is adequatecollateral circulation from the ulnar artery toperfuse the hand.

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Equipment 1-Arterial cannula with suitable size: ( 20 G for adults and 22

G for pediatrics and 24 for neonates)

2-Disinfectant solution

3-Sterile gloves, Sterile drape

4-Face mask, gown, and over head

5-Adhesive tab

6-Anesthetic such as lidocaine can be used .

Environment preparation

-Comfortable Environment and Close curtains

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Patient preparation -Inspect potential areas of arterial cannulation assess for

signs of infection, skin breakdown, and the presence of

the radial pulse.

-Perform Allen test

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1. Wash hands and Wear clean gloves2. Check doctor and indication of arterial catheter3. Explain procedure to the patient.4. Hyper extended the patient’s wrist in place with anarm board and gauze dressing so that the wrist isexposed.5. Extend the wrist and fixe to an arm board with tape orgauze.6. Disinfect the site with a chlorhexidine 0.5%) oriodinated

7. Apply a large sterile field over the wrist area.

8. Palpate the artery between the first and second

fingers.

9. Stabilize artery by pulling skin taut.

10. Once pulsatile blood flow is noted the catheter

should be gently inserted into the artery with 45angle

(for femoral artery 90 angle).

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11. Backing simply the needle catheter out, and place cap

slowly to avoid bleeding.

12. Secure the catheter using visible adhesive tape

13. Return supplies, Properly dispose sharp needles.

14. Ultrasound used to increase the success of first

Cannulation.

Documentation Indication of arterial cannula Site of insertion, size of catheter Any problems and how it managed

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