How To Take A Set of Arterial Blood Gases (Abgs) : Think Lemon Juice in A Salted Paper Cut ..It Does Smart A Little!
How To Take A Set of Arterial Blood Gases (Abgs) : Think Lemon Juice in A Salted Paper Cut ..It Does Smart A Little!
How To Take A Set of Arterial Blood Gases (Abgs) : Think Lemon Juice in A Salted Paper Cut ..It Does Smart A Little!
(ABGs)
Think lemon juice in a salted paper cut …..it does smart a little!
Part (a) – Skills practice
In order to perform the skills in this part of
the module – you will need to be in a
skills centre with access to :-
• The ‘blood gas’ manekin arm (you will
need someone else to pump the arterial
pulse!)
• A blood gas syringe
• A piece of clean gauze and an alcohol
wipe
Generic approach to all procedures
• Introduce yourself with name and role
• Check you have the correct patient by introduction and ID band (if in-patient)
• Explain procedure and gain verbal consent – ‘Is that alright / OK?’
• Check you have ALL the appropriate items to do the procedure and they are
in working order.
• Wash hands prior and after procedure
• Position the patient for ease of procedure and their comfort; Ensure they are
able to maintain this position for the duration of the procedure.
• Proceed explaining and reassuring as you carry out the procedure.
• Once completed thank the patient AND reposition them comfortably whilst
maintaining their dignity.
• CLEAR UP THE MESS! Place sharps and other similar items e.g. bloodied
items, into the sharps bin.
• Explain / Confirm to nursing staff what you have done and what if anything
you would like done as a result e.g. ‘I have re-sited a cannula in the left arm to
be used for IV antibiotics’; Indwelling catheter – ‘Please measure and record
hourly urine output’; Agree any observations that may need to be done and
other issues – NBM; Analgesia; Possible complications.
• Record procedure in the notes – include any difficulties and possible
complications. Accurately record any conversation with patient and relatives
around these problems.
Procedure – How to take ABGs
• Unfortunately taking ABGs hurt! Doing them badly means they really hurt.
• If they are done badly, patients (a) stop anyone else taking them (b) don’t come back to hospital
despite being unwell. Both of these can seriously affect their health!
• You should watch a few sets of gases being done before trying them yourself (here’s one we
prepared earlier ….)
http://www.etu.sgul.ac.uk/cso/video.php?skill=arterial_blood_gas
• Introduce yourself to the patient, gain verbal consent after explaining the procedure. (What are the
common complications of this procedure?)
• You will need to check you have all the correct equipment before proceeding
• Wash your hands and put on your gloves.
• Ask the patient to place their hand palm upwards comfortably supported on a surface e.g. the arm
of a chair
• Check there is a radial and ulnar pulse (Allen’s test) - note: rarely, if ever done in practice!
• The radial pulse is very superficial so you will need to bear this in mind when stabbing the patient
• Clean the area with an alcohol wipe
• Empty the syringe of the heparin solution so ‘heparinising’ the needle
• Place the index finger of your non-dominant hand over the radial pulse
• Insert the ABG needle at an angle of about 30 – 400 under your index finger.
• DO NOT use the ‘split finger’ technique where you place the needle vertically in between your
‘split’ index and middle fingers as you will end up doing a radial bone biopsy!
• Allow the appropriate amount of blood to fill the syringe (you may need to augment the action of
the needle if the patient has a very sluggish circulation (common in the sick patients that you will
be taking blood gasses from!))
• Remove the needle and press down hard over the puncture site with a piece of clean gauze for a
couple of minutes. If the patient is well enough you can ask them to do this for you.
• Thank the patient and ensure they are comfortable before leaving. You will invariably need to
return to act on the results of the ABGs
• Take the syringe immediately to the ABG machine for analysis. If there is any delay you will need
to ice the sample
How to interpret Arterial Blood Gases
(ABGs)
pH HCO3-
PaCO2
STEP (3) You must consider each component
separately.
• Start with the
respiratory
component, or
• Start with the pH
component
• Don’t mix them up!
• To do so leads to
heartache and
confusion!
Jimmy Floyd Hasselbaink
Step 3(a) Let’s start with the pH
component
Consider pH HCO3- [M]
PaCO2 [R]
• The HCO3- should be considered as
the Metabolic [M] component of the
equation
ACIDOSIS – ALKALOSIS
pH < 7.35 pH> 7.45
• Metabolic Acidosis • Metabolic Alkalosis
Low pH – Low HCO3- HIGH pH – HIGH HCO3-
Mechanism
• By the equation Anion Gap = [Na+ + K+] - [HCO3- + Cl-]
• If HCO3- is lost this has to be, and is, balanced by retention of chloride
ions in the renal tubules
• Hence NAGMA is invariably accompanied by hyperchloraemia.
• With the ingestion of acidic compounds producing H+ and Cl- the net loss
of bicarbonate (in buffering the H+) is countered by the increase in
chloride.
High Anion Gap Metabolic Acidosis [HAGMA]
Principally due to
(a) Increased endogenous H+ (increased production or failure of
elimination)
If you think about the metabolism of endogenous acids –logically there are several sources of HAGMA
• Increased Lactic acid production I.e. lactic acidosis (severe sepsis, shock,
hypoxaemia, paracetamol overdose, biguanides).
• Increased Ketogenesis – DKA, starvation, alcohol induced
• Decreased excretion of acids from the kidneys – renal failure
• Decreased elimination of urea – liver and renal failure
• Decreased hepatic elimination of lactate – liver disease
The patients listed below have all presented with abnormalities of their arterial blood gases. You may assume the ABGs were all taken on room
air. Although in a clinical setting you would hope that many had been placed on oxygen therapy the moment they presented!
Implied diagnoses – e.g. Metabolic acidosis with type II respiratory failure
Cause: Lactic acidosis secondary to severe respiratory failure eg pulmonary oedema
Normals 1 2 3 4 5 6
pH 7.35 –7.45 7.21 7.61 7.05 7.36 7.48 7.51
PaCO2 (KPa) 4.6 – 6.4 7.30 4.9 2.7 6.8 2.7 2.8
HCO3- 22 - 28 14.6 48.7 7.1 31.3 20.3 25.9
(mmol/l)
PaO2 >10.6 5.9 13.6 13.5 8.2 8.1 14.0
(KPa)
Sats >96% 76% 99% 98% 86% 85% 100%
Base Excess 0+/-2 -7.9 +18 -21 +4.9 -4.1 +0.76
(mmol/l)
Implied Diagnoses
Causes
For more on ABGs
• http://www.acid-base.com/index.php
Another Old Londoner tries to teach medical students
ABGs!
• http://www.studentbmj.com/issues/04/03/educatio
n/105.php
Very good overview of ABGs; worth visiting just
for the questions at the end
• http://www.usyd.edu.au/su/anaes/lectures/a
cidbase_mjb/description.html
Excessively technified version of acid-base - fantastic
references and historical perspective! – someone,
somewhere will love it! Explains Base excess in lots of
detail!