1. Invasive Blood Gas Analysis and Cardiovascular Monitoring
Chapter 10
Invasive Blood Gas Analysis and Cardiovascular Monitoring

2. Indications Similar to that of an adult
Acid base balance, ventilation, oxygenation status
Oxyhemoglobin, intrapulmonary shunting
Response changes to therapy
Severity of diseases….
Respiratory distress
Baby on oxygen
Shock
Sepsis
Suspected metabolic disorder
Failure to thrive (weight loss or no wt gain)

3. Pain Control Pain control during draw
Infants most likely have higher pain sensitivity
Groups older than 4 months anesthetic cream may be used
Premature newborns/neonates not intubated may use a pacifier dipped in 24% sucrose, intubated may give as drops on the tongue

4. Pain Control
The synergistic effect of the combination of sucrose and non-nutritive sucking has shown clinically effective and safe in relieving the pain of simple procedures such as venipuncture or heel stick in preterm and term infants, but further research is needed on these interventions alone and in combination with other behavioral interventions in neonates.

5. Blood Gas Sampling

6. ABG sampling sites
Brachial and femoral sites are avoided because both feed large distal networks and neither has collateral circulation
Brachial sites are hard to palpate due to large fat pad in arm, high risk in damaging nerve
Femoral site puncture never done in neonates due to proximity to vein, nerves and hip joint
Preferred site for ABG in both neonatal and pediatric populations is radial (easy to manipulate wrist and collateral circulation)

7. ABG sampling sites
Dorsalis pedis or posterior tibial artery considered if radial artery shows poor collateral circulation
Temporal artery provides an alternative site

8. ABG Sampling Sites Umbilical artery catheter (UAC)
Clots may form on the end
Remember, it is post-ductal blood so the PaO2 may be lower than pre-ductal PaO2

9. ABG Sampling Sites: Punctures
Radial artery and temporal artery
Can be hard to hit
Brachial should not be used
NEVER use the femoral artery in an infant!

10. ABG Sampling Sites: Capillary
Easier to puncture than radial or temporal artery
PO2 may not correlate well to PaO2
Heel has to be warmed prior to puncture to “arterialize” the site

11. Puncture Sites

12. Allen’s test Can be modified depending on age of child
For patients who cannot follow order
For foot (dorsalis pedis and posterior tibial arteries)
a. Elevate infant’s hand.
b. Occlude both radial and ulnar arteries at wrist.
c. Massage palm toward wrist.
d. Release occlusion of the ulnar artery only.
e. Look for color to return to the hand in 6 seconds or less indicating adequate collateral supply. Do not puncture radial artery if color returns take more than 6 seconds.
f. Document inadequate collateral circulation

13. Arterial Puncture Procedure
Often more difficult and therefore less frequently done
Requires more skill, time and patience
On pediatrics, have two people, one to console the child and one to puncture
For neonates, may use a transillumination light to visulize the artery
May be performed in cases of low perfusion where a CBG is not appropriate

14. Arterial Puncture Procedure
Equipment required
1 ml preheparinzed tuberculin syringe
25 Gauge needle or 25 Gauge butterfly
Gloves
Alcohol wipes/ Iodine
Gauze
Needle cap
Label

18. Arterial Puncture Procedure
Position needle for arterial puncture against direction of blood flow.
Keep angle of entry shallow for superficial vessels:
a. 35 to 45 degrees for superficial artery, advance slowly/gently. May insert through artery, may have to pull back slowly if flash disappears. If resistance occurs withdraw, most likely hitting bone
b. Palpate artery using index finger and middle finger of the non dominate hand to stabilize artery
C. If using a butterfly only require enough to fill tubing, otherwise roughly ml is required for adequate sampling. Get enough blood and run it quickly to avoid having to do it again.

19. Arterial Puncture Procedure
Contraindications are similar to adults as are hazards.
Just remember that ABG’s are not done if a less invasive means can achieve the same results; such as a CBG

20. Factors affecting arterial blood gas values
Clotting – heparin is utilized to prevent clotting of the blood sample.
The sample must be rotated/agitated to ensure adequate mixing of heparin and blood to prevent clotting.
Excessive heparin – changes the pH of the specimen.
Air contact – no air must come into contact with the blood sample. Air contact can increase the PO2 and decrease the PCO2 since there is usually more oxygen and less carbon dioxide in the air than in the
blood as measured by partial pressures.
Temperature – red cell metabolism must be minimal. The sample must be placed immediately in ice slush to slow metabolism. Red cells that are warm will continue to metabolize, giving off CO2 and consuming O2, thus affecting the blood gas values.
Steady rate – the blood should be drawn when the patient is in an equilibrated state, that is, when at least 20 minutes have elapse since any change has occurred or been made that might affect the blood gas
Significant changes are respiratory rate, tidal volume
, minute volume, Fi02, and suctioning before sampling time.

21. Capillary Blood Gas Samples
Less blood required
Less invasive
Correlates best with pH and PaCO2

22. Capillary Blood Gas Samples
Conditions of decreased venous return (right heart failure) can lead to venous congestion and higher capillary CO2 levels, increased cardiac output may lead to decreased capillary CO2 levels
CBG should be correlated with an initial ABG if possible
Accuracy of CBG affected by hypotension, hypothermia, hypovolemia
PcO2 values are not utilized and do not correlate with arterial (unless patient has hypoxia), but may be used to trend PaO2 values

23. Procedure for CBG

25. Procedure for CBG (cont.)

26. Procedure for CBG (cont.)
Select puncture site and warm area for 5-10 minutes, use a heel warmer C
Give a 12% to 24% sucrose solution pacifier 2 minutes before procedure
Wash hands/gloves
Remove heel warmer, clean site with alcohol or iodine, wipe dry with gauze, alcohol will hemolyze the blood
Immobolize the area by grasping the hand or foot and stabilize the area by anchoring the hand or foot on a hard surface, swaddle newborns/infants
Hold heel gently/firmly, wrap forefinger around infants upper heel and ankle while holding the arch of the foot with the thumb

27. Procedure for CBG (cont.)
Position lancet and depress – depth around 1-2 mm, only puncture once without slicing
Ease thumb pressure after the lancet is removed
Wipe away the first drop of blood which may be contaminated with intracellular, interstitial or lymphatic fluids with a dry gauze
Apply moderate pressure to the heel or digit without massaging or squeezing, until a free flowing drop of blood appears
Squeezing or “milking” the sample may cause hemolysis (more fragile RBC’s in neonates); also may cause brusing and contamination

28. Procedure for CBG (cont.)
Place tip of capillary into the droplet without touching the puncture wound
Hold the tube angled horizontally or slightly downward but avoid getting air into tube.
Fill tube as much as possible to avoid air contamination
Do not scrap the skin, may contaminate the sample with skin cells
If sample can not be analyzed immediately insert a metal mixing “flea” into the capillary tube and seal it, mix the sample by running a magnet gently back and forth (if available) or simply roll in your fingers

29. Contraindications Need accurate assessment of oxygenation
Neonates less than 24 hours old
Decreased peripheral blood flow
Polycythemia
Avoid areas that are:
Edematous
Inflamed
Infected
Callused

30. Complications May not accurately reflect patient’s condition
Mismanagement
Burns
Infection
Scarring/bruising
Inflammatory changes
Nerve damage
Artery damage
Bruising
Hematoma
Bleeding

31. Arterial Catheter Indications: Need for continuous measurement, Sites
Umbilical arteries
Neonates
Peripheral arteries
Radial artery
Posterior tibial
Dorsalis pedis

32. Arterial Catheter (cont.)
Direct measurement of BP (MAP)
Waveform
Patency of arterial line
Quality of pulse pressure
Calculation of MAP

33. Continuous Invasive Blood Gas Monitoring
Closed loop
Frequent ABGs
Low volume

35. UAC procedure
Umbilical artery lines are entered for removal of blood for monitoring of laboratory work and arterial blood gases.
Umbilical arterial lines are entered for the administration of intravenous fluids and medications.
Any time an arterial line is entered, sterile technique should be maintained.
Care should be taken to prevent blood clots or air emboli from entering the patient.
The umbilical artery line should be maintained as a closed circuit to prevent the loss of blood or intravenous fluids.

36. UAC procedure Contraindications
Signs of complications (i.e.: leg blanching, discoloration, decreased peripheral pulses, improper position of catheter) indicating that infusion or withdrawal through the catheter may cause or further decrease circulation to an extremity.
An infant with an already depleted blood volume.

37. UAC procedure Equipment required
3 cc sterile dry syringe for clearing line
1 cc sterile syringe with dead space filled with 1000 units per cc of heparin
1 cc syringe for drawing lab work
1 cc syringe of normal saline for flush (This syringe is placed on the stopcock at the beginning of each shift).

38. Step
Action 1
Verify Physician's Order and Patient identification. Evaluate infant for feasibility of drawing ABG. 2
Assemble Equipment. 3
Wash hands. Wear gloves. 4
Check position of stopcock, making sure it is closed to the flush syringe. 5
Remove flush syringe, cap and set aside. 6
Place 3 cc drying syringe on stopcock. 7
Turn stopcock off to intravenous fluids 8
Draw back 2-2½ cc of blood to clear line and obtain an uncontaminated blood sample. 9
One-fourth turn stopcock off. Remove syringe, cap and set aside 10
Place appropriate syringe on stopcock. 11
Turn stopcock off to intravenous fluids and draw blood sample needed.
0.3 cc for ABG in heparinized TB syringe (flush syringe with 1000u Heparin leaving a tiny amount in dead space of syringe).
Appropriate amount for laboratory work in proper vacutainer tubes. 12
Remove cap from the syringe of blood drawn earlier to clear the line. Replace this into stopcock.

39. Step
Action 13
One-fourth turn stopcock and remove sample syringe.
For ABG's prepare for transport -- Remove air bubbles and ice sample.
For laboratory -- Place in appropriate vacutainer and label. 14
Remove cap from the syringe of blood drawn earlier to clear the line. Replace this into stopcock 15
Turn stopcock off to intravenous fluids, draw slightly back on syringe and flick to remove air bubbles. Then slowly re-infuse blood. Observe line to make sure no air or clots are infused. 16
One-fourth turn stopcock OFF, remove syringe. 17
Remove cap from flushing syringe, place in stopcock. 18
Turn stopcock off to intravenous fluids, draw back slightly on syringe and flick any air bubbles to top, using as little flush as possible to clear line of blood. 19
Return stopcock off to flush syringe, leaving I.V. open. 20
Make sure all connections are tightly secure and that the stopcock is open to intravenous infusions. 21 22
Observe infant for any adverse reaction to the procedure. 23
Wash hands. 24
Chart the amount of blood withdrawn, keeping a running total. The amount of flush solution used will be added to the cumulative total of fluid intake.

40. UAC Care
The umbilical arterial catheter should be maintained as a sterile infusion line. Good hand washing technique is IMPERATIVE.
The arterial line should be observed at all times to maintain a closed system to:
Prevent loss of blood
Prevent loss of I.V. fluids
Prevent air embolisms.
Maintain patency of line.

41. Central Venous Catheters
Sites vary with patient age and condition
Measures
Right atrial pressure
Mixed venous blood gases/saturations
CVP
Volume status

42. Pulmonary Artery Catheters
Less frequently used with children

43. Pulmonary Artery Catheters

44. Cardiac Output

45. Noninvasive Measurement of Cardiac Output
Fick equation
Rebreathing CO2
Pulse oximetry
Perfusion Index

46. Normal values of arterial O2 tension
Oxygen tension in term neonates is mm of Hg and in children mm of Hg.
PaO2 monitoring has recognized shortcoming.
Validity of values are optimal when blood gas samples are obtained from indwelling catheters under quiet, resting conditions. In a crying neonate due to pain of percutaneous puncture values obtained may not reflect steady state conditions.
paO2 values vary considerably throughout the day in sick neonates.
Intermittent sampling produces only a limited view of a single point in time.

47. Normal values of arterial O2 tension
Transcutaneous (TcPO2) monitors are useful for judging trends in oxygenation during management of acute lung disease. These monitors measure skin surface pO2 (not paO2), which under proper conditions is closely correlated with arterial pO2
The TcPO2 sensor combines a miniature blood gas electrode with a servo controlled probe. The sensor is applied to the skin in a way that excludes any effects of environmental air on values measured. The technique depends on heating the skin at the sensor site to 43.5C to 44C.

48. Normal values of arterial O2 tension
Correlation is poor and TcPO2 may underestimate paO2
Such conditions include circulatory insufficiency, inadequate electrode temperature, improper calibration and lack of user expertise, patient age greater than 10 weeks (skin thickness factor), and use of vasodilator agents.
Maturation and thickening of skin with increasing postnatal age limits the use of transcutaneous monitoring to neonates.
All of these artifacts of measurement result in underestimation of arterial pO2
Under usual circumstances TcPO2 should be in the 40 to 80 mm Hg range.

49. Normal values of arterial O2 tension
There is a time lag between measured TcPO2
and paO2 values. As a result, oxygen concentration
should not be continuously raised and lowered in attempts to “chase” fluctuating TcPO2

50. ABG Values: ELBW/Premature <28 wk
pH: >7.20
PaCO2: 45-55
Depends on pH
PaO2: 45-65
HCO3: 15-18

51. ABG Values: 28-40 wk GA pH: 7.25 – 7.45 PaCO2: 45-55 PaO2: 50-70
HCO3: 18-20

52. ABG Values Term infant to toddler (up to 2)
pH:
PaCO2: 30-40
PaO2:
HCO3: 20-22

53. ABG Values Child to adult
Normal ranges for all categories

54. Metabolic Acidosis Diarrhea
Small bowel. Biliary or pancreatic tube or fistula drainage
Hyperalimentation
Ingestion of chloride compounds
Renal tubular acidosis
Renal failure
Carbonic anhydrase deficiency
Lactic Acidosis (sepsis, hypoxia, cold stress)
Ketoacidosis (starvation, DM)
Toxins (salicylate, poisoning, methanol, ethylene)
Inborn errors of metabolism

55. Metabolic Alkalosis Vomiting NG suctioning
Congenital chloride-wasting diarrhea
Dehydration
Drugs (diuretics, steroids, Sodium Bicarb)
Cushings syndrome
Bartters syndrome
Hypokalemia
Hypocholermia
Chewing tobacco
Massive blood transfusion
Cystic fibrosis

56. Bartter syndrome
Bartter syndrome is a rare inherited defect in the thick ascending limb of the loop of Henle. It is characterized by hypokalemia, alkalosis, and normal to low blood pressure.
Seen between 24 and 30 weeks of gestation with polyhydramnios
After birth, the infant is seen with polyuria, and polydipsia Life-threatening dehydration may result if the infant does not receive adequate fluids. About 85% of infants dispose of excess amounts of calcium in the urine (hypercalciuria) and kidneys which may lead to kidney stones. In rare occasions, the infant may progress to renal failure.

57. Cushings syndrome
Associated with prolonged exposure to inappropriately high levels of the hormone cortisol. This can be caused by taking glucocorticoid drugs, or diseases that result in excess cortisol, adrenocorticotropic hormone
pituitary-dependent cause of Cushing's syndrome: a tumor (adenoma) in the pituitary gland produces large amounts of ACTH, causing the adrenal glands to produce elevated levels of cortisol. It is the most common non-iatrogenic cause of Cushing's syndrome, responsible for 70% of cases excluding glucocorticoid related cases
Symptoms include rapid weight gain, particularly of the trunk and face with sparing of the limbs (central obesity). A common sign is the growth of fat pads along the collar bone and on the back of the neck (buffalo hump) and a round face often referred to as a "moon face."

58. Capillary gases use the same values EXCEPT for PO2
Capillary PO2: 35-50
Capillary %sat: 75-85%

59. Why lower PO2 values Are acceptable in the neonate
O2 dissociation curve is shifted to the left so affinity is increased – hemoglobin saturates at a lower PaO2
Presence of HBF
Decreased 2,3-DPG
Neonate not considered hypoxemic until PaO2 is less than 50!

60. Cyanosis Classic definition: 5 grams% of unsaturated hemoglobin
Infant may not show signs of cyanosis until PaO2 < 40 (%sat between 75-85%)

61. Effects of Hypoxia Decreased tissue oxygenation Lactic acidosis
Hypoglycemia
Increased PVR and PAP
May allow shunting across ductus arteriosus or foramen ovale
Decreased surfactant
Worsening of hypoxemia
Decreased thermogenesis
Cold stress/hypothermia
Brain & CNS damage

62. Hyperoxia may damage the neonate’s eyes and/or lungs
Hyperoxia: PaO2 > 100
Hyperoxia may damage the neonate’s eyes and/or lungs

63. Retinopathy of Prematurity (ROP)
Hyperoxia causes vasospasm and ischemia in retinal arterioles
Ischemia and compensatory vasodilation and proliferation causes retinal edema which may lead to detachment and blindness
ROP incidence increases with these three factors:
Prematurity, hyperoxia (it’s the PaO2, not the FIO2), and the duration of O2
Vitamin A and/or E may help prevent it

64. O2 Toxicity in the Lungs Here it is the FIO2 which causes high PAO2
This causes the following pathological changes:
Decreased alveolar volume, ie decreased FRC (why?)
Increased surface tension due to decreased surfactant
Inflammatory exudate and hyaline membrane formation
Sloughing of alveolar epithelium
Fibrosis

65. Management of O2 Therapy
Keep PaO2 between 50-70!
For hypoxemia on 21%, start FIO2 between 25-35%
Use guideline that 1% change in FIO2 will maximally change PAO2 by 7 mmhg
Avoid Flip-Flop phenomenon
Changing FIO2 by more than 5-10% at one time may cause sudden deterioration
The longer the infant is on O2, the more prone he is to Flip-Flop
It is not unusual to limit changes in FIO2 to 1-2%!

66. O2 Therapy Devices

67. Nasal Cannula Should be used with a blender
One or both prongs may be removed
Special flowmeters allow flows of less than 1 LPM to be used
Vapotherm– high humidity and flow through cannula, e.g. 5-6 LPM

68. Hoods Best to use a blender to flood the hood with a precise FIO2
Flow needs to be 5-7 LPM to flush out CO2
Noise inside hood may be damaging to infants hearing
Note: A heated, humidified flow of LPM may be used in isolette