Arterial Blood Gas Sampling (2025)

by Gan Kiat Kee & Arif Alper Cevik

Introduction

Arterial blood gas (ABG) sampling is a critical procedure performed in the emergency department (ED) that involves obtaining blood from a peripheral artery to assess a patient’s respiratory and metabolic status. This technique is essential for diagnosing and managing various acute conditions, particularly in critically ill patients. The common sites for ABG sampling include the radial, brachial, femoral, and dorsalis pedis arteries. The radial artery is often preferred due to its accessibility and the presence of collateral circulation, which minimizes the risk of complications [1]. ABG sampling can be performed via a single percutaneous needle puncture or through an indwelling catheter for repeated measurements, which is particularly useful in ongoing monitoring of patients with unstable conditions [2].

The analysis of ABG provides vital information regarding the patient’s acid-base balance and respiratory function. Key parameters measured include the partial pressures of oxygen (PaO2) and carbon dioxide (PaCO2), pH, and bicarbonate (HCO3) levels. These measurements are crucial for evaluating the efficacy of gas exchange in the lungs and the metabolic status of the patient [3]. For instance, a low pH coupled with elevated PaCO2 may indicate respiratory acidosis, while a low HCO3 may suggest metabolic acidosis. Additionally, advanced blood gas analyzers can provide further insights by measuring total hemoglobin (tHb), oxyhemoglobin saturation (HbO2), and dysfunctional hemoglobins such as methemoglobin (MetHb) and carboxyhemoglobin (COHb), which are particularly relevant in cases of carbon monoxide poisoning or other hemoglobinopathies [3].

The ability to interpret ABG results is an essential skill for healthcare professionals, particularly in emergency settings where rapid decision-making is crucial. Medical trainees are encouraged to gain proficiency in ABG sampling and interpretation under supervision, as these skills are fundamental to the effective management of patients experiencing respiratory distress, shock, or metabolic derangements [1].

Indications

ABG sampling is primarily indicated for evaluating the adequacy of oxygenation and ventilation in patients. By measuring the partial pressures of oxygen (PaO2) and carbon dioxide (PaCO2), healthcare providers can assess respiratory function and the effectiveness of gas exchange in the lungs. For instance, a low PaO2 may indicate hypoxemia, necessitating immediate intervention, while elevated PaCO2 can signify respiratory failure or impaired ventilation [4]. This immediate assessment is crucial in emergencies such as acute respiratory distress or exacerbations of chronic obstructive pulmonary disease (COPD), where timely identification of respiratory compromise can significantly influence patient outcomes [5].

In addition to evaluating oxygenation and ventilation, ABG sampling is essential for identifying and monitoring acid-base disturbances. The measurement of pH, PaCO2, and bicarbonate (HCO3) levels provides critical information regarding the patient’s metabolic and respiratory status. For example, an acidic pH coupled with elevated PaCO2 may suggest respiratory acidosis, commonly seen in conditions such as acute asthma attacks or severe pneumonia [6]. Conversely, metabolic acidosis may be indicated by a low pH with normal or low PaCO2 levels, often observed in patients with diabetic ketoacidosis or renal failure. Monitoring these parameters can guide therapeutic decisions and help clinicians tailor interventions to restore acid-base balance effectively [6].

Furthermore, ABG sampling plays a significant role in detecting and quantifying abnormal hemoglobin levels, such as methemoglobin (MetHb) and carboxyhemoglobin (COHb). These conditions can arise from exposure to certain chemicals or gases, and their identification is critical in emergency settings. For instance, elevated COHb levels indicate carbon monoxide poisoning, which requires immediate treatment [7]. The ability to quickly diagnose such abnormalities through ABG sampling can be life-saving, particularly in cases of suspected toxic exposure.

Lastly, ABG sampling is invaluable in assessing the response to therapeutic interventions, particularly in hypoxic patients receiving oxygen therapy. By comparing pre- and post-intervention ABG values, clinicians can evaluate the effectiveness of treatments and make necessary adjustments to optimize patient care. In situations where venous sampling is not feasible due to the patient’s condition or the urgency of the situation, ABG sampling serves as a critical alternative for obtaining essential blood gas information [4].

Contraindications

Certain contraindications must be considered to ensure patient safety and the accuracy of results. One primary contraindication is the presence of a known deficiency in collateral circulation, which can be assessed using the modified Allen’s test. An abnormal result indicates insufficient blood flow to the hand, increasing the risk of ischemia if an artery is punctured [8-10]. Therefore, performing an ABG in such cases could lead to serious complications, including limb ischemia or necrosis.

In addition to collateral circulation issues, the presence of local infections at the puncture site is another significant contraindication. An infected site can introduce pathogens into the bloodstream, leading to systemic infections or further complications for the patient [11]. Moreover, anatomical abnormalities such as full-thickness burns, arteriovenous fistulas, stents, or vascular grafts at the puncture site can complicate the procedure and increase the risk of complications. These malformations may alter normal blood flow patterns or make it difficult to locate the artery accurately, which can lead to unsuccessful attempts or injury to surrounding structures [8-10].

Severe peripheral vascular disease, including conditions like Buerger’s disease or limb ischemia, also serves as a contraindication for ABG sampling. In patients with these conditions, blood flow to the extremities is already compromised, and the additional trauma of arterial puncture could exacerbate ischemic symptoms [12]. Lastly, patients suffering from active Raynaud syndrome should be excluded from ABG sampling, as the procedure could trigger or worsen their vasospastic episodes, leading to further complications [13].

Some conditions may pose relative contraindications [8-10] to this procedure. Patients with Raynaud disease may experience exacerbated symptoms during and after the puncture, potentially resulting in complications such as ischemia or necrosis at the site of the arterial puncture [14]. Furthermore, even in the absence of spasm, individuals with a history of Raynaud disease may have altered peripheral vascular function, increasing the likelihood of complications during ABG sampling.

Another important relative contraindication is the presence of poor peripheral perfusion, which can severely affect the ability to obtain an adequate blood sample. In patients with compromised perfusion, such as those in shock or with peripheral vascular disease, the risk of inadequate sampling and subsequent complications at the puncture site is elevated. Poor perfusion can lead to difficulties in locating the artery, increasing the risk of multiple punctures and subsequent tissue trauma [15]. Thus, clinicians must assess the patient’s peripheral circulation before proceeding with ABG sampling to avoid unnecessary complications.

Additionally, patients with supratherapeutic anticoagulation or those receiving thrombolytic agents, such as streptokinase or tissue plasminogen activator, represent another group with relative contraindications for ABG sampling [16]. The risk of bleeding complications in these patients is significantly heightened due to their altered coagulation status. Similarly, individuals with existing coagulopathy should be approached with caution, as the likelihood of significant bleeding increases, which could lead to hematoma formation or other vascular complications. In these cases, the clinical necessity of obtaining an ABG sample must be carefully weighed against the potential risks involved, and alternative methods of assessment should be considered if appropriate.

Equipment and Patient Preparation

Equipment

The equipment used in ABG sampling includes the following [16]:

Gloves: Non-sterile gloves may be used, but it is essential to avoid touching the puncture site after the area has been cleaned.
Syringe for Sampling: A standard syringe with a 25-gauge needle and a 3-mL capacity is preferred. Using a higher-capacity syringe may reduce maneuverability, while smaller needles may increase the risk of traumatic hemolysis, potentially affecting the accuracy of hemoglobin and potassium measurements. A 23-gauge needle may also be used.
Lithium Heparin: Aspirate 1-2 mL of lithium heparin (1000 U/mL) into the syringe through the needle and then expel it. Leave the plunger depressed to allow arterial blood flow to fill the syringe.
Pre-Heparinized ABG Syringe (Alternative): Many ABG kits include a prefilled heparinized syringe with features like a protective needle sleeve and a syringe cap. Some syringe models have vented plungers that enable presetting a specific blood volume; for these, the plunger is positioned midway in the syringe before the puncture and not pulled back during the procedure. Expel the prefilled heparin before repositioning the vented plunger at the 2-mL mark.
Antiseptic Skin Solution: Commonly used solutions include chlorhexidine, povidone-iodine, or 70% isopropyl alcohol.
Needle and Syringe for Local Anesthesia (Optional): A 25-gauge needle with a syringe and 1% lidocaine hydrochloride without epinephrine may be used for local anesthesia if needed.
Sterile Gauze and Adhesive Bandage: Sterile gauze (2 × 2 inches or 5 × 5 cm) is used to cover the puncture site, secured with an adhesive bandage after sample collection.
Syringe Cap: Usually included in ABG kits to seal the syringe after sampling.
Sharps Container: A container specifically designed for the safe disposal of needles and other sharp objects.
Ice Bag: A bag with crushed ice to transport the sample to the laboratory if point-of-care analysis is unavailable.
Non-Sterile Apron: Optional protective clothing to maintain hygiene during the procedure.
Rolled Towel: Used to position the hand optimally for the procedure.

Site Selection

Arterial blood gas sampling requires selecting an appropriate site for puncture based on accessibility, patient tolerance, and anatomical considerations. Below are the common sites used for ABG sampling [17]:

Radial Artery
The radial artery is the preferred site for ABG sampling due to its superficial location, good collateral blood supply, and better patient tolerance. It is located medial to the radial styloid process and lateral to the flexor carpi radialis tendon, approximately 2-3 cm proximal to the ventral surface of the wrist crease. The artery can be palpated between the styloid process of the radius and the flexor carpi radialis tendon with the wrist extended.

Brachial Artery
The brachial artery is harder to access due to its deeper location compared to the radial artery. It is best identified in the antecubital fossa, medial to the biceps tendon, with the shoulder abducted, elbow extended, and the forearm supinated with the palm facing upward. The needle is typically inserted at a 30° angle just above the elbow crease. Higher up, the artery can also be palpated in the groove between the biceps and triceps tendons. The basilic vein and brachial nerve are located in close proximity to this artery.

Femoral Artery
The femoral artery is ideal in cases where the radial and brachial arteries are inaccessible. It is located in the midline between the symphysis pubis and the anterior superior iliac crest, approximately 2-4 cm distal to the inguinal ligament. The artery can be palpated just below the midpoint of the inguinal ligament with the lower limb extended and the patient in a supine position. Needle insertion is performed just below the inguinal ligament at a 90° angle. The femoral artery lies medial to the femoral nerve and lateral to the femoral vein.

Dorsalis Pedis Artery
The dorsalis pedis artery is a less commonly used site for ABG sampling. It can be palpated lateral to the extensor tendon at the midfoot level. This site is generally reserved for specific clinical scenarios where other arteries are not accessible.

Each site has its unique anatomical landmarks and considerations, which should be carefully evaluated to ensure accuracy and minimize complications during the procedure.

Patient Preparation

Proper patient preparation is essential to ensure the accuracy of radial artery blood gas sampling and minimize patient discomfort or complications. Below are the key steps to prepare the patient for the procedure [16,17]:

Introduction and Identification
Begin by introducing yourself to the patient and confirming their full name. Verify that the details on the laboratory form match the patient’s identity to prevent errors.

Patient History and Consent
Inquire about any allergies, phobias, or a history of fainting during previous injections or blood collection. Clearly explain the purpose, benefits, and potential risks of the procedure in simple terms. Once the patient or their next of kin fully understands the information, obtain verbal consent. Note that written consent is not required unless mandated by institutional policy.

Alleviating Anxiety
Address any patient concerns and provide reassurance to help alleviate fear or anxiety. Ensuring the patient is calm can significantly improve their experience and the procedure’s success.

Procedure Steps

The following steps outline the procedure for radial artery blood gas sampling, as recommended by W.H.O. guidelines [16,17]:

Patient Introduction and Identification
Approach the patient, introduce yourself, and confirm the patient’s full name. Verify the details on the laboratory form to ensure accurate identification.

Patient Positioning
Place the patient in a comfortable supine position on a firm surface. For radial artery sampling, ensure the arm is resting comfortably with the forearm supinated and the wrist dorsiflexed at approximately 40°. A rolled towel or gauze roll can be placed under the wrist to improve comfort and elevate the radial artery to a more superficial position. Avoid excessive wrist extension to prevent interference from flexor tendons, which could make pulse detection challenging.

Assess Collateral Circulation
Perform a modified Allen test to assess collateral circulation of the radial artery. If the test fails, repeat it on the other hand. Once an adequate site is identified, note the anatomical landmarks for accurate needle placement. If re-palpation is required, ensure sterile gloves are worn.

Preparation of Equipment and Work Area
Perform hand hygiene, prepare a clean work area, and gather all necessary equipment. Don an impervious gown or apron and face protection if there is a risk of blood exposure.
Site Disinfection
Disinfect the chosen puncture site using an antiseptic skin solution such as chlorhexidine or povidone-iodine. Allow the area to air dry completely before proceeding.
Needle and Syringe Assembly
If the needle and syringe are not preassembled, prepare them by attaching the heparinized syringe to the needle and setting the syringe plunger to the required fill level recommended by the laboratory.
Needle Insertion
Hold the syringe and needle like a dart, with the needle bevel facing upward. Use your index finger to palpate the radial pulse, then inform the patient about the puncture. Insert the needle at a 30º–45º angle approximately 1 cm distal to the palpating finger to avoid contamination of the puncture site.
Blood Collection
Advance the needle into the radial artery until a flashback of blood is observed. Allow the syringe to fill passively with 2–3 mL of arterial blood without pulling back the plunger.
Needle Withdrawal and Hemostasis
After withdrawing the required amount of arterial blood, remove the needle while simultaneously applying firm pressure to the puncture site with sterile gauze. Maintain pressure until hemostasis is achieved. For patients without anticoagulation or coagulopathy, this typically takes 3–5 minutes, while anticoagulated patients or those with bleeding disorders or hypertension may require up to 10–15 minutes of continuous pressure. Avoid checking the puncture site prematurely, as this can increase the risk of hemorrhage or hematoma formation.
Needle Safety and Specimen Handling
Activate the needle safety mechanism to cover the needle or use a one-hand scoop technique to recap it. Dispose of the needle safely in a sharps container.
Sample Preparation
Expel air bubbles from the syringe, cap it, and roll the specimen gently between your hands to mix it without compromising the sample’s integrity. Cap the syringe securely to prevent air contamination or leakage during transport.
Labeling and Transport
Label the sample syringe appropriately and place it in a container with ice to preserve the sample. Transport it immediately to the laboratory, ensuring proper handling protocols are followed. Adhere to the recommended time frames for sample analysis to ensure accurate results:
- For samples held at 4°C: Analysis should be conducted within 60 minutes.
- For samples held at room temperature: Analysis should be conducted within 15 minutes.
Cleanup and Hygiene
Dispose of all used materials and personal protective equipment in accordance with hospital protocols. Remove gloves and wash hands thoroughly with soap and water or use an alcohol-based hand rub.
Patient Reassessment
Check the puncture site for ongoing bleeding or other complications. Apply additional pressure if necessary and thank the patient for their cooperation.
Special Considerations
In critically ill or unresponsive patients, explain the procedure to family members or next of kin if possible. Additionally, minimize air bubbles in the sample as they can distort gas readings by altering PaO2 and PaCO2 levels.
Use of Local Anesthesia (Optional)
Local anesthesia, such as lidocaine HCl 1% without epinephrine, may be administered subcutaneously to reduce discomfort [18, 19]. However, this step is not always necessary, as the pain from administering the anesthetic is often comparable to the pain of the procedure itself. If used, 0.5–1 mL of anesthetic should be injected to form a small dermal papule at the puncture site. Care should be taken not to distort the anatomy, and the clinician should aspirate before injection to confirm the needle is not inside a blood vessel.

Post Procedure Care and Recommendations

After completing the blood sampling procedure, appropriate post-procedure care is essential to ensure patient safety and minimize complications [16,17].

Closely monitor the patient for any new symptoms, such as changes in skin color, persistent or worsening pain, active bleeding, impaired limb movement, or altered sensation. Monitoring is particularly crucial for patients receiving anticoagulants or thrombolytic agents, as delayed re-bleeding can occur hours after the procedure.

Complications

The radial artery blood gas sampling procedure, although relatively safe, is associated with several potential complications. These complications and their preventive measures are detailed below [16]:

Arteriospasm and Temporary Arterial Occlusion
Arteriospasm can lead to temporary arterial occlusion, which may compromise blood flow to the affected limb. This can be prevented by helping the patient relax through clear explanations of the procedure, ensuring the patient is in a comfortable position, and using analgesia when necessary.
Excessive Bleeding or Hematoma Formation
Excessive bleeding or hematoma may cause compartment syndrome and subsequent limb ischemia. Prevention involves avoiding puncturing the far side of the artery, applying immediate and firm pressure at the puncture site for at least 3–5 minutes in non-anticoagulated patients, or 10–15 minutes for those on anticoagulants or with coagulopathy. Close monitoring is essential to ensure cessation of bleeding.
Nerve Damage
Nerve damage may occur during the procedure and can present as persistent pain or paresis. To minimize this risk, healthcare personnel should select an appropriate sampling site and avoid excessive redirection of the needle during the procedure.
Vasovagal Response or Fainting Episodes
A vasovagal response may lead to fainting or lightheadedness in some patients. This can be mitigated by ensuring the patient is in a supine position with their feet elevated.
Infection at the Puncture Site or Needle-Stick Injuries
Infection at the puncture site and needle-stick injuries pose risks to both patients and healthcare personnel. Strict adherence to infection prevention and control measures, such as using aseptic techniques and wearing appropriate personal protective equipment, is essential to prevent these complications.
Air or Thrombus Embolism
Air or thrombus embolism may occur if air bubbles are introduced during sampling or if an inappropriate syringe is used. This risk can be reduced by expelling air bubbles from the syringe and using a properly heparinized syringe during the procedure.
Anaphylaxis from Local Anesthetic Agents
Anaphylaxis may occur in response to local anesthetic agents. Taking a thorough patient history regarding previous allergic reactions or anaphylaxis is crucial before administering local anesthesia.
Specific Concerns for Femoral Sampling
In cases involving femoral artery sampling, be particularly cautious about bleeding complications. The larger caliber and deeper location of the femoral artery can allow significant blood accumulation without immediate clinical findings, increasing the risk of circulatory compromise.
Other Notable Complications
- Local Pain: May occur at the puncture site but can be minimized with proper technique and patient reassurance.
- Vessel Laceration: Can result in profuse bleeding, requiring immediate evaluation and management.
- Compartment Syndrome: A rapidly expanding hematoma may compromise regional circulation, necessitating prompt intervention. Symptoms include pain, paresthesias, pallor, absence of pulses, and persistent limb pain.
- Limb Ischemia: Caused by arterial occlusion, thrombus formation, or vasospasm, it may present as absent distal pulses, coldness, and skin discoloration.

Hints and Pitfalls

To optimize the accuracy and success of radial ABG sampling while minimizing patient discomfort and complications, the following considerations should be observed [20]:

Analgesia for Patient Comfort
For patients experiencing anxiety or pain during the procedure, cryoanalgesia can be applied by placing an ice bag on the wrist for 3 minutes before arterial puncture. Alternatively, 0.5–1 mL of lignocaine 1% can be injected superficially to create a small wheal at the puncture site 30–60 seconds prior to sampling. Care should be taken to avoid deeper or larger volume injections, which may distort the anatomy and hinder vessel identification.
Preventing Pre-Analytic Errors
ABG measurements are highly sensitive to pre-analytic errors, including:
- Presence of air in the sample, which can falsely elevate PaO2 and lower PaCO2.
- Collection of venous rather than arterial blood.
- Clotted samples due to improper anticoagulation, inadequate mixing, or exposure to air.
- Delays in sample analysis exceeding 15 minutes at room temperature or 60 minutes at 4°C.
Cooling Samples to Preserve Accuracy
If analysis is expected to be delayed beyond 15 minutes, samples should be stored in a container with crushed ice to reduce metabolic activity of leukocytes and platelets. This prevents oxygen consumption and the associated clinically significant fall in PaO2, particularly in patients with leukocytosis or thrombocytosis.
Impact of Air Bubbles
Air bubbles introduced into the sample equilibrate with arterial blood, artificially increasing PaO2 toward 150 mmHg and decreasing PaCO2 toward 0 mmHg. Careful handling is essential to avoid air contamination.
Use of Heparin as an Anticoagulant
Heparin must be added to the syringe to prevent clotting. Flushing the syringe with heparin leaves an adequate amount in the dead space to ensure anticoagulation without affecting ABG results. Excess heparin should be expelled, as it can alter pH (falsely low) and gas measurements (falsely low PaO2 and PaCO2).
Frequency of Sampling and Site Rotation
The frequency of ABG sampling should be dictated by the patient’s clinical status. Repeated sampling at the same site increases the risk of hematoma, scarring, and arterial damage. Alternative sites should be used, or an indwelling catheter may be considered for patients requiring frequent sampling.
Techniques for Unsuccessful Sampling
Avoid pulling back the syringe plunger during unsuccessful attempts, as this increases the likelihood of venous sampling. Instead, withdraw the needle slowly until it is just beneath the skin and reattempt. Successful arterial sampling is indicated by the passive filling of the syringe with bright red, pulsating blood.

Special Patient Groups

Performing ABG sampling in pediatric patients presents unique challenges due to their fear, anxiety, and anticipation of pain, which may result in uncooperative behavior [20]. It is crucial to explain the procedure thoroughly to both the child and their parents before starting, ensuring informed consent is obtained. Allowing parents to be present during the procedure can provide comfort to the child, but healthcare providers should be mindful of the possibility that the parent may faint. In some cases, physical restraint of the child may be necessary to complete the procedure, although this approach could potentially traumatize the child. An alternative to percutaneous arterial sampling is capillary blood sampling from the heel, which can be used for gas analysis when arterial access is unavailable or when the clinician is less confident performing an arterial puncture.

For infants, arterial blood can be obtained from the radial, brachial, or dorsalis pedis arteries, while the umbilical arteries are an option in newborns. The radial artery remains the site of choice. In these patients, a small-gauge butterfly needle is preferred over the standard needle and syringe used in adults. Unlike adults, continuous but gentle suction should be applied during the procedure, and the appearance of pulsating blood is a reassuring sign that the radial artery has been successfully punctured.

In obese, edematous, or pregnant patients, the anatomical landmarks for arterial puncture may be difficult to identify. In such cases, the use of ultrasound guidance is highly beneficial for locating the artery. Ultrasound not only improves the success rate of arterial access but also reduces potential complications associated with repeated punctures, such as injury to the vessel or surrounding tissues.

Both pediatric and pregnant populations require special attention due to their unique anatomical and physiological considerations. In pediatrics, fear and discomfort associated with the procedure can make the hospital experience traumatic, emphasizing the need for proper explanation, comfort measures, and, when appropriate, pain-reducing products. In pregnant patients, the challenges often stem from anatomical changes caused by fluid retention or increased body mass.

Authors

Gan Kiat Kee

Dr Gan Kiat Kee is an enthusiastic and passionate emergency physician from Hospital Sultanah Aminah Johor Bahru, Johor, Malaysia. He has obtained his medical degree from University Sains Malaysia and completed his post-graduate training in emergency medicine from the same university. He has special interest in acute trauma care and ultrasound guided procedures especially in ultrasound guided regional anaesthesia for pain management in trauma patient. He is also the founder for Emergency Department Regional Anaesthesia (EDRA) of his current working department. Owing to his great interest in simulation and bedside teaching, he has been appointed as adjunct lecturer by Clinical School Johor Bahru, Monash University Malaysia and has been active in teaching various life support.

Arif Alper Cevik, MD, FEMAT, FIFEM

Prof Cevik is an Emergency Medicine academician at United Arab Emirates University, interested in international emergency medicine, emergency medicine education, medical education, point of care ultrasound and trauma. He is the founder and director of the International Emergency Medicine Education Project – iem-student.org, chair of the International Federation for Emergency Medicine (IFEM) core curriculum and education committee and board member of the Asian Society for Emergency Medicine and Emirati Board of Emergency Medicine.

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