Reprinted from the May 2001 issue of RESPIRATORY CARE [Respir Care 2001;46(5):506–513]
AARC Clinical Practice Guideline
Capillary Blood Gas Sampling for Neonatal & Pediatric Patients
CBGS 1.0 PROCEDURE:
Capillary sampling for blood gas analysis
CBGS 2.0 DESCRIPTION:
Capillary blood gas (CBG) samples may be used in place of samples from arterial punctures or indwelling arterial catheters to estimate acid-base balance (pH) and adequacy of ventilation (PaCO2).(1-3) Capillary PO2 measurements are of little value in estimating arterial oxygenation.(4-6)
A puncture or small incision is made with a lancet or similar device into the cutaneous layer of the skin at a highly vascularized area (heel, finger, toe). (The lancet may be used freehand or as part of a device that limits puncture depth.) To accelerate blood flow and reduce the difference between the arterial and venous gas pressures, the area is warmed prior to the puncture. As the blood flows freely from the puncture site, the sample is collected in a heparinized glass capillary tube.(7-9)
CBGS 3.0 SETTING:
Capillary sampling may be performed by trained health care personnel in
- 3.1 Acute care hospitals,
- 3.2 Clinics,
- 3.3 Physician offices,
- 3.4 Extended care facilities,
- 3.5 Homes.
CBGS 4.0 INDICATIONS:
Capillary blood gas sampling is indicated when
- 4.1 Arterial blood gas analysis is indicated but arterial access is not available.
- 4.2 Noninvasive monitor readings are abnormal: transcutaneous values, end-tidal CO2, pulse oximetry.
- 4.3 Assessment of initiation, administration, or change in therapeutic modalities (ie, mechanical ventilation) is indicated.
- 4.4 A change in patient status is detected by history or physical assessment.
- 4.5 Monitoring the severity and progression of a documented disease process is desirable.
CBGS 5.0 CONTRAINDICATIONS:
- 5.1 Capillary punctures should not be performed
- 5.1.1 at or through the following sites:(10)
- 188.8.131.52 posterior curvature of the heel, as the device may puncture the bone;(11)
- 184.108.40.206 the heel of a patient who has begun walking and has callus development;(12)
- 220.127.116.11 the fingers of neonates (to avoid nerve damage);(13)
- 18.104.22.168 previous puncture sites;(14,15)
- 22.214.171.124 inflamed, swollen, or edematous tissues;(14,15)
- 126.96.36.199 cyanotic or poorly perfused tissues;(14,15)
- 188.8.131.52 localized areas of infection;(14,15)
- 184.108.40.206 peripheral arteries.
- 5.1.2 on patients less than 24 hours old, due to poor peripheral perfusion;(1)
- 5.1.3 when there is need for direct analysis of oxygenation;(1-3)
- 5.1.4 when there is need for direct analysis of arterial blood;
- 5.2 Relative contraindications include
- 5.2.1 peripheral vasoconstriction;(1)
- 5.2.2 polycythemia (due to shorter clotting times);(1)
- 5.2.3 hypotension may be a relative contraindication.(1)
CBGS 6.0 HAZARDS/COMPLICATIONS:
- 6.1 Infection
- 6.1.1 Introduction of contagion at sampling site and consequent infection in patient, including calcaneus osteomyelitis(9,16) and cellulitis
- 6.1.2 Inadvertent puncture or incision and consequent infection in sampler
- 6.2 Burns
- 6.3 Hematoma
- 6.4 Bone calcification(14)
- 6.5 Nerve damage(9)
- 6.6 Bruising
- 6.7 Scarring(12)
- 6.8 Puncture of posterior medial aspect of heel may result in tibial artery laceration(11)
- 6.9 Pain
- 6.10 Bleeding
- 6.11 Inappropriate patient management may result from reliance on capillary PO2 values.(17,18)
CBGS 7.0 LIMITATIONS OF METHOD/ VALIDATION OF RESULTS:
- 7.1 Limitations
- 7.1.1 Inadequate warming of the site prior to a puncture may result in capillary values that correlate poorly with arterial pH and PCO2 values.(19,20)
- 7.1.2 Undue squeezing of the puncture site may result in venous and lymphatic contamination of the sample.(14)
- 7.1.3 A second puncture may be needed to obtain an adequate amount of blood for analysis.
- 7.1.4 Variability in capillary PO2 values precludes using these samples for assessing oxygenation status.(1,2,3,18,20,21)
- 7.2 Validation of results
- 7.2.1 Sample must be anticoagulated and obtained anaerobically with capillary tube filled completely and air bubbles expelled immediately. Sample should be immediately chilled or analyzed within 10-15 minutes if left at room temperature.(22)
- 7.2.2 A respiratory assessment of the patient should be documented in the medical record at the time a capillary sample is performed (See 11.0 Monitoring).
- 7.2.3 An arterial sample may be analyzed to compare with the capillary pH and PCO2 values.
CBGS 8.0 ASSESSMENT OF NEED:
Capillary blood gas sampling is an intermittent procedure and should be performed when a documented need exists. Routine or standing orders for capillary puncture are not recommended. The following may assist the clinician in assessing the need for capillary blood gas sampling:
- 8.1 History and physical assessment;(23)
- 8.2 Noninvasive respiratory monitoring values
- 8.2.1 Pulse oximetry;(23)
- 8.2.2 Transcutaneous values;
- 8.2.3 End-tidal CO2 values;
- 8.3 Patient response to initiation, administration, or change in therapeutic modalities;(23-25)
- 8.4 Lack of arterial access for blood gas sampling.(1-3)
CBGS 9.0 ASSESSMENT OF TEST QUALITY:
Sampling of capillary blood is useful for patient management only if the procedure is carried out according to an established quality assurance program. The validity of the test may be jeopardized if any of the following occur:(10,26,27)
- 9.1 The sample is contaminated by air;
- 9.2 Clots prevent accurate analysis;
- 9.3 Quantity of sample is insufficient for analysis;
- 9.4 Analysis of sample is delayed (> 15 minutes for samples at room temperature, or > 60 minutes for samples held at 4°C).(22)
CBGS 10.0 RESOURCES:
- 10.1 Equipment: Single puncture-preheparinized glass capillary (eg, Natelson) tubes, metal fleas, magnet, clay/wax sealant or caps, lancet to make incision < 2.5 mm in depth, gauze/cotton balls, ice, gloves, skin antiseptic, warm and moist cloth/diaper or commercially prepared warming pads (42°C), sharps container, labeling materials(10)
- 10.2 Personnel: Capillary sampling must be performed under direction of a physician. Individuals who perform capillary sampling should have a background in mathematics and science and specific training in capillary blood sampling and related procedures. They must competently demonstrate capillary blood gas sampling and undergo periodic skills assessment of technique: implementation of Universal Precautions; success at obtaining a quality sample; preparation, storage and transport of specimens; documentation; and post sampling site care and/or complication rate.(10,28,29)
CBGS 11.0 MONITORING:
The following should be monitored and documented in the medical record as part of the capillary sampling procedure:
- 11.1 FIO2 or prescribed oxygen flow;(10,23,28,29)
- 11.2 Oxygen administration device or ventilator settings;(10,23,27,28)
- 11.3 Free flow of blood without the necessity for `milking' the foot or finger to obtain a sample;(10,14)
- 11.4 Presence/absence of air or clot in sample;(10,26,27)
- 11.5 Patient temperature, respiratory rate, position or level of activity, and clinical appearance;(10,27)
- 11.6 Ease or difficulty of obtaining sample;(10,27,28)
- 11.7 Appearance of puncture site;(14,15)
- 11.8 Complications or adverse reactions to the procedure;
- 11.9 Date, time, and sampling site;(10)
- 11.10 Noninvasive monitoring values: transcutaneous O2 & CO2, end-tidal CO2, and/or pulse oximetry;(23)
- 11.11 Results of the blood gas analysis.
CBGS 12.0 FREQUENCY:
The frequency of capillary sampling should depend upon the clinical status of the patient and the indications for performing the procedure, not upon a prescribed frequency.
- 12.1 Those patients requiring frequent CBGs should be considered candidates for placement of an indwelling arterial access for blood gas sampling or noninvasive monitoring techniques, to limit trauma associated with repeated punctures.
- 12.2 Repeated puncture of the foot/finger increases the risk of scarring or serious laceration. Care should be exercised to alternate the sampling site for patients requiring multiple punctures.(14,15)
CBGS 13.0 INFECTION CONTROL:
Perinatal-Pediatrics Guidelines Committee:
- 13.1 Universal Precautions as published by the Centers for Disease Control and directives issued by the Department of Labor concerning occupational exposure to blood-borne pathogens must be followed during capillary sampling.(29,30)
- 13.2 Aseptic techniques should be employed due to the invasive nature of this procedure. Punc-ture site should be cleaned with antiseptic solution.(10)
- 13.3 Blood specimens, contaminated materials, and lancets must be disposed of in appropriate containers.(29)
- 13.4 Gloves should be worn by caregivers to protect against blood splashes on sores or skin breaks.(29)
Lynne K Bower RRT, Chairman, Boston MA
Sherry L Barnhart RRT, Mattoon IL
Peter Betit BS RRT, Boston MA
Barbara Hendon BA RCP RRT, Wylie TX
Joanne Masi-Lynch BS RRT, Salt Lake City UT
Barbara G Wilson MEd RRT, Durham NC
- Koch G, Wendel H. Comparison of pH, carbon dioxide tension, standard bicarbonate and oxygen tension in capillary blood and in arterial blood during the neonatal period. Acta Paediatr Scand 1967;56:10-16.
- Duc GV, Cumarasamy N. Digital arteriolar oxygen tension as a guide to oxygen therapy of the newborn. Biol Neonate 1974;24:134-137.
- McLain BI, Evans J, Dear PFR. Comparison of capillary and arterial blood gas measurements in neonates. Arch Dis Child 1988;63:743-747.
- Desai SD, Holloway R, Thambiran AK, Wesley AG. A comparison between arterial and arterialized capillary blood in infants. S Afr Med J 1967;41:13-15.
- Corbet AJS, Burnard ED. Oxygen tension measurements on digital blood in the newborn. Pediatrics 1970;46:780-782.
- Karna P, Poland RL. Monitoring critically ill newborn infants with digital capillary blood samples: an alternative. J Pediatr 1978;92:270-273.
- Blumenfeld TA, Turi GK, Blanc WA. Recommended site and depth of newborn heel skin punctures based on anatomical measurements and histopathology. Lancet 1979;1:230-233.
- Phelan S. Phlebotomy techniques. Chicago: American Society of Clinical Pathologists, 1993.
- Pendergraph GE. Handbook of phlebotomy, 3rd ed. Philadelphia: Lea & Febiger, 1992:82-89.
- National Committee for Clinical Laboratory Standards. Procedures for the collection of diagnostic blood specimens by skin puncture, 3rd ed. Villanova PA: NCCLS, 1992.
- Kisling JA, Schreiner RL. Techniques of obtaining arterial blood from newborn infants. Respir Care 1977;22: 513-518.
- Sell EJ, Hansen RC, Struck-Pierce S. Calcified nodules on the heel: a complication of neonatal intensive care. J Pediatr 1980;96:473-475.
- Powers WF. Digital capillary sampling (letter). J Pediatr 1978;93(4):729-730.
- Meites S. Skin puncture and blood collecting techniques for infants: update and problems. In: Meites S, ed. Pediatric clinical chemistry, 3rd ed. Washington DC: American Association for Clinical Chemistry, 1989:5-15.
- College of American Pathologists. So you're going to collect a blood specimen, 5th ed. Northfield IL: College of American Pathologists, 1992.
- Lilien LD, Harris VJ, Ramamurthy RS, Pildes RS. Neonatal osteomyelitis of the calcaneus: complication of heel puncture. J Pediatr 1976;88:478-480.
- Graham G, Kenny MA. Changes in transcutaneous oxygen tension during capillary blood-gas sampling. Clin Chem 1980;26:1860-1863.
- Courtney SE, Weber KR, Breakie LA, Malin SW, Bender CV, Guo SM, Siervogel RM. Capillary blood gases in the neonate: a reassessment and review of the literature. Am J Dis Child 1990;144:168-172.
- Gandy G, Grann L, Cunningham N, et al. The validity of pH and PCO2 measurements in capillary samples in sick and healthy newborn infants. Pediatrics 1964;34:192-197.
- Hunt CE. Capillary blood sampling in the infant: usefulness and limitations of two methods of sampling, compared with arterial blood. Pediatrics 1973;51:501-506.
- Folger GM Jr, Kouri P, Sabbah HN. Arterialized capillary blood sampling in the neonate: a reappraisal. Heart Lung 1980;9:521-526.
- Thomsen A. Arterial blood sampling in small infants. Acta Paediatr 1964;53:237-240.
- Raffin TA. Indications for arterial blood gas analysis. Ann Intern Med 1986;105:390-398.
- Thorson SH, Marini JJ, Pierson DJ, Hudson LD. Variability of arterial blood gas values in stable patients in the ICU. Chest 1983;84(1):14-18.
- Browning JA, Kaiser DL, Durbin CG Jr. The effect of guidelines on the appropriate use of arterial blood gas analysis in the intensive care unit. Respir Care 1989;34(4):269-276.
- Moran RF, Van Kessel A. Blood gas quality assurance. NSCPT Analyzer 1981;11(1):18-26.
- Bruck E, Eichhorn JH, Ray-Meredith S, Shanahan JK, Slockbower JM. Percutaneous collection of arterial blood for laboratory analysis. National Committee for Clinical Laboratory Standards 1985;H11A;5(3):39-59.
- Shapiro BA, Harrison RA, Cane RD, Templin R. Clinical application of blood gases, 4th ed. St Louis: Year Book Medical Publishers Inc, 1989.
- Centers for Disease Control. Update: Universal Precautions for prevention of transmission of human immunodeficiency virus, hepatitis B virus, and other blood-borne pathogens in health care settings. MMWR 1988;37:377-382,387-388.
- Department of Labor, Occupational Safety and Health Administration. Occupational expose to bloodborne pathogens. 29 CFRR Part 1910.1030. Federal Register, Friday December 06, 1991.
Interested persons may copy these Guidelines for noncommercial
purposes of scientific or educational advancement. Please credit AARC and Respiratory
Reprinted from the May 2001 issue of RESPIRATORY CARE [Respir Care 2001;46(5):506–513]