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LHSC HOME » CRITICAL CARE TRAUMA CENTRE » VENOUS BLOOD GAS SAMPLING

VENOUS BLOOD GAS SAMPLING

PROCEDURE FOR VENOUS BLOOD GAS SAMPLING

Ensure that patient and health care provider safety standards are met during this procedure including:

Risk assessment and appropriate PPE

4 Moments of Hand Hygiene

Procedural Safety Pause is performed

Two patient identification

Safe patient handling practices

Biomedical waste disposal policies

1. Refer to Procedure for Blood Procedures for drawing blood from an indwelling line or
Sampling from an Indwelling Line measurement of blood gases can be found in the

2. Site Selection and Considerations for Venous Blood Procedures menu.

Gas Samples
This procedure reviews the types of venous blood gas
3. Document samples, indications and specific considerations.

PROCEDURE RATIONALE FOR PROCEDURE

1. Refer to Blood Sampling and Blood Gas 1. The flush solution within the catheter dead space must
Procedures be removed to prevent dilution of the sample.

Follow the procedures for Blood Gas Measurement

and Blood Sampling from an Indwelling Line.

Follow LHSC policies for hand hygiene and infection

control before, during and after procedure. Perform
hand hygiene and don a mask with eye shield and non-
sterile gloves prior to blood sampling.

LHSC Hand Hygiene Policy

LHSC Routine Practices

LHSC Donning and Doffing Policy

Confirm 2 patient identifiers as per LHSC Policy for

Patient Identification

2. VENOUS BLOOD GASES: SITE SELECTION AND CONSIDERATIONS

Venous blood gases can be drawn via several different methods. The location and method of sampling should always
be considered when interpreting the results.

Assessment of Carbon Dioxide, Bicarbonate and pH

In the absence of an arterial line, a venous blood gas sample can be used to evaluate carbon dioxide, pH and
bicarbonate. Venous blood gases do not evaluate arterial oxygenation, therefore, they must be combined with pulse
oximetry values to fully assess ventilation. The role of venous blood gas samples in the evaluation of oxygen delivery
is discussed below.

The preferred method for assessment for assessment of acid-base balance is to draw the sample from a central venous
catheter. A central venous catheter provides a broader reflection of systemic pH than a peripheral stab. The correlation
of central venous blood gases to arterial blood gases (Gold Standard) is also supported by the most research evidence
and clinical experience.

A central venous sample is still limited to reflect only the venous return from organs captured by the catheter location
(e.g., central venous catheter reflects upper extremity and brain).

In the absence of a central venous catheter, a peripheral venipuncture stab can be used for blood gas measurements for
the purpose of screening for systemic acidosis. Attempt to draw sample with < 1 minute of tournequet time**.
the purpose of screening for systemic acidosis. Attempt to draw sample with < 1 minute of tournequet time**.

Laboratory orders and clinical documentation should clearly identify the origin of a venous sample for blood gas
analysis. For example, there should be clear documentation to differentiate whether a venous sample was drawn from a
peripheral stab or an indwelling central venous catheter. Central line samples should also identify the site of
measurement to differentiate central venous (IJ, PICC, SC), mixed venous (pulmonary artery lumen of PA catheter) or
femoral venous sites to aid in the interpretation of results. Gases may also be impacted if a patient has a regional blood
flow problem if that area is captured in the blood gas sample (e.g., a blood gas from a right subclavian line in a patient
with an ischemic right arm).

Correlation between central venous and arterial blood gases:

Central Venous Peripheral Venous

pH 0.03-0.05 below arterial 0.02-0.04 below arterial

PCO2 4-5 mmHg above arterial 3-8 mmHg above arterial

HCO3 almost same as arterial 1-2 mmol/L above arterial

PO2/SO2 No correlation to arterial No correlation to arterial

**Correlation between venous and arterial gases may deteriorate in shock, therefore, arterial confirmation
is recommended in hypotensive or critically ill patients. Intermittent correlation between arterial and
venous gases is recommended when venous gases are used for serial trending**

Confirmation of Venous Access Placement:

Mixed venous (SvO2), central venous (ScvO2) and femoral venous gases may be used to confirm venous placement of
a central venous catheter (rule out inadvertent arterial placement). When using the venous oxygen saturation to rule
out arterial placement, be cautious to compare the results to a known arterial sample. A low oxygen level during severe

shock could lead to incorrect interpretation.

Assessment of Extraction:

Mixed Venous Gases (SvO2 ):

Abbreviated SvO2

Drawn from the pulmonary artery port of the pulmonary artery catheter

Captures blood from the superior and inferior vena cavae and the coronary sinus to reflect a true mixture of all of
the venous blood coming back to the right side of the heart

Venous blood entering the pulmonary artery is already "mixed" or "averaged", but has not yet been reoxygenated
at the pulmonary capillary

Reflects the amount of oxygen "leftover" after all of the tissues of the body have extracted oxygen but before the
blood is reoxygenated at the lung

Is the "Gold Standard" for assessment of oxygen extraction

Normal value is 60-80%

Low ScvO Readings:

A low SvO2 suggests that tissue oxygen extraction is increased (there is less oxygen leftover)

A low SvO2 is most suggestive of increased extraction if it occurs in the setting of a relatively normal arterial
oxygen saturation (extraction is truly the difference between arterial and venous oxygen content)

Extraction increases when cardiac output alone is insufficient to meet tissue oxygen demand. It is therefore our
"second compensatory response".

A low venous oxygen saturation (suggesting increased oxygen extraction) is an indication to increase the
patient's cardiac output (and oxygen delivery)

Oxygen Delivery = Cardiac Output X Oxygen Content (Hb X SaO2)

SvO2 can be used to titrate therapies aimed at raising the cardiac output (e.g., HR, preload, contractility,
afterload, SaO2 or Hb manipulation)

High SvO2 Readings:

SvO2 may be falsely elevated if the tip of the pulmonary artery catheter is wedged, distally placed or if
excessive vacuum has been applied to the sampling syringe. Any of these technical problems can cause
oxygenated blood to be pulled from the pulmonary capillary into the syringe,falsely elevating the SvO2 result.
 oxygenated blood to be pulled from the pulmonary capillary into the syringe,falsely elevating the SvO2 result.

Aspiration of air into the blood gas syringe during sampling, or the presence of an air bubble are potential
causes for false elevation of SvO2

The normal mixed venous PO2 (PvO2) is 40 mmHg. This generally produces an SvO2 of ~70%. If the PvO2
rises above 60 mmHg, the SvO2 may rise to arterial saturation levels. A high arterial PaO2 during administration
of 100% oxygen can produce abnormally high PvO2 and SvO2 values.

Rarely, a high SvO2 reading may indicate failure of the cells to extract. This could occur in end stage multi
organ failure or with cell toxins such as cyanide (e.g., in house fires or nitroprusside toxicity). These scenarios
would be accompanied by lactic acidosis (final compensation when extraction is also inadequate).

High readings are most commonly due to sampling issues or high arterial oxygen concentrations

Central Venous Gases (ScvO2 ):

Abbreviated ScvO2

Drawn from an internal jugular or subclavian or PICC line

Reflects the amount of oxygen "leftover" that is coming from just the head and upper extremities

Is a surrogate for SvO2 but it misses the inferior vena cava blood (gut, kidney and low extremities) and coronary
sinus, therefore may not correlate with SvO2 during shock

Interpret results and utilize to evaluate therapies aimed at improving oxygen delivery as per SvO2 , trends in
ScvO2 are more valuable than the absolute value

If a patient has a pulmonary artery catheter in place, it is useful to measure SvO2 and ScvO2 just prior to
pulmonary artery catheter removal to identify the correlation between these two values prior to switching to ScvO2
monitoring alone

Low ScvO2 Readings:

 A low ScvO2 suggests that tissue oxygen extraction is increased (there is less oxygen leftover)

A low ScvO2 is most suggestive of increased extraction if it occurs in the setting of a relatively normal
arterial oxygen saturation (extraction is truly the difference between arterial and venous oxygen content)

Extraction increases when cardiac output alone is insufficient to meet tissue oxygen demand. It is therefore
our "second compensatory response".

A low venous oxygen saturation (suggesting increased oxygen extraction) is an indication to increase the
patient's cardiac output (and oxygen delivery)

Oxygen Delivery = Cardiac Output X Oxygen Content (Hb X SaO2)

SvO2 can be used to titrate therapies aimed at raising the cardiac output (e.g., HR, preload, contractility,
afterload, SaO2 or Hb manipulation)

High ScvO2 Readings:

Is not subject to the catheter placement or aspiration technique challenges of the pulmonary artery catheter

Aspiration of air into the blood gas syringe during sampling, or the presence of an air bubble are potential
causes for false elevation of ScvO2

The central venous PO2 (PcvO2) is 40 mmHg. This generally produces an ScvO2 of >70%. If the PcvO2
rises above 60 mmHg, the ScvO2 may rise to arterial saturation levels. A high arterial PaO2 during
administration of 100% oxygen can produce abnormally high PcvO2 and ScvO2 values.

Rarely, a high ScvO2 reading may indicate failure of the cells to extract. This could occur in end stage
multiorgan failure or with cell toxins such as cyanide (e.g., in house fires or nitrorusside toxicity).These
scenarios would be accompanied by lactic acidosis (final compensation when extraction is also inadequate)

An increase in ScvO2 could represent regional extraction failure such as in neurological death or near
neurological death.

Femoral Venous Blood Gases:

Femoral venous gases represent the "leftover" oxygen from the lower extremities and sometimes the gut. These values
are usually much lower than ScvO2 or SvO2 values and it is unclear how these values should be interpreted.

Femoral venous gases do not correlate to ScvO2 , and in shock when there is gut ischemia, may demonstrate very low
oxygen levels. The absolute value is rarely helpful, but the trend in venous gas measurement can be used as a marker of
cardiac output adequacy and/or treatment response.
 Peripheral Venous Gases :

Peripheral venous gases are not used to evaluate extraction

or oxygenation.

They can be used to determine acid-base balance or follow acid-base balance trends.

9. Document 9. To ensure appropriative interpretation and

Document results in the clinical record and interventions are made.
communicate any significant findings to the physician
and respiratory therapist.

Ensure that documentation in the graphic record and

core lab or GEM orders correctly identifies the type of
sample (e.g., peripheral venous, central venous or
mixed venous)

References:

Theordore, A., Manaker, S., and Finlay, G. (March 20, 2013). Venous blood gases and other alternatives to arterial blood gases.
www.uptodate.com

Developed: November 28, 1988 (Morgan, B)

Updated: June 30, 2016; Revised August 17, 2018

Brenda Morgan RN BScN MSc CNCC, CCTC

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