Heel prick of BGA in neonates:

clinical pathology perspective

Ro Shinta C Solin
Outline

• Preanalytical Consideration for Blood Gas Analysis (BGA)

• Capillary Blood Collection with heel prick for BGA
• BGA parameter correlation: Capillaries vs Arteries
• Pitfalls of Heel Prick specimen for BGA
 Preanalytical Consideration
for Blood Gas Analysis (BGA)
• The instruments  PCO2,
PO2,& pH are highly
automated.
• Proper specimen collection
and handling are critical
for accurate
determinations
• Best Specimen: Whole
Resteli V. 2017. Extending the scope of eqa to the extra analytical phases. Digital image available
blood (arterial)
from https://cmpt.ca/extending-the-scope-of-eqa-to-the-extra-analytical-phases/

1. Scott MG, et al. Electrolytes and Blood Gases in Burtis, C. A., Ashwood, E. R., Bruns, D. E., & Tietz, N. W. (2015). Tietz textbook of clinical chemistry
and molecular diagnostics. St. Louis, Mo: Elsevier/Saunders.
 Preanalytical Consideration
for BGA
• Specimen best collected :
• anaerobically
• lyophilized heparin anticoagulant (1- 3-mL)
in sterile syringes.
• Anaerobic collection
• The PCO2 of air (+/- 0.25 mm Hg; blood
(≈40 mm Hg).
• blood exposed to air
• pCO2 will decrease,
• blood pH will rise.
• PO2 of atmospheric air (≈155 mm Hg)
• ≈60 mm Hg higher, arterial blood
• ≈100 mm Hg higher than venous blood
• Anaerobic Collection
• × air in the needle
• × air in the syringe hub dead space.
1. Scott MG, et al. Electrolytes and Blood Gases in Burtis, C. A., Ashwood, E. R., Bruns, D. E., & Tietz, N. W. (2015). Tietz textbook of clinical chemistry
and molecular diagnostics. St. Louis, Mo: Elsevier/Saunders.
 Preanalytical • Best Specimen for BGA:
Consideration • Arterial
for BGA • Vein (Mixed Vein)
• Capillary (alternative) : newborns,
infants, & children younger than 2
years.
• Arterialized capillary blood
• Freely flowing blood (arterioles)  corresponds
closely to arterial blood in composition.
• first blood drop to appear should be wiped away
• subsequent free-forming drops  capillary
collection tube containing lyophilized heparin.
• Only free-flowing blood provides a satisfactory
sample
• Taking up the drops ASAP : minimizes aerobic
exposure

1. Warekois, R. S., & Robinson, R. (2016). Capillary collection. Phlebotomy: Worktext and procedures manual. St. Louis, Missouri: Elsevier.
2. Scott MG, et al. Electrolytes and Blood Gases in Burtis, C. A., Ashwood, E. R., Bruns, D. E., & Tietz, N. W. (2015). Tietz textbook of clinical chemistry and molecular diagnostics.
St. Louis, Mo: Elsevier/Saunders.
 Preanalytical
Consideration
• Capillary blood collection may be inappropriate for: for BGA
• Severely dehydrated
• Poor circulation
• Plasma-based coagulation studies are required
• require large volumes of blood (ie, erythrocyte sedimentation rate, blood
cultures)
• with a callus, skin ulceration, or blister at the intended puncture site
• Thrombocytopenia and/or platelet abnormalities
• Patients with peripheral edema
• If pO2 are needed to evaluate the gas exchange function of the lungs
• Patients with other physical conditions or specific diseases may necessitate
the use of alternative methods of obtaining blood specimens.
CLSI. Collection of Capillary Blood Specimens. 7th ed. CLSI standard GP42. Clinical and Laboratory Standards
Institute; 2020
 Preanalytical
Consideration
for BGA
Site of Dermal puncture General Consideration Site of Dermal puncture
• Collection should be performed
on:
• warm,
BD Microtainer Quikheel Lancet. (Courtesy
and • healthy skin ( free from scars,
• Infant: on the medial and cuts, bruises, & rashes.
© Becton, Dickinson and Co.)

lateral borders of the heel • away from bone

• The center of the plantar surface :
too close to the calcaneus, • Avoid previous puncture sites
• The arch  close to nerves &
tendons.
1. Warekois, R. S., & Robinson, R. (2016). Capillary collection. Phlebotomy: Worktext and procedures manual. St. Louis, Missouri: Elsevier.
2. Scott MG, et al. Electrolytes and Blood Gases in Burtis, C. A., Ashwood, E. R., Bruns, D. E., & Tietz, N. W. (2015). Tietz textbook of clinical chemistry
and molecular diagnostics. St. Louis, Mo: Elsevier/Saunders.
 Preanalytical
Consideration
for BGA
• Puncture depth (minimized risk
of infection)
• Heel puncture, the max depth:
2.0 mm
• Premature babies, the
recommended depth: 0.65 -
0.85 mm.
• Bone puncture risk of
osteochondritis,
osteomyelitis
Location of capillary bed in the layer of capillary
skin of the heel
CLSI. Collection of Capillary Blood Specimens. 7th ed. CLSI standard GP42. Clinical and Laboratory Standards
Institute; 2020
 Preanalytical
Consideration
for BGA
• Transport and analysis
• Transport & analysis of specimens should be
prompt.
• Delay >5-10 min kept on ice for transport
• Adverse effects of glycolysis and respiration 
best prevented by analysis within 30 minutes
after collection.
• Glycolysis and the resulting effects on pH,
PO2, and PCO2 increase dramatically with
markedly elevated WBC, as occurs in
leukemia.
1. Scott MG, et al. Electrolytes and Blood Gases in Burtis, C. A., Ashwood, E. R., Bruns, D. E., & Tietz, N. W. (2015). Tietz textbook of clinical chemistry
and molecular diagnostics. St. Louis, Mo: Elsevier/Saunders.
 Preanalytical
Consideration
for BGA
Site of Dermal puncture General Consideration Site of Dermal puncture
• Collection should be performed on:
• warm,
• healthy skin ( free from scars, cuts, bruises, &
rashes.
BD Microtainer Quikheel Lancet. (Courtesy
• away from bone
and

• Avoid previous puncture sites

© Becton, Dickinson and Co.)

• Infant: on the medial and • Bone puncture risk of osteochondritis,

lateral borders of the heel osteomyelitis
• The center of the plantar surface : • Puncture depth (minimized risk of infection)
too close to the calcaneus, • Heel puncture, the max depth: 2.0 mm
• The arch  close to nerves & • Premature babies, the recommended depth: 0.65 -
tendons. 0.85 mm.

1. Scott MG, et al. Electrolytes and Blood Gases in Burtis, C. A., Ashwood, E. R., Bruns, D. E., & Tietz, N. W. (2015). Tietz textbook of clinical chemistry
and molecular diagnostics. St. Louis, Mo: Elsevier/Saunders.
 Capillary Blood Collection
with heel prick for BGA
• After
documenting
on the
requisition Assemble your
equipment.
• Sanitize your
hands and put
on gloves.

1. Warekois, R. S., & Robinson, R. (2016). Capillary collection. Phlebotomy: Worktext and procedures manual. St. Louis, Missouri: Elsevier
2. Johnson K, Cress G, Connolly N et al. Neonatal Laboratory blood sampling: comparison of results from arterial catheters with those from an automated capillary device. Neonatal Network 2000;
19: 27–34..
3. McLain B, Evans J, Dear P. Comparison of capillary and arterial blood gas measurements in neonates. Arch Dis Child 1988; 63: 743–47.
 Capillary Blood Collection
with heel prick for BGA
• Select and clean the site
• Place your thumb in the
arch, wrap your hand over
the top of the foot, and
Warm the site to 40° C to place your index finger
42° C for 5 to 10 minutes ** behind the heel.
• After documenting on the
requisition
• Sanitize your hands and
put on gloves.

**Arterializing effect with heel warmer vs unwarmed heel:

• Johnson et al: there was no significant difference in pH, pCO2 and pO2 for capillary blood
• McLain et al, mean values for pH, pCO2 and pO2 of warmed heel blood were all slightly closer to mean values for
arterial blood butn statistical analysis : non significant

1. Warekois, R. S., & Robinson, R. (2016). Capillary collection. Phlebotomy: Worktext and procedures manual. St. Louis, Missouri: Elsevier
2. Johnson K, Cress G, Connolly N et al. Neonatal Laboratory blood sampling: comparison of results from arterial catheters with those from an automated capillary device. Neonatal Network 2000;
19: 27–34..
3. McLain B, Evans J, Dear P. Comparison of capillary and arterial blood gas measurements in neonates. Arch Dis Child 1988; 63: 743–47.
 Capillary Blood Collection
with heel prick for BGA

• Prepare to collect
the sample.
• Wipe away the first
• Make the puncture, drop of blood with a
• Dispose of the clean gauze pad to
blade properly. prevent
contaminating the
sample with tissue
fluid.

1. Warekois, R. S., & Robinson, R. (2016). Capillary collection. Phlebotomy: Worktext and procedures manual. St. Louis, Missouri: Elsevier
2. Johnson K, Cress G, Connolly N et al. Neonatal Laboratory blood sampling: comparison of results from arterial catheters with those from an automated capillary device. Neonatal Network 2000;
19: 27–34..
3. McLain B, Evans J, Dear P. Comparison of capillary and arterial blood gas measurements in neonates. Arch Dis Child 1988; 63: 743–47.
 Capillary Blood Collection
with heel prick for BGA

• Collect the
sample. •C o l l e c t t h e
• Once blood is sample in a
flowing freely, heparinized
position the pipet.
container for •No air bubble
collection.

1. Warekois, R. S., & Robinson, R. (2016). Capillary collection. Phlebotomy: Worktext and procedures manual. St. Louis, Missouri: Elsevier
2. Johnson K, Cress G, Connolly N et al. Neonatal Laboratory blood sampling: comparison of results from arterial catheters with those from an automated capillary device. Neonatal Network 2000;
19: 27–34..
3. McLain B, Evans J, Dear P. Comparison of capillary and arterial blood gas measurements in neonates. Arch Dis Child 1988; 63: 743–47.
 Capillary Blood Collection
with heel prick for BGA
• Before collection, • Seal both ends of the
insert a metal filing tube with clay or
( flea) plastic caps
• After collection, a • Apply pressure to the
magnet is used to puncture site using a
draw the flea back clean gauze square.
and forth (mix the • Label, transport,
contents with the analyze
heparin).

The International Federation of Clinical Chemistry and Laboratory Medicine (IFCC)

recomendation :
transportation time minimal, and analyzing samples room temperature within 15
1.
minutes,
Warekois, R. S., & Robinson, R. (2016). Capillary collection. Phlebotomy: Worktext and procedures manual. St. Louis, Missouri: Elsevier
2.
3.
CLSIK, Cress
Johnson guidelines
G, Connolly N(C46-A2): transfer
et al. Neonatal Laboratory bycomparison
blood sampling: handof results
(not fromvia pneumatic
arterial catheters tube)
with those from an
McLain B, Evans J, Dear P. Comparison of capillary and arterial blood gas measurements in neonates. Arch Dis Child 1988; 63: 743–47.
automated capillary device. Neonatal Network 2000; 19: 27–34..
 Capillary vs Arterial Blood

• Blood obtained by heel stick is not pure capillary

blood, but a mixture of blood (arterioles, capillaries
& venules, small interstitial fluid)
• Capillary samples do not provide reliable
measurements of PaO2.
• Yang et al (2002): 33 paired samples of capillary
blood (heel-stick) & simultaneous arterial blood
sampling via arterial puncture
• The average correlations between capillary and
arterial samples
• r= 0.92 for pH,
• r= 0.93 for PCO2,
• r= 1.05 for HCO3-
.
Yang K-C, Su B-H, Tsai F-J, Peng C-T. The comparison between capillary blood sampling and arterial blood sampling in an NICU. Acta paediatrica
Taiwanica = Taiwan er ke yi xue hui za zhi. 2002;43(3):124-126. Accessed May 30, 2022.
 BGA parameter correlation
: Capillaries vs Arteries

• Reference range by Cousineau et al:

• 126 term neonates (64 M, 62 F) with gestational age was 39.6 ± 1.2 weeks and birth
weight was 3426 ± 406 g (Mean ± 1 SD), heel prick with warming taken free-flowing
capillary blood (collected at 48 ±12 h of life)
• pH and pCO2, in this study are close to those of Dollberg et al, despite the fact that they
reported values for term healthy neonates much closer to birth (2 to 4 h of life)
Cousineau J, Anctil S, Carceller A, Gonthier M, Delvin EE. Neonate capillary blood gas reference values. Clinical Biochemistry. 2005
Oct;38(10):905-907. DOI: 10.1016/j.clinbiochem.2005.07.006. PMID: 16109393.
S. Dollberg, R. Bauer, R. Lubetzky, F.B. Mimouni. A reappraisal of neonatal blood chemistry reference ranges using the Nova M electrodes
Am. J. Perinatol., 18 (2001), pp. 433-439
 BGA parameter correlation
: Capillaries vs Arteries
• Baik-Schneditz N et al, Study
 normal values of capillary
BGA (term neonates after
uncomplicated neonatal
transition)
• lower pH and higher pCO2
values

Baik-Schneditz N, Schwaberger B, Urlesberger B, et al. Acid Base and Blood Gas Analysis in Term Neonates Immediately
After Birth with Uncomplicated Neonatal Transition. Research Square; 2021. DOI: 10.21203/rs.3.rs-858091/v1.
 Pitfalls of Heel Prick
specimen for BGA
• Each of steps is associated with the potential for error

Laboratory Testing Processes Potential Errors

Test ordering Inappropriate test, Handwriting not legible
Wrong patient identification
Special requirements not specified
Cost or delayed order
Specimen acquisition Incorrect tube or container
Incorrect patient identification
Inadequate volume
Invalid specimen (e.g., hemolyzed, too dilute)
Collected at wrong time
Improper transport conditions

1. Scott MG, et al. Electrolytes and Blood Gases in Burtis, C. A., Ashwood, E. R., Bruns, D. E., & Tietz, N. W. (2015). Tietz textbook of clinical chemistry
and molecular diagnostics. St. Louis, Mo: Elsevier/Saunders.
 Pitfalls of Heel Prick
specimen for BGA
• Each of steps is associated with the potential for error
Laboratory Testing Processes Potential Errors
Analytical measurement Instrument not calibrated correctly, Specimen mix-up
Incorrect volume of specimen
Interfering substance present
Instrument precision problem
Poorly written laboratory procedure
Test reporting Wrong patient identification
Report not posted in chart
Report not legible
Report delayed
Transcription error

1. Scott MG, et al. Electrolytes and Blood Gases in Burtis, C. A., Ashwood, E. R., Bruns, D. E., & Tietz, N. W. (2015). Tietz textbook of clinical chemistry
and molecular diagnostics. St. Louis, Mo: Elsevier/Saunders.
 Pitfalls of Heel Prick
specimen for BGA
• Each of steps is associated with the potential for error

Laboratory Testing Processes Potential Errors

Test interpretation Interfering substances not recognized
Specificity of test not understood
Precision limitations not recognized
Analytical sensitivity not appropriate
Previous values not available for comparison

1. Scott MG, et al. Electrolytes and Blood Gases in Burtis, C. A., Ashwood, E. R., Bruns, D. E., & Tietz, N. W. (2015). Tietz textbook of clinical chemistry
and molecular diagnostics. St. Louis, Mo: Elsevier/Saunders.
 Pitfalls of Heel Prick
specimen for BGA
• Indication:
• Repeat testing BGA contribute significantly to iatrogenic anemia in critically ill
patients (40%)
• CLSI guidelines (C46-A2) justifications for repeating an analysis: result
inconsistent with a previous result or condition
• Wrong Identification
• Wrong type or amount of anticoagulant (lyophilized heparin vs liquid
heparin)
• Air aspiration or bubble formation in blood gas syringes.

Baird G. Preanalytical considerations in blood gas analysis. Biochem Med (Zagreb).

2013;23(1):19-27. doi: 10.11613/bm.2013.005. PMID: 23457763; PMCID:
PMC3900096.
 Pitfalls of Heel Prick
specimen for BGA
• Hemolysis (avoid constant massaging  cut off flow, cause hemolysis, &
introduce tissue fluid back into the sample)
• Increased K concentrations
• The values of gas partial pressures & pH, are not greatly affected by hemolysis
• Gross Hemolysis affect measurement of Hematocrit in BGA
• Not visually inspecting the sample for clots
• Inadequate mixing of sample before analysis

Baird G. Preanalytical considerations in blood gas analysis. Biochem Med (Zagreb).

2013;23(1):19-27. doi: 10.11613/bm.2013.005. PMID: 23457763; PMCID:
PMC3900096.
 Take Home Message
• Best Specimen: Arterial blood
• Heel prick sampling can be alternative specimen for BGA in
neonates
• Anaerobic sampling is critical for BGA
• Control of preanalytical variables in BGA testing is critical for
ensuring an accurate result