Arterial Blood Gas Analysis (ABG)

Arterial blood gas (ABG) analysis is used to measure the partial pressures of oxygen (PaO2) and
carbon dioxide (pacO2)' and the pH of an arterial sample. Oxygen content (O2CT), oxygen saturation
(SaO2) and bicarbonate (RCO3 -) values are also measured. A blood sample for ABG analysis may be
drawn by percutaneous arterial puncture or from an arterial line.
Purpose

To evaluate gas exchange in the lungs.

To assess integrity of the ventilatory control system.
To determine the acid-base level of the blood
To monitor respiratory therapy

Measure of H+ ion concentration

Blood is slightly alkaline pH 7.35 to 7.45
Below 7.35 is acidosis
Above 7.45 is alkalosis

PH

Regulators of Acid/Base

Metabolic processes produce acids that must be neutralized and excreted

Regulatory mechanisms
Buffers
Respiratory system
Renal system

The Respiratory Buffer Response

A normal by-product of cellular metabolism is carbon dioxide (CO2). CO2 is carried in the
blood to the lungs, where excess CO2 combines with water (H2O) to form carbonic acid
(H2CO3). The blood pH will change according to the level of carbonic acid present. This
triggers the lungs to either increase or decrease the rate and depth of ventilation until the
appropriate amount of CO2 has been re-established. Activation of the lungs to compensate foran
imbalance starts to occur within 1 to 3 minutes.
The Renal Buffer Response
In an effort to maintain the pH of the blood within its normal range, the kidneys excrete or
retain bicarbonate (HCO3
-). As the blood pH decreases, the kidneys will compensate by
retaining HCO3
- and as the pH rises, the kidneys excrete HCO3
- through the urine. Although the
kidneys provide an excellent means of regulating acid-base balance, the system may take from

hours to days to correct the imbalance. When the respiratory and renal systems are working
together, they are able to keep the blood pH balanced by maintaining 1 part acid to 20 parts

Acid-Base Disorders
Respiratory Acidosis
Respiratory acidosis is defined as a pH less than 7.35 with a PaCO2 greater than 45 mm Hg.
Acidosis is caused by an accumulation of CO2 which combines with water in the body to
produce carbonic acid, thus, lowering the pH of the blood. Any condition that results in
hypoventilation can cause respiratory acidosis. These conditions include:
Central nervous system depression related to head injury
Central nervous system depression related to medications such as narcotics, sedatives, or
anesthesia
Impaired respiratory muscle function related to spinal cord injury, neuromuscular diseases,
or neuromuscular blocking drugs
Pulmonary disorders such as atelectasis, pneumonia, pneumothorax, pulmonary edema, or
bronchial obstruction
Massive pulmonary embolus
Hypoventilation due to pain, chest wall injury/deformity, or abdominal distension
The signs and symptoms of respiratory acidosis are centered within the pulmonary, nervous,
and cardiovascular systems. Pulmonary symptoms include dyspnea, respiratory distress, and/or
shallow respirations. Nervous system manifestations include headache, restlessness, and
confusion. If CO2 levels become extremely high, drowsiness and unresponsiveness may be
noted. Cardiovascular symptoms include tachycardia and dysrhythmias.
Increasing ventilation will correct respiratory acidosis. The method for achieving this will vary
with the cause of hypoventilation. If the patient is unstable, manual ventilation with a bagvalvemask (BVM) is indicated until the underlying problem can be addressed. After
stabilization, rapidly resolvable causes are addressed immediately. Causes that can be treated
rapidly include pneumothorax, pain, and CNS depression related to medications. If the cause
cannot be readily resolved, the patient may require mechanical ventilation while treatment is
rendered. Although patients with hypoventilation often require supplemental oxygen, it is important to
remember that oxygen alone will not correct the problem.
Respiratory Alkalosis
Respiratory alkalosis is defined as a pH greater than 7.45 with a PaCO2 less than 35 mm Hg.
Any condition that causes hyperventilation can result in respiratory alkalosis. These conditions
include:
Psychological responses, such as anxiety or fear
Pain
Increased metabolic demands, such as fever, sepsis, pregnancy, or thyrotoxicosis
Medications, such as respiratory stimulants.
Central nervous system lesions
Signs and symptoms of respiratory alkalosis are largely associated with the nervous and
cardiovascular systems. Nervous system alterations include light-headedness, numbness and

tingling, confusion, inability to concentrate, and blurred vision. Cardiac symptoms include
dysrhythmias and palpitations. Additionally, the patient may experience dry mouth,
diaphoresis, and tetanic spasms of the arms and legs.
Treatment of respiratory alkalosis centers on resolving the underlying problem. Patients
presenting with respiratory alkalosis have dramatically increased work of breathing and must
be monitored closely for respiratory muscle fatigue. When the respiratory muscles become
exhausted, acute respiratory failure may ensue
Metabolic Acidosis
Metabolic acidosis is defined as a bicarbonate level of less than 22 mEq/L with a pH of less
than 7.35. Metabolic acidosis is caused by either a deficit of base in the bloodstream or an
excess of acids, other than CO2. Diarrhea and intestinal fistulas may cause decreased levels of
base. Causes of increased acids include:
Renal failure
Diabetic ketoacidosis
Anaerobic metabolism
Starvation
Salicylate intoxication
Symptoms of metabolic acidosis center around the central nervous system, cardiovascular,
pulmonary and GI systems.
manifestations
headache
confusion , restlessness progressing to lethargy, then stupor or coma.
Cardiac dysrhythmias are common
Kussmaul respirations occur in an effort to compensate for the pH by blowing off more
CO2.
Warm, flushed skin, as well as nausea and vomiting are commonly noted.
Metabolic Alkalosis
Metabolic alkalosis is defined as a bicarbonate level greater than 26 mEq/liter with a pH greater
than 7.45. Either an excess of base or a loss of acid within the body can cause metabolic
alkalosis. Excess base occurs from ingestion of antacids, excess use of bicarbonate, or use of
lactate in dialysis. Loss of acids can occur secondary to protracted vomiting, gastric suction,
hypochloremia, excess administration of diuretics, or high levels of aldosterone.
Symptoms of metabolic alkalosis
Dizziness
Lethargy
Disorientation
seizures and coma.
Weakness
muscle twitching
muscle cramps and tetany.

 nausea, vomiting, and respiratory depression.

PROCEDURE
Equipment
Arterial Blood Gas (ABG) Kit

Prepackaged and contains all necessary equipment

3 5 cc syringe
Pre-heparin zed
22ga x 2 needle
Alcohol swap
Gauze pad
Biohazard bag
Misc. items

Site Selection

Radial artery
Brachial artery
Inguinal artey
Femoral artery
Posterior tibia
Dorsalis pedis

Radial Artery - 45 insertion angle

Requires modified Allens test for collateral circulation

Brachial Artery - 60 - 90 insertion angle

Femoral Artery - 90 insertion angle
Dorsalis Pedis Artery
Site must be adequately compressed until clotted Approximately
5 minutes Patients receiving anticoagulation therapy take longer

Hazards

Hematoma
Arterial laceration
Hemorrhage
Vasovagal reaction Sympathetic nervous system response to pain

Loss of limb

Blood gas specimen should collected anaerobically

Expel air bubbles immediately
Blood gas specimen must be adequately anticoagulated
Sodium heparin
Lithium heparin (electrolytes)

Handling

Sample volume should be 1 2 ml

Specimen should be adequately identified
Patient name / ID number
Date / Time
Ordering physician
Accession number
Puncture site
Oxygen adjunct and FiO2
Ventilator settings (if applicable

Components of the Arterial Blood Gas

The arterial blood gas provides the following values:
pH
Measurement of acidity or alkalinity, based on the hydrogen (H+) ions present.
The normal range is 7.35 to 7.45
PaO2
The partial pressure of oxygen that is dissolved in arterial blood.
The normal range is 80 to 100 mm Hg.
SaO2
The arterial oxygen saturation.
The normal range is 95% to 100%.
PaCO2
The amount of carbon dioxide dissolved in arterial blood.
The normal range is 35 to 45 mm Hg.
HCO3
The calculated value of the amount of bicarbonate in the bloodstream.
The normal range is 22 to 26 mEq/liter

B.E.
The base excess indicates the amount of excess or insufficient level of bicarbonate in the
system.
The normal range is 2 to +2 mEq/liter.
(A negative base excess indicates a base deficit in the blood.)
The arterial blood gas is used to evaluate both acid-base balance and oxygenation, each
representing separate conditions. Acid-base evaluation requires a focus on three of the reported
components: pH, PaCO2 and HCO3.

This process involves three steps.

Step One
Assess the pH to determine if the blood is within normal range, alkalotic or acidotic. If it is
above 7.45, the blood is alkalotic. If it is below 7.35, the blood is acidotic.
Step Two
If the blood is alkalotic or acidotic, we now need to determine if it is caused primarily by a
respiratory or metabolic problem. To do this, assess the PaCO2 level. Remember that with a
respiratory problem, as the pH decreases below 7.35, the PaCO2 should rise. If the pH rises
above 7.45, the PaCO2 should fall. Compare the pH and the PaCO2 values. If pH and PaCO2 are
indeed moving in opposite directions, then the problem is primarily respiratory in nature.
Step Three
Finally, assess the HCO3 value. Recall that with a metabolic problem, normally as the pH
increases, the HCO3 should also increase. Likewise, as the pH decreases, so should the HCO3.
Compare the two values. If they are moving in the same direction, then the problem is
primarily metabolic in nature. The following chart summarizes the relationships between pH,
PaCO2 and HCO3.
pH PaCO2
HCO3
Respiratory Acidosis

normal
Respiratory Alkalosis

normal

Metabolic Acidosis

normal

Metabolic Alkalosis

normal

Assessment of Fluid, Electrolyte, and Acid-Base Imbalances

Subjective data
Important health information
Past health history
Medications
Surgery or other treatments

Functional health patterns

Health perceptionhealth management pattern
Recent changes in body weight
Current problems related to fluid, electrolyte, acid-base balance
Nutritional-metabolic pattern
Elimination pattern
Activity-exercise pattern
Cognitive-perceptual pattern
Any changes in sensations such as numbness, tingling, etc.
Objective data
Physical examination
Laboratory values

TREATMENT OF RESPIRATORY ACIDOSIS

Treatment is aimed at the underlying lung disease, and may include:

Bronchodilator drugs to reverse some types of airway obstruction
Noninvasive positive-pressure ventilation (sometimes called CPAP or BiPAP) or mechanical
ventilation if needed
Oxygen if the blood oxygen level is low
Treatment to stop smoking

RESPIRATORY ALKALOSIS

Treatment is aimed at the condition that causes respiratory alkalosis.

Breathing into a paper bag -- or using a mask that causes patient to re-breathe carbon dioxide
-- sometimes helps reduce symptoms

METABLOIC ALKALOSIS

Re-expand volume with Normal Saline ( Primary Therapy)

Supplement with Potassium to treat hypokalemia H+ blockers or PPIs if vomiting/NG suction
to prevent further losses in H+ ions
Discontinue diuretics
Acetazolamide if NS contraindicated due to CHF.
HCl or NH4Cl in emergency.
Hemodialysis in patients with marked renal failure

METABLOIC ACIDOSIS
Treatment is aimed at the underlying condition. In certain circumstances, sodium bicarbonate (baking
soda) may be given to improve the acidity of the blood.

CONCLUSION

ABG analysis play a crucial role in the treatment of the patient with the acid base disorder in
clinical setting , nurses are the primary care provider ,they should must be aware of the result of ABG
so that prompt action can be taken for the recovery of the patient.

BIBLIOGRAPHY
1. Black joyce M, MEDICAL SURGICAL NURSING CLINICAL MANAGEMENT
FOR POSITIVE OUTCOME 7TH ed, Elsevier publication , a division of reed
Elsevier India private ltd, p.g.no 1509 - 1542
2. Dirksen lewis etal; MEDICAL SURGICAL NURSING ASSESSMENT AND
MANAGEMENT OF CLINICAL PROBLEM 6th ed , mosby publication , united
state , p.g no 912 938
3. smeltzer Suzanne C, etal BRUNNER AND SUDDARTHS TEXTBOOK OF
MEDICAL SURGICAL NURSING 11TH ed, lippincot Williams and wilkins
publication, wolters kluwer pvt. Ltd , new delhi p.g no 974 1017