Arterial Blood Gas Analysis

Vanessa Klee MSIV

What is an ABG?
The Components
pH / PaCO2 / PaO2 / HCO3 / O2sat / BE

Desired Ranges
pH - 7.35 - 7.45 PaCO2 - 35-45 mmHg PaO2 - 80-100 mmHg HCO3 - 21-27 O2sat - 95-100% Base Excess - +/-2 mEq/L

Why Order an ABG?

Aids in establishing a diagnosis Helps guide treatment plan Aids in ventilator management Improvement in acid/base management allows for optimal function of medications Acid/base status may alter electrolyte levels critical to patient status/care

Logistics
When to order an arterial line - Need for continuous BP monitoring Need for multiple ABGs

Where to place -- the options

Radial Femoral Brachial Dorsalis Pedis Axillary

Acid Base Balance

The body produces acids daily
15,000 mmol CO2 50-100 mEq Nonvolatile acids

The lungs and kidneys attempt to maintain balance

Acid Base Balance

Assessment of status via bicarbonatecarbon dioxide buffer system
CO2 + H2O <--> H2CO3 <--> HCO3- + H+
ph = 6.10 + log ([HCO3] / [0.03 x PCO2])

The Terms
ACIDS
Acidemia Acidosis
Respiratory CO2 Metabolic HCO3

BASES
Alkalemia Alkalosis
Respiratory CO2 Metabolic HCO3

Respiratory Acidosis
ph, CO2, Ventilation Causes
CNS depression Pleural disease COPD/ARDS Musculoskeletal disorders Compensation for metabolic alkalosis

Respiratory Acidosis
Acute vs Chronic
Acute - little kidney involvement. Buffering via titration via Hb for example
pH by 0.08 for 10mmHg in CO2

Chronic - Renal compensation via synthesis and retention of HCO3 (Cl to balance charges hypochloremia)
pH by 0.03 for 10mmHg in CO2

Respiratory Alkalosis
pH, CO2, Ventilation CO2 HCO3 (Cl to balance charges hyperchloremia) Causes
Intracerebral hemorrhage Salicylate and Progesterone drug usage Anxiety lung compliance Cirrhosis of the liver Sepsis

Respiratory Alkalosis
Acute vs. Chronic
Acute - HCO3 by 2 mEq/L for every 10mmHg in PCO2 Chronic - Ratio increases to 4 mEq/L of HCO3 for every 10mmHg in PCO2 Decreased bicarb reabsorption and decreased ammonium excretion to normalize pH

Metabolic Acidosis
pH, HCO3 12-24 hours for complete activation of respiratory compensation PCO2 by 1.2mmHg for every 1 mEq/L HCO3 The degree of compensation is assessed via the Winters Formula
PCO2 = 1.5(HCO3) +8 2

The Causes
Metabolic Gap Acidosis
M - Methanol U - Uremia D - DKA P - Paraldehyde I - INH L - Lactic Acidosis E - Ehylene Glycol S - Salicylate

Non Gap Metabolic Acidosis

Hyperalimentation Acetazolamide RTA (Calculate urine anion gap) Diarrhea Pancreatic Fistula

Metabolic Alkalosis
pH, HCO3 PCO2 by 0.7 for every 1mEq/L in HCO3 Causes
Vomiting Diuretics Chronic diarrhea Hypokalemia Renal Failure

Mixed Acid-Base Disorders

Patients may have two or more acidbase disorders at one time
Delta Gap
Delta HCO3 = HCO3 + Change in anion gap >24 = metabolic alkalosis

The Steps
Start with the pH Note the PCO2 Calculate anion gap Determine compensation

Sample Problem #1
An ill-appearing alcoholic male presents with nausea and vomiting.
ABG - 7.4 / 41 / 85 / 22 Na- 137 / K- 3.8 / Cl- 90 / HCO3- 22

Sample Problem #1
Anion Gap = 137 - (90 + 22) = 25 anion gap metabolic acidosis Winters Formula = 1.5(22) + 8 2 = 39 2 compensated Delta Gap = 25 - 10 = 15 15 + 22 = 37 metabolic alkalosis

Sample Problem #2
22 year old female presents for attempted overdose. She has taken an unknown amount of Midol containing aspirin, cinnamedrine, and caffeine. On exam she is experiencing respiratory distress.

Sample Problem #2
ABG - 7.47 / 19 / 123 / 14 Na- 145 / K- 3.6 / Cl- 109 / HCO3- 17 ASA level - 38.2 mg/dL

Sample Problem #2
Anion Gap = 145 - (109 + 17) = 19 anion gap metabolic acidosis Winters Formula = 1.5 (17) + 8 2 = 34 2 uncompensated Delta Gap = 19 - 10 = 9 9 + 17 = 26 no metabolic alkalosis

Sample Problem #3
47 year old male experienced crush injury at construction site. ABG - 7.3 / 32 / 96 / 15 Na- 135 / K-5 / Cl- 98 / HCO3- 15 / BUN- 38 / Cr- 1.7 CK- 42, 346

Sample Problem #3
Anion Gap = 135 - (98 + 15) = 22 anion gap metabolic acidosis Winters Formula = 1.5 (15) + 8 2 = 30 2 compensated Delta Gap = 22 - 10 = 12 12 + 15 = 27 mild metabolic alkalosis

Sample Problem #4
1 month old male presents with projectile emesis x 2 days. ABG - 7.49 / 40 / 98 / 30 Na- 140 / K- 2.9 / Cl- 92 / HCO3- 32

Sample Problem #4
Metabolic Alkalosis, hypochloremic Winters Formula = 1.5 (30) + 8 2 = 53 2 uncompensated