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
Information Obtained from an
ABG:
• Acid base status
• Oxygenation
• Dissolved O2 (pO2)
• Saturation of hemoglobin
• CO2 elimination
• Levels of carboxyhemoglobin and
methemoglobin
 Indications:
• Assess the ventilatory status,
oxygenation and acid base status
• Assess the response to an intervention
 Contraindications:
• Bleeding diathesis
• AV fistula
• Severe peripheral vascular disease,
absence of an arterial pulse
• Infection over site
Why an ABG instead of Pulse
oximetry?
• Pulse oximetry uses light absorption at
two wavelengths to determine
hemoglobin saturation.
• Pulse oximetry is non-invasive and
provides immediate and continuous
data.
Why an ABG instead of Pulse
oximetry?
• Pulse oximetry does not assess ventilation
(pCO2) or acid base status.
• Pulse oximetry becomes unreliable when
saturations fall below 70-80%.
• Technical sources of error (ambient or
fluorescent light, hypoperfusion, nail polish,
skin pigmentation)
• Pulse oximetry cannot interpret
methemoglobin or carboxyhemoglobin.
 Which Artery to Choose?
• The radial artery is superficial, has
collaterals and is easily compressed. It
should almost always be the first
choice.
• Other arteries (femoral, dorsalis pedis,
brachial) can be used in emergencies.
 Preparing to perform the
Procedure:
• Make sure you and the patient are
comfortable.
• Assess the patency of the radial and
ulnar arteries.
 Collection Problems:
• Type of syringe
• Plastic vs. glass
• Use of heparin
• Air bubbles
• Specimen handling and transport
 Type of Syringe
• Glass-
• Impermeable to gases
• Expensive and impractical
• Plastic-
• Somewhat permeable to gases
• Disposable and inexpensive
 Heparin
• Liquid
• Dilutional effect if <2-3 ml of blood
collected
• Preloaded dry heparin powder
• Eliminates dilution problem
• Mixing becomes more important
• May alter sodium or potassium levels
 Air bubbles
• Gas equilibration between ambient air
(pO2 ~ 150, pCO2~0) and arterial
blood.
• pO2 will begin to rise, pCO2 will fall
• Effect is a function of duration of
exposure and surface area of air
bubble.
• Effect is amplified by pneumatic tube
transport.
 Transport
• After specimen collected and air bubble
removed, gently mix and invert syringe.
• Because the wbcs are metabolically
active, they will consume oxygen.
• Plastic syringes are gas permeable.
• Key: Minimize time from sample
acquisition to analysis.
 Transport
• Placing the AGB on ice may help
minimize changes, depending on the
type of syringe, pO2 and white blood
cell count.
• Its probably not as important if the
specimen is delivered immediately.
 Performing the Procedure:
• Put on gloves
• Prepare the site
• Drape the bed
• Cleanse the radial area with a alcohol
• Position the wrist (hyper-extended,
using a rolled up towel if necessary)
• Palpate the arterial pulse and visualize
the course of the artery.
 Acid/Base Relationship

H2O + CO2  H2CO3  HCO3 +

H+
 Buffers
There are two buffers that work in pairs

H2CO3 NaHCO3
Carbonic acid base bicarbonate

These buffers are linked to the

respiratory and renal compensatory
system
 The Respiratory buffer response

• The blood pH will change acc.to

the level of H2CO3 present.
• This triggers the lungs to either
increase or decrease the rate and
depth of ventilation
• Activation of the lungs to
compensate for an imbalance
starts to occur within 1-3 minutes
 The Renal Buffer Response
• The kidneys excrete or retain
bicarbonate(HCO3-).
• If blood pH decreases, the kidneys
will compensate by retaining HCO3
• Renal system may take from hours
to days to correct the imbalance.
 ACID BASE DISORDER
Res. Acidosis
• is defined as a pH less than 7.35 with a
paco2 greater than 45 mmHg.
• Acidosis –accumulation of co2,
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.
 Causes
1. Central nervous system depression r/t
medications such as narcotics, sedatives, or
anesthesia.
2. Impaired muscle function r/t spinal cord injury,
neuromuscular diseases, or neuromuscular
blocking drugs.
3. Pulmonary disorders such as atelectasis,
pneumonia, pneumothorax, pulmonary edema
or bronchial obstruction
4. Massive pulmonary embolus
5. Hypoventilation due to pain chest wall injury, or
abdominal pain.
 Signs & symptoms of Respiratory
Acidosis

• Respiratory : Dyspnoea, respiratory

distress and/or shallow respiration.
• Nervous: Headache, restlessness and
confusion. If co2 level extremely high
drowsiness and unresponsiveness may be
noted.
• CVS: Tacycardia and dysrhythmias
 Management
• Increase the ventilation.
• Causes can be treated rapidly include
pneumothorax, pain and CNS
depression r/t medication.
• If the cause can not be readily resolved,
mechanical ventilation.
 Respiratory alkalosis
• Psychological responses, anxiety or fear.
• Pain
• Increased metabolic demands such as fever,
sepsis, pregnancy or thyrotoxicosis.
• Medications such as respiratory stimulants.
• Central nervous system lesions
 Signs & symptoms
• CNS: Light Headedness, numbness,
tingling, confusion, inability to
concentrate and blurred vision.
• Dysrhythmias and palpitations
• Dry mouth, diaphoresis and tetanic
spasms of the arms and legs.
 Management

• Resolve the underlying problem

• Monitor for respiratory muscle
fatigue
• When the respiratory muscle
become exhausted, acute
respiratory failure may ensue
 Metabolic Acidosis
• Bicarbonate less than 22mEq/L with a
pH of less than 7.35.
• Renal failure
• Diabetic ketoacidosis
• Anaerobic metabolism
• Starvation
• Salicylate intoxication
 Sign & symptoms
• CNS: Headache, confusion and
restlessness progressing to lethargy,
then stupor or coma.
• CVS: Dysrhythmias
• Kussmaul’s respirations
• Warm, flushed skin as well as nausea
and vomiting
 Management
• Treat the cause
• Hypoxia of any tissue bed will produce metabolic
acids as a result of anaerobic metabolism even if
the pao2 is normal
• Restore tissue perfusion to the hypoxic tissues
• The use of bicarbonate is indicated for known
bicarbonate - responsive acidosis such as seen
with renal failure
 Metabolic alkalosis
• Bicarbonate more than 26m Eq /L with a pH
more than 7.45
• Excess of base /loss of acid can cause
• Ingestion of excess antacids, excess use of
bicarbonate, or use of lactate in dialysis.
• Protracted vomiting, gastric
suction,hypchoremia,excess use of diuretics, or
high levels of aldesterone.
 Signs/symptoms
• CNS: Dizziness, lethargy
disorientation, siezures & coma.
• M/S: weakness, muscle twitching,
muscle cramps and tetany.
• Nausea, vomiting and respiratory
depression.
• It is difficult to treat.
 COMPONENTS OF THE
ABG
pH: Measurement of acidity or alkalinity, based on the hydrogen (H+)
7.35 – 7.45
Pao2 The partial pressure oxygen that is dissolved in arterial blood.
80-100 mm Hg.
PCO2: The amount of carbon dioxide dissolved in arterial blood.
35– 45 mmHg
HCO3
: The calculated value of the amount of bicarbonate in the blood
22 – 26 mmol/L
B.E:
The base excess indicates the amount of excess or insufficient
level of bicarbonate. -2 to +2mEq/L
(A negative base excess indicates a base deficit in blood)

SaO2:The arterial oxygen saturation.

>95%
 Stepwise approach to ABG
• Step 1: Acidemic or Alkalemic?
• Step 2: Is the primary disturbance respiratory
or metabolic?
• Step 3. Asses to Pa O2. A value below 80mm Hg
indicates Hypoxemia. For a respiratory
disturbance, determine whether it is acute or
chronic.
• Step 4. For a metabolic acidosis, determine
whether an anion gap is present.
• Step 5. Assess the normal compensation by the
respiratory system for a metabolic disturbance
 STEPS TO AN ABG
INTERPRETATION
• Step:1
• Assess the pH –acidotic/alkalotic
• If above 7.5 – alkalotic
• If below 7.35 – acidotic
 Contd…..
• Step 2:
• Assess the paCO2 level.
• pH decreases below 7.35, the paCO2
should rise.
• If pH rises above 7.45 paCO2 should
fall.
• If pH and paCO2 moves in opposite
direction – primary respiratory problem.
 contd
• Step:2
• Assess HCO3 value
• If pH increases the HCO3 should also
increase
• If pH decreases HCO3 should also
decrease
• They are moving in the same direction
• primary problem is metabolic
• Step 3
Assess pao2 < 80 mm Hg - Hypoxemia
For a resp. disturbance : acute, chronic
The differentiation between A/C &
CHR.respiratory disorders is based on
whether there is associated acidemia /
alkalemia.
If the change in paco2 is associated with the
change in pH, the disorder is acute.
In chronic process the compensatory process
brings the pH to within the clinically
acceptable range ( 7.30 – 7.50)
• J is a 45 years old female admitted with the severe attack of
asthma. She has been experiencing increasing shortness of
breath since admission three hours ago. Her arterial blood
gas result is as follows:
• pH : 7.22
• paCO2 : 55
• HCO3 : 25
• Follow the steps
• pH is low – acidosis
• paCO2 is high – in the opposite direction of the pH.
• Hco3 is Normal.
• Respiratory Acidosis
• Need to improve ventilation by oxygen therapy,
mechanical ventilation, pulmonary toilet or by
administering bronchodilators.
• EXAMPLE 2: Mr. D is a 55 years old
admitted with recurring bowel
obstruction has been experiencing
intractable vomiting for the last several
hours. His ABG is:
• pH : 7.5
• paCO2 :42
• HCO3 : 33
• Metabolic alkalosis
• Management: IV fluids, measures to
reduce the excess base
 pH PaCo2 HC03

normal
Respiratory
acidosis
Respiratory normal
Alkalosis
Metabolic normal
Acidosis
Metabolic normal
Alkalosis
 BASE EXCESS

• Is a calculated value estimates the

metabolic component of an acid based
abnormality.
• It is an estimate of the amount of strong
acid or base needed to correct the met.
component of an acid base disorder
(restore plasma pH to 7.40at a Paco2 40
mmHg)
 Formula
• With the base excess is -10 in a 50kg
person with metabolic acidosis mM of
Hco3 needed for correction is:

= 0.3 X body weight X BE

= 0.3 X 50 X10 = 150 mM
 Anion GAP
Step 4
• Calculation of AG is useful approach to
analyse metabolic acidosis
AG = (Na+ + K+) – (cl- + Hco3-)
• * A change in the pH of 0.08 for each 10
mm Hg indicates an ACUTE condition.
* A change in the pH of 0.03 for each 10
mm Hg indicates a CHRONIC condition.
 REMEMBER

• K etoacidosis
• U remia
• S epsis
• S alicylate & other drugs
• M ethanol
• A lcohol (Ethanol)
• L actic acidosis
• E thylene glycol
 COMPENSATION
• Step 5
• A patient can be uncompensated or
partially compensated or fully
compensated
• pH remains outside the normal range
• pH has returned within normal range-
fully compensated though other values
may be still abnormal
• Be aware that neither the system has
the ability to overcompensate
 ABG Interpretation
Step 5 cont…
Determine if there is a compensatory
mechanism working to try to correct the pH.

ie: if have primary respiratory acidosis will

have increased PaCO2 and decreased pH.
Compensation occurs when the kidneys retain
HCO3.
 Assess the PaCO2
• In an uncompensated state – when the pH and
paCO2 moves in the same direction: the primary
problem is metabolic.
• The decreasing paco2 indicates that the lungs
acting as a buffer response (blowing of the
excess CO2)
• If evidence of compensation is present but the
pH has not been corrected to within the normal
range, this would be described as metabolic
disorder with the partial respiratory
compensation.
 Assess the HCO3
• The pH and the HCO3 moving in
the opposite directions, we would
conclude that the primary disorder
is respiratory and the kidneys
acting as a buffer response: are
compensating by retaining HCO3 to
return the pH to normal range.
 Example 3
• Mrs. H is admitted, he is kidney dialysis
patient who has missed his last 2
appointments at the dialysis centre his
ABG results:
• pH : 7.32
• paCo2 : 32
• HCO3 : 18
• Pao2 : 88
• Partially compensated metabolic
Acidosis
 Example 4
• Mr. K with COPD.His ABG is:
• pH : 7.35
• PaCO2 : 48
• HCO3 : 28
• PaO2 : 90
• Fully compensated Respiratory
Acidosis
 Example 5
• Mr. S is a 53 year old man presented to
ED with the following ABG.
• pH : 7.51
• PaCO2 : 50
• HCO3 : 40
• Pao2 : 40 (21%O2)
• He has metabolic alkalosis
• Acute respiratory alkalosis (acute
hyperventilation).
 FULLY COMPENSATED
pH paco2 Hco3
Resp.Acidosis Normal
but<7.40
Resp.Alkalosis Normal
but>7.40
Met. Acidosis Normal
but<7.40
Met. Alkalosis Normal
but>7.40
 Partially compensated

pH paco2 Hco3

Res.Acidosis

Res.Alkalosis

Met. Acidosis

Met.Alkalosis
~ PaCO – pH Relationship
2

80 7.20

60 7.30

40 7.40

30 7.50

20 7.60
 Precautions
 Excessive Heparin Decreases bicarbonate and
PaCO2
 Large Air bubbles not expelled from sample PaO2
rises, PaCO2 may fall slightly.

 Fever or Hypothermia, Hyperventilation or breath

holding (Due to anxiety) may lead to erroneous lab
results
 Care must be taken to prevent bleeding
 2SD NORMAL CL.ACCEPTABLE

• PH 7.35 – 7.45 7.30 – 7.50

• PCO2 35 – 45 30 – 50
• PO2 97 >80
(ON 21% O2)

(ON VENTILATOR) 60 – 90
• HCO3 24 - 28
 Take Home Message:
Valuable information can be gained from an
ABG as to the patients physiologic condition

Remember that ABG analysis if only part of the patient

assessment.

Be systematic with your analysis, start with ABC’s as always

and look for hypoxia (which you can usually treat quickly),
then follow the four steps.

A quick assessment of patient oxygenation can be achieved

with a pulse oximeter which measures SaO2.
It’s not magic understanding
ABG’s, it just takes a little
practice!
 Practice ABG’s

1. PaO2 90 SaO2 95 pH 7.48 PaCO2 32 HCO3 24

2. PaO2 60 SaO2 90 pH 7.32 PaCO2 48 HCO3 25
3. PaO2 95 SaO2 100 pH 7.30 PaCO2 40 HCO3 18
4. PaO2 87 SaO2 94 pH 7.38 PaCO2 48 HCO3 28
5. PaO2 94 SaO2 99 pH 7.49 PaCO2 40 HCO3 30
6. PaO2 62 SaO2 91 pH 7.35 PaCO2 48 HCO3 27
7. PaO2 93 SaO2 97 pH 7.45 PaCO2 47 HCO3 29
8. PaO2 95 SaO2 99 pH 7.31 PaCO2 38 HCO3 15
9. PaO2 65 SaO2 89 pH 7.30 PaCO2 50 HCO3 24
10. PaO2 110 SaO2 100 pH 7.48 PaCO2 40 HCO3 30
 Answers to Practice ABG’s

1. Respiratory alkalosis
2. Respiratory acidosis
3. Metabolic acidosis
4. Compensated Respiratory acidosis
5. Metabolic alkalosis
6. Compensated Respiratory acidosis
7. Compensated Metabolic alkalosis
8. Metabolic acidosis
9. Respiratory acidosis
10. Metabolic alkalosis