ARTERIAL BLOOD GAS

One of the most important things to know when working in a critical care area is what an ABG is telling you. Hopefully this will make things easier for you. Im relating this to an intubated patient, as opposed to one with a natural airway. Also Im pretty much writing this off the top of my head, so forgive me if things dont make a lot of sense. THEY MAKE SENSE TO ME OK!?
1. SaO2 (oxygen saturation) = 95 - 100%

What is it? Its basically telling us how much oxygen is bound to haemoglobin in the arterial blood. This should be between 95 - 100%. What if its less than 95%? It means that there may not be enough yummy oxygen going to the tissues of the body. This can include any part of the body, from more vital organs such as the brain and heart, right down to your little toe. What do I do now? Thanks to the delight that is the oxyhaemoglobin dissociation curve, you could probably predict the PaO2 without the need for an ABG (that is, by just looking at the sats probe and not even doing an ABG in the first place). BUT, assuming youre looking at the SaO2 on an ABG anyway, lets look at the PaO2 for confirmation, and then decide what to do.
2. PaO2 (Partial Pressure of Oxygen in the blood) = 75 - 100mmHg

What is it? This is telling you about the actual amount of oxygen in the blood, rather than how much of it is saturating the haemoglobin. If theres not enough oxygen, the body cannot function properly! So I have a low SaO2 and PaO2.. Help! Does the patient need more oxygen? FiO2 refers to the oxygen delivery (in %). Maybe you should increase it to allow the lungs to take in more oxygen for gas exchange. Is the patient using enough of their lungs? Critically ill patients may not be utilising all of their alveoli for a number of reasons. By recruiting more alveoli to take part in gas exchange, more oxygen is able to enter more alveoli, allowing more gas exchange and therefore more oxygen in the blood! How do we do this? By using PEEP; that is, positive end expiratory pressure. By adding some positive pressure in the lungs following expiration (and before inspiration), air remains in the alveoli, keeping them open and allowing gas exchange to continue. Without PEEP, these recruited alveoli may collapse again.

3. pH = 7.35 - 7.45

I Learnt About pH in Chemistry pH refers to how acidic or alkalotic a substance is. The best pH of arterial blood is between 7.35 and 7.45. Below 7.35, and the patient is acidotic. Above 7.45, and the patient is alkalotic.

The pH is off What Now? Now its time to figure out why. Is it due to a respiratory problem or a metabolic problem?
4. PaCO2 = 35 - 45mmHg

CO2 (carbon dioxide) is an acidic substance. Therefore, if the CO2 is high, the pH will be low! So that means if the CO2 is low, the pH will be high! Easy enough, right? My CO2 is high, my pH is low, help! High CO2 means RESPIRATORY ACIDOSIS. It is caused by the patient basically not blowing off enough CO2. For example, if you have a patient breathing at a rate of 6 breaths per minute, theyre probably not going to be getting rid of that CO2. At the same time, if your CO2 is low, this is RESPIRATORY ALKALOSIS. The patient might be hyperventilating, that is breathing very quickly and getting rid of a lot of CO2. In mandatory ventilation (when the ventilator is giving breaths to the patient, rather than the patient breathing on their own), increasing or decreasing the respiratory rate, or frequency at which they are breathing can make a big difference to CO2. In addition to this, is the patient being given enough time to get all that expiration out? Have a look at their inspiratory to expiratory ratio (I:E ratio). This controls the length of time of inspiration in comparison to the length of time of expiration. For example, if your ratio is set at 1:2, and your frequency is 10 breaths per minute, each inspiration and expiration will occur within 6 seconds (60 seconds divided by 10 breaths = 1 breath every 6 seconds). Your inspiration will be 2 seconds long, and your expiration will be 4 seconds long = 1:2! However, you may need to increase the expiration time in certain situations to allow the proper flow of CO2 out of the patient. Thats all well and good, but my CO2 is ok and my pH is still off. WTF. Time to consider metabolic involvement, my friend.
5. HCO3- (Bicarbonate) = 22 - 26

What the hell is this crap. Im not going to go into the details of carbonic acid and hydrogen atoms and bla bla bla, but basically, your HCO3- is going to tell you if there is a metabolic problem, rather than a respiratory problem. HCO3- is an alkalotic substance. So if your HCO3- is HIGH, your pH will follow it; this is METABOLIC ALKALOSIS. HCO3- has dropped? pH is low? METABOLIC ACIDOSIS. Now what? There will be other things (meds, etc) that will be done in an effort to correct this. Im not going to go into them because it will confuse me as much as you.
6. Base Excess = -2 to +2

Number 1 rule: If a New Zealander tries to explain base ixciss to you, it might take you a minute to understand what they are talking about. This happened to me today. Dont let the accent fool you. Do I really need to know about this? Its good to know if you have figured out that the pH is crappy because of a metabolic problem. If base excess is high (above +2), its a metabolic alkalosis. If base excess is low (below -2), its a metabolic alkalosis. My HCO3- is high/low, so who gives a crap about the base excess? The body is an amazing thing. It will try a number of things in an attempt to correct the pH. You will most likely come across ABGs with a super high CO2 and super low HCO3(or vice versa) and normal pH, and wonder what the hell is going on. Have a look at the base excess. Itll give you an idea as to whether the body is trying to revert a metabolic or respiratory problem. Im probably confusing you with this. Ill stop. But I will tell you this..
7. My pH is Normal, but everything else is screwed!!!!

The body is probably compensating. Good effort, body! Still need to correct those off numbers though, depending on the cause (respiratory or metabolic). Always a good thing to keep an eye on. If the lactate increases, it means that anaerobic metabolism is occurring in the body. That means that there are parts of the body with a lack of oxygen, and so they are having to rely on working without it. The body needs more oxygen; see step 2!!!!!!!

8. Lactate = 0.5 - 1.6

SO IN SUMMARY

Respiratory acidosis: pH < 7.35 CO2 > 45 Increase frequency of respirations, increase I:E ratio. Respiratory alkalosis: pH > 7.45 CO2 < 35 Decrease frequency of respirations, decrease I:E ratio if needed (not too much though, we still need time to breathe air in too!!!).

Metabolic acidosis: pH < 7.35 HCO3- < 22 Base excess < -2 Metabolic alkalosis:

 pH > 7.45 HCO3- > 26 Base excess > +2 pH Normal, Everything Else Gone To Shit: Compensation for one of the above four. Inadequate Oxygenation: PaO2 < 75 SaO2 < 95% Lactate > 1.6 Increase FiO2, increase PEEP - watch that the peak inspiratory pressure doesnt get too high though. You want an absolute max of 35. Thats a whole different story about volumes and pressures and stuff that I wont go into right now. And thats the ABG. In a very very small nutshell. You can also get BGLs, potassium levels, etc from them. Quite useful things. I hope this helps out some of you :)