Arterial blood gas

By
Mrs. Amala Rajan Reader

Medical Nursing Dept

Life is a struggle, not against sin, not against the Money Power, not against malicious animal magnetism, but against hydrogen ions." H.L. MENCKEN

What is an ABG
Arterial Blood Gas Drawn from artery- radial, brachial, femoral It is an invasive procedure. Caution must be taken with patient on anticoagulants. Arterial blood gas analysis is an essential part of diagnosing and managing the patients oxygenation status, ventilation failure and acid base balance.

What Is An ABG?
pH [H+] PCO2 Partial pressure CO2

PO2

Partial pressure O2

HCO3 Bicarbonate BE Base excess

SaO2 Oxygen Saturation

Acid/Base Balance
The pH is a measurement of the acidity or alkalinity of the blood. It is inversely proportional to the no. of (H+) in the blood. The normal pH range is 7.35-7.45. Changes in body system functions that occur in an acidic state decreases the force of cardiac contractions, decreases the vascular response to catecholamines, and a diminished response to the effects and actions of certain medications. An alkalotic state interferes with tissue oxygenation and normal neurological and muscular functioning. Significant changes in the blood pH above 7.8 or below 6.8 will interfere with cellular functioning, and if uncorrected, will lead to death.

Acid/Base Relationship

H2O + CO2 H+

H2CO3

HCO3 +

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. 2. Central nervous system depression r/t medications such as narcotics, sedatives, or anesthesia. Impaired muscle function r/t 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, or abdominal pain.

3.

4. 5.

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 Kussmauls 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.

pH: Measurement of acidity or alkalinity, based on the hydrogen (H+)

COMPONENTS OF THE ABG

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 normal

Respiratory acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis

normal

normal

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 U S S M A L E etoacidosis remia epsis alicylate & other drugs ethanol lcohol (Ethanol) actic acidosis thylene glycol

 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

COMPENSATION

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 Resp.Acidosis Normal but<7.40 Resp.Alkalosis Normal but>7.40 Met. Acidosis Normal but<7.40 Met. Alkalosis Normal but>7.40 Hco3

Partially compensated
pH
Res.Acidosis Res.Alkalosis Met. Acidosis Met.Alkalosis

paco2

Hco3

~ PaCO pH Relationship
2

80 60 40 30 20

7.20 7.30 7.40 7.50 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 PCO2 35 45 PO2 97

(ON 21% O2) (ON VENTILATOR)

7.30 7.50 30 50 >80

60 90 24 - 28

HCO3

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 ABCs 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.

Its not magic understanding ABGs, it just takes a little practice!

Practice ABGs
1. PaO2 2. PaO2 3. PaO2 4. PaO2 5. PaO2 6. PaO2 7. PaO2 8. PaO2 9. PaO2 10. PaO2 90 60 95 87 94 62 93 95 65 110 SaO2 95 SaO2 90 SaO2 100 SaO2 94 SaO2 99 SaO2 91 SaO2 97 SaO2 99 SaO2 89 SaO2 100 pH 7.48 pH 7.32 pH 7.30 pH 7.38 pH 7.49 pH 7.35 pH 7.45 pH 7.31 pH 7.30 pH 7.48 PaCO2 32 PaCO2 48 PaCO2 40 PaCO2 48 PaCO2 40 PaCO2 48 PaCO2 47 PaCO2 38 PaCO2 50 PaCO2 40 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 24 25 18 28 30 27 29 15 24 30

What is going on?

Answers to Practice ABGs

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

Any Questions?