Arterial Blood Gases Interpretation

Amit Kocheta DNB Trainee Moderator : Dr Ausim Anesthesia & Critical Care Department BMHRC

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.

When to do ABG
1. Assess the adequacy of ventilation & oxygenation (whether the patient is on a ventilator or not) 2. Establish the diagnosis & severity of respiratory failure. 3. Guide therapy O2 administration, mechanical ventilation, weaning 4. Assess changes in acid-base homeostasis 5. Guide treatment for acid-base abnormalities

When to do ABG..
6. Manage patients in ICUs for :1. Respiratory dysfunction or failure 2. Cardiac failure 3. Renal failure 4. Hepatic failure 5. Polytrauma 6. Multiorgan failure 7. Diabetic ketoacidosis 8. Sepsis 9. Burns 10. Various type of poisoning etc.

When to do ABG..
7. Monitor patient during : Cardiopulmonary surgery Cardiopulmonary exercise testing Sleep studies

8. Determine prognosis in critically ill patients

Explanation of Terms
Hb, HCT, FiO2, PaO2, PaCO2, pH, Na+, K+, Ca++, Sat(%)
RQ
HCO3A (Actual) HCO3S (Standard)

CO2 produced : O2 consumed, Set value (0.85), Can be fed

Parameter for non respiratory component of acid base balance. Parameter for non respiratory component of acid base balance but reported after standarising at PCO2 at 40 mmHg, temp. 37degree C, SaO2 100%

Base Excess (BE)

Standard Base Excess

HCO3 amount above or below normal content (0) of buffer base, (+) or (-) depends upon entered Hb value & measured pH & PCO2 values
HCO3 amount above (+) or below (-) normal content (0) of buffer base. Calculated from a standard Hb value of 6gm % & measured pH & PCO2 values

Explanation of Terms
BB (buffer bases) TCO2 Content O2 CT, CaO2, O2 Content A-a DO2 P50 Ca 7.4 Li LAC GLU Sum of all buffer anions in blood, metabolic index (Hb, HCO3, protein, phosphate) HCO3 concentration + Dissolved CO2 in plasma Hb bound O2 + plasma dissolved O2 Difference between PO2 Alveolar & PO2 Arterial Semi saturation pressure = Partial pressure of O2 at which Hb is 50% saturated Calcium ion conc. Computed for pH 7.4 Lithium ion conc. Lactate conc. Glucose conc.

Known Normal & Reference Values for Calculations

Hb (gm%) HCT (%) FiO2 RQ PaO2 (mmHg) Measured/Fed/Calcul ated (HCT/3) Measured/Calculated (3xHb) Fed Base Excess (mEq/L) 0.85 TCO2 content (mEq/L) 80 to 100 BB (mEq/L) O2 Sat (%) ~ 27 48 >95 0 +/- 2 K+ Ca++ Cl3.5 to 5.1 1.12 to 1.32 97 to 100

PaCO2 (mmHg)
pH HCO3 A (mEq/L) Na+

35 to 45
7.35 to 7.45 22 to 26 135 to 145

O2 CT (ml/dl)
P50 (mmHg) A a DO2 (mmHg)

16 to 22
27 5 to 25

Terminology
Acidemia : Blood pH <7.35 Acidosis: A primary physiologic process that, occurring
alone, tend to cause acidemia (e.g. respiratory acidosis from hypoventilation or metabolic acidosis from decreased perfusion or shock)

Alkalemia : Blood pH >7.45 Alkalosis: A primary physiologic process that, occurring

alone, tend to cause alkalemia (e.g. respiratory alkalosis from acute hyperventilation or metabolic alkalosis from excessive diuretic therapy)

Terminology
Primary acid-base disorders
(Respiratory Acidosis, Respiratory Alkalosis, Metabolic Acidosis, Metabolic Alkalosis)

Manifest as initial changes in PaCO2 or HCO3

First Change Disorder Change Primary disorder Respiratory Acidosis Respiratory Alkalosis Metabolic Alkalosis Metabolic Acidosis Effect pH

Rises

Acidemia

Falls

PaCO2

Respiratory Falls Alkalemia Rises

Rises

Alkalemia

Rises

HCO3-

Metabolic Falls Acidemia Falls

Terminology
Compensation
-when the acid base imbalance exists over a period of time Secondary changes in HCO3- or PaCO2
Occurring in response to the primary event To normalize pH

Done by the organ system which is not primarily affected

respiratory compensation for metabolic disorders metabolic compensation for respiratory disorders
Resultant Blood Gas States
Uncompensated Abnormal pH Partially Compensated Abnormal pH Fully Compensated Normal pH Other values may remain abnormal

..Compensations
Respiratory Compensation Characteristics Rapid, in 1-3 min, Complete Renal Compensation Slow, in hours to days, Incomplete

Mechanism in Acidosis

Wash off excessive CO2 by increasing ventilation (as in metabolic acidosis)

Secrete H+ ions out Reabsorb filtered HCO3 ions Produce of new HCO3 ions (as in respiratory acidosis)

Mechanism in Alkalosis

Retain CO2 by decreasing ventilation (as metabolic alkalosis)

Excess HCO3 filtered into renal tubules, eliminated in urine (as in respiratory alkalosis)

Reading the Report Step-by-Step

Arterial, Venous or Mixed

Sometimes, there is no way to know if the sample is arterial or venous !
Arterial Ask the person who aspirated the sample PO2 O2 Saturation values No. of attempts Single or Multiple punctures pH Blood pulsates Syringe plunger may rise on its own > 40 mmHg Sao2 > 75% Single puncture, Rapid filling Abnormal or normal, Not diagnostic Abnormal or normal, Not diagnostic Venous Blood does not pulsate Syringe plunger never rises on its own < 40 mmHg (often < 30 mmHg) SvO2 < 75% Multiple, Lower PO2 due to venous admixture Abnormal or normal, Not diagnostic Abnormal or normal, Not diagnostic

PCO2

Venous admixture (CHD)

Lower PaO2 values ~ Venous admixture

Reading the Report Step-by-Step

Step 1
Check if the required parameters have been correctly fed ?

Barometric pressure Patients temperature Hemoglobin

(if machine does not measure, does not calculate)

FiO2 Results in the report are bound to change, get incorrect and misleading if the above values are not correctly filled

Barometric pressure (PB)

(Weight of Atmosphere) Air = O2 21%, N2 78%, Other gases 1% Composition does not change with altitude, PB decreases with height PB = sum of Pressures of all constituent gases P = p1 + p2 + p3 + p4 Each gas exerts its own Partial Pressure

p = % gas x PB p of a gas (O2 & CO2 ) will change according to Concentration & PB All machines calculate & adjust readings according to PB

 Alveolar gas equation :

PAO2 = PiO2 1.2(PaCO2) PiO2 = FiO2 (PB 47) All machines calculate PAO2 from PiO2 (affected by FiO2 and PB ) A-aDO2 will be affected if PB & FiO2 is not fed properly Feed PB if the machine does not measure PB on its own

Except in a temporary unsteady state, alveolar PO2 (PAO2) is always higher than arterial PO2 (PaO2). As a result, whenever PAO2 decreases, PaO2 does as well. Thus, from the AG equation:
If FIO2 and PB are constant, then as PaCO2 increases both PAO2 and PaO2 will decrease (hypercapnia causes hypoxemia). If FIO2 decreases and PB and PaCO2 are constant, both PAO2 and PaO2 will decrease (suffocation causes hypoxemia).

If PB decreases (e.g., with altitude), and PaCO2 and FIO2 are constant, both PAO2 and PaO2 will decrease (mountain climbing causes hypoxemia).

Temperature Effect on PaCO2 & PaO2

Machine always analyses blood at 37 C Hyperthermic Patient = > 37 C (Sample) Measured PaO2 and PaCO2 will be less than actual (Pressure Temperature p decreases when subjected to lower relative temperature of machine and falsely lower pressures get measured) Hypothermic Patient = < 37 C (Sample) Measured PaO2 and PaCO2 will be more than actual (Pressure Temperature p increases when subjected to higher relative temperature of machine and falsely higher pressures get measured)

For each C above or below 37 Example = Febrile patient, 39 degree C degree C

Change in PaO2 5 mmHg

Measured PaO2 = 80 mmHg True in vivo PaO2 = 90 mmHg

Change in PaCO2 2 mmHg

Measured PaCO2 = 40 mmHg True PaCO2 = 44 mmHg

Feeding correct Temperature value allows some machines to correct accordingly, (or Apply formulae manually)

Temperature - Effect on SaO2

Temperature affects position, shifting of ODC When machine does not measure actual SO2 But calculates SO2 from PO2 (ODC), SO2 values can be false.

Change in Temperature Increase

Decrease

Shifting of ODC Right

Left

Calculated SO2 at 37C Higher than actual Lower than actual

Hemoglobin
Derived (From Hematocrit) Measured (Co oximeters) Not entered ! (Default value Wrong) Manually entered True assessment of adequacy of O2 in arterial blood can only be made if Hb value are entered SaO2 & PaO2 do not incorporate Hb content in their calculations. Hb affects Buffer Base values

Total Oxygen Content (CaO2 ) ml o2/dl

Total O2 attached to Hb Content Hb content (gm%) O2 carried by 1 gm Hb (ml) Saturation Hb Total Dissolved O2 carried by Plasma PaO2 Solubility Coefficient

15 x 1.34 x 100 (say) = 20.10 + 100 x 0.003 = 0.30 = 20.40 ml / dL Normal = 16 to 22 ml/dl

 Entering FiO2 is very important Most common mistake

FiO2 not entered while the sample is fed in the machine % FiO2 written on the report later on manually Hb also not entered at the time of feeding sample but told later on

FiO2

If FiO2 not fed properly

Interpretation of PO2 affected adversely A-aDO2 values are wrongly calculated

Interpretation of adequacy of Oxygenation affected if Hb not fed properly

Step - 2 Analyse the Adequacy of Oxygenation

(i) Look at PaO2 and SaO2 first
Healthy Adult Sea Level, Room Air, A-a O2 = 4 mmHg, PAO2 = 101

PaO2 (mmHg)

Sao2 (%)

Normal values (on air) Mild Hypoxemia Moderate hypoxemia Severe Hypoxemia

>80 60-79 40-59 <40

>95 90-94 75-89 <75

PaO2 Important

Low PaO2 = Surely something wrong in terms of Oxygenation Low PaO2 = degree of hypoxemia Saturation of Hb (SaO2) is dependent upon PaO2 Never rely totally on PaO2 & SaO2 Look at other parameters also (CaO2)

Acceptable PaO2 Values on Room Air

Age Group Accepable PaO2 (mm Hg) Adults upto 60 yrs > 80 & Children Newborn 40-70 70 yrs > 70 80 yrs > 60 90 yrs > 50
Estimate formula of age: PaO2=100mmHg - (age0.33) 5mmHg 60 yrs 80 mm Hg 1mm Hg/yr

(ii) Relate PaO2 with FiO2 Classify Hypoxemia

FiO2 x 5 = PaO2
Inspired O2 % 30 40 50 80 100 PaO2 mmHg >150 >200 >250 >400 >500

Hypoxemia on O2 therapy
Uncorrected: PaO2 < 80 mm Hg (< expected on RA & FIO2) Corrected: PaO2 = 80-100 mm Hg (= expected on RA but < expected for FIO2) Excessively Corrected: PaO2 > 100 mm Hg (> expected on RA but < expected for FIO2) PaO2 > expected for FIO2: 1. Error in sample/analyzer 2. Pts O2 consumption reduced 3. Pt does not req O2 therapy (if 1 & 2 NA)

(iii) Find if Oxygenation is adequate or not CaO2

PaO2 & SaO2 may not give true estimate

Low PaO2 but still adequate oxygen content (V/Q imbalance) Normal PaO2, Still profound hypoxemia (Anemia, Altered affinity of Hb for O2) Calculated SaO2 may mislead & show false normal results (CO, MHb) If no co-oximeter in the machine, SaO2 is calculated from PaO2
Total Oxygen Content CaO2 measured directly or calculated by O2 content equation. CaO2 = Hb(gm%) x 1.34 x SaO2 + 0.003 x PaO2(mmHg).

Step 3 : Acid Base disturbances Analyze pH

pH 7.35 7.45 (7.4) < 7.35 Normal Acidemia Analysis No acid-base disorder Or, Compensated disorder Uncompensated Acidosis (or partially compensated)

> 7.45

Alkalemia

Uncompensated Alkalosis (or partially compensated)

Alkalemia (pH >7.45)

Acidemia (pH < 7.35)

Mild
Moderate Severe Incompatible to life

7.30 7.34
7.20 7.29 < 7.2 < 6.8

7.46 7.50
7.51 7.54 > 7.55 > 7.8

Step 4 Analyze the Primary disorder

Respiratory or Metabolic ?

Respiratory
Change
PaCO2

Disorder
Respiratory

Change
>45 < 35

pH

Primary Disorder
Respiratory Acidosis Respiratory Alkalosis

For every 20 mmHg rises in PaCO2 = pH should fall by 0.10 For every 10 mmHg fall in PaCO2 = pH should rise by 0.10
PaCO2 = 65 (20 mm rise from 45) pH = 7.25 (0.10 fall from 7.35) PaCO2 = 25 (10 mm fall from 35) pH = 7.55 (0.10 rise from 7.45)

If pH & PaCO2 move in opposite directions Primary defect is Respiratory.

If pH is not moving in opposite direction as PaCO2 Primary defect is Not Respiratory (Metabolic).

Metabolic
Change Disorder Change > 26 HCO3 (base) Metabolic < 22 pH Primary disorder Metabolic alkalosis Metabolic acidosis

If pH moves in same direction as HCO3 Primary defect is Metabolic If pH moves in opposite direction as HCO3 Primary defect is not Metabolic (Respiratory)

Step 5 : Analyse and Correlate Compensation

Body tries to bring pH towards normal, with time Lungs and kidneys are primary buffer response systems pH outside normal range Uncompensated or Partially compensated pH normal range Fully compensated (or no acid base disturbance) pH = 7.4 No acid base disturbance or mixed disorder Analyze and Correlate pH, PaCO2 and HCO3

Step-6 : Calculate the Expected Compensation Match it with actual

For every 10 mmHg change in PaCO2 Disorder Change in PaCO2 Compensation (Kidney)

Respiratory acidosis
Respiratory alkalosis

10 mmHg Acute rise

10 mmHg Chronic rise 10 mmHg Acute fall 10 mmHg Chronic fall For every 1 mEq/L change in HCO3

1 mEq/L rise in HCO3

4 mEq/L rise in HCO3 2 mEq/L fall in HCO3 4 mEq/L fall in HCO3

Disorder Metabolic acidosis Metabolic alkalosis

Change in HCO3 1 mEq/L fall 1 mEq/L rise

Compensation (Lungs) 1.25 mmHg fall in PaCO2 0.75 mmHg rise in PaCO2

Match the Calculated Compensation with the Actual (Report)

 In metabolic acidosis the expected PaCO2 can be calculated as = 1.5 x (HCO3-) +8.

In metabolic alkalosis the expected PaCO2 can be calculated as = 0.9 x (HCO3-) +9. A simpler rule, applicable in both metabolic alkalosis and acidosis, is the 7.XX rule. This only works in mmHg. This rule states that the PaCO2 (in mmHg) should equal the first two digits after the decimal point in the pH

Step 7 : Find out if the Disorder is Mixed ?

(1) Check relative movement of pH PaCO2 and pH HCO3 If both pairs moving & in correct directions Mixed disorder (2) Analyze compensation by Presuming Primary disorder as Respiratory or Metabolic If analysis supports no compensation Mixed disorder

Step 8 : Unmask Hidden Metabolic Disorders

Use concept of Serum Electrolytes Do not interpret any ABG data without Serum Electrolytes (Na+, K+, Cl-, CO2) Three Parameters need to be determined 1. Anion Gap and its change from normal ( AG) 2. Venous CO2 and its change from normal ( CO2) 3. Bicarbonate Gap (BG)

Anion Gap and its change from normal

AG = (Routinely measured Cations Routinely measured Anions) AG = (Na + K) (Cl + HCO3) AG = (Na) (Cl + CO2) Normal AG = 12 4 mEq/L Change in AG from normal ( AG) = Measured AG 12 Positive (+) or Elevated AG (> 16) Metabolic Acidosis Negative (-) or Low AG Reduction in unmeasured Anions (Hypoproteinemia) Excess unmeasured Cations (Lithium Toxicity) Excess abnormal +vely charged proteins (Multiple Myeloma) Halide ion measured as Chloride (Bromism, Cough syrups)

Venous CO2 and its change from normal

Index of Plasma HCO3 Total CO2 = Plasma HCO3 + Dissolved CO2 in Plasma Normal = 24 30 mEq/L (27 mEq/L)

Change in Venous CO2 from normal ( CO2) = 27 measured CO2

Bicarbonate Gap
Unmasks the co-existence of 2 metabolic disorders BG = AG - CO2 BG = (Measured AG 12) (27 Measured CO2) Positive (+) or Elevated BG = > + 6 mEq/L
Metabolic Alkalosis Bicarbonate retention as compensation for Respiratory Acidosis

Negative (-) or Low BG = < 6 mEq/L

Metabolic Acidosis Bicarbonate excretion as compensation for Respiratory Alkalosis

Steps (Summary)
Step 1 : Check if the required parameters have been correctly fed? Step 2 : Analyse the Adequacy of Oxygenation. Step 3 : Analyse pH Acidemia or Alkalemia? Step 4 : Analyse the Primary disorder - Respiratory or Metabolic ? Step 5 : Analyse and Correlate Compensation. Step 6 : Calculate the Expected Compensation. Match it with actual. Step 7 : Find out if the Disorder is Mixed ? Step 8 : Unmask Hidden Metabolic Disorders.

Conditions Invalidating or Modifying ABG Results

DELAYED ANALYSIS Consumption of O2 & Production of CO2 continues after blood drawn into syringe Iced Sample maintains values for 1-2 hours Uniced sample quickly becomes invalid PaCO2 3-10 mmHg/hour PaO2 at a rate related to initial value & dependant on Hb Sat

EXCESSIVE HEPARIN
Dilutional effect on results HCO3- & PaCO2 Syringe be emptied of heparin after flushing Risk of alteration of results with: 1. size of syringe/needle 2. vol of sample 25% lower values if 1ml sample taken in 10 ml syringe (0.25 ml heparin in needle) Syringes must be > 50% full with blood sample HYPERVENTILATION OR BREATH HOLDING May lead to erroneous lab results

 AIR BUBBLES 1. PO2 150 mmHg & PCO2 0 mm Hg in air bubble(R.A.) 2. Mixing with sample lead to PaO2& PaCO2 3. Mixing/Agitation S.A. for diffusion more erroneous results 4. Discard sample if excessive air bubbles 5. Seal with cork/cap imm after taking sample FEVER OR HYPOTHERMIA 1. Most ABG analyzers report data at N body temp 2. If severe hyper/hypothermia, values of pH & PCO2 at 37 C can be significantly diff from pts actual values 3. Changes in PO2 values with temp predictable

4. No significant change of HCO3-, O2 Sat, O2 capacity/content, CO2 content values with temp 5. No consensus regarding reporting of ABG values esp pH & PCO2 after doing temp correction 6. ? Interpret values measured at 37 C: Most clinicians do not remember normal values of pH & PCO2 at temp other than 37C In pts with hypo/hyperthermia, body temp usually changes with time (per se/effect of rewarming/cooling strategies) hence if all calculations done at 37 C easier to compare Values other than pH & PCO2 do not change with temp

7. ? Use Nomogram to convert values at 37C to pts temp 8. Some analysers calculate values at both 37C and pts temp automatically if entered 9. Pts temp should be mentioned while sending sample & lab should mention whether values being given in report at 37 C/pts actual temp
WBC COUNT 0.1 ml of O2 consumed/dL of blood in 10 min in pts with N TLC Marked increase in pts with very high TLC/plt counts hence imm chilling/analysis essential

 TYPE OF SYRINGE 1. pH & PCO2 values unaffected 2. PO2 values drop more rapidly in plastic syringes (ONLY if PO2 > 400 mm Hg) 3. Other adv of glass syringes: Min friction of barrel with syringe wall Usually no need to pull back barrel less chance of air bubbles entering syringe Small air bubbles adhere to sides of plastic syringes difficult to expel Though glass syringes preferred, differences usually not of clinical significance plastic syringes can be and continue to be used

SUMMARY
SERIAL ABGs CLINICAL PROFILE SUPPORTING LAB DATA/ INVESTIGATIONAL TOOLS

CLINICIANS JUDGEMENT
CORRECT INTERPRETATION
SIMPLE DISORDER (DEG OF COMPENSATION)

MIXED DISORDER (ORDER OF PRIMARY & SUBSEQUENT DISORDERS)

OXYGENATION /VENTILATORY STATUS

Acidemia

Resp and/or Met Acidosis Resp Acidosis and Met Alkalosis

pH

No acidemia /alkalemia

No A-B Dis Met Acidosis and Resp Alkalosis

Alkalemia

Resp and/or Met Alkalosis

pCO2 , HCO3

Resp + Met Alkalosis

pCO2 , HCO3 N

Uncomp Resp Alkalosis

pH

pCO2 N, HCO3 Uncomp Met Alkalosis

pCO2 , HCO3

Comp(F/P) Met Alkalosis

pCO2 , HCO3

Comp(F/P) Resp Alkalosis

pCO2 , HCO3

Resp + Met Acidosis

pCO2 , HCO3 N

Uncomp Resp Acidosis

pH

pCO2 N, HCO3 Uncomp Met Acidosis

pCO2 , HCO3

Comp(F/P) Resp Acidosis

pCO2 , HCO3

Comp(F/P) Met Acidosis

Comp(F) Resp Acidosis

pCO2 , HCO3
Comp(F) Met Alkalosis Resp Acidosis + Met Alkalosis N or N

pH

pCO2 N, HCO3 N

N Acid Base Homeostasis

Comp(F) Met Acidosis Comp(F) Resp Alkalosis pCO2 , HCO3 Met acidosis + Resp alkalosis

Thank You