INTERPRETATION OF ARTERIAL BLOOD GASES (ABGS)

I Interpretation of Arterial Blood Gases (ABGs)David A. Kaufman, MD D Chief, Section of Pulmonary, Critical Care & Sleep Medicine Bridgeport Hospital-Yale New Haven HealthAssistant Clinical Professor, Yale University School of Medicine(Section of Pulmonary & Critical Care Medicine) Introduction: Interpreting an arterial blood gas (ABG) is a crucial skill for physicians, nurses, respiratory therapists, and other health care personnel. ABG interpretation is especially important in critically ill patients. The following six-step process helps ensure a complete interpretation of every ABG. In addition, you will find tables that list commonly encountered acid-base disorders. Many methods exist to guide the interpretation of the ABG. This discussion does not include some methods, such as analysis of base excess or Stewarts strong ion difference. A summary of these techniques can be found in some of the suggested articles. It is unclear whether these alternate methods offer clinically important advantages over the presented approach, which is based on the anion gap. Readers are welcome to discuss their observations and share their comments on the ATS Critical Care Forums. 6-step approach: Step 1: Assess the internal consistency of the values using the Henderseon-Hasselbach equation: [H+] = 24(PaCO2) [HCO3-]

If the pH and the [H+] are inconsistent, the ABG is probably not valid. pH 7.00 7.05 7.10 A Approximate [H+](mmol/L) 100 89 79

7.15 7.20 7.25 7.30 7.35 7.40 7.45 7.50 7.55 7.60 7.65

71 63 56 50 45 40 35 32 28 25 22

Step 2: Is there alkalemia or acidemia present? pH < 7.35 acidemiapH > 7.45 alkalemia This is usually the primary disorder Remember: an acidosis or alkalosis may be present even if the pH is in the normal range (7.35 7.45) You will need to check the PaCO2, HCO3- and anion gap Step 3: Is the disturbance respiratory or metabolic? What is the relationship between the direction of change in the pH and the direction of change in the PaCO2? In primary respiratory disorders, the pH and PaCO2 change in opposite directions; in metabolic disorders the pH and PaCO2 change in the same direction. Acidosis Acidosis Alkalosis Alkalosis Respiratory Metabolic& Respiratory Metabolic pH pH pH pH PaCO2 PaCO2 PaCO2 PaCO2

Step 4: Is there appropriate compensation for the primary disturbance?

Usually, compensation does not return the pH to normal (7.35 7.45). Disorder Metabolic acidosis Expected compensation PaCO2 = (1.5 x [HCO3-]) +8 Increase in [HCO3-]= PaCO2/10 Increase in [HCO3-]= 3.5( PaCO2/10) Increase in PaCO2 = 40 + 0.6(HCO3-) Decrease in [HCO3-]= 2( PaCO2/10) Decrease in [HCO3-] = 5( PaCO2/10) to 7( PaCO2/10) Correction factor 2

Acute respiratory acidosis

Chronic respiratory acidosis (3-5 days)

Metabolic alkalosis

Acute respiratory alkalosis

Chronic respiratory alkalosis

If the observed compensation is not the expected compensation, it is likely that more than one acid-base disorder is present. Step 5: Calculate the anion gap (if a metabolic acidosis exists): AG= [Na+]-( [Cl-] + [HCO3-] )-12 2 A normal anion gap is approximately 12 meq/L. In patients with hypoalbuminemia, the normal anion gap is lower than 12 meq/L; the normal anion gap in patients with hypoalbuminemia is about 2.5 meq/L lower for each 1 gm/dL decrease in the plasma albumin concentration (for example, a patient with a plasma albumin of 2.0 gm/dL would be approximately 7 meq/L.) If the anion gap is elevated, consider calculating the osmolal gap in compatible clinical situations. Elevation in AG is not explained by an obvious case (DKA, lactic acidosis,

renal failure Toxic ingestion is suspected OSM gap = measured OSM (2[Na+] - glucose/18 BUN/2.8 The OSM gap should be < 10 Step 6: If an increased anion gap is present, assess the relationship between the increase in the anion gap and the decrease in [HCO3-]. Assess the ratio of the change in the anion gap (AG ) to the change in [HCO3-] ([HCO3-]): AG/[HCO3-] This ratio should be between 1.0 and 2.0 if an uncomplicated anion gap metabolic acidosis is present. If this ratio falls outside of this range, then another metabolic disorder is present: If AG/[HCO3-] < 1.0, then a concurrent non-anion gap metabolic acidosis is likely to be present. If AG/[HCO3-] > 2.0, then a concurrent metabolic alkalosis is likely to be present. It is important to remember what the expected normal anion gap for your patient should be, by adjusting for hypoalbuminemia (see Step 5, above.) Table 1: Characteristics of acid-base disturbances Disorder Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis pH Primary problem in HCO3 in HCO3 in PaCO2 in PaCO2 Compensatio n in PaCO2 in PaCO2 in [HCO3-] in [HCO3-]

Table 2: Selected etiologies of respiratory acidosis Airway obstruction- Upper- Lower COPD asthma

other obstructive lung disease CNS depression Sleep disordered breathing (OSA or OHS) Neuromuscular impairment Ventilatory restriction Increased CO2 production: shivering, rigors, seizures, malignant hyperthermia, hypermetabolism, increased intake of carbohydrates Incorrect mechanical ventilation settings Table 3: Selected etiologies of respiratory alkalosis CNS stimulation: fever, pain, fear, anxiety, CVA, cerebral edema, brain trauma, brain tumor, CNS infection Hypoxemia or hypoxia: lung disease, profound anemia, low FiO2 Stimulation of chest receptors: pulmonary edema, pleural effusion, pneumonia, pneumothorax, pulmonary embolus Drugs, hormones: salicylates, catecholamines, medroxyprogesterone, progestins Pregnancy, liver disease, sepsis, hyperthyroidism Incorrect mechanical ventilation settings Table 4: Selected causes of metabolic alkalosis Hypovolemia with Cl- depletion GI loss of H+ Vomiting, gastric suction, villous adenoma, diarrhea with chloride-rich fluid Renal loss H+ Loop and thiazide diuretics, post-hypercapnia (especially after institution of mechanical ventilation) Hypervolemia, Cl- expansion Renal loss of H+: edematous states (heart failure, cirrhosis, nephrotic syndrome), hyperaldosteronism, hypercortisolism, excess ACTH, exogenous steroids, hyperreninemia, severe hypokalemia, renal artery stenosis, bicarbonate administration Table 5: Selected etiologies of metabolic acidosis Elevated anion gap: Methanol intoxication Uremia Diabetic ketoacidosisa, alcoholic ketoacidosis, starvation ketoacidosis Paraldehyde toxicity Isoniazid Lactic acidosisa Type A: tissue ischemia Type B: Altered cellular metabolism Ethanolb or ethylene glycolb intoxication Salicylate intoxication

a Most common causes of metabolic acidosis with an elevated anion gapb

Frequently associated with an osmolal gap Normal anion gap: will have increase in [Cl-] GI loss of HCO3Diarrhea, ileostomy, proximal colostomy, ureteral diversion Renal loss of HCO3proximal RTA carbonic anhydrase inhibitor (acetazolamide) Renal tubular disease ATN Chronic renal disease Distal RTA Aldosterone inhibitors or absence NaCl infusion, TPN, NH4+ administration Table 6: Selected mixed and complex acid-base disturbances Disorder Characteristics in pH in HCO3 in PaCO2 Selected situations Cardiac arrest Intoxications Multi-organ failure

Respiratory acidosis with metabolic acidosis

Respiratory alkalosis with metabolic alkalosis

Respiratory acidosis with metabolic alkalosis

Cirrhosis with diuretics Pregnancy with vomiting Over ventilation of COPD pH in normal range COPD with diuretics, in PaCO2, in HCO3vomiting, NG suction Severe hypokalemia in pH in HCO3- in PaCO2 Sepsis pH in normal range Salicylate toxicity in PaCO2 in Renal failure with HCO3 CHF or pneumonia Advanced liver disease pH in normal range Uremia or

Respiratory alkalosis with metabolic acidosis

Metabolic acidosis

with metabolic alkalosis

HCO3- normal

ketoacidosis with vomiting, NG suction, diuretics, etc.

Hypotension
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2009)

Hypotension
ICD-10 ICD-9 DiseasesDB MedlinePlus MeSH Classification and external resources I95 458or more commonly used 796.3 6539 007278 D007022

In physiology and medicine, hypotension is abnormally low blood pressure, especially in the arteries of the systemic circulation.[1] It is best understood as a physiological state, rather than a disease. It is often associated with shock, though not necessarily indicative of it. Hypotension is the opposite of hypertension, which is high blood pressure. Blood pressure is the force of blood pushing against the walls of the arteries as the heart pumps out blood. If it is lower than normal, then it is called low blood pressure or hypotension. Hypotension is generally considered to be systolic blood pressure less than 90 millimeters of mercury (mm Hg) or diastolic less than 60 mm Hg. [2][3] However in practice, blood pressure is considered too low only if noticeable symptoms are present.[4] For some people who exercise and are in top physical condition, low blood pressure is a sign of good health and fitness.[5] For many people, low blood pressure can cause

dizziness and fainting or indicate serious heart, endocrine or neurological disorders. Severely low blood pressure can deprive the brain and other vital organs of oxygen and nutrients, leading to a life-threatening condition called shock.
Contents [hide] 1 Signs and symptoms 2 Causes 3 Pathophysiology 4 Syndromes 5 Diagnosis 6 Treatment 7 See also 8 References 9 External links

[edit]

Signs and symptoms

The cardinal symptoms of hypotension include lightheadedness or dizziness.[citation
needed] If the blood pressure is sufficiently low, fainting and often seizures will occur.

Low blood pressure is sometimes associated with certain symptoms, many of which are related to causes rather than effects of hypotension: Chest pain Shortness of breath Irregular heartbeat Fever higher than 38.3 C (101F) Headache Stiff neck Severe upper back pain Cough with phlegm Prolonged diarrhea or vomiting Dyspepsia Dysuria Adverse effect of medications Acute, life-threatening allergic reaction

Seizures Loss of consciousness Profound fatigue Temporary blurring or loss of vision Connective tissue disorder Ehlers-Danlos Syndrome Black tarry stools [edit]

Causes
Low blood pressure can be caused by low blood volume, hormonal changes, widening of blood vessels, medicine side effects, anemia, heart problems or endocrine problems. Reduced blood volume, hypovolemia, is the most common cause of hypotension. This can result from hemorrhage; insufficient fluid intake, as in starvation; or excessive fluid losses from diarrhea or vomiting. Hypovolemia is often induced by excessive use of diuretics. Other medications can produce hypotension by different mechanisms. Chronic use of alpha blockers or beta blockers can lead to hypotension. Beta blockers can cause hypotension both by slowing the heart rate and by decreasing the pumping ability of the heart muscle. Decreased cardiac output despite normal blood volume, due to severe congestive heart failure, large myocardial infarction, heart valve problems, heart attack, heart failure, or extremely low heart rate (bradycardia), often produces hypotension and can rapidly progress to cardiogenic shock. Arrhythmias often result in hypotension by this mechanism. Some heart conditions can lead to low blood pressure, including extremely low heart rate (bradycardia), heart valve problems, heart attack and heart failure. These conditions may cause low blood pressure because they prevent the body from being able to circulate enough blood. Excessive vasodilation, or insufficient constriction of the resistance blood vessels (mostly arterioles), causes hypotension. This can be due to decreased sympathetic nervous system output or to increased parasympathetic activity occurring as a consequence of injury to the brain or spinal cord or of dysautonomia, an intrinsic

abnormality in autonomic system functioning. Excessive vasodilation can also result from sepsis, acidosis, or medications, such as nitrate preparations, calcium channel blockers, or angiotensin II receptor blockers (ACE inhibitors). Many anesthetic agents and techniques, including spinal anesthesia and most inhalational agents, produce significant vasodilation. Meditation, yoga, or other mental-physiological disciplines may produce hypotensive effects. Lower blood pressure is a side effect of certain botanicals,[6] which can also interact with hypotensive medications. An example is the theobromine in Theobroma cacao, which lowers blood pressure[7] through its actions as both a vasodilator and a diuretic, [8] and has been used to treat high blood pressure.[9][10] [edit]

Pathophysiology
Blood pressure is continuously regulated by the autonomic nervous system, using an elaborate network of receptors, nerves, and hormones to balance the effects of the sympathetic nervous system, which tends to raise blood pressure, and the parasympathetic nervous system, which lowers it. The vast and rapid compensation abilities of the autonomic nervous system allow normal individuals to maintain an acceptable blood pressure over a wide range of activities and in many disease states. [edit]

Syndromes
Orthostatic hypotension, also called "postural hypotension", is a common form of low blood pressure. It occurs after a change in body position, typically when a person stands up from either a seated or lying position. It is usually transient and represents a delay in the normal compensatory ability of the autonomic nervous system. It is commonly seen in hypovolemia and as a result of various medications. In addition to blood pressure-lowering medications, many psychiatric medications, in particular antidepressants, can have this side effect. Simple blood pressure and heart rate measurements while lying, seated, and standing (with a two-minute delay in between each position change) can confirm the presence of orthostatic hypotension. Orthostatic hypotension is indicated if there is a drop in 20 mmHg of systolic pressure (and a 10

mmHg drop in diastolic pressure in some facilities) and a 20 beats per minute increase in heart rate. Neurocardiogenic syncope is a form of dysautonomia characterized by an inappropriate drop in blood pressure while in the upright position. Neurocardiogenic syncope is related to vasovagal syncope in that both occur as a result of increased activity of the vagus nerve, the mainstay of the parasympathetic nervous system. Another, but rarer form, is postprandial hypotension, a drastic decline in blood pressure which occurs 30 to 75 minutes after eating substantial meals.[11] When a great deal of blood is diverted to the intestines (a kind of "splanchnic blood pooling") to facilitate digestion and absorption, the body must increase cardiac output and peripheral vasoconstriction to maintain enough blood pressure to perfuse vital organs, such as the brain. Postprandial hypotension is believed to be caused by the autonomic nervous system not compensating appropriately, because of aging or a specific disorder. [edit]

Diagnosis
For most adults, the healthiest blood pressure is at or below 120/80 mmHg. A small drop in blood pressure, even as little as 20 mmHg, can result in transient hypotension.
[12]

Evaluation of neurocardiogenic syncope is done with a tilt table test. [edit]

Treatment
The treatment for hypotension depends on its cause. Chronic hypotension rarely exists as more than a symptom. Asymptomatic hypotension in healthy people usually does not require treatment. Adding electrolytes to a diet can relieve symptoms of mild hypotension. In mild cases, where the patient is still responsive, laying the person in dorsal decubitus (lying on the back) position and lifting the legs will increase venous return, thus making more blood available to critical organs at the chest and head. The Trendelenburg position, though used historically, is no longer recommended.[13] The treatment of hypotensive shock always follows the first four following steps. Outcomes, in terms of mortality, are directly linked to the speed in which hypotension is corrected. In parentheses are the still debated methods for achieving, and

benchmarks for evaluating, progress in correcting hypotension. A study[14] on septic shock provided the delineation of these general principles. However, since it focuses on hypotension due to infection, it is not applicable to all forms of severe hypotension. Volume resuscitation (usually with crystalloid) Blood pressure support with a vasopressor (all seem to be equivalent)[15] Ensure adequate tissue perfusion (maintain SvO2 >70 with use of blood or dobutamine) Address the underlying problem (i.e. antibiotic for infection, stent or CABG (coronary artery bypass graft surgery) for infarction, steroids for adrenal insufficiency, etc...) Medium-ter=-0oim (and less well-demonstrated) treatments of hypotension include: Blood sugar control (80-150 by one study) Early nutrition (by mouth or by tube to prevent ileus) Steroid support

Causes
Blood pressure is a measurement of the pressure in your arteries during the active and resting phases of each heartbeat. Here's what the numbers mean: Systolic pressure. The first (top) number in a blood pressure reading, this is the amount of pressure your heart generates when pumping blood through your arteries to the rest of your body. Diastolic pressure. The second (bottom) number in a blood pressure reading, this refers to the amount of pressure in your arteries when your heart is at rest between beats. Current guidelines identify normal blood pressure as equal to or lower than 120/80 many experts think 115/75 is even better. Although you can get an accurate blood pressure reading at any given time, blood pressure isn't always the same. It can vary considerably in a short amount of time sometimes from one heartbeat to the next, depending on body position, breathing

rhythm, stress level, physical condition, medications you take, what you eat and drink, and even time of day. Blood pressure is usually lowest at night and rises sharply on waking. Blood pressure: How low can you go?What's considered low blood pressure for you may be normal for someone else. Most doctors consider chronically low blood pressure too low only if it causes noticeable symptoms. Some experts define low blood pressure as readings lower than 90 systolic or 60 diastolic you need to have only one number in the low range for your blood pressure to be considered lower than normal. In other words, if your systolic pressure is a perfect 115, but your diastolic pressure is 50, you're considered to have lower than normal pressure. A sudden fall in blood pressure can also be dangerous. A change of just 20 mm Hg a drop from 110 systolic to 90 systolic, for example can cause dizziness and fainting when the brain fails to receive an adequate supply of blood. And big plunges, especially those caused by uncontrolled bleeding, severe infections or allergic reactions, can be life-threatening. Athletes and people who exercise regularly tend to have lower blood pressure and a slower heart rate than do people who aren't as fit. So, in general, do nonsmokers and people who eat a healthy diet and maintain a normal weight. But in some rare instances, low blood pressure can be a sign of serious, even lifethreatening disorders. Conditions that can cause low blood pressureSome medical conditions can cause low blood pressure. These include: Pregnancy. Because a woman's circulatory system expands rapidly during pregnancy, blood pressure is likely to drop. During the first 24 weeks of pregnancy, systolic pressure commonly drops by five to 10 mm Hg and diastolic pressure by as much as 10 to 15 mm Hg. This is normal, and blood pressure

usually returns to your pre-pregnancy level after you've given birth. Heart problems. Some heart conditions that can lead to low blood pressure include extremely low heart rate (bradycardia), heart valve problems, heart attack and heart failure. These conditions may cause low blood pressure because they prevent your body from being able to circulate enough blood. Endocrine problems. An underactive thyroid (hypothyroidism) or overactive thyroid (hyperthyroidism) can cause low blood pressure. In addition, other conditions, such as adrenal insufficiency (Addison's disease), low blood sugar (hypoglycemia) and, in some cases, diabetes, can trigger low blood pressure. Dehydration. When you become dehydrated, your body loses more water than it takes in. Even mild dehydration can cause weakness, dizziness and fatigue. Fever, vomiting, severe diarrhea, overuse of diuretics and strenuous exercise can all lead to dehydration. Far more serious is hypovolemic shock, a lifethreatening complication of dehydration. It occurs when low blood volume causes a sudden drop in blood pressure and a reduction in the amount of oxygen reaching your tissues. If untreated, severe hypovolemic shock can cause death within a few minutes or hours. Blood loss. Losing a lot of blood from a major injury or internal bleeding reduces the amount of blood in your body, leading to a severe drop in blood pressure. Severe infection (septicemia). Septicemia can happen when an infection in the body enters the bloodstream. These conditions can lead to a life-threatening drop in blood pressure called septic shock. Severe allergic reaction (anaphylaxis). Anaphylaxis is a severe and potentially life-threatening allergic reaction. Common triggers of anaphylaxis include foods, certain medications, insect venoms and latex. Anaphylaxis can cause breathing problems, hives, itching, a swollen throat and a drop in blood pressure. Lack of nutrients in your diet. A lack of the vitamins B-12 and folate can cause anemia, a condition in which your body doesn't produce enough red blood cells, causing low blood pressure.

Medications that can cause low blood pressureSome medications you may take can also cause low blood pressure, including: Diuretics (water pills) Alpha blockers Beta blockers Drugs for Parkinson's disease Certain types of antidepressants (tricyclic antidepressants) Sildenafil (Viagra), particularly in combination with the heart medication, nitroglycerine Types of low blood pressureDoctors often break down low blood pressure (hypotension) into different categories, depending on the causes and other factors. Some types of low blood pressure include: Low blood pressure on standing up (postural or orthostatic hypotension). This is a sudden drop in blood pressure when you stand up from a sitting position or if you stand up after lying down. Ordinarily, gravity causes blood to pool in your legs whenever you stand. Your body compensates for this by increasing your heart rate and constricting blood vessels, thereby ensuring that enough blood returns to your brain. But in people with postural hypotension, this compensating mechanism fails and blood pressure falls, leading to symptoms of dizziness, lightheadedness, blurred vision and even fainting. Postural hypotension can occur for a variety of reasons, including dehydration, prolonged bed rest, pregnancy, diabetes, heart problems, burns, excessive heat, large varicose veins and certain neurological disorders. A number of medications can also cause postural hypotension, particularly drugs used to treat high blood pressure diuretics, beta blockers, calcium channel blockers and angiotensinconverting enzyme (ACE) inhibitors as well as antidepressants and drugs used to treat Parkinson's disease and erectile dysfunction. Postural hypotension is especially common in older adults, with as many as 20 percent of those over age 65 experiencing postural hypotension. But postural hypotension can also affect young, otherwise healthy people who stand up suddenly after sitting with

their legs crossed for long periods or after working for a time in a squatting position. Low blood pressure after eating (postprandial hypotension). Postprandial hypotension is a sudden drop in blood pressure after eating. It affects mostly older adults. Just as gravity pulls blood to your feet when you stand, a large amount of blood flows to your digestive tract after you eat. Ordinarily, your body counteracts this by increasing your heart rate and constricting certain blood vessels to help maintain normal blood pressure. But in some people these mechanisms fail, leading to dizziness, faintness and falls. Postprandial hypotension is more likely to affect people with high blood pressure or autonomic nervous system disorders such as Parkinson's disease. Lowering the dose of blood pressure drugs and eating small, low-carbohydrate meals may help reduce symptoms. Low blood pressure from faulty brain signals (neurally mediated hypotension). This disorder causes blood pressure to drop after standing for long periods, leading to signs and symptoms such as dizziness, nausea and fainting. Neurally mediated hypotension mostly affects young people, and it seems to occur because of a miscommunication between the heart and the brain. When you stand for extended periods, your blood pressure falls as blood pools in your legs. Normally, your body then makes adjustments to normalize your blood pressure. But in people with neurally mediated hypotension, nerves in the heart's left ventricle actually signal the brain that blood pressure is too high, rather than too low. As a result, the brain lessens the heart rate, decreasing blood pressure even further. This causes more blood to pool in the legs and less blood to reach the brain, leading to lightheadedness and fainting. Low blood pressure due to nervous system damage (multiple system atrophy with orthostatic hypotension). Also called Shy-Drager syndrome, this rare disorder causes progressive damage to the autonomic nervous system, which controls involuntary functions such as blood pressure, heart rate, breathing and digestion. Although this condition can be associated with muscle tremors, slowed movement, problems with coordination and speech, and incontinence, its main characteristic is severe orthostatic hypotension in

combination with very high blood pressure when lying down