Arterial Blood Gas Analysis

Wirral Respiratory Unit Teaching Pack

Maria Parsonage Advanced Nurse Practitioner Wirral University Teaching Hospitals Foundation Trust

Housekeeping
Introduction Plan for session Fire Procedure Facilities Mobile Phones

Learning Outcomes
To have an understanding of the relevance of Arterial Blood Gas analysis in the Acute setting To have an understanding of normal arterial blood gas parameters To have an understanding of acid/base balance and be able to recognise metabolic and respiratory differences To understand when to alert medical staff

What is an ABG?
It is an invasive procedure Arterial blood is drawn from an artery
Radial Femoral Brachial

It can be a painful test It provides us with information on oxygenation and acid base abnormalities It should be performed by a clinician who has been appropriately trained

When and Why To Check ABGs

ABGs can provide us with valuable clinical information in acutely ill patients with both respiratory and metabolic compromise ABGs are indicated if your patient has a sudden deterioration in their condition such as
SaO2 RR Cyanosis Confusion GCS Rising MEWS

Parameters
pH pO2 pCO2 HCO3 BE ~ ~ ~ ~ ~ ~ H+ ions partial pressure O2 partial pressure pCO2 Bicarbonate Base excess Oxygen saturation

SaO2

pH
pH is directly proportional to hydrogen ion concentration and is the measurement of the acidity or alkalinity of a substance The pH scale is a continuum from 0 (strongly acidic) to 14 (strongly alkaline) The pH of blood is 7.35 7.45
Relatively small changes in pH can be dangerous for the patient

PO2 & PCO2

This stands for partial pressure of O2 and CO2 They reflect the measurements of the partial pressures which oxygen and carbon dioxide exert in the blood PO2 and PCO2 are usually measured in kilopascals (kPa)
some blood gas analysers measure them in millimetres of mercury (mmHg) If you need to convert kPa to mmHg, multiply the kPa by 7.5 Vice versa, divide mmHg by 7.5

Bicarbonate (HCO3)
Bicarbonate is referred to as the metabolic component We need to know the amount of HCO3 in the blood as 70% of CO2 is carried in this form from the tissues to the lungs for excretion

Base Excess (BE)

Rising levels of bicarbonate make the blood more alkaline and a depletion of bicarbonate makes it more acidic Base excess refers to the amount of base (alkali) which needs to be added or taken away from the blood to return the pH to 7.4

Oxygen Saturation (SaO2)

This refers to the amount of oxygen being carried by the haemoglobin (Hb) molecules The Hb molecule is divided into two portions
Globin - made of protein Haem - made of iron There are 4 groups of haem on each molecule of Hb Each haem group can bind 1 O2 molecule

Oxygen Dissociation Curve

The curve highlights the affinity of oxygen to haemoglobin When PO2 is high, oxygen is strongly affiliated to haemoglobin, so oxygen saturation will be high When PO2 is low there is less affinity of oxygen to haemoglobin, so oxygen saturation drops

Oxygen Dissociation Curve

It can be seen from the shape of the oxygen dissociation curve that initially there is a slight drop in SaO2 when there is a reduced PO2 However, at a certain point there is a sudden drop in saturation as indicated by the steep decline in the curve Therefore, SaO2 normally only drops sharply if the PO2 is at a very low level
8 kPa is the point at which the patient is hypoxaemic and is in respiratory failure

Normal Arterial Values

pH 7.36 7.44 pO2 11 13 kPa pCO2 4.7 5.9 kPa HCO3 21- 28 mmols/l BE 2 SaO2 >95%

Acid/ Base Relationship

The relationship is critical for homeostasis Significant derivations of the normal pH is poorly tolerated and can be life threatening Homeostasis is maintained by the respiratory and renal systems

Buffers
There are 2 buffers that work in pairs to maintain homeostasis H2CO3
Carbonic Acid

NaHCO3
Base Bicarbonate

The buffers kick in in minutes Respiratory acid/ base compensation is rapid and starts within minutes and completes within 24 hours Renal acid/base compensation takes hours and up to 5 days

Compensation
If there is respiratory acidosis (pH/ PCO2 ) the metabolic component (HCO3) will increase
This will increase alkalinity to compensate and bring pH back towards normal

If there is metabolic acidosis (HCO3) the respiratory component (PCO2 ) will decrease
Hyperventillation to blow off CO2 to compensate and bring the pH back towards normal

Compensation
If there is sufficient compensation to bring pH back to normal limits this is full compensation If there is some compensation, but not fully normalised pH then this is partial compensation

Compensatory Mechanisms
NORMAL VALUE PH 7.35 7.45 pCO2 4.5 6 kPa HCO3 22 28 kPa COMPENSATION RESP ALKALOSIS Normal until compensation Kidneys will HCO3 (SLOW)

RESP ACIDOSIS

Normal until compensation

Kidneys will HCO3 (SLOW)

METABOLIC ALKALOSIS

Normal until compensation

Lungs will try to CO2 (QUICK) Lungs will try to CO2 (QUICK)

METABOLIC ACIDOSIS

Normal until compensation

Respiratory Acidosis
Think of CO2 as an acid
A failure of the lungs to exhale adequate CO2

Causes
Hypoventillation drug overdose, narcosis, airway obstruction, respiratory arrest Impaired gas exchange Asthma, COPD

pH <7.35 PCO2 >5.9 kPa

Type I Respiratory Failure

Type I RF is defined as hypoxaemia (PO2 < 8 kPa) without hypercapnia (PCO2 > 6 kPa) It is typically caused by a ventilation/perfusion VQ mismatch The air flowing in and out of the lungs is not matched with the flow of blood to the lungs Parenchymal disease - CAP/ consolidation Diseases of vasculature - PE There may be acidaemia pH < 7.35 There may be compensation pH 7.35 - 7.45

Type II Respiratory Failure

Type II RF is defined as the build up of carbon dioxide (PCO2 > 6 kPa) that has been generated by the body The underlying causes include Reduced respiratory effort - fatigued patient Increased resistance to breathing - Asthma A decrease in the area of the lung available for gas exchange - COPD There may be acidaemia pH < 7.35 There may be compensation pH 7.35 - 7.45

Non Invasive Ventilation

NIV is indicated for patients with COPD with Type II respiratory failure
pH <7.35 PCO2 > 6 kPa +/- Hypoxaemia (PO2 < 8 kPa)

ACTRITE criteria accepts a PO2 > 7 kPa for patients with COPD and a PO2 > 8 kPa for patients with Cor Pulmonale (COPD and Right Heart Failure)

Respiratory Alkalosis
Causes Hyperventilation Think of CO2 as an acid
Too much exhaled CO2 Hypoxemia Metabolic acidosis Anxiety (hyperventillation)

pH >7.45 PCO2 <4.7 kPa

Neurological
SOL Trauma Infection

Other
Acute anaemia Salicylate overdose

Metabolic Acidosis
Failure of kidney function
Too much H+ in the blood

Causes Ketoacidosis
Type I DM

Renal tubular acidosis

Renal failure

pH <7.35 HCO3 <22 kPa

Lactic acidosis
Decreased tissue perfusion Severe hypoxemia Cardiac arrest

Excessive diarrhoea

Metabolic Alkalosis
plasma bicarbonate pH >7.45 HCO3 >28 kPa Causes
Hypokalaemia Gastric suction Vomiting Excessive alkali intake

4 Step Guide to Interpretation

1. 2.

Is the pH normal, acidotic or alkalotic? Are the pCO2 or HCO3 abnormal?

Which one appears to influence the pH

3.

If both the pCO2 and HCO3 are abnormal, the one which deviates most from the norm is most likely causing an abnormal pH Check the pO2
Is the patient hypoxaemic?

4.

Respiratory Case Study

35 year old presents with acute onset of DIB, wheeze and cough BP 100/60, HR 120bpm, Temp 37.1c, RR 36 min ABGs fiO2 60%
pH 7.30 PO2 8.9 kPa PCO2 5.2 kPa HCO3 24 kPa

What is the abnormality?

Respiratory Case Study

71 year old presents with 1/52 increasing shortness of breath, wheeze and cough BP 170/80, HR 100bpm, Temp 36.1c, RR 32 min ABGs fiO2 35%
pH 7.31 PO2 11.1 kPa PCO2 9.2 kPa HCO3 37 kPa

What is the abnormality?

Discussion/ Questions?

Arterial Blood Gas Sampling

Learning Outcomes
To have an understanding of the relevance of Arterial Blood Gas analysis in the Acute setting To demonstrate an understanding of the anatomy of arteries To perform and be aware of dangers and complications of this invasive technique To safely work towards competence

Arterial Sampling
There are two methods
Arterial puncture Taking sample from an indwelling arterial line

Samples are usually taken from the radial artery because it is easily accessible, although the brachial and femoral arteries are sometimes used

Arterial Puncture
In radial cannulation, a modified Allens test should be carried out to ensure the collateral circulation to the hand is adequate to maintain perfusion

Modified Allens Test

The radial and ulnar arteries are occluded by firm pressure while the fist is clenched until the hand blanches The hand is opened and the pressure is released from the ulnar artery Colour should return within 15 seconds to imply adequate arterial circulation

Equipment
Personal protective equipment Alcohol wipe Gauze Tape Name label and request form Arterial Blood Gas pre-heparinised syringe Sharps bin Blood bag with ice for transport

Components of the Procedure

Identification of a suitable artery to sample Universal precautions, cleaning and preparation of the sample site Arterial puncture and aspiration of arterial blood sample Occlusion of sample site with dressing and pressure applied to promote clotting and avoid bleeding or haematoma formation

Procedure
Wash your hands and put on PPE Locate the approximate position of the artery by slowly rolling your index finger from side to side Identify again the point of maximal pulsation of the radial artery Clean the skin over the proposed site of puncture

Procedure
Insert into the artery at 45 angle to the skin with bevel uppermost Guide the needle slowly toward the point of maximum pulsation When you hit the artery there will be a sudden gush of arterial blood into the hub of the needle

Post Procedure
Apply direct pressure over the site for 3-5 minutes Expel all air bubbles from the sample holding the syringe upright and allowing the bubbles to collect near the needle hub Then evacuate it by pushing on the plunger Carefully cap the needle with a rubber stopper

Post Procedure
Don't forget to label the tube with patient's name Place the sample in the bag containing ice and send it to the lab It is very important to return about 10 minutes later to check for adequate perfusion of the hand and for possible haematoma formation

Results
You should record FiO2 and temperature accurately on the ABG request If you have sent ABG to the lab for analysis you must review the results All ABGs should be interpreted in relation to the patients physical condition You must have an understanding of ABG parameters and know when to call for help

Discussion/ Questions?