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Arterial blood gas analysis
NS227 Woodrow P (2004) Arterial blood gas analysis. Nursing Standard. 18, 21, 45-52. Date of acceptance: December 1 2003. Aim and intended learning outcomes This article aims to give nurses an understanding of the main gas and acid-base measurements derived from an arterial sample, so that they can interpret results of samples from patients in their care. After reading this article you should be able to: ■ Describe what acid-base balance is, and its significance for homeostasis of the blood. ■ Discuss with junior colleagues the significance of carbon dioxide measurement. ■ Explain to a junior colleague how compensation occurs, and how it can be identified from blood gas samples. Introduction With increasing numbers of acutely ill patients in most wards, nurses often see arterial blood gases (ABGs) being taken by medical colleagues and, in some areas, by other nurses. ABGs can aid medical diagnosis, but nurses may be the first clinical staff to receive the results. Understanding the significance of these results, and knowing when medical help needs to be summoned urgently, can improve patient care. Nurses taking samples need to be able to interpret results. Understanding diagnostic results can make nursing care more holistic for the patient and rewarding for nurses. This article describes how nurses can analyse ABG samples. Blood gases may be analysed from capillary samples. Differences between arterial and capillary results are so slight that for practical purposes they can be considered identical. Information in this article therefore also applies to analysing capillary samples. Although commonly referred to as ‘blood gases’ or ‘ABGs’, most machines supply other results, such as electrolytes and metabolites, that are useful for patient care, but which are not gases or necessarily related to respiratory function. This article describes how to interpret the main ABG results. It does not discuss how to take samples, errors that can occur when taking samples, or care of arterial lines. The sample In a few specialist areas, such as intensive care units, patients may have an arterial line inserted, which enables samples to be obtained easily and painlessly. However, arterial lines are dangerous and should not be used where the patient is not monitored and observed continuously by staff familiar with the potential dangers. In most wards and departments, obtaining an ABG sample necessitates an ‘arterial stab’ – taking blood with a syringe and needle from an artery (usually the radial artery) in a similar way to taking blood from a vein. As arteries are deeper than veins, arterial stabs are painful. Local anaesthetics should be used (Hope et al 1998), but in the author’s experience rarely are. Arterial bleeds take longer to stop than venous ones. Sheehy and Lombardi (1995) recommend pressing on arterial sites for five minutes, although if patients have prolonged clotting or bleeding disorders, pressure may be needed for longer. Removing pressure too soon may cause haematoma or bruising. Once the sample has been obtained, nurses may be asked to transport, or arrange transport for, the sample. Because cells in blood are living, gas exchange and metabolism continue, so delays in analysing samples cause increasingly inaccurate results. Beaumont (1997) recommends analysing samples kept at room temperature within 15 minutes. Unless blood gas analysers are available in or very near the ward, samples should therefore be cooled to reduce metabolism, so prolonging the time available for reliable analysis. Common practice has been to insert the syringe into some ice. CluttonBrock (1997) suggests that this prolongs the reliable sampling time to 60 minutes. However, some

In brief Author Philip Woodrow MA, RGN, DipN, Grad Cert Ed, is Practice Development Nurse, Critical Care, East Kent Hospitals NHS Trust, Canterbury, Kent. Email: philip.woodrow@ ekht.nhs.uk Summary With increasing use of arterial blood gas analysis in various ward and other hospital settings to aid medical diagnosis and management, nurses who can interpret results are often able to initiate earlier interventions and understand the reasons for medical interventions. This article enables nurses to interpret such results. Key words ■ Oxygen therapy ■ Respiratory disorders These key words are based on subject headings from the British Nursing Index. This article has been subject to double-blind review.

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february 4/vol18/no21/2004 nursing standard 45

0. are affected by temperature. carbonic acid. Analysis Measured results.35-7. from an ABG analysis (if none is available in the notes of any patients on your ward. TIME OUT 2 Obtain a printout. The main acid in blood. Temperature Machines provide the option to measure results at the patient’s own temperature or at a default temperature of 37°C. as this may cause haemolysis. specialised areas such as critical care may be able to provide you with a copy). may be fed into the machine. but will be printed above the analysed results. however. while alkalis are chemicals that can absorb (receive) hydrogen ions. Was the sample analysed at 37°C or at the patient’s temperature? If you have the opportunity. to avoid variation in readings between different practitioners. Note down why the patient was admitted. saturation). sodium hydroxide. is fortunately weak. Vigorous shaking should be avoided.0. carbon dioxide. Such extremes of acidity or alkalinity in blood would be fatal. The author’s own preference is to sample all results at 37°C. many citrus fruits have a pH of 4. base excess). ask why. There are four main groups of results that will be analysed on most samples: ■ pH. or if recording of temperature was inaccurate then results may differ without any change in the patient. Acids are chemicals that can release (donate) hydrogen ions (H+). Which way measurements are affected depends on whether mainly plasma or mainly cells are inserted into the machine. Samples should therefore be mixed well during transportation. This article identifies the most important results for most adult patients. ■ Electrolytes and metabolites. body temperature varies between different sites. So anecdotal recommendations are to place the syringe in iced water. resting gastric pH is less than 3. or copy down results. If you obtain more than one printout. Potential hydrogen (pH) concentration of ions measures acidity or alkalinity. anecdotal claims have been made that ice immediately against the syringe wall causes haemolysis (breakdown of erythrocytes). where any trends will be from a consistent baseline. select one to use while reading this article. Dissociation of gases. such as his or her identification number and body temperature. you should find out the normal range and what abnormalities may suggest about patients’ conditions. it is debatable whether this method achieves any greater accuracy. ■ Respiratory function (oxygen. But human blood 46 nursing standard february 4/vol18/no21/2004 . However.35 = acidosis ■ >7. suggested ‘normal’ values and the sequence of printing results vary between machines. ■ Metabolic measures (bicarbonate. As with any machine. has a pH of 13. This article focuses on the first three aspects. axilla is replaced by tympanic measurement.45 = alkalosis mation may be optional. for example. identify what you would need to safely transport a sample to the nearest usable blood gas analyser. However. it is generally considered safer to measure all samples at the default temperature of 37°C. if transporting a container of iced water causes a further delay. When results are analysed.45 (Box 1). some people consider that gases should be measured at the patient’s temperature. This can be illustrated by re-analysing samples at different temperatures.45 ■ <7. and why the gas sample was taken. Depending on how the machine is programmed. Delay before measurement may also cause inaccuracies from separation of blood cells and plasma.monitoring patients Box 1. Electrolyte and metabolite measurements are useful but are additional to. and if the recorded temperature changes because a different site is used. but if additional measurements are used in your place of work. some infor- pH The normal range is 7. gas analysis. information about the patient. by rolling the syringe (like a cement mixer). causing inaccurate results: lower pH and oxygen (PaO2). Chemically. any other relevant history and treatment. so changes of less than 10 per cent are generally not considered significant. largely depending on how they have been programmed locally. Thus. If you identify any items that are not available in your clinical area. pH (overall acid-base balance) normal 7. inform your ward manager. Therefore. neutral pH is 7. with a pH of about 2. The pH scale measures moles per litre. higher carbon dioxide (PaCO2) and potassium (K+) (Gosling 1995). TIME OUT 1 Re-read the above paragraph. a strong alkali. and ranges between 1 (absolute acid) and 14 (absolute alkali): car batteries contain strong acids. so are not discussed here. it is important that all people measuring ABGs in a clinical area follow the same practice. rather than part of. and therefore all results derived from gases.35-7. there can be slight differences between different measurements (‘drift’). Wards and units should therefore make team decisions about whether or not to enter patients’ temperatures.

1 = 80nmol/l H+ ■ pH 6. In health.000016mmol/l) Box 3. Carbon dioxide is produced by body cells as a waste product of metabolism. some countries.5 x 10-8 per litre of blood. Hydrogen ion concentration ■ pH 7. ■ SaO2 (saturation of haemoglobin by oxygen). may lead to hypercapnia and hypoxia.000004millimole (40 nanamoles.2/7.5 approximates to kPa. while acidity increases oxygen dissociation from haemoglobin (the Bohr effect) and impairs cardiac contraction (= negative inotrope). metabolic acidosis) may stimulate an opposing abnormality of the other component (for example. Complications are cumulative as blood pH moves progressively further from the normal range. Similarly. slight changes in concentration can be life-threatening – doubling or halving acid concentration alters pH by 0. while moving one whole figure on the pH scale causes a tenfold change in hydrogen ion concentration (Fletcher and Dhrampal 2003). the body attempts to maintain homeostasis.133kPa. A logarithm presents large numbers in a few. With capillary or venous samples. Lactate is a metabolite measured by some analysers. so dividing mmHg by 7. more easily managed. because of the inability to remove sufficient carbon dioxide to maintain normal levels. is it acidic or alkalotic? Respiratory function Blood gas analysis measures ■ PaCO2 (partial pressure of arterial carbon dioxide). but both are life-threatening. Arterial carbon dioxide levels therefore indicate ventilation. blood pH below 7. Hypocapnia occurs with hyperventilation.35-7.0 = hypercapnia. with many decimal points. which removes more carbon dioxide. and old texts from the UK. So. respiratory alkalosis ■ >6.45. you may need to be able to convert these figures. This is called compensation.0kPa ■ <4. Acid-base balance is affected by both respiratory and metabolic function.5 = hypocapnia. Hypoventilation.35 and 7. Carbon dioxide (PaCO2) The normal range is 4.4 = 40nmol/l H+ ■ pH 7.8 =160nmol/l H+ (= 0. respiratory alkalosis) to maintain a normal pH. In health. The amount of carbon dioxide in the atmosphere is normally insignificant (about 0. in a more manageable and safer form. gases are almost always measured in kilopascals (kPa). which may occur in conjunction with respiratory failure. a small ‘c’ or’v’ may be printed. respiratory acidosis (Cornock 1996) TIME OUT 3 Look at the sample results you have selected. such as non-invasive ventilation (BTS 2002) or the respiratory stimulant doxapram (BTS 1997). The respiratory centres in the brainstem respond primarily to the level of arterial carbon dioxide. The pH scale is a negative logarithm. and it can only be identified by looking at pH together with both respiratory and metabolic results. However.5kPa) reduces the stimulus to breathe.35 is termed acidotic and that above pH 7. with healthy respiratory centres and lung function.35-7. produces lactic acid (Babb and Farmery 2003).56. Blood pH below 7. an abnormality of one component (for example. PaCO2 ■ Normal: 4. however. figures. use millimetres of mercury (mmHg).5-6. There are only 0. An abnormal pH does not identify whether problems are respiratory or metabolic (or both) in origin.45 means that the hydrogen ion concentration is normally 3. give gases in mmHg.0kPa) stimulates respiratory centres to increase the rate and depth of breathing. hypercapnia (>6. Inadequate ventilation may necessitate ventilatory support. This is only likely to be seen with: february 4/vol18/no21/2004 nursing standard 47 .monitoring patients is slightly alkaline. including the United States. Acidosis occurs more often than alkalosis. One millimetre of mercury (1mmHg) equals 0. A negative logarithm similarly represents small numbers. Box 2.7 = 20nmol/l H+ ■ pH 7. Normal blood lactate level is 1mmol/l or less. Is the acid-base balance normal? If not.0 or above 8.3 (Box 2).04%).0 makes survival very unlikely. The normal blood pH of 7. As homeostasis of blood pH is to maintain 7. Some printers omit the lower case ‘a’. if the machine is informed of the source of the sample.5 x 10-8 to 4. pH measures the overall acid-base balance of the blood sample. Slight changes in pH affect enzyme activity (Hornbein 1994). Anaerobic metabolism from poor perfusion. but might be used to measure electrolytes and metabolites.45. Therefore. such as during shock. normally ranging between 7. ■ PaO2 (partial pressure of arterial oxygen). Venous samples are very rarely taken. As US texts.45 is alkalotic. so decreasing the respiratory rate and depth.0kPa (Box 3).0 to 7. increased levels can cause life-threatening metabolic acidosis. respiratory responses can restore a life-threatening pH of 7. the amount of air moving in and out of the alveoli. Although this is a weak acid. In the UK. nmol) of hydrogen ions in each litre of blood. hypocapnia (<4.3 in three to 12 minutes (Guyton and Hall 2000).

only 10-15 per cent of patients with COPD may become apnoeic if given more than 28% oxygen (Bateman and Leach 1998). Oximetry readings may be falsely high as a result of: ■ Carbon monoxide (for example. and the patient reassured. vasoconstriction (Keenan 1995). differences between SpO2 and SaO2 are in practice negligible. The saturation measured in an ABG sample is the SaO2. ■ Shivering (Stoneham et al 1994). which carbon dioxide does not. But oxygen is far less soluble than carbon dioxide. however. Carbonic acid usually dissociates back into water and carbon dioxide. it can be reversed by the patient rebreathing his or her own carbon dioxide (using a paper bag). Hypoxia may be caused by hypoventilation. carbon dioxide being removed through the lungs and excess water being removed in urine. such as from vascular disease. However. For short-term use during acute crises. ■ Artificial (over-)ventilation. So if a patient is hyperoxic (PaO2 >13. Where urgent treatment is necessary to preserve life. so hypercapnia creates a respiratory acidosis.5kPa). so maximal (100%) oxygen should be given. there is a legal (Dimond 2002) and professional (NMC 2002) expectation that nurses will act in patients’ best interests. Compensatory metabolic acidosis should usually not be treated. This S-shaped curve represents significant changes in PaO2 with minimal changes in SaO2 48 nursing standard february 4/vol18/no21/2004 . both often being referred to as SO2.5-13. while hypocapnia creates a respiratory alkalosis. especially blue or black (Wahr and Tremper 1996). Its instability means that it dissociates (breaks down) easily. causes should be identified and if possible resolved. without oxygen. an acid has to contain hydrogen ions. ear probes do not. Falsely low oximetry readings may be caused by: ■ Poor perfusion (Jensen et al 1998). shown graphically by the oxygen saturation curve (Figure 1). Nurse-initiated oxygen therapy may be covered in some areas by patient group directions. Significant hyperoxia almost never occurs unless patients are given high concentration supplementary oxygen. With panic attacks. but this is usually only necessary in first-aid situations. which is why the arrow in the above formula points both ways. prolonged use of high concentrations can cause toxic damage. Hypoxic patients need oxygen. patients have hypoxia (PaO2 <11. Carbonic acid has two useful properties for human blood physiology: it is weak and unstable. Chemically. However. Precise levels for oxygen toxicity are debated but are often considered to be >60% oxygen for >24 hours (Hinds and Watson 1996). the cause of acidosis often requires treatment. as a result of respiratory Box 4.monitoring patients ■ Panic attacks. Pulse oximeter probes measure saturation of haemoglobin in peripheral (capillary) blood (SpO2). but in other areas nurses initiating oxygen should remember their individual accountability (NMC 2002). However. as the compensation maintains haemostasis. Oxygen is literally vital for cells. such as methylene blue (Fox 2002). and need supplementary oxygen to maintain adequate tissue oxygenation.5kPa). especially fluorescent light and heat lamps (Fox 2002. tissue cells die. ■ High blood bilirubin levels (bilirubinaemia) (Dobson 1993). Whereas most oximeter finger probes have effective light shields. oxygen toxicity is not an issue. More often. Arterial carbon dioxide therefore indicates the amount of carbonic acid. However. in which case carbon dioxide will be raised. not the ear. so any disease increasing the fluid barrier between alveolar air and pulmonary blood (for example. supplementary oxygen for prolonged use should be reduced. which legally require a prescription. ■ Bright light. Most readers will be familiar with oxygen saturation from pulse oximetry. Being a weak acid. ■ Intravenous dyes. Oxygen (PaO2) The normal range is 11. Artificial overventilation can be adjusted by reducing ventilator settings (rate and/or volume). so respiratory acidosis occurs only if excessive amounts of carbon dioxide are retained. from smoking a cigarette) (Dobson 1993). medical gases are drugs. Saturation (SaO2) The normal level is about 97%. such as during or immediately after cardiac arrest. pulmonary oedema. to survive. when carbon dioxide produced by cells diffuses into capillary blood it mixes with water (the main component of blood) to form carbonic acid: CO2 + H2O ↔ H2CO3. chest infection) may cause hypoxia while carbon dioxide remains normal (normocapnia). severe shock (Keenan 1995) or very irregular heart rhythms. large amounts of carbonic acid would be needed to create a life-threatening acidosis. Ralston et al 1991). Shading probes with the hand may result in a more accurate. and finger probes are contoured for a finger. Carbon dioxide is often referred to as a ‘potential acid’. and so for organs and the body. ■ Dark nail varnish. ■ Compensation for metabolic acidosis. Respiratory failure Type 1 ■ PaO2 <8kPa ■ PaCO2 <6kPa Type 2 ■ PaO2 <8kPa ■ PaCO2 >6kPa (BTS 2002) failure. reading. If hypocapnia causes problems.5kPa (Cornock 1996). lower. The relationship between partial pressure of oxygen in arterial blood (PaO2) and saturation of haemoglobin in arterial blood by oxygen (SaO2) is complex. Contrary to widespread belief.

but abnormal carbon dioxide levels can cause significant differences. With respiratory failure. as alternating between standardised and actual levels could result in patients being treated for differences in interpretation rather than for any physiological change. can dissociate into bicarbonate and a free hydrogen radical.3 PO2(kPa) 13. Therefore. It does not measure Hb. Using standardised rather than actual levels is therefore logical. the first has 97% of 14g/dl saturation and the second has 97% of 7g/dl. standardised figures are sometimes identified by ‘std’) and represents a more accurate estimation of metabolic function. insufficient carbon dioxide will be removed from the blood. used to measure metabolic acidbase balance. causing high blood carbon dioxide (hypercapnia) in addition to hypoxia. which decreases the affinity of haemoglobin for oxygen Normal oxygen dissociation curve SaO2 % 70 Venous Metabolic measures Bicarbonate (HCO3-) The normal range is 2427mmol/l (Coombs 2001). is it type 1 or type 2? Remember to check the Hb. 5. Low levels of bicarbonate are caused either by extensive buffering or by impaired/delayed response to produce sufficient buffer. analysers calculate how much bicarbonate results from respiratory dysfunction and subtract this from the actual bicarbonate. Saturation measures the percentage of haemoglobin (Hb) that is saturated by oxygen. to provide a computer estimation. Oxygen dissociation curve TIME OUT 4 Review the respiratory function of the patient whose results you are analysing. Bicarbonate is produced in various parts of the body. and is defined as PaO2 below 8kPa and PaCO2 below 6kPa (BTS 2002). eg from pyrexia or acidosis. so the Hb should be checked when considering the significance of oxygen saturation. So. Blood gas samples usually measure Hb. Do you think there should be any change in the patient’s oxygen therapy? If so. can be increased as a result of hypercapnia. if two patients both have oxygen saturations of 97%.3 february 4/vol18/no21/2004 nursing standard 49 . This is the standardised bicarbonate (SBC. actual and SBC are similar or identical.monitoring patients at higher levels (the ‘plateau’ of the curve). Base excess (BE) The normal level is ±2 (Cornock 1996). may cause hypoxia while carbon dioxide levels remain normal (normocapnia). Respiratory failure Respiratory failure results in inadequate oxygen in the blood. describe what you recommend. BE measures the number of Figure 1. however. Carbonic acid. Metabolic acid-base balance is also represented by base excess. normal or high. Bicarbonate is the main. bicarbonate and a hydrogen radical (a single H+ atom) can form carbonic acid: CO + H O ↔ H CO ↔ HCO .+ H+ 2 2 2 3 3 So bicarbonate. The British Thoracic Society (2002) defines respiratory failure as an arterial oxygen level below 8kPa (Box 4). and is defined as PaO2 below 8kPa and PaCO2 above 6kPa (BTS 2002). all staff should use the same measurement. such as pulmonary oedema. changes in SaO2 accelerate while changes in PaO2 reduce at lower levels (the ‘steep’ part of the curve). does the patient have a respiratory acidosis or alkalosis? What does this imply about his or her respiratory function? Identify whether you consider the oxygen status to be satisfactory. the main acid in blood. chemical buffer in plasma. Is the respiratory acid-base balance normal? If not. but one has an Hb of 14g/dl and the other has an Hb of 7g/dl. When gases are relatively normal. Does the patient have respiratory failure? If so. such as with liver failure. including the liver and kidneys. in COPD) or slow. giving the first patient nearly twice the amount of oxygen in the arterial blood. This is called type 1 respiratory failure. Carbon dioxide is 20 times more soluble than oxygen (Waterhouse and Campbell 2002). so diseases that increase the fluid barrier between alveolar air and pulmonary blood. Conversely. so levels indicate metabolic acid-base status. resulting in production of bicarbonate from respiratory acidosis. This is called type 2 respiratory failure. from the measured bicarbonate and carbon dioxide. When breathing is shallow (for example. although not the only. arterial carbon dioxide levels may be low. How do these findings compare with what you know of the patient’s respiratory function? 100 97 Arterial Shift to the right.

Most intravenous infusions are acidic. SBE >+2) ■ Respiratory alkalosis (PaCO2 <4. However. proteins). But with metabolic acidosis. but if bicarbonate is low.45. often develop compensatory chronic metabolic alkalosis. in the author’s workplace the pH of normal saline (0. Is the metabolic acid-base balance normal? If not.4 (assuming PaCO2 remains constant at 5. phosphate. from the patient’s history. Doubling or halving the amount of air reaching the alveoli (ventilation) can alter pH by 0.0. ■ Production and re-absorption of chemical buffers (bicarbonate. if any. kidneys and gut. is at least as powerful as all chemical buffers combined. provided the 50 nursing standard february 4/vol18/no21/2004 . You may like to use the case study in box 7 as an example. as experienced by some athletes during vigorous exercise. sometimes. and may be twice as powerful (Marieb 2004).35-7. there is a negative BE (Box 5). Compared with the pH scale. there is an excess of base. Metabolic control is more complex. Homeostasis of blood pH is 7. Its neutral is zero. the BE scale is linear.2 (Marieb 2004). The normal range is usually given as +2 to -2. Unlike the negative logarithmic pH scale.monitoring patients Box 5. while the pH of 5% glucose is 4.2 to normal in three to 12 minutes (Guyton and Hall 2000). it can be affected by respiratory function. Attempts to compensate may also be incomplete. With healthy lungs. SBE <-2) moles of acid or base needed to return 1 litre blood to pH 7. TIME OUT 5 Review the metabolic results from the patient whose results you are analysing. people with COPD. note how abnormal carbon dioxide is. the body maintains homeostasis. imbalance of either respiratory or metabolic function will be compensated for by an opposite imbalance of the other (Box 6). Respiratory effects on acid-base balance. Reducing respiratory acidosis (for example. and therefore hypercapnia with a chronic respiratory acidosis. A patient’s history often indicates which way.3kPa). ask the critical care outreach team. However. It is derived from measured bicarbonate. ■ Absorption of acids and alkalis from the diet (and other routes. relying on: ■ Hydrogen loss in urine. failing to normalise pH. like bicarbonate. Sometimes printouts fail to clearly show a minus sign. identify whether respiratory function is compensating for a metabolic problem or vice versa. ventilation can increase 15-fold (Marieb 2004). If nursing and medical colleagues in your area are not used to interpreting ABG results. Is compensation achieving normal pH? TIME OUT 7 Having completed your analysis of the results. discuss your findings and ideas with a colleague who is used to interpreting ABGs. Compensation (pH in normal range) ■ Respiratory acidosis (PaCO2 >6kPa) ■ Metabolic alkalosis (SBC >28. such as intravenous infusions). enough to return a severe acidosis of 7. ■ Production of metabolic acids from cells and in the stomach. through removal of carbon dioxide. Therefore.5kPa) ■ Metabolic acidosis (SBC <22. Box 6. removing the respiratory element to provide a purely metabolic estimation. metabolic responses take considerably longer (hours or. while altering respiratory rate and depth can (with a healthy respiratory system) normalise blood pH in a few minutes. so standardised base excess (SBE) is calculated. For example. days). causing overall alkalosis that persists for some days. TIME OUT 6 Is compensation occurring in the result you have analysed? If so. for example. Compensation In health.15. does the patient have a metabolic acidosis or alkalosis? What does this imply about his or her metabolic function? How do these findings compare with what you know of the patient’s renal and other metabolic functions? Are there significant differences between actual and standardised measurements? If so. compensation is occurring (Table 1). using non-invasive ventilation) in these patients may result in continuing metabolic (over-) compensation. BE measurement is simple. BE means an excess of base (alkali). mainly by the liver. With metabolic alkalosis.9%) is 5. BE will be negative. Metabolic acid-base balance Metabolic acidosis ■ ↓ HCO3-/SBC ■ ↓ BE/SBE Metabolic alkalosis ■ ↑ HCO3-/SBC ■ ↑ BE/SBE body remains healthy enough to respond.

55kPa 18. Uncompensated metabolic acidosis Temperature ■ pH ■ PaCO2 ■ PaO2 36. Understanding results can help nurses to understand treatments and interventions. The patient has a slight metabolic acidosis. especially for carbon dioxide. and partly from the three litres of nasal oxygen the patient was receiving. february 4/vol18/no21/2004 nursing standard 51 .296 5. The ventilator is currently delivering only air. like any other. as the patient is receiving non-invasive ventilation for respiratory failure caused by pneumonia. so supplementary oxygen needs to be added. Ventilation (PaCO2) is adequate.6mmol/l ■ Hb 10. you may benefit from finding out the significance. Like any other investigation.86kPa ■ PaO2 9. partly from hyperventilation.6% saturation is machine error.7mmol/l ■ HCO3–std ■ BE – act -3.4kPa 21. Now that ventilation has removed the respiratory acidosis.1 7. Interpreting ABG samples is a skill which. Potassium is also life-threateningly high.5g/dl ■ SaO2 100. There is a severe metabolic acidosis.1mmol/l ■ Na+ 139mmol/l ■ Ca2+ (calcium) 1. The patient had had a cardiac arrest. Three examples of successful and unsuccessful compensation Metabolic acidosis (compensated) Respiratory acidosis with (excessive) metabolic compensation (Not temperature corrected) ■ pH 7.9kPa Temperature corrected: ■ pH 7.monitoring patients Table 1. As you develop your skills further.584 ■ PaCO2 4. This would be the underlying problem.351 ■ PaCO2 3.14kPa ■ PaO2 30. This article has described how to interpret the most important results. of other measurements. improves with practice. Nurses who are not taking samples may be able to initiate earlier intervention if they are able to interpret results. ■ pH ■ PaCO2 ■ PaO2 ■ HCO3– act ■ BE ■ K+ ■ Lactate 7. It has not covered every possible measurement machines may make (which vary according to programming). for which respiratory compensation is occurring. and monitored using pulse oximetry. initiating metabolic compensation to maintain normal pH. or otherwise. While blood glucose level is now normal.6% ■ K+ 4. blood gas analysis may provide information that can be useful for treating patients. Before admission. taking arterial samples has traditionally been a medical role.5mmol/l ■ BE – std -3.10kPa 12.(chloride) 108mmol/l ■ Glu (glucose) 5.15kPa 30. metabolic alkalosis remains. and lactate is high. Oxygenation (PaO2. so making nursing more interesting. causing an overall alkalosis.9g/dl ■ SaO2 97.07mmol/l 3.65mmol/l This patient has a severe acidosis. The 100.4mmol/l ■ Hb 13.2mmol/l -8. Oxygen can be discontinued. In most wards. so the patient is ventilating adequately. and at the time this gas was taken was being hand-ventilated following successful resuscitation.361 3.6mmol/l ■ HCO3–act 21.9% This patient has an alkalosis.24kPa 33. the pneumonia had presumably caused increasing respiratory acidosis. but is hyperventilating (PaCO2). metabolic acidosis is reducing but persists. Conclusion ABG analysis provides useful monitoring. Oxygen is poor. This patient had type 1 diabetes and was recovering from diabetic ketoacidosis.15mmol/l ■ Cl. Lactate is normal. He or she has a metabolic alkalosis. Gases are normal.3mmol/l ■ HCO3– act ■ BE 11.5mmol/l This patient has a normal pH.1mmol/l ■ Lac (lactate) 0. SaO2) is excessive.3mmol/l 7. Changes in gas measurements from temperature correction and in metabolic measurements from standardisation are small and insignificant. Unfortunately. but some specialist nurses are now taking samples and so need to be able to interpret measurements.

British Thoracic Society (2002) Non invasive ventilation in acute respiratory failure.0mmol/l ■ SBE 2.0mmol/l ■ SO2 99% Mr Watts’ metabolic status remains unchanged. 3. Ralston A et al (1991) Potential errors in pulse oximetry. Mr Watts will need active treatment for his bronchopneumonia. 9. Hinds C. Beaumont T (1997) How to guides: arterial blood gas sampling. his blood gases are: ■ pH 7. British Medical Journal. Lancet. London. Lombardi J (1995) Emergency Care. Hornbein T (1994) Acid-base balance. Longman/Pearson Education. In Miller R (Ed) Anesthesia. 46. 13.47kPa ■ pO2 15. Dimond B (2002) Legal Aspects of Nursing. 57. 192-211. In Goldhill D. Withington P (Eds) Textbook of Intensive Care. Oxford. 798-801. Following prn (pro re nata. Care of the Critically Ill. 61-65. On 100% oxygen.54kPa ■ SBC 26. Leach R (1998) Acute oxygen therapy.32 ■ pCO2 7. 3. TIME OUT 8 Now that you have completed the article you might like to write a practice profile. and he is started on bilevel non-invasive ventilation. 52.78kPa ■ SBC 26. 7. his cough becomes productive. Hope R et al (1998) Oxford Handbook of Clinical Medicine. Fletcher S. Nursing Times. Fourth edition. Sheehy S. Nursing Times. Thorax. Tenth edition. Surgery. Jensen L et al (1998) Meta-analysis of arterial oxygen saturation monitoring by pulse oximetry in adults. or copying results on to notepaper. His oxygen saturation is below 86% and he is very dyspnoeic. Gosling P (1995) How to guides: blood gas analysis. 4-11. A physiotherapist is called. centre insert. 1. Fox N (2002) Pulse oximetry. This indicates a new respiratory problem. Thorax. Campbell I (2002) Respiration: gas transfer. British Thoracic Society (1997) Guidelines for the management of chronic obstructive pulmonary disease. His carbon dioxide (and acid-base balance) levels have been restored to normal. 9. 340-343. He has a non-productive cough. Second edition. 21. In Prys-Roberts C. 21. Anaesthesia. Nursing Standard. Coombs M (2001) Making sense of arterial blood gases. including rate and depth of breathing and oxygen saturation. Harlow. Marieb E (2004) Human Anatomy and Physiology. and probably other medications and investigations. 35. The sample confirms that the pulse oximetry measurement was accurate. so it is decided to discontinue bilevel noninvasive ventilation. 208a-208e. enables nurses to practise interpretation at a more convenient time REFERENCES Babb M. 1. Nursing care should include frequent (at least four-hourly) respiratory observations. Nursing and Midwifery Council (2002) Code of Professional Conduct. Cornock M (1996) Making sense of arterial blood gases and their interpretation. His oxygenation is greatly improved. WB Saunders. 98.4mmol/l ■ SO2 89% This result shows an overall acidosis.monitoring patients Box 7. Brown B Jr (Eds) International Practice of Anaesthesia. Fourth edition. Making a second copy of the printout from the machine. NMC. 8. including antibiotics. Philadelphia PA. or when required) salbutamol and ipratropium nebulisers. One hour after physiotherapy. Oxford University Press. Benjamin/Cummings. early discontinuation of non-invasive ventilation. Farmery A (2003) Haemorrhagic shock. Chapman & Hall. 7161. Anaesthesia and Critical Care. Watson D (1996) Intensive Care. centre insert. 36-38. 27. London. 291-295. Wahr J. which also contributes to severe hypoxia. San Francisco CA. Care of the Critically Ill. 97. 40. Dhrampal A (2003) Acid-base balance and arterial blood gas analysis. Bateman N. 4. Dobson F (1993) Shedding light on pulse oximetry. 65. following the second gas. 27. Raised carbon dioxide indicates poor ventilation. 92.425 ■ pCO2 5. 30-31. London. with bilevel non-invasive ventilation delivering 60% oxygen. Case study Mr Watts is admitted with bronchopneumonia. Hall J (2000) Textbook of Medical Physiology. 46. 344. Tremper K (1996) Oxygen measurement and monitoring techniques. achieving effective sputum clearance. Heart and Lung. Butterworth Heinemann. St Louis MO. Waterhouse J.44kPa ■ pO2 6. Guyton A. 387-408. his gases are: ■ pH 7. 52 nursing standard february 4/vol18/no21/2004 . WB Saunders. Churchill Livingstone. samples are often taken when patients’ conditions are too poor to spend time practising interpretation. Oxford. Further changes can be guided by pulse oximetry. New York NY. 8933. 1339-1342. as would be expected. Guidelines to help you are on page 55. Nursing Times. Third edition. with respiratory acidosis but no metabolic compensation. Stoneham M et al (1994) Knowledge about pulse oximetry among medical and nursing staff. 3.0mmol/l ■ SBE 2. Mosby. 55. These ABGs have enabled prompt (and probably earlier than might otherwise have occurred) interventions and. Supplement 5. Nursing Standard. 6. Fourth edition. 11. 317. He has no history of chronic respiratory disease. Keenan J (1995) Pulse oximetry. but it is decided to maintain 60% oxygen as non-invasive ventilation is being discontinued. regular physiotherapy. Clutton-Brock T (1997) The assessment and monitoring of respiratory function. 6. Surgery.

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