‫وزارة التعليم العالي‬

‫كلية الغد الدولية للعلوم الصحية‬

‫‪1‬‬
 Submitted
Arterial blood gas
An arterial blood gas (ABG) is a blood test that is performed using blood from an artery. It

involves puncturing an artery with a thin needle and syringe and drawing a small volume of

blood. The most common puncture site is the radial artery at the wrist,[1] but sometimes the

femoral artery in the groin or other sites are used. The blood can also be drawn from an arterial

catheter. Pulse oximetry plus transcutaneous carbon dioxide measurement is an alternative

method of obtaining similar information as well. An ABG is a test that measures the arterial

oxygen tension (PaO2), carbon dioxide tension (PaCO2), and acidity (pH). In addition, arterial

oxyhemoglobin saturation (SaO2) can be determined. Such information is vital when caring for

patients with critical illness or respiratory disease. As a result, the ABG is one of the most

common tests performed on patients in intensive care units (ICUs).

The test is used to determine the pH of the blood, the partial pressure of carbon dioxide and

oxygen, and the bicarbonate level. Many blood gas analyzers will also report concentrations of

lactate, hemoglobin, several electrolytes, oxyhemoglobin, carboxyhemoglobin and

methemoglobin. ABG testing is mainly used in pulmonology and critical care medicine to

determine gas exchange which reflect gas exchange across the alveolar-capillary membrane.

ABG testing also has a variety of applications in other areas of medicine. Combinations of

disorders can be complex and difficult to interpret, so calculators,[2] nomograms, and rules of

thumb[3] are commonly used.

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 Sampling and analysis

Arterial blood for blood gas analysis is usually drawn by a respiratory therapist and sometimes a
phlebotomist, nurse or doctor.[4] Blood is most commonly drawn from the radial artery because
it is easily accessible, can be compressed to control bleeding, and has less risk for occlusion, the
selection of which radial artery to draw from is based on the outcome of an Allen's test. The
femoral artery (or less often, the brachial artery) is also used, especially during emergency
situations or with children. Blood can also be taken from an arterial catheter already placed in
one of these arteries.
There are plastic and glass syringes used for blood gas samples. Most syringes come pre-
packaged and contain a small amount of heparin, to prevent coagulation or need to be
heparinised, by drawing up a small amount of liquid heparin and squirting it out again to remove
air bubbles. Once the sample is obtained, care is taken to eliminate visible gas bubbles, as these
bubbles can dissolve into the sample and cause inaccurate results. The sealed syringe is taken to
a blood gas analyzer. If a plastic blood gas syringe is used, the sample should be transported and
kept at room temperature and analyzed within 30 min. If prolonged time delays are expected
(i.e., greater than 30 min) prior to analysis, the sample should be drawn in a glass syringe and
immediately placed on ice <Reference: CLSI H11-A4>. Standard blood tests can also be
performed on arterial blood, such as measuring glucose, lactate, hemoglobins, dys-
haemoglobins, bilirubin and electrolytes.

Calculations
The machine used for analysis aspirates
this blood from the syringe and
measures the pH and the partial
pressures of oxygen and carbon dioxide.
The bicarbonate concentration is also
calculated. These results are usually
available for interpretation within five
minutes.
Two methods have been used in
medicine in the management of blood
gases of patients in hypothermia: pH-stat
method and alpha-stat method. Recent
studies suggest that the α-stat method is
superior.
pH-stat: the arterial carbon dioxide
tension (paCO2) is maintained at 5.3 kPa
(40 mmHg) and the pH is maintained at 7.40 when measured at the actual patient temperature. It
is then necessary to add CO2 to the sample to calculate results.
α-stat (alpha-stat): the arterial carbon dioxide tension and the pH are maintained at 5.3 kPa
(40mmHg) and 7.40 when measured at +37°C. When a patient is cooled down, the pH-value will
increase and the pCO2-value and the pO2-value will decrease with lowering of the temperature if
measured at the patients temperature.
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 Both the pH-stat and alpha-stat strategies have theoretical disadvantages. α-stat method is the
method of choice for optimal myocardial function. The pH-stat method may result in loss of
autoregulation in the brain (coupling of the cerebral blood flow with the metabolic rate in the
brain). By increasing the cerebral blood flow beyond the metabolic requirements, the pH-stat
method may lead to cerebral microembolisation and intracranial hypertension.

pH

The normal range for pH is 7.35-7.45. As the pH decreases (<7.35), it implies acidosis, while if
the pH increases (>7.45) it implies alkalosis. In the context of arterial blood gases, the most
common occurrence will be that of respiratory acidosis. Carbon dioxide is dissolved in the blood
as carbonic acid, a weak acid; however, in large concentrations, it can affect the pH drastically.
Whenever there is poor pulmonary ventilation, the carbon dioxide levels in the blood are
expected to rise. This leads to a rise of carbonic acid, leading to a decrease in pH. The first buffer
of pH will be the plasma proteins, since these can accept some H+ ions to try and maintain
homeostasis. As carbon dioxide concentrations continue to increase (Pa CO2 > 45 mmHg), a
condition known as respiratory acidosis occurs. The body tries to maintain homeostasis by
increasing the respiratory rate, a condition known as tachypneoa. This allows much more carbon
dioxide to escape the body through the lungs, thus increasing the pH by having less carbonic
acid. If a patient is in a critical setting and intubated, one must increase the number of breaths
mechanically.
On the other hand, respiratory alkolosis (Pa CO2 < 35mmHg) occurs when there is too little
carbon dioxide in the blood. This may be due to hyperventilation or else excessive breaths given
via a mechanical ventilator in a critical care setting. The action to be taken is to calm the patient
and try to reduce the number of breaths being taken to normalise the pH. The respiratory
pathway tries to compensate for the change in pH in a matter of 2–4 hours. If this is not enough,
the metabolic pathway takes place.
The kidney and the liver are two main organs responsible for the metabolic homeostasis of pH.
Bicarbonate is a base that helps to accept excess hydrogen ions whenever there is acidaemia.
However, this mechanism is slower than the respiratory pathway and may take from a few hours
to 3 days to take effect. In acidaemia, the bicarbonate levels rise, so that they can neutralise the
excess acid, while the contrary happens when there is alkalaemia. Thus when an arterial blood
gas test reveals, for example, an elevated bicarbonate, the problem has been present for a couple
of days, and metabolic compensation took place over a blood acedemia problem.
In general, it is much easier to correct acute pH derangements by adjusting respiration.
Metabolic compensations take place at a much later stage. However, in a critical setting, a patient
with a normal pH, a high CO2, and a high bicarbonate means that, although there is a high
carbon dioxide level, there is metabolic compensation. As a result one must be careful as to not
artificially adjust breaths to lower the carbon dioxide. In such case, lowering the carbon dioxide
abruptly means that the bicarbonate will be in excess and will cause a metabolic alkalosis. In
such a case, carbon dioxide levels should be slowly diminished.

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ANALYSIS ARTERIAL BLOOD GAS

The analysis of arterial blood gas values (ABG's) can detect the presence and identify the causes
of acid-base and oxygenation disturbances. The body operates efficiently within a fairly narrow
range of blood pH (acid-base balance). Even relatively small changes can be detrimental to
cellular function. The normal range of pH is maintained by removing acids from the blood via
two organ systems.
 Respiratory -ventilation at the lungs removes carbon dioxide in exhaled air
 Metabolic-excretion of acids in urine by the kidney
Acid-base abnormalities therefore are due to imbalances in one or both of these systems.
Respiratory mediated changes in acid-base status occur as a result of increases or decreases in
the exhalation of carbon dioxide. These changes occur within minutes. When the rate and depth
of ventilation increases, the CO2 level falls, more acid is removed and the blood pH will rise
becoming more alkalemic (less acidic). When ventilation decreases, CO2 levels rise, less acid is
removed and blood pH falls (more acidic).
Metabolic regulation of acid-base occurs in the kidney where bicarbonate is conserved while
acids (H+) are secreted into the urine. Metabolic mediated changes in acid-base tend to occur
more slowly than respiratory, taking several hours to days rather than minutes. So it is the
balance between the Respiratory and Metabolic regulators that maintains the acid-base status
within normal limits. We analyze arterial blood to determine if an acid-base disturbance is
present and which system, either Respiratory, Metabolic or both is responsible for the problem.
Arterial blood gases should never be interpreted by themselves. You must always interpret them
in light of the patient’s history and clinical presentation.

Blood Gas values in Calgary are slightly different than textbook sea level values because of
Calgary’s altitude, which causes the oxygen pressure to be decreased. The decreased PaO2 causes us
to increase our minute ventilation resulting in a lower PaCO2. In order that pH remain within normal
limits, the kidneys excrete HCO3- to compensate for the low PaCO2

When arterial blood is analyzed, the main variables are:

1. pH - a measure of how acidic or alkaline the blood is. The normal range is 7.35 - 7.45.
 If the pH is < 7.35 = acidemia
 When the pH falls below 7.20, the acidemia is severe
 If the pH is > 7.35 = alkalemia
 When the pH is > 7.50, the alkalemia is severe
So, the pH tells us if an acid-base abnormality is present and whether it is an acidemia
or an alkalemia.

2. PaCO2 is the partial pressure of carbon dioxide in the blood. The normal range for
Calgary is 30 - 40 mmHg. The PaCO2 indicates the adequacy of ventilation at the
lungs. An increase in CO2 due to hypoventilation causes a fall in pH (acidemia)
while a fall in CO2 due to hyperventilation causes a rise in pH (alkalemia).

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 3. PaO2 - the partial pressure of oxygen dissolved in the blood. This value reflects how
The PaO2effectively
must always thebelungs
interpreted in light
are moving of theinto
oxygen oxygen concentration
the blood. the the
In Calgary patient is range
normal
receiving.ofAPaO
PaO2 is 70 - 88 depending on the age of the patient.
2 of 85 mmHg when breathing room air (21%) indicates the lungs are
functioning
 normally
When the butPaOa PaO 2 of below
2 falls
85 when
50breathing
mmHg, you 100% oxygen
need to actmeans the lungs
promptly are it
to restore
to normal
greatly impaired in their levels.
ability to move oxygen into the blood.
4. HCO3- is the actual bicarbonate level in the blood. It only reflects changes in the
bicarbonate buffer system, the most important of the blood buffers. In Calgary the
normal range is 20 - 24
 If the bicarbonate is < 20 = acidemia
 If the bicarbonate is >24 = alkalemia

5. B.E/B.D. the Base Excess or Base Deficit - reflects the change in all blood buffering
systems. It is the most reliable indicator of the metabolic component of an acid-
base disturbance. The normal value range in Calgary is -5 to +1.
 If the B.E. is > +1 = Alkalemia
 If the B.E. is < -5 = Acidemia

So, as illustrated in diagram 1, the balance or imbalance in Respiratory and Metabolic factors
affects pH. A change in either side will affect pH.
Diagram 1

6. %HbO2 (SaO2)- reflects how much oxygen is being transported on hemoglobin. Normal
range in Calgary is 92 - 95%. Clinically we need to be concerned if a patient cannot
maintain a saturation of >90%

Interpreting Blood Gas Results

The easiest way to interpret blood gas results is with a step by step method.

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Step 1.
Is the pH within the normal range or not? If the pH is out of range you need to determine
if there is an alkalemia or an acidemia present.
pH > 7.45 = alkalemia (e.g. 7.52)
pH < 7.35 = acidemia (e.g. 7.24)
Step 2.
What is causing the abnormality in pH? There are only two possibilities, Respiratory (changes in
PaCO2) and /or Metabolic (changes in HCO3- or B.E.)
Respiratory
 Look at PaCO2 - increased PaCO2 when the pH is decreased =Respiratory Acidemia
or decreased PaCO2 when the pH is increased =Respiratory Alkalemia
Metabolic
 Look at HCO3- or B.E. - increased Base Excess or bicarbonate with an increased pH
= Metabolic Alkalemia or a decreased Base Excess or bicarbonate with a decreased
pH = Metabolic Acidemia

In a code situation, the pH may be very low, i.e. < 7.00 since both a metabolic
acidemia (anaerobic metabolism, lactic acidemia) and a respiratory acidemia
(inadequate ventilation) will be causing the pH to fall.
Step3:
Assess for the presence of a compensated acid base imbalance. Compensation is the
return of an abnormal pH towards normal (7.35 – 7.45) by the organ system that
was not primarily affected.

For example, if you hypoventilate and retain CO2 the pH will fall producing a Respiratory
Acidemia. If this condition persists for several hours the kidneys will begin to compensate by
retaining HCO3- thus raising the pH back towards normal. If the pH is just within normal limits but
the PaCO2 or B.E. is outside normal limits, then there is full compensation. Sometimes the pH
cannot be returned to normal limits and there is only partial compensation.
Step 4:
What is the oxygenation status? Look at the PaO2 and the %HbO2. A low PaO2 (< 77-88
mmHg) indicates a problem with the lungs while a low %HBO2 (< 90%) could be due to
a problem anywhere in the body's oxygen transport system; the lungs, blood or heart
pump.

Remember that COPD patients may ‘normally’ have a %HBO2 in the 88%
range.

BLOOD GAS EXAMPLES

1. Your patient returns from the O.R. on oxygen by simple mask at 6 lpm.

pH 7.25 pH is low indicating acidemia

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 PaCO2 68 CO2 is high- consistent with acidemia

PaO2 52 low due to hypoventilation

B.E. +1 normal

%HBO2 88% low due to low PaO2

Interpretation: Pure (no compensation) respiratory acidemia with

hypoxemia
2. Your patient is very agitated, bordering on hysteria. Blood gases are drawn on room air.

pH 7.54 high - indicating alkalemia

PaCO2 22 low (hyperventilation) – consistent with high pH

PaO2 78 normal

B.E. -2 normal

PaO2 78 normal

SaO2 97% normal

Interpretation: Pure respiratory alkalosis

3. A patient arrives in ER with a Hx of stomach pain. Patient states that he has been taking
anti-acid medication 6-8 times per day for 2 weeks. Room air blood gases reveal,

pH 7.52 high indicating alkalemia

PaCO2 38 normal

PaO2 78 normal

B.E. +8 high, consistent with alkalemia

%HbO2 96% normal

Interpretation: respiratory compensation for this situation because it

requires hypoventilation and retention of CO2 which
tends to stimulate breathing thus limiting any
compensation.

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4. Patient is brought to ER comatose. Provisional diagnosis is diabetic shock. Room air blood
gases:

pH 7.16 very low indicating severe acidemia

PaCO2 18 low (hyperventilation) not consistent with low pH

PaO2 95 high due to hyperventilation

B.E. -12 low, consistent with low pH

%HBO2 98% high due to high PaO2

Interpretation: partially compensated metabolic acidemia

5. You find your patient non-responsive with no sign of breathing or heart rate. The code team
arrives and a blood gas is drawn immediately while patient is receiving100% oxygen.

pH 6.98 extremely low. Severe acidemia

PaCO2 86 very high (hypoventilation) consistent with low pH

PaO2 34 very low. Severe hypoxemia

B.E. -12 low, consistent with a low pH

%HBO2 74% dangerously low due to hypoxemia

Interpretation: combined respiratory and metabolic acidemia with severe

hypoxemia

STATES OF COMPENSATION
* PaCO2 30-40mmHg HCO3- 20-24 mmol/L pH 7.36-7.44

Uncompensated  80 mmHg N 22 mmol/L  7.06

Partial Comp.  80 mmHg  36 mmol/L  7.30 Respiratory
Fully Comp.  80 mmHg  48 mmol/L N 7.40 Acidemia

Uncompensated  20 mmHg N 22 mmol/L  7.66

Partial Comp.  20 mmHg  16 mmol/L  7.53 Respiratory
Fully Comp.  20 mmHg  12 mmol/L N 7.40 Alkalemia

Uncompensated N 35 mmHg  12 mmol/L  7.16

Partial Comp.  23 mmHg  12 mmol/L  7.34 Metabolic
Fully Comp.  20 mmHg  11 mmol/L N 7.40 Acidemia

Uncompensated N 35 mmHg  48 mmol/L  7.70

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Partial Comp.  60 mmHg  48 mmol/L  7.53 Metabolic
Fully Comp.  80 mmHg  48 mmol/L N 7.40 Alkalemia

*NORMALS FOR CALGARY

Respiratory Alkalemia: Respiratory Acidemia:

 pH,  PaCO2  pH,  PaCO2
Hyperventilation due to:
Hypoventilation due to:
- Hypoxemia
- Cardiopulmonary disease
- Brain Tumor, Early stages of head
- Drug O.D. (Narcotics)
trauma, Encephalitis
- End-stage head trauma
- Fever
- CNS disease
- Psychoneurosis, Emotional stimuli
- Cervical spinal injury
- Early Salicylate poisoning
- Neuromuscular disease

Metabolic Alkalemia: Metabolic Acidemia:

 pH,  HCO3-  pH,  HCO3-
Excessive intake of base: Loss of Base: Diarrhea
- Vomiting Accumulation of acid:
-  Gastric suction - Severe hypoxemia (Lactic Acid)
- Electolyte imbalance:  Na+,  K+,  Cl- - Diabetes (Keto Acidosis)
- Salicylate Poisoning
Ethylene Glycol, Methanol poisoning
Electrolyte imbalance:  Na+,  K+,  Cl-

Respiratory Alkalemia: Respiratory Acidemia:

 pH,  PaCO2  pH,  PaCO2
Hyperventilation due to:
- Hypoxemia Hypoventilation due to:
- Brain Tumor, Early stages of head - Cardiopulmonary disease
trauma, Encephalitis - Drug O.D. (Narcotics)
- Fever - End-stage head trauma
- Psychoneurosis, Emotional stimuli - CNS disease
- Early Salicylate poisoning - Cervical spinal injury
- Neuromuscular disease

Metabolic Alkalemia: Metabolic Acidemia:

 pH,  HCO3-  pH,  HCO3-
Excessive intake of base: Loss of Base: Diarrhea
- Vomiting Accumulation of acid:
-  Gastric suction - Severe hypoxemia (Lactic Acid)
- Electolyte imbalance:  Na+,  K+,  Cl- - Diabetes (Keto Acidosis)
- Salicylate Poisoning
Ethylene Glycol, Methanol poisoning
Electrolyte imbalance:  Na+,  K+,  Cl-

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 Respiratory Acidosis:
Respiratory Alkalosis:  pH,  PaCO2
 pH,  PaCO2 Hypoventilation due to:
Hyperventilation due to:
- Cardiopulmonary disease
- Hypoxemia
- Drug O.D. (Narcotics)
- Brain Tumor, Early stages of head
- End-stage head trauma
trauma, Encephalitis
- CNS disease
- Fever
- Cervical spinal injury
- Psychoneurosis, Emotional stimuli
- Neuromuscular disease
- Early Salicylate poisoning

Metabolic Alkalosis:
 pH,  HCO3-
Metabolic Acidosis:
Excessive intake of base:  pH,  HCO3-
- Vomiting Loss of Base: Diarrhea
-  Gastric suction Accumulation of acid:
- Electolyte imbalance:  Na+,  K+,  Cl- - Severe hypoxemia (Lactic Acid)
- Diabetes (Keto Acidosis)
- Salicylate Poisoning
Ethylene Glycol, Methanol poisoning
Electrolyte imbalance:  Na+,  K+,  Cl-

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 Source
1.^ "Arterial Blood Gases - Indications and Interpretation".

patient.co.uk/doctor. 20 December 2010. Retrieved 10 February 2013.

2.^ Baillie K. "Arterial Blood Gas Interpreter". prognosis.org. Retrieved

2007-07-05. - Online arterial blood gas analysis

3.^ Baillie, JK (2008). "Simple, easily memorised "rules of thumb" for the

rapid assessment of physiological compensation for acid-base disorders".

Thorax 63 (3): 289–90. doi:10.1136/thx.2007.091223. PMID 18308967.

4- http://en.wikipedia.org http://freepdfdb.com

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 Conclusion

Praise be to Allah who did the blessing, and helped

me and completed this research in this picture that I
hope to earn any satisfaction, and that research is
useful achieving the purpose of it.

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 Index

Introduction .................................................................. 1

The Arterial blood gases.…......................................... 2-12

References ........................................... ….................... 12

Conclusion .......................................... ........................ 13

Index ........ ........................................... ....................... 14

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