INTRODUCTION

. Disorders of acid–base balance can lead to severe complications in many disease states,
and occasionally the abnormality may be so severe as to become a life-threatening risk
factor. The process of analysis and monitoring of arterial blood gas (ABG) is an essential part
of diagnosing and managing the oxygenation status and acid–base balance of the high-risk
patients, as well as in the care of critically ill patients in the Intensive Care Unit. Since both
areas manifest sudden and life-threatening changes in all the systems concerned, a
thorough understanding of acid–base balance is mandatory for any physician, and the
anesthesiologist is no exception. However, the understanding of ABGs and their
interpretation can sometimes be very confusing and also an arduous task. The proper
application of the concepts of acid–base balance will help the healthcare provider not only
to follow the progress of a patient, but also to evaluate the effectiveness of care being
provided.

INDICATION FOR ARTERIAL BLOOD GAS ANALYSIS

1. Collapse of unknown cause

2. Respiratory distress — hypoxia

3. Titration of artificial ventilation

4. Altered level of consciousness

5. Poisons/toxin ingestion

6. Metabolic disorders — diabetic ketoacidosis

7. Trauma — management of raised intracranial

8. Pressure

9. Shocked patient — sepsis, cardiogenic

10. Evaluation of intervention – fluid resuscitation

11. Inotropic therapy

UNDERSTANDING ACID BASE BALANCES
The body normally maintains a steady balance between acids produced during normal
metabolism and the bases that neutralize and promote the excretion of acids. Because this acids
alter the body’s internal environment. Their regulation is necessary to maintain homeostasis and
acid base balance. Many health problems may lead to acid base imbalances. Patients with
diabetes mellitus, chronic obstructive pulmonary disease, and kidney disease frequently develop
acid base imbalances. We should always consider the possibility of acid base imbalances in
patients with serious illness.
pH AND HYDROGEN ION CONCENTRATION
The acidity or alkalinity of solution depends on its hydrogen ion( H+) concentration.Plasma p H
is an indicator of hydrogen ion concentration. An increase in H+ ions concentration leads to
acidity; a decrease leads to alkalinity. The p H of a chemical solution may range from 1 to 14. A
solution of p H 7 is considered neutral. An acid solution has a less p H less than 7, and an alkaline
solution has a p H greater than 7. Blood is slightly alkaline (p H 7.35 to 7.45). Yet if it drops
below 7.35. the person has acidosis, even though the blood may never become truly acidic. If the
blood p H is greater than 7.45. the person has alkalosis.
ACID BASE REGULATION
Normally the body has three mechanisms by which it regulates the acid base balance to maintain
the arterial p H between 7.35 to 7.45. These mechanism are the following
1. The buffer system
 Bicarbonate- Carbonic acid buffer system
 Monohydrogen and dihydrogen phosphate buffer
 Intracellular and plasma buffer
 Haemoglobin buffer
2. The respiratory system
3. Renal system

Bicarbonate-carbonic acid buffer system:

Buffer systems prevent major changes in the p H of body fluids by removing or releasing
hydrogen ions. They can act quickly to prevent excessive changes in hydrogen ion concentration.
The body’s major extracellular buffer system is the bicarbonate carbonic acid buffer system,
which is assessed when arterial blood gases are measured. Normally there are 20 parts of
bicarbonate to one part of carbonic acid. If this ratio is altered the p H will change. Carbon
dioxide is a potential acid when dissolved in water it becomes carbonic acid. Therefore when
carbon dioxide is increased the carbonic acid content is also increased and vice versa.

The respiratory system:

The lungs under the control of medulla, control the carbon dioxide and thus carbonic acid content
of the ECF. They do so by adjusting ventilation in response to the amount of CO2 in the blood. A
rise in the partial pressure of CO2 in arterial blood is a powerful stimulant to respiration. Of
course the partial pressure of O2 also influences respiration but its effect is not marked as that
produced by PaCO2.
In metabolic acidosis, the respiratory rate increases, causing greater elimination of CO2. In
metabolic alkalosis, the respiratory rate decreases causing CO2 to be retained.

The Renal System

The kidneys regulate the bicarbonate level in the ECF; they can regenerate bicarbonate ions as
well as reabsorb them from the renal tubular cells. In respiratory acidosis and most cases of
metabolic acidosis, the kidneys excrete hydrogen ions and conserve bicarbonate ions to help
restore the balance. In respiratory and metabolic alkalosis, the kidneys retain hydrogen ions and
excrete bicarbonate ions to help restore balance.The kidneys cant compensate the metabolic
acidosis caused by renal failure.

ALTERATIONS IN ACID BASE BALANCE

An acid base imbalance results when there is alteration in the ratio of 20: 1 between base and acid
content. This occurs when a primary disease or process alters one side of the ratio.( eg CO2
retension in pulmonary disease ) and the compensatory processes that maintain the other side of
the ratio ( eg. Increased renal HCO3 – reabsorption) either fail or are inadequate.
Acid base imbalances are classified as respiratory or metabolic. Respiratory imbalances result
from retention or an excess CO2 altering carbonic acid concentrations; metabolic imbalances
affect the base HCO3. Therefore acidosis is caused by an increase in carbonic acid or decrease in
bicarbonate ions ( respiratory acidosis) Alkalosis is caused by a decrease in carbonic acid
( respiratory alkalosis) or an increase in HCO3 ( metabolic alkalosis) .Imbalances can be further
classified as Acute or Chronic. Chronic imbalances allows greater time for compensatory
changes.
Respiratory acidosis
Respiratory acidosis (carbonic acid excess ) occurs whenever the person hypoventilates.
Hypoventilation leads to build up of CO2, resulting in accumulation of carbonic acid in the
blood. Carbonic acid dissociates liberating H+ ions and there is a decrease in p H. If CO2 is not
eliminated from the blood, acidosis results from the accumulation of carbonic acid.
To compensate, the kidneys conserve HCO3 and secrete increased concentrations of H + ion into
the urine. During acute respiratory acidosis, the renal compensatory mechanism begin to operate
within 24 hours. Until the renal mechanism have an effect, the serum HCO3 level will usually be
normal.
Respiratory alkalosis
Respiratory alkalosis ( carbonic acid deficit) occurs with hyperventilation. The primary cause of
respiratory alkalosis is hypoxemia from acute pulmonary disorders. Anxiety, CNS disorders, and
mechanical over ventilation also increase the ventilation rate. The decrease in the partial pressure
of arterial CO2 ( PaCO2) level leads to decreased carbonic acid concentration and alkalosis
Compensated respiratory alkalosis is rare. In acute respiratory alkalosis, aggressive treatment of
the causes of hypoxemia is essential and usually does not allow time for compensation to occur.
However buffering of acute respiratory alkalosis may occur with shifting of HCO3 into the cells
for exchange of chloride ions( Cl -). In chronic respiratory alkalosis that occurs with pulmonary
fibrosis or CNS disorders, compensation may include renal excretion of HCO3
Metabolic acidosis
Metabolic acidosis (base bicarbonate deficit) occurs when an acid other than carbonic acid
accumulates in the body or when bicarbonate is lost from body fluids .Ketoacid accumulation in
diabetic ketoacidosis and lactic acid accumulation with shock are examples of accumulation of
acids. Severe diarrhea results in loss of HCO3- .In renal disease the kidneys lose their ability to
reabsorb HCO3- and secrete H+
The compensatory response to metabolic acidosis is to increase CO2 excretion by the lungs.
The patient often develops Kussmaul respiration (deep,rapid breathing ).In addition ,the kidneys
attempt to excrete additional acid.
If metabolic acidosis is present calculating the anion gap can help determine the source of the
acidosis .The anion gap is the difference between the cations and the anions in ECF that are
routinely measured .We can calculate an anion gap by summing the chloride and bicarbonate
levels and subtracting this number from the plasma sodium concentration .Ordinarily the sum of
the measured cations is greater than the sum of the measured anions..The anion gap is normally
10 to 14 mmol/L. The anion gap is increased in metabolic acidosis associated with acid gain (eg
lactic acidosis, diabetic ketoacidosis ) but remains normal in metabolic acidosis caused by
bicarbonate loss(eg diarrhea).
Metabolic Alkalosis
Metabolic alkalosis (base bicarbonate excess) occurs when a loss of acid (eg from prolonged
vomiting or gastric suction) or a gain in bicarbonate(eg from ingestion of baking soda ) occurs
.Renal excretion of bicarbonate occurs in response to metabolic alkalosis ,The compensatory
response to metabolic alkalosis is limited .There is a decreased repiratory rate to increase plasma
CO2.However once plasma CO2 reaches a certain level ,stimulation of chemoreceptors results in
ventilation.
Mixed Acid Base Disorders
A mixed acid base disorder occurs when two or more disorders are present at the same time .The
p H depends on the type ,severity and acuity of each of the disorders involved and any
compensatory mechanism at work. Respiratory acidosis combined with metabolic alkalosis (eg a
patient with chronic obstructive pulmonary disease also treated with a thiazide diuretic ) may
result in a near normal pH , whereas respiratory acidosis combined with metabolic acidosis will
cause a greater decrease in pH than either disorder alone. An example of a mixed alkalosis is a
patient who is hyperventilating because of postoperative pain and losing acid secondary to
nasogastric suctioning.

BLOOD GAS VALUES

Arterial blood gas(ABG) values provide objective information about a patient’s acid base status
the underlying cause of an imbalance ,the body’s ability to regulate p H and the patients overall
O2 status .Knowledge of the patients clinical situation and the pyhsologic extent of renal and
respiratory compensation enables you to identify acid base disorders as well as the patients ability
to compensate ,.Blood gas analysis also shows the partial pressure of arterial O2(PaO2) and
O2saturation .These values are used to identify hypoxemia.
THE PARAMETERS ASSESSED IN BLOOD GAS ANALYSIS
PARAMETER REFERENCE INTERVAL
pH 7.35- 7.45
PaCO2 35-45 mm Hg
Bicarbonate ( HCO3-) 22- 26 m Eq/ L
PaO2 80- 100 mm of hg
SaO2 >95 %
Base excess +_ 2.0 m Eq/L

 BACKGROUND INFORMATION ON ARTERIAL BLOOD SAMPLING

An arterial blood sample is collected from an artery, primarily to determine arterial blood
gases. Arterial blood sampling should only be performed by health workers for whom the
procedure is in the legal scope of practice for their position in their country and who have
demonstrated proficiency after formal training.
The sample can be obtained either through a catheter placed in an artery, or by using a needle
and syringe to puncture an artery. These syringes are pre-heparinized and handled to
minimize air exposure that will alter the blood gas values. This chapter describes only the
procedure for a radial artery blood draw.

CHOICE OF SITE
Several different arteries can be used for blood collection. The first choice is the radial artery,
which is located on the thumb side of the wrist; because of its small size, use of this artery
requires extensive skill in arterial blood sampling. Alternative sites for access are brachial or
femoral arteries, but these have several disadvantages in that they:
 may be harder to locate, because they are less superficial than the radial artery;
 have poor collateral circulation;
 are surrounded by structures that could be damaged by faulty technique.

PRACTICAL GUIDANCE ON ARTERIAL BLOOD SAMPLING

EQUIPMENT AND SUPPLIES

Assemble the relevant items pre-heparinized syringe;
 Needles (20, 23 and 25 gauge, of different lengths) – choose a size that is appropriate
for the site (smaller gauges are more likely to lyse the specimen)
 A safety syringe with a needle cover that allows the syringe to be capped before
transport, without manually recapping (this is best practice for radial blood sampling);
 A bandage to cover the puncture site after collection
 A container with crushed ice for transportation of the sample to the laboratory (if the
analysis is not done at the point of care);
 Where applicable, local anesthetic and an additional single-use sterile syringe and
needle.

PROCEDURE FOR ARTERIAL BLOOD SAMPLING USING RADIAL ARTERY

For sampling from the radial artery using a needle and syringe, follow the steps outlined
below.
1. Approach the patient, introduce yourself and ask the patient to state their full name .

2. Explain the arterial blood gas analysis evaluates how well the lungs are delivering the
oxygen to the blood and eliminating carbon dioxide.

3. Tell the patient that the test requires a blood sample.

4. Explain to the patient, who will perform the arterial puncture, when it will occur, and
where the puncture site will be; radial, brachial, or femoral artery.

5. Inform the patient that he may not need to restrict food and fluids.

6. Instruct the patient to breathe normally during the test, and warn him that he may
experience a brief cramping or throbbing pain at the puncture site.
7. Place the patient on their back, lying flat. Ask the nurse for assistance if the patient's position
needs to be altered to make them more comfortable. If the patient is clenching their fist,
holding their breath or crying, this can change breathing and thus alter the test result.
8. Locate the radial artery by performing an Allen test for collateral circulation. If the initial
test fails to locate the radial artery, repeat the test on the other hand. Once a site is identified,
note anatomic landmarks to be able to find the site again. If it will be necessary to palpate the
site again, put on sterile gloves.
9. Perform hand hygiene, clear off a bedside work area and prepare supplies. Put on an
impervious gown or apron, and face protection, if exposure to blood is anticipated.
10. Disinfect the sampling site on the patient with 70% alcohol and allow it to dry.
11. If the needle and syringe are not preassembled, assemble the needle and heparinized syringe
and pull the syringe plunger to the required fill level recommended by the local laboratory.
12. Holding the syringe and needle like a dart, use the index finger to locate the pulse again,
inform the patient that the skin is about to be pierced then insert the needle at a 45 degree
angle, approximately 1 cm distal to (i.e. away from) the index finger, to avoid contaminating
the area where the needle enters the skin.
13. Advance the needle into the radial artery until a blood flashback appears, then allow the
syringe to fill to the appropriate level. DO NOT pull back the syringe plunger.
14. Withdraw the needle and syringe; place a clean, dry piece of gauze or cotton wool over the
site and have the patient or an assistant apply firm pressure for sufficient time to stop the
bleeding. Check whether bleeding has stopped after 2–3 minutes. Five minutes or more may
be needed for patients who have high blood pressure or a bleeding disorder, or are taking
anticoagulants.
15. Activate the mechanisms of a safety needle to cover the needle before placing it in the ice
cup. In the absence of a safety-engineered device, use a one-hand scoop technique to recap
the needle after removal.
16. Expel air bubbles, cap the syringe and roll the specimen between the hands to gently mix it.
Cap the syringe to prevent contact between the arterial blood sample and the air, and to
prevent leaking during transport to the laboratory.
17. Label the sample syringe.
18. Dispose appropriately of all used material and personal protective equipment.
19. Remove gloves and wash hands thoroughly with soap and water, then dry using single-use
towels; alternatively, use alcohol rub solution.
20. Check the patient site for bleeding (if necessary, apply additional pressure) and thank the
patient.
21. Transport the sample immediately to the laboratory, following laboratory handling process.
TO INTERPRET THE RESULTS OF AN ABG PERFORM THE FOLLOWING SIX
STEPS. STEPS OF ANALYSIS OF THE ABG REPORT
SL NO STEPS
Determine whether the PH is acidotic or
1 alkalotic. Label values les than 7.35 as
acidotic and values greater than 7.45 as
alkalotic.
2 Analyze the PaCO2 to determine if the
patient has respiratory acidosis or
alkalosis .Since the lungs control PaCO2 it is
the respiratory component of the ABG .
3 Analyze the HCO3- level to determine if the
patient has metabolic acidosis or alkalosis
Note if the ph is between 7.35 and 7.45 and
4 the CO2 and the HCO3 are within normal
limits..
Determine if the CO2 or the HCO3-matches The CO2 is the parameter that
5 the acid or base alteration of the p H . For
example if the p H is acidotic (less than 7.35)
and the CO2 is high (respiratory acidosis)
but the HCO3- is high (metabolic alkalosis),
then it is diagnosed as respiratory acidosis.
6 Determine if the body is attempting to
compensate for the p H change
RATIONALE
Helps to determine the pH of the
blood.
Because CO2 forms carbonic acid
when dissolved in blood high PaCO2
levels indicate acidosis and low
PaCO2 levels indicate alkalosis.
Since the kidneys primarily control
HCO3 it is the metabolic component
of the ABG. Because HCO3- is a
base ,high levels of HCO3- result in
alkalosis and low levels result in
acidosis.
This happens when the ABGs are
normal
matches the pH alteration of acidosis.
If the parameter that does not match
the p H is moving in the opposite
direction the body is attempting to
compensate .In the example in step
5the HCO3- level is alkalotic this is
the opposite direction of respiratory
acidosis and considered mechanisms
are functioning the ph will return
toward 7.40 .When the pH is within
normal limits the patient has full
compensation.
COMPLICATIONS RELATED TO ARTERIAL BLOOD SAMPLING
There are several potential complications related to arterial blood sampling. The points below
list some of the complications related to the procedure, and how they can be prevented.
 Arteriospasm or involuntary contraction of the artery may be prevented simply by helping
the patient relax; this can be achieved, for example, by explaining the procedure and
positioning the person comfortably.

 Haematoma or excessive bleeding can be prevented by inserting the needle without

puncturing the far side of the vessel and by applying pressure immediately after blood is
drawn. Due to the higher pressure present in arteries, pressure should be applied for a
longer time than when sampling from a vein, and should be supervised more closely, to
check for cessation of bleeding.

 Nerve damage can be prevented by choosing an appropriate sampling site and avoiding

redirection of the needle.

 Fainting or a vasovagal response be prevented by ensuring that the patient is supine

(lying down on their back) with feet elevated before beginning the blood draw.
Patients requiring arterial blood sampling are usually inpatients or in the emergency
ward, so will generally already be lying in a hospital bed. Children may feel a loss of
control and fight more if placed in a supine position; in such cases, it may be
preferable to have the child sitting on the parent's lap, so that the parent can gently
restrain the child.
 Other problems can include a drop in blood pressure, complaints of feeling faint,
sweating or pallor that may precede a loss of consciousness.

Sampling errors
Inappropriate collection and handling of arterial blood specimens can produce incorrect
results. Reasons for an inaccurate blood result include:
 presence of air in the sample;
 12 an improper quantity of heparin in the syringe, or improper mixing after blood is
drawn;
 A delay in specimen transportation.
SPECIAL POINTS
 In order to prepare for an arterial blood gas test, the doctor may be informed about all
medications, supplements, and vitamins you’re taking.
 If the patient is on oxygen therapy but are able to breathe without it, then turning off
oxygen for 20 minutes for a “room air” test before the blood gas test can be done.
 The patient may have a few minutes of discomfort during or after the test. Collecting
blood from an artery typically hurts more than drawing it from a vein. Arteries are
deeper than veins, and there are sensitive nerves nearby.
 Minor side effects may be feeling of lightheadedness, fainting, dizzy, or nauseated
while the blood is drawn. To lower the chance of bruising, the puncture area must be
gently pressed for a few minutes after the needle comes out.
 Results of arterial blood gas test usually are available in less than 15 minutes.

CONCLUSION
 An arterial blood gas result can help in the assessment of a patient’s gas exchange,
ventilatory control and acid–base balance. Nurses are usually involved in taking and
analyzing the ABGs and normally they report these results to the doctors or anesthesiologists.
Out of these results the anesthesiologists will then prescribe further treatment for the
critically ill patient. Hence, it is important that nurses are familiar with the information
obtained to be able to detect the disturbances in ventilation, oxygen delivery and acid–base
balance.

REFERENCE

 Smeltzer S C, Bare B G, Hinkle J L, et al. Text book of Medical Surgical Nursing.

12th ed. New Delhi : Wolters Kluwer ; 2012. pg 297-98.

 Lewis, Dirksen, etal, Medical Surgical Nursing. 2 nd edition. New Delhi: Elsevier; pg
no 317, 500 – 16.

 www,webmd.com> lung> arterial.