REFLECTION OF LAB VISIT:

My classmates and I went to visit a Hospital laboratory, having never been in a professional

lab before my expectations were high. We were escorted through each section of the lab and

given a brief introduction to what each laboratory section does on a daily basis. We had three

hours to observe as much as we possibly could and soak in all the information we had been

provided with.

The first department we went to see was Blood Transfusion; they talked us through their

daily routine highlighting the importance of confidentiality when testing a patient’s blood.

The lab had a high level of professionalism, everyone moved independently and quickly in

order to get the work. One of the larger departments within the laboratory is the Microbiology

section. We were shown the growth mediums for bacteria and tissue culture. The department

consisted of many rooms each dedicated to a different aspect of microbiology. This

department requires a lot of staff members, the lab is very organised and there was a high

level of communication between the staff.

I found one of the most interesting departments within the laboratory to be Cellular

Pathology. The primary role of this section is to produce a diagnostic report describing the

appearance of the sample of tissue or body fluid from the patient. In the lab we witnessed

samples being preserved, waxed and stained. The lab was extremely busy, we observed

scientists working on some samples of large tissue. They mostly receive samples from the

hospital, cellular pathology is also involved in screening programmes such as the national

breast, prostate and colorectal screening. All of the labs contained a large amount of

instrumentation which in return has reduced the need for use of manual techniques.
There is a high work rate and each person has a responsibility and a time frame to work

within. I was in awe of all the workings that went on within the lab; all of the departments

had interesting aspects to them. Each department highlighted the importance of organisation

and labelling samples, as each test on a patient’s sample could potentially change their lives.

The lab is extremely busy as it receives samples from all of Connacht on a daily basis; they

have a very structured routine.

The visit to the lab certainly matched my preconceived ideas of what it would be like. I

expected the laboratory to be highly professional and automated. The scientists’ displayed a

great work ethic. I was astounded by the large amount of blood samples they receive on a

daily basis and by the level of organisation within the labs. I think that it was a great

experience to visit a lab; I got to see first-hand the experiments conducted on a daily basis. I

gained a lot of insight from visiting the hospital laboratory. I wouldn’t do anything to change

the outcome of the visit, as I believe that the outcome was positive. The scientists’ showed

great communication and organisation in the lab, they work together as a team when needed.

From what I have observed I am going to try to be more professional within the lab.

About ABGs:
In simplistic terms, an arterial blood gas (ABG) tells us about three main things:

Oxygenation: measurement of oxygen within the blood.

Ventilation: process of respiratory function (i.e. breathing).

Acid-base balance: the control of pH.

To enable us to interpret oxygenation, respiratory function and acid-base

balance, an ABG analyser gives us key bits of information. This includes the

pH, partial pressure of oxygen, partial pressure of carbon dioxide and calculated

bicarbonate.

Key components

pH (normal range 7.35-7.45): refers to the acidity or alkalinity of the blood.

Tight control needed for normal metabolic function.

PaCO2 (normal range 4.7-6.0 kPa / 35–45  mmHg): partial pressure of arterial

carbon dioxide. Essentially the concentration of carbon dioxide in the blood.

Altered by respiration and therefore provides the ‘respiratory’ component of the

blood gas.

PaO2 (normal range 10.6–13.3  kPa / 80–100  mmHg): partial pressure of

arterial oxygen. Essentially the concentration of oxygen in the blood.

HCO3- (normal range 22-26 mmol/L): calculated bicarbonate level.

Bicarbonate is an important buffer of acids. Regulated by the kidneys.

Therefore, provides the ‘metabolic’ component of the blood gas.

Base excess (normal range +2 to -2 mmol/L): measures ‘excess’ amount or

‘deficit’ amount of an acid or base. The term negative base excess often used

instead of base deficit.

Using these parameters, an ABG can give us information about what is going on

inside the body and the likely cause of dysfunction.

Additional components

In modern medicine, an ABG can give us a wealth of additional information,

including:
Electrolytes: sodium (Na+), potassium (K+), chloride (Cl-), ionised calcium

(Ca2+)

Creatinine (some analysers)

Lactate: byproduct of anaerobic respiration that is useful as a marker of tissue

perfusion

Haemoglobin and derivatives (e.g. carboxyhemoglobin, methaemoglobin)

Blood glucose level

Control of pH

Within the body, pH is tightly regulated by chemical buffers, the respiratory

system and renal system.

Understanding how the body tightly controls pH through the respiratory and

renal systems is important for ABG interpretation.

For more information, see our notes on pH control.

As a brief summary:

Respiratory system (quick response): controls pH through altered of carbon

dioxide. Increasing ventilation lower carbon dioxide level and therefore

increases pH. Decreasing ventilation raises carbon dioxide level and therefore

decreases pH.

Renal system (delayed response): controls pH through secretion of hydrogen

ions and reabsorption of bicarbonate. If both increased, pH rises. If both

decreased, pH falls.

Stepwise approach

When interpreting an ABG, it is important to use the same stepwise approach.

Determine oxygenation (PaO2)

Determine pH (acidosis or alkalosis)

Determine respiratory component (PaCO2)

Determine metabolic component (Bicarbonate)

Determine compensation
Final interpretation

Review other parameters

Step 1: Oxygenation

The normal partial pressure of oxygen (PaO2) is approximately 10.6–13.3  kPa.

Step 1 involves checking whether the patient has hypoxaemia (low blood

oxygen levels).

Firstly, check if the patient is receiving supplemental oxygen. This is

represented as a percentage (e.g. 24%, 60%). Room air is represented as 21%,

which is the partial pressure of oxygen at atmospheric pressure.

The PaO2 is always lower than alveoli oxygen. Therefore, it is estimated that

the Pa02 should be 10 less than the inspired oxygen (e.g. 11 kPa breathing at

21% room air).

Examples
If inspired oxygen is 35% via venturi mask, PaO2 should be roughly 25 kPa

If inspired oxygen at 60% via humidified oxygen, PaO2 should be roughly 50

kPa

If inspired oxygen at 24% nasal cannula, PaO2 should be roughly 14 kPa

Key values

Hypoxaemia: PaO2 < 10.6 kPa or difference between inspired oxygen and PaO2

> 10

Type 1 respiratory failure: PaO2 < 8 kPa

Type 2 respiratory failure: PaO2 < 8 kPa in association with raised PaCO2

Step 2: Acid-base balance (pH)

The normal arterial pH is 7.35-7.45.

Step 2 involves checking whether the patient is ‘acidotic’ or ‘alkalotic’

Acidosis: pH <7.35

Alkalosis: pH >7.45
Step 3: Respiratory component

The respiratory component of the ABG refers to the partial pressure of carbon

dioxide (normal range 4.7-6.0 kPa).

Step 3 involves checking the PaCO2, which is a reflection of the respiratory

contribution to acid-base regulation or ‘pH control’. The PaCO2 needs to be

check in context of the pH.

Acidosis (pH <7.35) and raised PaCO2 (> 6.0 kPa): suggest primary respiratory

acidosis (high CO2 contributing to acid load). If bicarbonate is also low, suggest

mixed respiratory and metabolic acidosis.

Alkalosis (pH >7.45) and low PaCO2 (< 4.7 kPa): suggests primary respiratory

alkalosis (low CO2 causes a lower acid load). If bicarbonate also high, reflects

respiratory and metabolic alkalosis.

Step 4: Metabolic component

The metabolic component of the ABG refers to the bicarbonate level (normal

range 22-26 mmol/L).

Step 4 involves checking the bicarbonate level, which is a reflection of the renal

(or ‘metabolic) contribution to pH control. Needs to be assessed in context of

the pH and PaCO2.

Acidosis (pH < 7.35) and bicarbonate decreased (< 22 mmol/L): suggests

primary metabolic acidosis (bicarbonate falls trying to buffer excess hydrogen

ions). If the PaCO2 is also raised, would be a mixed respiratory and metabolic

acidosis.

Alkalosis (pH >7.45) and bicarbonate increased (>26 mmol/L): suggests

primary metabolic alkalosis. If the PaCO2 is also low, would be a mixed

respiratory and metabolic alkalosis.

Base excess/deficit is often used interchangeably with bicarbonate as a marker

of the metabolic contribution to pH control.

Base deficit (< -2 mmol/L): used as a marker of low bicarbonate level

Base excess (> +2 mmol/L): used as a marker of high bicarbonate level

Step 5: Compensation
Compensation refers to the appropriate attempt of the respiratory or renal

systems to restore pH.

Both respiratory compensation and metabolic compensation can occur

depending on the acid-base abnormality. Respiratory compensation, through

alteration of carbon dioxide, is a quick mechanism. Metabolic (i.e. renal)

compensation through alteration of bicarbonate is a delayed mechanism.

Respiratory compensation

Acidosis (pH <7.35) and low PaCO2 (< 4.7 kPa): suggests respiratory

compensation to acidosis (trying to compensate by reducing CO2 and thus acid

load). Seen in metabolic acidosis.

Alkalosis (pH >7.45) and high PaCO2 (> 6.0 kPa): suggests respiratory

compensation to alkalosis (trying to compensate by increasing CO2 and thus

acid load). Seen in metabolic alkalosis.

Metabolic compensation
Acidosis (pH < 7.35) and bicarbonate increased (>26 mmol/L): suggests

metabolic compensation to acidosis (trying to conserve bicarbonate ions to

buffer hydrogen ions). Seen in respiratory acidosis.

Alkalosis (pH >7.45) and bicarbonate decreased (< 22 mmol/L): suggests

metabolic compensation to alkalosis (trying to reduce bicarbonate levels to

prevent hydrogen ion buffering). Seen in respiratory alkalosis.

Step 6: Final interpretation

Final interpretation should state the contribution of respiratory and metabolic

systems and presence of compensation.

Respiratory or metabolic component

Metabolic acidosis

Metabolic alkalosis

Respiratory acidosis

Respiratory alkalosis

Mixed (e.g. metabolic and respiratory acidosis)

With mixed results, it is useful to determine which is the predominant

abnormality (respiratory or metabolic).

Compensation

Not compensated: no evidence of appropriate respiratory or metabolic

compensation. For example, no rise in bicarbonate in respiratory acidosis.

Partial compensation: evidence of appropriate respiratory or metabolic

compensation, but pH not restored to normal. For example, a fall in PaCO2 in

context of metabolic acidosis (pH 7.30, PaCO2 3.5, HCO3- 15).

Complete compensation: evidence of appropriate respiratory or metabolic

compensation and restoration of normal pH. For example, chronic respiratory

acidosis with significantly elevated bicarbonate level (pH 7.36, PaCO2 8.3,

HCO3- 38).

Interpretation example

Mrs Smith’s arterial blood gas on 35% inspired oxygen

Mrs Smith has hypoxaemia (inappropriately low PaO2 for inspired oxygen)

with a metabolic acidosis (low pH, low bicarbonate) and evidence of partial

respiratory compensation (low PaCO2 in response to acidosis).

Step 7: Review other parameters

Modern blood gas analysers give a wealth of additional information.

Make sure you look at the additional information provided to you on a blood

gas analysis. There could be multiple abnormalities including electrolyte

disturbances, acute kidney injury, raised blood glucose or significant anaemia

CONCLUSION

To conclude it was a wonderful experience to get to visit a hospital lab. As a

training medical scientist I am excited about what the future holds. I have

gained an immeasurable amount of experience for this visit and I’ve learned
so much. It was amazing to see ea what each section does. It has surpassed

my expectations and I can’t wait to go back in third year to do my work

placement in a medical laboratory.”ch department of the lab and get a

briefing of what each section does. It has surpassed my expectations and I

can’t wait to go back in third year to do my work placement in a medical

laboratory.”