PEDIATRIC

ARTERIAL
BLOOD GAS
ANALYSIS
 INTRODUCTION

> The need for repeated samplings of arterial

blood for blood gas analysis in infant and small
child with severe respiratory or circulatory
disease leads to technical problems because
of the small size of the patient's arteries.
> On the other hand, blood gas values
obtained from arterialized capillary blood
correlate poorly with true arterial samples in
infants with cardiopulmonary disease.
  Several techniques are available for
arterial sampling, including methods of
multiple brachial or radial artery sampling.
Umbilical artery catheterization may be
used in the first few days of life.
In older infants, an arterial cutdown may
be necessary for placement of an
indwelling catheter, while in patients over
15 kg (33 lb) in weight, percutaneous
arterial cannulae can usually be placed. 
 BLOOD GAS is a test that helps determine
respiratory function, particularly how well a
child’s body is exchanging oxygen and
carbon dioxide, as well as the acid/base
status (pH) of the blood. While most
commonly used to determine a child’s
respiratory status, blood gases can also
assess issues caused by metabolic or renal
disorders.
 PURPOSE
> To determine the presence and type of
acid – base balance.
> To check for severe breathing problem
and lungs diseases.
> Assessment of the response to the
therapeutic intervention such as
mechanical ventilator.
 TYPES OF BLOOD GAS TESTS

There are three basic methods of obtaining

blood gases, based on how the sample is
acquired:
Arterial Blood Gas (ABG)
Capillary Blood Gas (CBG)
Venous Blood Gas (VBG)
 ARTERIAL BLOOD GASES (ABG) are the
most reliable, but require blood to be
obtained from an artery. Children in the
NICU or PICU may have a line placed in an
artery if frequent blood gases are needed.
Other children will need to have an arterial
stick, which is like drawing blood but from
an artery instead of a vein. This can be
painful and can cause considerable
bleeding for many children.
 Because Arterial Blood Gases can be
difficult to obtain without significant pain
or an arterial line, doctors often request a
Capillary Blood Gas (CBG) for more routine
checks of the body’s respiratory status. A
CBG only requires a finger prick or heel
stick, and is much less painful than an
ABG. The results, however, are not as
reliable as an ABG.
 Venous Blood Gases (VBG) are even more
unreliable, but may be required under certain
circumstances when an ABG or CBG cannot be
performed, as well as in some patients with
central lines who need ongoing monitoring. A VBG
typically provides an accurate pH level as well as a
decent carbon dioxide level, but the oxygen level
tends to read much lower as compared to an ABG.
The results are most useful in determining trends
or assessing children with milder conditions when
precision is not necessary.
 WHAT IS MEASURED?
A blood gas typically measures 3 things:
1. the pH of the sample (how acidic or
basic it is)
2. the oxygen level and
3. the carbon dioxide level.
Using these three values, as well as known
factors such as body temperature and
normal hemoglobin values, it is possible to
calculate a variety of additional numbers.
 THESE ARE THE VALUES TYPICALLY
MEASURED OR CALCULATED IN A BLOOD GAS:

pH: How acidic or basic the blood is.

PO2: The dissolved oxygen in the blood.
PaO2 is for arterial blood;
PvO2 is for venous blood.
PCO2: The dissolved carbon dioxide in the
blood. PaCO2 is for arterial blood;
PvCO2 is for venous blood.
 O2 saturation (SpO2): How much oxygen
the blood is carrying as a percentage of
how much it can carry.
HCO3: A calculation of how much
bicarbonate (base) is in the blood.
Base Excess/Deficit: A calculation to
determine the positive (excess) or negative
(deficit) amount of buffer (base) that has
been used up by the body.
 Arterial Capillary Venous

pH 7.35-7.45 7.35-7.45 7.32-7.42

PO2 80-100 mmHg 60-80 mmHg 24-48 mmHg

PCO2 35-45 mmHg 35-45 mmHg 38-52 mmHg

O2 Sat 90-100% 90-100% 40-70%

HCO3 19-25 mEq/L 19-25 mEq/L 19-25 mEq/L

Bases -3 to +3 -3 to +3 -3 to +3
Excess/Deficit

Normal values in children over the age of two are listed in the chart above.
Note that your lab may have slightly different values, and your child’s age and
condition may also change the range of what is considered normal.
 WHAT DOES IT MEAN?

Interpretation of blood gas results can be

challenging, even for nurses and other
medical professionals. The results must be
correlated with clinical data in order to
have meaning.
 For example, in a child with ongoing
respiratory insufficiency, a blood gas may
be performed periodically to ensure that
the child is able to blow off enough carbon
dioxide. In this instance, the most
important numbers are the PCO2 and
HCO3. If both of these numbers are high, it
suggests that the child is not adequately
ridding her body of carbon dioxide.
 In acutely ill children, looking at groups of
numbers can suggest the cause of the illness. For
example:
A low pH and high PCO2 suggests an acute
respiratory acidosis (too much acidity of the blood
caused by a respiratory issue), such as from not
breathing adequately
A low pH with a low HCO3 and normal PCO2
suggests an acute metabolic acidosis (too much
acidity of the blood caused by a metabolic issue),
such as severe dehydration
 A high pH and a low PCO2 suggests an
acute respiratory alkalosis (too little acidity
of the blood caused by a respiratory issue),
such as in hyperventilation from asthma
A high pH with a high HCO3 and normal
PCO2 suggests an acute metabolic
alkalosis (too little acidity of the blood
caused by a metabolic issue), such as with
vomiting
It is also possible to have chronic problems
with respiratory or metabolic acidosis, or
respiratory or metabolic alkalosis. A child
can also have a mixed state, such as a
metabolic acidosis combined with a
respiratory alkalosis, which can be seen in
severe asthma.
 BASIC FACTS TO REMEMBER
1.CO2 is a respiratory component and
considered a respiratory acid. It moves
opposite to the direction of pH and is
visualized as a see-saw (as paCO2 in blood
increases, pH decreases—respiratory
acidosis) 
RESPIRATORY ACIDOSIS
Visualization of Ph and pa CO2.
 BASIC FACTS TO REMEMBER

2. Bicarbonate is a metabolic component

and considered a base. It moves in the
same direction as pH and is visualized as
an elevator (Fig. 4) (as bicarbonate in blood
increases, pH increases—metabolic
alkalosis) [4].
 METABOLIC ALKALOSIS
Visualization of pH and bicarbonate as an
elevator.
 BASIC FACTS TO REMEMBER

3.If CO2 and HCO3− move in the same

direction, it is considered a primary disorder;
for example, if there is respiratory acidosis in
the body (CO2 retention), the bicarbonate
levels increase as a compensation
(metabolic alkalosis). The directions of both
CO2 and HCO3− are the same in this case.
 BASIC FACTS TO REMEMBER

4.If CO2 and HCO3− move in opposite

directions, it is considered a mixed
disorder; for example, mixed disorder in
the case of salicylate poisoning: primary
respiratory alkalosis due to salicylate-
induced hyperventilation and a primary 
metabolic acidosis due to salicylate
toxicity.
 ACID–BASE BALANCE 
> is a reflection of the pH level. The pH is the
measurement of the acidity or alkalinity of any
fluid and is recorded on a scale from
1 (very acidic) to 14 (very alkalotic).
> A fluid with a pH of 7 (water) is considered
neutral. The pH of blood falls within a narrow
range of 7.35–7.45. This range is essential for the
body systems to function properly.
> Mechanisms are in place to ensure that a
constant state of acid–base equilibrium exists
within the blood at all times. 
 > Significant alterations from this range
can interfere with cellular functioning and
ultimately, if uncorrected, death.
> Therefore, it is essential that nurses
recognize when a patient is not able to
maintain this delicate balance, and
intervene appropriately.
 MEASURING PH
> To quantify the H+ concentration in
blood, a simplified mathematical
expression, called pH, is used. In health,
the normal range for pH is 7.35–7.45.
> pH is a negative logarithm, which means
that the higher the H+ concentration, the
lower the pH and vice versa
 MAINTAINING ACID–BASE BALANCE

> The 3 systems that regulate the 

acid–base balance are the buffer system
(metabolic), kidneys (metabolic) and the lungs
(respiratory).
> The lungs regulate carbon dioxide (CO2) and the 
renal system regulates bicarbonate (HCO3), one of
the body’s buffers.
> Therefore, to maintain the tight balance both the
respiratory and metabolic system work together in
an attempt to compensate for any abnormalities
 OXYGENATION
> Determination of oxygenation should be
included in any physical assessment.
> When assessing ventilation status, it is
important to look at the PaO2 and SaO2 levels.
>The PaO2 represents the amount of oxygen
dissolved in the blood. A normal value for 
arterial blood gas is 80–100 mmHg.
> The SaO2 represents the amount of oxygen
bound to hemoglobin. 
 > A normal SaO2 value for arterial blood
gas is 95–100%. It is also important to
note that assessment of ABGs includes
determining the need for and treatment of 
pulmonary disease and determining 
acid–base balance in a patient with heart
failure, renal failure, uncontrolled diabetes,
a sleep disorder, severe infection, and 
drug overdose
ABG pH PaCO2 HCO3
Respirator
y acidosis normal

Respiratory acidosis
Causes of Respiratory Acidosis
> Hypoventilation
> Neuromuscular Weakness
(Guillian Barre Syndrome)
> Obesity
> Asthma
 2. RESPIRATORY ALKALOSIS
- it is defined as a pH greater than 7.45
with a PaCO2 lesser than 35 mmHg.
- alkalosis is due to excessive wash of co2
(hyperventilation), thus increasing the pH
of the blood.
 ABG pH PaCO2 HCO3

Respiratory normal
alkalosis

RESPIRATORY ALKALOSIS
 CAUSES
> Hyperventilation
> Fluid loss
> Liver disease
> Alteration in gas exchange
> Pneumonia
> Stress Clinical Ma
 3. METABOLIC ACIDOSIS
- it is defined as a pH less than 7.35 with a
HCO3 less than 22 meq/l
toxic causes: any disorder that will lead to
tissue hypoperfusion whatever the cause
will lead eventually to increase in lactic
production resulting in metabolic acidosis
 ABG pH PaCO2 HCO3
Metabolic normal
Acidosis

METABOLIC ACIDOSIS
1. Late salicylate
2. methanol
3. ethylene glycol
4. iron
 CAUSES
> Alcohol
> Cancer
> Diarrhea
> Liver failure
> Poisoning by aspirin and methanol
> Sever dehydration
> Seizure
 4. METABOLIC ALKALOSIS
- it is defined as a pH greater than 7.45
with HCO3 greater than 28 meq/l
Causes:
- it is due to excessive acid loss (repeated
vomiting & nasogastric suction) or
bicarbonate retention e.g. overuse of
sodium bicarbonate.
 ABG pH PaCO2 HCO3

Metabolic normal
Alkalosis

METABOLIC ALKALOSIS
 CAUSES
• Alcohol abuse
• Hyperaldesteron
• Diarrhea and vomiting
• High fever
• Diuretic therapy
• Cystic fibrosis
 NURSING DIAGNOSIS

• Impaired gas exchange

• Ineffective Breathing pattern
• Ineffective tissue perfusion
• Risk of infection at puncture site
• Risk of injury
 WHY AN ABG INSTEAD OF PULSE
OXIMETRY?

- Pulse oximetry uses light absorption at

two wavelengths to determine hemoglobin
saturation.
- Pulse oximetry is non-invasive and
provides immediate and continuous data.
WHY AN ABG INSTEAD OF PULSE OXIMETRY?
- Pulse oximetry does not assess ventilation
(pCO2) or acid base status.
- Pulse oximetry becomes unreliable when
saturations fall below 70-80%.
- Technical sources of error (ambient or
fluorescent light, hypoperfusion, nail polish,
skin pigmentation)
- Pulse oximetry cannot interpret
methemoglobin or carboxyhemoglobin.
 REFERENCES:
https://
www.sciencedirect.com/science/article/pii
/S0422763815301175#b0035

https://
emedicine.medscape.com/article/906440
-workup

https://emedicine.medscape.com/article/
906440-workup
THANK
YOU