ARTERIAL BLOOD GAS

ANALYSIS

Dr.Rakesh Chandra Chaurasia

PGT 3
IMS,BHU
Moderator: Dr.Manjaree Mishra
Asset.prof.
 What is an ABG?

• Arterial Blood Gas

• Drawn from artery- Radial, Brachial,

Femoral

• It is an invasive procedure
 Why to order an
ABG?
• Assess adequacy of ventilation and oxygenation

• Aids in establishing a diagnosis and severity of respiratory

failure

• Assess changes in acid- base homeostasis

• Helps to guide treatment plan

• Helps in management of ICU patients.

 Components of an ABG
– pH

– PaCO2

– PaO2

– HCO3

– O2saturation

– BE
 Others include

• Haemoglobin
• Hematocrit
• Na
• K
• Glucose
• Standard bicarbonate
• Buffer base
• Standard base excess
• TCO2
• Base Excess: It indicates increase in the amount
of buffer base.
• It is the number of mmol of strong acid needed
to adjust pH to 7.4 at PCO2 40 mm Hg.

• Base Deficit: It indicates decrease in the

amount of buffer base.
• Standard bicarbonate
It is the bicarbonate conc. In plasma in a completely
oxygenated blood sample at Pco2 of 40 mm Hg at 370C .

SBC > 24 mmol/l indicates metabolic

alkalosis SBC<24 mmol/lindicates metabolic
acidosis
Buffer base
It is the total equivalent conc. of all anion buffer
components of blood . Normal value =48 mmol/L
• Standard base excess
• It gives a view of the base excess of the entire
extracellular fluid.
• It indicates average Hb of the fluid space through which
bicarbonate distributes.
• standard base excess is the value when the
hemoglobin is at 5 g/dl.
Total plasma CO2 (T-CO2)
Total content of the CO2 normal value= 27 meq/L
 Normal Values

– pH - 7.35 - 7.45

– PaCO2 - 35-45 mmHg

– PaO2 - 80-100 mmHg

– HCO3 - 22-26

– O2sat - 95-100%

– Base Excess - +/-2 m Eq/L

 HOW TO DRAW AN ABG..???

• Equipments
• Site Selection
• Contraindication
• Puncture procedure
• Post puncture procedure
• Sample handling
 Equipments

1. One 1 cc to 5 cc vented, pre-heparinized, plastic syringe

2. One 20 - 25 gauge 1 –1 1/2” needle

Longer needles for brachial and femoral artery puncture

3. One Biohazard labelled plastic bag

4. . Two 1 x 1 inch sterile gauze

• 5. Alcohol prep pad
• 6. Specimen/Patient label
• 7. Iodine pad
• 8. One adhesive bandage
• 9. Lab Form
• 10. Ice
 Site Selection

• Radial Artery - 45 insertion angle

• Brachial Artery - 60 - 90 insertion angle

• Femoral Artery - 90 insertion angle

• Dorsalis Pedis Artery

• Posterior Tibial artery

KK
 Contraindication

• No absolute contraindications

• Dialysis shunt – choose another site

• Mastectomy – use opposite side

• Patient on anticoagulant/aspirin therapy – may have to hold

pressure on puncture site longer than normal
 Site specific contraindication

Radial : Buergers disease

Raynauds
Absent Ulnar collateral circulation AV
dialysis shunt

Femoral: Local infection

 Puncture procedure

1. Check for orders

2. Explain the patient about compression of puncture site
3. Make positive patient I.D.
4. Put on gloves
5. Assemble needle to syringe
a. keep needle sterile
b. eject excess heparin and air bubbles
c. pull back syringe plunger to at least 1 cc
 4 things that “hurt”

1. Needle through skin (sharp)

2. Needle through arterial wall (blunt)

3. Miss & catch nerve (shooting)

4. Miss & hit periostium (sharp)

 Site selection

1. Radial artery is always the first choice because it provides

collateral circulation.
• A. Palpate the right and left radials arterial pulse and
visualize the course of the artery.
• B. Pick strongest pulse
i. if radial pulse weak on right, move to left
ii. if pulse on left weak, then try brachial
• 2. Brachial used as alternative site
• 3. Femoral is the last choice in normal situations
Highest complication rate
ABG Specimen Collection/Handling

• Temperature correction specimen in analyzer

• Increase in patient temp: PO2, PCO2,

pH

• Decrease in patient temp: PO2, PCO2,

pH
 Technical Causes of Abnormal Results

• 1. Room air mixed with sample

• a. PaO2 will equilibrate to above 160

• 2. CO2 will be lower due to equilibration

• 3. Delay in running sample

• O2 consumption will continue as will CO2 production –

pH decreases
• Iced, sample will last an hour without a change in the
result
• un-iced, ABG's can be significantly changed after 10
• 4. Venous sample drawn
• a. Usually this in patients with shock
• b. Should doubt when PO2 is significantly lower than expected
• i. draw venous blood to check comparison or
• ii. redraw sample
• 5. Heparin

• a. Sodium Heparin 1% solution should be used

• b. ammonium heparin will alter pH

• c. dry lithium heparin is OK

• • All unnecessary heparin should be ejected from syringe, excess

can effect results
• 6. Patient pain
• a. Can cause hyperventilation or breath holding
• b. An anaesthetic may be injected prior to stick for pain
• • Usually 2% lidocaine
• • CAUTION – some people allergic to “caines”

• 7. Machine errors
• a. Improper calibration
• b. Air bubbles in electrode
 Calculation of pH

• pH is calculated from Henderson-

Hasselbalch equation .
• pH = pK + log acid/base
• pH = 6.1 + log HCO3-
H2CO3

Kassirer and Bliech modified equation

• H+ = 24 x PCO2/HCO3-
 Acid base disorders

• Acidemia –pH less than 7.35

• Acidosis – A process that would cause

acidemia, if not compensated

• Alkalemia–pH greater than 7.45

• Alkalosis – A process that would cause

alkalemia if not compensated
Four primary acid-base disorders

• Metabolic acidosis
• Metabolic alkalosis
• Respiratory acidosis
• Respiratory alkalosis
 SIMPLE VS. MIXED ACID-BASE DISORDER

Simple acid-base disorder – a single primary

process of acidosis or alkalosis.

Mixed acid-base disorder – presence of more

than one acid base disorder simultaneously
 COMPENSATION

The normal response of the respiratory system

or kidneys to change in pH induced by a primary
acid-base disorder
a. Renal compensation – kidneys adapt to alterations
in pH by changing the amount of HCO3-
generated/excreted.
Full renal compensation takes 2-5 days

b. Respiratory compensation – alteration in ventilation

allow immediate compensation for metabolic acid-
base disorders
Characteristics of  acid-base disorders
DISORDER PRIMARY RESPONSES COMPENSATOR
Y RESPONSE

Metabolic  [H+]  PH
acidosis  HCO3  pCO2
-

Metabolic  [H+]  PH  HCO3

alkalosis -
 pCO2

Respirator  [H+]  PH  pCO2

y acidosis  HCO3
-

Respirator  [H+]  PH  pCO2  HCO3

y alkalosis -
 Prediction of compensation
-
Metabolic acidosis PaCO2= (1.5 x HCO3 ) + 8 ± 2

PaCO2 will↑ 0.75 mmHg per

Metabolic alkalosis mmol/L ↑ in [HCO 3 ]
-

[HCO3-] will ↑ 0.1 mmol/L per

Acute
mmHg in PaCO2
Respiratory
acidosis [HCO3-] will ↑ 0.4 mmol/L per
Chronic
mmHg in PaCO2
[HCO3-] will ↑ 0.2 mmol/L per
Acute
Respiratory mmHg in PaCO2
alkalosis [HCO3-] will ↑ 0.4 mmol/L per
Chronic
mmHg in PaCO2
 Anion Gap

• Anion gap used to assess acid-base status in

D/D of meabolic acidosis

Anion gap based on principle of electro

neutrality:

• Total Serum Cations = Total Serum

Anions
• Na – (HCO3 + Cl) = Anion gap
• Normal Anion gap – 10 +/- 2meq/L
 Albumin is the major unmeasured anion

The anion gap should be corrected if there are

gross changes in serum albumin levels.

G (CORRECTED) = AG + { (4 – [ALBUMIN]) ×
5}
 Delta gap

• Difference between
– Change in anion gap (
AG)
– Change in bicarbonate ( HCO3- )

• Based on assumption that for each 1 meq/L

increase in AG, HCO3 will fall by 1 meq/L , to
maintain a stable anion content.

• Usual range: -6 to +6 meq/L ; should be 0

 AG =  HCO3-  Pure High AG Met Acidosis

 AG > HCO3- ( Gap >6)  HCO3- does not

decrease as expected.
Associated Metabolic Alkalosis or respiratory acidosis

 AG <  HCO3- ( Gap < -6)  HCO3- does not

increase as expected
Associated N AG Met Acidosis or rarely respiratory
alkalosis
Delta ratio may also be calculated
 PLASMA OSMOLAR GAP
Calculated Plasma Osmolarity = 2[Na+] + [Gluc]/18 +
[BUN]/2.8

Normal Measured Plasma Osmolarity > Calculated

Plasma Osmolarity (upto 10 mOsm/L)

Measured Plasma Osmolarity - Calculated Plasma

Osmolarity > 10 mOsm/kg indicates presence of abnormal
osmotically active substance
Ethanol
Methanol
Ethylene glycol
 URINARY ANION GAP

• Urinary NH + levels can be estimated by calculating the

4
urine anion gap (UAG)
• UAG = [Na+ + K+]u – [Cl–]u
• [Cl–]u > [Na+ + K+], the urine gap is negative by definition

• Helps to distinguish GI from renal causes of loss of

HCO3 by estimating Urinary NH4+ (elevated in GI
HCO3 loss but low in distal RTA).
• Hence a -ve UAG (av -20 meq/L) seen in former
while
+ve value (av +23 meq/L) seen in latter.
 Urine PH

• Non AG metabolic acidosis:

– If urine pH > 5.5 : Type 1 RTA
– If urine pH < 5.5 : Type 2 or
Type 4 RTA

• Type 2 or Type 4 RTA can be later

differentiated using serum K+ level
METABOLIC ACIDOSIS
 Causes of High AG Met Acidosis
1. Ketoacidosis:
Diabetic
Alcoholic
Starvation
2. Lactic Acidosis:
Type A (Inadequate O2 Delivery to Cells)
Type B (Inability of Cells to utilise O2)
Type D (Abn bowel anatomy)
3. Toxicity:
Salicylates Paraldehyd
Methanol e Toluene
Ethylene Glycol

4. Renal Failure
5. Rhabdomyolsis
 CAUSES OF NORMAL ANION GAP
METABOLIC ACIDOSIS

1. HCO3 loss:
GIT Diarrhoea
Pancreatic or biliary drainage
Urinary diversions
(ureterosigmoidostomy)

Renal Proximal (type 2) RTA

Ketoacidosis (during therapy)
Post-chronic hypocapnia
2. Impaired renal acid excretion:
Distal (type 1) RTA
Hyperkalemia (type 4) RTA
Hypoaldosteronism

3. Misc:
Acid Administration (NH4Cl)
Hyperalimentation
Cholestyramine Cl
HCl therapy (Rx of severe
met alkalosis)
METABOLIC ALKALOSIS
 CAUSES OF METABOLIC
ALKALOSIS
1.EXOGENOUS HCO3- LOADS
Acute alkali administration
Milk – alkali syndrome
2.Effective ECFV contraction, normotention, K+ deficiency and
secondary Hyperreninemic hyperaldosteronism:

GI LOSS: Vomiting
Gastric Aspiration
Villous adenoma
 RENAL LOSS : Diuretics
Post hypercapnic state
Hypercalcaemia
Recovery from LA/KA
Mg2+ deficiency
Bartters/Gitelmans syndr
Nonreabs anions –
penicill
3. ECFV expansion, hypertension,K+ deficiency,
and mineralocorticoid excess:
HIGH RENIN : RAS
Accelerated hypertension
Renin sec tumor
LOW RENIN :
PRIMARY ALDOSTERONISM –
Adenoma, hyperplasia , carcinoma
ADRENAL ENZYME DEFECTS –
11 b Hydroxylase, 17 alfa Hydr def
CUSHINGSSYNDROME OR DIS.
OTHERS-licorice, carbenoxolone

4. Gain of function mutation of renal sodium

channel with ECF expansion , hypertension , K+
deficiency and hyporeninemic hypoaldosteronism :
LIDDLES SYNDROME
RESPIRATORY ACIDOSIS
 Causes of Respiratory Acidosis
1.CENTRAL :
Drugs( anesthetics, morphine , sedatives)
Stroke
Infection
2. AIRWAY :
Obstruction
Asthma
3. PARENCHYMA
:
Emphysema
Pneumoconiosis
Bronchitis
ARDS
Barotrauma
• 4. NEUROMUSCULAR :
• Poliomyelitis
• Kyphoscoliosis
• Myasthenia
• Muscular dystrophies
5. MISCELLANEOUS
• Obesity
• Hypoventilation
• Permissive Hypercapnia
Respiratory Alkalosis
 Causes of Respiratory Alkalosis

1.CENTRAL NERVOUS SYSTEM STIMULATION

Structural Causes Non Structural Causes

Head trauma Pain
Brain tumor Anxiety
CVA Fever
Meningitis, Psychosis
encephalitis
2. HYPOXEMIA OR TISSUE
HYPOXIA
Pneumonia, pulm oedema
Aspiration
High Altitude
 3. STIMULATION OF CHEST RECEPTORS
:
• Hemothorax
• Flail chest
• Cardiac failure
• Pulmonary embolism
4. MIXED/UNKNOWN
MECHANISMS: Drugs – Salicylates Nicotine
Progesterone Thyroid hormone
Catecholamines
Xanthines (Aminophylline & related compounds)
Cirrhosis
Gram –ve Sepsis
Pregna
ncy Heat
exposure
Mecha
A Stepwise
Approach
to Solving
Acid-Base
Disorders
Assessment of validity of test results
• H+ in nmol/L = 24 × PCO₂/HCO₃

• If there is a discripancy between the 2

results, the blood should be reanalyzed.
Assessment of validity of test results
Relation b/w pH & H+ conc.
pH [H+] in nanomoles/L

7.00 100
7.10 80
7.30 50
7.40 40
7.52 30
7.70 20
8.00 10

pH is inversely related to [H+]; a pH change of 1.00

represents a 10-fold change in [H+]
Analyse the adequacy of oxygenation..
 STEP -2 : Comprehensive history and physical
examination.

 STEP -3 : Acidosis or alkalosis..???

See the pH (<7.35 or >7.45)

 STEP -4 : Identify the primary disorder

See the change in PCo2 & HCO3

 STEP -5 : Calculate the compensatory

response
Is adequately compensated???
 STEP -6 : Calculate anion gap

STEP -7 : Calculate the delta gap (unmask hidden

mixed disorders)

STEP -8 : Calculate the osmolar gap (for high AG

acidosis)

STEP -9 : Calculate the urinary anion gap (Non

AG metabolic acidosis)

 STEP -10 : Formulate differential diagnosis