REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine

Kovai Medical Center and Hospital
 ABG
(Arterial Blood Gas Analysis)

DR.LAKSHMIKANTH CHARAN.S MD.,IDCCM., EDIC.,

Dept. of Critical Care Medicine
Kovai Medical Center and Hospital
 AIM

• What is an ABG?

• When do you do an ABG?

• How do you interpret an ABG?

• How does an ABG helps us?

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 WHAT IS AN ABG?

 Arterial blood gas analysis is used to measure the pH and the partial
pressures of oxygen and carbon dioxide in arterial blood
 It provides us with information about

• ventilation,

• oxygenation and

• acid-base status,

the three closely interrelated physiology parameters, which maintain

the pH homeostasis (process that maintains the stability of the human
body's internal environment in response to changes in external
conditions.)
REFRESHER COURSE FOR CRITICAL CARE NURSES
Department of Critical Care Medicine
Decision to
Obtain an
ABG

Interpretation of
the ABG

Treating the
patient based on
the ABG

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 KEYS TO PROPER ABG MANAGEMENT

• Order the test when you need it

• Interpret the ABG fully every time, and SYSTEMATICALLY.

• Always interpret the ABG in the context of the patient you are

treating

• Don’t stop there: Treat the patient based on your

interpretation

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 WHEN TO TAKE AN ABG?

Indications for Ordering an ABG

• As with any test, get one when it will change your management for

a particular patient

• don’t get one if you will be doing something regardless of what the

ABG shows

• If there is no Arterial Line, radial arterial sticks HURT and can

result in blood vessel injury. Do it only when you need it.

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 WHEN TO TAKE AN ABG?
Indications for Ordering an ABG

• When there are concerns about VENTILATION

• Not awake enough to breathe:

• Obtunded COPD patient (due to hypercarbia)

• To verify no Hypercarbia in a patient with altered mental

status/obtundation

• Breathing too fast/concern for poor gas exchange or muscle fatigue:

• Anxious asthmatic/COPD breathing fast

• Septic patient breathing fast with concern for “tiring out”

REFRESHER COURSE FOR CRITICAL CARE NURSES
Department of Critical Care Medicine
 WHEN TO TAKE AN ABG?
Indications for Ordering an ABG

• When there are concerns about OXYGENATION when O2 Sat doesn’t

suffice :

• Concern for Carbon Monoxide Intoxication (carboxyhemoglobinemia)

or Methemoglobinemia (e.g. Benzocaine intoxication, congenital)

• On day of discharge to verify PO2 < 60, for the patient to qualify for

home oxygen

• PaO2/FiO2 is more specific

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 WHEN TO TAKE AN ABG?
Indications for Ordering an ABG

• When there are concerns about ACID-BASE BALANCE:

• Sepsis

• DKA

• Poly-drug overdose

• Increased anion gap or decreased bicarbonate on chemistries without

obvious cause

• To assess “adequacy of resuscitation” in both sepsis and trauma

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 WHEN TO TAKE AN ABG?
Indications for Ordering an ABG
• Miscellaneous:

• After intubation in all patients

• To monitor progression of disease or response to therapy in vented ICU

patients or COPD patients on BiPap/after other interventions.
• For rapid (<10 minutes) assessment of sodium, potassium, chloride, ionized
calcium (“ABG Plus”)
• During the “Apnea Test” to determine brain death

• To assess for candidacy for extubation as one of many criteria (ABG not
required in every patient)

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
INTERPRETATION OF THE ABG

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 ACID-BASE BALANCE: THEORY

• The lungs and the kidneys work in synchrony to keep the body’s pH very

close to 7.40.

• If one system goes out of order, the other (if it is functioning well) will

compensate for that problem by going in the opposite direction.

• The body will NOT compensate to get back to a pH of 7.40; if you get back

to 7.40, there is another (a “concomitant”) disorder

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 ABG INTERPRETATION

----- XXXX Diagnostics ------

The Blood Gas Report:
Blood Gas Report Normal Values
o
Measured 37.0 C
pH 7.463 pH 7.40 + 0.05
pCO2 44.4 mm Hg
pO2 113.2 mm Hg
PCO2 40 + 5 mm Hg
PO2 80 - 100 mm Hg
Calculated Data
HCO3 act 31.1 mmol / L
HCO3 24 + 4 mmol/L
O2 Sat 98.3 %
pO2 (A - a) 32.2 mm Hg

O2 Sat >95%
Entered Data A-a D 2.5+(0.21 x Age) mm Hg
FiO2 30.0 %

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 TECHNICAL ERRORS
Glass vs. plastic syringe:
Changes in pO2 are not clinically important

No effect on pH or pCO2
Heparin (1000 u / ml):
Need <0.1 ml / ml of blood
pH of heparin is 7.0; pCO2 trends down
Avoided by heparin flushing & drawing 2-4 cc blood
Delay in measurement:
Rate of changes in pH, pCO2 and pO2 can be reduced to 1/10 by

cooling in ice slush(4o C)

No major drifts up to 1 hour
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Department of Critical Care Medicine
 ABG STEPS

6
The 6 Step
Approach of ABG
Analysis

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 ABG STEPS

Step 1
Look at the pH
Is the patient acidemic pH < 7.35
or alkalemic pH > 7.45

Step 2
Is it a metabolic or respiratory disturbance ?
Acidemia: With HCO3 < 20 mmol/L = metabolic
With PCO2 >45 mm hg = respiratory

Alkalemia: With HCO3 >28 mmol/L = metabolic

With PCO2 <35 mm Hg = respiratory

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 ABG STEPS

Step 3
If there is a primary respiratory disturbance, is it acute?
Acute : Expect D pH = 0.08 x D PCO2 / 10
Chronic: Expect D pH = 0.03 x D PCO2 / 10

Step 4
For a respiratory disorder is renal compensation OK?

Respiratory acidosis: <24 hrs: D [HCO3] = 1/10 D PCO2

>24 hrs: D [HCO3] = 3/10 D PCO2

Respiratory alkalosis: 1- 2 hrs: D [HCO3] = 2/10 D PCO2

>2 days: D [HCO3] = 6/10 D PCO2
REFRESHER COURSE FOR CRITICAL CARE NURSES
Department of Critical Care Medicine
 ABG STEPS

Step 5
If the disturbance is metabolic is the respiratory
compensation appropriate?

For metabolic acidosis:

Expect PCO2 = (1.5 x [HCO3]) + 8 + 2
(Winter’s equation)

For metabolic alkalosis:

Expect PCO2 = (0.7 x [HCO3]) + 21 + 1.5

If not:
actual PCO2 > expected : hidden respiratory acidosis
actual PCO2 < expected : hidden respiratory alkalosis

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 ABG STEPS

Step 6
If there is metabolic acidosis, is there an anion gap?
- -
Na - (Cl + HCO3 ) = Anion Gap usually <12

If >12, Anion Gap Acidosis : Methanol

Uremia
Diabetic Ketoacidosis
Paraldehyde
Infection (lactic acid)
Ethylene Glycol
Salicylate

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Department of Critical Care Medicine
HOW IS IT USEFUL?

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 NON-ANION GAP ACIDOSIS DDX

• Renal Tubular Acidosis • Rapid IV Hydration

• Intestinal loss of bicarb • Correction of Respiratory
• Diarrhea Alkalosis
• pancreatic fistula • Hyperalimentation
• Ureteroenterostomy
• Drugs
• Acetazolamide
• Cholestyramine
• Acidifying agents
• Aldactone

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
METABOLIC ALKALOSIS DIFFERENTIAL

• “Chloride Unresponsive”
• “Chloride Responsive”
(Urine Na> 20)
(Urine Na <10) – Hypokalemia (get your
• GI Losses (vomiting, gastric Magnesium up too!)
drainage, etc.) – Excess Mineralocorticoid
• Diuretics (1° hyperaldo, Cushing’s,

• Rapid correction of chronic ACTH excess, 2°

hypercapnea hyperaldo, etc.)

• Cystic Fibrosis – Bartter’s Syndrome

– Renal insufficiency
• Laxative Abuse

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
RESPIRATORY ALKALOSIS DIFFERENTIAL

• The most important causes include

• EARLY SEPSIS
• Pain, Anxiety, Agitation
• Hepatic Failure
• Salicylate Toxicity

Note: Is normal in pregnancy and in high altitudes

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 ----- XXXX Diagnostics ------

Blood Gas Report Case 1

pH <7.35 ; acidemia
pCO >45; respiratory acidemia
2
o
Measured37.0 C D CO2 =70-40=30
pH 7.310
pCO2 70.2 mm Hg Expected D pH = 30/10 x0.08=0.24
pO2 45.5 mm Hg 30/10 x0.03=0.09
60 year old
Expected pHmale smoker
= 7.40-0.24=7.16
Calculated Data with progressive7.40-0.09=7.31
HCO3 act 33.2 mmol / L respiratory distress
Chronic resp. acidosis
and somnolence.
O2 Sat 78 % Limits:
pO2 (A - a) 9.5 mm Hg D DHCO3 = 3/10 of D pCO2
pO2 (a / A) 0.83 =3/10x30=9
Limits of HCO3 = 24+9=33
Entered Data Pure Resp Acidosis
FiO2 21 %
Hypoxia

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 ----- XXXX Diagnostics ------
pH <7.35 ; acidemia
Blood

Measured
Gas

37.0 C
Report
o
Limits:
Case 2
pH 7.23 Expected pCO2 = (1.5 x HCO3)+8 + 2
pCO2 28 mm Hg = (1.5 x 14)+ 8 + 2
pO2 110.5 mm Hg = 29
28 + 2old
year = 27 to 31 with
diabetic
Calculated Data Met. Acidosisrespiratory distress
HCO3 act 14 mmol / L fatigue and
HCO3 <22; metabolic acidemia
loss of appetite.
O2 Sat %
pO2 (A - a) mm Hg D
pO2 (a / A)
If Na = 130,
Entered Data Cl = 100
FiO2 21.0%
Anion Gap = 130 - (100 + 14)
= 130 - 114= 16

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine
 Thank You!

REFRESHER COURSE FOR CRITICAL CARE NURSES

Department of Critical Care Medicine