ARTERIAL BLOOD GAS

ANALYSIS
Basics on blood chemistry and
ABG/VBG interpretation.
Luke Heath
 The basics
 Always remove any air gap
and cap the syringe after taking
the blood.
 Invert the syringe to mix the
blood with the heparin.
 Process the sample within 10
minutes and invert regularly
while waiting.
 Add all requested information
including FiO2, as many values
are calculated.
 Venous gasses have differing
respiratory readings from
arterial.
 Cellular Respiration
C6H12O6 (Glucose) + 6 O2 (Oxygen) =
6 CO2 (Carbon Dioxide) + 6 H20
(Water) + Energy (ADP to ATP)

Every living cell is performing the

above process, and will die very
quickly without oxygen. Blood must
transport oxygen and glucose to all
cells and remove the carbon dioxide
from them. Blood is the lifeline for
every cell in the body.
The Fundamentals of
blood chemistry.
1. Acidity is related to free hydrogen ions
in solution.
2. Carbon dioxide in solution is acidic.
3. Haemoglobins (Hb) affinity for oxygen
is related to acidity.
4. The body must try to maintain
homeostasis.
 What is an acid?
 Acidity is measured on the pH scale, going from 0 to 14.
 Think of pH as the ‘power of Hydrogen’ (in the form of
free hydrogen ions, H+).
 The scale is a negative log. Each one point represents a
ten fold increase/decrease in hydrogen ions, so small
changes in number represent large changes in H+ ion
concentrations. The lower the number, the more acidic
the solution.
 Different chemicals and metabolites can result in free
hydrogen ions in solution and therefore a drop in pH
(increased acidity).
 CO2 is acidic in solution.
CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3-
(Carbon dioxide and water ↔ carbonic acid [weak acid] ↔ hydrogen ion and
bicarbonate)

The equation will balance itself (form an equilibrium), so if

there is a rise in CO2, there will be a corresponding increase in
H+ and HCO3-. Since H+ is responsible for acidity, the more CO2
dissolved in blood plasma, the more acid the blood becomes.
 Hb is sensitive to pH
Haemoglobin has a reduced affinity for oxygen the more
acid the blood becomes. Oxygen at greater pressure is
required to overcome this decreased affinity. This is called
the Bohr effect.
 When things work properly...
1. The pH of the blood is normal in the lungs, so Hb
has a high affinity for O2 and they bond.
2. In active cells CO2 is produced by respiration, this
creates an acid environment and O2 becomes less
bonded to Hb and is released to be used by the
cells (the Bohr effect). CO2 will now bond with Hb
3. When the blood reaches the lungs CO2 levels drop,
the blood becomes less acid and oxygen levels rise
helping push CO2 from Hb allowing O2 to bond
(the Haldane effect).
 Blood pH control - Ventilation
 The body has two methods of controlling blood
pH. Firstly, by controlling ventilation which will in
turn control the level of CO2 in the blood. Respiratory
rate is the primary control, but tidal volumes can also
increase to help change pH rapidly.
 Bicarbonate (HCO3-) is called a ‘buffer’, because
excess hydrogen ions can combine with it to reduce
their effect on pH. Non-respiratory hydrogen ions
can be removed as CO2 because of it, which is why
there is always a store of bicarbonate in the blood.
 Blood pH control – The kidneys
 The second method is via the kidneys,
which are able to excrete H+ or HCO3- in the
urine to adjust pH. This renal (or metabolic)
control takes many hours or days to effect
change
 It will be seen in COPD patients, who will
increase their bicarbonate levels to prevent an
acid blood despite their raised CO2 levels.
However, ventilation is the primary pH
control, which is why respiratory rate is such
an important clinical observation.
 Measuring dissolved gasses.
Oxygen and carbon dioxide are measured in the
blood by their partial pressure (sometimes called
‘tension’).
 The symbol is p.
 The unit of measurement of this pressure is
kilopascal, abbreviated to kPa.
 In normal arterial blood the partial pressure of
carbon dioxide is 4.6 – 6.4 kPa, and for oxygen it
is 11 – 14 kPa.
 A venous sample will have a lower oxygen and
slightly raised carbon dioxide.
 Respiratory Acidosis
 Blood pH should be between 7.35 -7.45.
 When ventilation or lung function are
compromised, CO2 levels rise in the blood
resulting in a raised pCO2 (> 6.4 kPa) and
acidic blood (< 7.35).
 Small changes in pH represent substantial
changes in hydrogen ion concentrations, so a
pH < 7 is sever acidosis. It indicates that the
blood cannot function properly because Hb
will have lost its affinity to carry oxygen.
 Respiratory Failure
Type 1
Hypoxia (low O2) without hypercapnia (raised
CO2 ).
pO2 < 8 kPa but pCO2 normal

Type 2
Hypoxia with hypercapnia.
pO2 < 8 kPa with pCO2 >7
 Bicarbonate
 Bicarbonate (HCO3-) is measured in mmol/L
(millimole per litre).
 The normal range is 22 -26 mmol/L.
 It helps ‘buffer’ hydrogen ions by promoting their
transfer into carbonic acid (which is less acidic than
hydrogen ions) and then CO2.
 Excess bicarbonate can lead to metabolic alkalosis,
too little to metabolic acidosis. The base deficit is a
calculation of how much bicarbonate would be
required to normalise a deficiency, the base excess
how much extra has been produced.
 Metabolic Acidosis
When the pH is < 7.35 and the pCO2 is not raised
the cause of the acidosis will probably be
metabolic. Bicarbonate will be reduced (base
deficit) as it bonds with H+ to push the equation to
the left. This can be from:

1. Lactic acid from non-oxygen respiration due to

high metabolic requirements (infection) or
hypoxia.
2. Ketoacidosis from fat metabolism in DKA.
3. Kidney failure.
 Respiratory Acidosis
When the pH is < 7.35 and the pCO2 is raised the
cause of the acidosis will probably be respiratory.
PO2 may be reduced or have been partially
corrected with increased FiO2. Bicarbonate will
be reduced (base deficit) as it bonds with H+ to
push the equation to the left. This can be from:

1. Hypoventilation (CVE, opiate, obstruction)

2. Pulmonary embolism.
3. Chest trauma (mechanical failure)
 Metabolic Alkalosis

When the pH is > 7.45 and the pCO2 is not low,

then the alkalosis will probably be metabolic in
nature. Bicarbonate may be raised (base excess).
It can be caused by:

1. Loss of hydrogen ions (vomiting – look at the

chloride levels)
2. Excess bicarbonate (chronic hypoventilation)
3. Potassium ion exchange (hypokaleamia
response)
 Respiratory Alkalosis
When a person
hyperventilates CO2 is
‘blown off’ causing blood
pH to rise (become
alkaline) resulting in a pH
> 7.45 and a pCO2 < 4.7
kPa. The pCO2 is a good
indicator of ventilatory
effectiveness.
 Compensation responses
Since there can be controlled and uncontrolled
metabolic or respiratory acidosis or alkalosis, it
follows that when an uncontrolled system creates an
acidosis a controlled system can try and correct it. In
chronic conditions the compensation will be
marked, in acute ones less so, but some
compensation will occur. However,
your body never over-compensates.
 Respiratory acidosis with metabolic
compensation.
An example would be someone with COPD. An
ABG might indicate:
pH 7.35
pCO2 8.5 kPa
pO2 9.3 kPa
HCO3 34 mmol/L
The pH is normal, but it shouldn't be because the
CO2 is high. The reason is the raised bicarbonate
produced by the kidneys, which promotes carbonic
acid formation which is less acidic than free
hydrogen ions.
 Metabolic acidosis with respiratory
compensation.
An example would be a septic patient. An ABG
might indicate:
pH 7.30
pCO2 2.4 kPa
pO2 10.2 kPa
HCO3 14.2 mmol/L
The pH is low, but it shouldn't be because the CO2 is
low (the pH should be high). The low CO2 indicates
hyperventilation. The reduced bicarbonate shows it
has been used to ‘mop up’ excess hydrogen ions to
remove them as CO2.
Respiratory acidosis to compensate
for metabolic alkalosis or the other
way round?

Look at your patient! You will know if they are

chronic COPD or have been acutely vomiting.

Your body never over-compensates, whatever

the direction of the pH, the process that
corresponds with that will be the primary cause,
all else will be compensation. Compensation can
be partial or fully achieved (ie. pH will be
normal with abnormal numbers)
 ABG analysis
What are the oxygen levels?
Cells die from lack of oxygen – it is the primary concern.
Is the pH normal?
If not, is it too high (alkali) or too low (acidic)
Does the pCO2 fit with the pH?
An acidic pH should have a high CO2 and vice versa.
Does the HCO3- fit with the pH?
An acidic pH should have a low HCO3- and vice versa.
Is the lactate raised?
A high lactate indicates an unmet metabolic demand and
suggests a metabolic cause.
What is the likely primary cause and what is the
compensation?
 Other ABG values.
Oximetery
ctHb. (Calculated total haemoglobin)
The level of haemoglobin in the blood, given in
grams per litre. Normal range between 120 -
170, lower in women.
FO2Hb (Fraction of oxygenated haemoglobin)
The amount of haemoglobin bound with
oxygen (not the same as pO2) given as %.
Hctc (Haematocrit)
The proportion, by volume, of the blood that
consists of red blood cells given as a %.
 Other ABG values.
Electrolytes
cK+ (Calculated potassium)
Given in mmol/L. Normal range 3.4 – 4.5
cNa+ (Calculated sodium)
Given in mmol/L. Normal range 136 – 146
cCa2+ (Calcualted ionised calcium)
Given in mmol/L. Normal range 1.2 – 1.4
cCl- (Calculated chloride)
Given in mmol/L. Normal range 98 – 106
mOsm (Osmolality)
Given in mmol/kg. Normal range 275 -295
 Other ABG values.
Metabolites and Acid/Base
cLac (calculated lactate)
Given in mmol/L. Normal range 0.5 – 1.6
cBase (calculated base deficit/excess)
Given in mmol/L. Normal range -2.4 - +2.2
cHCO3- (calculated bicarbonate)
Given in mmol/L. Normal range 22 -26
Don’t panic! But be cautious...
Blood gasses contain a large amount of
information, that is what makes them so useful.
Learning the values takes time, however, always
check the basics such as pH, pO2, pCO2 Hb,
electrolytes and base excess when you have
performed a test, or get the patients doctor to
sign that they have checked the results slip. It
would be pointless, and possibly negligent, to
perform a test that monitors the life chemistry of
a person who is unwell, and not have those
results reviewed by a competent person.