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1. Monitoring of the Respiration:
a) Ventilation ( CO2 ).

b) Gas exchange in the lung ( PO2, SaO2 ).

2. Monitoring of Acid - Base status (pH, HCO3, BE).

How to do ABG
1) Sampling: 1. Preparation of the syringe with Heparin (fill the syringe dead space only) 2. Desinfection of the puncture aria(Radial, Dorsalis pedis, Posterior tibial, Femoral, Brachial)

How to do ABG
Brachial and femoral arteries puncture are contraindicated in patients with abnormal haemostatic mechanism.
3. Punctures technique.
4. Press the puncture site firmly for 5 minutes.

5) How to treat the sample:

a)Remove all air bubbles. b)Mix the blood with Heparin (rotate the syringe between two fingers). c)Preferably the sample should be done immediately (accurate values ), otherwise put the sample in crushed ice ( properly ) till it has been done.

6) Complications :
a) Infection. b) Bleeding.
c) Heamatom. d) A-V fistula.

How to do ABG
2) Capillary: (Indicated in babies and small children)

1.Take a special preheparinized tube. 2.Improve the skin circulation of the puncture site (Ear, Heel). 3.Technique. (Avoid air bobbles)

PaCO2 : Partial tension of Carbon Dioxide in Arterial Blood.
Normal Value 35 - 45 mmHg (40)

PaCO2(Respiratory Acidosis ) 1) Decrease of excretion : a) Hypoventilation. b) Gas exchange ( COPD, ARDS ). 2) Over production ( Fever, TPN ).

PaCO2 ( Respiratory Alkalosis)
1) Hyperventilation:
a) Metabolic acidosis. b) Head injury. c) Psychiatric. d) Iatrogenic.

2) Decrease of production:
a) Hypothermia. b) Brian death.

PaO2: Partial Tension of Oxygen in Arterial blood .
Normal value : 70 - 100 mmHg

PaO2 = 102 - ( 0.33 X Age in years )

1) High FIO2. 2) Hyperbaric.

1) Respiratory failure ( ARDS, COPD, Pulmonary edema, Lung collapse etc..) 2) Congenital heart disease. 3) Low cardiac output ( Chock ). 4) Poisoning.

SaO2: Oxygen Saturation of Arterial blood.
The Percentage of Hemoglobin binds Oxygen
Normal value : 96 - 99 %

1) High FIO2.

1) Lung diseases. 2) Low cardiac output. 3) Increase the amount of abnormal Hb (Met Carboxy Hb). 4) R - L Shunting diseases.


Acid - Base Balance

Acid H+ + Base -

pH : Is the negative logarithm of Hydrogen Ions concentration.

pH = - Log( H+ )

Plasma pH = 7.35 - 7.45

( 7.4 )

Acids are H+ donors.

Bases are H+ acceptors, or give up OH- in solution.

Acids and bases can be: Strong dissociate completely in solution HCl, NaOH Weak dissociate only partially in solution Lactic acid, carbonic acid

The body produces more acids than bases

Acids take in with foods

Acids produced by metabolism of lipids and proteins

Cellular metabolism produces CO2.

Acid - Base Balance

How can the body maintain his pH constant ?

A buffer : is a solution that resist changes in (H+)concentration upon addition of stronger acid or base.
A buffer pair is a combination of weak acid with his strong base ( as salt ) . e.g. ( H2CO3 + NaHCO3 )

NaHCO3 + Hcl NaCl + H2CO3

Acid - Base Balance

Buffering system in the body :
1) Bicarbonate. 2) Phosphate. 3) Protein. 4) Hemoglobin.
The aim of acid - base compensation is to keep the ratio PCO2 / HCO3 constant

CO2 + H2O CO3H2 Carbonic Anhydrase

HCO3 + H

Acid - Base Balance

HCO3 : Plasma Bicarbonate
Normal value : 23 - 28 mmol / L

Metabolic Acidosis.
1) 2) 3) 4) 5) 6) 7) Shock. Diabetic ketoacidosis. Intoxication . Hypoxia. Renal failure. Intestinal obstruction. Compensatory.

Acid - Base Balance

Metabolic Alkalosis :
1) 2) 3) 4) Iatrogenic. Hypokalemia. Loss of acid (vomiting, long standing NGT ). Compensatory.

Acid-Base Imbalances
pH< 7.35 Acidemia pH > 7.45 Alkalemia The body response to acid-base imbalance is called compensation May be complete if brought back within normal limits Partial compensation if range is still outside norms.

If underlying problem is metabolic, hyperventilation or hypoventilation can help : respiratory compensation. If problem is respiratory, renal mechanisms can bring about metabolic compensation.

Determine the degree of compensation

Absent: pH is not within normal range The component that does not match the pH imbalance is still within its normal range

pH 7.18 PaCO2 38 PaO2 70 HCO3 15

Determine the degree of compensation

Complete: pH is within the normal range and both components are either above or below normal range

pH 7.36 PaCO2 67 PaO2 47 HCO3 37

Determine the degree of compensation

Partial: pH is not within normal range The component that does not match the pH disorder is above or below the normal range

pH 7.28 PaCO2 28 PaO2 70 HCO3 18

Rates of correction
Buffers function almost instantaneously Respiratory mechanisms take several minutes to hours Renal mechanisms may take several hours to days

Respiratory mechanisms
Exhalation of carbon dioxide Powerful, but only works with volatile acids Doesnt affect fixed acids like lactic acid CO2 + H20 H2CO3 H+ + HCO3Body pH can be adjusted by changing rate and depth of breathing

Kidney excretion
Can eliminate large amounts of acid Can also excrete base Can conserve and produce bicarb ions Most effective regulator of pH If kidneys fail, pH balance fails

Steps to Acid Base Analysis

pH Acidotic, alkalotic, or normal? PaCO2 High ,or low , or normal ? Causing or compensating?

HCO3 High, low, or normal? Causing or compensating?

How To Read an ABG ?

pH : between 7.35 and 7.45 ( normal )

PCO2 > 45 PCO2 < 35 HCO3 < 22 HCO3 > 28

R.Acidosis. R.Alkalosis. M.Acidosis. M.Alkalosis.

In most of these cases no need for correction .

How To Read an ABG ?

If pH < 7.35 Acidemia
PCO2 > 45 mmHg respiratory .( correct ventilation ) HCO3 < 22 mmol metabolic ( NaHCO3 ) PCO2 > 45 mmhg + HCO3 < 22 Mixed

Sodium Bicarbonate ?
Increase Acidosis intracellular (co2)

CO2 + H2O H2 CO3 H+ + HCO3 Increase Pco2

Indication :

Ph < 7.1

BE > 10 mmol

(Slow administration )

Caution : Hypokalemia

How To Read an ABG ?

If pH > 7.45 Alkalimia
PCO2 < 35 mmHg respiratory (correct hypocapenia) HCO3 > 28 mmHg metabolic. (correct electrolyte imbalance, Diamox)

PCO2 <35 mmhg + HCO3 > 28 Mixed

pH 7.60 PaCO2 30 PaO2 60 HCO3 22

What is this?
Non-compensated Alkalimia due to respiratory Alkalosis

pH 7.28 PaCO2 28 PaO2 70 HCO3 18

What is this?
Partially compensated Acidemia due to metabolic Acidosis

pH 7.36 PaCO2 67 PaO2 47 HCO3 37

What is this?
Completely compensated Respiratory Acidosis

pH 7.58 PaCO2 35 PaO2 75 HCO3 50

What is this?
Non-compensated Alkalimia due to metabolic Alkalosis

pH 7.18 PaCO2 38 PaO2 70 HCO3 15

What is this?
Non-compensated Acidemia due to Metabolic Acidosis

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