Arterial Blood Gas

for House Officers In Anaesthesia and Intensive Care Department of Anaesthesiology and Intensive Care Hospital

Content What is ABG? Normal values for ABG Definitions Acid-base balance Interpretation of ABG Practical considerations

What is ABG?

 An ABG is a blood test that measures the concentration of oxygen, carbon dioxide and bicarbonate in the blood

ABG readings
1. pH 2. Respiratory function O2, CO2, SaO2 3. Metabolic measures HCO3, base excess 4. Electrolytes and metabolytes

Normal Values for ABG

Normal values
pH PaO2 PaCO2 HCO3 7.35 - 7.45
To convert kPa to mmHg multiply by 7.5

>75 mmHg
35 45 mmHg 22 26 mmol/L -2 - +2

Base Excess

Many modern gas machines also measure K+ ,Na+ ,Cl- ,SaO2 ,Hb ,COHb ,MetHb ,Lactate

Definitions

Definitions
Hypoxaemia - a PaO2 of less than than 60
mmHg

Acidaemia - a pH of less than 7.35 Alkalaemia - a pH of greater than 7.45 Acidosis

Respiratory : PaCO2 of greater than 50 mmHg Metabolic : HCO3 of less than 22 mmol/L

Alkalosis
Respiratory : PaCO2 of less than 35 mmHg Metabolic : HCO3 of greater than 26 mmol/L

 Base excess
Observed Buffer Base minus Normal Buffer Base. It represents the amount of acid or alkali that must be added, in vitro, to a liter of fully oxygenated blood at PCO2 of 40 mmHg and 37oC, to achieve a normal pH (7.40) Std Bicarbonate and Base Excess are only truly valid within the closed in-vitro system

Acid Base Balance

Acid Base Balance

pH

CO2

HCO3

Acid Base Balance

CO2 + H2O

H+ + HCO3-

Excreted by Lungs

Excreted by Kidneys

pH

Less than 6.8

More than 7.8

Lungs
Cellular metabolism produces CO2 Concentration of carbonic acid alter blood pH pH changes results in lungs altering rate and depth of ventilation

Kidneys
Maintain blood pH by altering excretion of HCO3 When pH kidneys retain HCO3 When pH kidneys excrete HCO3

Relationship between PaCO2, HCO3, pH

Henderson-Hasselbach equation
pH = pKa + log [HCO3-] [H2CO3]
pH = 6.1 + log [HCO3-] 0.03 X PCO2

10 mm Hg PaCO2 0.08 unit pH 10 mmol [HCO3-] 0.15 unit pH

Interpretation of ABG

Step 1
Is there hypoxaemia? Is there significant lung injury?
A a Gradient
The gradient between alveolar PAO2 and arterial PaO2 in a person with healthy lungs is ~ 75 mmHg i.e. we would expect a person on an FiO2 of 60% to have a PaO2 ~ 375 mmHg (450-375=75) The higher the gradient, the worse the lung injury

Step 2
Assess the pH for acidemia or alkalemia

Step 3
Is it a respiratory problem?

Alkalosis

Acidosis

Step 4
Is it a metabolic problem?

Acidosis

Alkalosis

Step 5 Compensation
Respiratory compensation is quick Metabolic compensation is slow Compensation is not usually complete Patients never over compensate

Simple Acid-Base Disturbances

Acid-Base Disturbance Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis Primary Secondary Abnormality Response PaCO2 PaCO2 [HCO3-] [HCO3-] [HCO3-] [HCO3-] PaCO2 PaCO2 Expected Degree of Compensatory Response [HCO3-] = 0.35 X PaCO2 [HCO3-] = 0.50 X PaCO2 PaCO2 = (1.5 X [HCO3-]) + 8 PaCO2 = (0.9 X [HCO3-]) + 9

Causes of Respiratory Acidosis

Respiratory depression
Chemical depression Physical depression

Inadequate chest expansion

Skeletal problems Respiratory muscle weakness External conditions Airway obstruction Reduced alveolar-capillary diffusion

Causes of Respiratory Alkalosis

Anxiety, fear, or improper settings on mechanical ventilators
Direct stimulation of central respiratory center from fever, metabolic acidosis, central nervous system lesions, and drugs

Scenario 1
65 year old male with known COPD presents in A&E complaining of increased breathlessness. The paramedics have put him on a venturi mask to give an FI02 of 40% due to his breathlessness and initial low saturations. Significant findings on your examination is a drowsy patient with a resp rate of 8, SpO2 of 85% and wide-spread coarse crackles
Arterial blood gas analysis reveals:

FiO2 PaO2 pH PaCO2 HCO3

0.4 (40%) 52 mmHg 7.25 67 mmHg 35 mmol/L

Hypoxia Respiratory acidosis with chronic renal compensation Infective exacerbation of COPD ?Hypoxic drive ?tired

Scenario 2
18 year old male with diabetes has been suffering from diarrhoea and vomiting for 48 hours and because he has been unable to eat he has not taken his insulin. Significant findings on your examination are a resp rate of 40, heart rate of120, BP 95/50, Blood glucose 30mmol/l
Arterial blood gas analysis reveals:

FiO2 0.3 (30%) PaO2 160 mmHg pH 7.15 PaCO2 19 mmHg HCO3 10 Na 135 K 5.4 Cl 106 Anion Gap = ?24

Metabolic acidosis with respiratory compensation DKA

Anion Gap (use if metabolic acidosis)

(Na+ + K+) (HCO3- + Cl-)
Normal range 10 18mmol/l

anion gap
DKA Renal failure Lactic acidosis poisoning eg. salicylate, ethylene glycol

Normal anion gap

Chronic diarrhoea, ileostomy Addisons disease Pancreatic fistula Renal tubular acidosis

These lists are not exhaustive

Scenario 3
17 year old male has taken his fathers BMW (without asking) to impress his girlfriend and had an accident with a bus where the BMW came off much the worse. There is little abnormal to find on examination apart from bruising, a resp rate of 24, a pulse of 110 and a BP of 120/85
Arterial blood gas analysis reveals:

FiO2 PaO2 pH PaCO2 HCO3

0.21 (21%) 110 mmHg 7.53 23 mmHg 25.0

Respiratory alkalosis Anxiety

Scenario 4
A 75 year old female is on the surgical ward 2 days after a laparotomy for a perforated sigmoid colon secondary to diverticular disease. She has become hypotensive over the last 6 hours. A nurse has started 40% O2 On examination vital signs are: RR 35 min-1, SpO2 92%, HR 120 min-1, warm peripheries, BP 70/40 mmHg, Urine output 50 ml in the last 6 hours

Arterial blood gas analysis reveals:

FiO2 PaO2 pH PaCO2 HCO3-

0.4 (40%) 61 mmHg 7.17 28 mmHg 12 mmol l-1

Hypoxia Metabolic acidosis with respiratory compensation Shock secondary to Sepsis

Scenario 5
A 75 year old man presents to the emergency department after a witnessed out-of-hospital VF cardiac arrest. The paramedics arrived after 5 minutes, during which CPR had not been attempted. The paramedics had successfully restored spontaneous circulation after 3 shocks but have been unable to intubate him. He is breathing spontaneously with a re breathing mask.
On arrival: comatose (GCS 3) Resp rate 8 HR 120 min-1 BP 150/95 mmHg.

Arterial blood gas analysis reveals: FiO2 PaO2 pH PaCO2 HCO3 BE 0.85 (85%) 75 mmHg 7.10 52 mmHg 14 mmol/L - 10

Mixed respiratory and metabolic acidosis Hypoperfusion and respiratory failure

Practical Considerations

Practical points
1. Delayed analysis
Continued O2 use and CO2 production in syringe Invalid after 15 min unless iced Iced sample can keep 1-2h May result in sedimentation of rbc roll syringe in hand before test

2. Heparin
Necessary to prevent clotting Dilute blood unless > 50% of syringe volume filled with blood Heparin acidic

3. Air bubbles
PaO2 20kPa, PaCO2 0 in air Expel air and cap syringe immediately

4. WBC count
O2 consumed by white cells and platelets

5. Pain on sampling
Hyperventilation and breath holding due to pain of arterial puncture can affect results

6. If the ABG does not make sense, check patients clinically.

Any Questions?

Summary
You should now be able to:
Identify the hypoxic patient Identify an acidosis or alkalosis Recognise when compensation is taking place Formulate an initial treatment plan for some common scenarios Understand the role Arterial Blood Gases play in patient management

Thank you for your kind attention