ARTERIAL BLOOD

GAS
BY
SAUMYA GUPTA
Moderator:
Dr. VISHAL GUPTA
What Is An ABG?
pH [H+]

PCO2 Partial pressure

CO2

PO2 Partial pressure

O2
HCO3 Bicarbonate

BE Base excess

SaO2 Oxygen Saturation

NORMAL VALUES OF VARIOUS PARAMETERS
• pH : 7.35-7.45
• Bicarbonate : 22-26 meq/l
• pCO2: 35-45 mmHg
• pO2: 80-100 mmHg
• BASE EXCESS (BE) : +/- 2 mEq/l
• SaO2 (Oxygen saturation) : 95-100%
 Why Order an ABG?

• Aids in establishing a diagnosis

• Helps guide treatment plan
• Aids in ventilator management
• Improvement in acid/base management
allows for optimal function of medications
• Acid/base status may alter electrolyte levels
critical to patient status/care
 Logistics

• When to order an arterial line --

– Need for continuous BP monitoring
– Need for multiple ABGs
• Where to place -- the options
– Radial
– Femoral
– Brachial
– Dorsalis Pedis
– Axillary
 pH PaCo2 HC03

normal
Respiratory
acidosis
Respiratory normal
Alkalosis
Metabolic normal
Acidosis
Metabolic normal
Alkalosis
Complications of acidic state in body:
• Decreases force of cardiac contractions
• Decreases vascular response to catecholamines
• Diminished response to the effect and action of various medications

Complications of alkalotic state in body:

• Interferes with tissue oxygenation , normal neurological and
muscular functioning.

Significant changes in the blood pH below 6.8 and above 7.8 will
interfere with cellular functioning, and if left uncorrected, will lead to
death.
 Acid/Base Relationship

H2O + CO2  H2CO3  HCO3 + H+

 Henderson - Hasselbalch
Equation
• pH = pk + log HCO3- / PCO2 x 0.03

• pH = 6.01 + log HCO3- / PCO2 x 0.03

• pH = Kidney / Lung
 Buffers

There are two buffers that work in

pairs

H2CO3 NaHCO3
Carbonic acid base bicarbonate

These buffers are linked to the

respiratory and renal compensatory
system
 The Respiratory buffer
response
• The blood pH will change acc.to
the level of H2CO3 present.
• This triggers the lungs to either
increase or decrease the rate
and depth of ventilation
• Activation of the lungs to
compensate for an imbalance
starts to occur within 1-3 minutes
 The Renal Buffer Response

• The kidneys excrete or retain

bicarbonate(HCO3-).
• If blood pH decreases, the kidneys
will compensate by retaining HCO3
• Renal system may take from hours
to days to correct the imbalance.
 Mixed Acid-Base Disorders

• Patients may have two or more acid-base

disorders at one time

• Delta Gap
Delta HCO3 = HCO3 + Change in anion gap
>24 = metabolic alkalosis
EXPECTED CHANGES IN ACID-BASE DISORDERS

Primary Disorder Expected Changes

Metabolic acidosis PCO2 = 1.5 × HCO3 + (8 ± 2)
Metabolic alkalosis PCO2 = 0.7 × HCO3 + (21 ± 2)
Acute respiratory acidosis delta pH = 0.008 × (PCO2 - 40)
Chronic respiratory acidosis delta pH = 0.003 × (PCO2 - 40)
Acute respiratory alkalosis delta pH = 0.008 × (40 - PCO2)
Chronic respiratory alkalosis delta pH = 0.003 × (40 - PCO2)

From: THE ICU BOOK - 2nd Ed. (1998) [Corrected]

 Stepwise approach to ABG
• Step 1: Acidemic or Alkalemic?
• Step 2: Is the primary disturbance respiratory or
metabolic?
• Step 3. Asses to Pa O2. A value below 80mm Hg
indicates Hypoxemia. For a respiratory
disturbance, determine whether it is acute or
chronic.
• Step 4. For a metabolic acidosis, determine
whether an anion gap is present.
• Step 5. Assess the normal compensation by the
respiratory system for a metabolic disturbance
 STEPS TO AN ABG
INTERPRETATION
• Step:1
• Assess the pH –acidotic/alkalotic
• If above 7.5 – alkalotic
• If below 7.35 – acidotic
 Contd…..
• Step 2:
• Assess the paCO2 level.
• pH decreases below 7.35, the paCO2
should rise.
• If pH rises above 7.45 paCO2 should
fall.
• If pH and paCO2 moves in opposite
direction – primary respiratory
problem.
 contd
• Step:2
• Assess HCO3 value
• If pH increases the HCO3 should also
increase
• If pH decreases HCO3 should also
decrease
• They are moving in the same direction
• primary problem is metabolic
• Step 3
Assess pao2 < 80 mm Hg - Hypoxemia
For a resp. disturbance : acute, chronic
The differentiation between A/C & CHR.respiratory
disorders is based on whether there is associated
acidemia / alkalemia.
If the change in paco2 is associated with the change
in pH, the disorder is acute.
In chronic process the compensatory process brings
the pH to within the clinically acceptable range ( 7.30
– 7.50)
 BASE EXCESS

• Is a calculated value estimates the

metabolic component of an acid based
abnormality.
• It is an estimate of the amount of
strong acid or base needed to correct
the met. component of an acid base
disorder (restore plasma pH to 7.40at
a Paco2 40 mmHg)
 Base Excess
• A number reflecting all the buffer systems of the
body

• Can reflect an addition or deficit

• Useful for the formula to determine how much

Sodium Bicarbonate to administer to bring the pH
to normal levels
 Formula
• With the base excess is -10 in a 50kg
person with metabolic acidosis mM of
Hco3 needed for correction is:

= 0.3 X body weight X BE

= 0.3 X 50 X10 = 150 mM
 Anion GAP

Step 4
• Calculation of AG is useful approach to
analyse metabolic acidosis
AG = (Na+ + K+) – (cl- + Hco3-)
• * A change in the pH of 0.08 for each 10
mm Hg indicates an ACUTE condition.
* A change in the pH of 0.03 for each 10
mm Hg indicates a CHRONIC condition.
 COMPENSATION
• Step 5
• A patient can be uncompensated or
partially compensated or fully
compensated
• pH remains outside the normal range
• pH has returned within normal range-
fully compensated though other values
may be still abnormal
• Be aware that neither the system has
the ability to overcompensate
 ABG Interpretation
Step 5 cont…
Determine if there is a compensatory
mechanism working to try to correct the
pH.

ie: if have primary respiratory acidosis will

have increased PaCO2 and decreased pH.
Compensation occurs when the kidneys
retain HCO3.
 Assess the PaCO2
• In an uncompensated state – when the pH
and paCO2 moves in the same direction: the
primary problem is metabolic.
• The decreasing paco2 indicates that the
lungs acting as a buffer response (blowing
of the excess CO2)
• If evidence of compensation is present but
the pH has not been corrected to within the
normal range, this would be described as
metabolic disorder with the partial
respiratory compensation.
 Assess the HCO3
• The pH and the HCO3 moving in
the opposite directions, we would
conclude that the primary disorder
is respiratory and the kidneys
acting as a buffer response: are
compensating by retaining HCO3
to return the pH to normal range.
 pH paco2 Hco3
Resp.Acidosis Normal
but<7.40
Resp.Alkalosis Normal
but>7.40
Met. Acidosis Normal
but<7.40
Met. Alkalosis Normal
but>7.40
 Partially compensated

pH paco2 Hco3

Res.Acidosis

Res.Alkalosis

Met. Acidosis

Met.Alkalosis
• J is a 45 years old female admitted with the severe
attack of asthma. She has been experiencing
increasing shortness of breath since admission three
hours ago. Her arterial blood gas result is as follows:
• pH : 7.22
• paCO2 : 55
• HCO3 : 25
• Follow the steps
• pH is low – acidosis
• paCO2 is high – in the opposite direction of the pH.
• Hco3 is Normal.
• Respiratory Acidosis
• Need to improve ventilation by oxygen therapy,
mechanical ventilation, pulmonary toilet or by
administering bronchodilators.
 Example 5
• Mr. S is a 53 year old man presented to
ED with the following ABG.
• pH : 7.51
• PaCO2 : 50
• HCO3 : 40
• Pao2 : 40 (21%O2)
• He has metabolic alkalosis
• Acute respiratory alkalosis (acute
hyperventilation).
 Sample Problem #1

• An ill-appearing alcoholic male presents

with nausea and vomiting.
– ABG - 7.4 / 41 / 85 / 22
– Na- 137 / K- 3.8 / Cl- 90 / HCO3- 22
 Sample Problem #1

• Anion Gap = 137 - (90 + 22) = 25

 anion gap metabolic acidosis
• Winters Formula = 1.5(22) + 8  2
= 39  2
 compensated
• Delta Gap = 25 - 10 = 15
15 + 22 = 37
 metabolic alkalosis
 Sample Problem #3

• 47 year old male experienced crush injury

at construction site.
• ABG - 7.3 / 32 / 96 / 15
• Na- 135 / K-5 / Cl- 98 / HCO3- 15 / BUN- 38
/ Cr- 1.7
• CK- 42, 346
 Sample Problem #3

• Anion Gap = 135 - (98 + 15) = 22

 anion gap metabolic acidosis
• Winters Formula = 1.5 (15) + 8  2
= 30  2
 compensated
• Delta Gap = 22 - 10 = 12
12 + 15 = 27
 mild metabolic alkalosis
 Precautions
 Excessive Heparin Decreases bicarbonate and
PaCO2
 Large Air bubbles not expelled from sample PaO2
rises, PaCO2 may fall slightly.

 Fever or Hypothermia, Hyperventilation or breath

holding (Due to anxiety) may lead to erroneous lab
results
 Care must be taken to prevent bleeding