Arterial Blood Gas (ABG)

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Arterial Blood Gas (ABG)

Where do we get the blood


from? For an ABG
The ROLE of ABG
• The role is to provide information on acid / base balance
• Provides insight into the course and progression of the patients
disease
• Provides a precise measure of gaseous exchange and oxygenation
• Lastly it is the only accurate way to determine the alveolar-arterial
oxygen gradient (A-a)

• NB remember that ABG analysis is only a representation of the blood


gas at the time sampling and that changes in management of the
patient will affect the ABG
Continued
• Significant changes in the blood pH above 7.8 or below 6.8 will
interfere with cellular functioning, and if uncorrected, will lead to
death.

• How is PH maintained within the normal range? It is accomplished


using delicate buffer mechanisms between the respiratory and renal
systems.
The Bicarbonate Buffer Response
• 1st line HCO3
• Acts almost instantaneously to correct even minute variations in H+
levels
• H+ + HCO3 ↔ H2CO3 ↔ H2O + CO2 (Left or right)
• As this happens almost instantaneously, one could simplify the equation:
• H+ ↔ CO2
• An increase in H+ leads to an increase in CO2
• A decrease in H+ leads to a decrease in CO2
The Respiratory Buffer Response
• By-product of cellular metabolism is carbon dioxide
• CO2 is carried in the blood to the lungs, where excess CO2 combines
with water (H2O) to form carbonic acid (H2CO3).
• Blood pH will change according to the level of carbonic acid present.
• This triggers the lungs to either increase or decrease the rate and
depth of ventilation until the appropriate amount of CO2 has been re-
established.
• Compensation starts to occur within 1 to 3 minutes.
The Renal (Metabolic) Buffer Response
• To maintain the pH of the blood within its normal range, the kidneys
excrete or retain bicarbonate (HCO3-).
• As the blood pH decreases, the kidneys will compensate by retaining
HCO3 - and as the pH rises, the kidneys excrete HCO3 - through the
urine.
• Takes hours
Key concept

• The only 2 ways an acidotic state can exist is from either too much
pCO2 or too little HCO3.
• The only 2 ways an alkalotic state can exist is from either too little
pCO2 or too much HCO3.
Respiratory Acidosis:
• Defined as a pH less than 7.35 with a PaCO2 greater than 45mmHg.
• Any condition that results in hypoventilation can cause respiratory
acidosis

• Signs and Symptoms of Respiratory Acidosis:


• Pulmonary – dyspnea, respiratory distress & shallow respirations
• Neurological – headache, restlessness & confusion
• Cardiovascular – tachycardia & dysrhythmias
Respiratory Alkalosis
• Defined as a pH greater than 7.45 with a PaCO2 less than 35mmHg.
• Any condition that causes hyperventilation can result in respiratory
alkalosis
• Signs and Symptoms of Respiratory Alkalosis
• Neurological – light-headedness, numbness and tingling, confusion, inability to
concentrate & blurred vision
• Cardiovascular – dysrhythmias, palpitations & diaphoresis
• Miscellaneous - dry mouth & tetanic spasms of the arms and legs
Metabolic Acidosis:
• Defined as a bicarbonate level of less than 22 mEq/L with a pH of less than
7.35
• Metabolic acidosis is caused by either a deficit of base in the bloodstream
or an excess of acids, other than CO2.
• Diarrhea and intestinal fistulas may cause decreased levels of base
• Causes of increased acids include:
• Renal failure
• Diabetic ketoacidosis
• Anaerobic metabolism
• Starvation (coffee?)
• Salicylate intoxication
Metabolic Acidosis:
• Signs and Symptoms of Metabolic Acidosis:
• Neurological – headache, confusion, restlessness, lethargy, stupor or coma
• Cardiovascular – dysrhythmias & warm, flushed skin
• Pulmonary – Kussmauls respirations
• Gastrointestinal – nausea and vomiting

• The presence of metabolic acidosis should spur a search for hypoxic tissue
somewhere in the body.
• Why - hypoxia of any tissue bed will produce metabolic acids as a result of anaerobic
metabolism even if the PaO2 is normal.
Metabolic Alkalosis:
• Defined as a bicarbonate level greater than 26 mEq/liter with a pH greater
than 7.45.
• Excess base occurs from ingestion of antacids, excess use of bicarbonate, or
use of lactate in dialysis.
• Loss of acids can occur secondary to protracted vomiting, gastric suction,
hypochloremia, excess administration of diuretics, or high levels of
aldosterone.
• Signs and Symptoms of Metabolic Alkalosis:
• Pulmonary – Respiratory depression
• Neurological – dizziness, lethargy, disorientation, seizures & coma
• Musculoskeletal – weakness, muscle twitching, muscle cramps & tetany
• Gastrointestinal - nausea & vomiting
Step 1.
Look at PaO2
• Does the patient show Hypoxaemia ?
• PaO2 is a representation of O2 dissolved in arterial blood plasma (mmHg)
• It only represents 3% of O2 in the blood
• Normal range (At sea level)
• 80 – 100mmHg; but is age dependant
• Above 60years it decreases. Equation = 80mmHg – 1mmgh for every year above 60
• Infant 50 – 70mmHg
• AT ANY AGE A PaO2 below 40mmHg represents a life threating situation
• A PaO2 below prediction = Hypoxaemia
Step 2
P.H
• IS the patient PH acidic or alkaline
• PH represents the number of H+ ions in blood
• Normal range
• 7.35 – 7.45
• Mean of 7.4
Step 3
PaCO2
• Does PaCO2 show respiratory Acidosis or Alkolosis
• It is a measure of partial pressure of carbon dioxide dissolved in arterial blood plasma
• It measures the effectiveness of ventilation in relation to metabolic rate (can the body
get rid of PaCO2 produced by metabolism)
• Normal range
• 35 – 45 mmHg (book dependant)
• Above 45 acidosis (Respiratory) EG: COPD, oversedation
• Below 35 alkalosis (Respiratory) EG: Anxiety, Pregnacy
Step4
HCO3
• Does HCO3 show metabolic acidosis, alkalosis or Normalcy
• Bicarbonate is the acid base component that shows kidney function
• It is reduced or increases in the kidneys by renal mechanisms
• Normal range
• 22 – 26 mEq/l
• Less than 22 = metabolic acidosis Eg:
Ketoacidosis, lactic acidosis, renal failure or diarrhoea
• Greater than 26 = metabolic alkalosis Eg:
Fluid loss from upper gastrointestinal tract (Vommiting, nasogastric suction), Diuretic
therapy, Hypokalaemia, alkali administration or steroid therapy
Step 5
work it out
• Does PH show a compensated or uncompensated condition
• If PH is abnormal then PaCO2 or HCO3 must be abnormal (Or both)
• This would be and uncompensated condition because the body has not had time to
rectify the PH to normal
• If however the PH is in normal levels and the PaCO2 or HCO3 are abnormal the condition
is said to be compensated as the body try's to restore the PH
Put it to practice
Given the values what is the patient presenting
with
• PH – 7.25
• CO2 – 53
• P02 – 50
• O2 Sat – 79%
• HCO3 – 24

• Answer –
• Uncompensated respiratory acidosis with hypoxemia.
• Reason Why –
• An acute respiratory disorder
Put it to practice
• PH – 7.5
• CO2 – 30
• P02 – 100
• O2 Sat – 100%
• HCO3 – 23

• Answer –
• Uncompensated respiratory alkalosis
• Reason Why? –
• Hyperventilating
Put it to practice
• PH – 7.15
• CO2 – 44
• P02 – 91
• O2 Sat – 96%
• HCO3 – 16

• Answer –
• Uncompensated metabolic acidosis
• Reason Why –
• DKA
Put it to practice
• PH – 7.56
• CO2 – 38
• P02 – 93
• O2 Sat – 97%
• HCO3 – 35

• Answer –
• Uncompensated metabolic alkalosis
• Reason Why –
• Vomiting, NG tube drainage
Put it to practice
• PH – 7.30
• CO2 – 30
• P02 – 70
• O2 Sat – 91%
• HCO3 – 14

• HCO3 matches the pH, because they are both acidotic

• Answer –
• Partially--‐compensated metabolic acidosis with hypoxemia
• Why –
• renal failure, diarrhea, poisonings, diabetic ketoacidosis, and shock

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