Arterial blood gas

By
Mrs. Amala Rajan
Reader
Medical Nursing Dept

What is an ABG
Arterial Blood Gas
Drawn from artery- radial, brachial, femoral
It is an invasive procedure.
Caution must be taken with patient on
anticoagulants.
Arterial blood gas analysis is an essential
part of diagnosing and managing the
patients oxygenation status, ventilation
failure and acid base balance.

What Is An ABG?
pH

[H+]

PCO2
CO2

Partial pressure

PO2
O2

Partial pressure

HCO3 Bicarbonate
BE

Base excess

Acid/Base Balance
The pH is a measurement of the acidity or
alkalinity of the blood.
It is inversely proportional to the no. of (H+) in
the blood.
The normal pH range is 7.35-7.45.
Changes in body system functions that occur in
an acidic state decreases the force of cardiac
contractions, decreases the vascular response to
catecholamines, and a diminished response to the
effects and actions of certain medications.
An alkalotic state interferes with tissue
oxygenation and normal neurological and
muscular functioning.
Significant changes in the blood pH above 7.8 or

Buffers
There are two buffers that work in
pairs
H2CO3
Carbonic acid

NaHCO3
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

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.

ACID BASE DISORDER

Res. Acidosis
is defined as a pH less than 7.35
with a paco2 greater than 45
mmHg.
Acidosis accumulation of co2,
combines with water in the body
to produce carbonic acid, thus
lowering the pH of the blood.
Any condition that results in
hypoventilation can cause

Causes
1. Central nervous system depression r/t
medications such as narcotics, sedatives,
or anesthesia.
2. Impaired muscle function r/t spinal cord
injury, neuromuscular diseases, or
neuromuscular blocking drugs.
3. Pulmonary disorders such as atelectasis,
pneumonia, pneumothorax, pulmonary
edema or bronchial obstruction
4. Massive pulmonary embolus
5. Hypoventilation due to pain chest wall
injury, or abdominal pain.

Signs & symptoms of

Respiratory Acidosis
Respiratory : Dyspnoea, respiratory
distress and/or shallow respiration.
Nervous: Headache, restlessness and
confusion. If co2 level extremely high
drowsiness and unresponsiveness
may be noted.
CVS: Tacycardia and dysrhythmias

Management
Increase the ventilation.
Causes can be treated rapidly include
pneumothorax, pain and CNS
depression r/t medication.
If the cause can not be readily
resolved, mechanical ventilation.

Respiratory alkalosis
Psychological responses, anxiety or fear.
Pain
Increased metabolic demands such as
fever, sepsis, pregnancy or thyrotoxicosis.
Medications such as respiratory
stimulants.
Central nervous system lesions

Signs & symptoms

CNS: Light Headedness, numbness,
tingling, confusion, inability to
concentrate and blurred vision.
Dysrhythmias and palpitations
Dry mouth, diaphoresis and tetanic
spasms of the arms and legs.

Management
Resolve the underlying problem
Monitor for respiratory muscle
fatigue
When the respiratory muscle
become exhausted, acute
respiratory failure may ensue

Metabolic Acidosis
Bicarbonate less than 22mEq/L with
a pH of less than 7.35.
Renal failure
Diabetic ketoacidosis
Anaerobic metabolism
Starvation
Salicylate intoxication

Sign & symptoms

CNS: Headache, confusion and
restlessness progressing to lethargy,
then stupor or coma.
CVS: Dysrhythmias
Kussmauls respirations
Warm, flushed skin as well as nausea
and vomiting

Management
Treat the cause
Hypoxia of any tissue bed will produce
metabolic acids as a result of anaerobic
metabolism even if the pao2 is normal
Restore tissue perfusion to the hypoxic
tissues
The use of bicarbonate is indicated for
known bicarbonate - responsive acidosis
such as seen with renal failure

Metabolic alkalosis
Bicarbonate more than 26m Eq /L with a
pH more than 7.45
Excess of base /loss of acid can cause
Ingestion of excess antacids, excess use of
bicarbonate, or use of lactate in dialysis.
Protracted vomiting, gastric
suction,hypchoremia,excess use of
diuretics, or high levels of aldesterone.

Signs/symptoms
CNS: Dizziness, lethargy
disorientation, siezures & coma.
M/S: weakness, muscle
twitching, muscle cramps and
tetany.
Nausea, vomiting and
respiratory depression.
It is difficult to treat.

COMPONENTS OF THE
ABG

pH: Measurement of acidity or alkalinity, based on the hydrogen (H+)

Pao2

7.35 7.45
The partial pressure oxygen that is dissolved in arterial

blood.
80-100 mm Hg.
PCO2: The amount of carbon dioxide dissolved in arterial blood.
35 45 mmHg
HCO3
The calculated value of the amount of bicarbonate in the blood
:
22 26 mmol/L
B.E:
The base excess indicates the amount of excess or insufficient
level of bicarbonate. -2 to +2mEq/L
(A negative base excess indicates a base deficit in blood)
SaO2:The arterial oxygen saturation.

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

 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)

 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 2: Mr. D is a 55 years old

admitted with recurring bowel
obstruction has been experiencing
intractable vomiting for the last
several hours. His ABG is:
pH : 7.5
paCO2 :42
HCO3 : 33
Metabolic alkalosis
Management: IV fluids,
measures to reduce the

pH

PaCo2

HC03
normal

Respiratory
acidosis
Respiratory
Alkalosis

normal

Metabolic
Acidosis

normal

Metabolic
Alkalosis

normal

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)

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.

REMEMBER
K
U
S
S
M
A
L
E

etoacidosis
remia
epsis
alicylate & other drugs
ethanol
lcohol (Ethanol)
actic acidosis
thylene glycol

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 rangefully 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.

Example 3
Mrs. H is admitted, he is kidney
dialysis patient who has missed his
last 2 appointments at the dialysis
centre his ABG results:
pH
:
7.32
paCo2 :
32
HCO3 :
18
Pao2 :
88
Partially compensated metabolic
Acidosis

Example 4
Mr. K with COPD.His ABG is:
pH
:
7.35
PaCO2
:
48
HCO3
:
28
PaO2
:
90
Fully compensated
Respiratory Acidosis

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).

FULLY COMPENSATED
pH
Resp.Acidosis Normal
but<7.40
Resp.Alkalosis Normal
but>7.40
Met. Acidosis

Normal
but<7.40

Met. Alkalosis

Normal
but>7.40

paco2

Hco3

Partially compensated
pH
Res.Acidosis
Res.Alkalosis
Met. Acidosis
Met.Alkalosis

paco2

Hco3

~ PaCO pH Relationship
2

80

7.20

60

7.30

40

7.40

30

7.50

20

7.60

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

2SD NORMAL

CL.ACCEPTABLE

PH 7.35 7.45 7.30 7.50

PCO2
35 45
30 50
PO2
97
>80
(ON 21% O2)
(ON VENTILATOR)

HCO3

60 90
24 - 28

Take Home Message:

Valuable information can be gained from an
ABG as to the patients physiologic condition
Remember that ABG analysis if only part of the patient
assessment.
Be systematic with your analysis, start with ABCs as always
and look for hypoxia (which you can usually treat quickly),
then follow the four steps.
A quick assessment of patient oxygenation can be achieved
with a pulse oximeter which measures SaO2.

Practice ABGs
1. PaO2
2. PaO2
3. PaO2
4. PaO2
5. PaO2
6. PaO2
1. PaO2
2. PaO2
3. PaO2
10. PaO2

90
60
95
87
94
62
93
95
65
110

SaO2 95
SaO2 90
SaO2 100
SaO2 94
SaO2 99
SaO2 91
SaO2 97
SaO2 99
SaO2 89
SaO2 100

pH 7.48
pH 7.32
pH 7.30
pH 7.38
pH 7.49
pH 7.35
pH 7.45
pH 7.31
pH 7.30
pH 7.48

PaCO2 32
PaCO2 48
PaCO2 40
PaCO2 48
PaCO2 40
PaCO2 48
PaCO2 47
PaCO2 38
PaCO2 50
PaCO2 40

HCO3
HCO3
HCO3
HCO3
HCO3
HCO3
HCO3
HCO3
HCO3
HCO3

24
25
18
28
30
27
29
15
24
30

Answers to Practice ABGs

1. Respiratory alkalosis
2. Respiratory acidosis
3. Metabolic acidosis
4. Compensated Respiratory acidosis
5. Metabolic alkalosis
6. Compensated Respiratory acidosis
7. Compensated Metabolic alkalosis
8. Metabolic acidosis
9. Respiratory acidosis
10.Metabolic alkalosis