Arterial Blood gas analysis

Dr. Samaresh Das

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 Alveolar Ventilation
Alveolar Ventilation (V'A) : Gas exchange of lung during normal
breathing.
o High air exchange in functioning alveoli, higher alveolar
ventilation, would bring in fresh oxygen-rich air and efflux
carbon dioxide air rapidly
o Healthy subjects the partial pressure of alveolar carbon
dioxide (PACO2) is equivalent to the arterial carbon dioxide
(PaCO2), we substitute the arterial variable for that of the
alveolar value

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 Oxygenation
Oxygenation : Process of adding oxygen to the body system.
o clinical signs alone - Cyanosis, pallor and other physical findings
are not reliable.

o Saturation of peripheral oxygen (SpO2) levels measured with a

pulse oximeter correlate highly with arterial oxygenation

concentrations (PO2)

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Acid Base Balance

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 Basic Terminology
PH: Free H+ conc. , PH Inversely related to H+

Acid : Substance that can donate H+, lowers PH

Base : Substance that can accept H+, raise PH

Acidemia : PH <7.35 , raise H+

Alkalemia : PH >7.45, lower H+

Acidosis : Process/disease , ↓ PH , ↑ acid or ↓ alkali

Alkalosis : Process /disease ,↑ PH , ↓ acid or ↑ alkali

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 Why Order an ABG?
o Aids in establishing a diagnosis

o Helps guide treatment plan

o Aids in ventilator management

o Improvement in acid/base management allows for
optimal function of medications

o Acid/base status may alter electrolyte levels critical to

patient .

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 Logistics
• Where to place -- the options
– Radial
– Femoral
– Brachial
– Dorsalis Pedis

• When to Place an arterial line --

– Need for continuous BP monitoring
– Need for multiple ABGs

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 Technical Errors
Air bubbles
o PO2 150 mmHg & PCO2 0 mm Hg in air bubble.

o Discard sample if excessive air bubbles

o Seal with cork/cap after taking sample

Fever or Hypothermia
o Most ABG analyzers report data at N body temp
o If severe hyper/hypothermia, values of pH & PCO2 at 37 C
can be significantly diff from pt’s actual values

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 Acid Base Status
o Assessment via bicarbonate-carbon dioxide buffer
system in blood.
o H+ = 24 × ( Pco2 / HCO3)
o PCO2 / HCo3 identifies the primary acid base disoders
and secondary response

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 Sample collection
o Only the person who collect the sample can tell if he has
drawn a pulsating blood

o Partly mixed sample- Difficult to recognize

Arterial Venous

PH 7.35 - 7.45 7.36- 7.39

Pco2 35- 45 44 - 48

Po2 80 - 100 38 - 42

Hco3 24- 26 20 - 24

Sao2 95- 100 % 75%

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 Primary Acid Base Disorders &
secondary response
Primary Primary change Secondary
Disorder Response
Resp. Acidosis ↑ PcO2 ↑ Hco3

Resp. Alkalosis ↓ Pco2 ↓ Hco3

Met. Acidosis ↓ Hco3 ↓ Pco2

Met. Alkalosis ↑ Hco3 ↑ Pco2

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During compensation HCO3¯ &
PaCO2 move in the same
direction

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 Compensation

Respiratory compensation
is always FAST …12-24 hrs
Metabolic compensation
• is always SLOW..2- 3
days

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Metabolic acidosis

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 Response to Metabolic Acidosis
o Secondary response decrease Pco2 by increase ventilation
o Appears in 30-120 minute & can take 12-24 hrs
o Expected Paco2 = 40 - ( 1.2 × ∆ Hco3)

EXAMPLE:
Metabolic acidosis with a plasma HCO3 of 10 mEq/L,

∆ HCO3 is 24 – 10 = 14 mEq/L,

so the expected PaCO2 is 40 – (1.2 × 14) = 23 mm Hg.

o If the PaCO2 is >23 mm Hg, there is a secondary respiratory

acidosis.

o If the PaCO2 is <23 mmhg , there is secondary respiratory alkalosis

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Metabolic alkalosis

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 Response to Metabolic Alkalosis
o Secondary response : Increase Pco2 by decrease
ventilation

o This response is not as vigorous as the response to

metabolic acidosis

o Expected Paco2 = 40 + ( 0.7 × ∆ Hco3 )

o EXAMPLE: Metabolic alkalosis with plasma HCO3 of
40 mEq/L, so ∆ HCO3 is 40 – 24 = 16 mEq/L,

o So expected PaCO2 is 40 + ( 0.7 × 16) = 51 mm Hg.

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Respiratory acidosis

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Response to Respiratory Acidosis
o Secondary response of PaCO2 occurs in the kidneys,
o HCO3 absorption in the proximal tubes
o Response is relatively slow, take 2 or 3 days to reach
completion.
o Because of delay, respiratory acid-base disorders are
separated into acute and chronic disorders.

EXAMPLE: Acute increase in PaCO2 to 60 mm Hg,

Expected HCO3 = 24+ (0.1 × ∆ co2 )

For an chronic respiratory acidosis

o Expected HCO3 = 24+ (0.4 × ∆ co2 )

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Respiratory alkalosis

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Response to Respiratory Alkalosis
EXAMPLE:

For an acute decrease in PaCO2 to 24 mm Hg,

o Expected HCO3 = 24 - (0.2 × ∆ co2 )

For an chronic decrease in PaCO2 to 20 mm Hg,

o Expected HCO3 = 24 - (0.4 × ∆ co2 )

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Stepwise approach to
Acid Base analysis

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 Stepwise approach to Acid Base
analysis
o Structured, rule-based approach to the diagnosis of
primary, secondary, and mixed acid-base disorders using
the relationships between the PH, PCO2, and HCO3

Normal Values :
o pH = 7.35–7.45

o PCO2 = 35–45 mm Hg

o HCO3 = 22–26 mEq/L

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Stepwise approach to Acid Base
analysis
Acidemic pH < 7.35
Alkalemic pH > 7.45

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 Stepwise approach to Acid Base
analysis
o Stage I: PaCO2 and pH are used to identify the primary acid-
base disorder.
o Rule 1: If PaCO2 and/or the pH is outside the normal range,
there is an acid-base disorder.
o Rule 2: If PaCO2 and pH both abnormal, compare the
directional change.

o 2a. If PaCO2 and pH change in same direction, there is

primary metabolic acid-base disorder.
o 2b. If PaCO2 and pH change in opposite directions, there is
primary respiratory acid-base disorder.
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 Stepwise approach to Acid Base
analysis
EXAMPLE:
o pH = 7.23 , PaCO2 = 23 mm Hg.
o The pH and PaCO2 , both reduced (indicating a primary
metabolic disorder) and the pH acidemic , so the
diagnosis is primary metabolic acidosis.

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 Stepwise approach to Acid Base
analysis
Rule 3: If only pH or PaCO2 is abnormal, the condition is mixed
metabolic and respiratory disorder
o 3a. If PaCO2 is abnormal, the directional change in PaCO2
identifies the type of respiratory disorder (e.g., high PaCO2
indicates a respiratory acidosis), and the opposing metabolic
disorder.
o 3b. If the pH is abnormal, the directional change in pH
identifies the type of metabolic disorder (e.g., low pH
indicates a metabolic acidosis) and the opposing respiratory
disorder

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 Stepwise approach to Acid Base
analysis
EXAMPLE:

o pH = 7.38 and PaCO2 = 55 mm Hg.

o Only PaCO2 is abnormal, so there is a mixed metabolic and
respiratory disorder.

o The PaCO2 is elevated, indicating a respiratory acidosis, so

the metabolic disorder must be a metabolic alkalosis

o So condition is a mixed respiratory acidosis and metabolic

alkalosis. Both disorders are equivalent in severity because
the pH is normal
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Stepwise approach to Acid Base
analysis
Stage II: The goal in Stage II is to determine if there is an
additional acid-base disorder.
o Rule 4: For primary metabolic disorder, if the measured
PaCO2 is higher than expected, there is a secondary
respiratory acidosis, and if the measured PaCO2 is less
than expected, there is a secondary respiratory alkalosis

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 Stepwise approach to Acid Base
analysis
EXAMPLE:
o PaCO2 = 23 mm Hg, the pH = 7.32, and the HCO3 = 16 mEq/L. The
pH and PCO2 change in the same direction, indicating a primary
metabolic disorder, and the pH is acidemic, so the disorder is a
primary metabolic acidosis.

o Expected PaCO2 is 40 –1.2×(24 – 16) = 30 mm Hg.

o The measured PaCO2 (23 mm Hg) ,

o so there is an additional respiratory alkalosis. Therefore, this
condition is a primary metabolic acidosis with a secondary
respiratory alkalosis
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 Stepwise approach to Acid Base
analysis
Rule 5: For a primary respiratory disorder, a normal or near-
normal HCO3 indicates that the disorder is acute.

 Respiratory
compensation
is always FAST …12-24
hrs
 Metabolic compensation
• is always SLOW..2- 3
days

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 Stepwise approach to Acid Base
analysis
o Rule 6: Primary respiratory disorder where HCO3 is abnormal,
determine the expected HCO3 for a chronic respiratory disorder.

o 6a. For chronic respiratory acidosis, if the HCO3 is lower than

expected, there is an incomplete renal response, and if the HCO3 is
higher than expected, there is a secondary metabolic alkalosis.

o 6b. For a chronic respiratory alkalosis, if the HCO3 is higher than

expected, there is an incomplete renal response, and if the HCO3 is
lower than expected, there is a secondary metabolic acidosis

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 Stepwise approach to Acid Base
analysis

EXAMPLE:

PCO2 = 23 mm Hg, pH = 7.54, and the HCO3 = 32 mEq/L.

o The PaCO2 and pH change in opposite directions, indicating a

primary respiratory disorder, and the pH is alkaline, so the disorder

is a primary respiratory alkalosis.

o HCO3 is abnormal, indicating this is not an acute respiratory

alkalosis.

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 Stepwise approach to Acid Base
analysis
PCO2 = 23 mm Hg, pH = 7.54, and the HCO3 = 37 mEq/L.
Chr. Resp. Alk expected HCO3 = 24 + 0.4 ×(40 – 23) = 31
mEq/L.

o If measured HCO3 < 31 mEq/L, condition would be a

chr. Resp. alkalosis with incomplete renal response

o If measured HCO3 is > 31 mEq/L, indicate secondary

metabolic alkalosis

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 • ----- XXXX Diagnostics ------

• Blood Gas Report

o
•
•
Measured
pH
37.0 C
7.523 Case 1
• pCO2 30.1 mm Hg
• pO2 105.3 mm Hg

• Calculated Data
30 year old female with
• HCO3 act 22 sudden onset of
mmol / L
dyspnea.
• O2 Sat 98.3 %
• pO2 (A - a) 8 mm Hg 
• pO2 (a / A) 0.93
No Cough or Chest
Pain
• Entered Data
• FiO2 21.0 %
Vitals normal but RR
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26,
anxious.
 • ----- XXXX Diagnostics ------

• Blood Gas Report

o
•
•
Measured
pH
37.0 C
7.301
Case 2
• pCO2 76.2 mm Hg
• pO2 45.5 mm Hg

• Calculated Data
• HCO3 act 35.1 mmol / L 60 year old male
smoker
• O2 Sat 78% with progressive
• pO2 (A - a) 9.5 mm Hg 
• pO2 (a / A) 0.83 respiratory distress
and somnolence.
• Entered Data
• FiO2 21 %

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 • ----- XXXX Diagnostics ------

• Blood Gas Report

•
•
Measured
pH
37.0 C
7.23
o
Case 3
• pCO2 23 mm Hg
• pO2 110.5 mm Hg
• Calculated Data 28 year old
• HCO3 act 14 mmol / L diabetic with
• O2 Sat % respiratory
• pO2 (A - a) mm Hg  distress
• pO2 (a / A) fatigue and
• Entered Data loss of appetite.
• FiO2 21.0%
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 8) I shall practice gentle
mechanical ventilation and
not to try bring ABG to
perfect normal.
 9) I shall treat the patient, not
the ABG report.
 10) I shall always correlate
ABG report clinically.

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