Interpretation of

ARTERIAL BLOOD
GASES
 Arterial blood gas analysis - basic principles

It is a diagnostic procedure in which a blood is obtained from an artery directly by an arterial

puncture or accessed by a way of indwelling arterial catheter

Arterial blood gases (ABG) are obtained for two basic purposes:
1. To determine oxygenation
2. To determine acid-base status
When is an ABG required?
3. To establish a diagnosis
4. To assess illness severity
5. To guide and monitor treatment

Components of ABG
PH: measures hydrogen ion concentration in the blood, it shows blood’ acidity or alkalinity
PCO2 :It is the partial pressure of CO2 that is carried by the blood for excretion by the lungs, known
as respiratory parameter
PO2: It is the partial pressure of O2 that is dissolved in the blood , it reflects the body ability to pick
up oxygen from the lungs
HCO3 : known as the metabolic parameter, it reflects the kidney’s ability to retain and excrete
bicarbonate
How to take an ABG Pre-procedure
Blood gas kit • Record patient inspired oxygen concentration
• 1ml syringe • Check patient temperature
• 23-26 gauge needle • Explain the procedure to the patient
• Stopper or cap • Provide privacy for client
• Alcohol swab • If not using heparinized syringe , heparinize the
• Disposable gloves needle
• Plastic bag & crushed ice • Perform Allen's test
• Lidocaine (optional) • Wait at least 20 minutes before drawing blood
• Vial of heparin (1:1000) for ABG after initiating, changing, or
• Par code or label discontinuing oxygen therapy, or settings of
mechanical ventilation, after suctioning the
Sites for obtaining ABG patient or after extubation.
• Radial artery ( most common )
• Brachial artery
• Femoral artery

Radial is the most preferable site used because:

It is easy to access
It is not a deep artery which facilitate palpation,
stabilization and puncturing
The artery has a collateral blood circulation
 Procedure
• Wash hands
• Put on gloves
• Palpate the artery for maximum pulsation
• If radial, perform Allen's test
• Place a small towel roll under the patient wrist
• Instruct the patient to breath normally during the test and warn him that he may feel brief
cramping or throbbing pain at the puncture site
• Clean with alcohol swab in circular motion
• Skin and subcutaneous tissue may be infiltrated with local anesthetic agent if needed
• Insert needle at 45 radial ,60 brachial and 90 femoral
• Withdraw the needle and apply digital pressure
• Check bubbles in syringe
• Place the capped syringe in the container of ice immediately
• Maintain firm pressure on the puncture site for 5 minutes, if
patient has coagulation abnormalities apply pressure for
10 – 15 minutes
• Send labeled, iced specimen to the lab immediately
• Palpate the pulse distal to the puncture site
• Assess for cold hands, numbness, tingling or discoloration
• Documentation include: results of Allen's test, time the sample was drawn, temperature,
puncture site, time pressure was applied and if O2 therapy is there
• Make sure it’s noted on the slip whether the patient is breathing room air or oxygen. If oxygen,
document the number of liters . If the patient is receiving mechanical ventilation, FIO2 should be
documented
Complications
Arterio-spasm
Hematoma
Hemorrhage
Distal ischemia
Infection
Numbness
Venous blood gases: It is easier to obtain a venous sample
than an arterial sample. In some situations analysis of
venous blood can provide enough information to assist in
clinical decisions. In general, the pH, CO2 and HCO3ˉ
values are similar in venous and arterial blood . The main
difference is the partial pressure of oxygen in venous
blood is less than half that of arterial blood. Venous blood
should not therefore be used to assess oxygenation.
Arterial blood gas analysis - pulmonary gas exchange:
partial pressure
 Pulmonary gas exchange refers to the transfer of O2 from the atmosphere to the
bloodstream (oxygenation) and CO2 from the bloodstream to the atmosphere (CO2
elimination)
 Arterial blood gases help us to assess the effectiveness of gas exchange by providing
measurements of the partial pressure of O2 and CO2 in arterial blood.
 Partial pressure – contribution of one individual gas within a gas mixture. Gases
move from areas of higher partial pressure to lower partial pressure. At the alveolar-
capillary membrane, air in alveoli has a higher PO2 and lower PCO2. O2 molecules
move from alveoli to blood and CO2 move from blood to alveoli.
Note
 PO2= partial pressures of O2
 PaO2= partial pressures of O2 in arterial blood
 PCO2= partial pressures of CO2
 PaCO2= partial pressures of CO2 in arterial blood
Arterial blood gas analysis - pulmonary
gas exange
Carbon dioxide elimination:
 PaCO2 is determined by alveolar ventilation and the level of
ventilation is adjusted to maintain PaCO2 within tight limits
(ref. range: PaCO2= 35-45 mm Hg).

 Increased PaCO2 (hypercapnia) implies reduced

alveolar
ventilation

 Ventilation is regulated by an area in brainstem called

respiratory center. This area contains receptors that sense
PaCO2 and connect with the muscles involved in breathing. If
PaCO2 is abnormal, the respiratory center adjusts the rate and
depth of breathing accordingly.

control of ventilation
Arterial blood gas analysis – pulmonary gas exchange
Oxygenation:
Almost all O2 molecules in blood are bound to Hb.
The amount of
O2 in blood depends on the two factors:
1. Hb concentration - how much O2 blood has the
capacity to carry.
2. Saturation of Hb with O2 (SO2) - the
percentage of available binding sites on
Hb occupied by O2 molecules.
Note
SO2 – saturation in (any) blood
SaO2 – saturation in arterial blood (80-100 mm Hg)
With a normal PaO2 (80-100 mm Hg), Hb is maximally
saturated (SaO2>95%). This means blood has used up its
O2-carrying capacity and any further increase in PaO2
will not significantly increase arterial O2 content.
oxyhaemoglobin dissociation curve
Arterial blood gas analysis – hypoxia, hypoxemia and
impaired oxygenation

 The term hypoxia is a reduced O2 delivery to

tissues.
 The term hypoxemia is a reduced O2 content
(PaO2) in arterial blood. It may result from
impaired oxygenation, low haemoglobin
(anaemia) or reduced affinity of haemoglobin for
O2 (e.g. carbon monoxide)
 Impaired oxygenation refers to hypoxaemia
resulting from reduced transfer of O2 from lungs
to the bloodstream. It is identified by a low PaO2
(<10.7 kPa; <80 mmHg).
 Arterial blood gas analysis: acid-
base balance
 pH - measurement of acidity or alkalinity, based on hydrogen (H+) ions present.

 Human blood normally has a pH of 7.35–7.45 (H+ = 35–45 nmol/L) and, therefore, it is slightly alkaline. If
blood pH is below the normal range (<7.35), there is an acidaemia. If it is above the normal range (>7.45),
there is an alkalaemia.

 An acidosis is any process that lowers blood pH, whereas an alkalosis is any process that raises blood pH.
Arterial blood gas analysis: maintaining acid-
base balance
Arterial blood gas analysis: maintaining acid-base balance

The respiratory buffer response

Our lungs are responsible for removing CO2. PaCO2, the partial pressure of carbon dioxide in our
blood, is determined by alveolar ventilation. If CO2 production is altered, we adjust our breathing
to exhale more or less CO2, as necessary, to maintain PaCO2 within normal limits. The bulk of the
acid produced by our bodies is in the form of CO2, so it is our lungs that excrete the vast majority
of the acid load

CO2 is carried in the blood to the lungs. In blood CO2 combines with water to form carbonic acid.
The more CO2 is added to blood, the more H2CO3 is produced, which dissociates to release H+.

 H2CO3 level in blood  H2CO3 level in blood

 blood pH  blood pH
 the rate and depth of lung ventilation until  the rate and depth of lung ventilation until
the appropriate amount of CO2 has been re-
the established
appropriate amount of CO2 has been re-
established
Activation of the lungs to compensate for an imbalance starts to occur within 1-3 minutes.
Arterial blood gas analysis: acid-base balance

The renal buffer response

The kidneys are responsible for excreting metabolic acids. They secrete H+ ions into urine and
reabsorb HCO3− from urine. HCO3− is a base (and therefore accepts H+ ions), so it reduces the
concentration of H+ ions in blood. The kidneys can adjust urinary H+ and HCO3− excretion in
response to changes in metabolic acid production.

 blood pH  blood pH
kidneys will compensate by retaining HCO3 kidneys will compensate by excreting
HCO3
 HCO3 level
 HCO3 level

The system may take hours to days to correct the imbalance.

Arterial blood gas analysis: acid-base
balance
Disturbances of acid-base balance:
1. Metabolic
2. Respiratory
1
• Metabolic processes are those that primarily alter the HCO3 concentration in the blood. A
decrease in serum HCO3 (base) leads to a metabolic acidosis, while an increase in serum
HCO3 leads to a metabolic alkalosis.
2
• Respiratory processes alter the pH by changing the CO2 levels.
• CO2 is a respiratory acid. CO2 accumulation causes an acid state in the blood (through carbonic
acid), and as respirations (respiratory rate and/or tidal volume) increase, the body eliminates
more CO2 (acid) and is left with a respiratory alkalosis. A decrease in ventilation leads to
retention and increased levels of CO2, and thus a respiratory acidosis.
 Causes
Respiratory Acidosis

pH, CO2, Ventilation

Causes
CNS depression
Pleural disease
COPD/ARDS
Musculoskeletal disorders
Compensation for metabolic alkalosis

Respiratory Alkalosis

pH, CO2, Ventilation

 CO2  HCO3 (Cl to balance charges )
hyperchloremia)
Causes CHAMPS
C – CNS Disease e.g. Intracerebral hemorrhage/
Cirrhosis
H – Hypoxia
A – Anxiety
M – Over ventilation
P – Progesterone
S – Salicylate/Sepsis
Metabolic Gap Acidosis Metabolic alkalosis
M - Methanol ^pH, ^HCO3
U - Uremia  PCO2 by 0.1 for every 1mEq/L in ^HCO3
D – DKA - AKA
Causes – CLEVER PD
P - Paraldehyde
I – Isoniazid / Iron C- Contraction
L - Lactic Acidosis L - Liquorice
E - Ethylene Glycol E - Endocrine: Conn’s / Cushing’s / Bartter’s
R- Rhabdomyolysis V - Vomiting / NG Suction
S - Salicylate E - Excess Alkali
Non Gap Metabolic Acidosis R - Refeeding Alkalosis
H - Hyper alimentation P - Post Hyper-capnea
A - Acetazolamide D - Diuretics and Chronic diarrhoea
R - RTA
D - Diarrhea
U - Uretero-pelvic shunt
P - Pancreatic Fistula
S – Spironolactone
Steps to arterial blood gas interpretation: uncompensated acid-base
balance
Step 1
Asses the pH to determine if the blood gas is withis normal range (7,35-7,45) or alkalotic (>7,45) or
acidotic (<7,35)
Step 2
If the blood is alkalotic or acidotic, we need to determine if it is casued primarily by a respiratory
or metabolic problem. To do this, access the PaCO2 level. With the respiratory problem, as the pH
decreases below 7,35, the PaCO2 should rise. If the pH rises above 7,45, the PaCO2 should
decrease. Compare the pH and PaCO2 values. If pH and PaCO2 are moving in the oposite
directions, then the problem is primarily respiratory in nature.
Step 3
Access the HCO3 value. With the metabolic problem, normally as the pH increases, the HCO3
should also increase. As the pH decreases, the HCO3 should also decrease. Compare the pH and
HCO3 values. If pH and HCO3 are moving in the same directions, then the problem is primarily
matabolic in nature.
pH PaCO2 HCO3
Respiratory acidosis   normal
Respiratory alkalosis   normal
Metabolic acidosis  normal 
Metabolic alkalosis  normal 
Arterial blood gas analysis: maintaining acid-base balance
Compensation
When a patient develops an acid – base imbalance, the body attempts to compensate. Lungs and
kidneys are the primary buffer response system in the body. The body tries to overcome either a
respiratory or metabolic dysfunction in an attempt to return pH into normal value.
The patient can be

1. uncompensated
pH outside normal range
2. partially compensated

3. fully compensated
pH within normal range
Arterial blood gas interpretation: mixed acid – base
disturbances
When a primary respiratory disturbance and primary metabolic disturbance occur simultaneously,
there is said to be a mixed acid–base disturbance.

If these two processes oppose each other, By contrast, if the two processes cause pH to move
the pattern will be similar to a in the same direction (metabolic acidosis and
compensated acid–base disturbance and respiratory acidosis or metabolic alkalosis and
the resulting pH derangement will be respiratory alkalosis), a profound acidaemia or
minimised. alkalaemia may result.
Treatment of metabolic acidosis
The underlying condition behind the acidosis must be treated. In some cases, sodium bicarbonate
is prescribed to return the blood to a normal pH.Severe cases can lead to shock and can be life
threatening
Treatment of respiratory acidosis
 A doctor should be seen immediately to treat acute respiratory acidosis, as this can be
a life threatening condition. Treatment is targeted to the cause.
 Bronchodilator medications may be given to correct some forms of airway obstruction.
If your blood oxygen level is too low, you may require oxygen. Noninvasive positive
pressure ventilation or a breathing machine may be necessary.
Alkalosis : treatment
Carbon dioxide level needs to return to normal if respiratory alkalosis.
If rapid breathing caused by anxiety, taking slow, deep breaths can often improve symptoms
and regulate oxygen level.
If tests reveal that a low oxygen level, need to receive oxygen through a mask.
If rapid breathing is caused by pain, then treating the pain will help to bring respiratory rate back
to normal and improve symptoms.
If alkalosis is caused by a loss of chemicals such as chloride or potassium, then prescribe
medications or supplements to replace these chemicals.
Some cases of alkalosis result from an electrolyte imbalance, which may be corrected by
drinking plenty of fluids or drinks that contain electrolytes.
Most people recover from alkalosis once they receive treatment.
Example 1
Jane Doe is a 45-year-old female admitted to the nursing unit with a severe asthma attack. She
has been experiencing increasing shortness of breath since admission three hours ago.
Her arterial blood gas result is as follows
Clinical Laboratory:
pH 7.22
PaCO2 55
HCO3 25
Follow the steps:
1. Assess the pH. It is low therefore, we have acidosis.
2. Assess the PaCO2. It is high and in the opposite direction of the pH.
3. Assess the HCO3. It has remained within the normal range (22-26).
Acidosis is present (decreased pH) with the PaCO2being increased, reflecting a primary
respiratory problem. For this patient, we need to improve the ventilation status by providing
oxygen therapy, mechanical ventilation or by administering bronchodilators.
Example 2
John Doe is a 55-year-old male admitted with a recurring bowel obstruction. He has been
experiencing intractable vomiting for the last several hours, Here is his arterial blood gas result:
Clinical Laboratory:
pH 7.50
PaCO2 42
HCO3 33
Follow the steps again:
1. Assess the pH. It is high (normal 7.35-7.45), therefore, indicating alkalosis.
2. Assess the PaCO2. It is within the normal range (normal 35-45).
3. Assess the HCO3. It is high (normal 22-26) and moving in the same direction as the pH.

Alkalosis is present (increased pH) with the HCO3 increased, reflecting

a primary metabolic problem. Treatment of this patient might include administration of I.V. fluids
and measures to reduce the excess base.