Arterial blood gas

An arterial blood gas (ABG) is a blood test that is performed using blood from an artery. It
involves puncturing an artery with a thin needle and syringe and drawing a small volume of
blood. The most common puncture site is the radial artery at the wrist, but sometimes the
femoral artery in the groin or other sites are used. The blood can also be drawn from an
arterial catheter.

The test is used to determine the pH of the blood, the partial pressure of carbon dioxide and
oxygen, and the bicarbonate level. Many blood gas analyzers will also report concentrations
of lactate, hemoglobin, several electrolytes, oxyhemoglobin, carboxyhemoglobin and
methemoglobin. ABG testing is mainly used in pulmonology, to determine gas exchange
levels in the blood related to lung function, but has a variety of applications in other areas of
medicine. Combinations of disorders can be complex and difficult to interpret, so calculators
[1]
, nomograms, and rules of thumb[2] are commonly used.

Contents
[hide]

• 1 Extraction and analysis

o 1.1 Calculations
o 1.2 Helpful Guidelines
• 2 Reference ranges and interpretation
• 3 See also
• 4 References

• 5 External links

Extraction and analysis

Arterial blood for blood gas analysis is usually extracted by a phlebotomist, nurse, or
respiratory therapist.[3] Blood is most commonly drawn from the radial artery because it is
easily accessible, can be compressed to control bleeding, and has less risk for occlusion. The
femoral artery (or less often, the brachial artery) is also used, especially during emergency
situations or with children. Blood can also be taken from an arterial catheter already placed in
one of these arteries.

The syringe is pre-packaged and contains a small amount of heparin, to prevent coagulation
or needs to be heparinised, by drawing up a small amount of heparin and squirting it out
again. Once the sample is obtained, care is taken to eliminate visible gas bubbles, as these
bubbles can dissolve into the sample and cause inaccurate results. The sealed syringe is taken
to a blood gas analyzer. If the sample cannot be immediately analyzed, it is chilled in an ice
bath in a glass syringe to slow metabolic processes which can cause inaccuracy. Samples
drawn in plastic syringes are not iced and are analyzed within 30 minutes.[4]
Standard blood tests can also be performed on arterial blood, such as measuring glucose,
lactate, hemoglobins, dys-haemoglobins, bilirubin and electrolytes.

Calculations

Arterial blood gas device.

The machine used for analysis aspirates this blood from the syringe and measures the pH and
the partial pressures of oxygen and carbon dioxide. The bicarbonate concentration is also
calculated. These results are usually available for interpretation within five minutes.

Much controversy exists about optimal blood gas management of hypothermic patients.[citation
needed]
Two methods have been used in medicine in the management of blood gases of patients
in hypothermia: pH-stat method and alpha-stat method. Recent studies suggest that the α-stat
method is superior.

• pH-stat: the arterial carbon dioxide tension (paCO2) is maintained at 5.3 kPa (40
mmHg) and the pH is maintained at 7.40 when measured at the actual patient
temperature. It is then necessary to add CO2 to the sample to calculate results.
• α-stat (alpha-stat): the arterial carbon dioxide tension and the pH are maintained at 5.3
kPa (40mmHg) and 7.40 when measured at +37°C. When a patient is cooled down,
the pH-value will increase and the pCO2-value and the pO2-value will decrease with
lowering of the temperature if measured at the patients temperature.

Both the pH-stat and alpha-stat strategies have theoretical disadvantages. α-stat method is the
method of choice for optimal myocardial function. The pH-stat method may result in loss of
autoregulation in the brain (coupling of the cerebral blood flow with the metabolic rate in the
brain). By increasing the cerebral blood flow beyond the metabolic requirements, the pH-stat
method may lead to cerebral microembolisation and intracranial hypertension.[5]

Helpful Guidelines

1. A 1mmHg change in PaCO2 above or below 40 mmHg results in 0.008 unit change in
pH in the opposite direction. [6]
2. The PaCO2 will decrease by about 1 mmHg for every 1 mEq/L reduction in [HCO3-]
below 24 mEq/L
3. A change in [HCO3-] of 10 mEq/L will result in a change in pH of approximately 0.15
pH units in the same direction.
Reference ranges and interpretation
These are typical reference ranges, although various analysers and laboratories may employ
different ranges.

Analyte Range Interpretation

The pH or H+ indicates if a patient is acidotic (pH < 7.35; H+ >45)
pH 7.35–7.45
or alkalemic (pH > 7.45; H+ < 35).
35–45 nmol/L
H+ See above.
(nM)
A low O2 indicates that the patient is not respiring properly, and is
9.3–13.3 kPa
hypoxemic. At a PaO2 of less than 60 mm Hg, supplemental
PaO2 or 80–100
oxygen should be administered. At a PaO2 of less than 26 mmHg,
mmHg
the patient is at risk of death and must be oxygenated immediately.
The carbon dioxide partial pressure (PaCO2) indicates a respiratory
problem: for a constant metabolic rate, the PaCO2 is determined
entirely by ventilation.[7] A high PaCO2 (respiratory acidosis)
4.7–6.0 kPa indicates underventilation, a low PaCO2 (respiratory alkalosis)
PaCO2 or 35–45 hyper- or overventilation. PaCO2 levels can also become abnormal
mmHg when the respiratory system is working to compensate for a
metabolic issue so as to normalize the blood pH. An elevated
PaCO2 level is desired in some disorders associated with
respiratory failure; this is known as permissive hypercapnia.
The HCO3− ion indicates whether a metabolic problem is present
(such as ketoacidosis). A low HCO3− indicates metabolic acidosis,
22–26
HCO3− a high HCO3− indicates metabolic alkalosis. HCO3− levels can also
mmol/L
become abnormal when the kidneys are working to compensate for
a respiratory issue so as to normalize the blood pH.
21 to 27 the bicarbonate concentration in the blood at a CO2 of 5.33 kPa,
SBCe
mmol/L full oxygen saturation and 37 degrees Celsius.[8]
The base excess is used for the assessment of the metabolic
component of acid-base disorders, and indicates whether the
patient has metabolic acidosis or metabolic alkalosis. A negative
−3 to +3
Base excess base excess indicates that the patient has metabolic acidosis
mmol/L
(primary or secondary to respiratory alkalosis). A positive base
excess indicates that the patient has metabolic alkalosis (primary
or secondary to respiratory acidosis).[9]
0.8 to 1.5 [10]
HPO42−
mM
This is the total amount of CO2, and is the sum of HCO3− and
PCO2 by the formula:
total CO2 25 to 30
tCO2 = [HCO3−] + α*PCO2, where α=0.226 mM/kPa, HCO3− is
(tCO2 (P)c) mmol/L
expressed in millimolar concentration (mM) (mmol/l) and PCO2 is
expressed in kPa [11]
O2 Content vol% (mL
This is the sum of oxygen dissolved in plasma and chemically
(CaO2, oxygen/dL
bound to hemoglobin. [12]
CvO2, CcO2) blood)
Contamination with room air will result in abnormally low carbon dioxide and (generally)
normal oxygen levels. Delays in analysis (without chilling) may result in inaccurately low
oxygen and high carbon dioxide levels as a result of ongoing cellular respiration.

Lactate level analysis is often featured on blood gas machines in neonatal wards, as infants
often have elevated lactic acid.

See also