ARTERIAL BLOOD GAS

DR.MADE WIDIA, SP.A(K)

Normal ABG Parameters
Arterial Mixed Venous
Normal Range Normal Range
pH 7,40 7,35-7,45 7,36 7,31-7,41
PaCO
2
(mmHg) 40 35-45 46 41-51
PaO
2
(mmHg) 100 80-100 40 35-42
SaO
2
(%) 97 95-100 75 68-77
HCO3
-
(mEq/L) 24 22-26 24 22-26
BE (mEq/L) 0 2 0 2
Note.21% O2 at sea level
Oxygenation
Normal variations
Due to age, FiO
2
,or barometric pressure

Age: PaO
2
110-1/2 patients age

Abnormal variations
Hyperoxemia = above normal values
Hypoxemia = below normal values

Mild Hypoxemia Moderate Hypoxemia Severe Hypoxemia
PaO
2
(mmHg) 60-79 40-59 <40
SaO
2
(%) 91-94 86-90 <85
Notes: PaO2
65 mmHg - Begin O
2
therapy
60 mmHg O
2
stimulus to breathe
55 mmHg Begin O
2
therapy (CO
2
retainers)
30 mmHg Loss of conciousness
20 mmHg Brain damage likely
Signs and Symptoms of Acute Hypoxemia
(relative order of appearance)
Tachypnea Arrhytmias Loss of coordination
Dyspnea Blurred or tunnel vision Lethargy/weakness
Pallor Impair judgement Tremors/hyperactive
reflexes
Tachycardia Confusion Stupor
Hypertension Euphoria Coma30 mmHg
Headache Bradycardia Death
Anxiety Hypotension
Cyanosis Nausea/vomitting
Signs and Symptoms of Acute Hypercarbia
(relative order of appearance)
Tachypnea Hypotension
Dyspnea Drowsiness
Tachycardia Hallucination
Hypertension Convulsion
Vasodilatation (diaphoresis, flushing) Coma 70 mmHg
Headache Death
Bradypnea
Signs and Symptoms of Chronic Hypoxemia
(relative order of appearance)
Arrhytmias Papilledema
CO Polycythemia
Clubbing Impaired judgment
Dyspnea Myoclonic jerking
Irritability Pulmonary hypertension
Tiredness
Types Physiological cause Examples
Atmospheric Insufficient O2 available :
FiO
2
PaO
2

PIO
2
high altitude, drowning,
O
2
therapy error
Tidal Hypoventilation
(PaCO
2
PaO
2
)
Pulmonary obstruction,
pulmonary restriction, CNS
depression, N-M disorders
Alveolar Wasted ventilation, regional
hypoventilation :
(PaCO
2
PaO
2
)

shunt : (PvO
2
+ PaO
2
PaO
2
)

V/Q abnormality :
(PvO
2
+ PaO
2
PaO
2
)

Diffusion defect :
(PaO
2
blockPaO
2
)
Pulmonary emboli



Shock, pneumonia/atelectasis

COPD, high O
2
therapy


Fibrosis/sarcoidosis, A-C block,
pulmonary edema, O
2
therapy
Hypoxemia/Hypoxia-Cause and Effects
Types Physiological cause Examples
Hemoglobic Q abnormality : CaO
2
, PaO
2

normal, SaO
2

Anemia, hemmorrhage,
sickle cell, CO poisoning
Stagnan Q abnormality : O
2

transport (PvO
2
PaO
2
)
Cardiovascular failure,
arrhythmias, shock,
hemmorrhage
Histotoxic Cyanide poisoning
Demand metabolic demand causing
one or more hypoxias
Execise, fever, burns,
hyperthyroidism
Step 1:
Check pH
Step 2:
Check PaCO
2

(N=35-45)
Step 3:
Check HCO
3
-

(N=22-26)
Interpretation


(>7,45;
Alkalosis)
PC Metabolic Alkalosis
N Metabolic Alkalosis
N Respiratory Alkalosis
PC Respiratory Alkalosis
Normal
(7,35-7,45)
FC Metabolic Alkalosis (7,41-7,45)
FC Respiratory Acidosis (7,35-7,39)
N N Normal
FC Metabolic Acidosis (7,35-7,39)
FC Respiratory Alkalosis (7,41-7,45)

(<7,35;
Acidosis)
PC Respiratory Acidosis
N Respiratory Acidosis
N Metabolic Acidosis
PC Metabolic Acidosis
INTERPRETING ABGs
FC = Fully Compensated; PC = Partially Compensated
Respiratory Disorder pH and PaCO
2
go in opposite direction
Metabolic Disorder pH and HCO
3
-
go in same direction
Compensating* PaCO
2
and HCO
3
-
go in same direction
Mixed Disorder* PaCO
2
and HCO
3
-
go in opposite direction
Type of Disorders
*Expected compensation must be done to determine whether or not a disorder is pure or mixed
pH/PaCO2/HCO3- Relationship Expected Effects and Compensation

Respiratory Disorders

PaCO
2
pH HCO
3
-

Acute 10 mmHg 0,05 1 mEq/L
10 mmHg 0,10 2 mEq/L
Chronic 10 mmHg 0,03 4 mEq/L
10 mmHg 0,03 5 mEq/L

Metabolic Disorders

Acidosis PaCO
2
= last two digits of pH
PaCO
2
= (1,5 x HCO
3
-
) + 8 2
Alkalosis PaCO
2
change is variable, rarely above 55 mmHg
pH PaCO
2
HCO
3
-
K
+
Cl
-

Respiratory Acidosis (Ventilatory Failure)
Uncompensated (acute) N N N
Partially compensated N N
Fully compensated (chronic) N N
Respiratory Alkalosis (Alveolar hyperventilation)
Uncompensated (acute) N N N
Partially compensated N N
Fully compensated (chronic) N
Metabolic Acidosis
Uncompensated (acute) N
Partially compensated
Fully compensated (chronic) N N N
Metabolic Alkalosis
Uncompensated (acute) N
Partially compensated

Fully compensated (chronic)
N N N
Overview of Acid Base Disorders and Parameter Changes
Respiratory Alkalosis (Alveolar Hyperventilation)
CNS disorder
CVA (infarct)
Drugs : Ammonium
chloride; epinephrine,
progesterone, respiratory
stimulants, salicylate
poisoning (early)
Infections (G-)
Lesion (meningitis,
encephalitis)
Metabolic acidosis (CSF)
Psychogenic :
Anxiety, neurosis, pain
Trauma
Metabolic
Bacteremia
Exercise
Fever
Hepatic failure (coma)
Hyperthyroidism
Metabolic acidosis

Pulmonary
Asthma (early)
Atelectasis (early)
COPD (early)
Pneumonia (early)
Pulmonary burns
Pulmonary edema
Pulmonary embolism
Restrictive disorders
(mild or early)
Diaphragm movement
Abdominal distension
Obesity
Pregnancy

Cardiovascular
Anemia
Carbon monoxid poison
CHF
MI
Pulmonary embolism
Shock

Other
Altitude (high)
Hypoxemia (most common
cause)
Mechanical ventilation
Metabolic Acidosis
Anion gap
Cardiac arrest
Diarrhea
(severe,loss of HCO3
-
)
Cl
-

K
+

Liver failure
Acids
Ketones (DKA or
starvation)
Lactic (shock, hypoxia)
Renal failure (secretion
of acids)
Ingestion :
CO poison, cyanide,
ethylene glycol
(antifreeze), exogenous
acids (NH
4
Cl,diamox),
INH overdose, methanol
(sterno), paraldehyde,
phenformin, salicylate
poison (late stage)
Metabolic Alkalosis
Natural :
Inadequate diet
Ingestion of base
Vomiting (upper GI)
Iatrogenic :
HCO
3
-
during arrest, NG Sx (Cl-), K
+
,
Na
+
, massive blood replacement, IV
therapy (SO
4
+/or PO
4
), diuretic
therapy (excretion of H
+
, K
+
, Cl
-
),
steroid therapy, aldosteronism
(Cushings)
Cardiopulmonary System myocardial contractility
or myocardial
irritability
Pulmonary vascular
constriction
Systemic vasodilation
Arrhythmias
Heart failure
Flushed skin
color/diaphoresis
Pulmonary hypertension
Central Nervous System Depressed cortical function
Dilated cerebral vessels
or respiratory center
activity
Disoriented, somnolence,
coma
Focus neurological signs,
NM irritability
Headache, CSF pressure
Hyperventilation (if
metabolic)
Hypoventilation (if
respiratory)
Renal and Metabolic serum Cl
-
and K
+
(early)
excretion of Cl
-
and K
+

(later)
Reabsorption of HCO
3
-

Hyper/hypochloremia
Hyperkalemia
urine K
+

Nausea, vomiting
Physiological Effects and Clinical Manifestations of Acidosis
Cardiopulmonary System Bronchoconstriction
myocardial irritability
Pulmonary vascular
dilation
Systemic vasoconstriction
Arrhythmias
Dyspnea
PVR
HR, palpitations
Pale skin color
Central Nervous System Constricted cerebral
vessels (cerebral
edema)
excitability dan NM
irritability
or respiratory center
activity

Anxiety, nervousness, light-
headedness, tingling /
numbness, reflexes,
seizures, tetany
CSF pressure
Hyperventilation (if
respiratory)
Hypoventilation (limited, if
metabolic)
Renal and Metabolic serum Cl
-
and K
+
(early)
excretion of Cl
-
and K
+

(later)
Excretion of HCO
3
-


Hyper/hypochloremia
Hypokalemia
urine K
+

Physiological Effects and Clinical Manifestations of Alkalosis
Equation Comments Significance
Acid-Base
Anion Gap
1. AG = (Na
+
+ K
+
)-(Cl
-
+ HCO
3
-
)
2. AG = Na
+
- (Cl
-
+ HCO
3
-
)
3. AG = Na
+
- (Cl
-
+ CO
2
content)

Normal = 20 mEq/L
Normal = 12 mEq/L
Normal = 14 mEq/L
Alkalosis causes and anion
gap
Acidosis cause a anion gap

Evaluate the electrolyte balance
between cations and anions in the
extracellular fluid
Indicates if there is a metabolic
acidosis
AG = unmeasured anions: lactate
(hypoxia or hyperventilation),
poisons (alcohol,salicylates).
unmeasuredd cations : K
+,
Ca
++

,Mg
++

AG = unmeasured anions:albumin
unmeasured cations : K
+,
Ca
++

,Mg
++

Base Excess (BE)
1. BE = PaCO
2
+pH x 100
2
2. BE PaCO
2


3. BE HCO
3
-
+ 10pH
Base deficit (BD) = -BE
PaCO
2
from 40
pH from 7,40
Accurately only in range of :
PaCO
2 30-50,
pH 7,30-7,50
HCO
3
-
from 24


Use for compensated metabolic
conditions
Use for compensated metabolic
conditions
Bicarbonat Correction of pH
HCO
3
-
= (0,2)body weight x BD
Correct to pH 7,40
BD = Base Deficit
Used to correct for metabolic acidosis
Equation
Equation Comments Significance
Henderson-Hasselbach
1. pH = 6,1 + log (HCO
3
-
/H
2
CO
3
)
2. pH = 6,1 + log (HCO
3
-
/dissolved
CO
2
)
3. pH = 6,1 + total CO
2
0,03 PaCO
2

0,03 PaCO
2

4. PaCO
2
= total CO
2

0,3 x (1-antilog (pH-6,1))


Total CO
2
= volume%
2,2
Calculation of pH or PaCO
2

Rule of 8s
At : pH HCO
3
-
=
7,6 8/8 (PaCO
2
)
7,5 6/8 (PaCO
2
)
7,4 5/8 (PaCO
2
)
7,3 4/8 (PaCO
2
)
7,2 3/8 (PaCO
2
)
Examples : when
pH 7,4, PaCO
2
40, HCO
3
-
= 5/8
(40) = 25
pH 7,3, PaCO
2
60, HCO
3
-
= 4/8
(60) = 30
Estimate of HCO
3
-
in relation to pH
and PaCO
2

Siggaard-Anderson Nomogram See Appendix Used to determine BE, total CO
2
,
actual HCO
3
-
and standard HCO
3
-

T40 Bicarbonate
T40 = HCO
3
-
- expected HCO
3
-

HCO
3
-
= standard plasma
Expected HCO
3
-
= PaCO
2
-40
15

Used to find a true metabolic
component in acute hypercapnia