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Arterial Blood Gases

Steve Lan
Objectives
 Review of physiology
 Basic interpretation of ABGs
 Radial ABG technique
Some Definitions
 pH: concentration of H+ in terms of 10-
x per litre

• pH of 7.0 = 10-7 = 0.0000001


• pH of 6.0 = 10-6 = 0.000001
 Acidosis: acidic blood; increase in H+
concentration (therefore decrease in
pH)
 Alkalosis: alkalotic blood; increase in
base, therefore decrease in H+
Basic principles
 Human bodies were designed to maintain:

pH 7.35-7.45
PaO2 95-100
mmHg
PaCO2 35-45
mmHg
HCO3 22-26
mmHg
Buffers
 Limit pH changes when strong
acids/bases are introduced
 Weak acid and its conjugate base
 Addition of a strong acid is partly
neutralized by the weak base

HB (weak acid) H+ (strong acid) B- (conjugate weak base)


Bicarbonate Buffer System

CO2 + H20 H2CO3 H+ + HCO3-

 Main extracellular buffer


 Also affected by lungs and kidneys
Key Equation
Blood (instantaneously)

CO2 + H20 H2CO3 H+ + HCO3-


Key Equation

CO2 + H20 H2CO3 H+ + HCO3-

Lungs
(within minutes)
Key Equation

CO2 + H20 H2CO3 H+ + HCO3-

Excretion via kidneys


(hours to days)
Key Equation
Blood (instantaneously)

CO2 + H20 H2CO3 H+ + HCO3-

Lungs Excretion via kidneys


(hours to days)
(within minutes)
Respiratory Acidosis

CO2 + H20 H2CO3 H+ + HCO3-


 Increase in CO2 “pushes” balance towards
producing more H2CO3
 Concentration of H+ increases, lowering
pH
 Causes
• Impaired lung function
• Decreased respiratory drive
Respiratory Alkalosis

CO2 + H20 H2CO3 H+ + HCO3-


 Increased RR causes decreased CO2
 Balance shifts towards left
decreasing concentration of H+
(therefore increasing pH)
 Causes
• Hyperventilation (anxiety)
Metabolic Acidosis

CO2 + H20 H2CO3 H+ + HCO3-


 Abnormal metabolism releases H+,
increasing concentration of pH, and
decreasing pH
 Causes
• DKA, lactic acidosis (arrest)
• Toxins
• Loss of HCO3 in diarrhea
Metabolic Alkalosis

CO2 + H20 H2CO3 H+ + HCO3-


 Increased plasma HCO3- neutralizes
H+
 Decreased concentration of H+
 Causes:
• Loss of H+ in vomit
• Gain of HCO3 (ingestion, IV)
Interpreting the ABGs
 Remember the “normals”
• pH 7.4, PaCO2 40, HCO3 24
 Know the “expected compensation”
Compensation
Disorder Initial change Compensation
Metabolic Decrease HCO3 1 mmHg decrease in
Acidosis PaCO2 for every 1
decrease in HCO3
Metabolic Increase HCO3 0.3-0.5 mmHg increase
Alkalosis in PaCO2 for every 1
increase in HCO3
Respiratory Decrease in Acute: 2 decrease in
alkalosis PaCO2 HCO3 for every 10
decrease in PaCO2
Chronic: 4-5 decrease
Respiratory Increase in Acute: 1 increase in
acidosis PaCO2 HCO3 for every 10
increase in PaCO2
Chronic: 3 increase
Compensation
Disturbance PaCO2 HCO3

Resp acidosis ↑10 ↑1


(acute)
Resp acidosis ↑10 ↑3
(chronic)
Resp alkalosis ↓10 ↓2
(acute)
Resp alkalosis ↓10 ↓4
(chronic)
Metabolic ↓1 ↓1
acidosis
Metabolic ↑3 ↑10
alkalosis
Basic Approach
 Is the pH acidemic or alkalemic?
 What is the primary disturbance?
• Metabolic: change in HCO3 and pH in
same direction
• Respiratory: change in PaCO2 and pH in
opposite direction
 Is the compensation appropriate?
Case 1
 24 yo M hx of drug abuse, brought to
ER cyanotic
• pH 7.08
• PaCO2 80
• PaO2 37
• HCO3 26
Case 1
 24 yo M hx of drug abuse, brought to
ER cyanotic
• pH 7.08
• PaCO2 80
• PaO2 37
• HCO3 26
 Acidemic or Alkalemic?
 Acidemic
Case 1
 24 yo M hx of drug abuse, brought to
ER cyanotic
• pH 7.08
• PaCO2 80
• PaO2 37
• HCO3 26
 pH in relation to PaCO2 and HCO3?
Basic Approach
 Is the pH acidemic or alkalemic?
 What is the primary disturbance?
• Metabolic: change in HCO3 and pH
in same direction
• Respiratory: change in PaCO2 and
pH in opposite direction
 Is the compensation appropriate?
Case 1
 24 yo M hx of drug abuse, brought to
ER cyanotic
• pH 7.08
• PaCO2 80
• PaO2 37
• HCO3 26
 primarily respiratory
Case 1
 24 yo M hx of drug abuse, brought to
ER cyanotic
• pH 7.08
• PaCO2 80
• PaO2 37
• HCO3 26
 Is the compensation adequate?
Case 1
 PaCO2 increased by 40
 For every 10 increase you would
expect 1 increase in HCO3
 Expected HCO3 would be ~28
Case 1
 24 yo M hx of drug abuse, brought to ER
cyanotic
• pH 7.08
• PaCO2 80
• PaO2 37
• HCO3 26
 Acidemic, primarily respiratory, but mild
component of metabolic
 Also hypoxemic
 Narcotic OD
Case 2
 42 F IDDM, presents with 4d hx of unwell
• pH 7.23
• PaCO2 27
• PaO2 118
• HCO3 12
 Acidemia, metabolic
 DKA, Na 135, Cl 99
 AG = Na – Cl – HCO3 = 135 – 111 = 24
Case 3
 71 m hx of COPD, c/o SOB
• pH 7.21
• PaCO2 75
• PaO2 41
• HCO3 30
 Acidemia, resp (acute on chronic),
hypoxic
Case 4
 23 F c/o SOB, lightheaded and
perioral tingling
• pH 7.54
• PaCO2 22
• PaO2 115
• HCO3 21
 Alkalemia, resp (acute)
Case 5
 32 M c/o vomitting x 5d, HR 110 BP
90/50, dry MM
• pH 7.50
• PaCO2 47
• PaO2 80
• HCO3 38
 Alkalemia, metabolic
ABG Sampling
 Indications
• Assessment of illness, or response to
therapy
 Contraindications
• Positive Allen’s test
• Overlying infection
ABG sampling
 Sites
• Radial artery, brachial, femoral
 Complications
• Arterial spasm
• Hemorrhage/hematoma
• Nerve injury
• infection
Allen’s test
 Anatomy
Allen’s test
 Step 1: tight fist x 20 sec
 Step 2: Occlude radial and ulnar arteries
Allen’s test
 Step 3: open hand and look for
blanching
 Step 4: release ulnar artery and look
for capillary refill (5-7 sec)
ABG technique
 Position wrist
 Prep skin
 Insert needle ~45
degrees, bevel up
 Apply pressure x
5min post
procedure

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