Arterial blood gas

By Dr. Geetika Garg

What is ABG?
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. Puncturing sites
Radial Brachial Femoral

How to collect the sample?

TECHNIQUE FOR RADIAL ARTERY PUNCTURE : Perform modified Allens test. Clean the site Use 21 gauge needle with syringe. Flush syringe and needle with heparin. Palpate artery with one hand and enter skin at 45-degree angle. Obtain 2-4 ml of blood preferably without aspiration. After withdrawal of syringe, apply firm pressure at punctured site

PRECAUTIONS Avoid air bubble in the sample. As it can lead to increase in PaO2 and decrease in PaCO2. Avoid excess heparin as it can dilute the sample. If lab analysis will be delayed for more than few min , the sample should be refrigerated. At normal temp. RBC metabolism can produce lactic acid and may acidify the sample

What is the need for ABG?

In emergency, critical and unstable patients,

where significant acid base disorder is suspected, ABG is needed immediately. If history, examination and serum electrolytes suggest severe or progressive acid base disorder. Sick patients with significant respiratory distress secondary to acute respiratory diseases or exacerbation of chronic respiratory diseases.

BASIC PHYSIOLOGY
The body maintains pH within a normal range in spite of variation in dietary

intake of acid and alkali, and endogenous acid production.

ENDOGENOUS ACID PRODUCTION Normally when food is metabolized, two types of acids are added to ECF: Volatile Acid in form of carbonic acid (H2CO3) determines the CO2 level in blood (PaCO2) and is excreted by lung. Nonvolatile (fixed) Acid ( like sulfuric and phosphoric acids)- produced by dietary and endogenous protein catabolism and is excreted by the kidney.

REGULATION OF ACID BASE Buffers Respiratory regulation Renal regulation

HENDERSON HASSELBALCH EQUATION pH = 6.1 + log HCO3 /0.3 PaCO2 = pK + kidney/ lung

Buffers
Buffers are chemical systems, which either

release or accept H+. Buffers minimize change in pH induced by an acid or base load and provide immediate defence. Buffers act FASTEST And has LEAST BUFFERING POWER. Egs- bicarbonate, phosphate, proteins, Hb and bone bicarbonate.

Respiratory Regulation
By excreting volatile acids, lungs regulates

PaCO2. Maintains CO2 at 40 mm of Hg. When rate of CO2 production increases it will stimulate PaCO2 sensitive chemoreceptors at central medulla with resultant rise in rate and depth of breathing. This hyperventilation will maintain PaCO2 at normal range. Acts rapidly (in seconds and minutes) and DOUBLE BUFFERING POWER AS COMPARED TO CHEMICAL BUFFERS.

If underlying disorder (respiratory or CNS)

causes hypoventilation , CO2 excretion is reduced. Retained PaCO2 (hypercapnia) causes fall in pH leading to RESPIRATORY ACIDOSIS.
If the underlying disorder causes

inappropriately high hyperventilation, CO2 is washed out. Low PaCO2 (hypocapnia) causes rise in pH leading to RESPIRATORY ALKALOSIS.

Renal Regulation
Maintain plasma HCO3 concentration and

thereby pH regulation. Has got MOST POWERFUL buffering system within hours, and takes 5-6 days for peak effect. The kidney regulates HCO3 by excreting nonvolatile-fixed acids by following 3 main mechanism : - Excretion of H+ ions by tubular secretion. - Reabsorption of filtered bicarbonate ions. - Production of new HCO3 ions.

 METABOLIC ACID BASE DISORDERS In response to acid load, normal kidneys are able to

increase net acid excretion greatly (more than 10 time). Increasd excertion of H+ ions along with regeneration of bicarbonate will correct plasma HCO3 to normal range.

When there is primary increase in plasma HCO3 or when PaCO2 increase there will be increased renal HCO3 excretion in the urine. WHEN DOES METABOLIC REGULATION FAIL? Metabolic acidosis occurs when excess HCO3 is lost or acids are added or bicarbonate in not generated. Metabolic alkalosis occurs when excess H+ is lost , or increased HCO3 is generated, or renal bicarbonate excretion fails.

Basic Terminology
pH : It signifies free hydrogen ion

concentration. pH is inversely related to H+ ion concentration. Acid : A substance that can donate H+ ion or when added to solution raises H+ ion (lowers pH). Base : a substance that can accept H+ ion or when added to solution lowers H+ ion (i.e. raises pH). Anion : An ion with negative charge is anion (i.e. Cl,

Acidaemia : means acidic blood refers to a

blood pH below normal (pH < 7.35) and increased H+ ion concentration. Alkalaemia : means alkaline blood refers to a blood pH above normal (pH>7.45) and decreased H+ ion concentration. Acidosis : Abnormal process/ disease, which reduces pH due to increase in acid or decrease in alkali. Alkalosis : Abnormal process /disease, which

Clinical terminology Normal pH Acidaemia Alkalaemia Normal PaCo2 Respiratory acidosis Respiratory alkalosis Normal HCO3 Metabolic Acidosis Metabolic Alkalosis

Criteria 7.4 (7.35-7.45) pH < 7.35 pH >7.45 40 (35-45)mm of Hg PaCO2 >45 mm of Hg and low pH PaCO2 < 35 mm of Hg and high pH(22-26) mEq/L 24 HCO3 <22 mEq/L and low pH HCO3 >26 mEq/L and high pH

Primary Acid Base Disorders

Depend upon the initial disturbances whether

HCO3 or PaCO2.

When we see HCO3 we should think of

Metabolic cause.
When we see PaCO2 we should think of

Respiratory cause

Basic Disorder Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

pH Low High Low High

H+ High Low High Low

Primary Change HCO3 low HCO3 high PaCO2 high PaCO2 low

Secondary Change PaCO2 decreased PaCO2 increased HCO3 increased HCO3 decreased

Mixed Acid Base Disorder

Definition : defined as independent

coexistence of more than one primary acid base disorder.

Most common is mixed metabolic and

respiratory acidosis

Disorders Common causes Cardiac arrest (hypoventilation + Metabolic acidosis and respiratory acidosis (low pH, lactic acidosis) shock with respiratory failure HCO3, PaCO2) DKA with respirator y distress Metabolic acidosis and -salicylate intoxication respiratory alkalosis ( N pH, Gram negative sepsis Liver failure low HCO3 and PaCO2) Metabolic alkalosis and -COPD with diuretics respiratory acidosis ( N pH, - Metabolic alkalosis with severe high HCO3 and PaCO2) hypokalemia and respiratory weakness leads to hypoventilation Liver failure with vomiting Metabolic alkalosis and respiratory alkalosis (high pH, Pt on ventilator with continuous HCO3 and low PaCO2) nasogastric aspiration. DKA with vomiting Metabolic acidosis and metabolic alkalosis (near N vomiting with severe volume pH and HCO3) depletion causing lactic acidosis Respiratory acidosis and DO NOT CO- EXIST respiratory alkalosis

Triple mixed disorders

Metabolic acidosis, metabolic alkalosis with

respiratory alkalosis. Eg- alcoholic patient with vomiting (metabolic acidosis + alkalosis), who develops superimposed respiratory alkalosis from sepsis or liver diseases.

Metabolic acidosis, metabolic alkalosis with

respiratory acidosis Eg- COPD hypercapnic (respiratory acidosis) pt, who develops metabolic alkalosis from diuretics or vomiting, develops superimposed met acidosis from sepsis, hypotension or hypoxemia.

Evaluation and investigations of acid base disorder

HISTORY AND EXAMINATION PRIMARY INVESTIGATIONS : provide clue to

underlying disorder. Sr Na, K, Cl, HCO3, and anion gap, CBC, RFT, Urine examination, Blood sugar, etc.

ABG

Interpretation of Basic investigations

qpH normal value 7.4 (7.35-7.45) Normal value suggests either absence of disorders or presence of mixed disorders. low pH <7.35 : suggests acidosis High pH >7.45 : suggests alkalosis Relation of pH to H+ concentration (nEq/L) is H+ falls by 20% for each 0.1 pH unit increment.

pH 6.9 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 H+ 125 100 80 64 51 40 32 25 20

H+ = 24 PaCO2 / HCO3 1)

qHCO3 (mEq/L) normal value : 24 (22-26)mEq/L Low (<22mEq/L) : metabolic acidosis (primary change) or resp acidosis (secondary change) High (>26 mEq/L) : met alkalosis (primry change) or resp acidosis (secondary change) Normal HCO3 : doesnot exclude acid base disorders.

qPaCO2 (mm of Hg) normal value : 40 (35-45)mm of Hg High (>45) : resp acidosis (primary change) or met alk (sec change) Low (<35) : resp alk (primary change) or met

qAnion Gap (AG)

The charge difference between unmeasured

anion and cation is termed as anion gap. Unmeasured anions are anionic protein, phosphates, sulphate and organic acids. Unmeasured cations are Ca , Mg and K. ALBUMIN normally compromises most of the AG. AG = Na ( Cl+HCO3) = 12+_ 2 mEq/L

Importance of Anion Gap

AG helps in diagnosis of etiological cause of

metabolic acidosis. Increased AG acidosis characterized by 2 factors: - low HCO3 - increased anion gap REMEMBER , fall in HCO3 = rise in anion gap. AG in diagnosis of mixed disorder : If high AG metabolic acidosis is assoc. with a) normal HCO3 b)AG excess > HCO3 deficit, Think of superimposed metabolic alkalosis

Decreased Anion Gap

Decrease in unmeasured anions
Hypoalbuminemia

Increase in unmeasured cations

Hypercalcemia Hypermagnesemia Hyperkalemia Multiple myeloma Lithium toxicity

Normal Anion Gap Acidosis

H: hyperalimentation A: acetazolamide R: RTA D: diarrhea U: rectosigmoidostomy P: pancreatic fistula

Increased Anion Gap

Metabolic disorders

DKA Lactic Acidosis Alcoholic ketoacidosis Addition of exogenous acids salicylate poisoning methanol poisoning Failure to excrete acid acute/ chronic renal failure

Corrected AG
Hypoproteinamia common in critical illness Albumin has a lot of negative charge Albumin Gap = 40 apparent albumin Anion Gapcorr = AG + (albumin gap/4) For every 1 gm/dl decline in serum albumin a 2 mEq/L decrease in anion gap will occur.

Example of AGcorr
Albumin = 18 AG = 15 (normal) AGcorr Ie. Look for an unmeasured anion!

= 15 + (40-18)/4 = 20.5 (increased)

qSerum Potassium Normal value 3.5 -5.5 mEq/L Low K : metabolic or resp alkalosis, diarrhoea, proximal RTA High K : metabolic acidosis due to renal failure, Type 4 RTA, DKA or Resp acidosis

qPulse oxymetry Measures O2 saturation of arterial Hb. Normal value : 96-100% <90% saturation suggests marked tissue hypoxia (less than 60% PaO2). It tells nothing about PaCO2, hypercapnia can also occur with 100%O2. Only useful for hypoxemia screening.

 Urine Chloride level.

Differentiates metabolic alkalosis in 2 major groups

SALINE RESPONSIVE (<15mEq/L) ECF volume depletion vomiting / gastric suction Diuretics Hypercapnia correction No ECF Vol. Depletion NaHCO3 infusion Multiple transfusion

SALINE RESISTANT (>20mEq/L) Normal or increased ECF Vol Hyertensive Hyperaldosteronism Cushing syndrome Normotensive Bartters syndrome Severe K depletion

Diagnosis of acid base disturbances: step by step analysis

STEP-1 Is there an acidosis or alkalosis disorder? look at pH if pH <7.35 suggests acidosis if pH >7.45 suggests alkalosis

STEP-2 Is there an acid base disorder? look at PaCO2 and HCO3.

STEP-3 Is there the primary acid base disorder?

A)determine primary defect from pH, HCO3 and PaCO2 a) If pH is low (<7.35) pt has acidaemia, which can be either i) Metabolic acidosis low HCO3 ii) Respiratory acidosis high PaCO2 b) If pH is high (7.45) pt has alkalaemia which can be either i) Metabolic alkalosis high HCO3 ii) Respiratory alkalosis low PaCO2

B) to determine whether it is acute or chronic respiratory alkalosis/ acidosis H+/ PaCO2 <0.3 chronic >0.8 acute 0.3-0.8 acute on chronic

STEP-4 Calculate the expected compensation? determine whether actual value matches with the expected compensation. Matching of both confirms diagnosis of primary disorder.

Disorder Expected Compensation Metabolic acidosis (fall in HCO3) PaCO2 = (1.5 HCO3) + 8 PaCO2 = HCO3 +15 Metabolic alkalosis (rise in Rise in PaCO2 = 0.75rise in HCO3) HCO3 PaCO2 Respiratory Acidosis Rise in Acute (6-24hrs) : rise in HCO3 = 0.1 rise in PaCO2 fall in pH = 0.01 rise in PaCO2 Chronic (>24hrs) : rise in HCO3 = 0.4 rise in PaCO2 fall in pH = 0.003 rise in PaCO2 Respiratory Alkalosis Fall in PaCO2 Acute : fall in HCO3 =0.2fall in PaCO2 rise in pH = 0.01 fall in PaCO2 Chronic : fall in HCO3 =0.4 fall in PaCO2 rise in pH = 0.002 fall in PaCO2

STEP-5 Determine the presence of mixed acid base disorder A) CHECK THE DIRECTION OF CHANGES As per rule of same direction - simple acid base disorder . If changes are in opposite direction - mixed disorder

B) COMPARE EXPECTED COMPENSATION WITH ACTUAL VALUE. if value is either more or less as compared to calculated suggests mixed disorder.

C) CHECK THE ANION GAP In certain disorders pH, HCO3 and PaCO2 are normal and there is only increase in AG. metabolic acidosis

D) COMPARE FALL IN HCO3 WITH INCREASE IN PLASMA AG. i) rise in AG = Fall in HCO3 suggests high metabolic acidosis ii) Rise in AG > fall in HCO3 suggests co-existing metabolic alkalosis iii) Rise in AG < fall in HCO3 suggests non AG metabolic acidosis.

E) CHECK GAP-GAP RATIO AG/HCO3 = 1 , pure increased AG metabolic acidosis < 1 normal anion gap metabolic acidosis >2 associated metabolic acidosis

STEP-6 Check urinary chloride If urinary chloride <15 chloride responsive or ECV depletion. If urinary chloride >20 Chloride resistant

STEP-7 If pH is normal ABG may be normal or mixed disorder. a) Increase PaCO2 and decrease HCO3 respiratory and metabolic acidosis. b) Decrease PaCO2 and increase HCO3 respiratory and metabolic alkalosis. Calculate % difference (HCO3/HCO3 and PaCO2/PaCO2) to see which is dominant disorder.

STEP-8 Clinical correlation and to establish etiological diagnosis.

Lets practice

Case 1 : A 15 yr old boy is brought from examination hall in apprehensive state with c/o tightness of chest?
pH- 7.54 , HCO3 21mEq/L , PaCO2- 21mm of Hg

Analysis : pH high alkalosis low PaCO2 respiratory alkalosis HCO3 low compensation ( same direction rule). Expected compensation (fall in HCO3) in resp alkalosis Fall in HCO3 = 0.2 fall in PaCO2 = 0.2 x (40- 21) = 0.2 x 19 = 3.8 So expected fall in HCO3 = 24-3.8 = 20.2mEq/L 21mEq/L

= PRIMARY RESPIRATORY ALKALOSIS due to anxiety.

Case 2 : A patient with poorly controlled IDDM missed his insulin for 3 days. pH=7.1, HCO3= 8mEq/L, PaCO2= 20mmHg Na=140mEq/L, Cl=106mEq/L, urinary ketones+++

pH = low = acidosis HCo3= low = metabolic acidosis PaCO2 = low = compensation (same direction rule) Expected compensation (fall in PaCO2) will be PaCO2 = HCO3 x 1.5 +8 = 8 x 1.5 +8 = 12+8 = 20 Expected actual PaCO2 ( metabolic acidosis) Anion Gap [ AG= Na- (Cl+HCO3)] = 140- (106+8)=

26 High anion gap

= HIGH ANION GAP METABOLIC ACIDOSIS due to

DKA

Case 3 : A pt with severe diarrhoea , c/o difficulty in breathing. pH=7.1, HCO3 = 14mEq/L, PaCO2 = 44mm of Hg and K= 2 mEq/L
pH = low = acidosis HCO3 = low = metabolic acidosis PaCO2 expected to reduce due to

compensation. But actual PaCO2 = high = respiratory acidosis Very low K causes weakness of respmuscles leading to resp failure = respiratory acidosis

= Metabolic acidosis with respiratory acidosis

Case 4 : ABG of pt with CHF on frusemide is: pH=7.48, HCO3 = 34mEq/L, PaCO2= 48mm of Hg
pH= high = alkalosis HCO3 = high = met alkalosis PaCO2 = high = compensation (same direction

rule) Expected compensation Rise in PaCO2 = 0.75 x rise in HCO3 = 0.75 x (34-24) = 0.75 x 10 = 7.5 Expected PaCO2 = 40+7.5 = 47.5 actual PaCO2

= PRIMARY METABOLIC ALKALOSIS due to

Case 5 : following sleeping pills ingestion, pt presented in drowsy state with sluggish respiration with RR=4/min pH=7.1, HCO3= 28mEq/L, PaCO2=80mm Hg, PaO2 = 42 mm of Hg

pH = low = acidosis PaCO2 = high = respiratory acidosis PaO2 = low = hypoxemia (respiratory failure) HCO3 = high = compensation Expected compensation Rise in HCO3 = 0.1 x rise in PaCO2 = 0.1 x (80-40)

= 0.1 x 40 = 4 mEq/L expected HCO3 = 24+4 = 28 = actual HCO3

= Respiratory acidosis due to resp failure due to sleeping pills.

Case 6 : ABG of pt with shock on ventilatory support since last 4hour pH= 7.48, HCO3 = 14mEq/L , PaCO2 = 22mm of Hg
pH = high = alkalosis PaCO2 = low = resp alkalosis If setting of ventilator is high respiratory rate and

high tidal volume, it can cause respiratory alkalosis HCO3 = low = compensation Fall in HCO3 = 0.2 x fall in PaCO2 = 0.2 x (40-22) = 3.6 Expected HCO3 = 24-3.6 = 20.4mEq/L actual HCO3 Actual HCO3 = low (14) = metabolic acidosis

= MIXED DISORDER, respiratory alkalosis with

metabolic acidosis.

vomiting pH 7.4, HCO3 = 36mEq/L, PaCO2 = 60mm of Hg

pH is normal (either no disorder or has mixed

acid base disorder) HCO3 = high = met alkalosis PaCO2 = high = resp acidosis Met alkalosis expected to increase pH Resp acidosis expected to decrease pH

= MIXED DISORDER, respiratory acidosis with

met alkalosis

Case 8 : A C/O hepatic failure has persistent vomiting pH 7.54, HCO3 = 38mEq/L, PaCO= 44mm of Hg
pH= high= alkalosis HCO3= high = met alkalosis (vomiting) PaCO2 = high = compensation (same direction

rule) Expected compensation Rise in PaCO2 = 0.75 x rise in HCO3 = 0.75 x (3824) = 10.5 Expected PaCO2 = 40 +10.5 = 50.5mm Hg actual value

= MIXED DISORDER, metabolic alkalosis with respiratory alkalosis

THANKS

Compensation in Acid Base Disorders

What is compensation and how does it occur?

The bodys response to neutralise the effect of the initial

insult on pH homeostasis is called compensation. REMEMBER pH is maintained by the ratio of HCO3/PaCO2

To maintain normal pH, primary metabolic disorders (primary

change in HCO3 ) lead to compensatory respiratory responses (secondary change in PaCO2) Eg met acidosis (fall in HCO3) leads to low pH.Low pH stimulates the respiratory centre causing hyperventilation. Which leads to CO2 washout and decreased PaCO2 which returns ratio of PaCO2/HCO3 towards normal. This compensation keeps pH within a normal range.

Similarly, to maintain normal pH in primary respiratory

disorders (primary change in PaCO2) leads to compensatory metabolic (renal ) responses

 WHAT IS SAME DIRECTION RULE? The compensatory changes are in same direction

as the primary changes. Decreased HCO3 leads to Decreased PaCO2 and vice versa.

WHY TO CALCULATE AND CHECK COMPENSATION? Useful in differentiating simple from mixed

disorder. If expected change = actual change, disorder is simple If actual change is more or less than the expected, disorder is mixed. Compensation follows same direction rule. If

What is Expected Compensation?

Disorder Metabolic acidosis (fall in HCO3) alkalosis (rise in Metabolic HCO3) Respiratory Acidosis Acute (6-24hrs) : rise in HCO3 fall in pH Chronic (>24hrs) : rise in HCO3 fall in pH Respiratory Alkalosis Acute : fall in HCO3 rise in pH Chronic : fall in HCO3 rise in pH Expected Compensation PaCO2 = (1.5 HCO3) + 8 PaCO2 PaCO2 = 0.75rise in Rise in = HCO3 +15 HCO3 PaCO2 Rise in = 0.1 rise in PaCO2 = 0.01 rise in PaCO2 = 0.4 rise in PaCO2 = 0.003 rise in PaCO2 Fall in PaCO2 =0.2fall in PaCO2 = 0.01 fall in PaCO2 =0.4 fall in PaCO2 = 0.002 fall in PaCO2