Arterial Blood Gases: A Step by Step Guide

Arterial
A step Blood Gases

by step guide
A step by step guide
-
HCO + H+  H2CO3  CO2 + H20
3
Objectives
• To be able to interpret simple arterial blood

gas
• To know the meaning of common terms used
in arterial blood gas interpretation
• To know the normal ranges for arterial blood
gas values
Normal ABG Values?
PaO2 >10.0 kPa
To convert kPa
pH 7.35 - 7.45 to mmHg
multiply by 7.5
PaCO2 4.5 - 6.0 kPa
HCO3 22 - 26
Base Excess -2 - +2
Many modern gas machines also measure

K+ Na+ Cl- SaO2 Hb COHb MetHb Lactate
Definitions
• Hypoxia
– a PaO2 of less than than 8
• Acidaemia
– a pH of less than 7.35
• Alkalaemia
– a pH of greater than 7.45
• In practice acidaemia and alkalaemia are often

referred to as acidosis and alkalosis respectively
Definitions
• Acidosis
– Respiratory: a PaCO2 of greater than 6.0
– Metabolic: a HCO3 of less than 22
• Alkalosis
– Respiratory: a PaCO2 of less than 4.5
– Metabolic: a HCO3 of greater than 26
• Compensation
– the bodies attempt to keep the pH normal by
altering either the PaCO2 or HCO3
Causes of an acidosis
Respiratory eg:Respiratory Metabolic eg:

failure secondary to: • Renal failure
• Lung injury • DKA
– Trauma
• Poisoning
– Pulmonary Oedema
– ARDS
• Hypoperfusion leading to
anaerobic metabolism
• Respiratory depression
– Opiates
• Neurological
– Multiple Sclerosis
These lists are not exhaustive

Causes of an alkalosis
Respiratory Metabolic
• Hyperventilation • Vomiting
– Cerebral event – Loss of stomach acid
– Anxiety • Compensation for a
– Respiratory chronic respiratory
stimulants acidosis
• Doxepram
• acute salicylate
poisoning
– Acute compensation
for metabolic
acidosis
Anion Gap (use if metabolic acidosis)
(Na+ + K+) – (HCO3- + Cl-)
Normal range 10 – 18mmol/l
 anion gap • Normal anion gap
– DKA – Chronic diarrhoea,
– Renal failure ileostomy
– Lactic acidosis – Addison’s disease
– poisoning eg. – Pancreatic fistula
salicylate, – Renal tubular acidosis
ethylene glycol
5 steps to analysing an ABG
1. Is the patient hypoxic?
2. Is there a significant degree of lung injury?
A – a Gradient
The gradient between alveolar PAO2 and arterial
PaO2 in a person with healthy lungs is ~ 10 kPa
i.e. we would expect a person on an FiO2 of
60% to have a PaO2 ~ 50 kPa (60-50=10)
The higher the gradient, the worst the lung injury

5 steps to analysing an ABG
3. Does the patient have an acidaemia or an alkalaemia?
4. Is the cause respiratory or metabolic
5. Is there any attempt at compensation?

Compensation
• Respiratory compensation is quick

• Metabolic compensation is slow
• Compensation is not usually complete
• Patients never over compensate
Fill in the gaps
Acid-Base disorder pH PaCO2 HCO3
Respiratory acidosis N
Metabolic acidosis N
Respiratory alkalosis N
Metabolic alkalosis N
Respiratory acidosis with partial renal compensation
Metabolic acidosis with partial respiratory compensation
Respiratory alkalosis with partial renal compensation
Metabolic alkalosis with partial respiratory compensation
Mixed metabolic & respiratory acidosis

Scenario 1
65 year old male with known COPD presents in A&E complaining of
increased breathlessness. The paramedics have put him on a venturi
mask to give an FI02 of 40% due to his breathlessness and initial low
saturations.
Significant findings on your examination is a drowsy patient with a
resp rate of 8, SpO2 of 85% and wide-spread coarse crackles
Arterial blood gas analysis reveals:
FiO2 0.4 (40%)

PaO2 7.0 kPa Hypoxia
pH 7.25 Respiratory acidosis with
PaCO2 8.9 kPa
HCO3 35
chronic renal compensation
Infective exacerbation of
COPD
?Hypoxic drive ?tired
Scenario 2
18 year old male with diabetes has been suffering from D&V for 48
hours and because he has been unable to eat he has not taken his
insulin
Significant findings on your examination are a resp rate of 40, heart
rate of120, BP 95/50, Blood glucose 30mmol/l
FiO2 0.3 (30%)

PaO2 22.0 kPa
pH 7.15
PaCO2 2.5 kPa
Metabolic acidosis with
HCO3 10 respiratory compensation
Na 135 DKA
K 5.4
Cl 106
24
Anion Gap = ?
Scenario 3
17 year old male has taken his fathers BMW (without asking) to
impress his girlfriend and had a altercation with a large bus where the
BMW came off much the worse.
There is little abnormal to find on examination apart from bruising, a
resp rate of 24, a pulse of 110 and a BP of 120/85
FiO2 0.21 (21%)

PaO2 15.1 kPa
pH 7.53
PaCO2 3.1 kPa Respiratory alkalosis
HCO3 25.0
Anxiety
Scenario 4
A 75 year old female is on the surgical ward 2 days after a laparotomy for a
perforated sigmoid colon secondary to diverticular disease. She has become
hypotensive over the last 6 hours. A nurse has started 40% O2
On examination vital signs are: RR 35 min-1, SpO2 92%, HR 120 min-1,
warm peripheries, BP 70/40 mmHg, Urine output 50 ml in the last 6 hours
FiO2 0.4 (40%)

PaO2 8.2 kPa
pH 7.17 Hypoxia
PaCO2 3.7 kPa
HCO3- 12 mmol l-1 Metabolic acidosis with
respiratory compensation
Shock secondary to Sepsis
Scenario 5
A 75 year old man presents to the emergency department after a
witnessed out-of-hospital VF cardiac arrest.
The paramedics arrived after 5 minutes, during which CPR had not
been attempted. The paramedics had successfully restored
spontaneous circulation after 3 shocks but have been unable to
intubate him. He is breathing spontaneously with a re breathing mask
in situ.
On arrival: comatose (GCS 3)
Resp rate 8
HR 120 min-1
BP 150/95 mmHg.
FiO2 0.85 (85%)

PaO2 10.5 kPa Mixed respiratory and
pH
PaCO2
7.10
7.0 kPa
metabolic acidosis
HCO3 14 Hypoperfusion and
BE - 10
respiratory failure
Any Questions?
?
Summary
You should now be able to:
• Identify the hypoxic patient
• Identify an acidosis or alkalosis
• Recognise when compensation is
taking place
• Formulate an initial treatment plan for
some common scenarios
• Understand the role Arterial Blood
Gases play in patient management

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Arterial

A step Blood Gases

• To be able to interpret simple arterial blood

PaCO2 4.5 - 6.0 kPa

Many modern gas machines also measure

• In practice acidaemia and alkalaemia are often

Respiratory eg:Respiratory Metabolic eg:

These lists are not exhaustive

2. Is there a significant degree of lung injury?

The higher the gradient, the worst the lung injury

3. Does the patient have an acidaemia or an alkalaemia?

4. Is the cause respiratory or metabolic

5. Is there any attempt at compensation?

• Respiratory compensation is quick

Metabolic acidosis with partial respiratory compensation

Respiratory alkalosis with partial renal compensation

Metabolic alkalosis with partial respiratory compensation

Mixed metabolic & respiratory acidosis

FiO2 0.4 (40%)

Arterial blood gas analysis reveals:

FiO2 0.3 (30%)

Arterial blood gas analysis reveals:

FiO2 0.21 (21%)

Arterial blood gas analysis reveals:

FiO2 0.4 (40%)

FiO2 0.85 (85%)

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