Department of Medicine

G. R. Medical College, Gwalior

Arterial Blood Gas Analysis

Chairperson Guide
Prof Dr O. P. Jatav Dr. Neelima Singh
Prof & Head Associate Professor
Dept of Medicine Dept of Medicine

Presentor
Dr Shubham Upadhyay
PG Student
Arterial Blood Gas Analysis
Contents
• Maintenance of Body pH
• Collecting ABG Sample
• Normal Values
• Assessment of Oxygenation
• Types of Acid Base Disorders
1. Single Disorders
2. Mixed Disorders
• Step wise analysis of Acid Base Disorders
Maintenance of Body pH
Chemical Buffers
Act Immediately
• HCO3-/H2CO3 most imp.
• Proteins
• Hb
• PO43-/H3PO4
• SO42-/H2SO4
Maintenance of Body pH
Chemical Buffers
Act Immediately
• HCO3-/H2CO3 most imp.
• Proteins
• Hb
• PO43-/H3PO4
• SO42-/H2SO4
Maintenance of Body pH
Chemical Buffers Lungs
Act Immediately Acute- act within hours
• HCO3-/H2CO3 most imp. • pH decreases-->
• Proteins stimulation of resp.
• Hb centres-->
• PO43-/H3PO4 Hyperventilation-->CO2
• SO42-/H2SO4 washout-->PaCO2
decrease
Maintenance of Body pH
Chemical Buffers Lungs Kidneys
Act Immediately Acute- act within hours Slow -after 48 hrs
• HCO3-/H2CO3 most imp. • pH decreases--> • HCO3- reabsorption by
• Proteins stimulation of resp. proximal tubules
• Hb centres--> • H+ excretion by distal
• PO43-/H3PO4 Hyperventilation-->CO2 tubules
• SO42-/H2SO4 washout-->PaCO2 • NH3 synthesis &
decrease excretion by proximal
tubules-->binds with
diffusible H+ in lumen
and make it non-
diffusible
Collecting ABG Sample
• Take an arterial sample at room air and start O2 supplementation
immediately if required.
• Preference--Radial>Brachial>Femoral
• 22 Gauge needle flushed with Heparin
• Cool the sample immediately
• Avoid air bubbles
• Venous sample- absence of flash of blood, pulsations & autofilling of
syringe.
• Metabolism- blood cells consume O2, produce CO2 and decrease pH.
Normal Values
PARAMETER ARTERIAL BLOOD
pH 7.35- 7.45
pCO2 (mm of Hg) 35-45
pO2 (mm of Hg) >80
HCO3 (mmol/l) 22-26
SaO2 100
Normal Values
PARAMETER ARTERIAL BLOOD VENOUS BLOOD
pH 7.35- 7.45 7.31- 7.41
pCO2 (mm of Hg) 35-45 41-51
pO2 (mm of Hg) >80 30-40
HCO3 (mmol/l) 22-26 23-29
SaO2 100 75
 Assesment of Oxygenation
• Look at PaO2 and SaO2

• Look at PaO2/FiO2 ratio

- Normal- 1:400- 1:500
- <1:400- VQ mismatch/diffusion defect/intracardiac shunt
-<1:300- ARDS
• A-a gradient= PAO2 - PaO2
= [FiO2 x (Patm - PH20)- (PaCO2/0.8)] - PaO2
-For Room Air, = 150- PaCO2/0.8
- Normal A-a gradient for 20 yr person is 5 mmHg , which increases to 10 mmHg in a
35 year old person
Types of Acid Base Disorders
S. Primary Disorder Main Mechanism Compensatory Mech. Compensatory
No. Response
1. Metabolic Acidosis ↓ s. HCO3- Hyperventilation ↓ PaCO2
Types of Acid Base Disorders
S. Primary Disorder Main Mechanism Compensatory Mech. Compensatory
No. Response
1. Metabolic Acidosis ↓ s. HCO3- Hyperventilation ↓ PaCO2
2. Metabolic Alkalosis ↑ s. HCO3- Hypoventilation ↑ PaCO2
Types of Acid Base Disorders
S. Primary Disorder Main Mechanism Compensatory Mech. Compensatory
No. Response
1. Metabolic Acidosis ↓ s. HCO3- Hyperventilation ↓ PaCO2
2. Metabolic Alkalosis ↑ s. HCO3- Hypoventilation ↑ PaCO2
3. Respiratory Acidosis ↑ PaCO2 ↑ HCO3- reabsorption ↑ s. HCO3-
by kidneys
Types of Acid Base Disorders
S. Primary Disorder Main Mechanism Compensatory Mech. Compensatory
No. Response
1. Metabolic Acidosis ↓ s. HCO3- Hyperventilation ↓ PaCO2
2. Metabolic Alkalosis ↑ s. HCO3- Hypoventilation ↑ PaCO2
3. Respiratory Acidosis ↑ PaCO2 ↑ HCO3- reabsorption ↑ s. HCO3-
by kidneys
4. Respiratory Alkalosis ↓ PaCO2 ↓ HCO3- reabsorption ↓ s. HCO3-
by kidneys
Types of Acid Base Disorders
S. Primary Disorder Main Mechanism Compensatory Mech. Compensatory
No. Response
1. Metabolic Acidosis ↓ s. HCO3- Hyperventilation ↓ PaCO2
2. Metabolic Alkalosis ↑ s. HCO3- Hypoventilation ↑ PaCO2
3. Respiratory Acidosis ↑ PaCO2 ↑ HCO3- reabsorption ↑ s. HCO3-
by kidneys
4. Respiratory Alkalosis ↓ PaCO2 ↓ HCO3- reabsorption ↓ s. HCO3-
by kidneys

PaCO2 and HCO3 change in the same direction known as SAME DIRECTION RULE
Metabolic Acidosis
High Anion Gap Metabolic Acidosis

• Ketoacidosis
• Lactic Acidosis
• Salicylic Acid Overdose
• Methanol Poisoning
• Ethylene Glycol Poisoning
• Renal Failure (eGFR <20 ml/min)
normal AG= 12
+- 2 mmol/l
Metabolic Acidosis
High Anion Gap Metabolic Acidosis

• Ketoacidosis
• Lactic Acidosis
• Salicylic Acid Overdose
• Methanol Poisoning
• Ethylene Glycol Poisoning
• Renal Failure (eGFR <20 ml/min)
Metabolic Acidosis
High Anion Gap Metabolic Acidosis Non Anion Gap Metabolic Acidosis aka
Hyper Chloridic Acidosis
• Ketoacidosis • Diarrhea
• Lactic Acidosis • Pancreatic Fistula
• Salicylic Acid Overdose • Antacids containing Mg, Al(eg Digene)
• Methanol Poisoning • Renal Tubular Acidosis
• Ethylene Glycol Poisoning • Renal Tubular dysfunction (eGFR 20-50
• Renal Failure (eGFR <20 ml/min) ml/min)
• Drugs causing ↑ s K+= ACE -, ARB, K
sparing diuretics, Pentamidine,
Trimethoprim
Metabolic Alkalosis
Chloride Responsive(gain Chloride Unresponsive(loss of H+ due to increase in
of HCO3-) Aldosterone Activity)
• Vomiting Primary increase in Raectionary increase in
• Cl- losing diarrheas Aldosterone Activity: Aldosterone Activity:
• Diuretics- Thiazides, High BP Normal or Low BP
Loop • Primary • Bartter’s Syndrome
• Sweat Loss- Cystic Hyperaldosteronism- • Gitelman’s Syndrome
Fibrosis Conn’s Syndrome,
Cushing’s Syndrome
• Renin secreting tumor
• Liddle’s Syndrome

Other Causes:
• Milk Alkali Syndrome
• Penicillin Overdose
 Respiratory Acidosis
• aka Type 2 Respiratory Failure
• Mechanism-> Hypoventilation--> ↑ PaCO2
• Causes: Site Affected
Resp. Center Damage

Spinal Cord Damage (@C3 or above)

Phrenic N. Damage
NMJ Disorder

Muscle Damage (Diaphragm)

Chest Wall Stiffness

Chronic Damage of Small Airways
 Respiratory Acidosis
• aka Type 2 Respiratory Failure
• Mechanism-> Hypoventilation--> ↑ PaCO2
• Causes: Site Affected Cause
Resp. Center Damage - Drugs- Morphine, BZD
- Stroke- dec. blood supply to resp. centre
Spinal Cord Damage (@C3 or above) #, Polio, ALS
Phrenic N. Damage Neuropathy eg GBS
NMJ Disorder -presynaptic- Lambert Eaton Synd
-postsynaptic- Myasthenia Gravis
Muscle Damage (Diaphragm) -Dystrophy (Duchenne’s)
-Myopathies
Chest Wall Stiffness AS, Obesity, Kyphoscoliosis
Chronic Damage of Small Airways Chronic Bronchitis
Respiratory Alkalosis
• Mechanism- Primary stimulation of Resp. Centers
• Causes:
CENTRAL PERIPHERAL
1. Drugs- 1. Lungs
- Progesterone( eg Pregnancy) Compensatory in cases of
- Salicylate Pneumothorax, Alveolar edema,
2. Infections Pneumonia, ARDS
-Meningitis 2. Systemic Cytokines
-Encephalitis IL 1, IL6--> stimulate resp. center
3. Anxiety eg Fever, Sepsis
STEP WISE ANALYSIS OF ABG
Step 1. Clinical Information
Clinical Information Likely Disorder
Type 1 Diabetes with poor compliance to
Insulin
Step 1. Clinical Information
Clinical Information Likely Disorder
Type 1 Diabetes with poor compliance to
Insulin
Chronic Bronchitis
Step 1. Clinical Information
Clinical Information Likely Disorder
Type 1 Diabetes with poor compliance to
Insulin
Chronic Bronchitis
Severe Vomiting
Step 1. Clinical Information
Clinical Information Likely Disorder
Type 1 Diabetes with poor compliance to
Insulin
Chronic Bronchitis
Severe Vomiting
Diarrhea
Step 1. Clinical Information
Clinical Information Likely Disorder
Type 1 Diabetes with poor compliance to DKA (High AG Metabolic Acidosis)
Insulin
Chronic Bronchitis Respiratory Acidosis
Severe Vomiting Metabolic Alkalosis (Cl- responsive)
Diarrhea Metabolic Acidosis (Non AG)
Step 2. Look at pH
• For analysis purpose take normal pH as 7.4
• pH<7.4 = Acidosis
• pH>7.4 = Alkalosis

• For eg
7.36=
7.42=
7.40= Either no disorder or mixed disorder
Step 3. Metabolic or Respiratory?
1. Compare pHand HCO3
- If going in same direction= Metabolic
- If going in opposite direction= Respiratory
eg pH 7.2 , HCO3 28
2. Compare pHand PaCO2
- If going in same direction= Metabolic
- If going in opposite direction= Respiratory
eg eg pH 7.5 , PaCO2 60
Step 4. Calculate Compensatory Response
• If from Step 3, primary disorder is Metabolic, calculate compensatory
PaCO2

Compensatory or Expected PaCO2= 15 + HCO3-

Eg
- Metabolic Acidosis= pH -7.3 , HCO3-20 , Expected PaCO2-
- Metabolic Alkalosis= pH -7.49 , HCO3-30 , Expected PaCO2-
• If from Step 3, primary disorder is Respiratory, calculate compensatory
HCO3-
• For Respiratory Acidosis:
Resp. Acidosis Expected HCO3-
Acute For every 1↑ of PaCO2 from 40 HCO3- will ↑ by 0.1 from normal value of 24

Chronic For every 1↑ of PaCO2 from 40 HCO3- will ↑ by 0.4 from normal value of 24

• Eg Ph- 7.26 PaCO2- 70

Expected HCO3- (acute)-

Expected HCO3- (chronic)-
• For Respiratory Alkalosis:
Resp. Alkalosis Expected HCO3-
Acute For every 1↓ of PaCO2 from 40 HCO3- will ↓ by 0.2 from normal value of 24

Chronic For every 1↓ of PaCO2 from 40 HCO3- will ↓ by 0.4 from normal value of 24

• Eg Ph- 7.54 PaCO2- 20

Expected HCO3- (acute)-

Expected HCO3- (chronic)-

Step 5. Compare given value with expected
value
• Given value= Expected Value • Given value= Expected Value
Diag.= Single Disorder Diag.= Mixed Disorder

• If the primary diagnosis - Metabolic

Expected PaCO2 > Given PaCO2= Additional Resp. Acidosis
Expected PaCO2 < Given PaCO2= Additional Resp. Alkalosis

• If the primary diagnosis - Respiratory

Expected HCO3 > Given HCO3= Additional Metabolic Acidosis
Expected HCO3 < Given HCO3= Additional Metabolic Alkalosis
Examples
• pH- 7.30
Hco3- 20
paCO2- 35

• pH- 7.28
HCO3- 20
PaCO2- 15

• pH- 7.50
Hco3- 30
paCO2- 60
Step 6. Acute vs Chronic Disorder
• If pH is in extremes, it is likely a acute disorder (as kidneys work slowly
to compensate)
Change in pH > 0.2
• If pH is near normal, it is likely a chronic disorder (as kidneys have
compensated)
Change in pH <0.1
Step 6. Acute vs Chronic Disorder
• If pH is in extremes, it is likely a acute disorder (as kidneys work slowly
to compensate)
Change in pH > 0.2
• If pH is near normal, it is likely a chronic disorder (as kidneys have
compensated)
Change in pH <0.1
Resp. Disorder (Acidosis & Alkalosis) Expected pH
ACUTE For every 10 change of PaCO2 from 40 pH changes by 0.08 from 7.40

CHRONIC For every 10 change of PaCO2 from 40 pH changes by 0.03 from 7.40
QUIZ
 Q.1. A 15 yr old boy is brought from examination hall in
apprehensive state with tightness of chest
ABG= pH 7.55, Hco3 20, PaCO2 = 21
1. Clinical Information?
2. pH
3. Metabolic or Respiratory?
4. Compensatory Response?

5. Compare given value with expected

Single or mixed disorder?

6. Acute or Chronic?
Q.2. A patient with severe diarrhea, complains difficulty in
breathing
pH 7.1, HCO3 14, PaCO2 44, s K+ 2.0
1. Clinical Information?
2. pH
3. Metabolic or Respiratory?
4. Compensatory Response?

5. Compare given value with expected

Single or mixed disorder?

6. Acute or Chronic?
Q.3. ABG of patient with CHF on Frusemide
is as follows: pH 7.48, HCO3- 34, PaCO2- 49
1. Clinical Information?
2. pH
3. Metabolic or Respiratory?
4. Compensatory Response?

5. Compare given value with expected

Single or mixed disorder?

6. Acute or Chronic?
Q.4. k/c/o COPD develops severe vomiting
pH- 7.4, HCO3- 36, PaCO2- 60
1. Clinical Information?
2. pH
3. Metabolic or Respiratory?
4. Compensatory Response?

5. Compare given value with expected

Single or mixed disorder?

6. Acute or Chronic?