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Basics In Arterial Blood Gas Interpretation

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Basics In Arterial Blood Gas Interpretation

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Basics In Arterial Blood Gas Interpretation

  1. 1. Basics in Arterial Blood Gas Interpretation Crisbert I. Cualteros, M.D.
  2. 2. Obtaining Blood GasObtaining Blood Gas SamplesSamples Radial artery- best siteRadial artery- best site  located superficially, easy to palpatelocated superficially, easy to palpate & stabilize& stabilize  excellent collateral circulation viaexcellent collateral circulation via ulnar arteryulnar artery  not adjacent to large veinsnot adjacent to large veins  probing needle relatively pain-free ifprobing needle relatively pain-free if periosteum is avoidedperiosteum is avoided
  3. 3. TechniqueTechnique for Radial Arteryfor Radial Artery PuncturePuncture  Explain process to patient. Examine skin,Explain process to patient. Examine skin, palpate radial & ulnar arteries. Performpalpate radial & ulnar arteries. Perform modified Allen Test.modified Allen Test.
  4. 4. The Allen TestThe Allen Test  have the patienthave the patient clench his/her fistclench his/her fist  press on bothpress on both radial and ulnarradial and ulnar arteriesarteries  have the patienthave the patient unclench fistunclench fist  test for goodtest for good collateral flow.collateral flow.
  5. 5. Technique for Radial ArteryTechnique for Radial Artery PuncturePuncture  Position patient- hyperextend wrist. CleanPosition patient- hyperextend wrist. Clean site with 70% isopropyl alcohol.site with 70% isopropyl alcohol.  Use latex gloves while doing procedure.Use latex gloves while doing procedure.  Local anesthesia may be used.Local anesthesia may be used.  Use G20 or G21 needle. Flush syringe withUse G20 or G21 needle. Flush syringe with sodium heparin (10 mg/ml or 1,000sodium heparin (10 mg/ml or 1,000 units/ml) & empty.units/ml) & empty. 0.15-0.25 ml of heparin will0.15-0.25 ml of heparin will anticoagulate 2-4 ml of blood.anticoagulate 2-4 ml of blood.
  6. 6. Technique for Radial ArteryTechnique for Radial Artery PuncturePuncture  Palpate artery with one hand while holdingPalpate artery with one hand while holding properly prepared syringe & needle with otherproperly prepared syringe & needle with other hand. Hold syringe like a pencil & enter skinhand. Hold syringe like a pencil & enter skin at 45at 45 o . Advance needle slowly.  Never redirect needle without first withdrawing toNever redirect needle without first withdrawing to subcutaneous tissue.subcutaneous tissue.  Obtain 2-4 ml blood. If possible don’t aspirate.Obtain 2-4 ml blood. If possible don’t aspirate.  Remove air bubbles from syringe. ImmediatelyRemove air bubbles from syringe. Immediately seal syringe with cap.seal syringe with cap.  Place sample in ice slush. Analyze blood samplePlace sample in ice slush. Analyze blood sample within 10 minutes.within 10 minutes.  Apply pressure to site until bleeding has stopped.Apply pressure to site until bleeding has stopped.
  7. 7. Potential ComplicationsPotential Complications  PainPain  Hematoma, hemorrhageHematoma, hemorrhage  Trauma to vesselTrauma to vessel  ArteriospasmArteriospasm  Air or clotted-bloodAir or clotted-blood emboliemboli  Vasovagal responseVasovagal response  Arterial occlusionArterial occlusion  InfectionInfection
  8. 8. Indications for ABGIndications for ABG  Assess ventilation & acid-baseAssess ventilation & acid-base balancebalance  Assess oxygenation statusAssess oxygenation status
  9. 9. Ventilatory/Ventilatory/ Acid-Base StatusAcid-Base Status
  10. 10. Henderson-Hasselbach Parameters & theirHenderson-Hasselbach Parameters & their normal laboratory rangesnormal laboratory ranges pH=pH= [HCO[HCO33]p]p PPC02C02 pHpH PCO2PCO2 (mmHg)(mmHg) [HCO3]p[HCO3]p (mmol/L)(mmol/L) NormalNormal 7.35-7.457.35-7.45 35-4535-45 22-2622-26 AcidoticAcidotic < 7.35< 7.35 > 45> 45 < 22< 22 AlkaloticAlkalotic > 7.45> 7.45 < 35< 35 > 26> 26
  11. 11. Traditional Metabolic Acid-Base NomenclatureTraditional Metabolic Acid-Base Nomenclature NomenclatureNomenclature pHpH PCOPCO22 [HCO3][HCO3] pp BEBE Metabolic acidosisMetabolic acidosis Uncompensated (acute)Uncompensated (acute)  NN  (-)(-) Partly compensatedPartly compensated (subacute)(subacute)    (-)(-) Compensated (chronic)Compensated (chronic) NN   (-)(-) Metabolic alkalosisMetabolic alkalosis Uncompensated (acute)Uncompensated (acute)  NN  (+)(+) Partly compensatedPartly compensated (subacute)(subacute)    (+)(+) Compensated (chronic)Compensated (chronic) NN   (+)(+)
  12. 12. Traditional Respiratory Acid-Base NomenclatureTraditional Respiratory Acid-Base Nomenclature NomenclatureNomenclature pHpH PCOPCO 22 [HCO3][HCO3] pp BEBE RespiratoryRespiratory acidosisacidosis Uncompensated (acute)Uncompensated (acute)   NN NN Partly compensatedPartly compensated (subacute)(subacute)     Compensated (chronic)Compensated (chronic) NN    RespiratoryRespiratory alkalosisalkalosis Uncompensated (acute)Uncompensated (acute)   NN NN Partly compensatedPartly compensated (subacute)(subacute)     Compensated (chronic)Compensated (chronic) NN   
  13. 13. Base Excess/ DeficitBase Excess/ Deficit  Blood with large buffering capacity:Blood with large buffering capacity: significant changes in acid content with little change in freesignificant changes in acid content with little change in free HH++ concentrations (pH)concentrations (pH)  Acidemia or alkalemia:Acidemia or alkalemia:  buffering capacity, > potential forbuffering capacity, > potential for pH change from any given change in HpH change from any given change in H++ contentcontent  Buffering capacity depends on:Buffering capacity depends on: [HCO[HCO33 -- ]] RBC massRBC mass other factorsother factors  Base excess/deficit= (measured pH – predicted pH) x 100 xBase excess/deficit= (measured pH – predicted pH) x 100 x 2/32/3 Normal metabolic acid-base status:Normal metabolic acid-base status: ++ 3 mmol/L3 mmol/L Relatively balanced metabolic acid-base status:Relatively balanced metabolic acid-base status: ++ 55 mmol/Lmmol/L Clinically significant imbalance:Clinically significant imbalance: ++ 1010 mmol/Lmmol/L
  14. 14. Nomenclature & Criteria for Clinical InterpretationNomenclature & Criteria for Clinical Interpretation Clinical TerminologyClinical Terminology CriteriaCriteria Ventilatory failureVentilatory failure (respiratory acidosis)(respiratory acidosis) PPaaCOCO22 > 45> 45 mm Hgmm Hg Acute ventilatory failureAcute ventilatory failure (respiratory acidosis)(respiratory acidosis) PPaaCOCO22 > 45> 45 mmHgmmHg pH < 7.35pH < 7.35 Chronic ventilatory failureChronic ventilatory failure (respiratory acidosis)(respiratory acidosis) PPaaCOCO22 > 45> 45 mmHgmmHg pH 7.36- 7.44pH 7.36- 7.44 Alveolar hyperventilationAlveolar hyperventilation (respiratory alkalosis)(respiratory alkalosis) PPaaCOCO22 < 35< 35 mmHgmmHg Acute alveolar hyperventilationAcute alveolar hyperventilation (respiratory(respiratory PPaaCOCO22 < 35< 35 mmHgmmHg alkalosis)alkalosis) pH > 7.45pH > 7.45 Chronic alveolar hyperventilationChronic alveolar hyperventilation (respiratory(respiratory PPaaCOCO22 < 35< 35 mmHgmmHg alkalosis)alkalosis) pH 7.36-pH 7.36- 7.447.44
  15. 15. Nomenclature & Criteria for Clinical InterpretationNomenclature & Criteria for Clinical Interpretation Clinical TerminologyClinical Terminology CriteriaCriteria AcidemiaAcidemia pH < 7.35pH < 7.35 AlkalemiaAlkalemia pH > 7.45pH > 7.45 AcidosisAcidosis HCOHCO33 -- < 22 mmol/L< 22 mmol/L BD > 5 mmol/LBD > 5 mmol/L AlkalosisAlkalosis HCOHCO33 -- > 26 mmol/L> 26 mmol/L BE > 5 mmol/LBE > 5 mmol/L CombinedCombined Respiratory Acidosis & Metabolic AcidosisRespiratory Acidosis & Metabolic Acidosis Respiratory Alkalosis & Metabolic AlkalosisRespiratory Alkalosis & Metabolic Alkalosis MixedMixed Respiratory Acidosis & Metabolic AlkalosisRespiratory Acidosis & Metabolic Alkalosis Respiratory Alkalosis & Metabolic AcidosisRespiratory Alkalosis & Metabolic Acidosis
  16. 16. RespiratoryRespiratory AcidosisAcidosis AcuteAcute pH =pH = 0.08 x (PCO0.08 x (PCO22 – 40)– 40) 1010 ex. PCOex. PCO22 = 60= 60  pH =pH = 0.08 x (60 - 40)0.08 x (60 - 40) = 0.16= 0.16 1010 expected pH = 7.40 – 0.16 = 7.24expected pH = 7.40 – 0.16 = 7.24 HCOHCO33 -- increases 0.1 – 1 meq/L per 10 mmHg PCOincreases 0.1 – 1 meq/L per 10 mmHg PCO22 increaseincrease Compensation: cellular buffering: HCO3 renal adaptation: H+ secretion, Cl- reabsorption, net acid excretion
  17. 17. Respiratory acidosisRespiratory acidosis ChronicChronic pH =pH = 0.03 x (PCO0.03 x (PCO22 – 40)– 40) 1010 ex. PCOex. PCO22 = 60= 60  pH =pH = 0.03 x (60 – 40)0.03 x (60 – 40) = 0.06= 0.06 1010 expected pH = 7.40 – 0.06 = 7.34expected pH = 7.40 – 0.06 = 7.34 HCOHCO33 -- increases 1-3.5 meq/L per 10 mmHg PCOincreases 1-3.5 meq/L per 10 mmHg PCO22 increaseincrease
  18. 18. Respiratory AcidosisRespiratory Acidosis  COPDCOPD  OO22 excess in COPDexcess in COPD  DrugsDrugs • BarbituratesBarbiturates • AnestheticsAnesthetics • NarcoticsNarcotics • SedativesSedatives  Extreme ventilation-Extreme ventilation- perfusion mismatchperfusion mismatch  ExhaustionExhaustion  Inadequate MVInadequate MV  Neurologic disordersNeurologic disorders  NeuromuscularNeuromuscular diseasedisease • PoliomyelitisPoliomyelitis • ALLALL • G-B syndromeG-B syndrome • Electrolyte deficienciesElectrolyte deficiencies (K(K++ , PO, PO44 -- )) • Myasthenia gravisMyasthenia gravis  Excessive COExcessive CO22 productionproduction • TPNTPN • SepsisSepsis • Severe burnsSevere burns • NaHCONaHCO33 administrationadministration
  19. 19. RespiratoryRespiratory AlkalosisAlkalosis AcuteAcute pH =pH = 0.08 x (40 – PCO0.08 x (40 – PCO22)) 1010 ex. PCOex. PCO22 = 20= 20 pH =pH = 0.08 x (40 – 20)0.08 x (40 – 20) = 0.16= 0.16 1010 expected pH = 7.40 + 0.16 = 7.56expected pH = 7.40 + 0.16 = 7.56 HCOHCO33 -- decreases 0-2 meq/L per 10 mmHg PCOdecreases 0-2 meq/L per 10 mmHg PCO22 decreasedecrease Compensation: cellular buffering renal response: retention of endogenous acids, excretion of HCO3
  20. 20. Respiratory AlkalosisRespiratory Alkalosis ChronicChronic pH =pH = 0.03 x (40 – PCO0.03 x (40 – PCO22)) 1010 ex. PCOex. PCO22 = 20= 20  pH =pH = 0.03 x (40 – 20)0.03 x (40 – 20) = 0.06= 0.06 1010 expected pH = 7.40 + 0.06 = 7.46expected pH = 7.40 + 0.06 = 7.46 HCOHCO33 -- decreases 2-5 meq/L per 10 mmHg PCOdecreases 2-5 meq/L per 10 mmHg PCO22 decreasedecrease
  21. 21. Respiratory AlkalosisRespiratory Alkalosis Primary centralPrimary central disordersdisorders  HyperventilationHyperventilation syndrome, anxietysyndrome, anxiety  Cerebrovascular diseaseCerebrovascular disease  Meningitis, encephalitisMeningitis, encephalitis Pulmonary diseasePulmonary disease  Interstitial fibrosisInterstitial fibrosis  PneumoniaPneumonia  Pulmonary embolismPulmonary embolism  Pulmonary edemaPulmonary edema (some patients)(some patients) HypoxiaHypoxia Septicemia,Septicemia, hypotensionhypotension Hepatic failureHepatic failure DrugsDrugs  SalicylatesSalicylates  NicotineNicotine  XanthinesXanthines  ProgestationalProgestational hormoneshormones High altitudeHigh altitude Mechanical ventilatorsMechanical ventilators
  22. 22. Metabolic AcidosisMetabolic Acidosis Anion GapAnion Gap  artificial disparity between major plasma cationsartificial disparity between major plasma cations & anions that are routinely measured& anions that are routinely measured  major plasma cationsmajor plasma cations –– major plasma anionsmajor plasma anions  [Na[Na++ ]] –– ([Cl([Cl-- ] + [HCO3] + [HCO3-- ])])  1212 ++ 2 (normal)2 (normal)  Minor cations: KMinor cations: K++ , Ca, Ca++++  Minor anions: phosphates, sulfates, organicMinor anions: phosphates, sulfates, organic anionsanions
  23. 23. Metabolic AcidosisMetabolic Acidosis  Anion gap acidosisAnion gap acidosis ~ process increases “minor anions”~ process increases “minor anions” ~ ex. lactatemia, ketonemia, renal failure,~ ex. lactatemia, ketonemia, renal failure, excessiveexcessive organic salt treatment, dehydration,organic salt treatment, dehydration, ingestioningestion (salicylates, methanol, ethylene glycol,(salicylates, methanol, ethylene glycol, paraldehyde)paraldehyde) ~ process which decreases “minor cations” rare!~ process which decreases “minor cations” rare!  Non-anion gap acidosisNon-anion gap acidosis ~ associated with increased plasma Cl~ associated with increased plasma Cl-- that hasthat has replacedreplaced HCOHCO3 --
  24. 24. Metabolic AcidosisMetabolic Acidosis Abnormalities:Abnormalities:  Overproduction of acidsOverproduction of acids  Loss of buffer storesLoss of buffer stores  Underexcretion of acidsUnderexcretion of acids
  25. 25. Metabolic AcidosisMetabolic Acidosis Expected PCOExpected PCO22 = ( [HCO= ( [HCO33 -- ] x 1.5) + 8] x 1.5) + 8 ++ 22 ex. [HCOex. [HCO33 -- ] = 11] = 11 expected PCOexpected PCO22 = (11 x 1.5) + 8= (11 x 1.5) + 8 ++ 2 = 22.5-2 = 22.5- 26.526.5 PCOPCO22 decreases 1- 1.5 mmHg per 1 meq/L HCOdecreases 1- 1.5 mmHg per 1 meq/L HCO33 -- decreasedecrease
  26. 26. MetabolicMetabolic AcidosisAcidosis CompensationCompensation  ↓↓ pCOpCO22 (hyperventilation)(hyperventilation)  Pathway:Pathway: ↑ pCO2 HCO3 ratio ↑ H+ conc Acidification of ECF ↓ ECF ↓ pH Stimulation of brainstem ↑ RR ↓ pCO2 Normalization of pH ↓ HCO3
  27. 27. MetabolicMetabolic AcidosisAcidosis CompensationCompensation  Ionic shiftIonic shift • KK++ moves extracellularly for Hmoves extracellularly for H++ • HCOHCO33 -- generation, Hgeneration, H++ excretionexcretion
  28. 28. Corrected [HCOCorrected [HCO33 -- ] for Anion Gap] for Anion Gap Metabolic AcidosisMetabolic Acidosis Measured serum [HCOMeasured serum [HCO33 -- ] + (anion gap] + (anion gap – 12)– 12)
  29. 29. Metabolic AlkalosisMetabolic Alkalosis Expected PCOExpected PCO22 = ( [HCO= ( [HCO33 -- ] x 0.75 ) + 20] x 0.75 ) + 20 ++ 55 ex. [HCOex. [HCO33 -- ] = 34] = 34 expected PCOexpected PCO22 = (34 x 0.75) + 20= (34 x 0.75) + 20 ++ 5 = 40.5-5 = 40.5- 50.550.5 PCOPCO22 increases 0.5- 1 mmHg per 1 meq/L HCOincreases 0.5- 1 mmHg per 1 meq/L HCO33 -- increaseincrease
  30. 30. MetabolicMetabolic AlkalosisAlkalosis  PathwayPathway HCO3 ↓PaCO2 HCO3 ratio ↓ H+ conc Alkalinization of ECF ↑ PaCO2 with mild hypoxemia Normalization of pH
  31. 31. Causes of Metabolic Alkalosis Hypokalemia* Ingestion of large amounts of alkali or licorice Gastric fluid loss: Vomiting, NG suctioning* Hyperaldosteronism 20 to nonadrenal factors Bartter’s syndrome Inadequate renal perfusion diuretics (inhibiting NaCl reabsorption)* Bicarbonate administration Sodium bicarbonate overcorrection Blood transfusion Adrenocortical hypersecretion (e.g tumor) Steroids* Eucapnic ventilation posthypercapnia * Common in the ICU
  32. 32. Limits of CompensationLimits of Compensation Imbalance [HCO3 - ] meq/L PCO2 mmHg Respiratory AcidosisRespiratory Acidosis AcuteAcute 0.1- 1/ 10 mmHg0.1- 1/ 10 mmHg PCOPCO22 ChronicChronic 1- 3.5/ 10 mmHg1- 3.5/ 10 mmHg PCOPCO22 Respiratory AlkalosisRespiratory Alkalosis AcuteAcute 0- 2/ 10 mmHg PCO0- 2/ 10 mmHg PCO22 ChronicChronic 2- 5/ 10 mmHg PCO2- 5/ 10 mmHg PCO22 Metabolic AcidosisMetabolic Acidosis 1- 1.5/ 1 meq/L1- 1.5/ 1 meq/L [HCO[HCO33 -- ]]  Metabolic AlkalosisMetabolic Alkalosis 0.5- 1/ 1 meq/L0.5- 1/ 1 meq/L [HCO[HCO33 -- ]] 
  33. 33. Steps for Analyzing Acid- Base DisturbancesSteps for Analyzing Acid- Base Disturbances  Is patient acidemic or alkalotic?Is patient acidemic or alkalotic? pHpH  Is disturbance primarily respiratory or metabolic?Is disturbance primarily respiratory or metabolic? PCOPCO22, [HCO, [HCO33 -- ]]  If disturbance respiratory, is it acute or chronic?If disturbance respiratory, is it acute or chronic?  If disturbance metabolic, is anion gap normal orIf disturbance metabolic, is anion gap normal or abnormal?abnormal?  If disturbance metabolic, is the respiratoryIf disturbance metabolic, is the respiratory system compensating adequately?system compensating adequately?  If disturbance is anion gap metabolic acidosis, areIf disturbance is anion gap metabolic acidosis, are there any other metabolic disturbances present?there any other metabolic disturbances present?
  34. 34. Oxygenation StatusOxygenation Status
  35. 35. Normal ValuesNormal Values  Seated PO2 = 104.2 – 0.27 (age in years)Seated PO2 = 104.2 – 0.27 (age in years) Supine PO2 = 103.5 – 0.42 (age in years)Supine PO2 = 103.5 – 0.42 (age in years)  PatientsPatients << 60 y. o.60 y. o. PO2 = 100PO2 = 100 ++ 2020  Patients > 60 y. o.Patients > 60 y. o. PO2 = 80 – (# years > 60)PO2 = 80 – (# years > 60)
  36. 36. Steps for AnalyzingSteps for Analyzing Oxygenation StatusOxygenation Status
  37. 37. 1. Is the patient hypoxemic or normoxemic?1. Is the patient hypoxemic or normoxemic? Indices of Oxygenation:Indices of Oxygenation: a. AaDOa. AaDO22 = PAO= PAO22 – PaO– PaO22 PAOPAO22 = FiO= FiO22 (713) –(713) – PaCOPaCO22 0.80.8 PaOPaO22 = obtained from blood gas determination= obtained from blood gas determination b. aAOb. aAO22 == PaOPaO22 PAOPAO22 c. P/F ratio =c. P/F ratio = POPO22 FiOFiO22 Normal Value:Normal Value: patientspatients << 60 y. o. > 40060 y. o. > 400 patients > 60 y. o. expected P/F =patients > 60 y. o. expected P/F = 400400 –– [(age in years – 60) x 5][(age in years – 60) x 5] Actual P/F Ratio < expected =Actual P/F Ratio < expected = hypoxemichypoxemic Actual P/F RatioActual P/F Ratio >> expected =expected = normoxemicnormoxemic
  38. 38. 2. If hypoxemic, is it uncorrected,2. If hypoxemic, is it uncorrected, corrected, or overcorrected?corrected, or overcorrected? With OWith O22 supplementationsupplementation PaOPaO22 (mmHg)(mmHg) Uncorrected hypoxemiaUncorrected hypoxemia < 80< 80 Corrected hypoxemiaCorrected hypoxemia 80 – 12080 – 120 OvercorrectedOvercorrected > 120> 120 FiOFiO22 to PaOto PaO22 Relationship in Normal LungsRelationship in Normal Lungs FiOFiO22 PaOPaO22 (mmHg)(mmHg) 0.300.30 > 150> 150 0.400.40 > 200> 200 0.500.50 > 250> 250 0.800.80 > 400> 400 1.001.00 > 500> 500
  39. 39. Room Air (patientRoom Air (patient << 60 y. o.)60 y. o.) PaOPaO22 (mmHg)(mmHg) Mild hypoxemiaMild hypoxemia 60 to < 8060 to < 80 Moderate hypoxemiaModerate hypoxemia 40 to < 6040 to < 60 Severe hypoxemiaSevere hypoxemia < 40< 40 For each year > 60 subtract 1 mmHg for limits ofFor each year > 60 subtract 1 mmHg for limits of mild &mild & moderate hypoxemia.moderate hypoxemia. At any age, PaOAt any age, PaO22 < 40 mmHg indicates severe< 40 mmHg indicates severe hypoxemia.hypoxemia.
  40. 40. 3. If normoxemic, is oxygenation3. If normoxemic, is oxygenation adequate or more thanadequate or more than adequate?adequate?
  41. 41. Thank you !Thank you !

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