Arterial Blood Gas Analysis ..

Dr Deopujari Pediatrician Nagpur

The Goal :
To provide simple and bedside approach to ABG report

Not to:

In details

To teach physiology .

To teach theories on acid-base regulation

To look for alternative approaches to interpretation

A Systematic and pointed approach

Use of pH for Hydrogen Ion Activity .. The credit (or Blame) for introducing the term pH, the negative log of hydrogen ion (H+) concentration, goes to S. P. L. Srensen (1868-1939), who apparently was tired of writing seven zeros in a paper on enzyme activity and wanted a simpler designation..?.

H ION CONC. OH ION 14 N.MOLS / L. 20

pH stand for "power of hydrogen"

pH 7.70 7.52

30
40 50
H+ = 80 - last two digits of pH

7.40 7.30 7.22

H ION

60

----- XXXX Diagnostics -----Blood

248 Pt ID

Gas
05:36 2570 / 00

Report
Jul 22 2000
o

The Anatomy of a Blood Gas Report

Measured Values the most important Temperature Correction:
Is there any value to it?

Measured
pH pCO2 pO2 7.463 44.4 113.2

37.0 C
mm Hg mm Hg

Corrected
pH pCO2 pO2 7.439 47.6 123.5

38.6 C
mm Hg mm Hg

Calculated Data
HCO3 act HCO3 std BE O2 CT O2 Sat ct CO2 pO2 (A - a) pO2 (a / A) 31.1 30.5 6.6 14.7 98.3 32.4 32.2 0.79 mmol / L mmol / L mmol / L mL / dl % mmol / L mm Hg

Calculated Data:
Which are the useful ones?

Entered Data:
As important

Entered Data
Temp ct Hb FiO2 38.6 10.5 30.0
oC

g/dl %

----- XXXX Diagnostics -----Blood Gas Report

Bicarbonate:

Measured
pH pCO2 pO2 7.463 44.4 113.2

37.0 C
mm Hg mm Hg

Corrected

38.6 C

Calculated
HCO3 act HCO3 std BE O2 CT O2 Sat t CO2 pO2 (A - a) pO2 (a / A) 31.1 30.5 6.6 14.7 98.3 32.4 32.2 0.79

Data
mmol / L mmol / L mmol / L mL / dl % mmol / L mm Hg

Henderson - Hasselbach equation: pH = pK + Log HCO3 Dissolved CO2

Entered
Temp ct Hb FiO2 38.6 10.5 30.0

Data
oC

g/dl %

----- XXXX Diagnostics -----Blood Gas Report

Standard Bicarbonate:
Plasma HCO3 after equilibration to a PCO2 of 40 mm Hg
: reflects non-respiratory acid base change : does not quantify the extent of the buffer base abnormality : does not consider actual buffering capacity of blood

Measured
pH pCO2 pO2 7.463 44.4 113.2

37.0 C
mm Hg mm Hg

Corrected

38.6 C

Calculated
HCO3 act HCO3 std BE O2 CT O2 Sat t CO2 pO2 (A - a) pO2 (a / A) 31.1 30.5 6.6 14.7 98.3 32.4 32.2 0.79

Data
mmol / L mmol / L mmol / L mL / dl % mmol / L mm Hg

Base Excess:
(Sigaard-Andersen)

D base to normalise HCO3 (to 24) with PCO2 at 40 mm Hg

: reflects metabolic part of acid base D : no info. over that derived from pH, pCO2 and HCO3 : Misinterpreted in chronic or mixed disorders

Entered
Temp ct Hb FiO2 38.6 10.5 30.0

Data
oC

g/dl %

----- XXXX Diagnostics -----Blood Gas Report

Oxygenation Parameters:
O2 Content of blood:
Hb x O2 Sat + Dissolved O2

Measured
pH pCO2 pO2 7.463 44.4 113.2

37.0 C
mm Hg mm Hg

Corrected

38.6 C

Oxygen Saturation: ( remember this is calculated ) Alveolar / arterial gradient:

Calculated
HCO3 act HCO3 std BE O2 CT O2 Sat t CO2 pO2 (A - a) pO2 (a / A) 31.1 30.5 6.6 14.7 98.3 32.4 32.2 0.79

Data
mmol / L mmol / L mmol / L mL / dl % mmol / L mm Hg

Entered
Temp ct Hb FiO2 38.6 10.5 30.0

Data
oC

Arterial / alveolar ratio:

g/dl %

Rt. Shift
Lt.Shift

Alveolar-arterial Difference
Inspired O2 = 21 % piO2 = (760-45) x . 21 = 150 mmHg

O2 CO2

palvO2 = piO2 pCO2 / RQ = 150 40 / 0.8 = 150 50 = 100 mm Hg partO2 = 90 mmHg

palvO2 partO2 = 10 mmHg

Alveolar- arterial Difference

Oxygenation Failure piO2 = 150 pCO2 = 40 palvO2= 150 40/.8 =150-50 =100 Ventilation Failure piO2 = 150 pCO2 = 80 palvO2= 150-80/.8 =150-100 = 50 O2 CO2

pO2 = 45
D = 100 - 45 = 55
760 45 = 715 : 21 % of 715 = 150

pO2 = 45
D = 50 - 45 = 5
PAO2 (partial pres. of O2. in the alveolus.) = 150 - ( PaCO2 / .8 )

----- XXXX Diagnostics -----Blood Gas Report

Oxygenation:
Limitations of parameters: O2 Content of blood:
Useful in oxygen transport calculations Derived from calculated saturation

Measured
pH pCO2 pO2 7.463 44.4 113.2

37.0 C
mm Hg mm Hg

Corrected

38.6 C

Oxygen Saturation:
Ideally measured by co-oximetry Calculated values may be error-prone

Calculated
HCO3 act 31.1

Data
mmol / L

20 5 = 100 Alveolar / arterial gradient:

Arterial / alveolar ratio:
Proposed to be less variable Same limitations as A-a gradient

O2 CT O2 Sat t CO2 pO2 (A - a) pO2 (a / A)

14.7 98.3 32.4 32.2 0.79

mL / dl % mmol / L mm Hg

Reflects O2 exchange with fixed FiO2 Impractical Differentiates hypoventilation as cause

Entered
Temp ct Hb FiO2 38.6 10.5 30.0

Data
oC

g/dl %

----- XXXX Diagnostics -----Blood Gas Report

The essentials
The Blood Gas Report:
pH PCO2 PO2 HCO3 7.40 + 0.05 40 + 5 80 - 100 24 + 4 mm Hg mm Hg mmol/L

----- XXXX Diagnostics -----o Measured 37.0 C pH 7.463 Blood Gas Report pCO 44.4 mm Hg
2

pO2

Measured pH 7.463 Corrected

pCO2 pH pO2 pCO2 pO2

113.2

mm Hg o

Calculated HCO3 act 31.1 Calculated Data

HCO3 act O2 Sat HCO3 std pO2 (A - a) BE O2 CT O2 Sat Entered t CO2 FiO2(A - a) pO2 pO2 (a / A) 31.1 98.3 30.5 32.2 6.6 14.7 98.3 32.4 30.0 32.2 0.79

44.4 7.439 113.2 47.6 123.5

37.0 C o 38.6 C
mm Hg mm Hg mm Hg mm Hg

Data

mmol / L mmol / L % mmol / L mm Hg mmol / L mL / dl % Data/ L mmol % Hg mm

O2 Sat >95 Always mention and see

FIO2

Entered Data
Temp ct Hb FiO2 38.6 10.5 30.0
oC

g/dl %

Low PaO2 can be the result of

A ) low PAO2 ( Low Alveolar Pressure ) 1) low barometric pressure, 2) low fraction of inspired oxygen (FiO2) 3) Hypercarbia elevated (PaCO2). B ) Wide A / a gradient ( Normal Alveolar pressure ) 1) Shunt ( cardiac or non cardiac ) 2) Diffusion abnormality

Technical Errors
Glass vs. plastic syringe: Changes in pO2 are not clinically important No effect on pH or pCO2 Heparin (1000 u / ml): Need <0.1 ml / ml of blood pH of heparin is 7.0; pCO2 trends down Avoided by heparin flushing & drawing 2-4 cc blood Delay in measurement: Rate of changes in pH, pCO2 and pO2 can be reduced to 1/10 by cooling in ice slush(4o C) No major drifts up to 1 hour

The
Steps for Successful Blood Gas Analysis

Step 1
Look at the pH

The culprit
Is the patient or acidemic alkalemic pH < 7.35 pH > 7.45

Step 2
Acidemia:

CO responsible for this change ( culprit )? pH Who is 2

With HCO3 < 20 mmol/L = metabolic With PCO2 >45 mm hg = respiratory
With HCO3 >28 mmol/L = metabolic With PCO2 <35 mm Hg = respiratory pH

Alkalemia:

BICARB

Step 3
If there is a primary respiratory disturbance, is it acute? (Acute)change in pH = 0.08 for 10 mm change in PCO2 (Chronic)change in pH = 0.03 for 10 mm change in PCO2

Step 4
If the disturbance is metabolic is the respiratory compensation appropriate? For metabolic acidosis: Expected PCO2 = (1.5 x [HCO3]) + 8 ) + 2
(Winters equation) ( Last two digits of pH )

The last two digits

For metabolic alkalosis: Expected PCO2 = 6 mm for 10 mEq. rise in Bicarb. If : actual PCO2 more than expected : additional respiratory acidosis actual PCO2 less than expected : additional respiratory alkalosis

Step 4 cont.
If there is metabolic acidosis, is there a wide anion gap ? Na - (Cl-+ HCO3-) = Anion Gap usually <12 If >12, Anion Gap Acidosis : Common pediatric causes 1) Lactic acidosis 2) Metabolic disorders 3) Renal failure Methanol Uremia Diabetic Ketoacidosis Paraldehyde Infection (lactic acid) Ethylene Glycol Salicylate

th step

Clinical correlation

Same direction
HCO3 Same direction

pH

META.

PCO2
Opposite direction

pH

RESP.

24

CO2
= H ION CONC.
N.MOLS / L.

BICARBONATE 24 40 = 960

= H ION CONC.

BICARBONATE
960

N.MOLS / L.

= H ION CONC. = 40

24

N.MOLS / L.

H+

N.MOLS / L.

= 80 - last two digits of pH

pH

HYPER VENTILATION

CO2 BICARB CHANGES pH in same direction compensation HCO3

Primary lesion Primary lesion

METABOLIC ACIDOSIS

pH

HYPO VENTILATION

CO2 BICARB CHANGES pH in same direction compensation HCO3

Primary lesion

METABOLIC ALKALOSIS

pH

CO 2 CHANGES pH in opposite direction

BICARB

compensation CO 2

Primary lesion

Respiratory acidosis

RESP. ACIDOSIS
PCO2

ALKALOSIS META.

CO2+H20=H2CO3 = H + HCO3

pH

HIGH + H HIGH HCO3

HCO3

HCO3
ACUTE RISE : PCO2 10 : CHRONIC RISE : PCO2 10 : pH .08 pH .03

pH

CO 2 CHANGES pH in opposite direction

BICARB

compensation CO 2

Primary lesion Primary lesion

Respiratory alkalosis

RESP. ALK.

ACID. META.

CO2 + H20 = H2CO3 = H

+ +

HCO3

pH

CO2
+

HCO3

LOW H IONS LOW HCO3

ACUTE FALL : PCO2 10 : pH .08 CHRONIC FALL: PCO2 10 : pH .03

Pco2 of 10

pH

Acute change .08

Chronic change .03

INTERPRETATION OF A.B.G.
FOUR STEP METHOD OF DEOSAT 1) LOOK FOR pH 2) WHO IS THE CULPRIT ?

3) IF RESPIRATORY ACUTE / CHRONIC ?

4) IF METABOLIC / COMP. / ANION GAP CLINICAL CORRELATION

considered complete when the pH returns to normal range

compensation

Clinical blood gases by Malley

METABLIC ACIDOSIS CO2 = Up to 10 ? METABOLIC ALKALOSIS CO2 = Maximum 6O RESPIRATORY ACIDOSIS BICARB = Maximum 40 RESPIRATORY ALKALOSIS BICARB = Up to 10

COMPENSION LIMITS

----- XXXX Diagnostics ------

Blood

Gas

Report 37.0 C 7.523 30.1 mm Hg 105.3 mm Hg Data 22 98.3 8 0.93 Data 21.0 mmol / L % mm Hg D
o

Case 1
16 year old female with sudden onset of dyspnea.

Measured pH pCO2 pO2 Calculated HCO3 act O2 Sat pO2 (A - a) pO2 (a / A) Entered FiO2

No Cough or Chest Pain

Vitals normal but RR 56, anxious.

Case 2

6 year old male with progressive respiratory distress

Muscular dystrophy .
----- XXXX Diagnostics ------

pH <7.35 :acidemia

Blood

Gas

Report

Measured pH pCO2 pO2 Calculated HCO3 act O2 Sat pO2 (A - a) pO2 (a / A) Entered FiO2

respiratory acidemia : co2 and pH 37.0 C 7.301 D CO2 =76-40=36 76.2 mm Hg Expected D pH ( Acute ) = .08 for 10 45.5 mm Hg
o

Data 35.1 78 9.5 0.83 Data 21

Expected ( Acute ) pH = 7.40 - 0.29=7.11 Chronic resp. acidosis

mmol / L
% mm Hg D

Hypoxia Normal A-a gradient Due to hypoventilation

----- XXXX Diagnostics ------

Blood

Gas

Report
o

pH <7.35 ; acidemia

Case 3

Measured pH pCO2 pO2 Calculated HCO3 act O2 Sat pO2 (A - a) pO2 (a / A) Entered FiO2

pCO2 >45; respiratory acidemia 8-year-old male asthmatic; 37.0 C 7. 24 3 - 40 = of D CO2 = 49 days 9 cough, dyspnea 49.1 mm Hg Expectedand orthopnea not D pH ( Acute ) = 9/10 x 0.08 = 0.072 66.3 mm Hg
Data 18.0 92

Expectedresponding 7.40usual = 7.328 pH ( Acute ) = to - 0.072 Acute resp. acidosis

mmol / L

bronchodilators.

153-66= 87
Data 30

% O/E: 30 mm Hg 5 = 150RespiratoryMUST RISE ? WITHDINCREASE IN CO2 BICARB distress;

suprasternal and Metabolic acidosis + respiratory acidosis

%

intercostal retraction; tired looking; on 4 L NC.

Hypoxia piO2 = 715x.3=214.5 / palvO2 = 214-49/.8=153 Wide A / a gradient

Case 4 8 year old diabetic with respi. distress fatigue and loss of appetite.
----- XXXX Diagnostics ------

Blood

Gas

Report
o

pH <7.35 ; acidemia

Measured pH pCO2 pO2 Calculated HCO3 act O2 Sat pO2 (A - a) pO2 (a / A) Entered FiO2

37.0 C Last two digits of pH 7.23 Correspond with co2 23 mm Hg 110.5 mm Hg Data 14 mmol / L

HCO3 <22; metabolic acidemia % mm Hg D

Data 21.0

If Na = 130, Cl = 90 Anion Gap = 130 - (90 + 14) = 130 104 = 26

Case 5 : 10 year old child with encephalitis

----- XXXX Diagnostics ------

Blood

Gas

Report 37.0 C 7.46 28.1 mm Hg 55.3 mm Hg Data 19.2 mmol / L % mm Hg D Data 24.0
o

Measured pH pCO2 pO2 Calculated HCO3 act O2 Sat pO2 (A - a) pO2 (a / A) Entered FiO2

pH almost within normal range Mild alkalosis

Co2 is low , respiratory Co2 low by around 10 ( Acute ) by .08 (Chronic ) by .03
Bicarb looks low ? Is it expected ?

More cases

ABG OF THE DAY

The arterial blood gas report : Room air pH 7.39 PCO2 l5mniHg HCO3 8mmol/L PaO2 90 mmHg

PCO2 H ION CONCENTRATION =

24

BICARBONATE

= 45 nmol/lit

pH 7.39 PCO2 l5mniHg HCO3 8mmol/L PaO2 90 mmHg

1)

These findings are most consistent with. a) Metabolic acidosis with compensatory Hypocapnia. b) Primary metabolic acidosis with respiratory alkalosis. c) Acute respiratory alkalosis fully compensated. d) Chronic respiratory alkalosis fully compensated.
For metabolic acidosis: FULL COMPENSATION Expected PCO2 = (1.5 x [HCO3]) + 8 ) + 2 (Winters equation) PCO 2 SHOULD BE 20

pH 7.39 PCO2 l5mniHg HCO3 8mmol/L PaO2 90 mmHg

2) What is the oxygenation status a) Normal oxygenation status b) Hypoxemia c) None of the above
palvO2 = piO2 pCO2 / RQ = 150 15 / 0.8 = 150 18 = 132 mm Hg 132 90 = 42 WIDE A / a gradient

pCO2 70 60 50 40 30 20

pH 7.10 7.20 7.30 7.40 7.50 7.60

 When pH is normal and: Bicarbonate is high ( Metabolic alkalosis + respiratory acidosis ) Bicarbonate is low ( Metabolic acidosis + resp. alkalosis) Bicarbonate is normal and: anion gap is high ( Metabolic Acidosis + Metabolic alkalosis) When bicarbonate is normal and: pH is in acidic range ( Chronic resp. acidosis + resp alk.) pH is in alkalemic range ( Metab.alk. + resp alk.) Anion gap is elevated and: clinical and laboratory data suggest a diagnosis other than metabolic acidosis PCO2 level and bicarbonates are shifted from normal in opposing directions.

THANKS