By
Mrs. Amala Rajan Reader
Life is a struggle, not against sin, not against the Money Power, not against malicious animal magnetism, but against hydrogen ions." H.L. MENCKEN
What is an ABG
Arterial Blood Gas Drawn from artery- radial, brachial, femoral It is an invasive procedure. Caution must be taken with patient on anticoagulants. Arterial blood gas analysis is an essential part of diagnosing and managing the patients oxygenation status, ventilation failure and acid base balance.
What Is An ABG?
pH [H+] PCO2 Partial pressure CO2
PO2
Partial pressure O2
Acid/Base Balance
The pH is a measurement of the acidity or alkalinity of the blood. It is inversely proportional to the no. of (H+) in the blood. The normal pH range is 7.35-7.45. Changes in body system functions that occur in an acidic state decreases the force of cardiac contractions, decreases the vascular response to catecholamines, and a diminished response to the effects and actions of certain medications. An alkalotic state interferes with tissue oxygenation and normal neurological and muscular functioning. Significant changes in the blood pH above 7.8 or below 6.8 will interfere with cellular functioning, and if uncorrected, will lead to death.
Acid/Base Relationship
H2O + CO2 H+
H2CO3
HCO3 +
Buffers
There are two buffers that work in pairs
H2CO3 NaHCO3 Carbonic acid base bicarbonate These buffers are linked to the respiratory and renal compensatory system
Causes
1. 2. Central nervous system depression r/t medications such as narcotics, sedatives, or anesthesia. Impaired muscle function r/t spinal cord injury, neuromuscular diseases, or neuromuscular blocking drugs. Pulmonary disorders such as atelectasis, pneumonia, pneumothorax, pulmonary edema or bronchial obstruction Massive pulmonary embolus Hypoventilation due to pain chest wall injury, or abdominal pain.
3.
4. 5.
Management
Increase the ventilation. Causes can be treated rapidly include pneumothorax, pain and CNS depression r/t medication. If the cause can not be readily resolved, mechanical ventilation.
Respiratory alkalosis
Psychological responses, anxiety or fear. Pain Increased metabolic demands such as fever, sepsis, pregnancy or thyrotoxicosis. Medications such as respiratory stimulants. Central nervous system lesions
Management
Resolve the underlying problem Monitor for respiratory muscle fatigue When the respiratory muscle become exhausted, acute respiratory failure may ensue
Metabolic Acidosis
Bicarbonate less than 22mEq/L with a pH of less than 7.35. Renal failure Diabetic ketoacidosis Anaerobic metabolism Starvation Salicylate intoxication
Management
Treat the cause Hypoxia of any tissue bed will produce metabolic acids as a result of anaerobic metabolism even if the pao2 is normal Restore tissue perfusion to the hypoxic tissues The use of bicarbonate is indicated for known bicarbonate - responsive acidosis such as seen with renal failure
Metabolic alkalosis
Bicarbonate more than 26m Eq /L with a pH more than 7.45 Excess of base /loss of acid can cause Ingestion of excess antacids, excess use of bicarbonate, or use of lactate in dialysis. Protracted vomiting, gastric suction,hypchoremia,excess use of diuretics, or high levels of aldesterone.
Signs/symptoms
CNS: Dizziness, lethargy disorientation, siezures & coma. M/S: weakness, muscle twitching, muscle cramps and tetany. Nausea, vomiting and respiratory depression. It is difficult to treat.
7.35 7.45 Pao2 The partial pressure oxygen that is dissolved in arterial blood. 80-100 mm Hg. PCO2: The amount of carbon dioxide dissolved in arterial blood. 35 45 mmHg HCO3 The calculated value of the amount of bicarbonate in the blood : 22 26 mmol/L B.E: The base excess indicates the amount of excess or insufficient level of bicarbonate. -2 to +2mEq/L (A negative base excess indicates a base deficit in blood) SaO2:The arterial oxygen saturation. >95%
Step:1 Assess the pH acidotic/alkalotic If above 7.5 alkalotic If below 7.35 acidotic
Contd..
Step 2: Assess the paCO2 level. pH decreases below 7.35, the paCO2 should rise. If pH rises above 7.45 paCO2 should fall. If pH and paCO2 moves in opposite direction primary respiratory problem.
contd
Step:2 Assess HCO3 value If pH increases the HCO3 should also increase If pH decreases HCO3 should also decrease They are moving in the same direction primary problem is metabolic
Step 3 Assess pao2 < 80 mm Hg - Hypoxemia For a resp. disturbance : acute, chronic The differentiation between A/C & CHR.respiratory disorders is based on whether there is associated acidemia / alkalemia. If the change in paco2 is associated with the change in pH, the disorder is acute. In chronic process the compensatory process brings the pH to within the clinically acceptable range ( 7.30 7.50)
J is a 45 years old female admitted with the severe attack of asthma. She has been experiencing increasing shortness of breath since admission three hours ago. Her arterial blood gas result is as follows: pH : 7.22 paCO2 : 55 HCO3 : 25 Follow the steps pH is low acidosis paCO2 is high in the opposite direction of the pH. Hco3 is Normal. Respiratory Acidosis Need to improve ventilation by oxygen therapy, mechanical ventilation, pulmonary toilet or by administering bronchodilators.
EXAMPLE 2: Mr. D is a 55 years old admitted with recurring bowel obstruction has been experiencing intractable vomiting for the last several hours. His ABG is: pH : 7.5 paCO2 :42 HCO3 : 33 Metabolic alkalosis Management: IV fluids, measures to reduce the excess base
pH
PaCo2
normal
normal
BASE EXCESS
Is a calculated value estimates the metabolic component of an acid based abnormality. It is an estimate of the amount of strong acid or base needed to correct the met. component of an acid base disorder (restore plasma pH to 7.40at a Paco2 40 mmHg)
Formula
With the base excess is -10 in a 50kg person with metabolic acidosis mM of Hco3 needed for correction is:
Anion GAP
Step 4 Calculation of AG is useful approach to analyse metabolic acidosis AG = (Na+ + K+) (cl- + Hco3-) * A change in the pH of 0.08 for each 10 mm Hg indicates an ACUTE condition. * A change in the pH of 0.03 for each 10 mm Hg indicates a CHRONIC condition.
REMEMBER
K U S S M A L E etoacidosis remia epsis alicylate & other drugs ethanol lcohol (Ethanol) actic acidosis thylene glycol
Step 5 A patient can be uncompensated or partially compensated or fully compensated pH remains outside the normal range pH has returned within normal range- fully compensated though other values may be still abnormal Be aware that neither the system has the ability to overcompensate
COMPENSATION
ABG Interpretation
Step 5 cont
Determine if there is a compensatory mechanism working to try to correct the pH. ie: if have primary respiratory acidosis will have increased PaCO2 and decreased pH. Compensation occurs when the kidneys retain HCO3.
Example 3
Mrs. H is admitted, he is kidney dialysis patient who has missed his last 2 appointments at the dialysis centre his ABG results: pH : 7.32 paCo2 : 32 HCO3 : 18 Pao2 : 88 Partially compensated metabolic Acidosis
Example 4
Mr. K with COPD.His ABG is: pH : 7.35 PaCO2 : 48 HCO3 : 28 PaO2 : 90 Fully compensated Respiratory Acidosis
Example 5
Mr. S is a 53 year old man presented to ED with the following ABG. pH : 7.51 PaCO2 : 50 HCO3 : 40 Pao2 : 40 (21%O2) He has metabolic alkalosis Acute respiratory alkalosis (acute hyperventilation).
FULLY COMPENSATED
pH paco2 Resp.Acidosis Normal but<7.40 Resp.Alkalosis Normal but>7.40 Met. Acidosis Normal but<7.40 Met. Alkalosis Normal but>7.40 Hco3
Partially compensated
pH
Res.Acidosis Res.Alkalosis Met. Acidosis Met.Alkalosis
paco2
Hco3
~ PaCO pH Relationship
2
80 60 40 30 20
Precautions
Excessive Heparin Decreases bicarbonate and PaCO2
Large Air bubbles not expelled from sample PaO2 rises, PaCO2 may fall slightly.
Fever or Hypothermia, Hyperventilation or breath holding (Due to anxiety) may lead to erroneous lab results Care must be taken to prevent bleeding
2SD NORMAL
CL.ACCEPTABLE
HCO3
A quick assessment of patient oxygenation can be achieved with a pulse oximeter which measures SaO2.
Practice ABGs
1. PaO2 2. PaO2 3. PaO2 4. PaO2 5. PaO2 6. PaO2 7. PaO2 8. PaO2 9. PaO2 10. PaO2 90 60 95 87 94 62 93 95 65 110 SaO2 95 SaO2 90 SaO2 100 SaO2 94 SaO2 99 SaO2 91 SaO2 97 SaO2 99 SaO2 89 SaO2 100 pH 7.48 pH 7.32 pH 7.30 pH 7.38 pH 7.49 pH 7.35 pH 7.45 pH 7.31 pH 7.30 pH 7.48 PaCO2 32 PaCO2 48 PaCO2 40 PaCO2 48 PaCO2 40 PaCO2 48 PaCO2 47 PaCO2 38 PaCO2 50 PaCO2 40 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 24 25 18 28 30 27 29 15 24 30
Any Questions?