ABG Workshop

Arterial Blood Gas Analysis

 Learning Outcomes
By the end of this session you should understand:

• The normal ranges for arterial blood gas

values.

• How to use the 5-step approach to arterial

blood gas interpretation.

• Some of the common causes of arterial blood

gas abnormalities and what to do to correct
them.
 5-step approach to blood gas
interpretation
1- How is the patient?
-Will provide useful clues to help with interpretation of the
results.

2- Assess oxygenation? ( Is the patient hypoxaemic? ).

- The PaO2 should be > 10 kPa (75 mmHg) breathing air and
about 10 kPa less than the % inspired concentration.

( PaO2 (kPa) = % O2 inspired - 10 )

N.B. (1 kPa = 7.5 mmHg)

3- Determine the pH (or H+ concentration)?
PH: The -ve logarithm of [H+].
PH=1/ [H+]
( PH= 7.35-7.45 )

- Patient is acidaemic; PH < 7.35 (or H+ > 45 nmol/L).

- Patient is alkalaemic; PH > 7.45 ( or H+ < 35 nmol/L).

4- Determine the respiratory component?
( PaCO2 = 4.7-6 kPa (35-45 mmHg) )
PH= HCO3/ PCO2

- If the PaCO2 > 6kPa (45 mmHg) ;PH < 7.35 =

respiratory acidosis.
- If PaCO2 <4.7 kPa (35 mmHg); PH> 7.45 =
respiratory alkalosis.
5- Determine the metabolic component?
( HCO3= 22- 26 mmol/L (BE +2: -2 mmol/L) )

- BE (Base Excess): the quantity of strong (acid) or base

required to restore pH to 7.4.

- If the HCO3 > 26 mmol/L( BE> +2 mmol/L ); PH > 7.45=

metabolic alkalosis.
- If the HCO3 < 22 mmol/L (BE< -2 mmol/L ); PH< 7.35=
metabolic acidosis.
 5- step approach
1- How is your patient?

2- Assess oxygenation? (PaO2)

3- Determine PH? (Acidemia or alkalemia)

4- Determine the respirtatory component? (PaCO2 )

5- Determine the metabolic component? (HCO3/BE)

 Case Study 1
• Initial Information:
A 21-year old woman is thrown from her horse
at a local event. On the way to hospital she
has become unconscious and the paramedics
have inserted an oropharyngeal airway and
given high flow oxygen via a face mask. An
arterial blood gas sample has been taken.

• Arterial blood gas analysis reveals:

Inspired oxygen 40% (FIO2 0.4).

Normal values
PaO2 18.8 KPa >10 KPa (75 mmHg) on air.
PH 7.19 7.35-7.45
PCO2 10.2 KPa (77 mmHg) 4.7-6 KPa (35-45 mmHg).
HCO3 23.6 mmol/L 22-26 mmol/L.
BE -2.4 mmol/L +/- 2 mmol/L.

Diagnosis:

• Acute respiratory acidosis with impaired oxygenation.

 Case Study 2
• Initial Information:
A 60 year old man is brought to the ED after a
witnessed Out of hospital cardiac arrest. The
paramedics arrived after 7 min, during which CPR
had not been attempted. His initial rhythm was
VF and the paramedics subsequently restored a
spontaneous circulation after the 3rd shock.
• On arrival:-
Intubated, ventilated with 50% oxygen.
HR 120/min, BP 150/95 mmHg.
Comatose (GCS 3).
• Arterial blood gas analysis reveals:

Inspired oxygen50% (FIO2 0.4).

Normal values
PaO2 7.5 KPa(56mmHg) <10 KPa (75 mmHg) on air.
PH 7.10 7.35-7.45
PaCO2 6.2 KPa (47 mmHg) 4.7-6 KPa(35-45 mmHg).
HCO3 14mmol 22-26 mmol/L.
Base excess -10 mmol/L +/-2 mmol/L .

Diagnosis:

• There is a mixed metabolic and respiratory acidosis; the

Predominant component is metabolic, with significant
impairment of oxygenation.
 Case Study 3
• Initial Information:
A 65 year old man with severe COPD has been found
collapsed in the respiratory unit. On initial assessment by the
ward nurse he is apnoeic but has an easily palpable carotid
pulse. The nurse is attempting to ventilate his lungs with a bag
mask and supplemental oxygen (with reservoir) and has called
the cardiac arrest team.

• On arrival:-
Oropharyngeal airway, ventilated with bag mask, oxygen at
15 L/min.
Carotid pulse palpable, 90/min, SpO2 99%.
Comatose (GCS 3).
• Arterial blood gas analysis reveals:

Inspired oxygen 85% (FIO2 0.85).

Normal values
PaO2 19.5 KPa (147 mmHg) > 10 KPa (75 mmHg)on air.
PH 7.10 7.35-7.45
PaCO2 18 KPa (135 mmHg) 4.7-6 KPa (35-45 mmHg).
HCO3 36 mmol/L 22-26 mmol/L.
BE + 12 mmol/L +/-2 mmol/L.

Diagnosis:

• The significant acidaemia (PH 7.10) indicate an additional

acute respiratory acidosis as a result of the respiratory arrest.
In the preexisting compensated chronic respiratory acidosis,
the PH would have been close to normal.
 Case Study 4
• Initial Information:
A 75 year old woman is admitted to the ED following a VF
cardiac arrest, witnessed by paramedics. This had been
preceded by 30 min of severe central chest pain.
Spontaneous circulation restored after 2 shocks, but the
patient remained apnoeic and unresponsive. The
paramedics intubated her trachea and ventilated her with
an automatic ventilator.

• On arrival:-
Tube confirmed in trachea, tidal volume of 900 ml, rate of
18 breaths/min,100% oxygen.
Pulse 100/min, BP 90/54 mmHg.
Comatose (GCS 3).
• Arterial blood gas reveals:

Inspired oxygen 100% (FIO2 1.0).

Normal values
PaO2 25.4 KPa (192 mmHg) > 10 KPa (75 mmHg) on air.
PH 7.62 7.35-7.45
PaCO2 2.65 KPa (20 mmHg) 4.7-6 KPa (35-45 mmHg).
HCO3 20 mmol/L 22-26 mmol/L.
BE - 4 mmol/L +/- 2 mmol/L.

Diagnosis:

• Respiratory alkalosis, mild metablic acidosis & impaired

oxygenation.
 Case Study 5
• Initial Information:
An 18 year old insulin dependent diabetic is admitted to the
ED. He has been vomiting for 48 h and because he was
unable to eat, he has taken no insulin.

• On arrival:-
Breathing spontaneously; RR 35/min, oxygen 4 L/min via
Hudson mask, SpO2 98%.
HR 130/ min, BP 90/65 mmHg.
GCS 12 (E3, M5, V4).
• Arterial blood gas reveals:

Inspired oxygen 30% ( FIO2 0.3).

Normal values
PaO2 17 KPa (129 mmHg) > 10 KPa (75 mmHg) on air.
PH 6.89 7.35-7.45
PaCO2 2.48 KPa (19 mmHg) 4.7-6 KPa (35-45 mmHg).
HCO3 4.7 mmol/L 22-26 mmol/L.
BE -29.4 mmol/L +/-2 mmol/L.

The blood glucose is 30 mmol/L & there are ketones in the urine +++.

Diagnosis:

• These blood gas results are consistent with severe diabetic

ketoacidosis.
• There is a primary metabolic acidosis with partial compensation
provided by the respiratory alkalosis.
 Case Study 6
• Initial Information:
A 75 year old man is on the surgical ward 2 days after a
laparotomy for a perforated sigmoid colon secondary to
diverticular disease. He has become increasingly hypotensive
over the last 6 h, despite 1000 ml 0.9% saline.

• On arrival:-
RR 35/min, SpO2 92% on 4 L/min oxygen via facemask.
HR 120/min sinus tachycardia, warm peripheries, BP 70/40
mmHg.
Urine output 90 ml in the last 6 h.
GCS 13 (E3, M6, V4).
• Arterial blood gas reveals:

Inspired oxygen 40% (FIO2 0.4).

Normal values
PaO2 8.2 KPa (62 mmHg) > 10 KPa (75 mmHg) on air.
PH 7.17 7.35-7.45
PaCO2 4.5 KPa(34 mmHg) 4.7-6 KPa (35-45 mmHg).
HCO3 14 mmol/L 22-26 mmol/L.
BE -12 mmol/L +/-2 mmol/L.

Diagnosis:

• There is a primary metabolic acidosis with slight compensation provided by

the mild respiratory alkalosis. The degree of this is probably limited by the
presence of an acute abdomen. The most likely diagnosis is sepsis syndrome
secondary to intra-abdominal infection. The plasma lactate would be
elevated.
Waveform Capnography
Capnography Examples
 Waveform Capnography

A: Start Expiration
B: End Expiration = etCO2
Spontaneous breathing
Ventilated patient
High Quality CPR
Chest Compression Provider Tiring
EtCO2 with ROSC
Persistently low EtCO2-associated with poor
prognosis
Disconnection
Any Questions?
 Summary
This workshop has covered:
• The terms used to describe the results of arterial blood
gas analysis.

• The normal ranges for arterial blood gas values.

• How respiration and metabolism are linked.

• How to use the 5-step approach to arterial blood gas

interpretation.

• Some of the common causes of arterial blood gas

abnormalities and what to do to correct them.