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ABGs interpretation

By Farhana
Nursing instructor RCN
Objectives
• Explain ABGs sampling

• Discuss ABGS interpretation

• Discuss scenarios related to ABGs interpretation


ABGs sampling
• Procedure and precaution: site ( ideally) radial, brachial, and femoral
artery.
• Pre- heparinized syringe (500U Heparin)
• Ensured no air bubbles. Syringe must be sealed immediately after
withdrawing sample.
• ABGs syringe must be transported to the laboratory for early analysis
via COLD chain.
Conti…
• Patients body temperature effect the value of Pco2 and HCO3.
• ABGs analyzer is controlled for normal body temperature.

ABGs sample should Always be sent with relevant information


regarding o2, fio2 status and temperature.
ABGs
• Arterial blood gases (ABGs) are diagnostic tests performed on blood
taken from an artery which contains oxygen and carbon dioxide.

• ABGs measure how well the lungs can provide adequate oxygen to
the body and subsequently remove carbon dioxide. Analysis of blood
gases helps evaluate a person's respiratory and metabolic status.
• ABGs also measure blood pH and the integrity of the body's acid-base
balance.
By Deborah Leader, RN
Updated April 09, 2017
ABGs interpretation
• There are a number of tests that can help to identify acid-base status.
One extremely useful blood test is the arterial blood gas (ABG)
analysis.
Components of an ABG include:
• pH (potential of hydrogen ions)
• PaCO2 (partial pressure of arterial carbon dioxide)
• HCO3 (bicarbonate)
• PaO2 (partial pressure of arterial oxygen)
Normal values of ABGs
Normal ABG values fall within the following ranges:
Partial pressure of oxygen (PaO2):80 - 100 mm Hg
Partial pressure of carbon dioxide (PaCO2): 35 - 45 mm Hg
pH: 7.35 - 7.45
Oxygen saturation (SaO2): 94 - 100%
Bicarbonate - (HCO3): 22 - 26 mEq/lite
CONTI..
 The type of acidosis or alkalosis by evaluating the carbon dioxide and
bicarbonate values. These two components work to balance the pH.
The respiratory component involves the elimination (or retention) of
carbonic acid via carbon dioxide (CO2).

 The metabolic component involves the kidneys which produce


bicarbonate (HCO3). The kidneys can also help control the pH by
eliminating hydrogen (H+) ions.
CONTI…
The respiratory system can respond within minutes to an increase in
acid but the response is weak. The kidneys have a much more
powerful response but are slow to respond; usually taking
approximately 48 hours to make any change (Lian, 2010).
STEPS OF ANALYSING ABGS
Steps 1:
The pH The first step to interpret ABGs is to determine if the patient
has a normal pH. The pH will provide you your first most valuable piece
of information: does the patient have acidosis or alkalosis.
Recall that a normal pH value is 7.35 to 7.45. Now memorize the
following facts:
• When the patient’s pH is less than 7.35, the patient has some type
of acidosis.
• When the patient’s pH is above 7.45, the patient has some type of
alkalosis.
CONTI…
Some essential information is still missing though. You can’t address
the imbalance because you don’t know what type of acidosis or
alkalosis the patient is experiencing.
Step Two
Evaluating CO2 The second step to interpret an ABG result is to look at the
carbon dioxide level.
The normal carbon dioxide level for most patients is 35 to 45 mmHg. Note
the similarity between normal carbon dioxide levels (35-45 mm Hg) and
normal pH (7.35-7.45).
Also note that when you evaluate carbon dioxide values, you are
effectively looking at lung function. You will need to memorize that:
 • A carbon dioxide level greater than 45 mmHg indicates acidosis (there is
too much CO2 being retained).
 • A carbon dioxide (CO2) value less than 35 mmHg indicates alkalosis
(there is not enough CO2)
Steps 3
 Evaluating HCO3 Now it’s time to examine the bicarbonate
component of ABG analysis. The third step to interpret an ABG result
is to examine the bicarbonate level. A normal bicarbonate (HCO3)
level is 22-26 mEq. You will need to memorize that: An HCO3 level
less than 22 mEq indicates there is not enough HCO3.
A low level of bicarbonate means acidosis. An HCO3 value higher
than 26 mEq indicates a high level of bicarbonate, too much HCO3.
This means alkalosis (Lian, 2010
Step 4:
Matching pH, HCO3 and CO2 Using ROME A, you may have started to
notice that whenever the pH is high and the HCO3 is high, the patient
has metabolic alkalosis.
 In other words, when the direction of movement of the pH matches
the direction of movement of the HCO3 (the direction of movement
[up or down] is the same), the disorder is metabolic in nature.
Conversely, when the direction of movement of the pH is opposite to
the direction of movement of CO2, the disorder will be respiratory in
nature. (Martini et al., 2012).
CONTI…
• Using Acronyms Some people use the acronym
• “R.O.M.E.” to assist them in memorizing this concept/relationship.
• R =Respiratory
• O =Opposite
• M =Metabolic
• E =Equal
Case 1
• A 60 year-old man with amyotrophic lateral sclerosis is brought into clinic by his
family who are concerned that he is more somnolent than normal. On further
history, they report that he has been having problems with morning headaches
and does not feel very refreshed when he wakes up. An arterial blood gas is
performed and reveals: pH 7.37, PCO2 57, PO2 70, HCO3 - 32.
• Acid-base status:
• The patient has a low pH (acidemia)
• The PCO2 is high (respiratory acidosis) and the bicarbonate is high (metabolic
alkalosis). The low pH in combination with the high PCO2 tells us that the
respiratory acidosis is the primary process.
• The metabolic alkalosis is the compensatory process.
• Summary: A chronic respiratory acidosis with a compensatory metabolic
alkalosis.
Case 2
• A 45 year-old woman with a history of inhalant abuse presents to the emergency room complaining
of dyspnea. She has an SpO2 of 99% on room air and is obviously tachypneic on exam with what
appears to be Kussmaul’s respirations. A room air arterial blood gas is performed and reveals: pH
6.95, PCO2 9, PO2 128, HCO3 - 2. A chemistry panel revealed sodium of 130, chloride 98, HCO3 - 2.
• Acid-base status:
• The patient has a very low pH (acidemia)
• The patient has a low PCO2 (respiratory alkalosis) and a very low bicarbonate (metabolic acidosis).
The low pH in conjunction with the low bicarbonate tells us that the metabolic acidosis is the primary
process
• The anion gap is elevated at 30. This tells us that the patient has a primary elevated anion gap
metabolic acidosis.
• The respiratory alkalosis is the compensatory process, although in this case, despite a huge
compensatory increase in minute ventilation, the patient still has a very low pH.
• The delta gap is 30-12 = 18 and the delta-delta is 18 + 2 = 20. Since the delta-delta is below 22, we
know that there is an additional non-gap metabolic acidosis as well.
• Summary: Combined elevated anion gap and non-gap metabolic acidoses with compensatory
respiratory alkalosis.
Case.3
• patients oxygen saturation is 78% on room air. Before he is place on
supplemental oxygen, a room air arterial blood gas is drawn and reveals:
pH 7.25, PCO2 68, PO2 48, HCO3 - 31.
• Acid-base status:
• The patient has a low pH (acidemia)
• The patient has a high PCO2 (respiratory acidosis) and a high bicarbonate
(metabolic alkalosis). The combination of the low pH and the high
PCO2 tells us that the respiratory acidosis is the primary process.
• The metabolic alkalosis is the compensatory process. The pH is still low
despite this metabolic compensation
• Summary: Primary respiratory acidosis with compensatory metabolic
alkalosis.
Case.4
• A climber is coming down from the summit of Mt. Everest. At an altitude of
8,400 m (PB ~ 272 mmHg), he has a blood gas drawn while breathing
ambient air as part of a research project. The blood gas reveals pH 7.55,
PCO2 12, PO2 30 and HCO3 - 10.5.
• Acid-base status:
• The patient has a high pH (alkalemia)
• The PCO2 is low (respiratory alkalosis) and the bicarbonate
is low (metabolic acidosis). The high pH in conjunction with
the low PCO2 tells us that the respiratory alkalosis is the
primary process.
• The metabolic acidosis is the compensatory process
• Summary: Primary respiratory alkalosis with metabolic
compensation.
Case.5
• A 57 year-old woman presents with 2 days of fevers, dyspnea and a cough productive of
rust-colored sputum. Her room air oxygen saturation in the emergency room is found to
be 85% and the intern decides to obtain a room air arterial blood gas while they are
waiting for the chest x-ray to be done. The blood gas reveals: pH 7.54, PCO2 25, PO2 65,
HCO3 - 22,
• Acid-base status:
• The patient has a high pH (alkalemia)
• The PCO2 is low (respiratory alkalosis). The high pH in conjunction with
the low PCO2 tells us that the respiratory alkalosis is the primary
process.
• Although the bicarbonate is on the low side, the base excess of -1 tells
us that the patient does not have a metabolic acidosis. The patient,
therefore, has not mounted a compensatory response yet.
• Summary: Acute, uncompensated respiratory alkalosis
Case 1
• A 24 year-old woman is found down in Pioneer Square by some bystanders. The
medics are called and, upon arrival, find her with an oxygen saturation of 88% on
room air and pinpoint pupils on exam. She is brought into the Harborview ER
where a room air arterial blood gas is performed and reveals: pH 7.25, PCO2 60,
PO2 65 HCO3- 26, Base Excess 1. Her chemistry panel shows: sodium 137, chloride
100, bicarbonate 26.
• Acid-base status:
• The patient has a low pH (acidemia)
• The PCO2 is high (respiratory acidosis) and the bicarbonate is at the upper end of
normal. The low pH and high PCO2 imply that the respiratory acidosis is the
primary process
• The anion gap is 10 and is, therefore, normal. The patient does not have an
elevated anion gap acidosis.
• There is no compensatory process. Although the measured bicarbonate is just
above normal, the base excess of 1 tells us that there is no metabolic alkalosis
• The delta gap is 10 -12 = -2 and the delta-delta is -2 + 27 = 25. There is, therefore,
no metabolic process.
• Summary: An acute, uncompensated respiratory acidosis leading to acidemia.
Case 3

• A 65 year-old man is brought into the VA hospital with complaints of severe nausea and weakness.
He has had problems with peptic ulcer disease in the past and has been having similar pain for the
past two weeks. Rather than see a physician about this, he opted to deal with the problem on his
own and, over the past week, has been drinking significant quantities of milk and consuming large
quantities of TUMS (calcium carbonate). On his initial laboratory studies, he is found to have a
calcium level of 11.5 mg/dL, a creatinine of 1.4 and bicarbonate of 35. The resident working in the
ER decides to draw a room air blood gas that reveals: pH 7.45, PCO2 49, PO2 68, HCO3- 34
• His chemistry panel: sodium 139, chloride 95, and HCO3- 34
• Acid-base status:
• The patient has a high pH (alkalemia)
• The PCO2 is high (respiratory acidosis) and the bicarbonate is high (metabolic alkalosis). The high
pH and the high bicarbonate tell us that the metabolic alkalosis is the primary process.
• The anion gap is 10. This is a normal value
• The respiratory acidosis is the compensatory process
• The delta gap is 10 – 12 = -2. The delta delta is -2 + 34 = 32. This value is above 26 and tells us that
a metabolic alkalosis is present. This is the same process that was identified in the second step
above.
• Summary: A primary metabolic alkalosis with respiratory compensation.
Case 8
• A 47 year-old man with a history of heavy alcohol use presents with a two-day history of
severe abdominal pain, nausea and vomiting. On exam, his blood pressure is 90/50 and
he is markedly tender in his epigastrum. His initial laboratory studies reveal: sodium of
132, chloride 92, HCO3- 16, creatinine 1.5, amylase 400, lipase 250. A room air arterial
blood gas is drawn and reveals pH 7.28, PCO2 34, PO2 88, HCO3- 16.
• Acid-base status:
• The patient has a low pH (acidemia)
• The PCO2 is low (respiratory alkalosis) and the bicarbonate is low (metabolic acidosis).
The combination of the low pH and the low bicarbonate tells us that the metabolic
acidosis is the primary process
• The anion gap is elevated at 24. This tells us that the patient has a primary elevated
anion gap metabolic acidosis
• The respiratory alkalosis is the compensatory process
• The delta gap is 24-12 = 12. The delta delta is 12 + 17 = 29. Because the delta-delta is
greater than 26, we know that the patient has a concurrent metabolic alkalosis.
• Summary: Primary elevated anion gap metabolic acidosis with respiratory compensation
and a concurrent metabolic alkalosis.