Arterial Blood Gas Analysis

Vanessa Klee MSIV

What is an ABG?
The Components
pH / PaCO2 / PaO2 / HCO3 / O2sat / BE

Desired Ranges
pH - 7.35 - 7.45 PaCO2 - 35-45 mmHg PaO2 - 80-100 mmHg HCO3 - 21-27 O2sat - 95-100% Base Excess - +/-2 mEq/L

Why Order an ABG?

Aids in establishing a diagnosis Helps guide treatment plan Aids in ventilator management Improvement in acid/base management allows for optimal function of medications Acid/base status may alter electrolyte levels critical to patient status/care

Logistics
When to order an arterial line - Need for continuous BP monitoring Need for multiple ABGs

Where to place -- the options

Radial Femoral Brachial Dorsalis Pedis Axillary

Acid Base Balance

The body produces acids daily
15,000 mmol CO2 50-100 mEq Nonvolatile acids

The lungs and kidneys attempt to maintain balance

Acid Base Balance

Assessment of status via bicarbonatecarbon dioxide buffer system
CO2 + H2O <--> H2CO3 <--> HCO3- + H+ ph = 6.10 + log ([HCO3] / [0.03 x PCO2])

The Terms
ACIDS
Acidemia Acidosis
Respiratory oCO2 Metabolic qHCO3

BASES
Alkalemia Alkalosis
Respiratory qCO2 Metabolic oHCO3

Respiratory Acidosis
qph, oCO2, qVentilation Causes
CNS depression Pleural disease COPD/ARDS Musculoskeletal disorders Compensation for metabolic alkalosis

Respiratory Acidosis
Acute vs Chronic
Acute - little kidney involvement. Buffering via titration via Hb for example
pH qby 0.08 for 10mmHg o in CO2

Chronic - Renal compensation via synthesis and retention of HCO3 (qCl to balance charges hypochloremia)
pH qby 0.03 for 10mmHg oin CO2

Respiratory Alkalosis
opH, qCO2, oVentilation q CO2 q HCO3 (oCl to balance charges hyperchloremia) Causes
Intracerebral hemorrhage Salicylate and Progesterone drug usage Anxiety qlung compliance Cirrhosis of the liver Sepsis

Respiratory Alkalosis
Acute vs. Chronic
Acute - qHCO3 by 2 mEq/L for every 10mmHg q in PCO2 Chronic - Ratio increases to 4 mEq/L of HCO3 for every 10mmHg q in PCO2 Decreased bicarb reabsorption and decreased ammonium excretion to normalize pH

Metabolic Acidosis
qpH, qHCO3 12-24 hours for complete activation of respiratory compensation qPCO2 by 1.2mmHg for every 1 mEq/L qHCO3 The degree of compensation is assessed via the Winters Formula
PCO2 = 1.5(HCO3) +8 s 2

The Causes
Metabolic Gap Acidosis
M - Methanol U - Uremia D - DKA P - Paraldehyde I - INH L - Lactic Acidosis E - Ehylene Glycol S - Salicylate

Non Gap Metabolic Acidosis

Hyperalimentation Acetazolamide RTA (Calculate urine anion gap) Diarrhea Pancreatic Fistula

Metabolic Alkalosis
opH, oHCO3 oPCO2 by 0.7 for every 1mEq/L o in HCO3 Causes
Vomiting Diuretics Chronic diarrhea Hypokalemia Renal Failure

Mixed Acid-Base Disorders

Patients may have two or more acidbase disorders at one time Delta Gap
Delta HCO3 = HCO3 + Change in anion gap >24 = metabolic alkalosis

The Steps
Start with the pH Note the PCO2 Calculate anion gap Determine compensation

Sample Problem #1
An ill-appearing alcoholic male presents with nausea and vomiting.
ABG - 7.4 / 41 / 85 / 22 Na- 137 / K- 3.8 / Cl- 90 / HCO3- 22

Sample Problem #1
Anion Gap = 137 - (90 + 22) = 25 anion gap metabolic acidosis Winters Formula = 1.5(22) + 8 s 2 = 39 s 2 compensated Delta Gap = 25 - 10 = 15 15 + 22 = 37 metabolic alkalosis

Sample Problem #2
22 year old female presents for attempted overdose. She has taken an unknown amount of Midol containing aspirin, cinnamedrine, and caffeine. On exam she is experiencing respiratory distress.

Sample Problem #2
ABG - 7.47 / 19 / 123 / 14 Na- 145 / K- 3.6 / Cl- 109 / HCO3- 17 ASA level - 38.2 mg/dL

Sample Problem #2
Anion Gap = 145 - (109 + 17) = 19 anion gap metabolic acidosis Winters Formula = 1.5 (17) + 8 s 2 = 34 s 2 uncompensated Delta Gap = 19 - 10 = 9 9 + 17 = 26 no metabolic alkalosis

Sample Problem #3
47 year old male experienced crush injury at construction site. ABG - 7.3 / 32 / 96 / 15 Na- 135 / K-5 / Cl- 98 / HCO3- 15 / BUN- 38 / Cr- 1.7 CK- 42, 346

Sample Problem #3
Anion Gap = 135 - (98 + 15) = 22 anion gap metabolic acidosis Winters Formula = 1.5 (15) + 8 s 2 = 30 s 2 compensated Delta Gap = 22 - 10 = 12 12 + 15 = 27 mild metabolic alkalosis

Sample Problem #4
1 month old male presents with projectile emesis x 2 days. ABG - 7.49 / 40 / 98 / 30 Na- 140 / K- 2.9 / Cl- 92 / HCO3- 32

Sample Problem #4
Metabolic Alkalosis, hypochloremic Winters Formula = 1.5 (30) + 8 s 2 = 53 s 2 uncompensated