Prof. A K Sethi’s EORCAPS 2008 Prof.

A K Sethi’s EORCAPS 2008

:- BLOOD GAS ANALYSIS :-

Dr. T.C. Kriplani

POLIO – EPIDEMIC 1952- COPENHAGEN (DENMARK)

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Q. What is the difference between :

-Blood gas analysis
&
-Blood gas monitoring

Ans : Blood gas monitor is a patient dedicated

device that measures arterial pH, PaCO2 and
PaO2 without permanently removing blood.
For blood gas analysis – Blood is removed
from patient

DR. BJORN IBSEN

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Q. What are the principles of Gas analysis ? Q. What is the difference between electrode &
optode ?

Ans : Ans :
•Chemical (Haldane, Orsat-Henderson & Van Slyke) •Electrode : Sensor that operates via electrochemical
•Physical (Magnetic, infrared, gas chromatography) properties
•Specific electrodes •Optode : Sensor that operates via optical detection
of altered light

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 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Q. Who developed O2 electrode

Q. Who developed CO2 electrode
Ans : Dr. Leland Clark in 1956 Ans : Dr. John Severinghaus in 1959

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Q. What are the sites from where blood can be

drawn for blood gas analysis ?

Ans :
•Usually from peripheral art. (Radial, Brachial,
Femoral or Dorsalis pedis)
•Arterialised capillary sample

PHOTOGRAPH OF pH ELECTRODE •Rare cases venous blood is used

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Q. What are indications & contraindications of

Q. What are the complications of Arterial Puncture?
arterial blood gas analysis ?
Ans :
•Indications:
•To evaluate the adequacy of ventilation
•To Quantitate patient’s response to therapeutic intervention
•To monitor severity & progression of documented disease process
Contraindications:
Ans :
•-ve result of Allen’s test •Arteriospasm, Haematoma, Emboli (Air or clotted
•Coagulopathy or medium to high dose anticoagulation therapy blood), Anaphylaxis if LA is used, Haemorrhage,
(Heparin, Coumadin, streptokinase, Caprostat)
Trauma to vessel, Arterial occlusion, Vasovagal
•Femoral puncture avoided outside hospital response and Pain
•Arterial puncture not performed distal to surgical shunt

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 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008
Q. How Allen’s test is performed ? What precautions
should be taken while taking the sample ? Q. How arterialised capillary sample is taken ?
Ans : Allen E.V. (1929) Ans :
•Pt. closes hand as tightly as possible for 1 minute in order to squeeze out
blood
•Site – Finger, toe, heel or ear lobe
•Compress radial art. at wrist •Wrapping in warm pad (40-430 C) for 10 minutes
•Open the hand (extend fingers)
•Or
•Note the return of colour
•Full blushing – 7 seconds •Massage ear lobe for 2-3 minutes
•Borderline – 8 – 14 seconds •Heparinised capillary tube should be sealed after
•Abnormal (-ve test) - > 14 seconds
•LA – prevents arterial spasm, softens skin, increases subcutaneous space
collecting sample with clay at one end
(working room),
•Short steel wire is inserted then other end is sealed
•Ringe syringe with Heparin 1 in 1000
•Steel wire is moved with magnet to mix the sample

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Q. How to take an arterial blood gas sample ?
Q. What is the difference between :
Ans :
-Acidosis & Acidaemia
•Syringe with 22 to 23 G needle for radial artery
or
puncture
-Alkalosis & Alkalaemia
•Bevel facing up 20-300 angle, wrist extended 20-
Ans : In acidosis and alkalosis – Acid base
300 disturbance is at cellular level, there is a change in
•0.25 mL Heparin 1000 IU/mL concentration do PaCO2 or in HCO3- but there is no change in pH
coating and discard rest Where as in acidaemia there is change in pH below
normal (< 7.36) similarly in alkalaemia pH goes
•Send for analysis within 5-10 minutes or else store above normal (> 7.44)
in Ice child water (40C) maximum upto 60 minutes

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Q. What values are returned from ABGs ? Q. What is the actual bicarbonate and what is
standard bicarbonate ?

Ans :
•Actual bicarbonate (ABC) is calculated from
Ans : 3-5 values are actually measured (pH, PaO2, measured pH and PCO2 of whole blood sample
PaCO2, Hb & O2 saturation) all remaining values are
calculated like •Standard bicarbonate (SBC) is simply a measure of
bicarbonate concentration under standard conditions
ABC, TCO2, SBC, BE, SBE i.e., bicarbonate concentration in plasma of fully
oxygenated blood which has been equilibrated to a
PaCO2 of 40 mm of Hg at 370 C

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 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Q. What are primary and secondary acid base Q. What are the changes in actual HCO3- in levels in
derangements ? acute and chronic respiratory acidosis ?
Ans : Primary is the cause of acid-base drangement
where is the secondary is the compensatory change. Ans :
The end point is constant if compensation is in
range. PaCO2/ HCO3- is constant. •Acute respiratory acidosis : 1 mm of Hg rise in
Acid Base Disorder Primary Change Secondary Change
PaCO2 = 0.1 mmol/L rise in actual HCO3-
Respiratory Acidosis ↑ PaCO2 ↑ HCO3- •Chronic respiratory acidosis : 1 mm of Hg rise in
Alkalosis ↓ PCO2 ↓ HCO3-
PaCO2 = 0.4 mmol/L rise in HCO3-
Metabolic Acidosis ↓ HCO3- ↓ PCO2

Alkalosis ↑ HCO3- ↑ PCO2

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Q. What are the changes in actual HCO3- levels in Q. What are the changes in PaCO2 in metabolic
acute and chronic respiratory alkalosis ? acidosis and alkalosis ?

Ans : Ans :
•Acute : 1 mm of Hg fall in PaCO2 = 0.2 mmol/L •Metabolic acidosis : 1 mmol/L fall in HCO3- = 1-
fall in HCO3- 1.3 mm of Hg fall in PaCO2
•Chronic 1 mm of Hg fall in PaCO2= 0.5 mmol/L •Metabolic alkalosis : 1 mmol/L rise in HCO3- = 0.6
fall in HCO3- mm of Hg rise in PaCO2

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

BASIC RULES OF INTERPRETATION

Q. The rules of acid base interpretation are based on Q. What is RULE : 1?
which variables ? See pH – If abnormal
See the change – If moving in same direction
Ans : in PaCO2
•On three variables pH, PCO2 & HCO3-
i.e., if both are abnormal and are moving in same direction
•If outside normal range, it is abnormal
Diagnosis of primary metabolic disorder is made
Normal range :
pH 7.36 to 7.44 ↓ pH and ↓ PaCO2 ∆ metabolic acidosis or acidaemia
↑ pH and ↑ PaCO2 ∆ metabolic alkalosis or alkalaemia
PaCO2 36 to 44 mm of Hg
HCO3 - 22 to 26 mEq/L

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 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Q. What is RULE 2 ? Q. What is RULE 3 ?

z If pH is abnormal z pH – abnormal
& there is no change in PaCO2 or PaCO2 – moving in opposite
unexpected change is there direction
∆ of superimposed resp acid base ∆ Primary Resp Acid Base disorder
disorder is made along with primary ↓ pH ↑ PaCO2 Resp Acidosis /
metabolic disorder Acidaemia
z If PaCO2 more than expected
↑ pH ↓ PaCO2 Resp Alkalosis /
superimposed Resp acidosis Alkalemia
z If PaCO2 less than expected
(If primary Resp Acid-Base disorder is
superimposed Resp Alkalosis diagnosed then proceed to Rule – 4)

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Q. What is RULE 4 ? Q. What is RULE 5 ?

z To See whether primary Resp acid – base disorder
is acute, chronic or superimposed with metabolic zIfpH is normal
disorder
Acute Resp Acidosis = Change in pH & PaCO2 is abnormal (low or
= 0.008 x (PaCO2 – 40)
Chronic Resp Acidosis = Change in pH
high)
= 0.003 x (PaCO2 – 40) zA mixed Acid-Base disorder
Acute Resp Alkalosis = Change in pH
= 0.008 x (40 – PaCO2) (Acidosis or Alkalosis) is
Chronic Resp Alkalosis = Change in pH diagnosed
= 0.003 x (40- PaCO2)
If the calculated change is out of this range
metabolic disorder is superimposed)

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Q.
Q. RULE ORIENTED ACID BASE
z pH < 7.36
INTERPRETATIONS
z pH < 7.36 z PaCO2 > 40
z PaCO2 < 40 z pH is low and both are moving in opposite
direction (Rule 3 ) ∆ primary respiratory
z pH is low and both are moving in same acidaemia
direction (Rule 1 ) ∆ primary metabolic z Then one should calculate the change in either
acidaemia HCO3 or in pH whether expected or unexpected
z See the change in PaCO2 as per actual change
HCO3 value z (In acute respiratory disorder expected change in
z (1.0 mmol/l fall in HCO3 produces fall in pH = 0.008 x ↑ or ↓ PaCO2)
PaCO2 1-1.3 mm of Hg) z In chronic Resp disorder expected change in pH =
0.003 x ↑ or ↓ PaCO2
z If PaCO2 change is unexpected –
z If the change in HCO3 or in pH is unexpected one
superimposed respiratory disorder is their primary respiratory disorder is superimposed with
(Rule 2) metabolic disorder (Rule 4)

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 Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008
Q.
FURTHER ANALYSIS OF METABOLIC ACIDOSIS
pH = 7.4 Q. What is Anion Gap?

PaCO2 = 50 mm of Hg z To see whether acidosis is due to

(Resp acidosis + metabolic alkalosis) ↑ H+ or ↓ HCO-3
z AG (10-12 mEq/l normal) has been
(Rule 5)
used to identify this
pH = 7.4 z If AG ↑ (either it is ↑ in accumulation
PaCO2 = 30 mm of Hg of organic acids (lactic or ketoacids) or
due to ↓ H+ excretion by kidneys)
(Resp alkalosis + metabolic acidosis)
z If AG is normal (loss of HCO-3 in
(Rule 5) diarhoea)

Prof. A K Sethi’s EORCAPS 2008 Prof. A K Sethi’s EORCAPS 2008

Q. How AG is estimated ? Q. How a Mixed Metabolic Acidosis is

Ans : diagnosed?
•AG = Na+ - (Cl- + HCO3-) z Identified by :
= 10-12 mEq/L
“Gap Gap Ratio”
z ↑ AG and ↓ HCO3
UNMEASURED IONS
ANIONS (mEq/L) CATIONS (mEq/L)
z AG excess/HCO3- deficit
Proteins 15 Calcium 5 z AG – 12 / 24 – measured HCO3-
Organic acids 5 Potassium 4.5
z In mixed metabolic acidosis there is ↑
Phosphates 2
Sulphates 1
Magnesium 1.5
AG and proportional ↓ in HCO3- hence
the ratio is 1 (unity)
UA : 23 mEq/L UC : 11 mEq/L z In hyperchloraemic acidosis ↓ in
Anion Gap = UA – UC HCO3- is greater hence this ratio
23-11 = 12 mEq/L
becomes <1

Prof. A K Sethi’s EORCAPS 2008 pH 7.26

Q. A 27 years old epileptic man had grand mal Q.
seizures. Convulsions stopped without any PaCO2 26 mm of Hg
medication after 2 minutes. He was brought to
ABC 12.2 mmol/L
casualty:
Arterial blood gases shows: SBC 12.9 mmol/L

pH 7.26 z INTERPRETATION – BE - 13.3 mmol/L

z pH low – Acidaemia
PaCO2 26 mm of Hg z pH & PCO2 moving in same direction –
ABC 12.2 mmol/L Metabolic acidaemia (Rule 1)
z Compensated or uncompensated ?
SBC 12.9 mmol/L
z Actual HCO3 12.2 mmol deficit of 12 mmol/l
BE -13.3 mmol/L z 1 mol ↓ => 1 to 1.3 mm of Hg ↓ in PaCO2 ↓ has to
12-15 mm of Hg which is there (Rule 2)
INTERPRETATION -
z ∆ metabolic acidaemia with resp compensation

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 Prof. A K Sethi’s EORCAPS 2008 pH 7.5
Q. A patient admitted in surgical ward was on Q.
PaCO2 50 mm of Hg
gastric aspiration through Ryle’s tube because of
persistent vomitings: ABC 35 mmol/L
Arterial blood gases shows:
SBC 32 mmol/L
pH 7.5 z INTERPRETATION –
z pH high – alkalaemia BE +8 mmol/L
PaCO2 50 mm of Hg z Both pH and PCO2 moving in same direction
(Rule 1) metabolic alkalaemia
ABC 35 mmol/L
z ABC – 35 - ↑ of 11 mmol/l
SBC 32 mmol/L z 1 mmol ↑ HCO3- - ↑ PaCO2 0.6 mm of Hg
z 11 mmol – ↑ 6.6 mm of Hg expected rise
BE +8 mmol/L
(Rule 2)
INTERPRETATION - z ∆ metabolic alkalemia with poor resp
compensation

Q. A 33 years old man with insulin dependent pH 7.2

diabetes brought to emergency department not Q.
well for 3 days c/o frequency of urination, fever, PaCO2 20 mm of Hg
nausea, sweating had not been eating hence not
ABC 5.4 mmol/L
taking insulin:
Arterial blood gases shows: SBC 7.5 mmol/L
z INTERPRETATION – BE -26 mmol/L
pH 7.2
z pH 7.2 – Acidaemia
PaCO2 20 mm of Hg z Both pH and PCO2 (↓↓) moving in same direction
ABC 5.4 mmol/L (Rule 1) metabolic acidaemia
z ABC 5.4 mmol/L deficit of about 19 mmol
SBC 7.5 mmol/L z Expected ↓ PaCO2 – 1 mol – 1-1.3 mm of Hg
BE -26 mmol/L z 19 mmol – deficit expected decrease in PaCO2 19-
INTERPRETATION - 24 mm of Hg ↓ is 20 mm of Hg (Rule 2)
z ∆ metabolic acidaemia with well compensated

Q. A 29 yrs old lady known to have I.D.D.M.

complaining of shortness of breath from 36 hrs, Q. pH 7.39
PaCO2 27 mm of Hg
pleuritic chest pain, took contraceptive pill and ABC 16.6 mmol/L
her insulin. O/E she was distressed, tachypnoeic SBC 18.6 mmol/L
her blood glucose was 20 mmol/l. Receiving BE -7.6 mmol/L
40% oxygen via mask PaO2 97.4 mm of Hg

Arterial sample shows: z INTERPRETATION –

z pH low – Acidosis
pH 7.39
z Both pH and PaCO2 are moving in same direction
PaCO2 27 mm of Hg z Metabolic acidosis (Rule 1)
ABC 16.6 mmol/L z ABC 16.6 – deficit about 8 mmol/l
z 1 mmol ↓ - 1 to 1.3 mm of Hg ↓ in PaCO2
SBC 18.6 mmol/L
z 8 mmol ↓ - 8 to 10 mm of Hg ↓ in PaCO2
BE -7.6 mmol/L z But ↓ PaCO2 is more hence
PaO2 97.4 mm of Hg INTERPRETATION - z ∆ metabolic acidosis with respiratory alkalosis

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 pH 7.2
Q. A 19 years old boy brought in emergency Q.
with history of injecting some drug. O/E PaCO2 72 mm of Hg
respiration shallow 8/mt, responded to painful
stimuli. ABC 26.5 mmol/L

Arterial blood gases shows: SBC 26.0 mmol/L

pH 7.2 z INTERPRETATION –
BE 1.4 mmol/L
z pH low – Acidaemia
PaCO2 72 mm of Hg
z PaCO2 high both moving in opposite direction
ABC 26.5 mmol/L z ∆ Resp Acidaemia (Rule 3)
z Acute or chronic ?
SBC 26.0 mmol/L
z In acute 1 mm of Hg rise of CO2 produces rise of
BE 1.4 mmol/L HCO3 0.1 mmol/l - 0.1 x 30 = 3 mmol/l
z In chronic 0.4 mmol x 30 = 12 mmol/l
INTERPRETATION -
z ∆ Acute Resp Acidaemia

pH 7.36
Q. A 67 years old male with H/O cough and Q.
PaCO2 60 mm of Hg
respiratory distress and chronic smoking came in
emergency : ABC 32 mmol/L

Arterial blood gases shows: SBC 26 mmol/L

pH 7.36 z INTERPRETATION – BE + 0 mmol/L

PaCO2 60 mm of Hg z pH low – Acidosis

z pH & PCO2 moving in opposite direction Resp
ABC 32 mmol/L Acidosis (Rule 3)
SBC 26.0 mmol/L z Acute or Chronic
BE + 0 mmol/L z 20 x 0.1 = 2 mmol
z 20 x 0.4 = 8 mmol (seen)
INTERPRETATION - z Chronic Resp Acidosis

Q. A 18 years old girl was admitted in the hospital pH 7.5

after an argument with her boy friend. She Q.

PaCO2 26 mm of Hg
denied taking any medication. On examination
ABC 21 mmol/L
chest clear, respiratory rate 34 / mt. Blood gas
estimation shows : SBC 23 mmol/L

pH 7.5 z INTERPRETATION – BE -1 mmol/L

PaCO2 26 mm of Hg z pH high – Alkalemia

z pH & PaCO2 moving in opposite direction
ABC 20 mmol/L
z ∆ Resp Alkalemia (Rule 3)
SBC 23.0 mmol/L z Acute or Chronic ?
BE -1 mmol/L z Acute 0.2 mmol x 14 = 2.8
INTERPRETATION - z Chronic 0.5 mmol x 14 = 7
z ∆ Acute Resp Alkalaemia

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 pH 7.52
Q. A 52 years old man brought in emergency Q.
with history of cough and pleuritic chest pain for PaCO2 14.0 mm of Hg
few days increasingly becoming breathless: ABC 11 mmol/L

Arterial blood gases shows: SBC 14.0 mmol/L

z INTERPRETATION –
pH 7.52 BE +0.0 mmol/L
z pH high – Alkalaemia
PaCO2 14.0 mm of Hg z Both pH & PaCO2 moving in opposite direction
ABC 11 mmol/L z ∆ Resp Alkalaemia (Rule 3)
z Acute or Chronic ?
SBC 14.0 mmol/L
z Acute 26 x 0.2 = 5.2 mmol ↓
BE +0.0 mmol/L
z Chronic 26 x 0.5 = 13 mmol ↓
z ∆ Chronic Resp Alkalaemia
INTERPRETATION -

Q. A 40 years old woman who had taken Q. pH 6.84

overdose of Dothiepin (a tricyclic antidepressant) PaCO2 56.5 mm of Hg
2 hrs previously. She was unconscious with a
shallow breathing RR 8/mt: ABC 6.5 mmol/L

SBC 6.2 mmol/L

Arterial blood gases shows: z INTERPRETATION –
pH 6.84 z pH low – Acidaemia BE -29 mmol/L

z pH & PCO2 moving in opposite direction

PaCO2 56.5 mm of Hg
z ∆ Resp Acidaemia (Rule 3)
ABC 6.5 mmol/L z ? Acute 16 x 0.1 mmol = 1.6 mmol ↑
SBC 6.2 mmol/L z ? Chronic 16 x 0.4 mmol = 6.4 mmol ↑ (No
metabolic compensation) (Rule 4)
BE -29 mmol/L z Acute Resp Acidaemia with severe metabolic
acidaemia
INTERPRETATION -

Q. The normal expected alveolar and arterial

blood gradient of oxygen :
PAO2 = PIO2 – (PaCO2/ RQ)
•PAO2 – FIO2 (PB- PH2O) – PaCO2/ RQ
= 0.21 (760-47) – 40/0.8
= 100 mm of Hg
Gradient = 100-90 = 10 mm of Hg
Gradient varies from 4-38 mm of Hg depending on
Age of the patient (20-80 years)
Or
•A gradient of > 75 mm of Hg between inspired and
PaO2 shows the deficit of oxygen uptake