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Brief Communication

Arterial Blood Gas as a Prognostic Indicator in Patients with

Sepsis
Sayan Mukherjee, Suvrajyoti Das, Sudipta Mukherjee1, Pralay Shankar Ghosh1, Sanjay Bhattacharya
Departments of Microbiology and 1Critical Care Medicine, Tata Medical Center, Kolkata, West Bengal, India

Abstract
Abnormal arterial blood gas (ABG) among patients with sepsis is an important prognostic indicator. All‑cause mortality was the highest among
patients with respiratory acidosis (4/9 = 44.4%), followed by those having metabolic acidosis (3/8 = 37.5%). Median length of hospital and
intensive care unit stay was 15.75 days and 6.25 days for those with abnormal ABG and 11 and 3.5 days among those with normal ABG.
Median health‑care expenditure at the time of discharge or death of the patient was the highest in patients with respiratory acidosis ($14,473)
and least in patients with normal ABG ($3,384) (average expenditure among patients with abnormal ABG was [$10,059]).

Keywords: Arterial blood gas, health‑care expenditure, hospital stay, mortality, sepsis

Introduction level >2 mmol/L in the absence of hypovolemia. Definition of

sepsis (used as inclusion criteria) was the third international
Patients with sepsis  (i.e., infection with organ dysfunction)
consensus definitions for sepsis and septic shock; performance
and cardiorespiratory failure are at the risk of metabolic
of at least one ABG in the patient and age >18 years.[2] The
complications, which could be detected through arterial blood
exclusion criteria were: pediatric patients  (≤18  years) and
gas (ABG) analysis.[1] The objective of this study was to
those not fulfilling clinical definition of sepsis as per the
review: (a) the profile of metabolic abnormalities detected by
international criteria. The criteria of taking blood culture
ABG in patients with clinically suspected sepsis, (b) Correlate
were: (a) Axillary temperature ≥38.4°C (101°F), (b) diagnosis
ABG profiles with patient outcomes such as mortality, length
of sepsis and (c) suspected central line associated blood stream
of the hospital stay and length of the intensive care unit (ICU)
infection  (CLABSI) or secondary blood stream infection.
stay, (c) correlate ABG with microbiology of positive blood
Blood culture was taken using BactALERT system from
cultures, (d) correlate ABG with organ failures in sepsis and
Biomerieux, USA. ABG was performed using a GEM Premier
(e) correlate ABG with health‑care cost.
3500 analyzer (Instrumentation Laboratory, Barcelona, Spain).

Materials and Methods Results

The present study was conducted in the ICU, high‑dependency
unit and surgical ward of an oncology hospital in Eastern
India. The study duration was 40 days during the month of
May and June 2019. Patients with sepsis were identified as
those with suspected infection with at least 2 of the following
clinical criteria from a quick sequential organ failure
assessment (qSOFA) scoring system: Respiratory rate of 22/
min or greater, altered mentation or systolic blood pressure of
100 mmHg or less. Patients with septic shock were clinically
identified by a vasopressor requirement to maintain a mean
arterial pressure of 65 mm Hg or greater and serum lactate
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During the study period, 230  patients were admitted to
the ICU, HDU, surgical ward. Thirty‑six patients met
Address for correspondence: Dr. Sanjay Bhattacharya,
Department of Microbiology, Tata Medical Center, 14, Major Arterial Road
(EW), Newtown, Kolkata ‑ 700 160, West Bengal, India.
E‑mail: drsanjay1970@hotmail.com
Received: 17-12-2019 Revised: 01-07-2020 
Accepted: 25-07-2020 Published Online: 04-11-2020
This is an open access journal, and articles are distributed under the terms of the Creative
Commons Attribution‑NonCommercial‑ShareAlike 4.0 License, which allows others to
remix, tweak, and build upon the work non‑commercially, as long as appropriate credit
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For reprints contact: reprints@medknow.com

DOI: How to cite this article: Mukherjee S, Das S, Mukherjee S, Ghosh PS,
10.4103/ijmm.IJMM_19_478 Bhattacharya S. Arterial blood gas as a prognostic indicator in patients with
sepsis. Indian J Med Microbiol 2020;38:457-60.

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Mukherjee, et al.: ABG in sepsis

the inclusion criteria for sepsis  (15.7%)  [Figure  1]. The
median age of the patients (n = 36) was 58.5 years (range:
19–79  years). The male‑to‑female ratio of the study cohort
was 1:1. Thirteen patients had hematological malignancy
and 22 had solid‑organ neoplasm, and one had a benign
disease. Clinical diagnosis of the study patients included five
patients with community‑acquired respiratory tract infection;
four with hospital acquired respiratory tract infection, two
had urosepsis, six had surgical site infection, three patients
had CLABSI, and four had non‑CLABSI. Blood stream
infection included three patients with Escherichia coli
bacteremia (sensitive strain), one patient each with Pseudomonas
aeruginosa, Serratia marcescens and Burkholderia gladioli
bacteraemia (sensitive strain), one patient with Elizabethkingia
meningoseptica bacteraemia  (resistant isolate), and four
cases of Carbapenem‑resistant Klebsiella pneumoniae
bacteraemia (including one colistin‑resistant isolate). One third
of the patients (12/36: 33.3%) were either infected or colonised
with carbapenem‑resistant Enterobacteriaceae/Acinetobacter/
Pseudomonas aeuruginosa  (K. pneumoniae being the most
predominant with 10/36 patients infected or colonised with
this pathogen).
The median number of ABG performed in the study
cohort (n = 36) was 5.5 (range: 1–29; interquartile range [IQR]:
2.75–10.5). There were 78 instances of organ failures observed
in the study cohort. This included 26  (33.3%) instances of
circulatory failure, 22 respiratory failure (28.2%), 19 instances
of renal failure (24.4%) and 11 hepatic failure (14.1%). The
length of hospital stay of the study patients was between 5 and
57 days (IQR: 9–21.5). The median length of ICU stay was
5 days (IQR: 3–7.25). The all‑cause 30‑day mortality of the
total study cohort (n = 36) was 7/36 (19.4%) [Table 1]. The
30‑day all‑cause mortality in patients not included in the study
cohort (n = 194) during the same period was 5/194 (2.6%).
Discussion
ABG is an important investigation providing information about
blood pH (normal value 7.35–7.45), partial pressure of oxygen
(PaO2) and carbon dioxide (normal value PaO2: 75–100 mm Hg,
PaCO2: 35–45 mm Hg), bicarbonate (HCO3) (normal value:
HCO3: 22–26 mEq/L), lactate (normal value: 0.5–2 mEq/L),
base excess (normal value −2 to +2 mEq/L), and haemoglobin
or haematocrit.[3] In a Swedish study, it was reported that
the presence of metabolic alkalosis was independently
associated with an increased ICU length of stay.[4] A study
from India reported metabolic acidosis to be associated with
higher mortality in the ICU.[5] In an Australian study, blood
lactate was found to be the strongest predictor for mortality
in the multivariate analysis.[6] However, ABG as a test is not
readily available in many centres, especially in low‑  and
middle‑income countries, either due to resource constraints
or inadequacy of appropriately trained and qualified medical
personnel to perform and interpret the test. In our setting, the
average cost of an ABG was Rs. 895 INR ($13 USD).
The ABG report not only helps in classifying patients based on
metabolic abnormalities but also helps in clinical monitoring;
decide on specific interventions such as intubation, intravenous
fluid infusion, vasopressor administration or hemodialysis.
Management of sepsis requires a bundle of interventions
which includes taking blood cultures, administration of
antibiotics/intravenous fluid/oxygen and testing for blood
lactate. Although blood lactate is usually estimated by
performing an ABG, ABG per se is not part of the surviving

Figure 1: Consort diagram and the profile of the patients with sepsis. Note: Thirty-six patients >18 years of age met the inclusion criteria for sepsis

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Mukherjee, et al.: ABG in sepsis

Table 1: Arterial blood gas profile and clinical outcomes of sepsis patients according to the arterial blood gas performed
at the time of intensive care unit admission
n Mortality Hospital stay ICU stay Blood culture positivity Organ failure Healthcare expenditure: INR (USD)
Metabolic 8 3 Median: 14.5 Median: 3.5 2 Circulatory: 7 Median: rs. 537,074 ($7837)
acidosis Minimum: 8 Minimum: 1 Respiratory: 5 Minimum: 133,398 ($ 1947)
Maximum: 44 Maximum: 14 Renal: 5 Maximum: 1,631,147 ($23,802)
Hepatic: 3
Metabolic 1 0 Median: 29 Median: 9 0 Circulatory: 0 Median: 841,533 ($ 12,280)
alkalosis Minimum: 29 Minimum: 9 Respiratory: 1 Minimum: 841,533 ($ 12,280)
Maximum: 29 Maximum: 9 Renal: 1 Maximum: 841,533 ($ 12,280)
Hepatic: 0
Respiratory 9 4 Median: 17 Median: 13 6 Circulatory: 8 Median: 991,821 ($ 14,473)
acidosis Minimum: 5 Minimum: 5 Respiratory: 8 Minimum: 104,988 ($ 1532)
Maximum: 57 Maximum: 19 Renal: 7 Maximum: 1,894,031 ($ 27,638)
Hepatic: 5
Respiratory 10 0 Median: 12.5 Median: 3 3 Circulatory: 8 Median: 396,553 ($ 5787)
alkalosis Minimum: 6 Minimum: 2 Respiratory: 5 Minimum: 116,135 ($ 1695)
Maximum: 42 Maximum: 6 Renal: 5 Maximum: 890,188 ($ 12,990)
Hepatic: 2
Normal 8 0 Median: 11 Median: 3.5 0 Circulatory: 3 Median: 231,914 ($ 3384)
ABG Minimum: 7 Minimum: 0 Respiratory: 3 Minimum: 130,100 ($ 1898)
Maximum: 13 Maximum: 6 Renal: 1 Maximum: 667,545 ($ 9741)
Hepatic: 1
INR: Indian rupees; USD: United states dollars, ICU: Intensive care unit, ABG: Arterial blood gas

sepsis care bundles. However, the results of ABG are often a
major determinant with regard to specific interventions and
identifying possible source of the clinical problem. In our study,
we found blood lactate to be elevated at presentation to the ICU
in 24 patients (24/36 = 67%). Respiratory alkalosis was found
to be the most common ABG abnormality, and Gram‑negative
blood stream infection was the most common cause of sepsis.
In our study, respiratory acidosis was found to be the most
severe ABG abnormality in terms ICU stay, health‑care cost,
blood culture positivity and all‑cause mortality rate.
ABG is required for:  (a) To detect tissue hypoperfusion
which is defined as lactate concentration ≥4 mmol/L; (b) To
measure blood lactate concentration and targeting resuscitation
to normalise lactate;  (c) To detect acidosis or academia
resulting from tissue hypoperfusion academia for which fluids,
vasopressor, HCO3 therapy may be required; (d) To measure
hypoxemia and detect severe refractory hypoxemia which may
need mechanical ventilation  (MV); and  (e) Monitor HCO3
level in pH imbalance and HCO3 therapy. Other causes of
abnormal ABG were clinically excluded using history, physical
examination and other investigations (electrocardiogram and
echocardiography for the heart, chest X‑ray or computed
tomography scan changes for the chest, etc.).
Quick SOFA is a clinical scoring system based on the
measurement of blood pressure, respiratory rate and
sensorium. ABG analysis gives a more detailed result about
metabolic and respiratory parameters of a patient qSOFA.
In a study from Australia, SOFA demonstrated significantly
greater discrimination for in‑hospital mortality  (crude area
under the receiver operator characteristic [AUROC], 0.753)
than systemic inflammatory response syndrome criteria (crude
AUROC, 0.589) or qSOFA  (crude AUROC, 0.607).[7] In a
study from Brazil, the relative risk of death, ICU, and MV
need related to qSOFA at admission were 1.83, 0.98 and
1.60, respectively, and its sensitivity was 56.8% for death,
41.4% for ICU need and 53.6% for MV.[8] In another study
from Switzerland, the sensitivity of qSOFA was reported to
be 31.2% for ICU admission, 30.5% for ICU stay of ≥3 days
and 60.0% for mortality at 48 h.[9] Because of the limitations
of the clinical scoring systems such as SOFA and qSOFA and
the need of metabolic parameter data for clinical management,
ABG analysis has become the standard of care in septic
patients.[10]
Conclusion
In conclusion, this small pilot study indicates the value of
ABG as a cost effective and rapid  (~5  min from sample
collection to reporting) diagnostic, monitoring and prognostic
tool in the clinical management of patients with sepsis. In
resource‑constrained settings, it is an important clinical
investigation worth considering for installation at all levels
of health care which manages patients with sepsis, since it
requires significantly less infrastructure  (space, manpower,
consumables and overheads) and provides rapid results
enabling lifesaving supportive care.
Acknowledgments
This study was conducted as part of the Molecular Medical
Microbiology integrated MSc‑PhD Program which Tata
Medical Center and Indian Institute of Technology, Kharagpur
are jointly conducting.

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Mukherjee, et al.: ABG in sepsis

Financial support and sponsorship
Nil.
Conflicts of interest
There are no conflicts of interest.
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