CARDIO | Respiratory Zone Notes Bicarbonate (HCO3)

• measures the amount of a form of carbon dioxide known

ABG
as bicarbonate or bicarb that is in the blood normally
• arterial blood gas bicarb is transported into your lungs through your blood
• is a test that measures the blood levels of oxygen and and then is eliminated upon exhalation in the form of
carbon dioxide as well as the levels of acid-base in the carbon dioxide
body

ABG test
• used to check how well the lungs are moving oxygen into
different body parts
• how efficiently they are able to eliminate carbon dioxide
• healthy lungs move oxygen into the blood and push Oxygen Saturation (SpO2)
carbon dioxide out efficiently during inhalation and • measures the degree to which the haemoglobin
exhalation—gas exchange—with this process the body contained in your red blood cells is saturated with oxygen
receives energy while making sure to eliminate waste
• If the patient has breathing problems or a disease that
affects their lung function—ABG results can be abnormal

Importance of ABG

• ABG test is routinely used in the diagnosis and monitoring

Normal values normal value
of patients suffering from critical conditions
pH 7.35-7.45 ranges may vary
• this test provides a precise measurement of the levels of
PaO2 75-100mmHg slightly in different
oxygen and carbon dioxide in your body
PaCO2 35-45 mmHg publications
• it can help the doctor determine the patient's lung and
kidney function HCO3 22-26 mEq/L
• in most cases the doctor may order an ABG if the patient SpO2 94-100%
has the following symptoms:
ABG Indications
o breathing difficulties
✓ For the assessment of the patient's response to treatment
o changes in mental status
o nausea and vomiting strategies such as mechanical ventilation
✓ To determine the need for supplemental oxygen
• ABG can help the doctor to:
✓ For the diagnosis of respiratory metabolic and mixed
✓ Assess whether treatment for lung conditions are
acid-base disorders
effective
✓ To monitor the patient's acid-base status
✓ Check the acid-base balances in patients with kidney
disease diabetes and those recovering from drug ✓ For the procurement of a blood sample in emergency
overdoses situations when access to the vein is not possible
✓ Determine the presence of a ruptured blood vessel or ✓ For the quantification of hemoglobin levels
meta like disease
✓ Check for chemical poisoning ABG Contraindications

What are the normal ABG values?  The patient had an abnormal modified Allen test
 The patient had blood clotting problems
pH
 The patient has a local infection or damage at the
• this is used to measure the acidity or basicity of the blood
injection site
in the body
 The patient is on anticoagulation therapy
Partial pressure of oxygen (PaO2)  The patient is taking thrombolytic agents
• refers to the amount of oxygen in arterial blood  The patient has a disease affecting the blood vessels
• shows how efficiently oxygen is transported from the lungs  The patient has arteriaocenous fistulas or vascular grafts
to the blood
Modified Allen test

• assessment of blood flow was originally developed by

Edgar V Allen in 1929 as a non-invasive method of
assessing the patency of a patient's arteries
Partial pressure of carbon dioxide (PaCO2)
• is used to check for collateral circulation of the radial and
• measures how efficiently carbon dioxide is transported to
ulnar arteries in the wrist
the lungs to be removed from the body
Modified Allen tests
• measures the competency and quality of the artery and
should be performed prior to performing an arterial
puncture
• efficiently evaluates the adequacy of blood circulation at
one hand at a time
Proper steps in performing a Modified Allen test
Step 1: Have the patient make a fist.
Step 2: Locate the radial and ulnar arteries. Face the patient
and locate the radial and ulnar arteries.
The radial artery is located on the thumb side of the wrist and
the underside of the forearm, while the ulnar artery is on the
pinky side of the wrist.
Step 3: Grab the patient's hand.
Step 4: Locate the pulse. Place your middle finger on top of the
radial pulse and your pointer finger on the ulnar pulse of the
patient.
Step 5: Apply pressure to both arteries. When the pulses can
be felt apply occlusive pressure to both the ulnar and radial
arteries to temporarily stop blood circulation of the hand. Be
sure to tell the patient to relax his/her hand while doing this.
Step 6: Have the patient open their hand. This is done to check
whether the palm and fingers have blanched.
Blanching means that you have completely occluded the
radial and ulnar arteries with your fingers, the hand should
have a whitish appearance in color.
Step 7: Slowly release the pressure on the ulnar artery. You can
release pressure on the ulnar artery while keeping the radial
artery occluded. If the patient's hand flushes meaning that it
turns pink within 5 to 15 seconds this means that the ulnar
artery is patent or has a good blood flow = positive modified
allen test and you can proceed to stick the ABG at this site.
However, if flushing is not observed within five to fifteen
seconds this results suggests that the ulnar artery does not
have collateral circulation = negative modified allen test
In this case it's recommended not to puncture the radial artery
at this site you should either try the modified allen test on the
other hand or move on to the brachial artery
how to stick an ABG?
• an ABG test requires collecting a small sample of blood
from an artery. The sample must be obtained by either the
respiratory therapist doctor or qualified technician.
• before sticking the patient you must determine the best
site for collecting the blood sample
Possible ABG sample sites:
o the radial artery in the wrist
o the brachial artery in the upper arm
o the femoral artery in the groin
o a blood sample can also be obtained in a pre-
existing arterial line
an ABG blood sample cannot be obtained from a vein—vbg or
venous blood gas
once the site is determined the respiratory therapist will then
sterilize the injection site using an antiseptic or antimicrobial
solution
radial artery
• preferred site to stick the ABG
• has a good collateral circulation
• superficial; easy to palpate.
• not near any large veins
The patient will be positioned either:
• lying down
• sitting with the arm well supported
you may use a rolled towel under the patient's wrist for
patient’s comfort and to hyperextend the site of the
injection—this position makes it easier to palpate the pulse
and stick the artery
after the radial artery is located the respiratory therapist will
then insert a sterile needle into the artery to draw blood
in some cases the syringe needs to be repositioned in order to
locate and puncture the artery when doing this:
• withdraw the tip of the syringe to the subcutaneous tissue
to prevent severing the artery or tendons and avoiding
damage to the nearby tissues
it's also extremely painful for the patient if you're digging
around in their wrists with the needle while trying to hit the
artery
once the blood sample is obtained a sterile gauze and
bandage will be placed over the punctured wound in order to
stop bleeding and avoid infection
The blood sample will immediately be sent to the laboratory
for analysis
The specimen must be analyzed within 15 minutes after
extraction in order to ensure accurate ABG results are
obtained
it is important to keep in mind that an ABG stick may be
difficult to perform in:
o uncooperative patients
o those with hard-to-find pulses
o patients with cognitive impairment
o patients with tremors
o those with a significant amount of body fat
in some cases multiple attempts are needed in order to draw
the sample however repeated puncture of a single site
increases the prevalence of a hematoma which is swelling of
clotted blood within the tissue and also scarring
in severe cases it can also cut the artery and cause a
significant amount of bleeding so you may need to use an
alternate site in order to draw the blood sample if too many
unsuccessful attempts are made in the same spot
what are the potential errors when running an ABG?
there are several factors that can affect the results of an ABG
test:
• drawing the blood sample from the incorrect patient. This
can significantly alter the course of treatment of a critical
patient this can be caused by posting the ABG results on
the incorrect patient record or mislabeling the blood
sample
• Obtaining a blood sample from a vein instead of an artery.
acid-base balance involves maintaining adequate levels of
In some cases, inexperienced healthcare providers might
acids and bases in the blood and body tissues which is
stick the vein instead of the artery. In this case, the sample
measured by the: ph scale
will be filled with venous blood instead of arterial blood
which will show vastly different results. ph scale
• ranges from 0 (very acidic) to 14 (very alkaline)
• Blood clotting. It is highly recommended to analyze the
blood sample 10 minutes after extraction in order to avoid blood in the human body
clotting analyzing a blood sample that has already
• typically slightly more alkaline than acidic
clotted will yield inaccurate results and will basically
• normal ph ranges from 7.35 to 7.45
render the specimen useless
• goal of the body: to maintain the blood ph as close to 7.40
• Obtaining a blood sample on incorrect settings or support.
How is acid-base analysis performed?
This can significantly affect the course of the treatment of
the patient and the medical teams assessment of the an acid-base analysis can be performed by:
patient's needs. For instance if a blood sample was • looking at the results of an arterial blood gas or abg—it's a
obtained when the patient is still on supplemental oxygen test that measures the:
instead of room air the results can be misleading and can
o blood levels of oxygen ( PaO2)
yield falsely elevated PaO2 levels
o carbon dioxide (PaCO2)
• Air contamination of the blood sample. Air contamination o bicarbonate (HCO3)
can alter the results of an ABG sample by causing the o acid-base balance in the body
measured PaO2 to read inaccurately.
a sample of blood is collected from a syringe and the results
• Contamination caused by too much heparin. Too much are used to assess how well oxygen is being distributed
liquid heparin dilutes the blood sample and causes throughout the body.
changes in pH levels and can significantly affect the
it also looks at how well carbon dioxide is being removed
oxygen and carbon dioxide values
ABG interpretation
• Inappropriate mixing of the blood sample. Depending on
hospital or laboratory protocols health care providers • helps with the assessment of the patient's acid-base
thoroughly mix the blood sample with heparin balance
immediately upon collection in order to avoid clotting. It's if the ph is outside of the normal range the patient may
also remixed for it goes into the analyzer the best way to require other interventions such as:
mix the sample is to roll it between your palms the most
o oxygen therapy
common error that healthcare providers commit when
o mechanical ventilation
mixing the blood sample is vigorously shaking the vial or
container another error is not mixing iced samples for a acid-base normal values:
long enough amount of time it is recommended to mix ice pH
samples longer in order to promote mobilization and • refers to the acid-base balance of the blood
mixing of all the components of the blood sample
PaO2
• Prolonged delays in blood sample analysis. the blood • the partial pressure of oxygen
sample must be sent to the laboratory for analysis no • refers to the amount of oxygen in arterial blood
longer than 10 to 15 minutes after the blood was drawn
PaCO2
any delay in blood sample analysis causes changes in the
• partial pressure of carbon dioxide
pao2 and paco2 levels due to continuous red blood cell
• refers to the amount of carbon dioxide in arterial
metabolism
blood
Acid-Base Balance | Acidosis vs Alkalosis HCO3
Acid-base balance • bicarbonate
• refers to the total amount of co2 that is transported
• is the process by which the body maintains a proper
in the blood
acid-base equilibrium
SpO2
• refers to the degree of acidity and alkalinity in the body
• oxygen saturation
For our organs and systems to function properly: • refers to the amount of hemoglobin in the blood that
is saturated with oxygen
− the body must maintain acid-base homeostasis by
regulating the levels of acids and bases in the blood and Normal values the human body strives to regulate
tissues—the body does this through several mechanisms pH 7.35-7.45 the amount of carbon dioxide and
including: PaO2 75-100mmHg bicarbonate in the blood in order to
o respiration PaCO2 35-45 mmHg keep the ph within the normal
o excretion range
HCO3 22-26 mEq/L
o buffer systems
SpO2 94-100%
how is blood ph regulated?

our blood ph is regulated by the:

• lungs
- help with ventilation and oxygenation
- provide the blood with oxygen during inhalation
- removing carbon dioxide during exhalation
• kidneys
- help to regulate blood ph by excreting acids or
bases in order to maintain a proper balance
• buffer systems
- guarding against sudden swings in acidity and
alkalinity

acid-base disorders

2 types of abnormalities when it comes to maintaining acid-

base balance:

o acidosis
- blood has either too much acid
- blood has no enough basis
- results in a decreased ph
o alkalosis
- blood has too many bases
- blood has no enough acids
- results in an increased ph

2 types of acid-base disorders:

• respiratory
o respiratory acidosis or alkalosis occurs when the
lungs are removing too much or too little carbon
dioxide due to a condition of the lungs
• metabolic
o Metabolic acidosis or alkalosis occurs when there is
an imbalance in the production of acids or bases that
results from a lack of excretion by the kidneys

the steps for analyzing acid-base balance:

Step 1: collect and analyze an abg sample

Step 2: determine if the ph is alkalotic or acidotic
Step 3: determine if the issue is respiratory/metabolic related
Step 4: determine if it's compensated or uncompensated and
Step 5: perform the treatment modalities recommended by
the physician

Normal values PO2 ↑

pH 7.35-7.45 = hyperoxemia
PaO2 75-100mmHg
PaCO2 35-45 mmHg PO2 ↓
HCO3 22-26 mEq/L = hypoxemia

SpO2 94-100%
pH PaCO2 HCO3
Respiratory Acidosis ↓ ↑ Normal
Respiratory Alkalosis ↑ ↓ Normal
Metabolic Acidosis ↓ Normal ↓
Metabolic Alkalosis ↑ Normal ↑