ARE VENOUS AND ARTERIAL BLOOD GAS ANALYSIS

INTERCHANGEABLE IN ED ASSESSMENT OF ACUTE

RESPIRATORY DISEASE?

Anne-Maree Kelly
Professor and Director
Joseph Epstein Centre for Emergency Medicine
Research @Western Health
@kellyam_jec
Conflicts of interest

 I received financial support for travel and accommodation from Radiometer Pty
Ltd to present a similar presentation at 4thInternational Symposium on Blood Gas
and Critical Care in France in 2008.

 I am undertaking some research with A/Prof Rees into calculated values which
may be commercialised. I have no pecuniary interest in this program.

 I have not received industry funding for any of my blood gas research projects.
Objectives

 After this presentation, participants will:

 Understand the agreement performance of variables
on arterial and venous blood gas analysis, in particular
 pH
 pCO2

 Be aware of new approaches being taken to improve

accuracy of prediction of arterial values from venous
blood gas samples
Caveats

 Discussion will be limited to comparisons between

arterial and peripheral venous samples
 Not arterial vs central venous/ mixed venous, etc
Why venous rather than arterial?

 Less pain for patients

 Fewer complications, especially vascular and infection
 Fewer needle-stick injuries
 Easier blood draw
 Minimal training requirements
 Key questions in acute respiratory
disease

 Is my patient hypoxic?

 Does this patient have respiratory failure?

 Is this patient a CO2 retainer?

 Do I need to provide additional ventilatory support?

 Is my treatment working?
Is my patient hypoxic?

 VBG no good for this.

 In patients withadequate perfusion, pulse

oximetry isaccurate

 If the picture doesn’t add up, do an ABG

Can venous blood gas answer the question?

Using a venous blood gas, can I answer the question Yes/No/Sometimes

Does this patient have respiratory failure?

Is this patient a CO2 retainer?
Do I need to provide additional ventilatory support?
Is my treatment working?

In groups of 2-3, try to answer the questions if necessary

putting caveats/ conditions on your answer. (You have 2
minutes)
Statistical considerations

Venous value
 Outcome of interest is how closely
venous and arterial values agree, not
how well they correlate
 Weighted mean difference gives an
estimate of the accuracy between
the methods
 95% limits of agreement give
information about precision
Arterial value

95% LoA
Clinical considerations
 There is limited data about the tolerance clinicians have
with respect to agreement between arterial and venous
values of blood gas parameters

 Depending on this tolerance, the degree of agreement

may be acceptable or unacceptable
 Known variation between clinicians rethis

 Not known how tolerance of emergency physicians

compares to respiratory physicians or ICU specialists
Issues with the evidence

 Patient cohorts highlyvaried

 Patient groups of real interest are those at
high risk of acidosis or hypercarbia
 Reporting does not always report this detail
 Data may to be dominated by patients with
normalpH, pCO2and blood pressure
 Need for moreworkin high riskpatientgroups
 Does he have acute respiratoryacidosis?

VBG

 pH=7.26
•64 year old man
•Infective
exacerbation COAD
 pCO2=66mmHg
Does this patient have respiratory
failure?
 Interested in pH and pCO2(and HCO3)
 pH
 5 studies (643 patients)
 Weighted mean difference= 0.034 pH units
 95% limits of agreement generally +/- 0.1

 pCO2
 4 studies (452patients)
 Weighted man difference = 7.26 mmHg
 95% limits of agreement: up to -14 to +26mmHg
 All 3 studies reporting LoA report LoA band >20mmHg
HCO3 in respiratory disease

 2 studies (643patients)
 Weighted mean difference - -1.34mmmol/l
 No data re 95% limits of agreement

Interpret with caution!

 Does he have acute respiratoryacidosis?

VBG ABG

 pH=7.26  pH=7.30

 pCO2=66mmHg  pCO2=58mmHg

YES
 Is this patient a CO2 retainer?

VBG
•58 year old man
 pH=7.35
•Long smoking
history
 pCO2=45mmHg
•Chest infection
Venous pCO2: A screening test for hypercarbia?

Author, year No. Screeni Sens. Spec. NPV %ABG

ng cut- avoided
off
Kelly, 2002 196 45 100 57 100 43
Kelly, 2005 107 45 100 47 100 29
Ak, 2006 132 45 100 * 100 33
McCann 94 45 100 34 100 23
y, 2011
POOLED 529 45 100 53 100 35%
DATA (95% CI 97- (95% CI (95% CI (95% CI
100) 57-58) 97-100) 32-41)

Data limited to studies in cohorts with respiratory disease

 Is this patient a CO2 retainer?

VBG ABG

 pH=7.35  pH=7.42

 pCO2=45mmHg  pCO2=39mmHg

NO
 Do I ne d to provide additional
ventilatory support?

VBG

 pH=7.4 •40 year old female

•Exacerbation of
 pCO2=50mmHg asthma
 Do I ne d to provide additional
ventilatory support?

VBG ABG

 pH=7.4  pH=7.44

 pCO2=50mmHg  pCO2=56mmHg

?
 Blood gas are only part of thepuz le

 Pulse rate 125

 Respiratory rate 40
 Extreme accessory muscle use
 Looks tired

 What do you thinknow?

 Is my treatment working?

VBG

 Time 1 •75 year old man

 pH=7.16 •Mixed COAD/
 pCO2=83mmHg CHF
•On NIV
 Time 2
 pH=7.28
 pCO2=62mmHg
 Is my treatment working?

VBG ABG

 Time 1  Time 1
 pH=7.16  pH=7.23
 pCO2=83mmHg  pCO2=61

 Time 2  Time 2
 pH=7.28  pH = 7.3
 pCO2=62mmHg  pCO2=53mmHg
Monitoring trend
pCO2:
Average difference:0.4
LoA -17.3 to 18.2

pH:
Average difference:0.001
LoA -0.07 to +0.07

pH agreement is good; pCO2 direction same but magnitude varies

Can venous blood gas answer the question?

Using a venous blood gas, can I answer the question Yes/No/Sometimes

Does this patient have respiratory failure?

Is this patient a CO2 retainer?
Do I need to provide additional ventilatory support?
Is my treatment working?

What do you think now?

Mixed acid-basedisorders
 No attempt (yet) to determine if VBG can
accurately classify mixeddisorders

 Apply calculations to assess this withcaution

as is evidence-free zone!
Another approach
 Team from Center for Model Based Medical Decision
Support Systems, Dept of Health Science and
Technology, Aalborg University, Denmark (A/Prof
Steven Rees)
 Developed venous to arterial conversion method using
venous blood gas variables and pulse oximetry
 Designed to be incorporated into blood gas analysers
 The model
 The method calculates arterial values
using mathematical models to
simulate the transport of venous
blood back through the tissues until
simulated arterial oxygenation
matches that measured by
 Constant value of the respiratory
quotient of0.82
 Change in base excess from arterial
to venous blood is 0 mmol/l

Rees SE, Toftegaard M, Andreassen S. A method for calculation of arterial acid–base and blood gas status from measurements in the peripheral venous
blood. Comp Methods Programs Biomed. 2006, Vol 81, 18-25.
Validations
 Respiratory patients
 N=40 (55% acute
admissions)
 Arterial-calculated pH
difference = -0.001pH units
(95% LoA -0.026 to
+0.026)
 Arterial-calculated pCO2
difference = -0.68mmHg
(95% LoA -4.81 to +3.45
mmHg)
Rees et al. Eur Respir J. 2009
May;33(5):1141-7.
 Respiratory/ICU
 N=103
 Arterial-calculated pH
difference = -0.002pH units
(95% LoA -0.029 to
+0.025)
 Arterial-calculated pCO2
difference = 0.3mmHg
(95% LoA -3.58 to +4.18
mmHg)
Toftegaard et al. Emergency Medicine Journal. 2009
Apr;26(4):268-72
Monitoring over time:Example

pH pCO2

Red=measured arterial
Black dots =calculated arterial
Blue dashes=measured venous Courtesy of SE Rees (unpublished)
Take home messages
 Arteriovenous agreement for pH is good – clinically
interchangeable
 Arteriovenous agreement for pCO2has wide 95% limits
of agreement
 Venous pCO2can be used to screen for arterial
hypercarbia
 The clinical picture is more important than the numbers
 Venous values can probably be used to monitor trend, if
interpreted in conjunction withthe clinical picture
 Limitation: No data on agreement in mixed disease
Questions?