ABG INTERPRETATION

Adam Cooper, RN, MSN Nursing Education

Objectives
Whats an ABG? Understanding Acid/Base Relationship General approach to ABG Interpretation Clinical causes Abnormal ABGs Case studies

What is an ABG
Arterial Blood Gas Drawn from artery- radial, brachial, femoral It is an invasive procedure. Caution must be taken with patient on anticoagulants. Helps differentiate oxygen deficiencies from primary ventilatory deficiencies from primary metabolic acidbase abnormalities

Pulmonary System Basics

Purpose: O2 and CO2 gas exchange Exchanged between:
Atmosphere and the alveoli Alveoli and pulmonary blood Systemic blood and all body cells

CO2 is a by-product of aerobic metabolism

Eliminated through ventilation

Bio-Chem Review
Acid: substance that donates H+
Constantly produced from metabolism of carbs, fats, glucose, and protein

Base: substance that accepts H+

Able to combine with free H+ to prevent the H+ concentration from getting to high

What Is an ABG?
pH [H+]

PCO2 Partial pressure CO2 PO2 Partial pressure O2

HCO3 Bicarbonate BE SaO2 Base excess Oxygen Saturation

Acid/Base Relationship
This relationship is critical for homeostasis Significant deviations from normal pH ranges are poorly tolerated and may be life threatening Achieved by Respiratory and Renal systems

Buffers
There are two buffers that work in pairs H2CO3 Carbonic acid NaHCO3 base bicarbonate

These buffers are linked to the respiratory and renal compensatory system Able to change pH by taking up or releasing H+

Respiratory Component
Function of the lungs Carbonic acid H2CO3 Approximately 98% normal metabolites are in the form of CO2 CO2 + H2O H2CO3 Excess CO2 exhaled by the lungs

Metabolic Component
Function of the kidneys and GI tract Acid H+ Base bicarbonate Na HCO3 Process of kidneys excreting H+ into the urine and reabsorbing HCO3- into the blood from the renal tubules

Normal ABG values

pH PCO2 PO2 HCO3 BE SaO2 7.35 7.45 35 45 mmHg 80 100 mmHg 22 26 mmol/L -2 +2 >95%

Acidosis
pH PCO2 HCO3 < 7.35 > 45 < 22

Alkalosis
pH PCO2 HCO3 > 7.45 < 35 > 26

Respiratory Acidosis
pH + CO2 Think of CO2 as an acid Failure of the lungs to exhale adequate CO2 pH < 7.35 PCO2 > 45

Causes of Respiratory Acidosis

Emphysema Drug overdose Respiratory arrest Airway obstruction

Tx: Improve Ventilation (hand ventilate/adjust vent)

Metabolic Acidosis
pH + Bicarb 2 main reasons: a. Kidneys inability to excrete H+ b. Loss of HCO3 from GI Mainly failure of kidney function pH < 7.35 HCO3 < 22

Causes of Metabolic Acidosis

Renal failure (excretion problem) Diabetic ketoacidosis ( H+ levels) Lactic acidosis ( H+ levels) Excessive diarrhea (loss of HC03)

TX: Treat underlying cause. Give NaHC03

Respiratory Alkalosis
pH + CO2 Too much CO2 exhaled (hyperventilation) PCO2, H2CO3 insufficiency = pH pH > 7.45 PCO2 < 35

Causes of Respiratory Alkalosis

Hyperventilation Panic d/o Pain Acute anemia Salicylate overdose TX: Treat underlying cause. Slow respiratory rate

Metabolic Alkalosis
pH + Bicarb Kidneys failure to excrete HC03 GI r/t loss of gastric secretions (HCL) plasma bicarbonate pH > 7.45 HCO3 > 26

Causes of Metabolic Alkalosis

V/ and NG suction: ( loss of gastric secretions) Hypokalemia- Diuretics
(K+ causes shift of H+ in the cell)

Excessive alkali intake: Antacid abuse

TX: Treat underlying cause. KCL replacement Antiemetics, PPI (proton pump inhibitors)

How to Analyze an ABG

1. PO2 2. pH NL = 80 100 mmHg NL = 7.35 7.45 Acidotic <7.35 Alkalotic >7.45 NL = 35 45 mmHg Acidotic >45 Alkalotic <35 NL = 22 26 mmol/L Acidotic < 22 Alkalotic > 26

3. PCO2

4. HCO3

Four-step ABG Interpretation

Step 1: OXYGEN Examine PaO2 & SaO2 Determine oxygen status Low PaO2 (<80 mmHg) & SaO2 means hypoxia NL/elevated oxygen means adequate oxygenation

Four-step ABG Interpretation

Step 2: pH pH

acidosis alkalosis

<7.35 >7.45

Four-step ABG Interpretation

Step 3: BUFFERS study PaCO2 & HCO 3 respiratory irregularity if PaCO2 abnl & HCO3 NL metabolic irregularity if HCO3 abnl & PaCO2 NL

Four-step ABG Interpretation

Step 4: COMPENSATION Determine if there is a compensatory mechanism working to try to correct the pH. 7.35-7.39 = acidosis is the primary problem 7.41-7.45 = alkalosis is the primary problem For Example: If pt has primary respiratory acidosis they will have increased PaCO2 and decreased pH. Compensation occurs when the kidneys retain HCO3.

R.O.M.E.
Respiratory Opposite Metabolic Equal

Look at pH & CO2/HCO3

Base Excess
Amount of acid or base that needs to be added to 1 liter of arterial blood to get pH 7.4 (to normalize) HCO3: the lower the HCO3 level the more negative the base deficit. Normal: -2 +2 (-) means base deficit (metabolic acidosis) (+) means base excess (metabolic alkalosis)

Anion Gap
Measurement of the difference between Na+ (cation) and HCO 3 & Cl (anions) Allows us to narrow down the possible causes of a patients metabolic acidosis Normal: 8-12
Loss of HCO3 but replaced by Cl so Cl-, or renal tubular necrosis

High AG (>12): in acid production

Lactic acid, DKA, ETOH

Respiratory Acidosis
pH PaCO2 HCO3 7.30 60 26

Respiratory Alkalosis
pH PaCO2 HCO3 7.50 30 22

Metabolic Acidosis
pH PaCO2 HCO3 7.30 40 15

Metabolic Alkalosis
pH PCO2 HCO3 7.50 40 30

What are the compensations?

Respiratory acidosis Respiratory alkalosis metabolic alkalosis metabolic acidosis

In respiratory conditions, therefore, the kidneys will attempt to compensate and vise versa. In chronic respiratory acidosis (COPD) the kidneys increase the elimination of H+ and absorb more HCO3. The ABG will Show NL pH, CO2 and HCO3. Buffers kick in within minutes. Respiratory compensation is rapid and starts within minutes and complete within 24 hours. Kidney compensation takes hours and up to 5 days.

Drawing an ABG
A-Line
50-80% have arterial-lines Most post-op patients Difficult sticks and frequent lab draws Different syringe Waste 2-3ml Label and fill out rec No ice, tube to 15th floor lab

Drawing an ABG
Manually
Assess collateral circulation Only perform radial artery Dorsiflex wrist (small towel) Where pulse is the strongest 30-60 angle (not > 45) Automatically fills to pre-set volume (1-3mL) Pressure for 5 min or bleeding stops Expel air out of syringe through cap

Take Home Message:

Valuable information can be gained from an ABG as to the patients physiologic condition Remember that ABG analysis if only part of the patient assessment. Be systematic with your analysis, start with ABCs as always and look for hypoxia (which you can usually treat quickly), then follow the four steps. A quick assessment of patient oxygenation can be achieved with a pulse oximeter which measures SaO2.

Any Questions?

Practice ABGs
1. PaO2 2. PaO2 3. PaO2 4. PaO2 5. PaO2 6. PaO2 7. PaO2 8. PaO2 9. PaO2 10. PaO2 90 60 95 87 94 62 93 95 65 110 SaO2 95 SaO2 90 SaO2 100 SaO2 94 SaO2 99 SaO2 91 SaO2 97 SaO2 99 SaO2 89 SaO2 100 pH 7.48 pH 7.32 pH 7.30 pH 7.38 pH 7.49 pH 7.35 pH 7.45 pH 7.31 pH 7.30 pH 7.48 PaCO2 32 PaCO2 48 PaCO2 40 PaCO2 48 PaCO2 40 PaCO2 48 PaCO2 47 PaCO2 38 PaCO2 50 PaCO2 40 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 24 25 18 28 30 27 29 15 24 30

Answers to Practice ABGs

1. Respiratory alkalosis 2. Respiratory acidosis 3. Metabolic acidosis 4. Compensated Respiratory acidosis 5. Metabolic alkalosis 6. Compensated Respiratory acidosis 7. Compensated Metabolic alkalosis 8. Metabolic acidosis 9. Respiratory acidosis 10. Metabolic alkalosis