Blood Gases (ABGs)

Interpretation
Dr/Baha Eldin Hassan Ahmed
Fellow Paediatric critical care
Interpreting an arterial blood gas (ABG) is a crucial skill
for physicians, nurses, respiratory therapists, and other
health care personnel. ABG interpretation is especially
. important in critically ill patients
Blood gas and pH analysis has more immediacy and“
potential impact on patient care than any other
.”laboratory determination

National Committee for Clinical Laboratory Standards

(NCCLS)
OUTLINE
Review pre-analytical ABG issues and( 1
.consequences of improper technique
Use case studies to highlight some key clinical( 2
.concepts
Explore appropriate clinical ABG targets in( 3
.different clinical scenarios
Pre-analytical errors
Status of the patient Type of sample
Sample container ABG–
Plastic– CBG–
Glass– Storage and transport
Anticoagulant metabolism and–
Sample collection leakage
Who– Remixing
Where–
Before you take the
blood gas, patient should
:be
In a stable ventilatory–
.conditon
At rest for minimum of 15–
.minutes
supplemental oxygen– +
.minutes 30
Types of samples
ARTERIAL BLOOD GAS/1
used to assess oxgenation(pao2) ventilation (v) acid
.base balance(PH and HOC3)
VENOUS BLOOD GAS/2
Strongly affected by local circulatory and metabolic
.enviroment. Used to assess acid base balance
Pvco2 average 6 to 8mmHg higher than Paco2 and PH is
.slightly lower
CAPILLARY BLOOD GAS/3
correlation CBG with ABG is best for ph, moderate for
.Pco2 and worst for Po2
 Normal Arterial Blood Gas Values*

7.35 - 7.45 pH
35 - 45 mm Hg PaCO2
**70 - 100 mm Hg PaO2
93 - 98% SaO2
22 - 26 mEq/L HCO3¯
< 2.0% MetHb%
< 3.0% COHb%
-2.0 to 2.0 mEq/L Base excess
16 - 22 ml O2/dl CaO2

At sea level, breathing ambient air*

Age-dependent**
Causes of Acidosis
Respiratory Metabolic
Hypoventilation  Ketoacidosis 
Impaired gas exchange  Diabetes 
Renal Tubular Acidosis 
Renal Failure 
Lactic Acidosis 
Decreased perfusion 
Severe hypoxemia 
Causes of Alkalosis
Respiratory Metabolic
Hyperventilation due  Hypokalemia 
:to
Hypoxemia  Gastric suction or 
Metabolic acidosis  vomiting
Neurologic 
Lesions 
Hypochloremia 
Trauma 

Infection 
Interpretation Guidelines

. Step 1: Look at pH - this is the starting point 

If within normal range, a normal or 
compensated state exists. If outside normal
limits, assess whether acidosis or alkalosis is
present. The body never overcompensates.
Whichever state exists on the pH scale is the
primary abnormality
 Step 1: Assess the internal consistency of the
values using the Henderseon-Hasselbach
:equation
24(PaCO2)+[ = H]
[HCO3-]
If the pH and the [H+] are inconsistent, the ABG is
probably not valid
pH is inversely related to [H+]; a pH change of 1.00
represents a 10-fold change in [H+]
[H+] in nanomoles/L pH

100 7.00
80 7.10
50 7.30
40 7.40
30 7.52
20 7.70
10 8.00
. Step 2: Assess hypoxemic state
If PaO2 is <60 mmHg, hypoxic state exists. If PaO2 is
between 80 -100 mmHg, a normal condition exists.
. If PaO2 is >100 mmHg, a hyperoxic state exists
!Useful Tips
FiO 2: Measured Normal Range
21%
PaO2 16.1kPa 11.3 – 14.0

PaCO 1.3kPa 4.5 – 6.1

For a patient on air, with normal lungs,

PaO2 + PaCO2 =
approx 17kPa
Physiologically difficult to get PaCO2
<1kPa, therefore
values of PaO2 >16kPa indicate that
patient probably
receiving supplemental O2
. Step 3: Assess ventilatory status
If PaCO2 is <35 mmHg, it is termed "alkalosis"
(alveolar hyperventilation or hypocarbia). If
PaCO2 is between 35-45 mmHg, it is within
normal limits. If PaCO2 is >45 mmHg, it is
termed "acidosis" (ventilatory failure or
hypercarbia). If possible, determine whether this
. is an acute or chronic state
. Step 4: Assess metabolic component.
If bicarbonate (HCO3-) is <22 mEq/l, it is termed. 1
". "acidosis
If bicarbonate is between 22-28 mEq/l, it is within. 2
. normal limits
If bicarbonate is >28 mEq/l, it is termed. 3
". "alkalosis
If possible, determine whether this is an acute or. 4
chronic state
 Determination of primary acid-base disorders

Respiratory Metabolic
7.6 alkalosis alkalsosis

7.4
pH

7.2 Metabolic Respiratory

acidosis acidosis

30 40 50
PCO2 (mmHg)
Acute ventilatory failure (acute respiratory
acidosis)

Classification
pH v 
^ PaCO2 
HCO3-N 
Acute Respiratory Alkalosis
.PaCO2 is low and thus pH is high (alkalotic)
The increase in pH is accounted for entirely by the
.low in PaCO2
HCO3- and base excess will be in the normal range
because the kidneys have not had adequate time to
.establish effective compensatory mechanisms
Chronic alveolar hyperventilation
(compensated respiratory alkalosis
pH ^ N
PaCO2 v
HCO3- v
Acute metabolic acidosis

 pH v
PaCO2 N
HCO3- v
Chronic metabolic acidosis
pH v N
PaCO2 v
HCO3- v
Acute alveolar hyperventilation
(acute respiratory alkalosis
^ pH
^ PaCO2
 HCO3- N
Chronic ventilatory failure (compensated respiratory
acidosis)

pH v N
^ PaCO2
^ HCO3
Metabolic & Respiratory Acidosis
.Acute hypercapnic failure
.Unwell–
.Hypotension–
.Poor peripheral blood flow–
.Metabolise anaerobically – production of lactate
The respiratory & metabolic acidosis lowers
pH,PaCO2 due to alveolar hypoventilation, HCO3-
.is from non-respiratory acidosis
Acute metabolic alkalosis
^ pH
PaCO2 N
- ^ HCO3
Chronic metabolic alkalosis
pH ^ N
^ PaCO2
- ^ HCO3
A/Pure respiratory acidosis or (alkalosis)
mmhg rise(fall) in paco2 result in an 10 
.average 0.08 fall(rise) in PH

B/Pure metabolic acidosis (or alkalosis)

10mEq/l fall (rise) in hco3 result in 
average 0.15 fall (rise) in PH
Compensatory Mechanisms
Respiratory compensation
Complete within 24 hrs
Metabolic compensation
Complete within several days
Both the respiratory or renal compensation almost never
over-compensates
Compensated or Uncompensated—what does this
?mean
Evaluate pH—is it normal? Yes

Next evaluate pCO2 & HCO3

pH normal + increased pCO2 + increased HCO3 = compensated

respiratory acidosis

pH normal + decreased HCO3 + decreased pCO2 = compensated

metabolic acidosis
Compensated vs.
Uncompensated
Is pH normal? No .1
Acidotic vs. Alkalotic .2
Respiratory vs. Metabolic .3
pH<7.30 + pCO2>50 + normal HCO3 = uncompensated •
respiratory acidosis
pH<7.30 + HCO3<18 + normal pCO2 = uncompensated •
metabolic acidosis
pH>7.50 + pCO2<30 + normal HCO3 = uncompensated •
respiratory alkalosis
pH>7.50 + HCO3>30 + normal pCO2 = uncompensated •
metabolic alkalosis
All Roads Lead To
ROME
Respiratory Opposite
Metabolic Equal
Prediction of Compensatory Responses on Simple
Acid-Base Disturbances
Disorder Prediction of Compensation

Metabolic acidosis PaCO2 = (1.5x HCO3-) + 8 or

PaCO2 will ↓ 1.25 mmHg per mmol/L ↓ in [HCO3-] or

PaCO2 = [HCO3-] + 15

Metabolic alkalosis PaCO2 will ↑ 0.75 mmHg per mmol/L ↑ in [HCO3-]

or
PaCO2 will ↑ 6 mmHg per 10-mmol/L ↑ in [HCO3-] or

PaCO2 = [HCO3-] + 15

Respiratory alkalosis

Acute [HCO3-] will ↓ 2 mmol/L per 10-mmHg ↓ in PaCO2

Chronic [HCO3-] will ↓ 4 mmol/L per 10-mmHg ↓ in PaCO2

Respiratory acidosis

Acute [HCO3-] will ↑ 1 mmol/L per 10-mmHg ↑ in PaCO2

Chronic [HCO3-] will ↑ 4 mmol/L per 10-mmHg ↑ in PaCO2

Effect of ventilator setting changes
Ventilator change paco2
pao2
↑ PIP ↓
↑
↑ PEEP ↑
Minimal ↑
↑ Rate ↓
↑
↑ I:E ratio No change
↑
↑ Fio2 No change
↑
↑ Flow Minimal ↓
Minimal ↑
↑Power(HFOV) ↓ No change

↑MAP(HFOV) Minimal ↓
↑
Let’s Practice
year old diabetic presents with Kussmaul 12
breathing
pH 7.05
pCO2: 12 mmHg
pO2: 108 mmHg
HCO3: 5 mEq/L
BE: -30 mEq/L
Severe partly compensated metabolic acidosis without
hypoxemia due to ketoacidosis
year old w/hx of asthma, audibly wheezing x 1 week, has not slept in 2 9
nights; presents sitting up and using accessory muscles to breath
w/audible wheezes
pH: 7.51
pCO2: 25 mmHg
pO2 35 mmHg
HCO3: 22 mEq/L
BE: -2 mEq/L
Uncompensated respiratory alkalosis with severe
hypoxia due to asthma exacerbation
year old post op presenting with chills, fever 7
and hypotension
pH: 7.25
pCO2: 32 mmHg
pO2: 55 mmHg
HCO3: 10 mEq/L
BE: -15 mEq/L
Uncompensated metabolic acidosis due to low perfusion
state and hypoxia causing increased lactic acid
year old w/severe kyphoscoliosis, admitted for 17
pneumonia
pH: 7.37
pCO2: 25 mmHg
pO2: 60 mmHg
HCO3: 14 mEq/L
: -7 mEq/LBE
Compensated respiratory alkalosis due to chronic
hyperventilation secondary to hypoxia
Cases senario
Ph Paco2 Pao2 Hco3 BE O2 sa Fio2
7.2 48 73 14.5 10.5- 96.5% 40%

2days old preterm 28 weeks gestation on CPAP

for mild RDS ABG as above
 Ph Paco2 Pao2 Hc03 BE sao2 Fio2
7.5 42 57 35.6 +10.8 93% RA

9day old preterm on RA with NEC on continuous gastric

suction TPN with NA and K acetate CBG above
conclusion
The continuous arterial blood gas sensor is capable of
clinically accurate blood gas measurements. This
provides the clinician with immediate data that can
 . allow rapid interventions in unstable patients