abg presentation 3
TRANSCRIPT
Arterial Blood Gas Analysis
Vanessa Klee MSIV
What is an ABG?
• The Components• pH / PaCO2 / PaO2 / HCO3 / O2sat / BE
• Desired Ranges• pH - 7.35 - 7.45• PaCO2 - 35-45 mmHg• PaO2 - 80-100 mmHg• HCO3 - 21-27• O2sat - 95-100%• Base Excess - +/-2 mEq/L
Information Obtained from an ABG:
• Acid base status
• Oxygenation• Dissolved O2 (pO2)• Saturation of hemoglobin
• CO2 elimination
• Levels of carboxyhemoglobin and methemoglobin
Indications:
• Assess the ventilatory status, oxygenation and acid base status
• Assess the response to an intervention
Contraindications:
• Bleeding diathesis
• AV fistula
• Severe peripheral vascular disease, absence of an arterial pulse
• Infection over site
Why an ABG instead of Pulse oximetry?
• Pulse oximetry uses light absorption at two wavelengths to determine hemoglobin saturation.
• Pulse oximetry is non-invasive and provides immediate and continuous data.
Why an ABG instead of Pulse oximetry?
• Pulse oximetry does not assess ventilation (pCO2) or acid base status.
• Pulse oximetry becomes unreliable when saturations fall below 70-80%.
• Technical sources of error (ambient or fluorescent light, hypoperfusion, nail polish, skin pigmentation)
• Pulse oximetry cannot interpret methemoglobin or carboxyhemoglobin.
Which Artery to Choose?
• The radial artery is superficial, has collaterals and is easily compressed. It should almost always be the first choice.
• Other arteries (femoral, dorsalis pedis, brachial) can be used in emergencies.
Preparing to perform the Procedure:
• Make sure you and the patient are comfortable.
• Assess the patency of the radial and ulnar arteries.
Collection Problems:
• Type of syringe• Plastic vs. glass
• Use of heparin
• Air bubbles
• Specimen handling and transport
Type of Syringe
• Glass-• Impermeable to gases• Expensive and impractical
• Plastic-• Somewhat permeable to gases• Disposable and inexpensive
Heparin
• Liquid• Dilutional effect if <2-3 ml of blood
collected
• Preloaded dry heparin powder• Eliminates dilution problem• Mixing becomes more important• May alter sodium or potassium levels
Air bubbles• Gas equilibration between ambient air
(pO2 ~ 150, pCO2~0) and arterial blood.
• pO2 will begin to rise, pCO2 will fall• Effect is a function of duration of
exposure and surface area of air bubble.
• Effect is amplified by pneumatic tube transport.
Transport
• After specimen collected and air bubble removed, gently mix and invert syringe.
• Because the wbcs are metabolically active, they will consume oxygen.
• Plastic syringes are gas permeable.
• Key: Minimize time from sample acquisition to analysis.
Transport
• Placing the AGB on ice may help minimize changes, depending on the type of syringe, pO2 and white blood cell count.
• Its probably not as important if the specimen is delivered immediately.
Performing the Procedure:
• Put on gloves• Prepare the site
• Drape the bed• Cleanse the radial area with a alcohol
• Position the wrist (hyper-extended, using a rolled up towel if necessary)
• Palpate the arterial pulse and visualize the course of the artery.
H2O + CO2 H2CO3 HCO3
+ H+
Acid/Base Relationship
There are two buffers that work in pairs
H2CO3 NaHCO3
Carbonic acid base bicarbonate These buffers are linked to the respiratory and renal compensatory system
Buffers
The Respiratory buffer response
• The blood pH will change acc.to the level of H2CO3 present.
• This triggers the lungs to either increase or decrease the rate and depth of ventilation
• Activation of the lungs to compensate for an imbalance starts to occur within 1-3 minutes
The Renal Buffer Response
• The kidneys excrete or retain bicarbonate(HCO3-).
• If blood pH decreases, the kidneys will compensate by retaining HCO3
• Renal system may take from hours to days to correct the imbalance.
ACID BASE DISORDERRes. Acidosis• is defined as a pH less than 7.35
with a paco2 greater than 45 mmHg.• Acidosis –accumulation of co2,
combines with water in the body to produce carbonic acid, thus lowering the pH of the blood.
• Any condition that results in hypoventilation can cause respiratory acidosis.
Causes 1. Central nervous system depression r/t
medications such as narcotics, sedatives, or anesthesia.
2. Impaired muscle function r/t spinal cord injury, neuromuscular diseases, or neuromuscular blocking drugs.
3. Pulmonary disorders such as atelectasis, pneumonia, pneumothorax, pulmonary edema or bronchial obstruction
4. Massive pulmonary embolus5. Hypoventilation due to pain chest wall
injury, or abdominal pain.
Signs & symptoms of Respiratory Acidosis
• Respiratory : Dyspnoea, respiratory distress and/or shallow respiration.
• Nervous: Headache, restlessness and confusion. If co2 level extremely high drowsiness and unresponsiveness may be noted.
• CVS: Tacycardia and dysrhythmias
Management• Increase the ventilation. • Causes can be treated rapidly
include pneumothorax, pain and CNS depression r/t medication.
• If the cause can not be readily resolved, mechanical ventilation.
Respiratory alkalosis
• Psychological responses, anxiety or fear.• Pain• Increased metabolic demands such as
fever, sepsis, pregnancy or thyrotoxicosis.• Medications such as respiratory
stimulants.• Central nervous system lesions
Signs & symptoms• CNS: Light Headedness,
numbness, tingling, confusion, inability to concentrate and blurred vision.
• Dysrhythmias and palpitations• Dry mouth, diaphoresis and tetanic
spasms of the arms and legs.
Management
• Resolve the underlying problem
• Monitor for respiratory muscle fatigue
• When the respiratory muscle become exhausted, acute respiratory failure may ensue
Metabolic Acidosis
• Bicarbonate less than 22mEq/L with a pH of less than 7.35.
• Renal failure• Diabetic ketoacidosis• Anaerobic metabolism• Starvation• Salicylate intoxication
Sign & symptoms
• CNS: Headache, confusion and restlessness progressing to lethargy, then stupor or coma.
• CVS: Dysrhythmias• Kussmaul’s respirations• Warm, flushed skin as well as
nausea and vomiting
Management• Treat the cause• Hypoxia of any tissue bed will produce
metabolic acids as a result of anaerobic metabolism even if the pao2 is normal
• Restore tissue perfusion to the hypoxic tissues
• The use of bicarbonate is indicated for known bicarbonate - responsive acidosis such as seen with renal failure
Metabolic alkalosis• Bicarbonate more than 26m Eq /L with a
pH more than 7.45• Excess of base /loss of acid can cause• Ingestion of excess antacids, excess use of
bicarbonate, or use of lactate in dialysis.• Protracted vomiting, gastric
suction,hypchoremia,excess use of diuretics, or high levels of aldesterone.
Signs/symptoms
• CNS: Dizziness, lethargy disorientation, siezures & coma.
• M/S: weakness, muscle twitching, muscle cramps and tetany.
• Nausea, vomiting and respiratory depression.
• It is difficult to treat.
COMPONENTS OF THE ABG
pH: Measurement of acidity or alkalinity, based on the hydrogen (H+)
7.35 – 7.45Pao2 The partial pressure oxygen that is dissolved in arterial blood.
80-100 mm Hg. PCO2: The amount of carbon dioxide dissolved in arterial blood.
35– 45 mmHgHCO3
: The calculated value of the amount of bicarbonate in the blood 22 – 26 mmol/L
B.E: The base excess indicates the amount of excess or insufficient level of bicarbonate. -2 to +2mEq/L(A negative base excess indicates a base deficit in blood)
SaO2:The arterial oxygen saturation. >95%
Stepwise approach to ABG
• Step 1: Acidemic or Alkalemic? • Step 2: Is the primary disturbance
respiratory or metabolic? • Step 3. Asses to Pa O2. A value below 80mm
Hg indicates Hypoxemia. For a respiratory disturbance, determine whether it is acute or chronic.
• Step 4. For a metabolic acidosis, determine whether an anion gap is present.
• Step 5. Assess the normal compensation by the respiratory system for a metabolic disturbance
STEPS TO AN ABG INTERPRETATION
• Step:1• Assess the pH
–acidotic/alkalotic• If above 7.5 – alkalotic• If below 7.35 – acidotic
Contd…..• Step 2:• Assess the paCO2 level.• pH decreases below 7.35, the paCO2
should rise.• If pH rises above 7.45 paCO2 should
fall.• If pH and paCO2 moves in opposite
direction – primary respiratory problem.
contd• Step:2
• Assess HCO3 value
• If pH increases the HCO3 should also increase
• If pH decreases HCO3 should also decrease
• They are moving in the same direction• primary problem is metabolic
• Step 3Assess pao2 < 80 mm Hg - HypoxemiaFor a resp. disturbance : acute, chronic
The differentiation between A/C & CHR.respiratory disorders is based on whether there is associated acidemia / alkalemia.
If the change in paco2 is associated with the change in pH, the disorder is acute.
In chronic process the compensatory process brings the pH to within the clinically acceptable range ( 7.30 – 7.50)
• J is a 45 years old female admitted with the severe attack of asthma. She has been experiencing increasing shortness of breath since admission three hours ago. Her arterial blood gas result is as follows:
• pH : 7.22• paCO2 : 55• HCO3 : 25• Follow the steps• pH is low – acidosis• paCO2 is high – in the opposite direction of the pH. • Hco3 is Normal.• Respiratory Acidosis• Need to improve ventilation by oxygen
therapy, mechanical ventilation, pulmonary toilet or by administering bronchodilators.
• EXAMPLE 2: Mr. D is a 55 years old admitted with recurring bowel obstruction has been experiencing intractable vomiting for the last several hours. His ABG is:
• pH : 7.5• paCO2 :42• HCO3 : 33• Metabolic alkalosis• Management: IV fluids,
measures to reduce the excess base
Respiratory acidosis
pH PaCo2 HC03
normal
Respiratory
Alkalosis
normal
Metabolic Acidosis
normal
Metabolic Alkalosis
normal
BASE EXCESS
• Is a calculated value estimates the metabolic component of an acid based abnormality.
• It is an estimate of the amount of strong acid or base needed to correct the met. component of an acid base disorder (restore plasma pH to 7.40at a Paco2 40 mmHg)
Formula• With the base excess is -10 in a
50kg person with metabolic acidosis mM of Hco3 needed for correction is:
= 0.3 X body weight X BE = 0.3 X 50 X10 = 150 mM
Anion GAP
Step 4• Calculation of AG is useful approach to
analyse metabolic acidosis AG = (Na+ + K+) – (cl- + Hco3-)• * A change in the pH of 0.08 for each 10
mm Hg indicates an ACUTE condition.* A change in the pH of 0.03 for each 10 mm Hg indicates a CHRONIC condition.
• K etoacidosis• U remia• S epsis• S alicylate & other drugs• M ethanol• A lcohol (Ethanol)• L actic acidosis• E thylene glycol
REMEMBER
COMPENSATION• Step 5• A patient can be uncompensated or
partially compensated or fully compensated
• pH remains outside the normal range• pH has returned within normal range-
fully compensated though other values may be still abnormal
• Be aware that neither the system has the ability to overcompensate
Step 5 cont…Determine if there is a compensatory mechanism working to try to correct the pH.
ie: if have primary respiratory acidosis will have increased PaCO2 and decreased pH. Compensation occurs when the kidneys retain HCO3.
ABG Interpretation
Assess the PaCO2• In an uncompensated state – when the pH
and paCO2 moves in the same direction: the primary problem is metabolic.
• The decreasing paco2 indicates that the lungs acting as a buffer response (blowing of the excess CO2)
• If evidence of compensation is present but the pH has not been corrected to within the normal range, this would be described as metabolic disorder with the partial respiratory compensation.
Assess the HCO3
• The pH and the HCO3 moving in the opposite directions, we would conclude that the primary disorder is respiratory and the kidneys acting as a buffer response: are compensating by retaining HCO3 to return the pH to normal range.
Example 3• Mrs. H is admitted, he is kidney
dialysis patient who has missed his last 2 appointments at the dialysis centre his ABG results:
• pH : 7.32• paCo2 : 32• HCO3 : 18• Pao2 : 88• Partially compensated metabolic
Acidosis
Example 4• Mr. K with COPD.His ABG is:• pH : 7.35
• PaCO2 : 48
• HCO3 : 28
• PaO2 : 90
• Fully compensated Respiratory Acidosis
Example 5• Mr. S is a 53 year old man presented
to ED with the following ABG.• pH : 7.51• PaCO2 : 50• HCO3 : 40• Pao2 : 40 (21%O2)• He has metabolic alkalosis• Acute respiratory alkalosis
(acute hyperventilation).
FULLY COMPENSATEDpH paco2 Hco3
Resp.Acidosis Normal
but<7.40
Resp.Alkalosis Normal
but>7.40
Met. Acidosis Normal
but<7.40
Met. Alkalosis Normal
but>7.40
Partially compensated
pH paco2 Hco3
Res.Acidosis
Res.Alkalosis
Met. Acidosis
Met.Alkalosis
~ PaCO2 – pH Relationship80 7.20
60 7.30
40 7.40
30 7.50
20 7.60
Precautions Excessive Heparin Decreases bicarbonate
and PaCO2
Large Air bubbles not expelled from sample PaO2 rises, PaCO2 may fall slightly.
Fever or Hypothermia, Hyperventilation or breath holding (Due to anxiety) may lead to erroneous lab results
Care must be taken to prevent bleeding
2SD NORMAL CL.ACCEPTABLE
• PH 7.35 – 7.45 7.30 – 7.50
• PCO2 35 – 45 30 – 50
• PO2 97 >80 (ON 21% O2)
(ON VENTILATOR) 60 – 90
• HCO3 24 - 28
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 ABC’s 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.
It’s not magic understanding ABG’s, it just
takes a little practice!
Practice ABG’s
1. PaO2 90 SaO2 95 pH 7.48 PaCO2 32 HCO3 242. PaO2 60 SaO2 90 pH 7.32 PaCO2 48 HCO3 253. PaO2 95 SaO2 100 pH 7.30 PaCO2 40 HCO3 184. PaO2 87 SaO2 94 pH 7.38 PaCO2 48 HCO3 285. PaO2 94 SaO2 99 pH 7.49 PaCO2 40 HCO3 306. PaO2 62 SaO2 91 pH 7.35 PaCO2 48 HCO3 277. PaO2 93 SaO2 97 pH 7.45 PaCO2 47 HCO3 298. PaO2 95 SaO2 99 pH 7.31 PaCO2 38 HCO3 159. PaO2 65 SaO2 89 pH 7.30 PaCO2 50 HCO3 2410. PaO2 110 SaO2 100 pH 7.48 PaCO2 40 HCO3 30
Answers to Practice ABG’s
1. Respiratory alkalosis2. Respiratory acidosis3. Metabolic acidosis4. Compensated Respiratory acidosis5. Metabolic alkalosis6. Compensated Respiratory acidosis7. Compensated Metabolic alkalosis8. Metabolic acidosis9. Respiratory acidosis10.Metabolic alkalosis