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By MEDT/CPD (Kadek Ayu)

Sept, 2010
Definition
 Arterial Blood Gas (ABG) Analysis, is a test which
measures the amounts of oxygen and carbon dioxide,
as well as the acidity (pH) of the blood.
 is an essential part of diagnosing and managing a
patient’s oxygenation status and acid-base balance
 Some analysis machines give more results e.g. Na, K,
Cl, etc (not provided by Prodia, but from Sanglah)
Indication
 Respiratory failure (in acute and chronic sate)
 Any severe illness which may lead to a metabolic
acidosis e.g. Cardiac failure, liver failure, renal failure,
hyperglycemic sates associated with DM, multiorgan
failure, sepsis, Burns, Poisons/toxins
 Ventilated patient
 Sleep studies
 Severely unwell pt from any cause (affects prognosis)
Components of the Arterial Blood Gas
1. pH
• Measurement of acidity or alkalinity, based on the hydrogen (H+)
ions present.
• The normal range is 7.35 to 7.45
2. PaO2
• The partial pressure of oxygen that is dissolved in arterial blood.
• The normal range is 80 to 100 mm Hg.
3. SaO2
• The arterial oxygen saturation.
• The normal range is 95% to 100%.
4. PaCO2
• The amount of carbon dioxide dissolved in arterial blood.
• The normal range is 35 to 45 mm Hg.
Components of the Arterial Blood Gas Continue
5. HCO3
• The calculated value of the amount of bicarbonate in
the bloodstream
• The normal range is 22 to 26 mEq/liter
6. B.E.
• The base excess indicates the amount of excess or
insufficient level of bicarbonate in the system
• The normal range is –2 to +2 mEq/liter
• A negative base excess indicates a base deficit in the
blood
Acid-Base Balance
Overview
 The pH is a measurement of the acidity or alkalinity of the blood.
 The pH of a solution is measured on a scale from 1 (very acidic) to 14
(very alkalotic). A liquid with a pH of 7, such as water, is neutral
(neither acidic nor alkalotic).
 When the pH is below 7.35, the blood is said to be acidic, and above
7.45 the blood is said to be alkalotic.
Acid-Base Balance continue

The Respiratory Buffer Response


• A normal by-product of cellular metabolism is carbon
dioxide (CO2).
• CO2 is carried in the blood to the lungs, where excess CO2
combines with water (H2O) to form carbonic acid (H2CO3)
blood pH will change according to the level of carbonic
acid present.
• This triggers the lungs to either increase or decrease the
rate and depth of ventilation until the appropriate amount
of CO2 has been re-established.
Acid-Base Balance continue

The Renal Buffer Response


• To maintain the pH of the blood within its normal range,
the kidneys excrete or retain bicarbonate (HCO3-)
• As the blood pH decreases, the kidneys will compensate by
retaining HCO3- and as the pH rises, the kidneys excrete
HCO3- through the urine
• Although the kidneys provide an excellent means of
regulating acid-base balance, the system may take from
hours to days to correct the imbalance
Acid-Base Disorders
 Respiratory Acidosis
 Respiratory Alkalosis
 Metabolic Acidosis
 Metabolic Alkalosis
Respiratory Acidosis
 Defined as a pH less than 7.35 with a PaCO2 greater than 45 mm Hg
 Acidosis is caused by an accumulation of CO2 which 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
 Signs and symptoms:
 Pulmonary symptoms include dyspnoea, respiratory distress, and/or
shallow respirations.
 Nervous system manifestations include headache, restlessness, and
confusion. If CO2 levels become extremely high, drowsiness and
unresponsiveness may be noted.
 Cardiovascular symptoms include tachycardia and dysrhythmias.
• Increasing ventilation will correct respiratory acidosis
Respiratory Alkalosis
 Respiratory alkalosis is defined as a pH greater than 7.45 with a PaCO2
less than 35 mm Hg.
 Any condition that causes hyperventilation can result in respiratory
alkalosis
 Sign and symptom:
 Nervous system alterations include light-headedness, numbness
and tingling, confusion, inability to concentrate, and blurred
vision.
 Cardiac symptoms include dysrhythmias and palpitations
 Additionally, the patient may experience dry mouth, diaphoresis,
and tetanic spasms of the arms and legs.
Respiratory Alkalosis continue

 Treatment of respiratory alkalosis centers on resolving the


underlying problem.
 Patients presenting with respiratory alkalosis have
dramatically increased work of breathing and must be
monitored closely for respiratory muscle fatigue.
 When the respiratory muscles become exhausted, acute
respiratory failure may ensue.
Metabolic Acidosis
 Defined as a bicarbonate level of less than 22 mEq/L with a pH of less
than 7.35
 Metabolic acidosis is caused by either a deficit of base in the
bloodstream or an excess of acids, other than CO2
 Sing and symptom:
 Nervous system manifestations include headache, confusion, and
restlessness progressing to lethargy, then stupor or coma
 Cardiac dysrhythmias are common and Kussmaul respirations occur
in an effort to compensate for the pH by blowing off more CO2
 Warm, flushed skin, as well as nausea and vomiting are commonly
noted
Metabolic Alkalosis
 Metabolic alkalosis is defined as a bicarbonate level greater
than 26 mEq/liter with a pH greater than 7.45
 Sign and symptom:
 Neurologic symptoms include dizziness, lethargy,
disorientation, seizures and coma
 Musculoskeletal symptoms include weakness, muscle
twitching, muscle cramps and tetany
 The patient may also experience nausea, vomiting, and
respiratory depression
Steps to an Arterial Blood Gas Interpretation
 Step One
 Assess the pH to determine if the blood is within
normal range, alkalotic or acidotic.
 If it is above 7.45, the blood is alkalotic. If it is below
7.35, the blood is acidotic.
Steps to an Arterial Blood Gas Interpretation
continue

 Step Two
 If the blood is alkalotic or acidotic, we now need to
determine if it is caused primarily by a respiratory or
metabolic problem.
 To do this, assess the PaCO2 level. Remember that with a
respiratory problem, as the pH decreases below 7.35, the
PaCO2 should rise.
 If the pH rises above 7.45, the PaCO2 should fall. Compare
the pH and the PaCO2 values. If pH and PaCO2 are indeed
moving in opposite directions, then the problem is
primarily respiratory in nature.
Steps to an Arterial Blood Gas Interpretation
continue

 Step Three
 Finally, assess the HCO3 value. Recall that with a metabolic
problem, normally as the pH increases, the HCO3 should
also increase. Likewise, as the pH decreases, so should the
HCO3.
 Compare the two values. If they are moving in the same
direction, then the problem is primarily metabolic in
nature.
 The following chart summarizes the relationships between
pH, PaCO2 and HCO3.
Obtaining an Arterial Blood Sample
 Draw blood from an arterial line
 Percutaneous punture from an artery
(current metode in BIMC)

 Sites of puncture for sampling


 Radial artery (first choice / for nurses)
 Other sites (higher risk of neurovascular
injury)  need co-op with Dr
 Brachial artery

 Femoral artery
Contraindications
 Negative result of an Allen test
 Arterial puncture should not be performed through a lesion
 Never puncture same limb as there is a surgical shunt (absolutely
never through or distal to it)
 If there is evidence of infection or peripheral vascular
disease involving selected limbs, an alternative site
should be selected
 Femoral puncture should not be performed outside
the hospital need Dr assistance
 If pt on coagulant or medium to high dose anticoagulation
threatment may be a relative contraindication for arterial
puncture e.g. Heparin or coumadin, streptokinase and tissue
plasminogen activator but not necessarily aspirin)
COMPLICATIONS
 Hematoma
 Arteriospasm
 Air or clotted-blood emboli
 Anaphylaxis from local anestetic
 Hemorrhage
 Arterial occlusion
 Pain
 Trauma to the vessel
 Infection
Potential Sampling Error
 Air in the sample: Will elevate the pO2 in the sample, rendering it
inaccurate.
 Too much time before analyzing: Gas must be placed on ice if not
analyzed w/in 20 min.
 If not analyzed within 1 hrs, certain cells may continue to consume O2
and produce CO2 while in the syringe. This will affect your pO2 and
pCO2 unless the sample is not analyzed right away.
 Anticoagulants: Heparin can dilute the concentrations of gases in the
blood sample (willdecrease pCO2).
 Temperature: The temperature of the blood affects the pO2 and pCO2.
Allen Test
 Allen test must be done before collect blood sample from radial artery
 Indications
 Test wrist collateral Blood Flow
 Arterial Puncture for BGA
 Technique
 Patient elevates hand and makes a fist for 20 seconds
 Using your index and midle finger press on the radial and ulnar
arteries . Hold this position for for a few second
 Without removing your finger, ask pt to unclench his/her fist and
hold hand in a relaxed position. The palm should blanche white
 Release pressure on the ulnar artery. If the hand become flushed,
which indicates blood filling the vessels. Can safely proceed with
the radial artery puncture. If doesn’t flush, perform to the other arm
Allen Test continue

 Normal Result
 Hand color flushes within 5 to 7 seconds
 Abnormal result: Inadequate collateral circulation
 Hand remains white until radial pressure released
 Risk of serious hand ischemia if radial vessel spasm
Arterial Blood Gas Sampling
 Preparation
 Equipment
• Examination gloves
• Apron
• Small towel
• Alcohol Swabs
• 4 cm x 4 cm Sterile gauze
• Syringe 3 ml and Heparin 1:1000 or Heparinized Blood Gas Syringe
• Needle 22G or 23G
• Rubber cap
• Sharps box
• Box with ice or Plastic bag w/ crushed ice and call OB if not use lab
inside hospital
• bandage or tape
• Pt ID Label (name, DOB, MRN, date and time sample taken)
• Lab order form
• Underpad
• Trolley
• Assisting nurse if needed
Arterial Blood Gas Sampling continue

Preparation Phase :
• Labelled and fixed lab form and sign by Dr
• Identify you talk to the right pt with check ID pt (name, MRN, DOB)
• Explain to the pt that you need collect an arterial blood sample
• Obtain verbal consent and record inspired O2 concentration and
temperature on the lab form
• If using Syringe without Heparin :
 Disinfectand your hands

 With 3 cc Syringe and 21 gauge needle draw up 0.5 ml of heparin


(theoretically 1000U/ml, in BIMC we have 5000 units/ml)
 Rotate syringe and work plunger to distribute heparin

 Push out all heparin (leave just enough to wet the syringe)

 Change needle to 22/23 G


Arterial Blood Gas Sampling continue

 Preparation phase continues:


• If analyze will be done outside hospital, make sure office
boy is stand bywith the ice box in your departement
• Make sure yourselft, possible colleaghe assistant and all
equipment is ready
Arterial Blood Gas Sampling continue

 Performance Phase :
• Disinfectand your hands and wear gloves and apron
• Place underpad and rolled towel under pt wrist for support. If needed:
 Tape pt hand to bedrail to stabilise a good position
 Mark the position of the artery with a pen
• Locate the artery and palpate it for a strong pulse
• Perform allen test
• Using a circular motion, clean the area with alcohol for 30 second and
allow it dry completely
• Palpate the artery with the index and middle finger on one hand while
holding the syringe over the puncture site (keep finger separated, not to
touch and contamined)
• Find a puncture site as distal as possible (if fail can try again above)
• Hold the needle bevel up at 30° to 45° angle. When puncturing brachial
artery , hold needle at a 60°
Arterial Blood Gas Sampling continue

 Performance Phase continue :


• Slowly advance needle until spontaneous blood
enters
• Hold needle steady until 1-3 cc blood obtained
• Allow syringe to fill itself (avoid aspirating)
• If flow ceases
 Slowly withdraw needle 1-2 mm

 Repositions needle back inside arterial


lumen
Or
 Advance needle until you feel the bone

 Slowly withdraw needle until blood enter


and allow syringe to fill it self
Arterial Blood Gas Sampling continue

 Performance Phase continue :


• After collecting sample, withdraw needle and immediately
apply pressure over entry site in the same time
• Hold pressure at entry site for 5 minutes (can ask pt to do it
if possible)
• When bleedding stop apply a small pressure bandage

• If you put on a circulatory bandage, check distal blood flow


afterwards
 Express any air bubbles from syringe immediately after
needle withdrawing
 Cork needle into rubber cap or remove needle and cap
syringe then place removed needle in sharp box
Arterial Blood Gas Sampling continue

 Performance Phase continue :


 Roll syringe between fingers to mix heparin with sample
 Label sample with: Patient ID (name, DOB, MRN)
 Immediately place sample on ice
 Write down time of collecting sample on the lab form
 Deliver sample to the lab immediately (must be analyzed within 1
hrs)
 Monitor pt vital signs, and observe for signs of circulatory
impairment such as swelling, pain, numbness, tingling and watch
for bleeding at the puncture site
Arterial Blood Gas Sampling continue

Performance Phase continue :


 Documentation
 Lab form
 ID pt (name, DOB, MRN, Female/Male)
 Temperature and inspired O2 concentration
 Date and time of sampling
 Dr sign and sign by who take the sample
 Progress note
 Date and time
 Info to the pt and result of verbal consern
 Result of allen test
 Temperature and inspired O2 concentration
 Site choosen e.g. Right arm radial artery, number of attemps, success/fail-> why if
failed
 Pt reaction
 Handle of sample
Special Consideration
 If pt receiving O2, make sure that therapy has been under
way for at least 15 min before collecting sample
 Unless ordered, don’t turn off O2 therapy before collecting
arterial blood sample. Be sure to indicate on the lab
formthe amount and type of O2 therapy that pt is receiving
 If pt isn’t receiving O2, indicate that he/she breath of room
air
 If pt just had nebulizer treatment, wait about 20 min
before collecting the sample
 If pt scared for pain, apply Emla ® cream aprox one hr
before sampling
What to do if fail?
 Always put pressure on areaand try again higher up on
same time
 If two failed attemp, let pt rest for 15 min (if nort
emergency) and have another nurse to attemp t
sampling
 If venous blood: keep it, try again, if fail info Dr, if
agree to send , write on lab form “venous blood"
 Example 1
Jane Doe is a 45-year-old female admitted to the
nursing unit with a severe asthma attack. She has been
experiencing increasing shortness of breath since
admission three hours ago. Her arterial blood gas
result is as follows:
Follow the steps:
 Assess the pH. It is low (normal 7.35-7.45), therefore,
we have acidosis.
 Assess the PaCO2. It is high (normal 35-45) and in the
opposite direction of the pH.
 Assess the HCO3. It has remained within the normal
range (22-26)
 Refer to the chart. Acidosis is present (decreased pH)
with the PaCO3 being increased, reflecting a primary
respiratory problem
 Example 2
John Doe is a 55-year-old male admitted to your
nursing unit with a recurring bowel obstruction. He
has been experiencing intractable vomiting for the last
several hours despite the use of antiemetics. Here is
his arterial blood gas result:
Follow the three steps again:
 Assess the pH. It is high (normal 7.35-7.45), therefore,
indicating alkalosis
 Assess the PaCO2. It is within the normal range
(normal 35-45)
 Assess the HCO3. It is high (normal 22-26) and
moving in the same direction as the pH
 Again, look at the chart. Alkalosis is present (increased
pH) with the HCO3 increased, reflecting a primary
metabolic problem
 Example 3
John Doe is admitted to the hospital. He is a kidney
dialysis patient who has missed his last two
appointments at the dialysis center. His arterial blood
gas values are reported as follows:
Follow the three steps:
 Assess the pH. It is low (normal 7.35-7.45); therefore we have acidosis.
 Assess the PaCO2. It is low. Normally we would expect the pH and
PaCO2 to move in opposite directions, but this is not the case. Because
the pH and PaCO2 are moving in the same direction, it indicates that
the acid-base disorder is primarily metabolic. In this case,the lungs,
acting as the primary acid-base buffer, are now attempting to
compensate by“blowing off excessive C02”, and therefore increasing the
pH.
 Assess the HCO3. It is low (normal 22-26). We would expect the pH
and the HCO3- to move in the same direction, confirming that the
primary problem is metabolic.
 Because there is evidence of compensation (pH and PaCO2
 moving in the same direction) and because the pH remains below the
normal range, we would
 interpret this ABG result as a partially compensated metabolic acidosis
 Example 4
Jane Doe is a patient with chronic COPD being
admitted for surgery. Her admission labwork reveals
an arterial blood gas with the following values:
Follow the three steps:
 Assess the pH. It is within the normal range, but on the low side of
neutral (<7.40).
 Assess the PaCO2. It is high (normal 35-45). We would expect the pH
and PaCO2 to move in opposite directions if the primary problem is
respiratory.
 Assess the HCO3. It is also high (22-26). Normally, the pH and HCO3
should move in the same direction. Because they are moving in
opposite directions, it confirms that the primary acid-base disorder is
respiratory and that the kidneys are attempting to compensate by
retaining HCO3. Because the pH has returned into the low normal
range, we would interpret this ABG as a fully compensated respiratory
acidosis.
 Example 5
John Doe is a trauma patient with an altered mental
status. His initial arterial blood gas result is as follows
Follow the three steps:
 Assess the pH. It is low (normal 7.35-7.45). This indicates that an
acidosis exists.
 Assess the PaC02. It is high (normal 35-45). The pH and PaC02 are
moving in opposite directions, as we would expect if the problem were
primarily respiratory in nature.
 Assess the HC03. It is high (normal 22-26). Normally, the pH and HC03
should move in the same direction. Because they are moving in
opposite directions, it also confirms that the primary acid-base
disorder is respiratory in nature. In this case, the kidneys are
attempting to compensate by retaining HCO3 in the blood in an order
to return the pH back towards its normal range. Because there is
evidence of compensation occurring (pH and HC03 moving in opposite
directions), and seeing that the pH has not yet been restored to its
normal range, we would interpret this ABG result as a partially
compensated respiratory acidosis.
 Example 6
Jane Doe is a 54-year-old female admitted for an ileus.
She had been experiencing nausea and vomiting. An
NG tube has been in place for the last 24 hours. Here
are the last ABG results:
Follow the three steps:
 Assess the pH. It is normal, but on the high side of neutral (>7.40).
 Assess the PaC02. It is high (normal 35-45). Normally, we would expect
the pH and PaC02 to move in opposite directions. In this case, they are
moving in the same direction indicating that the primary acid-base
disorder is metabolic in nature. In this case, the lungs, acting as the
primary acid-base buffer system, are retaining C02 (hypoventilation) in
order to help lower the pH back towards its normal range.
 Assess the HC03. It is high (normal 22-26). Because it is moving in the
same direction, as we would expect, it confirms the primary acid-base
disorder is metabolic in nature
 Because there is evidence of compensation occurring (pH and PaC02
moving in the same direction) and because the pH has effectively been
returned to within its normal range, we would call this fully
compensated metabolic alkalosis
References
 Dr Gurvinder . (2008). Arterial Blood Gases - Indications and Interpretation. UK: EMIS
http://www.patient.co.uk/doctor/Arterial-Blood-Gases-Indications-and-
Interpretation.htm
 Orlando Regional Healthcare. (2004). Interpretation of the Arterial Blood Gas. FL:
Orlando Regional Healthcare, Education & Development. (Electronic)
Available:http://orlandohealth.com/pdf%20folder/Inter%20of%20Arterial%20Blood%20
Gas.pdf (05/08/10)
 Scott Moses, MD (2008). Allen Test. : Family Practice Notebook, LLC.
(Electronic)Available:http://www.fpnotebook.com/CV/Exam/AlnTst.htm.(03/08/10)
 Scott Moses, MD (2008). Arterial Pucture. : Family Practice Notebook, LLC.
(Electrocic)Available: http://www.fpnotebook.com/CV/Exam/AlnTst.htm (03/08/10)
 Williams and Wilkins, Lippincott. (2004). Nursing Procedures Fourth Edition. New York:
A Wolter Kluwer Company
 , Blood Gas Interpretation. : (Electrocnic)Available:
http://www.stritch.luc.edu/depts/peds/pdf/PICU-
%20BLOOD%20GAS%20INTERPRETATION.pdf (03/08/10)

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