4/27/2015

Arterial Blood Gas

Interpretation for the
Bedside Nurse

Andrea L. Briscoe, MSN, RN, CCRN

AnMed Health

Objectives
• Identify three essential components of the
ABG series
• Relate ABG results to potential
interventions in specific patient scenarios

Introduction

• Arterial Blood Gas (ABG) Overview

– Drawn from arterial source- radial (most often
used), brachial, and femoral
– Helpful in identifying respiratory/oxygenation
deficiencies and metabolic/acid-base balance
deficiencies
– Critical care patients may have arterial line
placed for frequent draws

1
 4/27/2015

Acid/Base Regulation
Review
• Buffering
– Normal body mechanism that occurs
rapidly in response to acid-base
disturbances to prevent changes in H+
• Respiratory- regulates the excretion or
retention of carbonic acid. Fast
response- usually within minutes but
response is weak.
– If pH decreases= the rate and depth of
breathing increases
– If pH increase= the rate and depth of
breathing decreases
• Renal System- regulates the excretion
and retention of bicarb (HCO3).
Slower response – usually about 48
hours but a powerful result.
– If pH decreases= the kidney will retain
HCO3
– If pH increases= the kidney will release
HCO3

Knowledge Gap

• Youssef, et al. (2013) indicated gap between

nurses’ knowledge and practices as compared
to the evident based guidelines of American
Association of Respiratory Care in
management of ABG sampling
• Recommendations were to enrich nursing
knowledge and practices related to:
– ABG indications, sampling practices, complications
of sampling and…
• Interpretation of Parameters

ABG COMPONENTS

pH
PO2
SaO2
PCO2
HCO3
BE

2
 4/27/2015

pH

• Measurement of acidity or alkalinity, based

on hydrogen (H+) ions.
• Normal is 7.35-7.45
– Increase in H+ = lower pH, more acidic
– Decrease in H+ = higher pH, more alkaline

PO2

• The partial pressure • ↑ PO2=

of oxygen that is hypoventilation is
dissolved in arterial present
blood. Reflection of • ↓ PO2=
alveolar ventilation. hyperventilation is
present
• Normal= adequate
Normal is 80-100 mmHg ventilation

SaO2
• Oxygenation
– Process by which oxygen
enters the bloodstream via the • Any problems with one or
lungs. Reflects saturation of more factors will cause
hemoglobin with oxygen. inadequate oxygenation of
• Oxygenation dependent the blood= ↓SaO2 or
factors: hypoxemia
– Atmospheric pressure Normal range is 95-100%
– Fraction of oxygen in inspired
air
– Movement of oxygen into the
lungs (ventilation!)
– Adequate blood flow to
pulmonary capillaries
(perfusion)
– Movement of oxygen across
the alveolar-capillary
membrane

3
 4/27/2015

PCO2

• Partial pressure of
carbon dioxide
dissolved in arterial
blood.
Normal is 35-45 mmHg

HCO3

• The calculated value

of bicarbonate in the
bloodstream.

Normal is 22-26 mmol/L

Base Excess(BE)/Deficit

• The base • Negative base level is

excess/deficit reported as a deficit and
associated with metabolic
indicates the amount
acidosis
of excess or
• Positive base level is
insufficient level of reported as excess and
bicarbonate in the associated with metabolic
system. alkalosis

Normal is -2 to +2 mEq/L

4
 4/27/2015

Normal ABG values

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

ABG Interpretation
Acid Base
• The only two ways an
pH 7.35 7.45
acidotic state can exist CO2 45 35
is from too much CO2 HCO3 22 26
or too little HCO3.
• The only two ways an
alkalotic state can So the key is finding what KIND
of acidotic or alkalotic state the
exist is too little CO2 patient is in: respiratory or
or too much HCO3. metabolic!
Figuring out what kind will then
guide your treatment!

Interpretation Methods

1. Stepwise approach
2. “Tic-tac-toe” method
3. Color Method

5
 4/27/2015

1. Stepwise Approach

• Step 1- Determine the pH (acidosis or alkalosis)

• Step 2- Evaluate PCO2
– ?Too much/too little acid?
– (>45= acidosis or <35= alkalosis)
• Step 3- Evaluate HCO3
– (>26= alkalosis or <22= acidosis)
• Step 4- Matching!
– Match the “problem” value with the pH

• Practice: pH7.24, PCO2 75, HCO3 28

↓ ↑
acidic too high normal

2. Tic-Tac-Toe Method

• In order to use the tic-tac-toe method you

must first get a sheet of paper and set up a
“tic-tac-toe” grid. Then label each “column” as
“acid”, “normal”, and “base”. It should look
like this:
Acid Normal Base

Practice ABG:
• pH7.24, PCO2 75, HCO3 28
1. Draw your tic-tac-toe layout.
2. Analyze your pH. Ask yourself is it normal, basic, or acidic? Since the
pH is less than 7.35 making it an acid, place it under the acid column.
3. Analyze your PCO2. Ask yourself is it normal, basic, or acidic? Since the
PCO2 is greater than 45 making it an acid, place it under the acid
column along with pH. Remember PCO2 is the opposite and the
normal is 35-45.
4. Analyze your HCO3. Ask yourself is it normal, basic, or acidic? Since
HCO3 is greater than 26 making it basic, place it under the base
column because the value is considered basic.
• Layout should look like this:
Acid Normal Base

pH HCO3

PCO2

6
 4/27/2015

3. Color Method

• Blue= base
• Red= acid
• Black= neutral
Practice ABG:
pH 7.24, PCO2 75, HCO3 28

Now find the parameter color that

matches the pH…
Respiratory Acidosis

ABG ALTERATIONS

Case Study #1
• A 55 year old male is found down in a hospital waiting
area. EMS is called and upon arrival, the patient is found
to have an oxygen saturation of 88% and pinpoint pupils.
He is brought to your ER where a room air arterial blood
gas is performed.
• Results: pH 7.25 PCO2 60 PO2 65 HCO3 26
• Acid-base status: _____________?

7
 4/27/2015

Respiratory Acidosis
↓pH + ↑CO2
• Hypoventilation caused by any of the following:
– COPD, Sleep apnea, or other lung diseases that result
in decreased excretion of CO2
– Over-sedation, head trauma, anesthesia, and drug
overdose
– Neuromuscular disorders like Guillian-Barrè
Pneumothorax, flail chest or other chest wall trauma
interfering with breathing mechanics
– Inappropriate ventilator settings
• Treatment: Improvement of ventilation
– Supplemental O2, Administration of reversal agents,
change in ventilator settings

Case Study #2
• A 72 year old female presents with 2 days of fever,
dyspnea, and productive cough. Her room air oxygen
saturation is 85% and a room air ABG is obtained while
waiting for portable chest X-ray.
• Results: pH 7.54 PCO2 25 PO2 65 HCO3 22
• Acid-base status: _____________?

Respiratory Alkalosis
↑pH + ↓CO2

• Excess CO2 exhaled (hyperventilation)

caused by any of the following:
– Anxiety/nervousness
– Hypoxemia or interstitial lung disease
– Pulmonary embolus, pulmonary edema
– Bacteremia (sepsis), liver disease, or fever
• Treatment:
– Treat underlying cause
– Slow respiratory rate

8
 4/27/2015

Case Study #3
• A 45 year old lawyer is brought to the hospital with
complaints of severe nausea and weakness. He has had
problems with peptic ulcer disease in the past and has
been having similar pain for the past 2 weeks. Room air
ABG is drawn.
• Results: pH 7.46 PCO2 45 PO2 68 HCO3 34
• Acid-base status: _____________?

Metabolic Acidosis
↓pH + ↓ HCO3
• Bicarbonate loss at a rate
exceeding capacity of kidneys to
restore caused by:
– Severe dehydration - leading to • Treatment:
hyperchloremic acidosis caused by
the loss of too much sodium – Treat underlying cause
bicarbonate from the body
(associated with Diabetic – Administration of Sodium
ketoacidosis) Bicarbonate either by IV push
– Lactic Acidosis caused by: Alcohol,
cancer, liver failure, hypoglycemia, or IV infusion
aspirin, seizures, shock states
– Kidney disease
– Poisoning by aspirin, ethylene
glycol (found in antifreeze), or
methanol
– Administration of
Hyperalimentation
– Rapid IV Infusion of non-bicarb
containing solutions which
produces a dilutional acidosis

Case Study #4
• A 24 year old male presents with a two-day history of
severe abdominal pain, nausea, and vomiting. On exam, his
blood pressure is 90/50 and he has a markedly tender
epigastrium. Room air ABG is drawn.
• Results: pH 7.22 PCO2 35 PO2 88 HCO3 16
• Acid-base status: _____________?

9
 4/27/2015

Metabolic Alkalosis
↑pH + ↑ HCO3

• Elevated bicarbonate level related to:

– Chloride depletion- vomiting, prolonged NG
suctioning, diuretic use
– Hypokalemic alkalosis caused by the kidneys' response
to an extreme lack or loss of potassium, which can
occur when people take certain diuretic medications.
– Excessive alkali intake, such as antacid abuse, massive
blood transfusion containing citrate
• Treatment:
– Treat underlying cause
– Administration of potassium/chloride replacement
along with IV fluid administration

Acid/Base Mnemonic
(ROME)

Respiratory
R Opposite
O ↓pH + ↑CO2 Acidosis
↑pH + ↓CO2 Alkalosis

Metabolic
M Equal
E ↓pH + ↓ HCO3 Acidosis
↑pH + ↑ HCO3 Alkalosis

Acid-Base Compensation

• Respiratory disturbances will result in

kidney compensation:
– Resp Acidosis
• Increase acid excretion
• Increase bicarb reabsorption
– Slow process
– Resp Alkalosis
• Increase bicarb excretion
– Slow process

10
 4/27/2015

Acid-Base Compensation
Cont.

• Metabolic disturbances result in pulmonary

compensation:
– Metabolic Acidosis
• Hyperventilation to decrease PCO2
– Rapid compensation!
– Metabolic Alkalosis
• Hypoventilation
– Rapid compensation

ABGs – Interpreting
Compensation

High pH Low pH
• pH of 7.40 is used as Alkalosis Acidosis
“normal” when BOTH the
pCO2 and HCO3 are High Low High Low
abnormal. PaCO2 PaCO2 PaCO2 PaCO2
• 7.35 – 7.45 Metabolic Respiratory Respiratory Metabolic
– So, 7.38 is now considered
acidosis. In order to Ex.
determine if the abnormality
is due to the kidneys pH 7.38 (7.40) Acidosis
(metabolic) or lungs PaCO2 56 (35-45) Acidosis-
(respiratory) find the 2 lungs
matching values.
– The match reveals the HCO3 35 (22-26) Alkalosis
method of
compensation. Compensated Respiratory
Acidosis

Using Technology in
Interpretation
• Graphical ABG visualization
– Shown improvement in accuracy of identification
– Decreased response times when using graphical
visualization
– “Visualization may help nurses during high-stress
situations when decisions must be made quickly”
(Doig, 2011)

11
 4/27/2015

Putting It Into Practice

• ABGs contain valuable • Practice, practice,

information but does practice!
not replace a
thorough patient
assessment!
• Be systematic with
your analysis!

References

• Alspach, J. G. (2006). Core Curriculum for Critical Care Nursing. 6th ed. Saunders Elsevier:
Annapolis.
• Barnette, L. & Kautz, D. D. (2013). Creative ways to teach arterial blood gas interpretation.
Dimensions of Critical Care Nursing. 32(2). 84-87. doi:10.1097/DCC.0b013e3182bc732
• Davis, M., Walsh, B., Sittig, S., & Restrepo, R. (2013). AARC Clinical Practice Guideline: Blood Gas
Analysis and Hemoximetry. Respiratory Care. 58(10):1694-1703.
• Doig, A., Albert, R., Syroid, N., Moon, S., & Agutter, J. (2011). Graphical arterial blood gas
visualization tool supports rapid and accurate data interpretation. CIN: Computers, Informatics,
Nursing. 29(4):TC53-TC60.
• Kaufman, D. Interpretation of arterial blood gases. Retrieved March 23, 2015 from
http://www.thoracic.org/professionals/clinlical_resources/critical_care/clinical_education.ahgs.php
• Youssef, W., Yahia, A., Shaaban, A., & Elhabashy, S. (2013). Factors affecting validity of arterial blood
gases results among critically ill patients: nursing perspectives. Journal of Education and Practice.
4(15):43-56.

PRACTICE ABG’S

*To work on your own. Answers on last slide.

12
 4/27/2015

#1

• pH 7.52
• pCO2 55
• pO2 92
• HCO3 42
• BE 17

#2

• pH 7.15
• pCO2 22
• pO2 92
• HCO3 9
• BE -30

#3

• pH 7.10
• pCO2 60
• pO2 125
• HCO3 22
• BE -15

13
 4/27/2015

#4

• pH 7.44
• pCO2 25
• pO2 60
• HCO3 22
• BE -7

#5

• pH 7.36
• pCO2 33
• pO2 55
• HCO3 18
• BE -5

Answers

1. Metabolic alkalosis
2. Metabolic acidosis
3. Respiratory acidosis
4. Compensated respiratory alkalosis
5. Compensated metabolic acidosis

14