Arterial Blood

Gas Analysis

Ram E. Rajagopalan,
MBBS, AB (Int. Med & Crit. Care)
Consultant & Head, Dept. of Critical Care Medicine
SUNDARAM MEDICAL FOUNDATION, Chennai
Goals of this talk:

To provide one approach to interpretation of

blood gases (Oxygenation & Acid-base disorders)

Not:
To teach physiology of respiratory gas exchange
To discuss theories on acid-base regulation
To debate alternative approaches to
interpretation
A Systematic Approach
As required for ECG
interpretation,
a systematic approach to
ABGs enhances accuracy.

There are NO short-cuts!

 ----- XXXX Diagnostics ------ The Anatomy
Blood Gas Report
248
Pt ID
05:36
2570 / 00
Jul 22 2000 of a Blood Gas Report
o
Measured 37.0 C
pH 7.463
Measured Values
pCO2 44.4 mm Hg
pO2 113.2 mm Hg

Corrected 38.6 C
o
Temperature Correction:
pH 7.439 Is there any value to it?
pCO2 47.6 mm Hg
pO2 123.5 mm Hg

Calculated Data Calculated Data:

HCO3 act 31.1 mmol / L
HCO3 std 30.5 mmol / L Which are the useful ones?
BE 6.6 mmol / L
O2 CT 14.7 mL / dl
O2 Sat 98.3 %
ct CO2 32.4 mmol / L
pO2 (A - a) 32.2 mm Hg
pO2 (a / A) 0.79 Entered Data:
Entered Data Derived from other sources
Temp 38.6 oC

ct Hb 10.5 g/dl
FiO2 30.0 %
Traditional Measurements

pH electrode

pCO2 electrode (Severinghaus)

pO2 electrode (Clark)

Additional options include:

Co-oximeter; measures O2 saturation
Na+, K+, Ca2+, Cl-
Haematocrit
 ----- XXXX Diagnostics ------ Temperature Correction:
Blood Gas Report A spin-off of microprocessor
capability?
o
Measured 37.0 C
pH 7.463 “ There is no scientific basis ... for applying
pCO2
pO2
44.4
113.2
mm Hg
mm Hg
temperature corrections to blood gas
o
measurements…”
Corrected 38.6 C Shapiro BA, OTCC, 1999.
pH 7.439
pCO2 47.6 mm Hg
pO2 123.5 mm Hg Uncorrected pH & pCO2 are reliable
Calculated Data reflections of in-vivo acid base status
HCO3 act 31.1 mmol / L
HCO3 std 30.5 mmol / L Temperature correction of pH & pCO2 do
BE 6.6 mmol / L
O2 CT 14.7 mL / dl not affect calculated bicarbonate
O2 Sat 98.3 %
o
t CO2
pO2 (A - a)
32.4
32.2
mmol / L
mm Hg
pCO2 reference points at 37 C are well
pO2 (a / A) 0.79 established as reliable reflectors of alveolar
Entered Data
ventilation
Temp 38.6 oC

ct Hb 10.5 g/dl Reliable data on DO2 and oxygen demand are

FiO2 30.0 % o
unavailable at temperatures other than 37 C
 ----- XXXX Diagnostics ------

Blood Gas Report

Bicarbonate:

Measured 37.0 C
o Bicarbonate is calculated on the
pH
pCO2
7.463
44.4 mm Hg
basis of the
pO2 113.2 mm Hg
Henderson equation:
o
Corrected 38.6 C
+ -
[H ] = 24 pCO2 / [HCO3 ]
Calculated Data or
HCO3 act 31.1 mmol / L
HCO3 std 30.5 mmol / L for the mathematically inclined…
BE 6.6 mmol / L
O2 CT 14.7 mL / dl
O2 Sat 98.3 % Henderson-Hasselbach equation:
t CO2 32.4 mmol / L
pO2 (A - a) 32.2 mm Hg
pO2 (a / A) 0.79
pH = pKc + Log [HCO3-]
Entered
Temp 38.6
Data
oC a pCO2
ct Hb 10.5 g/dl
FiO2 30.0 %
 ----- XXXX Diagnostics ------ Standard Bicarbonate:
Blood Gas Report Plasma HCO3 after equilibration
to a PCO2 of 40 mm Hg
o
Measured 37.0 C
pH 7.463
: reflects non-respiratory acid base change
pCO2 44.4 mm Hg : does not quantify the extent of the buffer
pO2 113.2 mm Hg
o
base abnormality
Corrected 38.6 C : does not consider actual buffering
capacity of blood

Calculated
HCO3 act 31.1
Data
mmol / L
Base Excess:
HCO3 std
BE
30.5
6.6
mmol / L
mmol / L D base to normalise HCO3 (to 24)
O2 CT 14.7 mL / dl
O2 Sat 98.3 % with PCO2 at 40 mm Hg
t CO2 32.4 mmol / L (Sigaard-Andersen)
pO2 (A - a) 32.2 mm Hg : reflects metabolic part of acid base D
pO2 (a / A) 0.79
: no info. over that derived from pH,
Entered Data pCO2 and HCO3
Temp 38.6 oC

ct Hb 10.5 g/dl : Misinterpreted in chronic or mixed

FiO2 30.0 %
disorders
----- XXXX Diagnostics ------

Blood Gas Report

Oxygenation
Parameters:
o
Measured 37.0 C
pH 7.463 O2 Content of blood:
pCO2 44.4 mm Hg
pO2 113.2 mm Hg Hb x O2 Sat x Const. + Dissolved O2
o
Corrected 38.6 C
Oxygen Saturation:
Calculated Data
HCO3 act 31.1 mmol / L
HCO3 std 30.5 mmol / L
BE
O2 CT
6.6
14.7
mmol / L
mL / dl
Alveolar / arterial gradient:
O2 Sat 98.3 %
t CO2 32.4 mmol / L
pO2 (A - a) 32.2 mm Hg
pO2 (a / A) 0.79

Entered Data
Temp 38.6 oC Arterial / alveolar ratio:
ct Hb 10.5 g/dl
FiO2 30.0 %
 Oxygen Saturation
100% Most blood gas
machines estimate
Saturation

saturation from an
idealized dissociation
curve
Gold standard is
0 60 120 co-oximetry
pO2
Errors may occur with abnormal haemoglobins.

Oxygen content is calculated from this.

Alveolar-arterial Difference
Inspired O2 = 21%= piO2 = (760-45) x .21=150 mmHg

palvO2 = piO2 - pCO2 / RQ

= 150 - 40/0.8
= 150 – 50 = 100 mm Hg
O2
CO2

partO2 = 90 mmHg

palvO2- partO2 = 10 mmHg

 Alveolar-arterial Difference
Oxygenation Failure Ventilation Failure
piO2 = 150 piO2 = 150

pCO2 = 40 pCO2 = 80

palvO2= 150 – 40/.8 palvO2= 150-80/.8

=150-50 O2 =150-100
=100 CO2 = 50

pO2 = 45 pO2 = 45

D = 100-45 = 55 D = 50-45 = 5
Arterial-alveolar Difference

A-a DO2 Severe

B
Moderate
C Mild

D Normal

% Inspired Oxygen
----- XXXX Diagnostics ------

Blood Gas Report

Oxygenation:
Limitations of parameters:
o
Measured 37.0 C O2 Content of blood:
pH 7.463
pCO2 44.4 mm Hg Useful in oxygen transport calculations
pO2 113.2 mm Hg
Derived from calculated saturation
o
Corrected 38.6 C
Oxygen Saturation:
Ideally measured by co-oximetry
Calculated values may be error-prone
Calculated Data
HCO3 act 31.1 mmol / L
Alveolar / arterial gradient:
O2 CT 14.7 mL / dl Reflects O2 exchange with fixed FiO2
O2 Sat 98.3 %
t CO2 32.4 mmol / L Impractical
pO2 (A - a) 32.2 mm Hg
pO2 (a / A) 0.79 Differentiates hypoventilation as cause
Entered Data
oC
Arterial / alveolar ratio:
Temp 38.6
ct Hb 10.5 g/dl Proposed to be less variable
FiO2 30.0 %
Same limitations as A-a gradient
 ----- XXXX Diagnostics ------
The Blood Gas Report:
Blood Gas Report
o
The essentials
Measured 37.0 C
pH 7.463
pCO2 44.4 mm Hg pH 7.40 + 0.05
pO2 113.2 mm Hg
PCO2 40 + 5 mm Hg
Calculated Data PO2 80 - 100 mm Hg
HCO3 act 31.1 mmol / L

O2 Sat 98.3 %
pO2 (A - a) 32.2 mm Hg
HCO3 24 + 4 mmol/L

Entered Data O2 Sat >95

FiO2 30.0 % A-a D 2.5+(0.21 x Age) mm Hg
Technical Errors
Glass vs. plastic syringe:
Changes in pO2 are not clinically important
No effect on pH or pCO2
Heparin (1000 u / ml):
Need <0.1 ml / ml of blood
pH of heparin is 7.0; pCO2 trends down
Avoided by heparin flushing & drawing 2-4 cc
blood
Delay in measurement:
Rate of changes in pH, pCO2 and pO2 can be
reduced to 1/10 by cooling in ice slush(4o C)
No major drifts up to 1 hour
The
Habits of
Highly
Successful
Blood Gas
Analysts
Dr. Ram “Covey” Rajagopalan
(With apologies to Narins, Emmett & Morganroth)
Step 1
Look at the pH
Is the patient acidemic pH < 7.35
or alkalemic pH > 7.45

Step 2
Is it a metabolic or respiratory disturbance ?
Acidemia: With HCO3 < 20 mmol/L = metabolic
With PCO2 >45 mm hg = respiratory

Alkalemia: With HCO3 >28 mmol/L = metabolic

With PCO2 <35 mm Hg = respiratory
Step 3
If there is a primary respiratory disturbance, is it acute?
Expect D pH = 0.08 x D PCO2 / 10

Step 4
For a respiratory disorder is renal compensation OK?

Respiratory acidosis: <24 hrs: D [HCO3] = 1/10 D PCO2

>24 hrs: D [HCO3] = 3/10 D PCO2

Respiratory alkalosis: 1- 2 hrs: D [HCO3] = 2/10 D PCO2

>2 days: D [HCO3] = 6/10 D PCO2
Step 5
If the disturbance is metabolic is the respiratory
compensation appropriate?

For metabolic acidosis:

Expect PCO2 = (1.5 x [HCO3]) + 8 + 2
(Winter’s equation)

For metabolic alkalosis:

Expect PCO2 = (0.7 x [HCO3]) + 21 + 1.5

If not:
actual PCO2 > expected : hidden respiratory acidosis
actual PCO2 < expected : hidden respiratory alkalosis
Step 6
If there is metabolic acidosis, is there an anion gap?

Na - (Cl-+ HCO3-) = Anion Gap usually <12

If >12, Anion Gap Acidosis : Methanol

Uremia
Diabetic Ketoacidosis
Paraldehyde
Infection (lactic acid)
Ethylene Glycol
Salicylate
Step 7
Does the anion gap explain the change in bicarbonate?

D anion gap (Anion gap -12) ~ D [HCO3]

If D anion gap is greater;

consider additional metabolic alkalosis

If D anion gap is less;

consider a nonanion gap metabolic acidosis
 ----- XXXX Diagnostics ------

Blood Gas Report Case 2

pH <7.35 ; acidemia

Measured
o
37.0 C pCO2 >45; respiratory acidemia
pH 7.301 D CO2 =76-40=36
pCO2 76.2 mm Hg Expected D pH = 36/10 x0.08=0.29
pO2 45.5 mm Hg Expected pH = 7.40-0.29=7.11
Calculated Data Chronic resp. acidosis
HCO3 act 35.1 mmol / L 60 year old male smoker
Limits:
with progressive
O2 Sat 78 % DHCO3 = 3/10 of D pCO2
pO2 (A - a) 9.5 mm Hg D respiratory distress
=3/10x36=10.8
pO2 (a / A) 0.83 and somnolence.
Limits of HCO3 = 24+11=35
Entered Data Pure Resp Acidosis
FiO2 21 %

Hypoxia
Normal A-a gradient
Due to hypoventilation
Blood
----- XXXX Diagnostics ------

Gas Report
Case 4
pH <7.35 ; acidemia

Measured
o
37.0 C pCO2 >45; respiratory male
18-year-old acidemia
asthmatic;
pH 7. 24
D3COdays of cough, dyspnea
2 = 49 - 40 = 9
pCO2 49.1 mm Hg
pO2 66.3 mm Hg
Expected D pH = 9/10 not
and orthopnea x 0.08 = 0.072
Expected pH = 7.40
responding to -usual
0.072 = 7.328
Calculated Data Acute resp. acidosis
HCO3 act 18.0 mmol / L bronchodilators.
Limits:
O2 Sat 92 %
DHCO3
O/E:= 1/10 of D pCO2
Respiratory distress;
pO2 (A - a) 153-66= 87 mm Hg D
=1/10x9=0.9
pO2 (a / A) suprasternal and
Limits of HCO3 = 24+1=25
Entered Data Respintercostal retraction;
Acidosis + Metabolic Acidosis
FiO2 30 % tired looking; on 4 L NC.
Hypoxia
piO2 = 715x.3=214.5 / palvO2 = 214-49/.8=153
 ----- XXXX Diagnostics ------
pH <7.35 ; acidemia
Blood
Measured
Gas Report
o
37.0 C Limits:
Case 5
pH 7.23 Expected pCO2 = (1.5 x HCO3)+8 + 2
pCO2 23 mm Hg = (1.5 x 14)+ 8 + 2
pO2 110.5 mm Hg = 29 + 2 = 27 to 31
Calculated Data Met. Acidosis
28 year+ Resp.
old alkalosis
diabetic with
HCO3 act 14 mmol / L
respiratory distress
HCO3 <22; metabolic acidemia
O2 Sat %
fatigue and
pO2 (A - a) mm Hg D
pO2 (a / A) loss of appetite.
Entered Data If Na = 130,
FiO2 21.0 % Cl = 100
Anion Gap = 130 - (100 + 14)
Normal AG= 12; D Gap = 16 - 12 = 4 = 130 - 114= 16
DHCO3 = 24 - 14 = 10, 2.5 accounted for by resp. alkalosis;
D/D 3.5 indicates additional non-gap acidosis
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material….please copy for
educational purposes….

… and thanks for not becoming comatose!