SL.

NO SPECIFIC TIME CONTENT AV AIDS TEACHERS LEARNERS EVALUATION

OBJECTIVES ACTIVITY ACTIVITY
INTRODUCTION
The arterial blood gas (ABG) measures the
acid-base balance (pH) and oxygenation of an
arterial blood sample. An ABG can be used to
assess respiratory compromise, status peri- or
post-cardiopulmonary arrest, and medical
conditions that cause metabolic abnormalities
(such as sepsis, diabetic ketoacidosis, renal
failure, toxic substance ingestion, drug
overdose, trauma or burns). An ABG can also
be used to evaluate the effectiveness of oxygen
therapy, ventilator support, fluid and
electrolyte replacement, and during
perioperative care.

TESTS COMMONLY INCLUDED

pH, pCO2, pO2, BE, SBC, O2 Saturation

PH

The pH is a measurement of the acidity of the

blood, indicating the number of hydrogen Ions
[H+] present. Most of the body’s hydrogen
ions are the result of carbohydrate and protein
metabolism. The hydrogen ion concentration
is maintained within a tight range of 7.35–7.45
by 3 mechanisms working in concert at
different time frames and at different levels.
The blood and tissue buffering system is
activated within seconds, followed by the
respiratory system where CO2 is moderated
within minutes, and the renal system where H+
is excreted and HCO3- recovered over several
hours or days to reach equilibrium.

Partial Pressure of Carbon Dioxide (pCO2)

The normal pCO2 range reflects the amount of

CO2 dissolved in the blood. Carbon dioxide is
produced by the internal respiration of tissue
cells and excreted from the body by external
respiration via the lungs.

Partial Pressure of Oxygen (pO2)

The partial pressure of oxygen (pO2) reflects

the amount of oxygen gas dissolved in the
blood.

O2 Saturation

Oxygen saturation measures the percentage

of haemoglobin that is fully combined with
oxygen as represented by the oxygen-
haemoglobin dissociation (saturation) curve.
The plateau of the haemoglobin dissociation
curve shows that there is a substantial reserve
for oxygen, and haemoglobin saturation
remains high at about 75–80% at pO2
greater than 40mmHg.
Base Excess (BE)

The BE is defined as the amount of acid

or base (in mmol) required to titrate 1 L
of blood to pH 7.4, at 37C and pCO2 of
40mmHg. The calculation of BE is
dependent on haemoglobin, pH and pCO2.
The BE does not distinguish a primary
metabolic disorder from metabolic
compensation for respiratory disorder

Bicarbonate [HCO3-]
HCO3- represents the calculated amount of
bicarbonate in the blood.
Standard Bicarbonate
The standard bicarbonate is the calculated
bicarbonate concentration corrected to pCO2
of 40mmHg.
SPECIMEN

An ABG specimen should be collected in

a
heparinised blood gas syringe anerobically
and analysed within 30 minutes; otherwise,
they should be placed on ice. Prior to an
arterial puncture, the Allen Test should be
performed to check for the ability of the
radial and ulnar arteries to return blood to
the hand. By engaging the patient while doing
the Allen Test, the phlebotomist engages the
patient and thus helps to put him or her at
ease further ensuring an optimal outcome.
While the use
of local anaesthesia in arterial puncture has
been recommended1 it is seldom practised. A
comparison of 5 arterial blood sample kits
showed that current available products satisfy
requirements for speed, ease of sampling, and
specimen quality2. Glycolysis can cause
significant changes in pH, pO2, and pCO2
after 20–30 minutes at room temperature3.
It is important to allay the anxiety of the
patient when obtaining the specimen as such a
“white coat” effect may skew ABG results.
The Clinical Laboratory and Standards
Institute (CLSI) recommends that ABG
specimens collected in plastic syringes should
be analysed within 30 minutes if they are left
at room temperature.Guidelines are also
available on ABG sampling and analysis

PRE-ANALYTICAL SOURCES OF
ERROR
Pre-analytical sources of error may be
introduced during patient preparation and
specimen handling. A patient safety procedure
that can never be overemphasised is positive
patient identification identifying the patient
and labelling the specimen at the bedside
using 2 primary identifiers. Rapid changes
in ABG results may be expected in an
agitated patient or following physical
exertion. Ideally, the

patient should be in a supine and relaxed

position, and a lapse of 20–30 minutes be
allowed if the fraction of inspired oxygen
(FiO2) has been changed before another
patient sample is drawn4. Commercial blood
gas syringes have been calibrated for the
correct amount of blood to anticoagulant
and strict anerobiosis. Excess heparin can
affect pH and cause specimen dilutionality of
ABG results.
AFTER CARE
To prevent haematoma at the puncture site
apply pressure for up to 10 minutes or even
longer for anticoagulated patients. Always
check for any bleeding thereafter.
INDICATIONS
ABG results provide information on the
acid-
base status, oxygenation (pO2 and
haemoglobin

saturation) and CO2 elimination. A

utilisation survey of a large tertiary hospital
showed that the reasons for requesting ABG
tests included change in ventilator setting,
respiratory event, part of clinical routine,
metabolic episode, pre- and post-intubation,
pre- and post-extubation, confirmation of
pulse oximetry results and abnormal results,
altered mental state, to establish brain death
and cardiac event7. Most labs have defined
“critical/alert values” for pH, pCO2 and pO2
which are to be called to the requesting
clinician. Active tele-notification has been
shown to be more effective than passive
electronic systems8. These values represent
patho-physiologic state at such variance with
normal as to be life-threatening if an action is
not taken quickly and for which an effective
action is possible .A report of the College
of American Pathologists (CAP) Q-Probes
Study in 623 institutions proposed that labs
develop policies for handling a second
critical value obtained on the same day based
on the
principle that physicians should not be
contacted needlessly with values they know
are previously elevated, and suggests that
perhaps only the first of a series of values
within 24 hours should require notification12.
(Table 1 lists the reference ranges and alert
values reported in the authors’ lab.)As
clinicians opt for less invasive assessments
of respiratory function such as
capnography,
pulse oximetry and spirometry, ABG may
be
indicated only to confirm the patient’s
status, for example acute asthma and
chronic obstructive pulmonary disease
(COPD)13–16.

CONCLUSION
Assessment of arterial blood gas (ABG)
results are the bane of many students and
junior doctors as it is poorly learned or

poorly taught. We offer a simple approach.

Oxygen saturation measures the percentage

of haemoglobin that is fully combined with
oxygen as represented by the oxygen-
haemoglobin dissociation (saturation) curve