Presentation on theme: "Venous Blood Gas Versus Arterial Blood Gas Analysis"— Presentation transcript:
1Venous Blood Gas Versus Arterial Blood Gas Analysis Ping-Wei ChenPGY-2Emergency Medicine
2It’s Go Time… 25 yo female Single vehicle rollover near Sundre Intubated for deteriorating GCSIn the ED:BP 70 palp, HR 122Not responding to painful stimuli01:23 - VBG ordered as part of workup01:41 – ABG ordered as part of workupI’m not really going to focus on the trauma aspect of this case because I want to get to the main topic of my talk, but at 1:23 am, a VBG is ordered as part of the workup for the patient not responding to painful stimulus greater than one hour after being RSI’d. There is some concern over the use of a tourniquette to obtain the VBG, and an ABG is subsequently ordered following.This is just one example of why one might run into conflict between VBGs and ABGs, however, I’ve had numerous other instances where I’ve encountered resistance for ordering a VBG.
3Objectives Controversy Can VBGs replace ABGs? When are VBGs and ABGs different?When might I want an ABG?NOT coveredElectrolytesLactate
4What’s all the fuss about? Arterial Blood GasVenous Blood GasPAINFULArterial injuryThrombosis with distal ischemiaHemorrhage/hematomaAneurysm formationMedian nerve damageInfectionNeedlestick injuryReflex sympathetic dystrophySamples can be drawn simultaneously at time of venipunctureShould be done without tourniquetteMore difficult to obtain in pulseless patientsControversy regarding level of agreement with arterial valuesQuestion: What has been some of the hassles that you people have experienced in ordering VBGs?Question: What are some of the consequences of obtaining ABG samples?Question:How would we expect values for pH, CO2, O2, and HCO3 to compare in VBG VS ABG?Largely a remnant of the past when pulse oximetry was not available to measure systemic oxygen levels.
5Prospective, observational study 218 subjects, ED population dyspnea, DKA, renal failure, seizures, ↓LOC, ingestions, ischemic colitisA priori definition of clinically important differencePearson correlation coefficientBland-Altman plotsThere are few large scale studies looking at this topic in ED populations, but many smaller studies looking at specific subsets of patients.Elegant study – Collected ABG and VBG in series in patients at Kingston General Hospital and recorded pH, PCO2, and calculated HCO3. Then, they surveyed 45 physicians to determine the level of difference that they would consider clinically important.Bland-Altman analysis: plots the difference between two methods of measurement (y-axis) against the average of the values obtained by the two methods. Limits of agreement are then determined to be the mean difference between the two values +/- 2SDs, determined to be the 95% confidence interval. Often used when two methods of measurement are being evaluated against each other to determine if they can be used interchangeably.87% samples within 5 mins, 96% samples within 10 mins, 100% samples within 30 minsRang et al Can J Emerg Med 4(1):7
6Results pH (r= 0.913) pCO2 (r=0.921) calculated HCO3 (r=0.953) Excellent correlationpH (r= 0.913)pCO2 (r=0.921)calculated HCO3 (r=0.953)In this study, they found excellent correlation between the values of those measured by ABG and VBG.However, correlation by itself is not good enough for one method of measurement to replace the other.
7Results Clinically Important Differences 26/45 physicians responded Here are the Bland-Altman plots for this study which you recall show the difference between two methods of measurement (y-axis) against the average of the values obtained by the two methods (x-axis). The one difference between these graphs and true Bland-Altman plots is that the dotted lines represent what the physicians thought were clinically significant differences rather than the values around the mean difference that would capture 95% of the differences between ABG and VBG values.Of the 26/45 physicians who responded to the survey, they defined the above as what they considered to be clinically important or “I would feel uncomfortable using only the venous value for clinical decisions if it was more than ___units away from the arterial value”.Physicians opinions:pH ±0.05 (66% study values) VS 0.08PCO2 ±6.6 (51% study values) VS 13.9HCO3 ±3.5 (87% study values) VS 3.5
8Result Mean Differences pH 0.036 (0.030-0.042) pCO2 6.0 mm Hg ( )HCO3 1.5 mEq/L ( )The mean differences found in this study were the above. The values in the brackets indicate the 2 standard deviations around the mean difference required to capture 95% of the differences between the VBG and ABG measurements.Bland and Altman state that if the mean difference between 2 measurements ±2SD is not clinically significant, then the two measurements could be used interchangeably.Therefore, from these results, VBG and ABG results are not equivalent, and cannot be used interchangeably, however, correlate well with each other.The authors’ conclusions were that although the values measured on VBG cannot be used interchangeably with those of an ABG, they can be used to follow trends or for broader use with a refined set of normal values.Therefore, the question you have to ask yourself is: are these differences enough to make you change your management?
9Prospective, observational study 246 subjects, ED population acute respiratory disease, suspected metabolic disorderpH onlyResults:Excellent correlation r=0.92Mean difference: 0.04 pH units (-0.11 to +0.04)Another study by Anne-Maree Kelly out of Australia looked at agreement in pH values between VBG and ABG.Kelly et al Emerg Med J. 18:340
10Prospective, observational study 95 patients, ED population AECOPD, pneumonia, sepsis, ARF/CRF, DKA, ACS, acute gastroenteritis, SLE, toxic ingestionBland-Altman AnalysisResults: ABG compared to VBGThe most recent study to look at ABG VS VBG is this one by Malatesha et al in the Journal of Emergency Medicine. They found the above results. From this, they concluded that agreement is excellent between pH values, and that there is acceptably narrow agreement in PCO2 and HCO3 values.Mean Difference95% Limits of AgreementpH0.015-0.1 to 0.13PCO2-3-7.6 to 6.8HCO3-0.74-5.8 to 4.3PO265-32.9 to 145.3
11Review article: 6 studies pH and HCO3 Results: Mean differencepH: 0.02 ( to 0.021), n=258, DKA patients onlypH: (-0.11 to 0.04), n =763, respiratory/metabolic illnessHCO3: mEq/L (N/A), n =21, DKA patients onlyHCO3: mEq/L (-2.73 to 5.13), n=763, respiratory/metabolic illnessRecently, Anne-Maree Kelly also reviewed 6 studies looking at the agreement between ABGs and VBGs in DKA patients. Some of the papers reviewed, however, did not specify DKA as the specific diagnosis, but only stated the diagnosis as mixed respiratory/metabolic disorder and as such were included in the review. They found the above.
12When are they different? Weil et al Difference in acid-base state between venous and arterial blood during cardiopulmonary resuscitation. NJEM. 315:153-6.Prospective, observational study (n=16)ICU/CCU patientsArteriovenous gradientThe literature identifies one population where VBGs differ from ABGsCritically ill patient population with major hemodynamic deficits prior to participation in the study. Already had pulmonary artery catheters in place.Pre-ArrestArrestpH0.06±0.020.30±0.05pCO211±2 mmHg36±6mmHg
13So when might I want an ABG? Unable to establish IV accessInability to obtain sampleInability to obtain O2 saturation by pulse oximeterPeripheral vasoconstrictionAbnormal hemoglobinsCarboxyhemoglobinMethemoglobinSickle hemoglobinIf you’re Mel Herbert or Michael Gauding of EMRap, the only time you would do a venous gas is if you couldn’t establish IV access!The only time I argue that you might want an ABG is when you can’t rely on your pulse oximeter to screen for hypoxia, which has been shown in the literature to be very good at doing this.Carboxyhemoglobin – artificially elevate O2 satMethemoglobin – artificially lowers O2 satSickle hemoglobin – can raise or lower O2 satQuestion: (for staff) Are there any other situations in which you might order an ABG instead of a VBG?
14N = 1 VBG at 01:32 ABG at 01:41 pH 7.11/pCO2 41/HCO3 14/lactate 6.6 In our N = 1 study with samples taken 9 minutes apart, we see that the correlation in pH, PCO2, and HCO3 are within the limits where our clinical decision making would not be affected. For interests sake, although this is not backed up by evidence, the lactates are not as far off as you might think even though a tourniquette was used to obtain the sample.
15Conclusions VBGs not interchangeable with ABGs BUT Consider ABG in: Excellent correlation with ABG valuesReasonable agreement on VBG for clinical decision making in EDpH lowerPCO2 3-6 mmHg higherHCO3 essentially the sameConsider ABG in:Inability to obtain sampleInability to utilize pulse oximeter