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Arterial Blood Gases. Aims and Objectives AIM AIM Assess degree to which lungs are able to provide adequate oxygen & remove CO2 & degree to which the.

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1 Arterial Blood Gases

2 Aims and Objectives AIM AIM Assess degree to which lungs are able to provide adequate oxygen & remove CO2 & degree to which the kidneys are able to reabsorb or excrete HCO3 Objectives Objectives  To give a basic understanding of normal blood gas parameters  Recognise abnormalities and differences between a metabolic and respiratory problem  Enable staff to analyse them in the critical care setting and identify when to alert medical staff

3 When and Why Do We Take Arterial Blood Gases? Arterial Blood Gases (ABG’s) can provide valuable clinical information in critically ill patient Arterial Blood Gases (ABG’s) can provide valuable clinical information in critically ill patient(www.resus.org.uk/pages/alsmBGap.pdf) ABG’s are indicated if the patient has a further deterioration in an already critical condition such as: ABG’s are indicated if the patient has a further deterioration in an already critical condition such as: Decrease in oxygen saturations head or neck trauma, injuries that may affect breathing Fall in conscious level (Glasgow Coma Score) Increased respiratory effort Cyanosis Patients undergoing prolonged anesthesia Patients undergoing prolonged anesthesia It is therefore an essential skill of the practitioner to be able to analyse the results and act on appropriately It is therefore an essential skill of the practitioner to be able to analyse the results and act on appropriately(www.edu.rcsed.ac.uk/lectures/lt8.htm)

4 Indications For An ABG! diagnosis, determine severity of a condition and direct further interventions diagnosis, determine severity of a condition and direct further interventions Enable both medical staff to evaluate how sufficiently the patient is oxygenating, transporting oxygen within the blood flow and acid base levels Enable both medical staff to evaluate how sufficiently the patient is oxygenating, transporting oxygen within the blood flow and acid base levels (Hess D, 2000) However it must be remembered that ABG analysis is only part of a respiratory assessment and cannot be conclusive of a patient condition

5 ABG’s can also be indicated to: Diagnose the different types of and severity of a respiratory failure Diagnose the different types of and severity of a respiratory failure i.e. cardiac and respiratory failure i.e. cardiac and respiratory failure Can be used as a guide for treatment therapy i.e. oxygen administration Can be used as a guide for treatment therapy i.e. oxygen administration Monitoring purposes during surgery Monitoring purposes during surgery (Williams, 1998)

6 NORMAL ARTERIAL BLOOD GAS VALUES! In order to make an analysis of an ABG we need to have a knowledge of normal ranges on which to base our analysis! In order to make an analysis of an ABG we need to have a knowledge of normal ranges on which to base our analysis! patient who have a preexisting respiratory complaints may almost certainly have altered blood gas values which will be known as normal for them patient who have a preexisting respiratory complaints may almost certainly have altered blood gas values which will be known as normal for them (Pruitt WC, 2004) LowerUpper PO 2 10kPa13kPa PCO 2 4.5kPa6kPa pH Hb14g/dl SaO 2 95% + HCO 3 22kPa28kPa

7 What Is PO 2 ? Partial pressure of O 2 in blood plasma Partial pressure of O 2 in blood plasma Partial pressure causes O 2 to diffuse from a region of higher pressure to a region of lower pressure, lungs to plasma, plasma to haemoglobin, haemoglobin to tissues Partial pressure causes O 2 to diffuse from a region of higher pressure to a region of lower pressure, lungs to plasma, plasma to haemoglobin, haemoglobin to tissues When breathing in normal room air a patient PO 2 will not exceed 13 kPa When breathing in normal room air a patient PO 2 will not exceed 13 kPa(www.acessmedicine.com) By giving supplementary O 2 the PO 2 can exceed normal ranges but the amount of O 2 carried to the tissues won’t increase, due to O 2 being carried in haemoglobin By giving supplementary O 2 the PO 2 can exceed normal ranges but the amount of O 2 carried to the tissues won’t increase, due to O 2 being carried in haemoglobin (Outreach/Clinical Education 2001)

8 PO 2, OXYGEN SATURATIONS (SpO 2 ) AND OXYGEN CONTENT OF BLOOD The maintenance of a normal PO 2 and SpO 2 can depend on the ability of O 2 to diffuse from the lungs into the blood stream The maintenance of a normal PO 2 and SpO 2 can depend on the ability of O 2 to diffuse from the lungs into the blood stream This can be impeded by various conditions including infection and swelling. If this occurs then PO 2 and SPO 2 will fall This can be impeded by various conditions including infection and swelling. If this occurs then PO 2 and SPO 2 will fall However, underlying respiratory conditions can deteriorate further despite the additional O 2 and continual assessment will be required However, underlying respiratory conditions can deteriorate further despite the additional O 2 and continual assessment will be required (DuBose et al. 1997)

9 GAS EXCHANGE Getting O 2 to body tissues requires good gas exchange from lung to blood stream, a good amount of heamoglobin to carry O 2 and a good blood pressure to circulate the oxygen laden heamoglobin to the tissues Getting O 2 to body tissues requires good gas exchange from lung to blood stream, a good amount of heamoglobin to carry O 2 and a good blood pressure to circulate the oxygen laden heamoglobin to the tissues Controlling respiratory function is also essential is gas exchange Controlling respiratory function is also essential is gas exchange Enzymes within the body work well within a narrow pH range, which is controlled by the body (Normal range 7.35 – 7.45) Enzymes within the body work well within a narrow pH range, which is controlled by the body (Normal range 7.35 – 7.45) Changes in the pH can cause both acidosis and alkalosis Changes in the pH can cause both acidosis and alkalosis (Outreach/Clinical Education 2001) (Outreach/Clinical Education 2001)

10 ACIDOSIS Acidosis occurs when a pH less than 7.35 Acidosis occurs when a pH less than 7.35 Acidosis is often a result of poor respiratory or renal function Acidosis is often a result of poor respiratory or renal function However, it should be remembered that acidosis can also be caused by other body systems, known as non – respiratory or metabolic acidosis However, it should be remembered that acidosis can also be caused by other body systems, known as non – respiratory or metabolic acidosis Both the kidneys and the lungs control the acid levels in the body, if respiratory failure occurs the kidneys will compensate and vice versa Both the kidneys and the lungs control the acid levels in the body, if respiratory failure occurs the kidneys will compensate and vice versa Alkalosis may also have respiratory or metabolic causes Alkalosis may also have respiratory or metabolic causes (www.edu.rcsed.ac.uk/lectures/lt8.htm) (www.edu.rcsed.ac.uk/lectures/lt8.htm)www.edu.rcsed.ac.uk/lectures/lt8.htm As acidosis becomes more severe respiration will increase with the patient becoming increasingly tired causing a rise in CO2 and worsening of acidosis As acidosis becomes more severe respiration will increase with the patient becoming increasingly tired causing a rise in CO2 and worsening of acidosis (www.nlm.nih.gov/medlineplus/ency/article/ htm)

11 Respiratory acidosis-Etiology Upper airway obstruction Upper airway obstruction Lower airway obstruction Lower airway obstruction Cardiogenic or non-cardiogenic pulmonary edema Cardiogenic or non-cardiogenic pulmonary edema Pneumonia Pneumonia Pulmonary emboli Pulmonary emboli Fat emboli Fat emboli Central nervous system depression Central nervous system depression Neuromascular impairment Neuromascular impairment Ventilatory restriction Ventilatory restriction

12 Respiratory Acidosis As CO 2 is dissolved it produces an increase in acidity As CO 2 is dissolved it produces an increase in acidity When respiratory acidosis occurs the patient ventilatory response is decreased causing carbon dioxide to be retained (in PC0 2 and in pH) When respiratory acidosis occurs the patient ventilatory response is decreased causing carbon dioxide to be retained (in PC0 2 and in pH) When this occurs the kidneys excrete hydrogen and retain bicarbonate (FitzSullivan et al. 2005) When this occurs the kidneys excrete hydrogen and retain bicarbonate (FitzSullivan et al. 2005) Bicarbonate can be measured using ABG analysis and the following may be seen Bicarbonate can be measured using ABG analysis and the following may be seen CO 2 to above 7kPa CO 2 to above 7kPa pH 7.35 HCO 3 to 32 mmols Kidneys excrete the hydrogen ions that cause acidity and retain bicarbonate to reduce the acidity Kidneys excrete the hydrogen ions that cause acidity and retain bicarbonate to reduce the acidity (Kellum 2005)

13 Metabolic Acidosis Hydrogen ions can cause acidosis pH than 7.35 with a normal CO2 Hydrogen ions can cause acidosis pH than 7.35 with a normal CO2 Loss of bicarbonate in conditions such as diarrhoea and failure to excrete hydrogen due to kidney failure Loss of bicarbonate in conditions such as diarrhoea and failure to excrete hydrogen due to kidney failure Drugs can also induce metabolic acidosis as can poor circulation Drugs can also induce metabolic acidosis as can poor circulation The respiratory compensation for metabolic acidosis includes a in respiratory rate and depth to blow ‘off’ carbon dioxide therefore reducing the acidity. On the ABG analysis a low CO2 will be seen The respiratory compensation for metabolic acidosis includes a in respiratory rate and depth to blow ‘off’ carbon dioxide therefore reducing the acidity. On the ABG analysis a low CO2 will be seen CO2 3.5kPa or CO2 3.5kPa or pH 7.35 HCO3 -18 mmols This is a response by the respiratory system on the increased acidity (Saad EB, 1996)

14 Metabolic Acidosis Normal AG acidosis The fall in bicarbonate is matched by a proportional rise in serum chloride (hyperchloremic metabolic acidosis). The fall in bicarbonate is matched by a proportional rise in serum chloride (hyperchloremic metabolic acidosis). Most common causes are gastrointestinal and renal loses of bicarbonate. Most common causes are gastrointestinal and renal loses of bicarbonate.

15 Alkalosis If a patient has an in respiratory rate and depth (hyperventilation) therefore ‘blowing off’ more than normal amounts of carbon dioxide a rise in pH can occur causing a respiratory alkalosis If a patient has an in respiratory rate and depth (hyperventilation) therefore ‘blowing off’ more than normal amounts of carbon dioxide a rise in pH can occur causing a respiratory alkalosis The ABG analysis may show The ABG analysis may show CO 2 3.5kPa ph 7.55 HC0 3 – 26mmols As this is a reversible condition the C0 2 is ‘blown off’ by the patient and make C0 2 and H 2 0, the concentration of the hydrogen ions, causing pH to rise above normal limits and cause an alkalosis As this is a reversible condition the C0 2 is ‘blown off’ by the patient and make C0 2 and H 2 0, the concentration of the hydrogen ions, causing pH to rise above normal limits and cause an alkalosis It is also important to remember that patient can be hyperventilating due to anxiety It is also important to remember that patient can be hyperventilating due to anxiety (Murray J et al. 2000)

16 Respiratory alkalosis-Etiology Central nervous system stimulation: Fever, pain, fear, cerebrovascular accident, CNS infection, trauma, tumor. Central nervous system stimulation: Fever, pain, fear, cerebrovascular accident, CNS infection, trauma, tumor. Hypoxia: High altitude, profound anemia, pulmonary disease. Hypoxia: High altitude, profound anemia, pulmonary disease. Stimulation of chest receptors: Pulmonary edema, pulmonary emboli, pneumonia, pneumothorax, pleural effusion. Stimulation of chest receptors: Pulmonary edema, pulmonary emboli, pneumonia, pneumothorax, pleural effusion. Drugs or hormones : Salicylates, medroxyprogesterone, catecholamines. Drugs or hormones : Salicylates, medroxyprogesterone, catecholamines. Miscellaneous: Sepsis, pregnancy, liver disease, hyperthyroidism. Miscellaneous: Sepsis, pregnancy, liver disease, hyperthyroidism.

17 Renal Compensation in Alkalosis As we are aware the lungs and kidneys compensate each other, in this scenario the kidneys try to compensate by excreting excess bicarbonate and retain the hydrogen ions As we are aware the lungs and kidneys compensate each other, in this scenario the kidneys try to compensate by excreting excess bicarbonate and retain the hydrogen ions An ABG analysis will show An ABG analysis will show C kPa ph 7.45 HC0 3 – 16mmols It must again be remembered when caring for clients that they may be chronically anxious therefore having a respiratory rate It must again be remembered when caring for clients that they may be chronically anxious therefore having a respiratory rate (Bennett et al. 1996)

18 METABOLIC ALKALOSIS Can be caused by various conditions including vomiting causing excess loss of hydrogen ions and excessive gain of bicarbonate Can be caused by various conditions including vomiting causing excess loss of hydrogen ions and excessive gain of bicarbonate The pH will be greater than 7.45, the HC0 3 less than 22mmols creating a metabolic alkalosis, it will appear on an ABG analysis as The pH will be greater than 7.45, the HC0 3 less than 22mmols creating a metabolic alkalosis, it will appear on an ABG analysis as PC kPa pH 7.55 HC0 3 – 18mmols The respiratory system will try and compensate in this situation by slowing down respiration rate and depth, therefore retaining C0 2 acidity of the blood. When the pH starts to return to within normal range the respiration is compensating for metabolic alkalosis The respiratory system will try and compensate in this situation by slowing down respiration rate and depth, therefore retaining C0 2 acidity of the blood. When the pH starts to return to within normal range the respiration is compensating for metabolic alkalosis (Markou et al. 2004) (Markou et al. 2004)

19 SUMMARY Is the patient well oxygenated, check resp rate, Sp0 2, resp pattern, colour etc. Is the patient well oxygenated, check resp rate, Sp0 2, resp pattern, colour etc. If these vary from the clients norm inform medical staff and complete blood gas analysis If these vary from the clients norm inform medical staff and complete blood gas analysis If pH < 7.35 you have an ACIDOSIS If pH < 7.35 you have an ACIDOSIS If pH 6kPa it is RESPIRATORY ACIDOSIS If pH 6kPa it is RESPIRATORY ACIDOSIS If pH < 7.35 and PC0 2 normal or < 4.5kPa it is METABOLIC ACIDOSIS If pH < 7.35 and PC0 2 normal or < 4.5kPa it is METABOLIC ACIDOSIS If pH > 7.45 it is an ALKALOSIS If pH > 7.45 it is an ALKALOSIS If pH > 7.45 and PC and PC0 2 < 4.5kPa it is a RESPIRATORY ALKALOSIS If pH > 7.45 and PC0 2 normal or > 6kPa it is a METABOLIC ALKALOSIS If pH > 7.45 and PC0 2 normal or > 6kPa it is a METABOLIC ALKALOSIS Renal compensation can normal pH in a respiratory disorder and will show an abnormal bicarbonate on ABG Analysis Renal compensation can normal pH in a respiratory disorder and will show an abnormal bicarbonate on ABG Analysis Respiratory compensation can aid in restoring a normal pH in a metabolic disorder creating an abnormal PC0 2 Respiratory compensation can aid in restoring a normal pH in a metabolic disorder creating an abnormal PC0 2

20 References Bennett J, Claude J And Plum F (1996) Cecil Textbook Of Medicine WB Saunders Co. Philadelphia Bennett J, Claude J And Plum F (1996) Cecil Textbook Of Medicine WB Saunders Co. Philadelphia DuBose Jr., Thomas D (1997) Acidosis And Alkalosis In Harrisons Principles Of Internal Medicine New York Mc Graw - Hill DuBose Jr., Thomas D (1997) Acidosis And Alkalosis In Harrisons Principles Of Internal Medicine New York Mc Graw - Hill Hess D (2000) Detection and monitoring of hypoxemia and oxygen therapy Chest (45) pp. 64 – 83 Hess D (2000) Detection and monitoring of hypoxemia and oxygen therapy Chest (45) pp. 64 – 83 FitzSullivan E, Salim A, Demetriades D, Asensio J And Martin MJ (2005) Serum Bicarbonate May Replace The Arterial Base Deficiet In The Trauma Intensive Care Unit American Journal Of Surgery December, 190 (6) pp FitzSullivan E, Salim A, Demetriades D, Asensio J And Martin MJ (2005) Serum Bicarbonate May Replace The Arterial Base Deficiet In The Trauma Intensive Care Unit American Journal Of Surgery December, 190 (6) pp Kellum JA (2005) Determinants Of Plasma Acid-Base Balance Critical Care Clinical April (2) pp:329 – 346 Kellum JA (2005) Determinants Of Plasma Acid-Base Balance Critical Care Clinical April (2) pp:329 – 346 Markou NK, Myrianthefs PM And Baltopoulos GJ (2004) Respiratory Failure: An Overview Critical Care Nurse October – December 27 (4) pp: Markou NK, Myrianthefs PM And Baltopoulos GJ (2004) Respiratory Failure: An Overview Critical Care Nurse October – December 27 (4) pp: Murray J And Nadel J (2000) Textbook Of Respiratory Medicine Third Edition Philadelphia WB Saunders Murray J And Nadel J (2000) Textbook Of Respiratory Medicine Third Edition Philadelphia WB Saunders Outreach/Clinical Education 2001 Leeds Teaching Hospitals Guidelines Outreach/Clinical Education 2001 Leeds Teaching Hospitals Guidelines Pruitt WC and Jacobs M 2004 Interpreting Arterial Blood Gases: Easy As ABC Nursing Aug; 34 (8) pp: Pruitt WC and Jacobs M 2004 Interpreting Arterial Blood Gases: Easy As ABC Nursing Aug; 34 (8) pp: Saad EB (1996) Oxford Textbook Of Medicine Oxford Medical Publications London Saad EB (1996) Oxford Textbook Of Medicine Oxford Medical Publications London Williams AJ (1998) ABC Of Oxygen. Assessing And Interpreting Arterial Blood Gases And Acid Base Balance British Medical Journal (317) pp Williams AJ (1998) ABC Of Oxygen. Assessing And Interpreting Arterial Blood Gases And Acid Base Balance British Medical Journal (317) pp


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