Blood Gas Analysis For Bedside Diagnosis
Blood Gas Analysis For Bedside Diagnosis
Blood Gas Analysis For Bedside Diagnosis
74]
Review Article
Arterial blood gas is an important routine investigation to monitor the acid‑base balance of patients,
effectiveness of gas exchange, and the state of their voluntary respiratory control. Majority of
the oral and maxillofacial surgeons find it difficult to interpret and clinically correlate the arterial
blood gas report in their everyday practice. This has led to underutilization of this simple tool.
The present article aims to simplify arterial blood gas analysis for a rapid and easy bedside
interpretation. In context of oral and maxillofacial surgery, arterial blood gas analysis plays a
Address for correspondence: vital role in the monitoring of postoperative patients, patients receiving oxygen therapy, those on
Dr. Virendra Singh,
intensive support, or with maxillofacial trauma with significant blood loss, sepsis, and comorbid
Department of Oral and
Maxillofacial Surgery, Post conditions like diabetes, kidney disorders, Cardiovascular system (CVS) conditions, and so on.
Graduate Institute of Dental The value of this analysis is limited by the understanding of the basic physiology and ability of
Sciences, Pt. B.D. Sharma the surgeon to interpret the report. Using a systematic and logical approach by using these
University of Health Sciences, steps would make the interpretation simple and easy to use for oral and maxillofacial surgeons.
Rohtak, Haryana ‑ 124 001, India.
E‑mail: drvirendrasingh1@yahoo.
co.in
Key words: Acidosis, alkalosis, blood gas analysis
Figure 1: Visualization of pH and paCO2 as a see‑saw Figure 2: Visualization of pH and bicarbonate as an elevator
Table 1: Components and normal values Table 2: Arterial versus venous blood gas
H+ Hydrogen ions, inversely proportional to pH 35-45 mmol/L Value Arterial blood Mixed venous
pH Acidity/alkalinity 7.35-7.45 pH 7.40 (7.35-7.45) 7.36 (7.31-7.41)
paO2 Partial pressure of oxygen in arterial blood 80-100 mmHg paO2 80-100 mmHg 35-40 mmHg
SaO2 Arterial oxygen saturation 95-100% O2 saturation 95% 70-75%
paCO2 Partial pressure of CO2 in arterial blood 35-45 mm Hg PaCO2 35-45 mmHg 41-51 mmHg
HCO3‑ Bicarbonate in blood 22-26 mEq/L HCO3‑ 22-26 mEqL–1 22-26 mEqL–1
BE Base excess (amount of excess or –2 to+2 BE –2 to+2 –2 to+2
insufficient amount of base in blood) mmol/L (Table adapted from[3]); O2: Oxygen, paO2: Partial pressure of oxygen in arterial
–ve in acidosis, +ve in alkalosis blood, pH: Acidity/alkalinity, PaCO2: Partial pressure of oxygen in arterial blood,
CO2: Carbon dioxide HCO3‑: Bicarbonate in blood, BE: Base excess
• The radial artery should be palpated for a pulse, Step 2: Check the pH.
and a preheparinised syringe with a 23‑ or 25‑gauge If pH < 7.35: Acidosis
needle should be inserted at an angle just distal to pH > 7.45: Alkalosis
the palpated pulse [Figure 4] pH = 7.40: Normal/mixed disorder/fully compensated
• After the puncture, sterile gauze should be placed disorder
firmly over the site and direct pressure applied for (Note: If mixed disorder, pH indicates stronger
several minutes to obtain hemostasis. component)
Errors[7]
Step 3: Check SaO2/paO2 (SaO2 is a more reliable indicator
• Allow a steady state after initiation or change in
as it depicts the saturation of hemoglobin in arterial
oxygen therapy, before obtaining a sample (in the
patients without overt pulmonary disease, a steady blood) Table 3.
state is reached between 3 and 10 minutes[8,9] and in Note: Always compare the SaO2 with FiO2, as the SaO2
patients with chronic airway obstruction, it takes could be within normal range but still much less than
about 20-30 minutes)[10] FiO2, if the patient is on supplemental oxygen (difference
• Always note the percentage of inspired air (FiO2) and should be less than 10).
condition of the patient
• Flush the syringe with heparin or use preheparinised Step 4: Check CO 2 and HCO 3‑ (bicarbonate) levels—
syringes. Do not use excess heparin as it causes sample identify the culprit [Table 4].
dilution.[4] Excess of heparin may affect the pH. Only Is it a respiratory/metabolic/mixed disorder?
0.05 mL is required to anticoagulate 1 mL of blood.
Because dead space volume of a standard 5 mL syringe Step 5: Check base excess (BE).
with 1” 22‑gauge needle is 0.02 mL, filling the dead It is defined as amount of base required to return the pH
space of the syringe with heparin provides sufficient to a normal range.
volume to anticoagulate a 4 mL blood sample[10] If it is positive, the metabolic picture is of alkalosis.
• Avoid air bubbles in syringe[4] If it is negative, the metabolic picture is of acidosis.
• Avoid delay in sample processing. As blood is a living Either of bicarbonate ions/base excess can be used to
tissue, O2 is being consumed and CO2 is produced in interpret metabolic acidosis/alkalosis.[7]
the blood sample. The delay may affect the blood gas
values. In case of delay, the sample should be placed The following tables show the interpretation of arterial
in ice and such iced samples can be processed for up blood gas report on the basis of using BE as a metabolic
to two hours without affecting the blood gas values.[10] index [Figures 5 and 6].
• Accidental venous sampling. The venous sample
report should not be discarded and can provide (Tables adapted from[11])
sufficient information.[7]
Step 6: Check for compensation.
Steps of interpretation Is there a compensatory response with respect to the
Step 1: Anticipate the disorder (keeping in mind the primary change?
clinical settings and the condition of the patient) (e.g., the If yes: Compensated, if no: Uncompensated.
patient may present with a history of insulin‑dependent In case of compensation, does it bring the pH to a normal
diabetes mellitus (IDDM), which may contribute to a range?
metabolic acidosis[2]). If yes: Fully compensated, if no: Partially compensated.
Example: If pH is 7.21, HCO3‑ is 14, and CO2 is 40.
HCO3‑ is decreased). Expected compensation would be and if this value is equal to the H + in the report, the
a decrease in CO2 causing respiratory alkalosis. Now arterial blood gas report is authentic.
consider this table [Table 5]:
Alternatively, subtract the last two digits of the
Rule of thumb pH (e.g., 20 in pH 7.20) from 80; this value is
• To check the authenticity of a laboratory arterial
blood gas report[4,12]
Table 5: Expected compensation
PCO 2 pH HCO3– pCO2 Compensation
+
H = 24 × (1)
HCO 3− 7.21 14 40 Uncompensated
7.21 14 30 ↓ Partially compensated
7.37 14 20 ↓↓ Fully compensated
Calculate this value from the arterial blood gas report
approximately equal to the H+ concentration (proposed monitoring and as an aid in management, but its value
by Burden et al.[13]). is limited by the understanding of the basic physiology
and ability of the surgeon to interpret the report.
For example, consider this arterial blood gas report: pH: Using a systematic and logical approach by using
7.42, pCO2: 30.8, HCO3‑: 19.3, H+: 38.1. these steps would make the interpretation simple and
easy to use.
+ 30.8
Now, H = 24 × = 38.3 = approximately equal to
19.3
measured H in the report.
+
References
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2. Mary‑Lynn Watson. Back to basics Acid Base Disorders. Can J CME
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3. pH: 7.52, paCO2: 31.0, HCO3‑: 29.4 1976;69:808-9.
The pH is alkalotic, paCO2 is decreased (alkalosis), 11. Drage S, Wilkinson D. Acid base balance. Update 13. 2001. World
and bicarbonate is increased (alkalosis). Federation of Societies of Anaesthesiologists. Available from:
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12. Kassirer JP, Bleich HL. Rapid estimation of plasma CO2 from pH and
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Conclusion How to cite this article: Singh V, Khatana S, Gupta P. Blood gas analysis
for bedside diagnosis. Natl J Maxillofac Surg 2013;4:136-41.
Arterial blood gas analysis is a useful tool for diagnosis Source of Support: Nil. Conflict of Interest: None declared.