ABG’s, what do they mean?

Arterial blood gases… Chances are if you work in a progressive care or intensive care unit you have seen ABG results or you will.

If you’re like me in the beginning, you have no idea how to interpret the results. For the longest time I had no idea what I was looking at. I knew the pH was indicative of acidosis or alkalosis, and that was the end of it. Once I started working in an ICU I wanted to really understand what the results meant. I made one of our respiratory therapist teach me how to understand the results (he was awesome and was happy to help). It turns out ABG results are not too terribly difficult to interpret. You are trying to obtain three key pieces of information:

  • Is the patient acidotic or alkalotic?
  • Is this a respiratory or a metabolic issue?
  • Is the body fully compensating, partially compensating?

While there is plenty of information on the ABG slip (or in the chart if your unit doesn’t have an ABG machine available) you can come up with the answer by looking at three key results: pH, paCO2, HCO3.

One of the ECCO learning modules I did had this handy little chart that made it easier to interpret the results. I thought I would share it with you all in case there is someone out there confused like I was, but may not have a quick resource available.

That’s it. This little handy chart has helped me a lot. It took what was, for me, a larger amount of overwhelming information and broke it down into something I could use. Here’s how to use it:

Look at the pH, is it <7.35 (you’re acidotic) or >7.45 (you’re alkalotic) or is it normal? Circle which side of the chart your value falls in. Then look at the PaCO2. We are looking at carbon dioxide in the blood here. Repeat the previous steps and circle where your value falls. Then look at your bicarb, HCO3. Circle where that value falls.

Remember pH tells you if they are acidotic or alkalotic. Now that you’ve figured that part out, it’s time to figure out if this is respiratory or metabolic. Look at your chart, is the CO2 circled on the same side as the pH? If yes, it’s respiratory. Is the bicarb circled on the same side as the pH? If yes, then it’s metabolic. Now, are we compensating? If you are partially compensating then you will have one value on the other side of the grid. If you are fully compensating then your pH will actually be normal.

I’m a person that needs to see something in action so let’s do a couple of examples:

Note let’s break out the chart:

pH is low so we know the patient is acidotic. The CO2 is on the same side as the pH. The bicarb is on the opposite side of the grid so the body is trying to compensate. We have respiratory acidosis, partially compensated.

Let’s do one more:

Bust out the handy dandy chart!

The pH is high so we know it’s alkalosis. The bicarb is on the same side of the chart as the pH but the CO2 is on the opposite side. Here we have metabolic alkalosis, the respiratory system is partially compensating, that’s why the CO2 is high.

I would like to mention one thing, if all your values are on the same side of the chart then it most likely means the one of the systems of the body aren’t compensating.

Hopefully this post is able to help someone out. If you have any other hints, tips, tricks let me know!

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Vitamin C and sepsis

You may or may not have heard about some new studies coming out that show some positive results adding vitamin C to sepsis treatment.

If you haven’t heard anything about it, don’t worry, you will.

This is what really kind of started it all. It was a retrospective study, not one you could really take back to your ICU and make evidence based changes on, but it provides some interesting factors to think about. This study gives some information about some of the preliminary findings. So far, (cautiously) it looks positive.

However, don’t think doctors around the world are ready to jump on the vitamin C boat just yet. There hasn’t really been a what I would call a “large scale” scientifically sound study completed just yet. It’s safe to say the idea remains controversial. Here is a really good article addressing the controversy surrounding the treatment. I did notice one thing when I read this article: while doctors may not be ready to jump on board do to a lack of evidence, most of them really hope vitamin C treatment does turn out to be beneficial. The health care field as a whole really wants a better treatment for sepsis, especially since what we are doing now is only partially successful.

I am hoping someone decides to do a large scale study and really put vitamin C to the test. I would love to know if this could potentially be an adjunct sepsis treatment or if it is time for medicine to go back to the drawing board. Trying new things is what helped the medical field advance this far, let’s not stop now!

“It’s ok, we’ve got it”

I don’t trust this phrase whenever it comes to my patient any other medical professional or anyone for that matter.

Why?

Because I’ve seen it come back to bite people.

The patient needs to go to the bathroom, you go in to help. The family says “it’s ok, we’ve got it”… Annnnnnnnd your patient is on the floor.

They want to place a central line at the bedside so you go in to assist. The fellow tells you “I’ve got my med students so it’s ok we’ve got it” annnnnnnnd then they proceed to place a femoral central line in the right subclavian because the student didn’t know the difference between the kits (this is a true story).

X-ray comes in for the morning film and needs to reposition the patient, you offer to help. They tell you “it’s ok I’ve got it” annnnnnnnd now your IV is ripped out and on the floor.

As far as I’m concerned, you don’t “got it”. Don’t you touch my patient without me being there. I’m going to help whether you like it or not. I do NOT have time to fill out safety events. I’m probably not even done with my regular charting.

It’s ok, I’ve got it.

97 victims

Most of us entered nursing to heal, to help, to try and save lives whenever we can. There are some people in our field that have joined for all the wrong reasons. One such person is Niel Högel.

I came across an NPR article (click to link to the story) about a German nurse that was serving a life sentence for two murders… They believe he may be responsible 97 more. NINETY SEVEN.

He said he did it for the thrill. He enjoyed the feeling of being the hero after resuscitating the patient. Unfortunately he wasn’t always successful. Patients lost their lives for a thrill.

As a nurse and former EMT, I will say providing care in the most critical time does give you an adrenaline rush. You get to a point of functioning on sheer instinct. That sense of accomplishment can really make your day. However, I have never craved that feeling so much that I thought of harming a patient to achieve it. I don’t know what brings someone to that point. When reading his story I wondered, did he become a nurse to pseudo-save lives or did this need develop as his career progressed? Were there warning signs in his outside life? Were there warning signs at the bedside? How many lives could have been saved? I just can’t wrap my head around it.

That’s so gross

You would think the grossest thing that I have seen as a nurse would involve the patient.

Oddly enough, no.

I can say for sure the grossest thing I have seen is the patient’s family member(s) sleeping on the floor of the room.

DO YOU KNOW WHAT HAS BEEN ON THAT FLOOR?!?!?

I have walked into the room and nearly tripped over a family member sleeping peacefully on the floor. I was immediately freaked out. Like, what makes someone think sleeping on a hospital floor is safe or sanitary?

Oh, you have to get up off that floor honey.

There have been soiled linens, blood, body fluids that I can’t describe, EVERYTHING on that floor. Glare all you want but I’m not leaving you down there.

People think hospitals are far cleaner than they actually are…

Consent and ethics

Nursing is fully aware of consent. We know that we need to have documentation that the patient accepts this treatment. It’s a no brainer. But, what if the patient doesn’t want treatment and the power of attorney does?

Prime example, you have an elderly patient that is obviously letting the family talk them into surgery. To no one’s surprise, it doesn’t go well. They end up sick. They have to remain intubated. They need an art line, central line, pressors, the works. Even on the ventilator they are adamantly shaking their head no to all the things you’re trying to do. They are fighting. They keep trying to pull away. They don’t want this.

Their family does.

The POA is who the doctors decide to ask for consent to treat. They completely bypass the patient. They’re intubated, they can’t answer for themselves right? If course the family wants everything done… So, everything is done. Is that fair to the patient?

Shouldn’t the patient be allowed to say no without having someone else choose otherwise? What is the fine line that decides when a patient no longer has the capacity to make their own decisions? Does intubation automatically take away that right? Does having a POA take away that right? If a patient is clearly communicating, even in the vent, shouldn’t we respect their wishes?

The nurse in me says yes. The nurse in me says to respect my patient’s dignity.

The nurse that’s been at the bedside for almost 8 years knows that that is normally not the case.

I have seen advanced directives ignored because the patient is unconscious and the family isn’t ready to let go. I’ve seen cases like the one mentioned above. I’ve seen doctors watch as the family is almost forcing a patient to go along with treatment and the doc just goes along with it as well. I’ve had to be a part of “moral distress” meetings because nurses were stressed over the ethical dilemmas involved in certain cases. When do we stop?

Resident-splaining

One thing that absolutely drives me nuts is having a new resident come to the trauma unit, that I have worked on for almost three years, and “resident-splain” something obvious to me!

What is resident-splaining? It’s when a resident condescendingly “explains” something to you that they assume you know nothing about because you’re just a nurse…

I’ve had a resident (not a very good one at that) start to “explain” calcium in the blood to me. Why? Well, we had given quite a lot of blood products and I asked about giving some calcium as the ABG showed the ionized calcium was low. This is common. Massive infusions almost always drop the serum calcium due to the citrate used in the unit of blood (if this is new to you, here is an article that explains it rather well). Like I said, I know this. Trauma nurses are typically very aware of this because, you know, we give a lot of blood. Trauma… Bleeding… But hey, I’m just a nurse.

Now, she’s not giving me the calcium I need. She starts explaining calcium in the blood and why I should go by the ionized calcium instead of the calcium level on his BMP. Remember, I told her the ionized calcium on the ABG was low… Ionized. Calcium. The level she is currently explaining to me. That level. That’s not enough, she’s not even looking at me while she is talking and it’s in a very condescending tone.

Bruh.

I finally stop her with this statement: “I’m well aware of the purpose of an ionized calcium which is why I told you what it was on the ABG that I just ran (can you hear the attitude in my voice?). I don’t need an explanation, I need calcium. Can you order that or did you need me to throw that order in real quick?” Her:

*blank stare* “Oh, yeah I can put that in for you…” *quickly and quietly begins ordering what I need*

I had no more issues with her for the duration of her rotation on our unit.

It’s irritating. So so irritating. I’m far too outspoken to have someone resident-splain things to me. Don’t try me buddy…

Helpful hint

So you’ve put in an naso/oro- gastric tube. Great! Did you verify placement? If so, how? Did you immediately get gastric contents back when you aspirated? Did you listen and confirm placement in the stomach? Did you use the CO2 detector that some institutions have?

I ask because I ran into a situation in which an OG tube was placed in the ER before my patient was sent to me. Helpful. Thanks. Except it wasn’t helpful at all. My new admission’s abdomen was quite distended despite the OG tube. I connected the tube to wall suction and got nothing out. I changed the canister and tubing just to make sure it wasn’t something wrong on that end. Nothing. I listened and couldn’t quite say with 100% certainty that I heard it in the stomach. Hmm… Not sure I want to use this…

And then he vomited. A lot. And kept vomiting while I held the yankauer in his mouth to keep him from aspirating.

Nope, that OG wasn’t in.

So, I took it out and decided to try my luck at placing an NG instead of an OG. As soon as the tube hit 60 cm in depth contents start pouring out. No need to auscultate that! Hooked it to suction and in about five minutes I got a full liter of contents out of him. Oh look, his abdomen isn’t as distended now…

I say all of that to say this: verify placement! However you choose to do so, make sure you KNOW that the NG or OG is in the stomach and not curled up in the back of the throat. Have someone verify it behind you if you aren’t sure. If all else fails, take it out. I would rather you send me a patient without a tube than send me a patient with a misplaced tube.

Go pee!

Hey… Hey you, busy nurse, go pee!

I know you have a blood sugar to grab. I know your other patient wants his 250th cup of ice. Yes, someone has labs due as well. Go pee. Seriously. It’s OK. All those things that you need to do will be there when to get back. I’m sure there is someone you can delegate some of your tasks to. You have to take a moment for yourself.

Go pee. Your bladder will thank you.

Forever alone

Sometimes I feel “forever alone” when I am around non-nursing people. As a nurse I get to be a part of something amazing. I’ll always be proud I am a nurse. I don’t feel like my profession makes me better than anyone else. I do feel like my profession changed me.

I have seen death first hand.

I have had to hold back tears while a family kisses their 16 year old goodbye. I have watched a person suffer in the ICU because the family guilted them into remainding a full code, and endure multiple surgeries that ultimately wouldn’t fix anything, until they finally passed away in that bed. I have watched families lose hope as the transplanted organ fails. I have had to comfort patients after a devastating diagnosis.

I have had my ass handed to me at work.

I have worked 12 straight hours without being able to eat or even stop to pee. I have dealt with physical and emotional abuse at the hands of patients and their loved ones. I have been talked down to by medical professionals that feel they are above me thanks to a difference in degrees.

I hold it all in when I’m with family and non nursing friends. When people say my job is “easy” since I work nights and everyone is asleep, I just laugh. When people are certain I’m “paid” because nurses make “so much money”, I just stare blankly. I listen to people complain about their jobs intently while they dismiss my complaints because I knew nursing was hard.

It can make you feel alone.

It’s not all family members and not all non-nursing friends but enough to make me not talk about my job unless I am talking to a select few. It’s why the nursing community is so INVALUABLE to me. We can swap stories about the worst of the worst. We can laugh about some seriously dark sh*t with no judgment! We understand each other. The nursing community keeps me from feeling “forever alone”. Sometimes we are all we’ve got 😁!