Blood Gas Analysis

Acid-base
Melissa Claus, Lecturer in Emergency and Critical Care

Objectives
Know info obtained with a blood gas and when
to perform one
Know how the sample is collected
Interpret acid-base abnormalities
Calculate the anion gap
Provide ddxs for acid-base abnormalities

Whats measured or calculated?

Acid-base parameters

pH
PCO2
Bicarbonate
Base Excess

Ventilation parameters
PCO2

Pulmonary function parameters

Arterial blood gas ONLY
PaO2
SaO2

Electrolytes, glucose, lactate

When is it indicated?
Hospitalized patients

Electrolytes
Acid-base status
Pulmonary function
Lactate

Anesthetized patients
Ventilation
Pulmonary function

Arterial or venous sampling

Arterial

Dorsal metatarsal artery

Femoral artery
Lingual artery
Auricular artery

Catheter placement

Venous
Central venous catheter
Jugular vein
Any peripheral vein

Youve collected your sample.

The machine has provided numbers.
Now you have to

Interpret the Results

Acids and Bases: Definitions

Acid = proton donor (HA)
Base = proton acceptor (A )
pKa = pH at which acid is 50% dissociated in
an aqueous solution
Depicts the strength of the acid
Low pKa (<-2) = strong acid completely
dissociates at body pH

Acids in the body

Volatile acid
CO2 (can form H2CO3)
Balance maintained by ventilation

Non-volatile acid = noncarbonic acids

All acids other than H2CO3
Phosphoric acid, sulfuric acid
Lactic acid, ketoacids
Toxins (e.g. ethylene glycol metabolites)

Balance maintained by excretion/retention

(kidney) or metabolism to CO2 and H2O

Buffers
Resist change when HA or A- are added
Weak acids, pKa within 1 unit of blood pH
Scavenge H+ or OH Essential to life

Buffers in the body

Carbonic acid/bicarbonate system = open
HCO3

+H

Others:

Hemoglobin
Albumin
Phosphate
Bone

H2CO3

CO2 + H2O
Carbonic Anhydrase

How to assess the acid-base status

Step 1: Assess pH

Step 2: Assess respiratory

contribution
Reference Ranges
pH:
7.34-7.39
PvO2: 49-67
PvCO2: 38-46
AG:
HCO3:
BE:

Step 3: Assess metabolic contribution

8-21
22-24
-2.3 to -0.1

Respiratory contribution
CO2 is a volatile acid controlled by ventilation
Hypoventilation = hypercapnia = acidosis
Hyperventilation = hypocapnia = alkalosis

Metabolic contribution
HCO3

Primary buffer, regulated by the kidneys

Hypobicarbonemia = acidosis
Hyperbicarbonemia = alkalosis
Also affected by PCO2 (ventilation)

HCO3

+H

H2CO3

Law of mass action

CO2 + H2O

Metabolic contribution
Base Excess
The mmol/L of strong acid or base required to
return the plasma to a normal pH (7.4)
PCO2 held constant at 40 mmHg
Temperature held constant at 37 C

Best parameter to use to assess metabolic aspect

Negative BE metabolic acidosis
Positive BE metabolic alkalosis

Compensation for pH changes

pH is tightly maintained around normal
pH

Primary Disorder

Primary
derangement

pH Metabolic Acidosis

HCO3, -BE

PCO2

pH Metabolic Alkalosis

HCO3, +BE

PCO2

pH Respiratory Acidosis

PCO2

HCO3, +BE

pH Respiratory Alkalosis

PCO2

HCO3, -BE

Respiratory = minutes
Metabolic = hours to days
NEVER OVERCOMPENSATES
NEVER brings pH to NORMAL

Compensatory
change

Causes of metabolic acidosis

Bicarbonate buffers an acid
High anion gap
Unmeasured anions: L.U.K.E.
Lactic acid
Ketoacids
Uremic acids

Ethylene glycol
metabolites

Bicarbonate is lost from the body

Normal anion gap, elevated chloride
Diarrhea
Renal tubular acidosis, CAI

Bicarbonate is diluted by Cl-containing solution

Compensation for respiratory alkalosis

Anion Gap
+

AG = (Na + K ) (Cl + HCO3 )

K+

Anion Gap

HCO3
Na+
Cl-

Unmeasured
Anions: L.U.K.E.

Loss of bicarb from

GI or kidney =
Chloride retention
Excess chloride
administration

Causes of metabolic alkalosis

Gastric acid loss
Pyloric obstruction
Gastric suctioning

Loop diuretics
Bicarb administration
Compensation
for respiratory acidosis

Causes of respiratory acidosis

Hypoventilation

Neuromuscular disease
Airway obstruction
Severe abdominal distension
Severe pleural space disease
End-stage pulmonary disease

Rebreathing
Compensation for metabolic alkalosis
Malignant hyperthermia

Causes of respiratory alkalosis

Excitement
Exercise
Pain
Pulmonary parenchymal disease
Fever, SIRS/Sepsis
Hypotension
Compensation for metabolic acidosis

Putting it all together

1.
2.
3.
4.
5.
6.
7.
8.

Assess pH
Assess respiratory contribution
Assess metabolic contribution
Decide which is the primary process
Determine if there is compensation
OR is this a mixed acid-base disorder?
If metabolic acidosis, calculate the AG
Differentials?

Stimpy
5 year old MC DSH
Straining, vomiting, anorexic, PD for 2 days
Indoors only, no toxins, previously healthy
Physical examination:
Markedly obtunded
HR 100
Firm 10 cm abd structure, painful when palpated

Stimpy
1.
2.
3.
4.
5.
6.
7.
8.

pH: Acidemia
Resp: Alkalosis
Metab: Acidosis
Primary: Metabolic
Compensation: Yup
Mixed? Nope
AG: 29.3
Differentials?

(Na + K ) (Cl + HCO3-)

Ref Ranges
146-157
3.5-4.8
116-126
1.1-1.4
3.7-9.3
0.5-2.0

7.33-7.41
35-45
34-38
12-16
15-21
-9 to -3

Causes of metabolic acidosis

with high AG
Unmeasured anions: L.U.K.E.

Lactic Acid
Uremic Acids
Ketoacids
Ethylene glycol metabolites

Ref Ranges
3.7-9.3
0.5-2.0

Uremia secondary to urethral obstruction

Carl
8 year old MC Cocker Spaniel
Found collapsed outside, unresponsive
Spends most of his time at owners car shop
Previously healthy
PE: Comatose, T 36.0, HR 120, RR 15.

Carl
Ref Ranges

1.
2.
3.
4.
5.
6.
7.
8.

pH: Acidemia
Resp: Acidosis
Metab: Acidosis
Primary: Neither
Compensation: Nope
Mixed? YES
AG: 22.4
Differentials?

0.8

140-150
3.9-4.9
109-120
1.2-1.5

5.9
1.4

3.6-6.2
0.5-2.0

7.34-7.38
49-67
38-42
8-21
22-24
-2.3 0

Met acidosis with high AG

Unmeasured anions: L.U.K.E.

Lactic Acid
Uremic Acids
Ketoacids
Ethylene glycol metabolites

Respiratory acidosis
Hypoventilation

CNS dz, neuropathy, NMJ-opathy, myopathy

Airway obstruction
Severe abdominal distension
Severe pleural space disease
End-stage pulmonary disease

Ivan
5 year old M Rottweiler
Acute onset of diarrhea yesterday, persisting
through today. Also anorexic and lethargic
PE: T 39.7, HR 120, RR 50. Markedly painful
on abdominal palpation. BP 120/80 (100).

Ivan
Ref Ranges

1.
2.
3.
4.
5.
6.
7.
8.

pH: Normal
Resp: Alkalosis
Metab: Acidosis
Primary: None
Compensation: Nope
Mixed? YES
AG: 19.4
Differentials?

140-150
3.9-4.9
109-120
1.2-1.5
3.6-6.2
0.5-2.0
7.401

7.375

7.34-7.38
49-67
38-42
8-21
22-24
-2.3 0

Met acidosis with normal AG

Bicarbonate has been lost from the body
Diarrhea
Renal tubular acidosis
CAI

Bicarbonate is diluted by Cl-containing solution

Respiratory alkalosis

Excitement
Exercise
Pain
Pulmonary parenchymal disease
Fever/SIRS/Sepsis
Hypotension

Millhouse
2 year old M greyhound
2 day history of vomiting, lethargy
No bowel movement in 3 days
Dietary indiscretion is his middle name
6 months ago, surgery for an intestinal F.B.
PE: ~7% dehydrated, mildly painful and very
nauseous on palpation of cranial abdomen

Millhouse
Ref Ranges

1.
2.
3.
4.
5.
6.
7.
8.

pH: Alkalemia
Resp: Acidosis
Metab: Alkalosis
Primary: Metabolic
Compensation: Yup
Mixed? Nope
AG: N/A
Differentials?

140-150
3.9-4.9
109-120
1.2-1.5
3.6-6.2
0.5-2.0

7.34-7.38
49-67
38-42
8-21
22-24
-2.3 0

Causes of metabolic alkalosis

Gastric acid loss
Pyloric obstruction
Gastric suctioning

Loop diuretics
Bicarb administration

Pearl
2 year old FS Nova Scotia Duck Tolling Retriever
Found sitting in the backyard next to a dead
snake. Difficulty rising, wobbly when walking
PE: QAR, RR 45, RE seems shallow. Unable to
ambulate weak in all 4 limbs.

Pearl
Ref Ranges

1.
2.
3.
4.
5.
6.
7.
8.

pH: Acidemia
Resp: Acidosis
Metab: Normal
Primary: Respiratory
Compensation: Nope
Mixed? Nope
AG: N/A
Differentials?

140-150
3.9-4.9
109-120
1.2-1.5
3.6-6.2
0.5-2.0

7.34-7.38
49-67
38-42
8-21
22-24
-2.3 0

Causes of respiratory acidosis

Hypoventilation

CNS dz, neuropathy, NMJ-opathy, or myopathy

Airway obstruction
Severe abdominal distension
Severe pleural space disease
End-stage pulmonary disease