ABG Analysis

Approaches1,2

Conventional approach uses carbon dioxide & bicarbonate relationship. However, role of electroneutrality must be appreciated. Miller's Anesthesia give a great description and endorsement of the Stewart approach.

Normal ABG Values

pH of 7.35 to 7.45 PaCO2 of 35 to 45 mmHg Bicarbonate of 22 to 26 mEq/L Base Excess plus to minus 2 Lactate of 0.7 to 2.1 mmol/L3.

My Approach to ABGs
1. Assess both the patient and look at the initial blood gas. o Make sure that the pH of agrees with the clinical picture and is not a laboratory error. Take immediate action if indicated. 2. Determine the direction of pH change and use this direction to identify primary processes. 3. Assess the amount and chronicity of compensation. 4. Evaluate electrolytes, albumin, and the need for lactate measurement. 5. Finally, compare your analysis against the clinical picture.

Classification
Classification quickly and efficiently identifies simple acid/base disorders. Various models can be found in standard anesthesia texts1,4.

In left column are potential disorders. Based on the pH's direction, identify a primary acidosis or alkalosis. Assess the carbon dioxide or bicarbonate to identify the primary change. Assess the carbon dioxide or bicarbonate for compensation versus mixed disorder.

Rules of Thumb5
For every 10 increase in CO2, the pH drops by 0.05 units. For every 10 decrease in CO2, the pH will drop by 0.1 units. Using the numbers from Barash, we could predict that decreasing the CO2 from 50 to 40 mmHg would increase the pH by 0.1 units. This should raise the pH from 7.24 to 7.34. The rules of thumb empower us to estimate how changes in ventilation will impact pH.

Base Excess
The rules of thumb worked on the respiratory side of our acid/base equation. The base excess formula uses the bicarbonate, or metabolic side. The base excess is the number of mEq of bicarbonate needed per liter of ECF to normalize the pH. This assumes both a normal temperature and carbon dioxide level. The bicarbonate dose required to completely normalize the pH is (0.3)(kg)(BE) where 0.3 is bicarbonate's volume of distribution. Do not give more than 1/2 of the calculated dose1.

Acute vs Chronic5
For every 10 rise in CO2, bicarbonate acutely rises by one.

In chronic disorders, bicarbonate rises 4 to 5 for every 10 mmHg rise in CO2. Great Transatlantic Debate2
The 1960s saw heated debate between prominent scientists in Copenhagen and Boston. The Americans advocated using 6 rules of thumb while the Danes promoted an approach using the base excess. According to a review by Dr Story, the strength of the debate is why some current texts do not mention the base excess. Try to find mention of the Base Excess in the 6th edition of Barash's Clinical Anesthesia. If you're lucky enough to work with a clinician who lived through this era, take advantage of the learning opportunity.

Normal ABGs with Elevated Lactate Levels.

According to a 2008 study, 20% of surgical and trauma patients had both normal ABGs and lactate levels above 46. If you are worried about perfusion, consider obtaining a lactate level.

Electroneutrality3
According to the law of electroneutrality, the number of positively and negatively charged molecules within a solution must be equal. Know that sodium, chloride, and albumin significantly impact the pH.

Useful Approximations3
Elevated sodium causes alkalosis. Low sodium levels create acidosis. Elevated chloride causes acidosis. Low chloride causes alkalosis. Low albumin causes alkalosis.

Anion Gap
Using the law of electroneutrality, the anion gap subtracts commonly measured anions from cations. A gap is created because of unmeasured anions. A growing anion gap indicates the presence of unmeasured anions such as lactate. Literature questions the anion gap's value. The anion gap may fail 50% of the time in acute patients. Because of this, one should consider drawing lactate levels whenever hypoperfusion is suspected7. John J. Nagelhout, K.L.P. Nurse Anesthesia, (2010). Story, D.A. Bench-to-bedside review: a brief history of clinical acid-base. Crit Care 8, 253-258 (2004).

1. 2.

3. 4. 5. 6. 7.

Miller, R.D. Miller's anesthesia, (Churchill Livingstone/Elsevier, Philadelphia, PA, 2010). Morgan, G.E., Mikhail, M.S. & Murray, M.J. Clinical anesthesiology, (Lange Medical Books/McGraw Hill, Medical Pub. Division, New York, 2006). Barash, P.G. Clinical anesthesia, (Wolters Kluwer/Lippincott Williams & Wilkins, Philadelphia, 2009). Tuhay, G., Pein, M.C., Masevicius, F.D., Kutscherauer, D.O. & Dubin, A. Severe hyperlactatemia with normal base excess: a quantitative analysis using conventional and Stewart approaches. Crit Care 12, R66 (2008). Chawla, L.S., et al. Anion gap, anion gap corrected for albumin, and base deficit fail to accurately diagnose clinically significant hyperlactatemia in critically ill patients. Journal of intensive care medicine 23, 122-127 (2008).