ABG analysis & Acid-Base Disorders

2012

Outline
1.
2.
3.
4.

Discuss simple steps in analyzing ABGs

Calculate the anion gap
Calculate the delta gap
Differentials for specific acid-base disorders

Steps for ABG analysis

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

What is the pH? Acidemia or Alkalemia?

What is the primary disorder present?
Is there appropriate compensation?
Is the compensation acute or chronic?
Is there an anion gap?
If there is a AG check the delta gap?
What is the differential for the clinical processes?

Normal Values
Variable
pH

Normal
Range
7.35 - 7.45

pCO2

35-45

Bicarbonate

22-26

Anion gap

10-14

Albumin

Step 1:

Look at the pH: is the blood acidemic or alkalemic?

EXAMPLE :
65yo M with CKD presenting with nausea, diarrhea
and acute respiratory distress

ABG :ABG 7.23/17/235 on 50% VM

BMP Na 123/ Cl 97/ HCO3 7/BUN 119/ Cr
5.1

ACIDMEIA OR ALKALEMIA ????

EXAMPLE ONE
ABG 7.23/17/235 on 50% VM
BMP Na 123/ Cl 97/ HCO3 7/BUN
119/ Cr 5.1
Answer PH = 7.23 , HCO3 7
Acidemia

Step 2: What is the primary disorder?

What disorder is
present?
Respiratory Acidosis

pH

pCO2 or HCO3

pH low

pCO2 high

Metabolic Acidosis

pH low

HCO3 low

Respiratory Alkalosis

pH high

pCO2 low

Metabolic Alkalosis

pH high

HCO3 high

EXAMPLE

ABG 7.23/17/235 on 50% VM

BMP Na 123/ Cl 97/ HCO3 7/BUN 119/ Cr 5.

PH is low , CO2 is Low

PH and PCO2 are going in same directions then its
most likely primary metabolic will check to see if
there is a mixed disoder.

Step 3-4: Is there appropriate

compensation? Is it chronic or acute?

Respiratory Acidosis

Acute: for every 10 increase in pCO2 -> HCO3 increases by 1 and

there is a decrease of 0.08 in pH MEMORIZE
Chronic: for every 10 increase in pCO2 -> HCO3 increases by 4
and there is a decrease of 0.03 in pH

Respiratory Alkalosis

Acute: for every 10 decrease in pCO2 -> HCO3 decreases by 2 and

there is a increase of 0.08 in PH MEMORIZE
Chronic: for every 10 decrease in pCO2 -> HCO3 decreases by 5
and there is a increase of 0.03 in PH

Step 3-4: Is there appropriate

compensation? Is it acute or chronic ?

Metabolic Acidosis
Winters formula: pCO2 = 1.5[HCO3] + 8 2 MEMORIZE
If serum pCO2 > expected pCO2 -> additional respiratory
acidosis

Metabolic Alkalosis
For every 10 increase in HCO3 -> pCO2 increases by 6

EXAMPLE

ABG 7.23/17/235 on 50% VM

BMP Na 123/ Cl 97/ HCO3 7/BUN 119/ Cr 5.

Winters formula : 17= 1.5 (7) +8 = 18.5

So correct compensation so there is only
one disorder Primary metabolic

Step 5: Calculate the anion gap

AG = Na Cl HCO3 (normal 12 2)
AG corrected = AG + 2.5[4 albumin]
If there is an anion Gap then calculate the
Delta/delta gap (step 6). Only need to calculate
delta gap (excess anion gap) when there is an anion
gap to determine additional hidden metabolic
disorders (nongap metabolic acidosis or metabolic
alkalosis)
If there is no anion gap then start analyzing for
non-anion acidosis

EXAMPLE

Calculate Anion gap

ABG 7.23/17/235 on 50% VM

BMP Na 123/ Cl 97/ HCO3 7/BUN 119/ Cr 5/
Albumin 4.

AG = Na Cl HCO3 (normal 12 2)
123 97 7 = 19

No need to correct for albumin as it is 4

Step 6: Calculate the different needed

formulas

Delta gap = (actual AG 12) + HCO3

Adjusted HCO3 should be 24 (+_ 6) {18-30}
If delta gap > 30 -> additional metabolic alkalosis
If delta gap < 18 -> additional non-gap metabolic
acidosis
If delta gap 18 30 -> no additional metabolic
disorders

EXAMPLE : Delta Gap

ABG 7.23/17/235 on 50% VM

BMP Na 123/ Cl 97/ HCO3 7/BUN 119/ Cr 5/
Albumin 4.
Delta

gap = (actual AG 12) + HCO3

(19-12) +7 = 14
Delta gap < 18 -> additional non-gap
metabolic acidosis
So Metabolic acidosis anion and non
anion gap

Metobolic acidosis: Anion gap acidosis

EXAMPLE: WHY ANION GAP?

65yo M with CKD presenting with nausea, diarrhea

and acute respiratory distress

ABG :ABG 7.23/17/235 on 50% VM

BMP Na 123/ Cl 97/ HCO3 7/BUN 119/ Cr
5.1

So for our patient for anion gap portion its due

to BUN of 119 UREMIA
But would still check lactic acid

Nongap metabolic acidosis

For non-gap metabolic acidosis, calculate the urine anion gap
UAG = UNA + UK UCL
If UAG>0: renal problem
If UAG<0: nonrenal problem (most commonly GI)

Causes of nongap metabolic acidosis - DURHAM

Diarrhea, ileostomy, colostomy, enteric fistulas
Ureteral diversions or pancreatic fistulas
RTA type I or IV, early renal failure
Hyperailmentation, hydrochloric acid administration
Acetazolamide, Addisons
Miscellaneous post-hypocapnia, toulene, sevelamer, cholestyramine ingestion

EXAMPLE : NON ANION GAP ACIDOSIS

65yo M with CKD presenting with nausea, diarrhea

and acute respiratory distress

ABG :ABG 7.23/17/235 on 50% VM

BMP Na 123/ Cl 97/ HCO3 7/BUN 119/ Cr
5.1

Most likely due to the diarrhea

Metabolic alkalosis

Calculate the urinary chloride to differentiate saline

responsive vs saline resistant

Must be off diuretics in order to interpret urine chloride

Saline responsive
UCL<10

Saline-resistant UCL >10

Vomiting

If hypertensive: Cushings, Conns, RAS,

renal failure with alkali administartion

NG suction

If not hypertensive: severe hypokalemia,

hypomagnesemia, Bartters, Gittelmans,
licorice ingestion
Exogenous corticosteroid administration

Over-diuresis
Post-hypercapnia

Respiratory Alkalosis
Causes of Respiratory Alkalosis
Anxiety, pain, fever
Hypoxia, CHF
Lung disease with or without hypoxia pulmonary embolus, reactive
airway, pneumonia
CNS diseases
Drug use salicylates, catecholamines, progesterone
Pregnancy
Sepsis, hypotension
Hepatic encephalopathy, liver failure
Mechanical ventilation
Hypothyroidism
High altitude

Respiratory Acidosis
Causes of respiratory acidosis
CNS depression sedatives, narcotics, CVA
Neuromuscular disorders acute or chronic
Acute airway obstruction foreign body, tumor, reactive airway
Severe pneumonia, pulmonary edema, pleural effusion
Chest cavity problems hemothorax, pneumothorax, flail chest
Chronic lung disease obstructive or restrictive
Central hypoventilation, OSA

Steps for ABG analysis

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

What is the pH? Acidemic or Alkalemic?

What is the primary disorder present?
Is there appropriate compensation?
Is the compensation acute or chronic?
Is there an anion gap?
If there is a AG, what is the delta gap?
What is the differential for the clinical processes?