ABG Interpretation

ABG Interpretation
First, does the patient have an acidosis or an alkalosis Second, what is the primary problem metabolic or respiratory Third, is there any compensation by the patient respiratory compensation is immediate while renal compensation takes time
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ABG Interpretation
It would be extremely unusual for either the respiratory or renal system to overcompensate The pH determines the primary problem After determining the primary and compensatory acid/base balance, evaluate the effectiveness of oxygenation
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Normal Values
pH 7.35 to 7.45 paCO2 36 to 44 mm Hg HCO3 22 to 26 meq/L

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Abnormal Values
pH < 7.35 Acidosis (metabolic and/or respiratory) pH > 7.45 Alkalosis (metabolic and/or respiratory) paCO2 > 44 mm Hg Respiratory acidosis (alveolar hypoventilation)
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paCO2 < 36 mm Hg Respiratory alkalosis (alveolar hyperventilation) HCO3 < 22 meq/L Metabolic acidosis HCO3 > 26 meq/L Metabolic alkalosis

Putting It Together Respiratory

So paCO2 > 44 with a pH < 7.35 represents a respiratory acidosis paCO2 < 36 with a pH > 7.45 represents a respiratory alkalosis For a primary respiratory problem, pH and paCO2 move in the opposite direction

For each deviation in paCO2 of 10 mm Hg in either direction, 0. 08 pH units change in the opposite direction

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Putting It Together - Metabolic

And HCO3 < 22 with a pH < 7.35 represents a metabolic acidosis HCO3 > 26 with a pH > 7.45 represents a metabolic alkalosis For a primary metabolic problem, pH and HCO3 are in the same direction, and paCO2 is also in the same direction
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Compensation
Thebodysattempttoreturnthe acid/base status to normal (i.e. pH closer to 7.4) Primary Problem Compensation respiratory acidosis metabolic alkalosis respiratory alkalosis metabolic acidosis metabolic acidosis respiratory alkalosis metabolic alkalosis respiratory acidosis
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 Acceptable ventilatory and metabolic acidbase status Respiratory acidosis (alveolar hypoventilation) - acute, chronic Respiratory alkalosis (alveolar hyperventilation) - acute, chronic Metabolic acidosis uncompensated, compensated Metabolic alkalosis uncompensated, partially compensated
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Classification of primary acidbase disturbances and compensation

Respiratory Alkalosis
Causes
Pain Anxiety Hypoxemia Restrictive lung disease Severe congestive heart failure Pulmonary emboli
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Drugs Sepsis Fever Thyrotoxicosis Pregnancy Overaggressive mechanical ventilation Hepatic failure

Metabolic Acidosis Elevated Anion Gap

Causes
Ketoacidosis - diabetic, alcoholic, starvation Lactic acidosis - hypoxia, shock, sepsis, seizures Toxic ingestion salicylates, methanol, ethylene glycol, ethanol, isopropyl alcohol, paraldehyde, toluene Renal failure - uremia
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Metabolic Acidosis Normal Anion Gap

Causes
Renal tubular acidosis Post respiratory alkalosis Hypoaldosteronism Potassium sparing diuretics Pancreatic loss of bicarbonate
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Diarrhea Carbonic anhydrase inhibitors Acid administration (HCl, NH4Cl, arginine HCl) Sulfamylon Cholestyramine Ureteral diversions

Summary
First, does the patient have an acidosis or an alkalosis
Look at the pH

Second, what is the primary problem metabolic or respiratory

Look at the pCO2 If the pCO2 change is in the opposite direction of the pH change, the primary problem is respiratory

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Assessing Oxygenation
Normal value for arterial blood gas 80-100mmHg Normal value for venous blood gas 40mmHg Normal SaO2
Arterial: 97% Venous: 75%

Summary
Third, is there any compensation by the patient - do the calculations
For a primary respiratory problem, is the pH change completely accounted for by the change in pCO2

if yes, then there is no metabolic compensation if not, then there is either partial compensation or concomitant metabolic problem

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Summary
For a metabolic problem, calculate the expected pCO2
if equal to calculated, then there is appropriate respiratory compensation if higher than calculated, there is concomitant respiratory acidosis if lower than calculated, there is concomitant respiratory alkalosis

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Summary
Next,dontforgettolookatthe effectiveness of oxygenation, (and look at the patient)
your patient may have a significantly increased work of breathing in order to maintainanormalbloodgas metabolic acidosis with a concomitant respiratory acidosis is concerning
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Case 1
LittleBillygotintosomeofdads barbiturates. He suffers a significant depression of mental status and respiration. You see him in the ER 3 hours after ingestion with a respiratory rate of 4. A blood gas is obtained (after doingtheABCs,ofcourse).Itshows pH = 7.16, pCO2 = 70, HCO3 = 22
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Case 1
What is the acid/base abnormality? 1. Uncompensated metabolic acidosis 2. Compensated respiratory acidosis 3. Uncompensated respiratory acidosis 4. Compensated metabolic alkalosis

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Case 1
Uncompensated respiratory acidosis There has not been time for metabolic compensation to occur. As the barbiturate toxicity took hold, this child slowed his respirations significantly, pCO2 built up in the blood, and an acidosis ensued.

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Case 2
Little Suzie has had vomiting and diarrhea for3days.Inhermomswords,She cantkeepanythingdownandshes runninout.Shehashad1wetdiaper in the last 24 hours. She appears lethargic and cool to touch with a prolonged capillary refill time. After addressingherABCs,herbloodgas reveals: pH=7.34, pCO2=26, HCO3=12
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Case 2
What is the acid/base abnormality? 1. Uncompensated metabolic acidosis 2. Compensated respiratory alkalosis 3. Uncompensated respiratory acidosis 4. Compensated metabolic acidosis

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Case 3
You are evaluating a 15 year old female in the ER who was brought in by EMS from school because of abdominal pain and vomiting. Review of system is negative except for a 10 lb. weight loss over the past 2 months and polyuria for the past 2 weeks. She has no other medical problems and denies any sexual activity or drug use. On exam, she is alert and oriented, afebrile, HR 115, RR 26 and regular, BP 114/75, pulse ox 95% on RA.
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Case 3
What is the blood gas interpretation? Uncompensated respiratory acidosis with severe hypoxia Uncompensated metabolic alkalosis Combined metabolic acidosis and respiratory acidosis with severe hypoxia Metabolic acidosis with respiratory compensation
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12 year old diabetic presents with Kussmaul breathing

pH : 7.05 pCO2: 12 mmHg pO2: 108 mmHg HCO3: 5 mEq/L BE: -30 mEq/L
Severe partly compensated metabolic acidosis without hypoxemia due to ketoacidosis

17 year old w/severe kyphoscoliosis, admitted for pneumonia

pH: 7.37 pCO2: 25 mmHg pO2: 60 mmHg HCO3: 14 mEq/L BE : -7 mEq/L

Compensated respiratory alkalosis due to chronic hyperventilation secondary to hypoxia

9 year old w/hx of asthma, audibly wheezing x 1 week, has not slept in 2 nights; presents sitting up and using accessory muscles to breath w/audible wheezes

pH: 7.51 pCO2: 25 mmHg pO2 35 mmHg HCO3: 22 mEq/L BE: -2 mEq/L
Uncompensated respiratory alkalosis with severe hypoxia due to asthma exacerbation

7 year old post op presenting with chills, fever and hypotension

pH: pCO2: pO2: HCO3: BE:

7.25 32 mmHg 55 mmHg 10 mEq/L -15 mEq/L

Uncompensated metabolic acidosis due to low perfusion state and hypoxia causing increased lactic acid

Post test
Ph 7.25 PCO2 55 HCO3 - 29 Ph 7.05 PCO2 20 HCO3 - 15

 7.48 32 12

7.36 52 34

References
The ICU Book Paul L. Marino, 1991, Algorithms for acid-base interpretations, p415-426 Textbook of Pediatric Intensive Care 3rd Edition edited by Mark C. Rogers, 1996, Respiratory Monitoring: Interpretation of clinical blood gas values, p355-361 Pediatric Critical Care Bradley Fuhrman and Jerry Zimmerman, 1992, Acid-Base Balance and Disorders, p689-696 Critical Care Physiology Robert Bartlett, 1996, Acid-Base physiology p165-173.
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