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ABG

INTERPRETATION
Michael Kassirer, MD
”Dept. Internal Medicine ”D
TASMC, Israel

ABG Interpretation 1
A/B Physiology
 HCO3- + H+  H2CO3  H2O + CO2

 Handersson-hasselbalch eq:
pH = 6.1 + Log (HCO3-/(0.3 X pCO2))

 pCO2 is determined by Alveolar ventilation.


 HCO3- is influenced by:
Proximal Tubules HCO3- reabsorption
Renal H+ excretion and HCO3- regeneration in distal
tubules
ABG Interpretation 2
Normal Arterial Blood Gas
*Values
 

pH
7.35-7.45
PaCO2
35-45 mm Hg
PaO2
70-100 mm Hg*
SaO2
93-98%
HCO3-
22-26 mEq/L
%MetHb ABG Interpretation <2.0% 3
ABG Interpretation – 5
steps
 Does the patient have an acidosis or an alkalosis:
The pH determines the primary problem!
Mixed disorder can normalize pH
 What is the 1º disorder – metabolic or respiratory.
There is no overcompensation!
If both HCO3- and pCO2 can explain the pH change, than a
combined
(mixed) AB disorder is present.
 Is there mixed A/B disorder
How is the compensation – appropriate or not.
Is there increased AG
What is the corrected HCO3-
ABG Interpretation 4
Abnormal Values

compensati
1º disorder
on
pH > HCO3 > 26 meq/L paCO2 1º Metabolic
7.45
paCO2 < 35 mm 1º
Alkalosis HCO3
Hg Respiratory

pH < HCO3 < 22 meq/L paCO2 1º Metabolic


7.35
paCO2 > 45 mm 1º
Acidosis HCO3
Hg Respiratory

ABG Interpretation 5
Expected Compensation
Metabolic acidosis:
 paCO2 = last 2 digits of pH X 100
 ↓ 1mEq/liter HCO3  ↓ 1-1.5mmHG of paCO2.

Metabolic alkalosis:
 paCO2 = 0.7(HCO3) + 20 (±1.5)
 ↑ 1mEq/liter HCO3  ↑ 0.5-0.7 mmHg of paCO2.

ABG Interpretation 6
Expected Compensation
Respiratory acidosis
 Acute:
↓ pH of 0.08 units for every 10mmHg ↑ paCO2
↑ HCO3 of 1mEq/liter per 10 mmHg ↑ paCO2
 Chronic:
↓ pH of 0.03 units for every 10mm Hg ↑ paCO2
↑ HCO3 of 3mEq/liter per 10 mmHg ↑ paCO2

The change in HCO3 indicate if there is full or partial


compensation for the respiratory derangement. Partial
compensation is due to either acute on chronic process, or
ABG Interpretation 7
mixed disorder.
Expected Compensation
Respiratory alkalosis
 Acute :
↑ pH increases 0.08 units for every 10 mmHg ↓
paCO2 ↓ HCO3 of 2 mEq/liter for every 10 mmHg
↓ paCO2
 Chronic:
↑ pH increases 0.02 units for every 10 mmHg ↓
paCO2
↓ HCO3 of 4-5 mEq/liter per 10 mmHg ↓ paCO2

The change in HCO3 indicate if there is full or partial


ABG Interpretation 8
Calculation of AG
Anion Gap = [Na + ] - ([Cl - ] + [HCO3
-
])
AG correct =
Increased AGAG + (4-Albumin)
(>12): X 2.5
  Normal AG
Ketoacidosis (10±2):
Lactic acdosis (shock, Renal tubular acidosis
sepsis)
Hypoaldosteronism (RTA
Renal Failure. IV)
Intoxication: High volume saline
Alcohol adminis.
Methylen-glycol GI loss
Methanol
ABG Interpretation 9
Is there combined AB
disorder
 An inappropriate compensation suggest the
presence of a combined disorder.
 Elevated AG suggest metabolic acidosis,
irrespective of the final pH
 If elevated AG – look for occult metabolic
disorder:
HCO3- correct = HCO3- + (AG correct – 10)

if corrected HCO3- does not normalize (i.e. expected


HCO3- after compensation) then a mixed disorder is
present. ABG Interpretation 10
Summary
 Does the patient have an acidosis or
an alkalosis?
– Look at the pH
 Whatis the primary problem:
metabolic or respiratory
– Look at the pCO2

ABG Interpretation 11
Summary
 Is there any compensation by the
patient? Do the calculations:
* For a 1° 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
*Forconcomitant metabolic
a 1° metabolic problemcalculate the expected
problem,
pCO2
 if equal to calculated, then there is appropriate respiratory
compensation
 if higher than calculated, there is concomitant respiratory
acidosis
ABG Interpretation 12
 if lower than calculated, there is concomitant respiratory
Summary
 Calculate the AG:
 Increased AG = Acquired acid.
 Acidosis + Normal AG = HCO3 loss (renal or
Extrarenal).

 If Acidosis + Increased AG Calculate


the Delta Gap (Corrected HCO3-)
 If Increased – Occult metabolic alkalosis
 If decreased – Occult metabolic acidosis.

ABG Interpretation 13
Alveolar ventilation and
pCO2
Fig 1: pCO2 rises rapidly
with diminished alveolar
ventilation, but only mildly
affected by
hyperventilation. This is
why significant alkalosis is
scarcely caused by
respiratory disorder alone.

ABG Interpretation 14