Dr Manisha Sahay

Currently i/c Professor and HOD, Nephrology Department,

OMC/OGH
MBBS Rajasthan
MD Ped Niloufer MD Ped Niloufer
DNB Neph ,Osmania General Hospital (Gold medal) 2003
10 gold medals till date
9 best paper awards at zonal and national conferences
Best young researcher award Indian Society of Nephrology
Executive committee member Young Nephrologists committee
International Society of nephrology
Executive committee member Indian society of Nephrology
Executive member of South Zone Indian society of Nephrology
Young Key Opinion leader in Transplantation India
Publications in national and international journals
ABC s of ABG
Dr. Manisha Sahay
i/c Professor & HOD
Dept of Nephrology
Osmania General Hospital
Hyderabad
Collection of sample
use local anaesthesia over the
radial artery before puncture.
(brachial/femoral)
Use a 20 or 21 gauge needle
Pre heparinised syringe (glass
Manisha Sahay
Pre heparinised syringe (glass
better)
Express the heparin from the
syringe before taking the
sample
At least 3 ml of blood is
required to avoid a dilution
effect from the heparin.
Any sample with more than
fine air bubbles should be
discarded.
Allen's test. The
Press for 5 minutes
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Allen's test. The
radial and ulnar
arteries are occluded
by firm pressure while
the fist is clenched.
The hand is opened
and the arteries
released one at a time
to check their ability
to return blood flow to
the hand
Avoid contact with air
Put in ice if delay
NORMAL ABG
Arterial pH 7.35 - 7.45 ; Venous 7.32 - 7.42
HCO3 art 22 to 26 mEq/L, venous 19 to 25 mEq/l
PaCO2 35-45 mm Hg, PvCO2 38-52 mm Hg
B.E. 2 to +2 mEq/liter
value outside normal - metabolic acidosis
Standard Bicarbonate: Standard Bicarbonate:
Calculated value. No added info.
PaO2
SO2
FiO2
CaO2
A-a
Definitely Confusing!
Steps for
Successful
No click
Successful
Bl ood Gas
Anal ysi s
1 Acidosis or alkalosis
2 Metabolic or
respiratory
ABCs of ABG
Manisha Sahay
respiratory
3 Compensation
4 Anion gap
5 AG and HCO3
6 Urine AG
Step 1
Look at the pH (Normal 7.35-7.45)
Is the patient acidemic pH < 7.35 Is the patient acidemic pH < 7.35
or alkalemic pH > 7.45
Step 2 (pH & CO2)
Look at the PCO2
(Normal =35-45 mmHg) (Normal =35-45 mmHg)
pH and pCO2 change in opposite direction in
respiratory problem
pH and pCO2 change in same direction in metabolic
problem
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Step 2
Metabolic OR Respiratory ?
Disorder pH PCO2
Metabolic
acidosis

Metabolic
Metabolic
Same direction
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Metabolic
alkalosis

Respiratory
acidosis

Respiratory
alkalosis

Same direction
Respiratory
Opposite direction
Step 3
Compensation(CO2 & HCO3)
Body tries to
compensate to
normalise pH
Manisha Sahay
HCO3 and CO2
always move in
same direction
HCO3
CO2
Step 3
Compensation
Disorder pH PCO2 HCO3
Respiratory
acidosis

Primary event Compensation
For compensation HCO3 and CO2 follow each other
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Respiratory
alkalosis

Metabolic
acidosis

Metabolic
alkalosis

Step 3:
Calculation of compensation
Disorder pH Primary
change
Compensatory
Response
Equation
Metabolic
Acidosis
[HCO
3
-
] PCO
2
PCO
2
1.2 HCO
3
Metabolic
Alkalosis
[HCO
3
-
] PCO
2
PCO
2
0.7 HCO
3
Alkalosis
Respiratory
Acidosis
PCO
2
[HCO
3
-
] Acute:
HCO
3
-
0.1 PCO
2
Chronic:
HCO
3
-
0.3 PCO
2
Respiratory
Alkalosis
PCO
2
[HCO
3
-
] Acute:
HCO
3
-
0.2 PCO
2
Chronic:
HCO
3
-
0.5 PCO
2
1.2
0.7
Compensation Formula Simplified
Metabolic
Acidosis
Alkalosis
0.1
0.3
0.2
0.5
AcuteChronic
Respiratory
Acidosis
Alkalosis
Step 4 Check Anion Gap
Manisha Sahay
What is anion gap?
[Na
+
] ([HC0
3
-
] + [Cl
-
])
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140 - (24 + 105) = 11
Normal = 12 + 2
NAG (loss of HCO3) Cl
High AG (high acid)
(MUDPILES)
1. Anion gap helps in etiology
of Metabolic acidosis
(DURHAM)
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M ethanol
U remia
D KA
P araldehyde
I nfection
L actic acidosis
E thylene Glycol
S alicylate
Diarrhea
Ureterosigmoid fistula
Renal tubular acidosis
Hyperalimentation
Acetazolamide
Miscellaneous conditions:
- pancreatic fistula,
cholestyramine, calcium chloride
2. Anion gap may identify
hidden acidosis
pH may be normal but if Anion
gap is high it indicates metabolic
acidosis hence always calculate
anion gap
Manisha Sahay
anion gap
AG is called the footprint of
metabolic acidosis
No use of ABG without
electrolytes
Step 5 check difference bet
AG and change in HCO3
Increase in AG should be equal to fall in
HCO3
AG = HCO3
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AG > HCO3 - metabolic alkalosis
AG < HCO3 - metabolic acidosis
Urine Anion-Gap = Na + K Cl
Normal Positive (+30- + 50) mmol/l
Step 6-Urine anion gap
In metabolic acidosis,
if Urine anion gap is negative-acidosis is
extrarenal (Kidneys excreting NH4)
Positive - DRTA
Step 7
Oxygenation and ventilation
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0 10 20 30 40 50 60 70 80 90 100 PaO
2
60
80
100
Rt. Shift
Normal arterio/venous difference
No click
Oxygen delivered
to tissues
with normally placed curve
20
40
60
Shift of the curve changes saturation for a given PaO
2
Normal
with normally placed curve
Delivered oxygen
with Rt. Shift curve
A Oxygenation
PaO2 80-95 mm Hg. Pv 28 - 48 mm
Reflects only dissolved oxygen not
bound to Hb
normal in anemia ,hypoxemia may
exist with normal O2,not
TCO2 19-20 ml/gm Hb
Hb X SO2 X 1.34 + 0.003X PaO2
1.34 ml O2 bound to each gm Hb
Best measure of hypoxemia
Anemia, CO poisoning, type of
Hb all affect TCO2
exist with normal O2,not
affected by Hb
SaO2-95 - 100%; SvO2 50 70%
only reflects % saturation of Hb
normal in anemia ,hypoxemia may
exist with normal SO2 ,not
affected by type of Hb
FIO2 - fractional inspired O2.
N= 21% in room air
FiO
2
5 = PaO
2
21 5 = 100
Manisha Sahay
State which of the following situations would be
expected to lower PaO
2
.
a) anemia.
b) carbon monoxide toxicity. b) carbon monoxide toxicity.
c) an abnormal hemoglobin that holds oxygen with half
the affinity of normal hemoglobin.
d) an abnormal hemoglobin that holds oxygen with
twice the affinity of normal hemoglobin.
e) lung disease with intra-pulmonary shunting.
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More on oxygenation..
CONDITION PaO2 SaO2 CaO2
Severe Anemia n n
CO Poisoning n CO Poisoning n
Severe V-Q
High Altitude
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Which patient is
more hypoxemic?
Patient A: PaO
2
Body needs O2 molecules,
so oxygen content (CaO
2
)
takes precedence over
partial pressure
in determining degrees
of hypoxemia
Patient A Patient A: PaO
2
85 mm Hg, SaO
2
95%, Hb 7 gm%
Patient B: PaO
2
55 mm Hg, SaO
2
85%, Hb 15 gm%
Manisha Sahay
Patient A
CaO
2
= .95 x 7 x 1.34 = 8.9 ml O
2
/dl
Patient B
CaO
2
= .85 x 15 x 1.34 = 17.1 ml O
2
/dl
Patient A, with the higher
PaO
2
, is more hypoxemic.
ALWAYS CHECK CaO2 CONTENT
ABG shows SO2 75%
Pulse oximeter shows SO2 97%
Which would you believe? Explain.
Manisha Sahay
ABG is reliable as it measures oxy Hb
separately while on pulse oximeter any
bound Hb is shown as saturated Hb eg
Hb bound to CO will also increase SO2 in
pulseox.
B. Ventilation
PaCO2 important for assessing ventilation
(N= 35-45 mmHg) (N= 35-45 mmHg)
> 45 hypoventilation
< 35 hyperventilation
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Hypoventilation
Ventilation
failure
CO2 , ,O2
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Lung
dz
Arterial blood pAO2
Oxygenation failure
CO2 N,O2

C. Oxygenation vs Ventilation failure

Alveolar-arterial O
2
gradient
PAO2-PaO2
PAO2 generally given on ABG
p
A
O
2
=p
i
O
2
pCO
2
/ RQ (respiratory quotient)
piO2=(Barometric Pr-Pr H2O) X FiO2
p
i
O
2
=(760-45) x . 21 = 150 mmHg

O
2
CO
2
PAO2=150 40 / 0.8
=150 50 = 100 mm Hg
PaO
2
=90 mmHg
p
A
O
2
p
a
O
2
=10 mmHg One click and wait
Alveolar- arterial Difference
Oxygenation Failure
WIDE GAP
p
i
O
2
=150
pCO
2
=40
Ventilation Failure
NORMAL GAP
p
i
O
2
=150
pCO
2
=80
No click
O
2
CO
2
PaO
2
=45
PaO
2
=45
p
alv
O
2
=150 40/.8
=150-50
=100
A-a =100 -45=55
p
alv
O
2
=150-80/.8
=150-100
=50
A-a =50 -45 =5
1 Acidosis or alkalosis
2 Metabolic or respiratory
3 Compensation
Metabolic acidosis: 1.2(HCO3 = PCO2
Metabolic alkalosis: 0.7( HCO3 = PCO2
Respiratory acidosis AcutC 0.1(PCO2) = HCO3
ABCs of ABG
Manisha Sahay
Respiratory acidosis AcutC 0.1(PCO2) = HCO3
Respiratory acidosis: Chronic 0.3(PCO2) = HCO3
Respiratory alkalosis Acute 0.2(PCO2) = HCO3
Respiratory alkalosis chronic0.5(PCO2) = HCO3
4 Anion gap
5 anion gap = HCO3- metabolic alkalosis
6 urine AG
7 Oxygenation and ventilation
Remember the golden rule of acid-base
interpretation: always look at a patient
HANDS ON ABG
Manisha Sahay
Case 1
A 16-year-old male with diabetes mellitus presents after
having eaten no food and taken no insulin for the last 3
days . He is hypotensive, tachycardic, and markedly
tachypneic (respiratory rate 36). He smells strongly of
acetone and is dehydrated, and clinical findings are
Manisha Sahay
acetone and is dehydrated, and clinical findings are
consistent with left lower lobe pneumonia. Results of
ABG testing are:
PaO2 = 68 mm Hg
PaCO2 = 17 mm Hg
HCO3- = 6 mEq/L
pH = 7.30.
What is the acid-base abnormality?
Case 2
A 16-year-old female presents with 24
hours of unremitting emesis. She is
dehydrated and hypotensive. Tests of
her ABG her ABG
PaO2 = 104 mm Hg,
PaCO2 = 46 mm Hg,
HCO3- = 35 mEq/L
pH = 7.49.
What is the acid-base
disturbance here?
Manisha Sahay
Blood Gas Report
Measured 37.0
o
C
pH 7.523
PaCO
2
30.1 mm Hg
Case 3
PaCO
2
30.1 mm Hg
PaO
2
105.3 mm Hg
Calculated Data
HCO
3
act 22 mmol / L
O
2
Sat 98.3 %
PO
2
(A - a) 8 mm Hg
DPO
2
(a / A) 0.93
FiO
2
21.0 %
Case 4 8 year old diabetic with respi. Distress
fatigue and loss of appetite.
Blood Gas Report
Measured 37.0
o
C
pH 7.23
PaCO2 23 mm Hg
PaO2 110.5 mm Hg PaO2 110.5 mm Hg
Calculated Data
HCO
3
act 14 mmol / L
Entered Data
FiO2 21.0 %
Na =130, Cl =90
Case 5
A 16-year-old male presents with anorexia
and unremitting emesis for 4 days
ABG testing
Manisha Sahay
ABG testing
HCO3 - = 18 mEq/L
PaCO2 = 33 mm Hg
pH = 7.36
Na = 130 meq/L
Cl = 89 meq/L
A 15 yr old type 1 diabetic presents with following
abnormalities after missing insulin
ABG:
pH 7.31
Case 6
pH 7.31
PaCO
2
26 mmHg
HCO
3
12 mEq/L
PaO
2
92 mm Hg
Evaluate the acid-base
disturbance(s)?
Serum Electrolytes:
Na 140 mEq/L
K 5.0 mEq/L
Cl 100 mEq/L
A 14 yr old boy presents with continuous vomitingof
3 days duration and drowsiness and appears
dehydrated
ABG
pH 7.50
PaCO
2
48
Case 7
PaCO
2
48
HCO
3
32
PaO
2
90
Na 139
K 3.9
Cl 85
Evaluate the acid-base disturbance(s)?
Case 8
A 15 yr girl admitted with renal failure
on furosemide now in respiratory failure
and is on ventilator
ABG ABG
PaCO
2
30 mm Hg
PaO
2
62 mm Hg
Na
+
145 mEq/L
K
+
2.9 mEq/L
Cl
-
98 mEq/L
HCO
3
-
21 mEq/L
pH 7.52
A 12-year-old girl has been mechanically ventilated for two
days following a drug overdose. Her arterial blood gas
values and electrolytes show:
ABG
Case 9
ABG
pH 7.45
PaCO
2
25 mm Hg
Na
+
142 mEq/L
K
+
4.0 mEq/L
Cl
-
100 mEq/L
HCO
3
- 18 mEq/L
A 10 year old boy
with renal
insufficiency admitted
with following values
ABG
Case 10
ABG
pH 7.20
PaCO
2
24 mm Hg
Na
+
140 mEq/L
K
+
5.6 mEq/L
Cl
-
110 mEq/L
HCO
3
- 10 mEq/L
Patient A B C
ECF volume Low Low Normal
Glucose 600 120 120
pH 7.20 7.20 7.20
Na 140 140 140
Types of metabolic acidosis
Na 140 140 140
Cl 103 118 118
HCO
3
-
10 10 10
AG 27 12 12
Ketones 4+ 0 0
Patient A B C
U. Na 10 50
U. K 14 47
U. Cl 74 28
Urine AG 50 +69
Urine electrolytes in Metabolic
Acidosis
Urine AG 50 +69
Dx:
In Normal anion gap Metabolic Acidosis,
Positive Urine AG suggests distal Renal Tubular Acidosis
Negative Urine AG suggests non-renal cause for Metabolic
Acidosis.
Urine Anion Gap = (U. Na + U. K U. Cl)
6 year old male with progressive respiratory distress
Muscular dystrophy .
Blood Gas Report
Measured 37.0
o
C
pH 7.301
PaCO
2
76.2 mm Hg
PaO
2
45.5 mm Hg
Case 11
PaO
2
45.5 mm Hg
Calculated Data
HCO
3
act 35.1
mmol / L
O
2
Sat 78 %
PO
2
(A - a) 9.5 mm Hg
PO
2
(a / A) 0.83
Entered Data
FiO
2
21%
Case 12
8-year-old male asthmatic;
3 days of cough, dyspnea
and orthopnea not
responding to usual
bronchodilators.
Blood Gas Report
Measured 37.0
o
C
pH 7. 24
PaCO
2
49.1 mm Hg
PaO
2
66.3 mm Hg
8-year-old male asthmatic with resp. distress
bronchodilators.
O/E: Respiratory distress;
suprasternal and
intercostal retraction;
tired looking; on 4 L NC.
Calculated Data
HCO
3
act18.0 mmol / L
O2 Sat 92 %
PO
2
(A a) mm Hg
Entered Data
FiO
2
30 %
1 Acidosis or alkalosis
2 Metabolic or respiratory
3 Compensation
Metabolic acidosis: 1.2(HCO3 = PCO2
Metabolic alkalosis: 0.7( HCO3 = PCO2
ABCs of ABG
Manisha Sahay
Respiratory acidosis AcutC 0.1(PCO2) = HCO3
Respiratory acidosis: Chronic 0.3(PCO2) = HCO3
Respiratory alkalosis Acute 0.2(PCO2) = HCO3
Respiratory alkalosis chronic0.5(PCO2) = HCO3
4 Anion gap
5 anion gap = HCO3- metabolic alkalosis
6 urine AG
7 oxygenation and ventilation
Remember the golden rule of acid-base
interpretation: always look at a patient
Practicemakesaman
perfect!!
Manisha Sahay