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Interpretation of ABG
Page
Basic knowledge about Arterial Blood Gases 2
What are arterial blood gases (ABGs)? 2
What information arterial blood gases provide and what they do not 2
Technique for Sampling Arterial Blood 3
Why must arterial blood gas samples be obtained anaerobically? 4
Why are ABG samples transported on ice? 4
Why is heparin used in bl. gas syringes? 5
Are blood gas levels stable or are they variable in apparently stable patients? 5
What is meant by PaO2, SaO2 %, CaO2, DO2? 6
What are the forms of Oxygen in blood? 6
Oxygen content equation 7
Oxygen Delivery and Utilization= DO2 8
How does hypoxia differ from hypoxemia 9
Why can't VBG be used instead of ABGs 11
Alveolar Gas Equation 12
Calculation of alveolo-arterial O2 gradient (AaDO2) 14
Indices of Oxygenation 16
PaCO2 Equation 16
Interpretation of ABG 20
Calculation of alveolo arterial O2 gradient(AaDO2 23
Summary of assessment of oxygenation 25
Acid-base status 28
Test Your Understanding 35
OBJECTIVE
It is important to understand
What information arterial blood gases provide and what they do not?
Indication & complication of ABG
Technique for Sampling Arterial Blood
Are blood gas levels stable or are they variable in apparently stable patients?
Why can't venous blood gases be used instead of ABGs?
It is essential to understand of the concepts of: - Partial pressure (tension),
Gas content.. and, Percent saturation.
How does hypoxia differ from hypoxemia?
What are arterial blood gases (ABGs)?
ABG define how well the lung is loading O2 into and removing CO2 from blood.
However, these are only the first and last steps in the gas transport system. (ABG)
sampling is still the most important pulmonary function test performed in
critically ill patient.
Why can't VBG be used instead of ABGs?
Difference bet. Arterial & Venous bl. Sample; Respir Care
37(8):913,1993
Arterial sample Venous sample
pH 7.35-7.45 7.35
PaO2 80 -100mmHg 38 - 42 mmHg
PaCO2 35 - 45 mmHg 44 - 48mmHg
(40 mmHg) (46 mmHg)
HCO3 22-26 mEq/L or 20-24 mEq/L
23-27 mEq/L
O2 sat. 95% or more 75%
A low mixed venous PO2 (<35 mm Hg) reflects tissue hypoxia may be due to
1. Decreased oxygen delivery or
2. Increased tissue oxygen uptake
Venous PaO2 (38 - 42 mmHg) is typically much lower than arterial PaO2
(80 -100mmHg), and there is often little relationship between the two.
For example, the mixed venous PO2 may be low and the arterial PO2 may be
high if cardiac output is reduced, lung function is normal, and FiO2 is high.
Normally, the mixed venous PaCO2 (44 - 48mmHg) is only slightly greater than
the arterial PaCO2 (35 - 45 mmHg). However, venous PCO2 depends on blood
flow and, in cases of low blood flow (e.g., cardiac arrest), the mixed venous
PCO2 may be high even though the arterial PCO2 is normal or decreased.
What information arterial blood gases provide and what they do not?
1. The determination of PaO2 and PaCO2 provides useful information about
the overall efficiency of external gas exchanges.
2. They do not assess how well O2 is being delivered to cells or the adequacy
of cellular function.
Technique for Sampling Arterial Blood
Arterial blood is sampled either through:-
1. An indwelling arterial catheter ..or
2. Percutaneous arterial puncture.
1. An indwelling arterial catheter
Advantage: - avoidance the acute changes in ventilation that can result from
apprehension and pain associated with percutaneous puncture.
Indication: - for continuous blood pressure monitoring and the need for
frequent ABG samples or other laboratory assessments.
Complications associated with arterial catheters
Serious complications, although rare, include hge, vascular occlusion, and
infection.
Thrombus formation is avoided by use of a continuous irrigation system,
although the presence of heparin in the irrigation may not be necessary.
When blood is collected from arterial catheters, the irrigation solution
must be cleared from the connected tubing, which can cause considerable
blood loss if samples are collected frequently and blood conservation
procedures are not used
2. Percutaneous arterial puncture
Three anatomic sites are generally used for obtaining ABG samples:
1. Radial artery
2. Brachial artery
3. Femoral artery.
For several reasons, the radial artery is the preferred sampling site
1. Because of its superficial location at the wrist, easy to palpate and pain
from the puncture is lessened, in addition, no large veins lie in its
immediate vicinity.
2. Easy to compress by direct pressure, facilitating hemostasis when sampling
is complete.
3. The ulnar artery usually provides an adequate collateral circulation to the
hand in the rare instance of post sampling thrombosis of the radial artery
(commonly assessed using the modified Allen's test)
4. The radial artery (unlike the brachial artery) is far enough away from
nerves (e.g., the medial nerve) that damage to the nerve is unlikely.
5. The radial site is generally more aseptic than the femoral site
Technique for Sampling
ABG samples are drawn anaerobically into plastic or glass syringes coated with
heparin.
The sample either immediately analyzed or placed on ice
How can the complications of arterial puncture be avoided?
The risk of bleeding complications is increased with anticoagulant or
thrombolytic therapy; in these cases, pressure must be manually applied to
the puncture site until all signs of bleeding are absent (a minimum of 5-10
minutes).
The risk of pain is decreased by use of a 22- or 23-gauge needle, and a local
anesthetic (e.g lidocaine) can be used to lessen the pain associated with
arterial puncture.
Why must arterial blood gas samples be obtained anaerobically?
Because room air at sea level has a PO2150 mmHg & PCO2 zero mmHg, air
bubbles in the syringe will artificially increase PaO2 and reduce PaCO2 with a
resultant increase in pH.
-----XXXX Diagnostics-----
Calculated Data
HCO3 act 31.2 mmol / L Calculated Data :
HCO3 std 30.5 mmol / L
BE 6.6 mmol / L
Which are useful one?
O2 ct 15.8 mL / dl
O2 Sat 98.4 %
ct CO2 32.5 mmol / L
pO2 (A -a) 30.2 mm Hg
pO2 (a/A) 0.78 Entered Data :
Entered Data Important
Temp 38.6 0C
FiO2 30.0 %
ct Hb 10.5 gm/dl
ABG: values
Measured values:
pH (the negative log of hydrogen ion conc.)
PaO2 (partial pressure of oxygen )
PaCO2 ( partial pressure of carbon dioxide)
(CaO2) oxygen content
(COHb) carboxy Hb
Calculated values:
HCO3 (Serum bicarbonate)
BE (Base excess )
P(A-a)O2 (alveolar- arterial gradient )
(SaO2) oxygen saturation
Hb saturation with oxygen (O2Hb)
carboxyhemoglobin (COHb)
methemoglobin (metHb).
If the patient's temperature is abnormal, the corrected values will differ from
those measured and reported by the blood gas analyzer.
Measured values should be considered and corrected values should be
discarded
Uncorrected pH & pCO2 are reliable reflections of in-vivo acid base status
Temperature correction of pH & pCO2 dont affect calculated bicarbonate
There is no scientific basis ... for applying temperature corrections to blood
gas measurements (Shapiro BA, OTCC, 1999).
pCO2 reference points at 37o C are well established as a reliable reflectors of
alveolar ventilation
Reliable data on DO2 and oxygen demand are unavailable at temperatures
other than 37o C
Bicarbonate is calculated on the basis of the Henderson equation: [H+] = 24
pCO2 / [HCO3-]
Indications of ABG
1. Evaluation of the ventilation
2. Assessment of oxygenation
3. Assessment of acid-base status
VCO2 x 0.863
PaCO2 = ---------------------------
VA (Lmin)
The PaCO2 equation shows that the only physiologic reason for elevated PaCO2 is
inadequate alveolar ventilation (VA) for the amount of the bodys CO2
production (VCO2). Since alveolar ventilation (VA) equals total or minute
ventilation (VE) minus dead space ventilation (VD),
hypercapnia can arise from
1. Insufficient minute ventilation (VE)
2. Increased dead space ventilation (VD)
3. Or a combination of both
State of alveolar
PaCO2 Condition in blood
ventilation
> 45 mm Hg Hypercapnia Hypoventilation
35 - 45 mm Hg Eucapnia Normal ventilation
< 35 mm Hg Hypocapnia Hyperventilation
Dangers of Hypercapnia
Bodys CO2 production
PaCO2 -------------------------------------------------
Alveolar ventilation (VA) (Lmin)
Elevated PaCO2 poses serious derangement in the respiratory system for three
reasons:
1. An elevated PaCO2 will lower the PAO2 (Alveolar gas equation), and as a result
will lower the PaO2.
The higher the baseline PaCO2, the greater it will rise for a given fall in
alveolar ventilation, e.g., a 1 L/min decrease in VA will raise PaCO2 a
greater amount when the baseline PaCO2 is 50 mm Hg than when it is 40
mm Hg.
Causes
1. What is the PaCO2 of a patient with respiratory rate 24/min, tidal volume 300
ml, dead space volume 150 ml, and CO2 production 300 ml/min? The patient
shows some evidence of respiratory distress.
2. What is the PaCO2 of a patient with respiratory rate 10/min, tidal volume 600
ml, dead space volume 150 ml, and CO2 production 200 ml/min? The patient
shows some evidence of respiratory distress.
VCO2 x 0.863
PaCO2 = ---------------------------
VA (Lmin)
ANSWER
1) First, you must calculate the alveolar ventilation. Since minute ventilation
is 24 x 300 or 7.2 L/min, and dead space ventilation is 24 x 150 or 3.6
L/min, alveolar ventilation is 3.6 L/min. Then
300 ml/min x .863
PaCO2 = ----------------------- = 71.9 mm Hg
3.6 L/min
Indications of ABG.cont.
1. Evaluation of the ventilation
2. Assessment of oxygenation
3. Assessment of acid-base status
2. Assessment of oxygenation
Assessment of oxygenation status includes:-
1. Is the pt hypoxemic or normoxemic
2. Assessment of level of hypoxemia (PaO2)
3. Oxygen content equation (CaO2: 16 - 22 ml O2/dl)
4. Alveolar gas equation: Calculation of alveolo-arterial O2 gradient(AaDO2)
5. lung injury score (If present)
What is the forms of Oxygen in blood? ? ?
Oxygen in blood exist in two forms
1) In physical solution (PaO2) i.e. dissolved in plasma & RBCs.
It is little in amount (0.3 cc/100 cc blood). So; it is not enough at all for
tissue oxygenation, but it is very important because its tension determine the
direction and rate of diffusion of O2 from or to blood.
NB: Tissue oxygenation which is about 225-250 cc/ min at rest
2) In chemical combination SaO2 % i.e. with hemoglobin.
Normally , blood contains about 15 gm %
Each gram of hemoglobin will bind 1.34 ml O2 when it is fully saturated
with O2, but blood in circulation is never fully saturated with O2 (Why).
Tissues need a requisite amount of oxygen molecules for metabolism.
Neither the PaO2 nor the SaO2 tells how much oxygen is in the blood.
CaO2Normally 16 - 22 ml /dl
Hb = hemoglobin in gm%
1.34 = ml O2 that can be bound to each gm of Hb
0.003 is solubility coefficient of oxygen in plasma
SaO2 is percent saturation of hemoglobin with oxygen
Normal SaO2 range in healthy adults (measured by pulse oximetry) of O2
Daytime healthy adults SaO2 96-98%
Transient dips in saturation are common during sleep (~84%)
(PaO2) is little in amount (0.3 cc/100 cc blood) & not enough at all for tissue
oxygenation, but it is very important?? ?
At an atmospheric pressure of 100 kPa (760mmHg) dry air contains: -
20.9% O2, 0.03% CO2 and 79.03% N2 (with minor contributions from other gases)
The diffusion of a gas across membrane occurs from the higher tension (=
Pressure) to lower tension regardless of the amount of gas present on either side.
Therefore, O2 pass from Alveoli (PAO2 100 mmHg) Arterial blood (PaO2 90
mmHg) tissue (PO2 40 mmHg) venous
blood (PO2 40 mmHg)
Dashed line represents the approximate
intracellular anaerobic threshold
1) Pulmonary system
Determine PaO2
2) CVS
Determine COP
Determine blood flow
3) Hematological system
Determine Hb concentration
DO2 (Total O2 delivery ml/min) = COP X (Hb x 1.34 x SaO2) + (0.003 x PaO2) X 10
CAUSES OF HYPOXIA
1. Hypoxemic hypoxia: Lower-than-normal PaO2 (hypoxemia)
2. Anemic hypoxia: Decreased RBCs cell count, or decreased release of oxygen
from hemoglobin to the tissues i.e carboxyhemoglobin, methemoglobin, or
hemoglobinopathy or sulph-Hb
3. Stagnant hypoxia: Decreased cardiac output or decreased local perfusion
4. Histotoxic hypoxia: Cyanide poisoning
ANSWER
1. To calculate PAO2 the PaCO2 must be subtracted from the PIO2. Again, the
barometric pressure is 760 mm Hg since the values are obtained at sea level.
EBP=760-47=713
Pt on FiO2
AaDO2 = [(EBP X FiO2) (1.25 X PaCO2)] PaO2
Can the PaO2 normally be more than 100 mm Hg or less than 75 mm Hg?
Indices of Oxygenation
Normal Value:
patients < 60 y. > 400
patients > 60 y expected P/F = 400 [(age in years 60) x 5]
Actual P/F Ratio < expected = hypoxemic
Actual P/F Ratio > expected = normoxemic
1. Acute lung injury (ALI): PaO2/FIO2 300 mm Hg or less,
2. ARDS: PaO2/FIO2 200 mmHg
Interpretation of ABG
1. Type of blood Sample
2. Assessment of oxygenation status includes:-
a) Is the pt hypoxemic or normoxemic
b) Assessment of level of hypoxemia (PaO2)
c) Oxygen content equation (CaO2: 16 - 22 ml O2/dl)
d) Alveolar gas equation: Calculation of alveolo-arterial O2
gradient(AaDO2)
e) lung injury score (If present)
3. Assessment of acid base status
Difference bet. Arterial & Venous bl. sample
Respir Care 37(8):913,1993
Arterial sample Venous sample
pH 7.35-7.45 7.35
PaO2 80 -100mmHg 38 - 42 mmHg
PaCO2 35 - 45 mmHg 44 - 48mmHg
(40 mmHg) (46 mmHg)
HCO3 22-26 mEq/L or 20-24 mEq/L
23-27 mEq/L
O2 sat. 95% or more 75%
BE The base excess indicates the amount of excess or insufficient
level of bicarbonate in the system.
Normal + 3 mmol/L
Relatively balanced + 5 mmol/L
Significant imbalance: + 10 mmol/L
Remember:- A negative BE indicates a base deficit in the blood
CaO 16 - 22 ml O2/dl
2
%MetHb < 2.0%
%COHb < 3.0%
Na+ 135 148 mEq/L
K+ 3.5 5.5 mEq/L
Cl- 95 -105 mEq/L
Interpretation of ABG
1. Type of blood Sample.
Acceptable lower limits for PaO2 (at see level) can be determined by the following:-
1. For person in sitting position
PaO2 = 104.2 (0.27 age) mmHg
e.g pt. 45 y old the acceptable lower limits for PaO2 at room air in sitting position
= 104.2 (0.27 45) = 104.2 12.15= 92.05 mmHg
e.g pt. 85 y old the acceptable lower limits for PaO2 at room air in sitting position
= 104.2 (0.27 85) = 104.2 22.95= 81.25 mmHg
2. For person in supine position
PaO2 = 103.5 (0.42 age) 4 mmHg
e.g Same pt. 45 y old the acceptable lower limits for PaO2 at room air in supine
position = 103.5 (0.42 45) 4 = 103.5 18.9= 84.6 4 mmHg
e.g Same pt. 85 y old the acceptable lower limits for PaO2 at room air in supine
position = 103.5 (0.42 85) = 103.5 35.7 = 67.8 4 mmHg
The optimally ventilated alveoli that are not perfused well are called high V/Q
units (acting like dead space)
And alveoli that are optimally perfused but not adequately ventilated are
called low V/Q units (acting like a shunt).
AaDO2 measure all factors that impair the equilibrium of arterial bl. with
alveolar gas
O2
O2
Answers
Type 1 RF
2) Identical to Problem 1, except that the dramatic increase in PaO2 with 100%
O2 indicates that ventilation-perfusion mismatch is the major cause of the
hypoxemia.
ACID-BASE STATUS
Measured values from ABG include PaO2, PaCO2 and pH, not serum HCO3.
Therefore, must either measure serum HCO3 (as part of serum electrolyte values)
or use a value calculated from Pco2 and pH according to the Henderson
Hasselbalch equation. Look at the pH value to determine the net disturbance in
acid-base balance.
Clinical Terminology
Step (5) for primary metabolic acidosis, there is an increased anion gap?
Step (6) for an increased anion gap metabolic acidosis, are there any other
derangement
Mantra
MC 1 for 1
MK 10 for 7
1
4
2
5
Metabolic Acidosis: 1 HCO3 from normal(24) => 1 PCO2 from normal(40)
Metabolic Alkalosis: 10 HCO3 => 7 PCO2
Acute Resp Acid: 10 PCO2 = 1 HCO3
Chronic Resp Acid: 10 PCO2 = 4 HCO3
Acute Resp Alk: 10 PCO2 => 2 HCO3
Chronic Resp Alk: 10 PCO2 => 5 HCO3
These are the relationships that the mantra refers to. They are not
mathematically derived formulas. Rather, they reflect the way in which
human physiology predictably responds to acid-base perturbations. They are
empiric observations, and, combined with a few other rules, they help you
understand whether the patient has a single, double, or even triple acid-base
disorder.
pH
Abnormal (or )
c) Combined
Respiratory Acidosis & Metabolic Acidosis
Respiratory Alkalosis & Metabolic Alkalosis
Interpretation Quiz
CASE (1)
pH [HCO3-] PaCO2
CASE (2)
pH [HCO3-] PaCO2
CASE (3)
pH [HCO3-] PaCO2
pH [HCO3-] PaCO2
CASE (5)
pH [HCO3-] PaCO2
Compensatory Level of
Primary mechanism mechanism compensation
pH [HCO3-] PaCO2
CASE (7)
pH [HCO3-] PaCO2
CASE (9)
pH [HCO3-] PaCO2
CASE (1)
CASE (4)
CASE (6)
CASE (7)
pH PaO2 PaCO2
Management
Increasing ventilation will correct respiratory acidosis. The method for achieving
this will vary with the cause of hypoventilation. If the patient is unstable, manual
ventilation with a bagmask is indicated until the underlying problem can be
addressed. After stabilization, rapidly resolvable causes are addressed
immediately. Causes that can be treated rapidly include pneumothorax, pain,
and CNS depression related to medications. If the cause cannot be readily
resolved, the patient may require mechanical ventilation while treatment is
rendered. Although patients with hypoventilation often require supplemental
oxygen, it is important to remember that oxygen alone will not correct the
problem.
Respiratory Alkalosis
Primary central disorders
Hyperventilation syndrome, anxiety
Cerebrovascular disease
Meningitis, encephalitis
Pulmonary disease
Interstitial fibrosis
Pneumonia
Pulmonary embolism
Pulmonary edema (some patients)
Hypoxia
Septicemia, hypotension
Hepatic failure
Drugs
Salicylates
Nicotine
Xanthines
Progestational hormones
53 DR: TAGHRID SAID
Basic knowledge about ABG 2015
High altitude
Mechanical ventilators
Management
Treatment of respiratory alkalosis centers on resolving the underlying problem.
Patients presenting with respiratory alkalosis have dramatically increased work
of breathing and must be monitored closely for respiratory muscle fatigue.
When the respiratory muscles become exhausted, acute respiratory failure may
ensue.
Selected mixed and complex acid-base disturbances
Disorder Characteristics Selected situations
Respiratory acidosis in pH 4) Cardiac arrest
with metabolic acidosis in HCO3 5) Intoxications
in PaCO2 6) Multi-organ failure
(combined)
Respiratory alkalosis in pH 1. Cirrhosis with diuretics
with metabolic alkalosis in HCO3- 2. Pregnancy with vomiting
in PaCO2 3. Over ventilation of COPD
(combined)
Resp. acidosis with pH normal 1. COPD with diuretics, vomiting,
metabolic alkalosis in PaCO2, NG suction
in HCO3- 2. Severe hypokalemia
(Mixed)
Respiratory alkalosis pH normal 1. Sepsis
with metabolic acidosis in PaCO2 2. Salicylate toxicity
in HCO3 3. Renal failure with CHF or pn.
(Mixed) 4. Advanced liver disease
pH normal
Metabolic acidosis with HCO3- normal Uremia or ketoacidosis with
metabolic alkalosis vomiting, NG suction, diuretics.
Base excess/deficit
Base Ecxess(BE): the base required to titrate a blood sample to pH 7.4 at
40 mmHg PaCO2 and 37 C.
BE = HCO3 at pH 7.4 - 24
BE = [HCO3 measured 10 (7.4 pH measured)] - 24
Normal value= 2.5 mmole/L
It measures the amount of metabolic acid or base added to ECF.
PH change of 0.1unit = base(HCO3) change of 7meq /l
Using base excess for bicarbonate therapy:
HCO3= 0.1 -BE wt in kg (ignoring minus sign)
Also HCO3= 0.1 wt (24 - HCO3)
However it cannot specify or quantify the type and amount of added acids.
Blood with large buffering capacity: significant changes in acid content with
little change in free H+ concentrations (pH)
Acidemia or alkalemia: i.e buffering capacity > potential for pH change from
any given change in H+ content
Buffering capacity depends on: [HCO3-]; RBC mass; other factors
Artificial disparity between major plasma cations & anions that are
routinely measured
Non-anion gap acidosis : associated with increased plasma Cl- that has replaced
HCO3-
~ ex. GIT loss of HCO3- (diarrhea), renal wasting of HCO3- (RTA), ingestion
of acids, parenteral hyperalimentation, carbonic anhydrase inhibitors
These are the processes that classically make up the differential diagnosis of
an elevated anion gap metabolic acidosis. The mnemonic KUSEMALE may or
may not be helpful
Additional RuThe HCO3 normally falls 1 for every 1 increase in anion gap, with
the exception of sepsis.
This is a critical relationship for interpreting complex acid-base disorders.
Sometimes called the delta-delta, any elevation in the anion gap above 12
should result in a commensurate drop in the HCO3.
The Anions of Sepsis HPLC studies have failed to identify the anions
responsible for the AG in sepsis.
Lactate accounts for a portion.
H+ is likely from ATP hydrolysis which drives the fall in bicarbonate and is
not coupled to lactate production.
Sepsis is an exception to this rule, and the reasons for this remain poorly
understood.
What Lowers Anion Gap? Hypoalbuminemia
Lithium
Myeloma
Since albumin is the major unmeasured anion, when its levels are low, the
anion gap decreases. In fact this relationship is predictable: for every
1g/dl that albumin is decreased below 4.0 g/dl, the anion gap should
decrease by 2.5mmol/L. Therefore the upper limit of the anion gap for a
patient with a serum albumin of 2.0 would be 12 (2.5 X 2) = 7 Lithium is
an unmeasured cation. Just as unmeasured anions increase the anion
gap, unmeasured cations decrease it. Halide intoxication is rare but can
Na=140, Cl=96
diagnosisThe pH is normal, as are the HCO3 and pCO2. BUT, the anion gap is
20, elevated by 8. Thus there is a metabolic acidosis present. According to
the delta-delta rule, the HCO3 should be down by 8. IT is not so there has
to be an offsetting metabolic alkalosis present to result in the normal HCO3.
diagnosis AG metabolic acidosis and
Metabolic alkalosis A double acid-base disorder that is invisible
unless you calculate the anion gap.
pH = 7.40, HCO3=24, PCO2=40
Na=140, Cl=104
OK everything looks normal here even the anion gap, which is 12.
pH = 7.40, HCO3=24, PCO2=40
Na=140, Cl=104, albumin=1.1
Oops. We know that the upper level of the normal range for the anion
gap drops by 2.5 for every 1g/dl drop in albumin from 4.0. Thus the upper
level of the anion gap for this patient would be 12 (3 x 2.5) = 4.5. Thus
the anion gap of 12 represents an elevation of 7.5, and the HCO3 should
be down by that amount. As in the last example, this implies the
presence of an offsetting metabolic alkalosis.
For every 1.0 g/dl that the serum albumin is below 4.0, the upper limit of
the anion gap is decreased by 2.5
Normal upper limit = 12
Alb 3.0 upper limit = 9.5
Alb 2.0 upper limit = 7.0
Alb 1.9 upper limit = 4.5Oops. We know that the upper level of the normal
range for the anion gap drops by 2.5 for every 1g/dl drop in albumin from
4.0. Thus the upper level of the anion gap for this patient would be 12 (3 x
2.5) = 4.5. Thus the anion gap of 12 represents an elevation of 7.5, and the
HCO3 should be down by that amount. As in the last example, this implies
the presence of an offsetting metabolic alkalosis.
pH = 7.40, HCO3=24, PCO2=40
Na=140, Cl=104, albumin=1.1
Oops. We know that the upper level of the normal range for the anion
gap drops by 2.5 for every 1g/dl drop in albumin from 4.0. Thus the upper
level of the anion gap for this patient would be 12 (3 x 2.5) = 4.5. Thus
the anion gap of 12 represents an elevation of 7.5, and the HCO3 should
be down by that amount. As in the last example, this implies the
presence of an offsetting metabolic alkalosis.
Diagnosis: Anion Gap Metabolic
Acidosis Metabolic Alkalosis
Another invisible disorder uncovered with careful analysis for the patients
lab values.
Dogmatic StatementYou cannot interpret arterial blood gases without
looking at the electrolytesBe sure to check the albumin as well.
Summary Metabolic Acidosis: 1 HCO3 => 1 PCO2
Metabolic : 10 HCO3 => 7 PCO2
Acute Resp Acid: 10 PCO2 = 1 HCO3
Chronic Resp Acid: 10 PCO2 = 4 HCO3
Acute Resp Alk: 10 PCO2 => 2 HCO3
Chronic Resp Alk: 10 PCO2 => 5 HCO3
But dont forget to check the anion gap and the serum albumin!
1. If the process is acute; the pH value should change approximately 0.08 units for
each 10 mm Hg change in Pco2.
2. If the process is chronic, the kidneys compensate (by retaining or losing HCO3)
and blunt the pH change in response to any change in Pco2.
4. If the pH value does not move in the appropriate direction for the Pco2 change,
then a metabolic disorder is the primary disorder.
5. An alkalotic pH (7.44) indicates the presence of :-
b. a metabolic acidosis
c. Or both.
7. Look at Pco2.
3. A low pH value with a low Pco2 indicates a primary metabolic acidosis with
respiratory compensation.
4. A high pH value with a high Pco2 can indicate a primary metabolic alkalosis
with secondary suppression of respiratory drive.
5. However, in many patients the latter pattern of a high pH value with a high
Pco2 often represents a complex acid-base disturbance, such as a chronic
compensated respiratory acidosis with a superimposed primary metabolic
alkalosis (e.g., as a result of diuretics, vomiting, or nasogastric suction).
1. Hypokalemia*
Bartters syndrome
Inadequate renal perfusion
diuretics (inhibiting NaCl reabsorption)*
5. Bicarbonate administration
7. Steroids*
1. A 78 year old woman with a history of HTN, A fib, DM, and COPD presents
with severe abdominal pain. On examination she has diffuse severe
tenderness throughout the abdomen, mild wheezes and the following vital
signs:
3. A 29 year old female is struck by a car while crossing the street. She is awake
and alert with normal vital signs and oxygen saturation and a large bruise
across her right flank.
An IV line is placed. Should she get a complete gas or just a lactate? If so,
venous or arterial?
4. A 26 year old male with a history of insulin requiring diabetes presents with
abdominal pain, vomiting once, and polydipsia. He has missed one day of
medication. His glucose is 487 mg/dL
5. An 8 week old male presents in respiratory distress after 2 days of cough and
nasal congestion with poor feeding. His oxygen saturation is 88% on room
air. His lungs sound clear.
Conclusions
All decisions must be made with regards to the clinical context of the
patient and whether management would be potentially affected.
References
1. Bowers, B., (2009). Arterial Blood Gas Analysis: An Easy Learning Guide.
Primary Health Care, 19 (7), 11.
4. Dunford, F. (2009). Book reviews. Arterial blood gas analysis: an easy learning
guide. New Zealand Journal of Physiotherapy, 37 (2), 97.
5. Greaney, B. (2008). Book mark. Arterial blood gas analysis: an easy learning
guide. Emergency Nurse, 16 (7), 6.