Abg DR Pkjain Ccef July 2008

Self assessment
A 19 yr pregnant insulin dependent diabetic admitted

with polyuria and thirst. h/o poor compliance with
medical therapy.
She was afebrile. Chest was clear. Circulation was
adequate. Peri-oral herpes +. Urinalysis: 2+ ketones,
4+ glucose. Biochemistry: Na
+
136, K
+
4.8, Cl
-
101,
glucose 19 mmol/L, urea 8.1 mmol/L and creatinine
0.09 mmol/L. Arterial Blood Gases:
pH 7.26
pCO
2
16 mmHg
pO
2
128 mmHg
HCO
3
7.1 mmol/l

Examples in ABG Interpretation (Dr. P.K.Jain)
Case 1
A 26 year old man with unknown past medical history
is brought in to the ER by ambulance, after friends
found him unresponsive in his apartment. He had last
been seen at a party four hours prior.

ABG: pH 7.25 Na
+
137
PCO
2
60 K
+
4.5
HCO
3
-
26 Cl
-
100
PO
2
55
Case 2
A 67 year old man with diabetes and early diabetic
nephropathy (without overt renal failure) presents for a
routine clinic visit. He is currently asymptomatic.
Because of some abnormalities on his routine blood
chemistries, you elect to send him for an ABG.

ABG: pH 7.35 Na
+
135
PCO
2
34 K
+
5.1
HCO
3
-
18 Cl
-
110
PO
2
92
Cr 1.4
Urine pH: 5.0
Case 3
A 68 year old woman with metastatic colon cancer
presents to the ER with 1 hour of chest pain and
shortness of breath. She has no known previous
cardiac or pulmonary problems.

ABG: pH 7.49 Na
+
133
PCO
2
28 K
+
3.9
HCO
3
-
21 Cl
-
102
PO
2
52

Case 4
A 6 year old girl with severe gastroenteritis is admitted
to the hospital for fluid rehydration, and is noted to
have a high [HCO
3
-
] on hospital day #2. An ABG is
ordered:

ABG: pH 7.47 Na
+
130
PCO
2
46 K
+
3.2
HCO
3
-
32 Cl
-
86
PO
2
96
Urine pH: 5.8
Case 5
A 75 year old man with morbid obesity is sent to the
ER by his skilled nursing facility after he developed a
fever of 103 and rigors 2 hours ago. In the ER he is
lucid and states that he feels terrible, but offers no
localizing symptoms. His ER vitals include a heart rate
of 115, and a blood pressure of 84/46.

ABG: pH 7.12 Na
+
138
PCO
2
50 K
+
4.2
HCO
3
-
13 Cl
-
99
PO
2
52
Urine pH: 5.0
Case 6
A 25 year old man with type I diabetes presents to the
ER with 24 hours of severe nausea, vomiting, and
abdominal pain.

ABG: pH 7.15 Na
+
138
PCO
2
30 K
+
5.6
HCO
3
-
10 Cl
-
88
PO
2
88
Cr 1.1
Urine pH: 5.0
Case 7
A 62 year old woman with severe COPD comes to
the ER complaining of increased cough and
shortness of breath for the past 12 hours. There are
no baseline ABGs to compare to, however, her
HCO
3
-
measured during a routine clinic visit 3
months ago was 34 mEq/L.

ABG: pH 7.21 Na
+
135
PCO
2
85 K
+
4.0
HCO
3
-
33 Cl
-
90
PO
2
47
Urine pH 5.5
Case 8
A 36 year old man with a history of alcoholism is
brought to the casualty after being found on the floor of
his apartment unresponsive, soiled with vomit, and
with an empty pill bottle nearby.

ABG: pH 7.03 Na
+
134
PCO
2
75 K
+
5.2
HCO
3
-
19 Cl
-
90
PO
2
48 HCO
3
-
20

Urine pH 5.0
The Painful Fact
The more you learn
the more you wonder how you
managed so far.
Poorly collected sample wrong ABG report
Practical things they dont teach you at
college:
Where to collect blood from?
Heparin amount.
Preventing air contact.
Transportation.
Clinical Information: FiO
2
Do not Cap or Bend the needle !!!
PO
2
: 150

PCO
2
: 0
PO
2
: 90
PCO
2
: 42
Patient with PO2: 30, PCO2: 80
PO
2
: 30
PCO
2
: 80
PO
2
: 30
PCO
2
: 80

x
Blood
A I R
Plug (airtight) the needle !!!
ABG
ICE
ABG
APPROACH TO INTERPRETATION OF ABG
You are on duty. A 54 yr male patient, known Diabetic on
irregular treatment is admitted to the ICU. You start him
on 2L/min oxygen. Arterial Blood Gas study shows:
PO
2
= 108 mmHg
PCO
2
= 30 mmHg
pH =7.20
HCO
3
=15 mmHg
What is your interpretation?
What will be your next action?
[H+] x [HCO3]
PCO2
= 24 Henderson equation
Step 1: Check consistency of the Report !
pH Subtract from [H+]
6.8 160
6.9 130
7.0 100 100
7.1 90 80
7.2
80
60
7.3 50
7.4 40
7.5 30
7.6 85 25
7.7 90 20
7.8 95 15
40 x 24
40
= 24
60 x 15
30
= 30
Eg. In this patient
pH =7.2, PCO
2
= 30, HCO
3
=15
pH [H]
6.8
6.9
7.0
7.1
7.2
7.3
7.4 40
7.5
7.6
7.7
7.8
7.9
pH [H]
6.8
6.9
7.0
7.1
7.2
7.3 50
7.4 40
7.5 30
7.6
7.7
7.8
7.9
pH [H]
6.8 160
6.9
7.0
7.1 80
7.2
7.3 50
7.4 40
7.5 30
7.6
7.7 20
7.8
7.9
pH [H]
6.8 160
6.9 120
7.0
7.1 80
7.2 60
7.3 50
7.4 40
7.5 30
7.6
7.7 20
7.8 15
7.9
pH [H]
6.8 160
6.9 120
7.0 100
7.1 80
7.2 60
7.3 50
7.4 40
7.5 30
7.6 25
7.7 20
7.8 15
7.9 12
pH [H]
6.8 160
6.9 120
7.0 100
7.1 80
7.2 60
7.3 50
7.4 40
7.5 30
7.6 25
7.7 20
7.8 15
7.9 12
pH [H]
6.8
6.9
7.0
7.1
7.2
7.3
7.4
7.5
7.6
7.7
7.8
7.9
What is the corresponding
[H] value for following pH?

pH

7.7 ..

6.9 ..

7.1 ..

7.55 ..
Self Assessment..
pH [H]
6.8 160
6.9 120
7.0 100
7.1 80
7.2 60
7.3 50
7.4 40
7.5 30
7.6 25
7.7 20
7.8 15
7.9 12
What is the corresponding
[H] value for following pH?

pH

7.7 ..

6.9 ..

7.1 ..

7.55 ..
Step 2: Obtain relevant clinical history!
a. Metabolic acidosis:
DM/renal failure/muscle over activity/ hypotension/
diarrhea/ diamox, metformin/ alcoholism.

b. Metabolic alkalosis:
Vomiting, RT aspiration/hypovolemia, diuretic/ NaHCO3
administration/ hypokalemia (paralytic ileus)

c. Respiratory acidosis:
COPD, muscular weakness, post-op.

d. Respiratory alkalosis:
Tachypnea, hepatic coma, sepsis
Importance of the Clinical Details
Case 1: A previously healthy 37 yr man is
having an elective open cholecystectomy.
He is on no routine medication.
Preoperative urea /electrolytes were normal.
Parameter Value
pH 7.10
PO2 75 mmHg
PCO2 70 mmHg
HCO3 27 mmol/L
Parameter Value
pH 7.10
PO2 75 mmHg
PCO2 90 mmHg
HCO3 27 mmol/L
Case 2: A 75 yr man with severe COPD is
admitted with fever, confusion and
significant respiratory distress. He lives
alone and has been unwell for a week and
has deteriorated over the previous 4 days.
There is a long history of heavy smoking.
Biochemistry & hematology results are not
yet available..
Parameter Value
pH 7.10
PO2 75 mmHg
PCO2 90 mmHg
HCO3 27 mmol/L
Parameter Value
pH 7.10
PO2 75 mmHg
PCO2 70 mmHg
HCO3 27 mmol/L
Case 2: A 75 yr man with severe COPD is
admitted with fever, confusion and
significant respiratory distress. He lives
alone and has been unwell for a week and
has deteriorated over the previous 4 days.
There is a long history of heavy smoking.
Biochemistry & hematology results are not
yet available..
Acute Respiratory
acidosis
Chronic Respiratory
Acidosis + Acute
metabolic acidosis.
Step 3: Oxygenation Status:
a. -oxemia status
b. expected Vs observed PaO
2
.
c. oxygen cost of breathing

Step 4: Ventilatory Status.
Look at PaCO
2

Step 5: Acid - Base Status..
Interpretation of oxygenation status
On room air,
PO
2
of 80-100 Normal
PO
2
of 60-79 Mild hypoxemia
PO
2
of 40-59 Moderate hypoxemia
PO
2
of < 40 Severe hypoxemia
If patient receiving O
2
then expected PO
2
is ~ 5 x
FiO
2.
(on 30 %

O
2
the expected

PO
2
will be 5 x 30
=150 mmHg)
PAO
2
= [(760-47) x FiO
2
] (PaCO
2
/ 0.8).
PAO
2
= (713 x FiO
2
) (PaCO
2
x 1.25).
FiO
2
0.5
PO
2
150 mmHg
pH 7.32
pCO
2
42 mmHg
HCO
3
21.3 mmol/L
SBE -5.8 mmol/L
A 32 yr female with 32 week pregnancy meets with motor vehicle
accident. Rib fractures ++ and on NSAIDs. BP-Normal, Abdomen
not tender. ABG report is as follows:
Comment on her oxygenation status.
FiO
2
0.5
PO
2
150 mmHg
pH 7.32
pCO
2
42 mmHg
HCO
3
21.3 mmol/L
SBE -5.8 mmol/L
PO2 high.
PAO2 = (713x0.5)-(42 x 1.25)
= 356 53 = 303

PA-aO2 = 303-150 = 153 !!

? Pulm contusion, ? Pneumothorax
A 45 yr female on mechanical ventilation post-laparotomy.
ABG shows:
FiO
2
0.45
PO
2
240 mmHg
pH 7.27
pCO
2
75 mmHg
HCO
3
34 mmol/L
SBE 5.2 mmol/L
Comment on the oxygenation status in this patient.
A 45 yr female on mechanical ventilation post-laparotomy. ABG
shows
FiO
2
0.45
PO
2
240 mmHg
pH 7.27
pCO
2
75 mmHg
HCO
3
34 mmol/L
SBE 5.2 mmol/L
PO2 is high.
PAO2= (713 x 0.45)-(75x1.25)
= 320 94 = 226
PA-aO2 = 226-240 = -14 !!!
Either PO2 is wrong or patient on higher
FiO2 than 45%!
O2
a. -oxemia status
2
.

Look at PaCO
2

Interpretation of Ventilation status
Normal PCO
2
is 35-45 mmHg.
PCO
2
< 35 mmHg hyper ventilation
PCO
2
> 45 mmHg hypo ventilation

One exception

FiO
2
0.5
PO
2
150 mmHg
pH 7.32
pCO
2
42 mmHg
HCO
3
21.3 mmol/L
SBE -5.8 mmol/L
Comment on her ventilatory status.
FiO
2
0.5
PO
2
150 mmHg
pH 7.32
pCO
2
42 mmHg
HCO
3
21.3 mmol/L
SBE -5.8 mmol/L
Initial impression PCO2 is normal.
But at 32 wk pregnancy normally PCO2
is 30 with compensatory fall in HCO3 (10
x .5 =5) i. e. HCO3 was 19 to start with!
The increase in CO2 is therefore not by 2
but by 12 and has therefore caused partial
compensation by increasing HCO3 by
less than (12 x .3 = 3.6)
FiO
2
0.21
PO
2
60 mmHg
pH 7.34
pCO
2
60 mmHg
HCO
3
32 mmol/L
SBE 4.3 mmol/L
SaO2 90 %
You are called to casualty to opine on ABG of this 65 yr male
with mild pain in abdomen. The medical officer is concerned
about his barrel chest and low saturation on pulse oximetry. ABG
report is as follows:
Comment on his ventilatory status.
Explain the hypoxemia.
FiO
2
0.21
PO
2
60 mmHg
pH 7.34
pCO
2
60 mmHg
HCO
3
32 mmol/L
SBE 4.3 mmol/L
SaO2 90 %
You are called to casualty to opine on ABG of this 65 yr male
with mild pain in abdomen. The medical officer is concerned
about his barrel chest and low saturation on pulse oximetry.
ABG report is as follows:
Patient is hypoventilating.
PAO2 = (713 x .21)-(60 x 1.25)
= 150-75= 75
PA-aO2 = 75-60 = 15 (normal)
no lung pathology
Low PO2 is due to hypoventilation !!!
APPROACH TO INTERPRETATION OF ABG

a. -oxemia status
2
.

Look at PaCO
2

Primary Acid-Base Disorders
Alterations in pH can result from:
1. Respiratory component (pCO
2
) or
2. Metabolic component (HCO
3
-
).
Metabolic Acidosis
(Too little HCO
3
-
)
Metabolic Alkalosis
(Too much HCO
3
-
)
Respiratory Acidosis
(Too much CO
2
)
Respiratory Alkalosis
(Too little CO
2
)
Compensation
When a primary acid-base disorder exists, the
body attempts to return the pH to normal via
the other half of acid base metabolism.

Primary metabolic disorder Respiratory compensation

Primary respiratory disorder Metabolic compensation
International Consensus
Secondary or compensatory responses
should NOT be designated as acidosis
or alkalosis
Simple acid base disorders
Metabolic acid.
Respiratory acid.
Respiratory alk.
Disorder pH HCO
3
-
PaCO
2

Acidosis
Alkalosis
Metabolic alk.
Disorder pH HCO
3
-
PaCO
2

Acidosis
Metabolic acid.
Respiratory acid.
Alkalosis
Metabolic alk.
Respiratory alk.
Disorder pH HCO
3
-
PaCO
2

Acidosis
Metabolic acid.
Respiratory acid.
Alkalosis
Metabolic alk.
Respiratory alk.
Disorder pH HCO
3
-
PaCO
2

Acidosis
Metabolic acid.
Respiratory acid.
Alkalosis
Metabolic alk.
Respiratory alk.
Disorder pH HCO
3
-
PaCO
2

Acidosis
Metabolic acid.
Respiratory acid.
Alkalosis
Metabolic alk.
Respiratory alk.
Practical Approach
Determine primary disorder:

pH < 7.35 acidemia
HCO
3
< 24 metabolic acidosis
pCO
2
> 40 respiratory acidosis

pH > 7.45 alkalemia
HCO
3
> 24 metabolic alkalosis
pCO
2
< 40 respiratory alkalosis
b. Identify primary/dominant acid-base disorder.
A patient presents with breathlessness since 1 day. He is
given oxygen. Arterial blood gas is analysed and shows
FiO
2
0.40 Patient has diabetes with blood
sugar of 450 mg%.

pH acidemia
PCO2 low alkalosis
HCO3 low acidosis

Therefore Metabolic Acidosis
PO
2
165
pH

7.26
PCO
2
27
HCO
3
12
Na 140
cl 99
Metabolic acidosis
Metformin
toxicity ??
??Convulsions
Lactic acidosis ??
??Starvation
Diabetes ?
Ethylene Glycol
intoxication ???
???
???
???
???
???
???
Cations = Anions
Na
K
UC
Cl
HCO
3
UA
Na+K+UC = Cl+HCO
3
+UA
Concept of Anion gap
Na
Cl
HCO
3
Anion gap = Na ( Cl+HCO
3
)
K
UC
UA
Na
Cl
HCO
3
3
)
K
3
)
Do not forget the bigger
picture
Lactic acidosis/
Ketoacidosis
Na
K
UC
Cl
HCO
3
UA
Na+K+UC = Cl+HCO
3
+UA
High anion gap metabolic acidosis
Lactic acidosis/
Ketoacidosis
Na
Cl
HCO
3
Na+K+UC = Cl+HCO
3
+UA
High anion gap metabolic acidosis
Hyperchloremic
acidosis
Na
K
UC
Cl
HCO
3
UA
Na+K+UC = Cl+HCO
3
+UA
Normal anion gap metabolic acidosis
Hyperchloremic
acidosis
Na
K
UC
Cl
HCO
3
UA
Na+K+UC = Cl+HCO
3
+UA
Normal anion gap metabolic acidosis
Calculate anionic gap (AG)
Anionic Gap = Na (Cl + HCO3).
Metabolic acidosis with increased AG.
Lactic acidosis
Diabetic ketoacidosis, starvation ketoacidosis.
Renal failure
Toxicity: ethanol, ethylene glycol, salicylate
Metabolic Acidosis with normal AG
Renal: RTA, Diamox.
GI causes: severe diarrhea, fistulas/ drains.
Recovery from ketoacidosis (DKA + saline).

f. In Normal AG Acidosis
Urinary Anionic Gap = [Na + K] [Cl]
(Pre-requisites: no ketosis, carbenicillin, urine pH <6.5)

Negative UAG => GI or iatrogenic
Positive UAG (>20-30 meq/L)=> RTA- (I, II, IV).
Look at urine pH: >6.0 Distal (type I) RTA
Look at urine pH: <5.5 Proximal (type II) RTA/ (type IV)
Look at serum K+
- Hypokalemia Proximal (type II) RTA/
- Hyperkalemia aldosterone deficiency (type IV) RTA
f In N-AG Metabolic Acidosis look at urinary electrolytes.
Normal AG acidosis:
1. Urinary electrolytes:
urinary Na, K BOTH LOW diarrhea, recent diuretics.
urinary Na, K BOTH HIGH RTA (1/2), current diuretics.
urinary Na HIGH but urinary K LOW vomiting, (RTA type 4).
urinary Na LOW but urinary K HIGH lower GI loss.
2. Urinary pH and ammonia estimation:
i) If urine pH <5.5, give IV NaHCO3 till urine alkaline.
If urine pH >6.0 before normalization of S.HCO3 => proximal
RTA
If urine pH remains acidic => diarrhoea
ii) If urine pH >6.0, give IV NaHCO3 and check urine pH.
If urine pH remains unchanged despite NaHCO3 => distal RTA
Normal anion gap is 12 but is influenced by
1. albumin levels and
2. pH of blood.

Both disturbances common in critically ill patients!

SO it is important to know what should be the EXPECTED
value in that patient at that time.

HOW??
Anion Gap: Expected AG & Actual AG
a. Calculate actual Anionic Gap: = Na (Cl + HCO3)
b. Correct expected Anionic gap (S. proteins / pH):
for every 1 gm% of S. albumin the AG by 2 mEq/L
(4 gm% for albumin)
e.g. In patient with nephrotic syndrome/cirrhosis:
S. Albumin 2 gm%, so expected AG = 12 4 = 8 mEq/L.
e.g. In volume depleted patient with S. Albumin is 6 gm%,
Therefore expected AG = 12 + 4 = 16 mEq/L.

In acidemic states : normal AG by 2meq/L
In alkalemic states: normal AG by 4 mEq/L
e.g. In patient with contraction metabolic alkalosis (pH 7.5,
Albumin 5 gm%): expected AG = 12 + 4 + 2 = 18 mEq/L.
Anion Gap: Expected AG & Actual AG
b. Identify primary/dominant acid-base disorder.
A patient presents with breathlessness since 1 day. He is given
oxygen. Arterial blood gas is analyzed and shows
FiO
2
0.40 Patient has diabetes with blood sugar of 450mg%.
pH => Acidemia
PCO2 => alkalosis
HCO3 => acidosis
Therefore Metabolic Acidosis.
Anionic Gap = Na (Cl + HCO3)
= 140- (99+12) = 29
(expected AG = 12-2= 10)
PO
2
165
pH

7.26
PCO
2
27
HCO
3
12
Na 140
cl 99
c. Identify compensatory disorder.
1. Metabolic acidosis:
a. PCO2 = HCO3 (actually 1.0 1.5 times HCO3)
2. Metabolic alkalosis:
a. PCO2 = 0.5 HCO3 (actually 0.5 -1.0)
3. Respiratory acidosis:
a. Acute: Change in PCO2 by 10 changes HCO3 by 1
Change in PCO2 by 10 changes pH by 0.08
b. Chronic: Change in PCO2 by 10 changes HCO3 by 3.5
4. Respiratory alkalosis:
b. Chronic: Change in PCO2 by 10 changes HCO3 by 5
R. acidosis R. Alkalosis
Acute 1 2
Chronic 3 4
R. acidosis R. Alkalosis
Acute 1 2
Chronic 3 (3.5) 4 (5)
1. Metabolic acidosis:
a. PCO2 = HCO3 (actually 1.0 1.5 times HCO3)
2. Metabolic alkalosis:
a. PCO2 = 0.5 HCO3 (actually 0.5 -1.0)
If HCO3=12 then
PCO2 = 40-12=28
If HCO3=34 then
PCO2 = 40+5=45
If PCO2 = 60
HCO3=26 (acute)
=31 (chronic)
If PCO2 = 20
HCO3=20 (acute)
=14 (chronic)
shows
FiO
2
0.45
PO
2
240 mmHg
pH 7.27
pCO
2
75 mmHg
HCO
3
34 mmol/L
SBE 5.2 mmol/L
Comment on the acid base status in this patient.
shows
FiO
2
0.45
PO
2
240 mmHg
pH 7.27
pCO
2
75 mmHg
HCO
3
34 mmol/L
SBE 5.2 mmol/L
Acidemia.
Acute resp. acidosis
(acute because on vent PCO2 = 75 will not be
missed!)
HCO3 = 24 + (35 x .1) = 27.5
But HCO3 >27 primary Met. Alkalosis
? Hypovolemia, ? Hypokalemia
If resp. acidosis is chronic then HCO3 = 24 + 35 x .3 = 34.5.
However clinical data insufficient (diagnosis of acute and
chronic).
d. Identify simple from mixed acid-base disorder.
Current HCO3 is 10.
10
24
C
B
A
Current HCO3 is 10.
10
24
C
B
A
Renal
failure
Current HCO3 is 10.
32
10
24
C
B
A
vomiting
Current HCO3 is 10.
32
10
24
C
B
A
vomiting
Lactic
acidosis
(hypovolemic
shock)
Current HCO3 is 10.
32
18
10
24
C
B
A
DKA
Current HCO3 is 10.
32
18
10
24
C
B
A
DKA
NaCl
infudion
Current HCO3 is 10.
32
18
10
24
C
B
A
Current HCO3 is 10.
10
C
B
A
Simpler to calculated corrected HCO3:
Corrected HCO3 = actual HCO3 + AG
32
18
10
24
C
B
A
ABG Normal
Met.
Acidosis
(High AG)
Met acidosis
(High AG)
+ Met alkalosis
Met acidosis
(High AG) +
(Normal AG)
pH 7.40 7.29 7.38 7.10
PCO2 40 30 35 20
HCO3 24 14 20 6
AG 12 20 26 20
AG
0 +10 + 14 +10
HCO3 + AG 24 24 34 16
Corrected HCO3 = actual HCO3 + AG
ABG Normal
Met. Acidosis
(a)

Met acidosis
(b)

Met acidosis
(c)
pH
7.40 7.29 7.38 7.10
PCO2
40 30 35 20
HCO3
24 14 20 6
AG
12 20 26 20
???? ???? ????
ABG Normal
Met. Acidosis
(High AG)
Met acidosis (High AG)
+ Met alkalosis
Met acidosis
(High AG) +
Met acidosis
(Normal AG)
pH
7.40 7.29 7.38 7.10
PCO2
40 30 35 20
HCO3
24 14 20 6
AG
12 20 26 20
AG
0 +10 + 14 +10
HCO3
0 -10 -4 -18
AG/ HCO3
1 >1-2 (3.5) <1
Metabolic acidosis with low ionized Calcium
1. Pancreatitis
2. Renal failure
3. Rabdomyolyisis
4. Tumor cell lysis syndrome
5. Ethylene glycol toxicity
6. HF poisoning
Metabolic acidosis with low Blood sugar
1. Liver cell failure
2. Convulsions
3. Metformin toxicity
4. Adrenal insufficiency
5. ? starvation
Metabolic Alkalosis
Bartters syndrome ???
Gitelmann Syndrome
???
Primary
hyperaldosteronism ???
Villus adenoma ???
Metabolic Alkalosis
Commonest cause are
Hypovolemia
(Contraction alkalosis)
Hypokalemia

So assess volume status
Cannot use Urinary Na??
If volume OK then investigate hypokalemia!

Cl
Na
HCO3
Approach to Metabolic alkalosis
Check Urinary Chlorides:
U
Cl
< 20 mEq/L Hypovolemia (Vomiting/ RT, Diuretics).
U
Cl
> 20 mEq/L Then Check Urinary K
+
:
U
K
< 20 mEq/day vomiting
U
K
> 30 mEq/day diuretics or mineralocorticoid excess
Then Check BP:
Normal diuretic abuse, Bartters syndrome.
Hypertensive check S. Aldosterone/ Renin:
- Primary hyperaldosteronism.
- Secondary hyperaldosteronism.
- Cushings syndrome (increased cortisol).
Oxygen in Metabolic alkalosis!
Hypoventilation (response to metabolic alkalosis)
Pulmonary microatelectasis (from hypoventilation)
Increased V/Q mismatch (as alkalosis inhibits hypoxic
pulmonary vasoconstriction)
Peripheral oxygen unloading may be impaired
because of the alkalotic shift of the haemoglobin
oxygen dissociation curve to the left.
Normal compensatory response is to increase cardiac
output but this ability is impaired if hypovolaemia and
decreased myocardial contractility are present.

Hypokalemia + Metabolic disorder
? Metabolic acidosis ? Metabolic alkalosis
Check Urinary K
Urinary K < 20 mEq/L + metabolic acidosis:
GI loss: diarrhea, laxative abuse, fistula, villus
adenoma.
Urinary K > 20 mEq/L + metabolic acidosis:
RTA (type 1 &2), acetazolamide therapy,DKA,
Ureterosigmoidostomy.
Urinary K > 20 mEq/L + metabolic alkalosis:
(see urinary chlorides) --
FiO
2
0.21
PO
2
103 mmHg
pH 7.25
pCO
2
26 mmHg
HCO
3
11.2 mmol/L
SBE -16.2 mmol/L
Na

141 mEq/L
K

3.6 mEq/L
Cl 114 mEq/L
Glucose 180 mg %
You are managing a severe DKA in ICU. 10 hrs post admission,
there is persisting Acidemia despite aggressive treatment. ABG
and electrolytes of this 43 yr male at this time is as follows:
Comment on the acid base status
FiO
2
0.21
PO
2
103 mmHg
pH 7.25
pCO
2
26 mmHg
HCO
3
11.2 mmol/L
SBE -16.2 mmol/L
Na

141 mEq/L
K

3.6 mEq/L
Cl 114 mEq/L
Glucose 180 mg %
You are managing a severe DKA in ICU. 10 hrs post admission,
there is persisting Acidemia despite aggressive treatment. ABG
and electrolytes of this 43 yr male at this time is as follows:
Acidemia. Met. Acidosis.
AG = 141- (114 + 11) = 16 (increased)
AG = 16 -10 = 6
Corrected HCO3 = 11.2 + 6 = 17.2
Therefore another acidosis normal AG
metabolic acidosis (hyperchloremia due
to saline infusion in large quantity).
Final diagnosis: Met acidosis with
increased AG plus Met acidosis with
Normal AG.

e. In high AG acidosis: Calculate of Osmolal gap.
a. Osmolal gap = measured ~ calculated Osmolality
< 10 mOsm/kg H20

b. Calculated Osmolality = 2[Na] + [glucose]/18 + [BUN]/2.8

FiO
2
0.21
PO
2
112 mmHg
pH 7.10
pCO
2
14 mmHg
HCO
3
16 mmol/L
Na

131 mEq/L
K

3.0 mEq/L
Cl 94 mEq/L
Glucose 252 mg %
A 24 yr male admitted in coma. He has rapid deep breathing.
Clinical examination otherwise normal. His CSF and CT head are
normal. The ABG and biochemistry on admission is as follows:
Comment on the acid base status.
urea

10 mmol/L
creat 0.7 mg%
Posm

324 mosm/Kg
Ca ionized

1.2 mEq/L
FiO
2
0.21
PO
2
112 mmHg
pH 7.10
pCO
2
14 mmHg
HCO
3
16 mmol/L
Na

131 mEq/L
K

3.0 mEq/L
Cl 94 mEq/L
Glucose 252 mg %
A 24 yr male admitted in coma. He has rapid deep breathing.
Clinical examination otherwise normal. His CSF and CT head are
normal. The ABG and biochemistry on admission is as follows:
Acidemia.
Metabolic acidosis with AG = 21.
Measured Posm = 324
Calculated Posm = 2 x (131) + 252/18 = 276
Therefore osmolar gap = 324 276 = 48
urea

10 mmol/L
creat 0.7 mg%
Posm

324 mosm/Kg
Ca ionized

1.2 mEq/L
DD: ethanol
poisoning, methanol
poisoning, ethylene
glycol poisoning
FiO
2
0.21
PO
2
112 mmHg
pH 7.10
pCO
2
14 mmHg
HCO
3
16 mmol/L
Na

131 mEq/L
K

3.0 mEq/L
Cl 94 mEq/L
Glucose 252 mg %
This patient after 24 hrs develops fixed dilated pupils. Suggest a
likely diagnosis.
urea

10 mmol/L
creat 0.7 mg%
Posm

324 mosm/Kg
Ca ionized

1.2 mEq/L
FiO
2
0.21
PO
2
112 mmHg
pH 7.10
pCO
2
14 mmHg
HCO
3
16 mmol/L
Na

131 mEq/L
K

3.0 mEq/L
Cl 94 mEq/L
Glucose 252 mg %
This patient after 24 hrs develops fixed dilated pupils. Suggest a
likely diagnosis.
Methanol toxicity manifests 1-7 hrs after
ingestion (CNS, visual, GI symptoms).
Visual symptoms due to formic acid
Normal Ca ionized is against ethylene glycol.
Urine examination showing calcium oxalate
crystals would favour ethylene glycol intoxication.
urea

10 mmol/L
creat 0.7 mg%
Posm

324 mosm/Kg
Ca ionized

1.2 mEq/L
DD: ethanol poisoning, methanol poisoning,
ethylene glycol poisoning
Oxalate
crystals
in another case
A patient of multiple myeloma with asthma is admitted with status
asthma to the ICU and is put on ventilator. On 100% FiO2 the
arterial blood gas report is as follows:
FiO
2
100%
PaO
2
477
PaCO
2
47
pH 7.23
HCO
3
19
Hb 7.2
S. Albumin 2.0 gm%
You are the treating physician in the
ICU. How would you proceed on
seeing this report ?
A patient of multiple myeloma with asthma is admitted with
status asthma and is put on ventilator. On 100% FiO2 the
FiO
2
100%
PaO
2
477
PaCO
2
47
pH 7.23
HCO
3
19
Hb 7.2
S. Albumin 2.0 gm%
Oxygenation status:
Ventilatory Status:
Acid-base status:
Acidemia resp acidosis + metabolic
acidosis
What next ??
FiO
2
100%
PaO
2
477
PaCo
2
47
pH 7.23
HCO
3
19
Hb 7.2
S. Albumin 2.0 gm%
Sr. Na 131
Sr. K 3.4
Sr. Cl 104
Resp acidosis + Metabolic acidosis
FiO
2
100%
PaO
2
477
PaCo
2
47
pH 7.23
HCO
3
19
Hb 7.2
S. Albumin 2.0 gm%
Sr. Na 131
Sr. K 3.4
Sr. Cl 104
Resp acidosis + metabolic acidosis
Expected anionic gap = 12 2 4 = 6 2
Actual AG = 131-(104+19) = 8
AG = 0
Therefore Met Acidosis with normal anionic
gap
What next ??
FiO
2
100%
PaO
2
477
PaCo
2
47
pH 7.23
HCO
3
19
Hb 7.2
S. Albumin 2.0 gm%
Sr. Na 131
Sr. K 3.4
Sr. Cl 104
Ur. Na 146
Ur. K 27.6
Ur. Cl 146
Resp acidosis + metabolic acidosis with normal
anionic gap.
FiO
2
100%
PaO
2
477
PaCo
2
47
pH 7.23
HCO
3
19
Hb 7.2
S. Albumin 2.0 gm%
Sr. Na 131
Sr. K 3.4
Sr. Cl 104
Ur. Na 146
Ur. K 27.6
Ur. Cl 146
Resp acidosis + normal AG metabolic acidosis

Urinary AG = 146 + 27.6 146 =27.6
Positive UAG RTA
What next ??
FiO
2
100%
PaO
2
477
PaCo
2
47
pH 7.23
HCO
3
19
Hb 7.2
Sr. Na 131
Sr. K 3.4
Sr. Cl 104
Ur. Na 146
Ur. K 27.6
Ur. Cl 146
Ur. pH 6.1
Resp acidosis + normal AG metabolic
acidosis due to RTA
FiO
2
100%
PaO
2
477
PaCo
2
47
pH 7.23
HCO
3
19
Hb 7.2
Sr. Na 131
Sr. K 3.4
Sr. Cl 104
Ur. Na 146
Ur. K 27.6
Ur. Cl 146
Ur. pH 6.1
Resp acidosis + normal AG metabolic acidosis
due to RTA
Urine pH > 5.5 and Serum K low
Therefore Distal (Type I) Renal Tubular
Acidosis
FiO
2
100%
PaO
2
477
PaCo
2
47
pH 7.23
HCO
3
19
Hb 7.2
Sr. Na 131
Sr. K 3.4
Sr. Cl 104
Ur. Na 146
Ur. K 27.6
Ur. Cl 146
Ur. pH 6.1
Respiratory acidosis (related to severe airways
resistance and permissive hypercapnia as
protective lung strategy)

+ normal AG metabolic acidosis (due to Type 1
RTA) from multiple myeloma.
Case 1
A 26 year old man with unknown past medical history
is brought in to the ER by ambulance, after friends
found him unresponsive in his apartment. He had last
been seen at a party four hours prior.

ABG: pH 7.25 Na
+
137
PCO
2
60 K
+
4.5
HCO
3
-
26 Cl
-
100
PO
2
55
Case 2
A 67 year old man with diabetes and early diabetic
nephropathy (without overt renal failure) presents for a
routine clinic visit. He is currently asymptomatic.
Because of some abnormalities on his routine blood
chemistries, you elect to send him for an ABG.

ABG: pH 7.35 Na
+
135
PCO
2
34 K
+
5.1
HCO
3
-
18 Cl
-
110
PO
2
92
Cr 1.4
Urine pH: 5.0
Case 3
A 68 year old woman with metastatic colon cancer
presents to the ER with 1 hour of chest pain and
shortness of breath. She has no known previous
cardiac or pulmonary problems.

ABG: pH 7.49 Na
+
133
PCO
2
28 K
+
3.9
HCO
3
-
21 Cl
-
102
PO
2
52

Case 4
A 6 year old girl with severe gastroenteritis is admitted
to the hospital for fluid rehydration, and is noted to
have a high [HCO
3
-
] on hospital day #2. An ABG is
ordered:

ABG: pH 7.47 Na
+
130
PCO
2
46 K
+
3.2
HCO
3
-
32 Cl
-
86
PO
2
96
Urine pH: 5.8
Case 5
A 75 year old man with morbid obesity is sent to the
ER by his skilled nursing facility after he developed a
fever of 103 and rigors 2 hours ago. In the ER he is
lucid and states that he feels terrible, but offers no
localizing symptoms. His ER vitals include a heart rate
of 115, and a blood pressure of 84/46.

ABG: pH 7.12 Na
+
138
PCO
2
50 K
+
4.2
HCO
3
-
13 Cl
-
99
PO
2
52
Urine pH: 5.0
Case 6
A 25 year old man with type I diabetes presents to the
ER with 24 hours of severe nausea, vomiting, and
abdominal pain.

ABG: pH 7.15 Na
+
138
PCO
2
30 K
+
5.6
HCO
3
-
10 Cl
-
88
PO
2
88
Cr 1.1
Urine pH: 5.0
Case 7
A 62 year old woman with severe COPD comes to
the ER complaining of increased cough and
shortness of breath for the past 12 hours. There are
no baseline ABGs to compare to, however, her
HCO
3
-
measured during a routine clinic visit 3
months ago was 34 mEq/L.

ABG: pH 7.21 Na
+
135
PCO
2
85 K
+
4.0
HCO
3
-
33 Cl
-
90
PO
2
47
Urine pH 5.5
Case 8
A 36 year old man with a history of alcoholism is
brought to the ER after being found on the floor of his
apartment unresponsive, soiled with vomit, and with an
empty pill bottle nearby.

ABG: pH 7.03 Na
+
134
PCO
2
75 K
+
5.2
HCO
3
-
19 Cl
-
90
PO
2
48 HCO
3
-
20

Urine pH 5.0
Additional case
65 yr male develops hypotension (90/56) intra-op with
ST depression. He is shifted to ICU where he has
Ventricular fibrillation that responds to DC shock. Arterial
Blood Gases are collected soon afterwards.
pH 7.27
pCO2 55.4 mmHg
pO2 144 mmHg
HCO3 24.3 mmol/l
Biochemistry (mmol/l): Na
+
138, K
+
4.7, Cl
-
103,
urea 6.4 & creatinine 0.07
Why ABG in a ventilated patient?
We take breathing for granted.
Mechanical ventilation shows us how
complex it really is!
No substitute for measurement of PO
2
,
PCO
2
, pH, HCO
3
in a ventilated patient.
Appropriateness of the ventilator setting.
As guide to corrections necessary.
Case scenario 1
34 year male with GB syndrome
presents with progressive weakness
involving muscles of breathing and is
intubated and ventilated with Vt 600
ml, RR 20/min, FiO
2
40%. ABG done
soon afterward shows:
PO
2
198, PCO
2
28, pH 7.5, HCO
3
22.
Is the ventilator settings appropriate for
this patient?
What is not right?
Case scenario 1
34 year male with GB syndrome presents
with progressive weakness involving
muscles of breathing and is intubated and
ventilated with Vt 600 ml, RR 20/min, FiO
2

40%. ABG done soon afterward shows:
PO
2
198, PCO
2
28, pH 7.5, HCO
3
22.
What are the adjustments to be made on the
ventilator to correct for PO
2
and PCO
2
?
How to adjust the FiO
2
for the PaO
2
PaO
2
is directly proportional to FiO
2
.
PaO
2
FiO
2

PaO
2
/ FiO
2
is a constant

PaO
2
/ FiO
2
(new) = PaO
2
/ FiO
2
(old)

In this patient: 100 / FiO
2
= 198 / 40
FiO
2
new = 100 x 40 = 20.2%
198
Case Scenario 2
A patient being mechanically ventilated
on assist control mode with Vt 450 ml,
RR 18, FiO
2
70% has an ABG report as
follows:
PO
2
170, PCO
2
34, pH 7.5, HCO
3
26.
What PO
2
can I expect if I reduce the FiO
2

to 40%?

How to predict the PaO
2
PaO
2
/FiO
2
is a constant at any given
time.
PaO
2
/FiO
2
(new) = PaO
2
/FiO
2
(old)

In this patient: PaO
2
/ 40 = 170/ 70
PaO
2
expected = 170 x 40 = 97.1%
70
Back to case 1
34 year male with GB syndrome
presents with progressive weakness
involving muscles of breathing and is
intubated and ventilated with Vt 600
ml, RR 20/min, FiO
2
40%. ABG done
soon afterward shows:
PO
2
198, PCO
2
28, pH 7.5, HCO
3
22.
How to readjust ventilator for PCO
2
?
How to adjust MV for PCO
2
PCO
2
is inversely proportional to minute
ventilation.
PCO
2
1/ minute ventilation
PCO
2
x MV (old) = PCO
2
x MV (new)

PCO
2
x Vt (old) = PCO
2
x Vt (new)
PCO
2
x RR (old) = PCO
2
x RR (new)

Back to the case
Vt 600 ml, RR 20/min, FiO
2
40%. ABG:
PO
2
198, PCO
2
28, pH 7.5, HCO
3
22.
PCO
2
x Vt (old) = PCO
2
x Vt (new)
28 x 600 = 35 x Vt (new)
Correct Vt setting is 480 ml.
PCO
2
x RR (old) = PCO
2
x RR (new)
28 x 20 = 35 x RR (new)
Correct RR = 16/min
Words of Wisdom
Do not interpret any blood gas data
without the serum electrolytes:
Na
+
, K
+
, Cl
-
.
Do not interpret any blood gas data
without clinical history.
Do not interpret any PO
2
without FiO
2
.

Abg DR Pkjain Ccef July 2008

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