Acid Base Balance and

Arterial Blood Gas Analysis

Gail Ross-Adjie
Emergency Nurse Educator
gailross@iinet.com.au

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Acid Base Balance

Overall acid-base balance is

maintained by controlling hydrogen
(H+) ion concentration
pH is a measure of H+ concentration
and shows the bloods acidity &
alkalinity
Complex mechanisms ensure
maintenance of the normal values

Normal Arterial Blood Gas

Values

pH 7.35 7.45
pO2 (oxygen) 80 100 mmHg
pCO2 (carbon dioxide) 35 45 mmHg
HCO3 (bicarbonate) 22 28 mEq/l

ABG Sites

From an arterial line if the patient has one

Otherwise from

Radial
Brachial or
Femoral artery

Apply firm pressure to site for 5 mins

Made sure the request form states whether
the patient is breathing room air or
supplemental O2 (either mask or ventilator)

PaCO2 reflects how well the body is

eliminating CO2
PaO2 reflects how well the body is
picking up oxygen from the lungs
HCO3 reflects the kidneys ability to
retain and excrete HCO3

Effect of pH

pH < 7 causes depression of the

central nervous system (CNS) leading
to confusion and coma
Ph > 7.6 causes excitability of the CNS
leading to tremor, muscle spasm and
convulsions

Acidosis

Indicated by a blood pH value less

than 7.35
May go as low as 6.80

Alkalosis

Indicated by a blood pH value more

than 7.45
May go as high as 8.00

Acidosis

Two types

Respiratory acidosis
Metabolic acidosis

Alkalosis

Two types

Respiratory alkalosis
Metabolic alkalosis

Respiratory Acidosis
(CO2 retention)

Caused by an increase in pCO2

pH < 7.30
pCO2 > 45
HCO3 > 26 mEq/l

Causes

Hypoventilation often 2 head injury or

overdose causing drowsiness
Pulmonary oedema
Respiratory arrest

Treatment

Treatment is aimed at increasing the

exhalation of CO2
May require intubation & ventilation
If already ventilated, increase
respiratory rate
Suction the airway if excessive
secretions

Respiratory Alkalosis
(excess CO2 excretion)

Caused by a decrease in pCO2

pH > 7.45
pCO2 < 35
HCO3 < 22 mEq/l

Causes

Hyperventilation

usually due to anxiety or pain

RR too high on the ventilator

May present with spasm in fingers

Respiratory stimulation from

Head injury
Hypoxia
Fever
Some drugs

Treatment

Aim is to increase the pCO2

Get patient to breath into a paper bag
(re-inhaling their own CO2)
If ventilated, RR
Fix underlying cause

Metabolic Acidosis
(HCO3 loss or acid retention)

Caused by an increase in acidic

metabolic products (eg. ketones) and
a in HCO3
pH < 7.35
pCO2 < 35
HCO3 < 22mEq/l

Causes

Renal failure
HCO3 loss from diarrhoea
Diabetic ketoacidosis (DKA)
Starvation
Ingestion of acid

Treatment

Correct the underlying cause

Use of IV HCO3 is controversial and
does not show any benefit in those
with DKA (Cooper cited in Dunn, 2000, p. 264)

Metabolic Alkalosis
(HCO3 retention, acid loss)

Caused by an excess of HCO3 in the

body or a in gastric acid
pH > 7.45
HCO3 > 26 mEq/l

Causes

Caused by a loss of acid in the body or

a high intake of alkalis
Usually a result of excessive vomiting
leading to a in gastric acid or a high
intake of alkali medicines (antacids)
Excessive gastric suctioning

Treatment

Treat the underlying cause

So

If pH < 7.35 the patient has an acidosis

If pH > 7.45 the patient has an alkalosis
The problem is metabolic if HCO3 is
abnormal
The problem is respiratory if the CO2 is
abnormal

Steps involved in analyzing

ABGs
1.
2.
3.

Is the pH normal?
Is the CO2 normal?
Is the HCO3 normal?

Examples
32yo male motorbike rider hit by car. No
helmet. GCS 8 on arrival to ED. ABG's:
pH 7.20
pO2 70 mmHg
pCO2 110 mmHg
What is wrong and how could we correct it?

14 yo girl with 2 day history of diarrhoea

and vomiting. ABGs:
pH 7.50
pO2 95
pCO2 40
HCO3 29 mEq/l

28 yo woman presents complaining of

severe abdominal pain and spasm in
her fingers. She is anxious ++
pH 7.55
pCO2 26
pO2 96
HCO3 21 mEq/l

42 yo male is bought in by his family with a

history of insulin dependent diabetes. He is
drowsy and complains of abdominal pain,
excessive thirst and urination. His BSL is
elevated. ABGs:
pH 7.18
HCO3 19
pO2 60
pCO2 66

References

Respiratory Care Made Incredibly Easy. (2005). Philadelphia:

Lippincott Williams & Wilkins.

Dunn, R. (2000). Laboratory Medicine. In R. Dunn (Ed.), The

Emergency Medicine Manual (2nd ed.). Adelaide: Venom.

Miller, D. T., & Lunde, J. R. (2003). Laboratory Specimen Collection.

In L. Newberry (Ed.), Sheehy's Emergency Nursing Principles and
Practice (5th ed.). St Louis: Mosby.

Tortora, G. J., & Anagnostakos, N. P. (1991). Principles of Anatomy

and Physiology (4th ed.). New York: Harper & Row.

West, J. B. (2005). Respiratory Physiology: The Essentials (7th ed.).

Philadelphia: Lippincott, Williams & Wilkins.