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# ABG INTERPRETATION

ABG INTERPRETATION

Determine
1. 2. 3. 4. 1. 2.

If acidosis or alkalosis Primary disorder is respiratory or metabolic If respiratory whether acute or chronic If Metabolic acidosis

## Anion gap present or not

If metabolic respiratory compensation adequate or not For anion gap acidosis any concomitant disturbance present or

NORMAL VALUES
pH

7.40
3

HCO PCO
2

: 24

: 40

METABOLIC ACIDOSIS

First step is to see the anion gap AG = Na (Cl + HCO3) Then to see if respiratory compensation is adequate Use Winters formula Expected PCO2 : [1.5 x HCO3] + 8 (+/2) If PCO2 is > expected additional resp acidosis If PCO2 is < expexted additional resp alkalosis For AG metabolic acidosis see if there is additional disorder

## RULES FOR COMPENSATION

Metabolic Acidosis

## PaCO2 should fall by 1 - 1.5 mm Hg x the fall in plasma [HCO3]

Metabolic Alkalosis

CASE NO. 1

## Na: 123 Cl: 99 HCO3- : 5 PaCO2 : 10 pH: 7.31

STEP 1

ACIDOSIS OR ALKALOSIS

## pH : 7.31 Normal pH : 7.40 This pt is ACIDOTIC

STEP 2

REPIRATORY OR METABOLIC
PCO2 : 10 Normal PCO2: 40 HCO3 : 5 Normal HCO3: 24 METABOLIC ACIDOSIS

STEP 4

## IF METABOLIC DISORDER WHAT IS THE ANION GAP

Na : 123 Cl : 99 HCO3 : 5 Anion gap: Na (Cl HCO) = 123 (99+5) = 19 Normal anion gap = 8 12 Pt has ANION GAP METABOLIC ACIDOSIS

STEP 5

## IF METABOLIC PROB RESPIRATORY COMPENSATION ADEQUATE

Expected PCO2: (+/- 2) = 1.5 x 5 + 8 = 7.5 + 8 = 15.5 (+/- 2) = 13.5 17.5 PCO2 in our pt : expected)

[1.5 x (HCO3)] + 8

10 (lower than

STEP 6

## FOR ANION GAP ACIDOSIS ANY OTHER METABOLIC PROBLEMS

Corrected HCO3 = measured HCO3 + (AG 12) = 5 + (19 12) = 5 + 7 = 12 Pts AG is 19 (normal 12) so 7 mEq of HCO3 was used to generate AG Add 7 to pts current HCO3 (7 + 5 = 12) which gives the pts HCO3 before AG acidosis developed. Meaning this pt has a additional NON-ANION GAP METABOLIC ACIDOSIS

CASE NO 2

## Na : 125 mEq/L Cl : 100 mEq/L HCO3- : 8 mEq/L PaCO2 : 28 mmHg pH : 7.07

STEP 1

ACIDOSIS OR ALKALOSIS
pH : 7.07 So this is acidosis

STEP 2

REPIRATORY OR METABOLIC
PCO2 : 28 HCO3 : 8 Low HCO3 and low PCO2 Metabolic acidosis

STEP 4

## IF METABOLIC DISORDER WHAT IS THE ANION GAP

Na : 125 Cl : 100 HCO3 : 8 AG : Na (Cl + HCO3) = 125 (100+8)

= 17

STEP 5

[1.5 x (HCO3)] +

## [1.5 x 8] + 8 +/- 2 12 + 8 +/- 2 18 22

Pts PCO2 : 28 So there is additional PRIMARY

STEP 6

FOR ANION GAP ACIDOSIS ANY OTHER METABOLIC PROBLEMS Delta gap = measured HCO3 + (AG 12)

= = =

8 + ( 17 12) 8+5 13

## So pt has additional NON ANION GAP METABOLIC ACIDOSIS also

CASE 3
Na = 128 Cl = 90

HCO3 = 4 7.0/14/90/4/95%

PH = acidemia AG = 128 (90 + 4) = 34 Winters formula 1.5(4) + 8 = 14 Delta gap = 4 + (34 12) = 26

RESPIRATORY ACIDOSIS

Determine if the event is Acute or Chronic Acute : for every 10 rise in PCO2, pH drops by a factor of 0.08 Chronic : for every 10 rise in PCO2, pH drops by a factor of 0.03 Expected decrease in pH for acute resp acidosis = 0.08 x (measured PaCO2 40) 10 Expected decrease in pH for chronic resp acidosis

RESPIRATORY ACIDOSIS

## Plasma [HCO3] should rise by ~4mmoles/l for each 10 mm Hg increment in PaCO2

Determine if the event is Acute or Chronic Acute : for every 10 drop in PCO2, pH rises by a factor of 0.08 Chronic : for every 10 drop in PCO2, pH rises by a factor of 0.03 Expected decrease in pH for acute resp alkalosis = 0.08 x (40 measured PaCO2) 10 Expected decrease in pH for chronic resp alkalosis = 0.03 x (40 measured PaCO2)

RESPIRATORY ALKALOSIS

RESPIRATORY ALKALOSIS

## Acute Respiratory Alkalosis

Plasma [HCO3] should fall by ~1-3 mmole/l for each 10 mm Hg decrement in PaCO2, usually not to less than 18 mmoles/l Plasma [HCO3] should fall by ~2-5 mmole/l for each 10 mm Hg decrement in PaCO2, usually not to less than 14 mmoles/l

CASE 4

## Na : 135 Cl : 93 HCO3 : 30 PCO2 : 80 pH : 7.18

Step 1: pH: 7.18, Acidosis Step 2: PCO2-80, HCO3-30 (Respiratory) Step 3 : Acute or chronic
Rise in PCO2 = 80 40 = 40 Drop in pH = 7.40 7.18 = 0.22 If it was acute = PCO2 (rose by a factor of 4), pH would have dropped by factor of four (4 x 0.08) = 0.32 (7.40 0.32 = 7.08) If it was chronic = pH would have dropped by 4 x 0.03 = 0.12 (7.40

CASE 5

56 y/o with COPD exacerbation and hypotension and associated diarrhea x 7 days presents with the following 139 110 20 ABG: 120 4.0 10 1.5 7.22/30/65/10/90% , PH(7.22) = acidemia Low HCO3 and low PCO2 = Met Acidosis AG = 139 (10 + 110) = 19 Winters formula PaCO2 = 1.5 (HCO3) + 8 = 1.5 (10) + 8 = 23

CASE 5

This pateint has Anion gap metabolic acidosis Respiratory acidosis Non-anion gap metabolic acidosis

CASE 6

40 y/o with pneumonia and low BP on dopamine. She has been having N/V over the last three days Na = 130, Cl = 90, HCO3 = 10 ABG = 7.26/15/65/10/90% PH = acidemia Low HCO3 / Low PCO2 = Met acidosis AG = 130 (90 + 10) = 30 Expected PCo2 = 1.5(10) + 8 = 23 Delta HCo3 = 10 + (30 12) = 28

CASE 6

## Anion gap metabolic acidosis Respiratory alkalosis Metabolic alkalosis

CASE 7

A 3 year old is brought to the pedes ER at ~3am, stuporous and tachypneic. History is remarkable for his parents having cleaned out their medicine cabinet earlier that day. An ABG and electrolytes have been accidentally drawn by the nurse.

CASE 7

Available data: pH=7.53, PaCO2=12; Na+=140, K+=3.0, Cl-=106, HCO3=10 Which variable (PaCO2, HCO3) is deranged in a direction consistent with alkalosis? ed PaCO2, ed HCO3; so Respiratory Alkalosis Acute respiratory alkalosis Plasma [HCO ] should fall by ~1-3 mmole/l 3 for each 10 mm Hg decrement in PaCO2, usually not to less than 18 mmoles/l PaCO2 ed by ~30 mm Hg; HCO3 should fall by 3-9 mmole/l; HCO3 is too great, so

CASE 7

What is the anion gap? 140 - (106 + 10) = 24; elevated anion gap consistent with metabolic acidosis What is the differential diagnosis? Combined (true) respiratory alkalosis and metabolic acidosis seen in sepsis, or salicylate intoxication

CASE 8

A 5 year old with Bartters Syndrome is brought to clinic, where she collapses. She has recently been febrile, but history is otherwise unremarkable. An ABG and serum electrolytes are obtained: pH=6.9, PaCO2=81; Na+=142, K+=2.8, Cl-=87, HCO3=16

CASE 8

What is the primary disturbance? _________ Acidosis Which variable (PaCO2, HCO3) is deranged in a direction consistent with acidosis? Both; pick most abnormal value-Respiratory Acidosis Is compensation appropriate?

CASE 8

## Plasma [HCO3] should rise by ~1mmole/l for each 10 mm Hg increment in PaCO2

Since HCO3 is inappropriately depressed, compensation is not appropriate, and there is a concomitant metabolic acidosis as well What is the anion gap?

CASE 8

Combined Respiratory Acidosis and Metabolic Acidosis; are there other disorders present? What about the dx of Bartters Syndrome? Bartters Syndrome characterized by hypokalemic metabolic alkalosis Does this patient have a concealed metabolic alkalosis?

CASE 8

Anion gap is 39, or 25-27 greater than normal Typically, increases in anion gap correlate with decreases in HCO3 Assuming a 1:1 relationship, as anion gap increases by 25, HCO3 should fall by 25 Starting HCO3 must have been 16 + 25 = 41

CASE 8

Therefore, starting HCO3 was ~41 mmol/l, consistent with expected chronic metabolic alkalosis. This metabolic alkalosis was concealed by the supervening profound metabolic and respiratory acidoses associated with her arrest event. Final diagnosis: Metabolic alkalosis, metabolic acidosis, &