ABG Interpretation

ABG Interpretation
• First, does the patient have an acidosis
or an alkalosis
• Second, what is the primary problem –
metabolic or respiratory
• Third, is there any compensation by the
patient – respiratory compensation is
immediate while renal compensation
takes time

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 ABG Interpretation
• It would be extremely unusual for either
the respiratory or renal system to
overcompensate
• The pH determines the primary problem
• After determining the primary and
compensatory acid/base balance,
evaluate the effectiveness of
oxygenation
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 Normal Values
• pH 7.35 to 7.45
• paCO2 36 to 44 mm Hg
• HCO3 22 to 26 meq/L

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 Abnormal Values
pH < 7.35 paCO2 < 36 mm Hg
• Acidosis (metabolic • Respiratory alkalosis
and/or respiratory) (alveolar
pH > 7.45 hyperventilation)
• Alkalosis (metabolic HCO3 < 22 meq/L
and/or respiratory) • Metabolic acidosis
paCO2 > 44 mm Hg HCO3 > 26 meq/L
• Respiratory acidosis • Metabolic alkalosis
(alveolar
hypoventilation)

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 Putting It Together -
Respiratory
So
paCO2 > 44 with a pH < 7.35 represents a
respiratory acidosis
paCO2 < 36 with a pH > 7.45 represents a
respiratory alkalosis
For a primary respiratory problem, pH and
paCO2 move in the opposite direction
– For each deviation in paCO2 of 10 mm Hg in either
direction, 0. 08 pH units change in the opposite
direction
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 Putting It Together - Metabolic
And
HCO3 < 22 with a pH < 7.35 represents a
metabolic acidosis
HCO3 > 26 with a pH > 7.45 represents a
metabolic alkalosis
For a primary metabolic problem, pH and
HCO3 are in the same direction, and
paCO2 is also in the same direction
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 Compensation
• The body’s attempt to return the
acid/base status to normal (i.e. pH
closer to 7.4)
Primary Problem Compensation
respiratory acidosis metabolic alkalosis
respiratory alkalosis metabolic acidosis
metabolic acidosis respiratory alkalosis
metabolic alkalosis respiratory acidosis
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 Classification of primary acid-
base disturbances and
compensation
• Acceptable ventilatory and metabolic acid-
base status
• Respiratory acidosis (alveolar
hypoventilation) - acute, chronic
• Respiratory alkalosis (alveolar
hyperventilation) - acute, chronic
• Metabolic acidosis – uncompensated,
compensated
• Metabolic alkalosis – uncompensated,
partially compensated
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 Respiratory Alkalosis
• Causes – Drugs
– Pain – Sepsis
– Anxiety – Fever
– Hypoxemia – Thyrotoxicosis
– Restrictive lung – Pregnancy
disease – Overaggressive
– Severe congestive mechanical
heart failure ventilation
– Pulmonary emboli – Hepatic failure

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 Metabolic Acidosis
Elevated Anion Gap
• Causes
– Ketoacidosis - diabetic, alcoholic,
starvation
– Lactic acidosis - hypoxia, shock, sepsis,
seizures
– Toxic ingestion – salicylates, methanol,
ethylene glycol, ethanol, isopropyl alcohol,
paraldehyde, toluene
– Renal failure - uremia
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 Metabolic Acidosis
Normal Anion Gap
• Causes – Diarrhea
– Renal tubular – Carbonic anhydrase
acidosis inhibitors
– Post respiratory – Acid administration
alkalosis (HCl, NH4Cl, arginine
– Hypoaldosteronism HCl)
– Potassium sparing – Sulfamylon
diuretics – Cholestyramine
– Pancreatic loss of – Ureteral diversions
bicarbonate
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 Summary
• First, does the patient have an acidosis or an
alkalosis
– Look at the pH
• Second, what is the primary problem –
metabolic or respiratory
– Look at the pCO2
– If the pCO2 change is in the opposite direction of
the pH change, the primary problem is respiratory

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 Assessing Oxygenation
• Normal value for arterial blood gas
80-100mmHg
• Normal value for venous blood gas
40mmHg
• Normal SaO2
– Arterial: 97%
– Venous: 75%
 Summary
• Third, is there any compensation by the
patient - do the calculations
– For a primary respiratory problem, is the
pH change completely accounted for by
the change in pCO2
• if yes, then there is no metabolic compensation
• if not, then there is either partial compensation
or concomitant metabolic problem

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 Summary
– For a metabolic problem, calculate the
expected pCO2
• if equal to calculated, then there is appropriate
respiratory compensation
• if higher than calculated, there is concomitant
respiratory acidosis
• if lower than calculated, there is concomitant
respiratory alkalosis

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 Summary
• Next, don’t forget to look at the
effectiveness of oxygenation, (and look
at the patient)
– your patient may have a significantly
increased work of breathing in order to
maintain a “normal” blood gas
– metabolic acidosis with a concomitant
respiratory acidosis is concerning

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 Case 1
Little Billy got into some of dad’s
barbiturates. He suffers a significant
depression of mental status and
respiration. You see him in the ER 3
hours after ingestion with a respiratory
rate of 4. A blood gas is obtained (after
doing the ABC’s, of course). It shows
pH = 7.16, pCO2 = 70, HCO3 = 22

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 Case 1
What is the acid/base abnormality?
2. Uncompensated metabolic acidosis
3. Compensated respiratory acidosis
4. Uncompensated respiratory acidosis
5. Compensated metabolic alkalosis

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 Case 1
Uncompensated respiratory acidosis
• There has not been time for metabolic
compensation to occur. As the
barbiturate toxicity took hold, this child
slowed his respirations significantly,
pCO2 built up in the blood, and an
acidosis ensued.

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 Case 2
Little Suzie has had vomiting and diarrhea
for 3 days. In her mom’s words, “She
can’t keep anything down and she’s
runnin’ out.” She has had 1 wet diaper
in the last 24 hours. She appears
lethargic and cool to touch with a
prolonged capillary refill time. After
addressing her ABC’s, her blood gas
reveals: pH=7.34, pCO2=26, HCO3=12
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 Case 2
What is the acid/base abnormality?
2. Uncompensated metabolic acidosis
3. Compensated respiratory alkalosis
4. Uncompensated respiratory acidosis
5. Compensated metabolic acidosis

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 Case 3
You are evaluating a 15 year old female in the
ER who was brought in by EMS from school
because of abdominal pain and vomiting.
Review of system is negative except for a 10
lb. weight loss over the past 2 months and
polyuria for the past 2 weeks. She has no
other medical problems and denies any
sexual activity or drug use. On exam, she is
alert and oriented, afebrile, HR 115, RR 26
and regular, BP 114/75, pulse ox 95% on RA.

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 Case 3
What is the blood gas interpretation?
• Uncompensated respiratory acidosis with
severe hypoxia
• Uncompensated metabolic alkalosis
• Combined metabolic acidosis and respiratory
acidosis with severe hypoxia
• Metabolic acidosis with respiratory
compensation

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 12 year old diabetic presents with Kussmaul
breathing

• pH : 7.05
• pCO2: 12 mmHg
• pO2: 108 mmHg
• HCO3: 5 mEq/L
• BE: -30 mEq/L
– Severe partly compensated metabolic
acidosis without hypoxemia due to
ketoacidosis
 17 year old w/severe kyphoscoliosis, admitted for
pneumonia

• pH: 7.37
• pCO2: 25 mmHg
• pO2: 60 mmHg
• HCO3: 14 mEq/L
• BE: -7 mEq/L
– Compensated respiratory alkalosis due
to chronic hyperventilation secondary to
hypoxia
 9 year old w/hx of asthma, audibly wheezing x 1 week, has
not slept in 2 nights; presents sitting up and using accessory
muscles to breath w/audible wheezes

• pH: 7.51
• pCO2: 25 mmHg
• pO2 35 mmHg
• HCO3: 22 mEq/L
• BE: -2 mEq/L
– Uncompensated respiratory alkalosis
with severe hypoxia due to asthma
exacerbation
 7 year old post op presenting with chills, fever and
hypotension

• pH: 7.25
• pCO2: 32 mmHg
• pO2: 55 mmHg
• HCO3: 10 mEq/L
• BE: -15 mEq/L
– Uncompensated metabolic acidosis due
to low perfusion state and hypoxia
causing increased lactic acid
 Post test
• Ph – 7.25 • Ph – 7.05
• PCO2 – 55 • PCO2 – 20
• HCO3 - 29 • HCO3 - 15
• 7.48 • 7.36
• 32 • 52
• 12 • 34
 References
• The ICU Book – Paul L. Marino, 1991,
Algorithms for acid-base interpretations,
p415-426
• Textbook of Pediatric Intensive Care 3rd
Edition – edited by Mark C. Rogers, 1996,
Respiratory Monitoring: Interpretation of
clinical blood gas values, p355-361
• Pediatric Critical Care – Bradley Fuhrman
and Jerry Zimmerman, 1992, Acid-Base
Balance and Disorders, p689-696
• Critical Care Physiology – Robert Bartlett,
1996, Acid-Base physiology p165-173.
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