Simple Method of Acid Base Balance Interpretation

A FOUR STEP METHOD FOR INTERPRETATION OF AB S

Usef!lness This method is simple, easy and can be used for the majority of ABGs. It only addresses acid-base balance and considers just 3 values.

pH, Pa"O# H"O$%

Step &' Use pH to determine Acidosis or Al(alosis' ph 7.35-7.45 Normal or Compensated

< 7.35 Acidosis

> 7.45 Alkalosis

Step #' Use Pa"O# to determine respirator) effect' PaCO2 <3

3 -!

"! Tends to#ard acidosis %auses lo# p' (eutrali)es hi&h p'

Tends to#ard al$alosis %auses hi&h p' (eutrali)es lo# p'

(ormal or Compensated

Step $' Ass!me meta*olic ca!se +hen respirator) is r!led o!t'

*ou+ll be ri&ht most of the time if you remember this simple table,

High pH Low pH Alkalosis Acidosis High aC!" Low aC!" High aC!" Low aC!"

#eta$olic %espirator& %espirator& #eta$olic If Pa"O# is abnormal and pH is normal, it indicates compensation. o p' " -.! #ould be a compensated al$alosis. o p' < -.! #ould be a compensated acidosis. These steps #ill ma$e more sense if #e apply them to actual ABG values. "lic( here to interpret some AB ,al!es !sin- these steps' *ou may #ant to refer bac$ to these steps .clic$ on /lin$ed/ steps or use /BA%0/ button on your bro#ser1 or print out this pa&e for reference. Step .' Use H"/$ to ,erif) meta*olic effect

(ormal H"O$% is 22-23

Please note0

4emember, the first three steps apply to the majority of cases, but do not ta$e into account, o the possibility of complete compensation, but those cases are usually less serious, and o instances of combined respiratory and metabolic imbalance, but those cases are pretty rare. /%ombined/ disturbance means H"O$% alters the p' in the same direction as the Pa"O#' 'i&h Pa"O# and lo# H"O$% .acidosis1 or 5o# Pa"O# and hi&h H"O$% .al$alosis1.

Example 1

ABG Value pH 7.3' PaCO2 +nterpretation 4*

Which step? (tep ) (tep "

Rationale Normal pH Normal aC!" o!mal ABG ,acid

$ase is

$alancedthere are no pH changes. so i/ the respirator& acid is normal. the meta$olic $ase cannot $e ca0sing changes either.1

Example 2

ABG Value pH 7."

Which step? (tep )

Rationale Low pH
indicates acidosis

High PaCO2 PaCO2 5* (tep "

indicates respirator& ca0se /or acidosis

+nterpretation

!espi!ato!" acidosis

Example #

ABG Value pH 7.4'

Which step? (tep )

Rationale High pH
indicates alkalosis

Low PaCO2 PaCO2 3* (tep "

indicates respirator& ca0se /or alkalosis ,lo respirator& acid is ca0sing higher pH1

+nterpretation

!espi!ato!" alkalosis

Example $

ABG Value pH 7."3

Which step? (tep )

Rationale Low pH
indicates acidosis

Low PaCO2
r0les o0t respirator& ca0se /or acidosis. there/ore meta$olic ca0se. Low respirator& acid is compensating /or lower pH.

PaCO2

3)

(tep 3

+nterpretation

meta%olic acidosis

Example &

ABG Value pH 7.42

Which step? (tep )

Rationale High pH
indicates alkalosis

High PaC'2 and High pH PaCO2 47 (tep 3

indicates meta$olic ca0se o/ alkalosis. %espirator& acid is compensating /or high pH.

+nterpretation

Pa!tiall" compensated meta%olic alkalosis

Example (

ABG Value pH 7.43

Which step? (tep )

Rationale pH is normal $0t

higher than 7.4. there/ore compensated

alkalosis.

PaCO2 +nterpretation

33

Low PaCO2 (tep 3

ca0ses alkalosis

Compensated !espi!ato!" alkalosis

"ase St!dies
The follo#in& are e6amples of clinical situations and the ABGs that may result, as #ell as causes and solutions for ABG abnormalities. "ase & 7rs. 8uffer is a 3 -year-old sin&le mother, just &ettin& off the ni&ht shift. 9he reports to the :; in the early mornin& #ith shortness of breath. 9he has cyanosis of the lips. 9he has had a productive cou&h for 2 #ee$s. 'er temperature is <=2.2, blood pressure <<=>-3, heart rate <=?, respirations 32, rapid and shallo#. Breath sounds are diminished in both bases, #ith coarse rhonchi in the upper lobes. %hest @-ray indicates bilateral pneumonia.

ABG results are, o p'A -.!! o 8a%B2A 2? o '%B3A 2! o 8aB2A !

Pro*lems0

8a%B2 is lo#. p' is on the hi&h side of normal, therefore compensated respirator) al(alosis. Also, 8aB2 is lo#, probably due to mucous displacin& air in the alveoli affected by the pneumonia .see 9huntin&1.

Sol!tions0

7rs. 8uffer most li$ely has A4;9 alon& #ith her pneumonia. The al$alosis need not be treated directly. 7rs. 8uffer is hyperventilatin& to increase o6y&enation, #hich is incidentally blo#in& off %B2. Improve 8aB2 and a normal respiratory rate should normali)e the p'. 'i&h CiB2 can help, but if she has interstitial lun& fluid, she may need intubation and 8::8, or a Bi8A8 to raise her 8aB2. .%lic$ here to compare Bi8A8 to other respiratory treatments.1 :6pect orders for antibiotics, and possibly steroidal anti-inflammatory a&ents. %hest physiotherapy and vi&orous cou&hin& or suctionin& #ill help the patient clear her air#ays of e6cess mucous and increase the number of functionin& alveoli. "ase #

7r. Dorried is a 2-year-old #ido#. 'e is retired and livin& alone. 'e enters the :; complainin& of shortness of breath and tin&lin& in fin&ers. 'is breathin& is shallo# and rapid. 'e denies diabetesE blood su&ar is normal. There are no :0G chan&es. 'e has no si&nificant respiratory or cardiac history. 'e ta$es several antian6iety medications. 'e says he has had an6iety attac$s before. Dhile bein& #or$ed up for chest pain an ABG is done,

ABG results are, o p'A -.!? o 8a%B2A 2? o '%B3A 22 o 8aB2A ?

Pro*lem0

p' is hi&h, 8a%B2 is lo# respirator) al(alosis'

Sol!tion0

If he is hyperventilatin& from an an6iety attac$, the simplest solution is to have him breathe into a paper ba&. 'e #ill rebreathe some e6haled %B2.This #ill increase 8a%B2 and tri&&er his normal respiratory drive to ta$e over breathin& control. F 8lease note this #ill not +or( on a person #ith chronic %B2 retention, such as a %B8; patient. These people develop a hypo6ic drive, and do not respond to %B2 chan&es.

"ase $ *ou are the critical care nurse about to receive 7r. 9#eet, a 2!-year-old ;0A .diabetic $etoacidosis1 patient from the :;. The medical dia&nosis tells you to e6pect acidosis. In report you learn that his blood &lucose on arrival #as -?=. 'e has been started on an insulin drip and has received one amp of bicarb. *ou #ill be doin& fin&er stic$ blood su&ars every hour.

ABG results are, o p'A -.33 o 8a%B2A 2 o '%B3A<2 o 8aB2A ?G

Pro*lem0

The p' is acidotic, 8a%B2 is 2 .lo#1 #hich should create al$alosis. This is a respirator) compensation for the meta*olic acidosis. The underlyin& problem is, of course, a meta*olic acidosis.

Sol!tion0

Insulin, so the body can use the su&ar in the blood and stop ma$in& $etones, #hich are an acidic by-product of protein metabolism. In the mean time, p' should be maintained near normal so that o6y&enation is not compromised

)))* +he ,and o- ABG .

3$ased on a concept $& La0ra 4asparis 5on/rolio. %N. H6 !nce 0pon a time there was a land known as A74. 89er&one there was related with onl& a limited n0m$er o/ names /or the pop0lation. :he& were also 9er& polite and had their own eti;0ette /or learning each other<s names. Now + wo0ld like to introd0ce &o0 to &o0r patient. Let<s /ig0re o0t what her name is= All o/ the people in the land o/ A74 ha9e a /irst name. a middle name. and a last name. >o0 ?0st ha9e to look at them one name at a time.

A* +he ,ast ame ). @irst. look at her pH. ,Normal A 7.35-7.451 ". +/ her pH is < ,less than1 7.35- her last name is AC)/O0)0. 3. +/ her pH is > ,greater than1 7.45- her last name is A,1A,O0)0. ,Note= :o $e an a$sol0tel& per/ect last name--her pH needs to $e 7.4*. (o. keep in mind. that i/ her pH is 7.35-7.3'--she<s thinking a$o0t marr&ing into the AC)/O0)0 /amil&. +/ her pH is 7.4)-7.45--she<s thinking a$o0t marr&ing into the A,1A,O0)0 /amil&.1 B* +he 2i!st ame Now that &o0 know &o0r patient<s last name. &o0 wo0ld like to also learn her /irst name. ). Look at her pH again. ". +/ it is 7.35-7.45 ,normal1 then her /irst name is CO3PE 0A+E/* 3. +/ the pH is <7.35 or >7.45--then her /irst name is 4 CO3PE 0A+E/* C* +he 3iddle ame Now that &o0 know &o0r patient<s /irst and last name. &o0 wo0ld like to know her middle name. ,Name Alert= :hese people are all related and &o0 ha9e man& patients with the same /irst and last name. A middle name will gi9e &o0 more in/ormation to go on.1 ). @irst &o0 need to look at the C!" and HC!3. ,%emem$er= Normal C!" A 35-45. Normal HC!3 A ""-"B1 ". :he middle name will either $e %espirator& or #eta$olic. 3. +/ the C!" is <35 or >45--her middle name is RE0P)RA+OR5* 4. +/ the HC!3 is <"" or >"B--her middle name is 3E+ABO,)C. /* +he 2amil" 2eud ). pH and HC!3 are Ckissin< co0sinsC--the& like to go in the same direction. ". 70t C!" is the C$lack sheepC--pH r0ns the opposite direction when it sees him coming. :here/ore= 3. 6ecreased pH with 6ecreased HC!3 A AC)/O0)0. 4. +ncreased pH with +ncreased HC!3 A A,1A,O0)0. 5. 6ecreased pH with +ncreased C!" A AC)/O0)0. B. +ncreased pH with 6ecreased C!" A A,1A,O0)0.

)V* ,et6s P!actice

A. %espirator& :herap& gi9es &o0 an A74 with the /ollowing n0m$ers= pH A 7.B* C!" A 3* HC!3 A "" ). Dhat is her last nameE ,Her pH is >7.45 so her last name is A,1A,O0)0.1 ". Dhat is her /irst nameE ,Her pH is not in the normal range o/ 7.35-7.45 so her /irst name is 4 CO3PE 0A+E/.1 3. Dhat is her middle nameE ,Her C!" is <35 and her HC!3 is normal so her middle name is RE0P)RA+OR5.1 4. >o0 ha9e now $een introd0ced to 4 CO3PE 0A+E/ RE0P)RA+OR5 A,1A,O0)0.

7. pH A 7.3) C!" A 5* HC!3 A "5 ). Dhat is her last nameE ,Her pH is <7.35 so her last name is AC)/O0)0.1 ". Dhat is her /irst nameE ,Her pH is not in the normal range so her /irst name is 4 CO3PE 0A+E/.1 3. Dhat is her middle nameE ,Her C!" is >45 and her HC!3 is normal so her middle name is RE0P)RA+OR5.1 5. >o0 ha9e now $een introd0ced to 4 CO3PE 0A+E/ RE0P)RA+OR5 AC)/O0)0*

C. pH A 7.55 C!" A 4* HC!3 A 3* ). Dhat is her last nameE ,Her pH is >7.45 so her last name is A,1A,O0)0.1 ". Dhat is her /irst nameE ,Her pH is not in the normal range so her /irst name is 4 CO3PE 0A+E/.1

3. Dhat is her middle nameE ,Her C!" is normal $0t her HC!3 is >"B so her middle name is 3E+ABO,)C.1 4. >o0 ha9e now $een introd0ced to 4 CO3PE 0A+E/ 3E+ABO,)C A,1A,O0)0*

6. pH A 7.35 C!" A 45 HC!3 A ") ). Dhat is her last nameE ,Her pH is normal--$0t it is <7.4*. (o her last name might $e AC)/O0)0. (he hasn<t decided i/ she wants to get married &et.1 ". Dhat is her /irst nameE ,Her pH is normal so her /irst name is CO3PE 0A+E/.1 3. Dhat is her middle nameE ,Her C!" is normal $0t her HC!3 is <"". (o her middle name is 3E+ABO,)C. Note= 7eca0se she has a middle name--she has decided to get married. :alk a$o0t a good reason to marr&F1 4. >o0 ha9e $een introd0ced to CO3PE 0A+E/ 3E+ABO,)C AC)/O0)0