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Usefulness
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,
PaCO2
HCO3-
7.35-7.45
> 7.45
Acidosis
Normal or
Compensated
Alkalosis
Tends
toward
alkalosis
Causes
high pH
Neutralizes
low pH
35 -45
> 45
Normal
or
Compensated
Tends
toward
acidosis
Causes low
pH
Neutralizes
high pH
You'll be right most of the time if you remember this simple table:
High pH
Low pH
Alkalosis
Acidosis
Please note:
Remember, the first three steps apply to the majority of cases, but do not take
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.
"Combined" disturbance means HCO3- alters the pH in the same
direction as the PaCO2.
High PaCO2 and low HCO3- (acidosis) or
Low PaCO2 and high HCO3- (alkalosis).
Example 1
ABG Value
pH
7.39
PaCO2
40
Which step?
Step 1
Step 2
base is
balanced;
there are no
pH changes,
so if the
respiratory
acid is
normal, the
metabolic
base cannot
be causing
changes
either.)
Interpretation
Rationale
Normal pH
Normal
PaCO2
Normal
ABG (acid
Example 2
ABG Value
pH
Which step?
7.2
Step 1
Rationale
Low pH
indicates
acidosis
High
PaCO2
PaCO2
50
Step 2
respiratory
acidosis
Interpretation
indicates
respiratory
cause for
acidosis
Example 3
ABG Value
pH
PaCO2
Which step?
Rationale
High pH
7.49
Step 1
indicates
alkalosis
30
Step 2
Low PaCO2
indicates
respiratory
cause for
alkalosis (lo
respiratory
acid is
causing higher
pH)
respiratory
alkalosis
Interpretation
Example 4
ABG Value
pH
Which step?
7.23
Step 1
Rationale
Low pH
indicates
acidosis
Low
PaCO2 rules
PaCO2
31
Step 3
metabolic
acidosis
Interpretation
out
respiratory
cause for
acidosis,
therefore
metabolic
cause. Low
respiratory
acid is
compensating
for lower pH.
Example 5
ABG Value
pH
PaCO2
Which step?
Rationale
High pH
7.48
Step 1
indicates
alkalosis
47
Step 3
High PaC02
and High pH
indicates
metabolic cause
of alkalosis.
Respiratory
acid is
compensating
for high pH.
Partially
compensated
metabolic
alkalosis
Interpretation
Example 6
ABG Value
pH
Which step?
7.43
PaCO2
33
Interpretation
Step 1
Step 3
Rationale
pH is normal
but higher than
7.4, therefore
compensated
alkalosis.
Low PaCO2
causes alkalosis
Compensated
respiratory
alkalosis
Case Studies
The following are examples of clinical situations and the ABGs that may result, as
well as causes and solutions for ABG abnormalities.
Case 1
Mrs. Puffer is a 35-year-old single mother, just getting off the night shift. She reports
to the ED in the early morning with shortness of breath. She has cyanosis of the
lips. She has had a productive cough for 2 weeks. Her temperature is 102.2, blood
pressure 110/76, heart rate 108, respirations 32, rapid and shallow. Breath sounds
are diminished in both bases, with coarse rhonchi in the upper lobes. Chest X-ray
indicates bilateral pneumonia.
o
o
o
o
pH= 7.44
PaCO2= 28
HCO3= 24
PaO2= 54
Problems:
PaCO2 is low.
pH is on the high side of normal, therefore compensated respiratory
alkalosis.
Also, PaO2 is low, probably due to mucous displacing air in the alveoli
affected by the pneumonia (see Shunting).
Solutions:
Mrs. Puffer most likely has ARDS along with her pneumonia.
The alkalosis need not be treated directly. Mrs. Puffer is hyperventilating to
increase oxygenation, which is incidentally blowing off CO2. Improve PaO2
and a normal respiratory rate should normalize the pH.
High FiO2 can help, but if she has interstitial lung fluid, she may need
intubation and PEEP, or a BiPAP to raise her PaO2. (Click here to compare
BiPAP to other respiratory treatments.)
Expect orders for antibiotics, and possibly steroidal anti-inflammatory agents.
Chest physiotherapy and vigorous coughing or suctioning will help the patient
clear her airways of excess mucous and increase the number of functioning
alveoli.
Case 2
Mr. Worried is a 52-year-old widow. He is retired and living alone. He enters the ED
complaining of shortness of breath and tingling in fingers. His breathing is shallow
and rapid. He denies diabetes; blood sugar is normal. There are no EKG changes.
He has no significant respiratory or cardiac history. He takes several antianxiety
medications. He says he has had anxiety attacks before. While being worked up for
chest pain an ABG is done:
Problem:
pH is high,
PaCO2 is low
respiratory alkalosis.
Solution:
Case 3
You are the critical care nurse about to receive Mr. Sweet, a 24-year-old DKA
(diabetic ketoacidosis) patient from the ED. The medical diagnosis tells you to
expect acidosis. In report you learn that his blood glucose on arrival was 780. He
has been started on an insulin drip and has received one amp of bicarb. You will be
doing finger stick blood sugars every hour.
Problem:
The pH is acidotic,
PaCO2 is 25 (low) which should create alkalosis.
This is a respiratory compensation for the metabolic acidosis.
The underlying problem is, of course, a metabolic acidosis.
Solution:
Insulin, so the body can use the sugar in the blood and stop making ketones,
which are an acidic by-product of protein metabolism.
In the mean time, pH should be maintained near normal so that oxygenation is
not compromised