Arterial Blood Gas Assessments

Chapter 4
Arterial Blood Gas

Assessments
Mosby items and derived items © 2011, 2006 by Mosby, Inc., an affiliate of Elsevier Inc. 1
Table 4-1. Normal Blood Gas Values
Box 4-1. Acid-Base Disturbance Classifications
This Chapter Provides the Following
Review
 The PCO2/HCO3/pH relationship—an
essential cornerstone of ABG interpretations
 The six most common acid-base
abnormalities seen in the clinical setting
 The metabolic acid-base abnormalities
 The hazards of oxygen therapy in the patient
with chronic ventilatory failure with hypoxemia
Figure 4-1. Nomogram of the PCO2/HCO3-/pH relationship.
Figure 4-2. Acute ventilatory failure is confirmed when the reported PCO2, pH, and HCO3
values all intersect within the red-colored respiratory acidosis bar. For example, when the
-
PCO2 is 60 mm Hg at a time when the pH is 7.28 and the HCO3 is 26 mEq/L, acute ventilatory
failure is confirmed.
Figure 4-3. Acute alveolar hyperventilation is confirmed when the reported PCO2, pH, and
HCO3 values all intersect within the red-colored respiratory alkalosis bar. For example,
when the reported PCO2 is 25 mm Hg at a time when the pH is 7.55 and the HCO3 is 21
mEq/L, acute alveolar hyperventilation is confirmed.
A Quick Clinical Calculation
for
Acute PaCO2 Changes in pH and
HCO3
Acute Increases in PaCO2
(e.g., Acute Hypoventilation)
Using the Normal ABG Values as a
Baseline—pH 7.40, PaCO2 40, and HCO3 24:
 For every 10 mm Hg the PaCO2 increases,
the pH will decrease about 0.06 units and the
HCO3 will increase about 1 mEq/L.
 Or, for every 20 mm Hg the PaCO2 increases,
the pH will decrease about 0.12 units and the
HCO3 will increase about 2 mEq/L.
Using the Normal ABG Values as a Baseline—
pH 7.40, PaCO2 40, and HCO3 24 (Cont’d)
 Thus if the patient’s PaCO2 suddenly were to
increase to, say, 60 mm Hg, the expected pH
change would be about 7.28 and the HCO3
would be about 26 mEq/L.
 It should be noted, however, that if the
patient’s PaO2 is severely low, lactic acid may
also be present.
 This results in a combined metabolic and
respiratory acidosis.
 In such cases the patient’s expected pH and
HCO3 values would both be lower than expected
for a particular PaCO2 level.
Acute Decreases in PaCO2
(e.g., Acute Hyperventilation)
pH 7.40, PaCO2 40, and HCO3 24
 For every 5 mm Hg the PaCO2 decreases,
the pH will increase about 0.06 units and the
HCO3 will decrease about 1 mEq/L.
 Or, for every 10 mm Hg the PaCO2
decreases, the pH will increase about 0.12
units and the HCO3 will decrease about 2
mEq/L.
 Thus if the patient’s PaCO2 suddenly were to
decrease to, say, 30 mm Hg, the expected pH
change would be about 7.52 and the HCO3
would be about 22 mEq/L.
 Again, it should be noted, however, that if the
patient’s PaO2 is severely low, lactic acid may
also be present.
 In such cases the patient’s expected pH and
HCO3 values would both be lower than
expected for a particular PaCO2 level.
Table 4-2. General Rule of Thumb for the Paco2/ HCO−3/pH Relationship
The Six Most Common Acid-Base
Abnormalities Seen in the Clinical Setting
 Acute alveolar hyperventilation
 Acute ventilatory failure
 Chronic ventilatory failure with hypoxemia
 Acute alveolar hyperventilation superimposed
on chronic ventilatory failure
 Acute ventilatory failure superimposed on
chronic ventilatory failure
Acute Alveolar Hyperventilation with
Hypoxemia
(Acute Respiratory Alkalosis)
ABG Changes Example
 pH: increased 7.55

 PaCO2: decreased 29 mm Hg
 HCO3: decreased 22 mEq/L
 PaO2: decreased 61 mm Hg*
*When pulmonary pathology is present

The most common cause of acute
alveolar hyperventilation is:
Hypoxemia
Figure 4-4. Relationship of venous admixture to the stimulation of peripheral
chemoreceptors in response to alveolar consolidation.
Figure 4-5. The PaO2 and PaCO2 trends during acute alveolar hyperventilation.
Box 4-2. Pathophysiologic Mechanisms That Lead to a Reduction in the Paco2
Acute Ventilatory Failure with
Hypoxemia
(Acute Respiratory Acidosis)
ABG Changes Example
 pH: decreased 7.21

 PaCO2: increased 79 mm Hg
 HCO3: increased (slightly) 28 mEq/L
 PaO2: decreased 57 mm Hg
Chronic Ventilatory Failure with
Hypoxemia
(Compensated Respiratory Acidosis)
ABG Changes Example
pH: normal 7.38

PaCO2: increased 66 mm Hg
HCO3: increased (significantly) 35 mEq/L
PaO2: decreased 63 mm Hg
Box 4-3. Respiratory Diseases Associated with Chronic Ventilatory Failure during the
Advanced Stages
Figure 4-6. The PaO2 and PaCO2 trends during acute or chronic ventilatory failure.
Acute Ventilatory Changes
Superimposed on Chronic Ventilatory Failurez
 Acute alveolar hyperventilation superimposed
on chronic ventilatory failure
 Acute ventilatory failure superimposed on
chronic ventilatory failure
Acute Alveolar Hyperventilation
Superimposed on Chronic Ventilatory Failure
(Acute Hyperventilation on Compensated Respiratory
Acidosis)
ABG Changes Example
pH: increased 7.53

HCO3: increased 37 mEq/L
Table 4-3. Examples of Acute Changes in Chronic Ventilatory Failure
Acute Ventilatory Failure
Superimposed on Chronic Ventilatory Failure
(Acute Hypoventilation on Compensated Respiratory
Acidosis)
ABG Changes Example
pH: decreased 7.21

HCO3: increased 43 mEq/L
Table 4-3. Examples of Acute Changes in Chronic Ventilatory Failure
Lactic Acidosis
Metabolic Acidosis
 Because acute hypoxemia is commonly
associated with respiratory disorders, acute
metabolic acidosis (caused by lactic acid)
often further compromises respiratory acid-
base status.
Lactic Acidosis
Metabolic Acidosis (Cont’d)
ABG Changes Example
pH: decreased 7.21
PaCO2: normal or decreased 35 mm Hg
HCO3: decreased 19 mEq/L
Figure 4-1. Nomogram of the PCO2/HCO3/pH relationship.
Metabolic Acid-Base
Abnormalities
Metabolic Acidosis
ABG Changes Example
pH: decreased 7.26

PaCO2: normal 37 mm Hg
PaO2: normal 94 mm Hg
(or decreased if lactic (or 52 mm Hg if
acidosis is present) lactic acidosis is present)
Anion Gap
 The anion gap is used to determine if a
patient’s metabolic acidosis is caused by
either:
1. the accumulation of fixed acids (e.g., lactic acids,
keto acids, or salicylate intoxication), or
2. an excessive loss of HCO3
.
Anion Gap (Cont’d)
 The law of electroneutrality states that the
total number of plasma positively charged
ions (cations) must equal the total number of
plasma negatively charged ions (anions) in
the body fluids.
 To calculate the anion gap, the most
commonly measured cations are sodium
(Na+) ions.
 The most commonly measured anions are
chloride (Cl−) ions and bicarbonate (HCO3)
ions.
 The normal plasma concentrations of these
cations and anions are as follows:
Na+: 140 mEq/L
Cl−: 105 mEq/L
HCO3: 24 mEq/L
 Mathematically, the anion gap is the
calculated difference between the Na+ ions
and the sum of the HCO3 and Cl− ions:
Anion gap = [Na+] − ([Cl−] + [HCO3])

= 140 − 105 + 24
= 140 − 129
= 11 mEq/L
 The normal range for the anion gap is 9 to 14
mEq/L.
 An anion gap greater than 14 mEq/L
represents metabolic acidosis.
 An elevated anion gap is frequently caused
by the accumulation of fixed acids—for
example:
• Lactic acids
• Keto acids
• Salicylate intoxication
 This is because the H+ ions that are
generated by the fixed acids chemically react
with—and are buffered by—the plasma
HCO3
 This action causes
1. The HCO3 concentration to decrease and
2. The anion gap to increase
 Clinically, when the patient exhibits both
metabolic acidosis and an increased anion
gap, the respiratory care practitioner must
investigate further to determine the source of
the fixed acids.
 This needs to be done in order to appropriately
treat the patient.
 For example, metabolic acidosis caused by:
1. Lactic acids justifies the need for oxygen
therapy—to reverse the accumulation of the lactic
acids, or
2. Ketone acids justifies the need for insulin—to
reverse the accumulation of the ketone acids.
 It is interesting that metabolic acidosis caused
by an excessive loss of HCO3 does not cause
the anion gap to increase.
 For example, in renal disease or severe diarrhea
 This is because as the HCO3 concentration
decreases, the Cl− concentration usually
increases to maintain electroneutrality.
 In short, for each HCO3 ion that is lost, a Cl−
anion takes its place
 Law of electroneutrality
 This action maintains a normal anion gap.
 Metabolic acidosis caused by a decreased
HCO3 level is commonly called
hyperchloremic metabolic acidosis.
Summary
 When metabolic acidosis is accompanied by
an increased anion gap, the most likely cause
of the acidosis is fixed acids.
 Lactic acids
 Keto acids
 Salicylate intoxication
Summary (Cont’d)
 Or, when metabolic acidosis is seen with a
normal anion gap, the most likely cause of
the acidosis is an excessive loss of HCO3
 For example, caused by renal disease or severe
diarrhea
Metabolic Alkalosis
ABG Changes Example
pH: increased 7.56

PaCO2: normal 44 mm Hg
PaO2: normal 94 mm Hg
Figure 4-1. Nomogram of the PCO2/HCO3/pH relationship.
Box 4-4. Common Causes of Metabolic Acid-Base Abnormalities
The Hazards of Oxygen Therapy in
Patients with Chronic Ventilatory Failure
with Hypoxemia
 High oxygen concentrations may suppress
the patient’s so-called hypoxic drive to
breathe.

Arterial Blood Gas Assessments

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Chapter 4

Arterial Blood Gas

(e.g., Acute Hypoventilation)

(e.g., Acute Hyperventilation)

ABG Changes Example

 pH: increased 7.55

*When pulmonary pathology is present

ABG Changes Example

 pH: decreased 7.21

ABG Changes Example

pH: normal 7.38

ABG Changes Example

pH: increased 7.53

ABG Changes Example

pH: decreased 7.21

ABG Changes Example

pH: decreased 7.26

Anion gap = [Na+] − ([Cl−] + [HCO3])

ABG Changes Example

pH: increased 7.56

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