INTERPRETATION

OF ARTERIAL
BLOOD GAS

DR. S.J BASHA MD.,MRCP (IRELAND)

CONSULTANT CRITICAL CARE
ASSISTANT PROFESSOR
DR.PSIMS & RF
 NORMAL ABG

PH 7.35-7.45
PaCo2 35-45 mmHg
PaO2 80-100 mmHg
HcO3 22-26 mEq
BE 0 mEq
Base deficit and Base excess

Base deficit: Amount of strong cation

required to bring PH back to 7.4 with PCO2
corrected to 40 mm Hg.

Base Excess: Amount of strong anion

required to bring back the PH to 7.4 with
PCO2 corrected to 40mm Hg.
 Expected arterial PaO2

PaO2=104.2-(0.27Xage)

Expected arterial PaO2 for the percentage

of oxygen we deliver

FiO2 x 5

Fio2 50 x5 = 250 mm Hg
Is it a correct ABG ??

65 yrs old lady is admitted with progressive shortness of

breath, swelling of feet.

PH 7.03

PaCO2 113

PaO2 50 mm Hg

Hco3 30 mEq

BE – 13.3 mEq

In room air
Henderson _ Hasselbalch equation

PH - PK + Log( [A-] / [HA])

H+ = 24 X ( Paco2 / HCO 3 )
H+ = 24 X 110/ 30= 88 nEq/L
TYPES OF ACID BASE DISORDERS

 Respiratory acidosis
- Acute
- Chronic

 Respiratory Alkalosis
- Acute
- Chronic

 Metabolic Acidosis

 Metabolic Alkalosis
 RO ME

Respiratory Acidosis Metabolic Acidosis

/ Alkalosis /Alkalosis

-- PH PCO2 --- PH 7.20 ---->

PH 7.2 PCo2 55 PCo2 30 --->

COMPENSATORY
RESPONSE

 PULMONARY COMPENSATION

 RENAL COMPENSATION
COMPENSATORY RESPONSE

 Compensatory responses are not strong

enough to keep the PH constant , they only
limit the change

 Metabolic acid base disorders elicit prompt

ventilatory response that are mediated by
peripheral chemoreceptors located in the
carotid body

 Compensatory mechanisms are slow in the

case of primary respiratory disorders.
Primary Acid base disorders and
associated compensatory changes

Primary disorder primary change compensated change

 Respiratory acidosis PCo2 HCO3

 Respiratory alkalosis PCo2 HCO3

 Metabolic acidosis HCo3 PCO2

 Metabolic alkalosis HCO3 PCO2

PRIMARY ACID-BASE DISORDER &EXPECTED COMPENSATION
 Disorder s Primary defect Compensatory Response Magnitate of
Disorder Primary defect Compensatory Magnitude of compensation
componsation
response
 Acute PCO2 HCO3 HCo3 in eq per 10 – Hg
PCo Chronic
Respiratory
2 PCO2 HCO3 HCo3 in eq per
10 –acidosis
Hg PCo2
Resp Alkalosis
-Acute PCOpcO2
2 HCO
HcO3
3 HcO3 HCo 3 in 2 eq per
1mEq/10mm Hg 10pcO2
–
Hg PCo2
Acute-Chronic
chronic PCO
pcO2
2 HCO
HcO3
3 HcO3 4mEq/10mm
HCo Hg10 pcO2
3 in 5 eq per – Hg
PCo2
Respiratory
Metabolic Acidosis
Alkalosis HCO3 PCO2 PCO2 1.3 mg P 8 1 n eg
HCO3-Acute pcO2 HcO3 HcO3 2mEq/10mm Hg pcO2
Mebolic Alkalosis
-Chronic HCO3 PCO2 PCO2 0.7 mg P 8 1 n eg
HCO3 HCO3 5 mEq/10mm Hg pcO2
pcO2 HcO3
Mebolic Alkalosis

Metabolic pcO2 1.3 mm Hg / 1mEq

Acidosis HcO3 pcO2
HcO3
Metabolic pcO2 0.7 mmHg / 1mEq
Alkalosis HcO3 pcO2 HcO3
65 years old lady known HTN for 15 years is
presented to ICU with complaints of progressive
SOB, swelling of feet and LOC

 PH 7.03
PCO2 113 mm Hg
PO2 50 mm Hg
HCO3 30 mm Hg
BE -13.3
 Room air
113 – 40 = 73 /10 = 7.3
24+ 7.3 = 31.3

 So it is Acute respiratory acidosis

Acute Respiratory Acidosis
• Expected P
H = 7.40- ( 0.008 X Paco
2 – 40 )

Chronic Respiratory Acidosis

• ExCpected PH = 7.40- ( 0.003 X Paco 2 – 40 )
 70 years old gentleman is admitted with fever, progressive SOB, change
in the mental status. He is in pulmonary edema.

 PH 7.48

 PCO2 27 mm Hg

PO2 65 mm Hg

HCO3 21.8

BE -3.4

 On 24 % O2

40 – 27 = 13

2 / 10 * 13 = 2.6 24 – 2.6 = 21.4

 so it is acute respiratory alkalosis.

 Acute respiratory alkalosis:
 Expected PH=7.40+(0.008X(40-Paco2)

 Chronic respiratory alkalosis

 Expected PH=7.40+(.003X40-Paco2)
Respiratory Alkalosis

Rarely serum HcO3 goes < 15 mEq as

compensation. If so concomitant,
primary metabolic acidosis is present
Causes of respiratory alkalosis
Hypoxia
 Decreased inspired oxygen tension

 High altitude

 V/Q inequality

 Hypotension

 Severe anemia

Pharmacological
 Salicylates

 Nicotine

 Pregnancy
 Hepatic failure
 Sepsis
CNS Mediated disorders:
Anxiety hyper ventilation syndrome
CVA
Infection
Trauma
Tumor

Pulmonary diseases:
IPF,
Pneumonia,
Pulmonary embolism,
Pulmonary edema
Mechanical over ventilation.
35 years old gentleman got admitted to the
ICU with fever, abdominal pain for 10 days.
Found to be in severe shock.

PH 7.23
PCO2 21.3
PO2 98
HCO3 12
BE -11
FiO2 50%

12x1.3= 15.6
40- 15 = 25
So it is metabolic Acidosis
Expected PCo2=(1.5X(HCO3))+8±2
• Anion gap Na + - ( HCO3 + CI )

• Normal value ( 8-12 )

• In hypo albuminemia a 2 mEq

drop in anion gap will occur for
every 1 gram decline in Albumin
UNMEASURED ANION UNMEASURED CATIONS
Proteins,mostly albumin 15mEq/L Calcium 5 mEq/L

Organic acids 5mEq/L Potassium 4.5 mEq/L

Phosphates 2mEq/L Magnesium 1.5mEq/L

Sulfates 1mEq/L

Totals =23mEq/L Totals=11mEq/L

 High Anion gap metabolic acidosis

• D.K.A
• Lactic Acidosis

• Renal failure

• Methyl Alcohol

• Ethylene glycol

• Salicylic Acid

• Sodium Carbenicillin therapy

Lactic Acid
• Type A : ( Decrease perfusion, cardiogenic , septic
shock , cyanide poisoning )
• Type B : DKA , liver disease Leukemia, lymphoma

Parenteral nutrition without thiamine causes severe

refractory lactic acidosis.
SERUM OSMOLALITY

2x([Na+][millimoles / liter]+(glucose[mg/dl]/
18+(BUN mg/dl)/2.8

NORMAL: 10mOsm/kg

Increased Osmolol Gap indicates toxic alcoholos

- methanol, ethyleneglycol,diethylene
glycol,propylene glycol
 Normal Anion gap acidosis
• Diarrhea
• Carbonic anhydrase inhibitors
• Renal tubular acidosis
• Ileal loop bladder
• Arginine, lysine in TPN
 Differentiate between renal and extra
renal causes by measuring urinary
anion gap
URINARY ANION GAP:
[Na+]+[K+]-[Cl-]
Healthy subjects typically have a gap of
0 to slightly <10mEq/L
>20 mEq/L is seen metabolic acidosis
when kidneys are unable to excrete
ammonia(renal tubular acidosis)
LOW OR NEGATIVE ANION GAP: is observed when high
levels of cations ,as seen in

1. LITHIUM TOXICITY
2. MONOCLONAL Ig G GAMMOPATHY
3. DISORDERS CHARACTERISED BY HIGH LEVELS
OF CALCIUM OR MAGNESIUM
20 years old lady, diagnosed as nephrotic
syndrome for further evaluation . She developed
progressive SOB . X- ray chest shows pulmonary
edema
PH 7.10
PCO2 53 mm Hg
PO2 111 mm Hg
HCO3 14 mEq
BE -13.3 mEq
Fio2 60 %

1 HCo3 - 1.3 PCo2

10 - 13
40 – 13 = 27 mm Hg

Metabolic acidosis + Respiratory

 STEWART APPROACH

• Strong ionic difference

• SID = ( Na+ ) + ( K+ ) + ( Ca 2 ) + (Mg+ ) - ( Cl - ) + ( A - )
= 40-44 MEq
40 years old gentleman got admitted with
intestinal obstruction. Post OP 2nd day with
N.G tube
PH 7.50
PCO2 51mm Hg
PO2 65 mm Hg
HCO3 40m Eq
BE +7 m Eq
1 mEq HCO3 ---- 0.7 mm Hg PCO2

40-24 : 16 mEq HCo3 --- 16x 0.7 = 11.2

40+11 = 51 mm Hg
So it is metabolic alkalosis

For metabolic alkolosis:

Expected PCo2=(0.7X[HCO3])+21±1.5
Rarely PCo2 raises above 55 mm Hg. If
high, suspect superimposed respiratory
acidosis.
 { Saline responsive
( Ucl < 25 mEq /1 )
Excessive body Bicarbonate
content
• Renal Alkalosis
• Diuretic therapy
• Loss of HCl from Vomiting
N.G suction
• Antacids, Transfusions
Normal body bicarbonate
content
Contraction alkalosis
Metabolic alkalosis
{ Saline unresponsive
( Ucl > 40 mEq / 1)
Excessive body Bi carbonate
content
Normotensive
• Bartter syndrome
• Severe potassium depletion
• Refeeding alkalosis
• Hyper calcemia and hyper para
thyroidism
Hypertensive
• Primary aldosteronism
• Hyper reninism
• Liddle syndrome
• licorice
Mixed Acid base Disorders if either PH or PCo2 is
normal suspect a mixed metabolic and
respiratory acid base disorder
Corrected HCO3-=Measured HCO3- +(anion gap-12)
If >24 mmol Metabolic alkalosis coexists
If <24mmol NAGMA(non anion gap metabolic acidosis) coexists
 Delta – Delta Gap
Delta gap=delta AG-delta[HCO3]

eg:Patient with a anion gap metabolic acidosis has

HCO3- OF 10mEq/L and an anion gap of 26

corrected HCO3- =10+(26-12)

=24mmol

OR

delta AG-delta [HCO3-]=(26-12)-24-10)

=14-14=0 mmol
<0.4 Hyper chloremic normal AG acidosis

< 1 High anion gap and Normal anion gap acidosis

1-2 Pure high anion gap acidosis

>2 High AG Acidosis and concurrent metabolic

alkalosis or pre existing compensatory respiratory
acidosis.