ABG INTERPRETATION

Types of Acid Base Disturbances

 Metabolic Acidosis
 Metabolic Alkalosis
 Respiratory Acidosis
 Respiratory Alkalosis
 Mixed Acid Base Disturbance
Regulatory Mechanisms
 Chemical Buffers
 Lungs

 Kidneys
DETERMINE CLUES
FROM THE
CLINICAL SETTING
CLUES FROM
CLINICAL SETTING

METABOLIC ACIDOSIS
 ↓ HCO3, ↓pH
 ↑ endogenous acid production
 Endogenous acid accumulation

 Loss of bicarbonate
CLUES FROM
CLINICAL SETTING
HIGH ANION GAP METABOLIC ACIDOSIS
 ↑ or accumulation of endogenous acids

 Lactic Acidosis : Shock, seizure, sepsis

 Ketoacidosis : DM, alcoholic, starvation

 Toxins: Ethylene glycol, methanol,

salicylates
 Renal failure : Acute & Chronic
CLUES FROM
CLINICAL SETTING
NORMAL ANION GAP METABOLIC ACIDOSIS
 Loss of HCO3

 GIT : Diarrhea
 Kidneys : Renal Tubular Acidosis

Carbonic Anhydrase Inhibitor

Compensation for Resp Alkalosis
CLUES FROM
CLINICAL SETTING
METABOLIC ALKALOSIS
 ↑HCO3, ↑pH
 Net gain of HCO3 or loss of HCl
Vomiting
Diuretic use
CLUES FROM
CLINICAL SETTING
RESPIRATORY ACIDOSIS

 ↑ PaCO2, ↓ pH
 Alveolar hypoventilation
CLUES FROM
CLINICAL SETTING
RESPIRATORY ACIDOSIS
 Pulmonary diseases : Asthma, COPD,
Pneumonia
 Respiratory muscle fatigue: Myasthenia

 Depression of Respiratory Center :

Anesthetics, Sedatives, Head Trauma,

Stroke
CLUES FROM
CLINICAL SETTING
RESPIRATORY ALKALOSIS

 ↓ PaCO2, ↑ pH
 Alveolar hyperventilation
CLUES FROM
CLINICAL SETTING
RESPIRATORY ALKALOSIS
 CNS Stimulation: pain, anxiety, fever, CVA

 Hypoxemia: anemia, aspiration,

pneumonia
 Drugs: salicylates, xanthines,
progesterone
 Sepsis, mechanical hyperventilation
 DETERMINE
THE
PRIMARY DISORDER
STEPWISE APPROACH
 Acidosis or Alkalosis?
 Respiratory or Metabolic?

 Calculate the Anion Gap

 Check the Compensatory Response

 Identify specific etiologies for the acid-

base disorder
 Prescribe treatment
DETERMINE
PRIMARY DISORDER
 Check the trend of the pH, HCO3, pCO2
 The change that produces the pH is the
primary disorder

pH = 7.25 HCO3 = 12 pCO2 = 30

ACIDOSIS ACIDOSIS ALKALOSIS

METABOLIC ACIDOSIS
DETERMINE
PRIMARY DISORDER
 Check the trend of the pH, HCO3, pCO2
 The change that produces the pH is the
primary disorder

pH = 7.25 HCO3 = 28 pCO2 = 60

ACIDOSIS ALKALOSIS ACIDOSIS

RESPIRATORY ACIDOSIS
DETERMINE
PRIMARY DISORDER
 Check the trend of the pH, HCO3, pCO2
 The change that produces the pH is the
primary disorder

pH = 7.55 HCO3 = 19 pCO2 = 20

ALKALOSIS ACIDOSIS ALKALOSIS

RESPIRATORY ALKALOSIS
DETERMINE
PRIMARY DISORDER
 If the trend is the same, check the percent
difference
 The bigger %difference is the 10 disorder
(16-24)/24 = 0.33 (60-40)/40 = 0.5
pH = 7.25 HCO3 = 16 pCO2 = 60

ACIDOSIS ACIDOSIS ACIDOSIS

RESPIRATORY ACIDOSIS
DETERMINE
PRIMARY DISORDER
 If the trend is the same, check the percent
difference
 The bigger %difference is the 10 disorder
(38-24)/24 = 0.58 (30-40)/40 = 0.25
pH = 7.55 HCO3 = 38 pCO2 = 30

ALKALOSIS ALKALOSIS ALKALOSIS

METABOLIC ALKALOSIS
 CHECK THE
COMPENSATORY RESPONSE
PREDICTED COMPENSATORY
RESPONSE
MAC pCO2 will ↓ 1.25 mmHg per mmol/L ↓ in HCO3

MALK pCO2 will ↑ 0.75 mmHg per mmol/L ↑ in HCO3

RALK HCO3 will ↓ 2mmol/L per 10mmHg ↓ in pCO2

HCO3 will ↓ 4mmol/L per 10mmHg ↓ in pCO2

RAC HCO3 will ↑ 1mmol/L per 10mmHg ↑ in pCO2

HCO3 will ↑ 4mmol/L per 10mmHg ↑ in pCO2
COMPENSATORY
RESPONSE
METABOLIC ACIDOSIS
pCO2 will ↓ 1.25 mmHg per mmol ↓ in HCO3

24-12 =12 mmol ↓ in HCO3

HCO3 =12 12 x 1.25 = 15 fall in pCO2
40-15 = 25 expected pCO2
COMPENSATORY
RESPONSE

METABOLIC ALKALOSIS
pCO2 will ↑ 0.75mmHg per mmol ↑in HCO3

24 - 35 = 11 x 0.75 = 8
HCO3 =35
8 + 40 = 48
COMPENSATORY
RESPONSE

ACUTE RESPIRATORY ACIDOSIS

HCO3 will ↑ .1mmol per 1mmHg ↑ in pCO2

40-80 = 40 x 0.1 = 4
pCO2 =80
24 +4 = 28
COMPENSATORY
RESPONSE
 Values beyond the predicted
compensatory response indicate a mixed
acid base disturbance
pH = 7.3 24 – 16 = 8 x 1.25 = 10
HCO3 = 16 40 – 10 = 30
pCO2 = 33
Metabolic Acidosis + Respiratory Acidosis
STEPWISE APPROACH
 Acidosis or Alkalosis?
 Respiratory or Metabolic?

 Calculate the Anion Gap

 Check the Compensatory Response

 Identify specific etiologies for the acid-

base disorder
 Prescribe treatment
CALCULATE THE
ANION GAP
Concept of the Anion Gap
Unmeasured Anions Unmeasured Cations
Proteins, Albumin 15mEqs/L Calcium 5mEqs/L

Organic Acids 5mEqs/L Potassium 4.5mEqs/L

Phosphates 2mEqs/L Magnesium 1.5mEqs/L

Sulfates 1mEq/L

TOTAL: 23mEqs/L TOTAL: 11mEqs/L

ANION GAP
 Normal : 12 mEq/L
 Tool to narrow down potential causes of
metabolic acidosis
 Unreliable in cases of low serum albumin
(cirrhosis ,nephrotic syndrome ,malnutrition)
ANION GAP

AG = Na – (HCO3 + Cl)

Na 135
HCO3 15
Cl 97
AG = 135 – (15 + 97) = 23
CASE 1
56F with vomiting and diarrhea for 3 days
despite intake of loperamide. Her last
urine output was 12 hours ago.

PE showed BP = 80/60, HR = 110, RR = 28.

There is poor skin turgor.
CASE 1
serum Na = 130 pH = 7.30
K = 2.5 pCO2 = 30
Cl = 105 HCO3 = 15
BUN = 15 pO2 = 90
crea = 177
RBS = 100
pH = acidosis, pCO2 =alk, Metabolic
HCO3 = acidosis Acidosis
CASE 1
serum Na = 130 pH = 7.30
K = 2.5 pCO2 = 30
Cl = 105 HCO3 = 15
BUN = 15 pO2 = 90
crea = 177
RBS = 100
AG= 130 – (105+15) = 10 NAGMA
CASE 1
serum Na = 130 pH = 7.30
K = 2.5 pCO2 = 30
Cl = 105 HCO3 = 15
BUN = 15 pO2 = 90
crea = 177
RBS = 100 Metabolic
pCO2 = 9 x 1.25 = 11.25 acidosis +
40 – 11.25 = 28.75 Respiratory
acidosis
CASE 1

1) Hydrate
2) Hydrate + IV NaHCO3
3) Hydrate + oral NaHCO3
4) Hydrate + correct hypokalemia

How will you correct the acid base disorder?

 INDICATION & ADMINISTRATION
OF HCO3 THERAPY

 Severe acidosis: pH < 7.2, HCO3 < 10 mmol

 HCO3 deficit = (Base deficit x KgBW) / 4
HCO3 deficit = (KgBW x 0.4) x (Desired-Actual)

 Give ½ of calculated dose, slow IV push

over 30-45mins, repeat ABG after 5mins
COMPLICATIONS OF
HCO3 THERAPY

 Volume overload
 Hypertension
 Hypokalemia
 overshoot alkalosis
 Stimulates organic acid production
CASE 2
30M with epilepsy has a grand mal seizure.
Labs showed:
pH = 7.14 Na = 140
pCO2= 45 K=4
HCO3 = 17 Cl = 98
pO2 = 45
%pCO2 =13, %HCO3 = 29 Metabolic
Acidosis
CASE 2
30M with epilepsy has a grand mal seizure.
Labs showed:
pH = 7.14 Na = 140
pCO2= 45 K=4
HCO3 = 17 Cl = 98
pO2 = 45
pCO2 = 24 – 17 = 7 x 1.25 = 9
Metabolic &
40 – 9 = 31 Respiratory
Acidosis
CASE 2
30M with epilepsy has a grand mal seizure.
Labs showed:
pH = 7.14 Na = 140
pCO2= 45 K=4
HCO3 = 17 Cl = 98
pO2 = 45
AG = 140 – (98 + 17) = 25 HAGMA +
RAc
CASE 2
30M with epilepsy has a grand mal seizure.
Labs showed:
pH = 7.14 Na = 140
pCO2= 45 K=4
HCO3 = 17 Cl = 98
pO2 = 45

How will you correct the acid base disorder?

CASE 2
1) IV NaHCO3 based on HCO3 deficit
2) oral NaHCO3 at 1 mEq/kg/day
3) intubate
4) no treatment

How will you correct the acid base disorder?

CASE 3
19F, fashion model, is surprised to find her
K=2.7 mmol/L because she was
normokalemic 6 months ago. She admits
to being on a diet of fruit and vegetables
but denies vomiting and the use of
diuretics or laxatives. She is
asymptomatic. BP = 90/55 with subtle
signs of volume contraction.
CASE 3
serum Na 138
K 2.7
Cl 96
HCO3 30
pH 7.45
pCO2 45

pH = alk, pCO2 =acidosis Metabolic

HCO3 = alkalosis Alkalosis
 CASE 3
serum Na 138
K 2.7
Cl 96
HCO3 30
pH 7.45
pCO2 45
Compensated
pCO2 =30 – 24 = 6 x 0.75 = 4.5 Metabolic
40 + 4.5 = 44.5 Alkalosis
CASE 3
1) diuretic intake
2) surreptitious vomiting
3) Adrenal tumor
4) nonreabsorbable anion

What is the cause of the acid base disorder?

 CASE 3

1) correct hypokalemia
2) hydrate with NSS
3) administer acidyfing agent
4) give carbonic anhydrase inhibitor

How should her acid-base disorder be managed?

CASE 4
73 Male , with long standing COPD with
Cor pulmonale (pCO2 stable at 52-58
mmHg), and peripheral edema has been
taking furosemide for 6 months. Five days
ago, he had anorexia, fever, and
productive cough. Later he was found
disoriented and somnolent.
CASE 4
PE: BP=110/70, HR=110, RR =24, T=40
Drowsy, disoriented, in respiratory
distress
(+) wheezes with prolonged expiratory
phase, fine crackles BLFs
(+) trace pitting edema
CASE 4
Na 136
K 3.2
Cl 78
HCO3 40
pH 7.33
pCO2 78
pO2 43
pH = acidosis pCO2 Respiratory
=acidosis, HCO = alk Acidosis
 Respiratory Acidosis & M. Alkalosis
CASE 4
Na 136 HCO3 40
K 3.2 pH 7.33
Cl 78 pCO2 78
pO2 43

HCO3 = 24 + 6 +
HCO3= (55-40) x 0.4 = 6 HCO3
2.3 = 32.3
= (78-55) x 0.1 = 2.3
CASE 4
Na 136
K 3.2
Cl 78
HCO3 40
pH 7.33
pCO2 78
pO2 43
How should this patient be managed?
CASE 4

1) intubation and mechanical ventilation

2) low flow oxygenation by nasal prong
3) oxygen by face mask
4) sodium bicarbonate infusion with KCl

How should this patient be managed?

MANAGEMENT OF
RESPIRATORY ACIDOSIS
 Correct underlying cause for
hypoventilation
  effective alveolar ventilation 
intubate, mechanically ventilate
 Antagonize sedative drugs
 Stimulate respiration
 Correct metabolic alkalosis
QUESTIONS?
Thank You