Acid Base Disorders

ABG interpretation

ABG

By Mohamed Cheikh
Consultant in Intenral Medicine and
Rheumatology
 This is our roadmap

First part Second part Third

Simple • ABG analysis •
understandin .steps
part
g of acid base Exercises •
.balance to master
.it
Home settings

Preset settings:
-Temp 20
-Humidity 10
-Water supply
-Electricity.
Body settings (Homeostatsis)

Preset settings:
- Ph 7.35-7.45
- Vital signs
- Electrolytes
- volume status
Co2 HCo3
 HCo3

Co2 HCo3 HCo3

Co2 Co2 HCo3 HCo3 HCo3

Co2 Co2 Co2 HCo3 HCo3 HCo3

Acidosis Alkalosis
 Co2 HCo3

Co2 Co2 HCo3 HCo3

Co2 Co2 Co2 HCo3 HCo3 HCo3

Acidosis Alkalosis
 Co2

Co2 Co2 HCo3

Co2 Co2 Co2 HCo3 HCo3

Co2 Co2 Co2 HCo3 HCo3 HCo3

Acidosis Alkalosis
 Co2 HCo3

Co2 Co2 HCo3 HCo3

Co2 Co2 Co2 HCo3 HCo3 HCo3

Acidosis Alkalosis
Bicarbonate loss and/or Co2 accumulation = Acidosis

Bicarbonate gain and/or Co2 loss = Alkalosis

What about compensation
General roles for compensations

Respiratory Metabolic
General roles for compensations

Respiratory Metabolic
 General roles for compensations

Hyperventilation Co2 HCo3 excretion HCo3

Hypoventilation Co2 HCo3 retention HCo3

Respiratory Metabolic
General roles for compensations

Respiratory Metabolic
General roles for compensations

Compensation usually correct pH TOWARD

the normal range but usually never reach 7.4
and NEVER EVER over correct.

Respiratory Metabolic
 Co2 HCo3

Co2 Co2 HCo3 HCo3

Co2 Co2 Co2

HCo3 HCo3 HCo3

Acidosis Alkalosis
 ABG ABG results
How to interpret

In 5 simple steps
1 Check pH, Hco3, and Co2

.to determine the primary disorder

 The role of 4

pH 7.4 7.35–7.45
Hco3 24 22–26
Co2 40 35–45
ROMA
This is our ROMA

Respiratory
Opposes
Metabolic
Agrees
 ”Remember “ROMA

Primary disorder pH HCo3 PCo2

Respiratory Alkalosis

Respiratory Acidosis
Metabolic Alkalosis
Metabolic Acidosis
 Example 1
pH 7.2
Hco3 13
Co2 29

• What is the primary disorder?

Metabolic Acidosis
 Example 2
pH 7.31
Hco3 29
Co2 60

• What is the primary disorder?

• A Respiratory Acidosis
• B Respiratory Alkalosis
• C Metabolic Acidosis
•D Metabolic Alkalosis
 Example 3
pH 7.52
Hco3 24
Co2 25

• What is the primary disorder?

• A Respiratory Acidosis
• B Respiratory Alkalosis
• C Metabolic Acidosis
•D Metabolic Alkalosis
 Example 4
pH 7.49
Hco3 34
Co2 50

• What is the primary disorder?

• A Respiratory Acidosis
• B Respiratory Alkalosis
• C Metabolic Acidosis
•D Metabolic Alkalosis
2 Check for compensation
If reaches normal range: complete
If not: partial
 Co2 HCo3

Co2 Co2 HCo3 HCo3

Co2 Co2 Co2

HCo3 HCo3 HCo3

Acidosis Alkalosis
Compensations
 Example 1
pH 7.2
Hco3 13
Co2 29

• What is the expected Co2?

Metabolic Acidosis
 Example 2
pH 7.31
Hco3 30
Co2 60

• What is the Expected HCo3?

Chronic Respiratory Acidosis

 Example 3
pH 7.52
Hco3
Co2 25

• What is the Expected HCo3?

Acute Respiratory Alkalosis

A. 13
B. 16
C. 21
D. 40
 Example 4
pH 7.49
Hco3 34
Co2

• What is the expected Co2?

Metabolic Alkalosis

•A. 45
•B. 40
•C. 35
•D. 25
3 Check for mixed disorders
It’s when the compensation is not
appropriate.
Or when ROMA is not ROMA
 Compensated HCo3
• If it is too high:
• Mixed 1ry metabolic Alkalosis

• If it is too low:
• Mixed 1ry metabolic Acidosis
 Compensated Co2
• If it is too high:
• Mixed 1ry Respiratory Acidosis

• If it is too low:
• Mixed 1ry Respiratory Alkalosis
 ”When no “ROMA

Primary disorder pH HCo3 PCo2

Mixed Alkalosis

Mixed Acidosis
 Example 1
pH 7.2
Hco3 13
Co2 29

• What is the expected Co2?

Metabolic Acidosis
 Example 2
pH 7.52
Hco3 21
Co2 25

• What is the Expected HCo3?

Acute Respiratory Alkalosis

4
Calculate the Anion Gap (AG)
!! Always do it. Even if the pH is normal
?What is Anion Gap (AG)
?What causes high AG
 ?What is Anion Gap (AG)
• If the AG is high: High Anion Gap Metabolic
Acidosis (HAGMA).

• If the AG is normal: Normal Anion Gap

Metabolic Acidosis (NAGMA).
 ?How to calculate the AG
• The easiest equation is:

AG = Na – Cl – HCo3
Normal AG is 10 +/- 2
 Example 1
Na 134
Cl 100
HCo3 20
AG 14

• What is the calculated AG?

 Example 2
Na 134
Cl 103
HCo3 20
AG

• What is the calculated AG?

•A. 11
•B. 14
•C.9
•D. 5
 Alert Alert Alert Alert

High AG ALONE
means there is
HAGMA EVEN if the
pH is 7.40000
5 Calculate the corrected HCo3
Only and Only if AG is high
 The corrected HCo3
• Very simple concept in pt with High Anion Gap
Metabolic Acidosis (HAGMA)

• Corrected HCo3 =
∆ AG + measured HCo3
 The corrected HCo3
• If normal (22-26): HAGMA alone.

• If high >26: HAGMA + Metabolic Alkalosis

• If low <22: HAGMA + Normal Anion Gap

Metabolic Acidosis.
 Quick recap for the 5 steps:
1. Check pH, Hco3, and Co2 to determine the
primary disorder.
2. Check for compensation.
3. Check for mixed disorders.
4. Always Calculate the Anion Gap (AG).
5. Calculate the corrected HCo3 only if AG is
high.
1. Determine
the primary
disorder

2. Check for
compensation

3. Check for
mixed disorders

4. Calculate the
Anion Gap

5. Calculate the
corrected HCo3
 Example 1
pH 7.31 1. The primary disorder is
Hco3 17 Metabolic Acidosis
Co2 33 2. Compensation:
Yes, partial
Na 135
3. Mixed disorder:
Cl 106
No
4. AG is
12 Normal
5. Corrected HCo3
No need
 Example 2
pH 7.55 1. The primary disorder is
Hco3 21 Respiratory Alkalosis
Co2 24 2. Compensation:
yes, partial
Na 135
3. Mixed disorder:
Cl 104
No
History: Acute setting 4. AG is
10 Normal
5. Corrected HCo3
No need
 Example 3
pH 7.39 1. The primary disorder is
Hco3 36 Respiratory Acidosis
Co2 62 2. Compensation:
mixed
Na 144
3. Mixed disorder:
Cl 100
Metabolic Alkalosis
History: chronic setting 4. AG is
8 Normal
5. Corrected HCo3
No need
 Example 4
pH 7.57 1. The primary disorder is
Hco3 32 Metabolic Alkalosis
Co2 34 2. Compensation:
mixed
Na 144
3. Mixed disorder:
Cl 100
Respiratory Alkalosis
4. AG is
10 Normal
5. Corrected HCo3
No need
 Example 5
pH 7.20 1. The primary disorder is
Hco3 12 Metabolic Acidosis
Co2 28 2. Compensation:
Yes, partial
Na 135
3. Mixed disorder:
Cl 105
-
4. AG is
18 (HAGMA)
5. Corrected HCo3
18 (low) HAGMA + NAGMA
Contacts:
@msheikh74
0569080435