ABG analysis and acid base

balance
 The 6 steps of ABG analysis
• Step 1: History and physical exam
• Step 2: ABG + chemistry
• Step 3: Identify the primary disturbance
• Step 4: calculate the expected compensation
• Step5: Calculate the gaps
– Anion Gap
– Osmolar Gap
• Step 6: affirm that the ABG results are consistent
with previous results.
 History and physical Exam
Metabolic Acidosis Metabolic Alkalosis
Hypotension / Shock Vomiting
Severe Sepsis Diuretic Use
Diarrhoea
Renal failure
DKA
Ethylene Glycol poisoning
Respiratory Acidosis Respiratory Alkalosis
COPD PE
Severe sepsis
Cirrhosis
 ABG + bloods
• Depending on history and what you anticipate

• Always: U&E, Bone profil

• Sometimes: Serum osmolarity, urinary osmolarity,

Na and Cl, Serum lactate, TFT, Glucose, cortisol

• Special tests: rarely

 Identify the distubance
• Respiratory Acidosis: PCO2 >6.0
• Respiratory Alkalosis: PC02 < 4.5
• Acute respiratory failure: pH = <7.35 + PCO2
>6.0
• Chronic respiratory failure:
 Identify the disturbance
Acid Base
Disorder

Respiratory Respiratory
Acidosis Alkalosis
PCO2 > 6.0 PCO2 <4.5

Acute Chronic Acute Chronic

pH <7.35 pH = 7.36 – 7.44 pH > 7.45 pH 7.36 – 7.44
PCO2 >6.0 PCO2 > 6.0 PCO2 < 4.5 PCO2 <4.5

Acidemia : pH < 7.35, Acidosis HCO3<22 And Alkalosis HCO3>26

 Calculate expected compensation
Steps Example

• HCO3 / 5 • HC03 - 20 /5 = 4

• ADD 1 • 4 +1 = 5

• +/- 0.3 • 5.3 – 4.7 PCO2 is expected

 Calculate the expected compensation
• Metabolic Acidosis:
– Change in PaCO2 = 1.2 x change in HCO3

• Metabolic Alkalosis:
• Change in PaCO2 = 0.6 x change in HCO3

• Acute respiratory Acidosis:

– Change on HCO3 = 0.1 x change in pACO2

• Chronic respiratory acidosis:

– Change on HCO3 = 0.35 x change in pACO2

• Acute respiratory Alkalosis:

– Change on HCO3 = 0.2 x change in pACO2

• Chronic respiratory alkalosis:

– Change on HCO3 = 0.5x change in pACO2
 Calculate the gaps
• Anion Gap:
– In High Anion Gap: acid dissociated in H + unmeasured anion

– In Normal anion Gap: acid dissociated into H+ Cl

• The principle:
– If Gap > 15 ( this is metabolic acidosis)
– Compare the fall in HCO3 ( 25 – HCO3) with the rise in the GAP (
delta anion gap) and if > 5 this is a mixed disturbance
• If AG > fall in HCO3 – component of acidosis is due to HCO3 loss
• If AG < fall in HCO3 - coexisting metabolic alkalosis
 Calculate the Gaps
• Osmolar GAP
– Normal ~ 290,
– calculated to measured difference < 10
 Metabolic
Acidosis

Elevated Anion
Normal Anion
Gap

Lactate Lactate Normal or

Toxins / Shock Hypokalaemic
Normal elevated hyperkalaemic
 Metabolic
Acidosis

Elevated Anion
Normal Anion
Gap

Toxins / Shock Normal or

Lactate Normal / Lactate elevated hyperkalaemic
High
Hypotension /
Shock Ethylene Glycole
Renal Failure Sepsis Methanol
Rhabdo Drugs Salicyclate
Ketoacidosis Liver Failure Paraldehyde
1. DKA Lorazepam
2. Starvation Propofol Hypokalaemi
3. ETOH c
5-Oxoproline
4. Defects on Beri-beri
Gluconeogenesis
 Metabolic
Acidosis

Elevated Anion
Normal Anion
Gap

Lactate
Normal / High Toxins / Shock

Hypokalaemic Normal or
hyperkalaemic
1. RTA
1. Early Renal Filure
2. Diarrhoea
Lactate 3. Post Hypocapnic
elevated acidosis 2. N. Saline
4. Carbonic Anhydrase
Inhibitors 3. Hydronephrosis
 Metabolic Alkalosis

High / Normal Urine Cl

Low Urinary Chloride

Hypertension Normo-tension

GI loss
Diuretics
Posthypercapnia
Villous Edema
CF
 Metabolic
Alkalosis

Low Urinary High / Normal Urine Cl

Chloride

Causes
Hypertension Normo-tension

Bartter Syndrome
Hyperaldosteronism
Gitelman
Liddle’s
Excess HCO3
Conn’s
administration
Cushing
THE end