ABG Interpretation

Basic Interpretation of Arterial Blood Gases

Information Gleaned
An indication of the patients acid-base status The origin of the imbalance An impression of the ability of the body to regulate pH A reflection of the patients oxygenation status
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Jean M. Davis, RN

Anatomy of an ABG
pH/PCO2/HCO3-/PO2
7.40/40/24/98

pH
Indicates whether the person is in a normal, acidotic or alkalotic state Concentration of hydrogen ions expressed as a negative logarithm Homeostatic mechanisms attempt to maintain balance at a ratio of 20:1 (HCO3- to PCO2) Normal value: 7.35 7.45
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May add other parameters

Base excess Anion gap Oxygen saturation A-a Gradient
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PCO2
Partial pressure of CO2 being carried in the blood to lungs for excretion Represents RESPIRATORY component Normal: 35 45 mmHg

HCO3-

Represents the amount of bicarbonate present in the blood METABOLIC component Renal tubules regulate balance of hydrogen ions and bicarbonate ions
Acidosis excrete hydrogen, reabsorb bicarb Alkalosis retain hydrogen, excrete bicarb

Kidneys generate additional bicarbonate when needed Normal: 22 26 mEq/L

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ABG Interpretation

PO2
Partial pressure of oxygen dissolved in the blood Must have sufficient partial pressure in order to bind to Hgb for transport to tissues Normal: 80 100 mmHg
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Base Excess
Includes the total of bases (alkalis) such as bicarb, Hgb, plasma proteins Excess metabolic acids cause bicarb level to drop, creating a NEGATIVE BE (sometimes called base deficit) May be used to guide bicarbonate administration Normal: between -2 and +2
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Using BE to Administer Bicarb

Base deficit is the mEq of bicarb that is deficient per liter of extracellular fluid Do not routinely treat a base deficit of less than 10 (BE: 10) Do not routinely treat an arterial pH of greater than 7.20 unless there is CV instability
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Calculating Dose of Bicarb

Approximately 25% of the adults TBW in Kg is equivalent to the number of liters of extracellular water Base deficit x weight in Kg 4 = Deficient mEq of bicarb

Calculate the deficiency, and give half the calculated dose; repeat ABG in 5 minutes 9
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Using BE to Administer Bicarb

Patient wgt: 100 Kg Base Deficit: 10 (BE: -10) 10 x 100 = 1000 / 4 = 250 Give = 125 mEq Bicarb
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Using BE to Administer Bicarb

Patient wgt: 70 Kg Base Deficit: 11 (BE: -11) 11 x 70 = 770 / 4 = 192 Give = 96 mEq Bicarb
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ABG Interpretation

Using BE to Administer Bicarb

Patient wgt: 80 Kg Base Deficit: 12 (BE: -12) 12 x 80 = 960 / 4 = 240 Give = 120 mEq Bicarb
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Using BE to Administer Bicarb

Patient wgt: 120 Kg Base Deficit: 11 (BE: -11) 11 x 120 = 1320 / 4 = 330 Give = 165 mEq Bicarb
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Anion Gap
Assists in determining which type of metabolic acidosis Formula: (Na++K+)-(HCO3-+Cl-)
Lactic/diabetic acidosis Bicarb losing acidosis
Normal gap = 3-11 mEq/L 15 Increased gap = >11 mEq/L

SaO2
Percentage of O2 the Hgb is carrying in relation to how much it could carry Percentage of O2 binding sites on Hgb that are occupied by oxygen Normal: 95 100 %

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Alveolar to arterial Gradient (A-a Gradient)

Assessment of alveolar capillary exchange The larger the gradient, the more serious Normal = 20-65

Steps Used to Interpret ABGs

Determine acid/base balance Determine cause of pH change Compensated or uncompensated Determine oxygen status

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ABG Interpretation

Determine Acid/Base Balance

Normal pH: 7.35 7.45 Acidosis: < 7.35 Alkalosis: > 7.45

Determine Cause of pH Change

Decide whether the cause is

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CO2
Respiratory component Acid

Respiratory Acidosis
High CO2 level causes acidosis Results from Hypoventilation
Causes retention of CO2 Consequent drop in blood pH
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Change in PCO2 and pH

In acute respiratory disturbances, variation from normal PCO2 by 10 mmHg causes change in pH of 0.08 In chronic respiratory disturbances, variation from normal PCO2 by 10 mmHg causes change in pH of 0.03
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Change in PCO2 and pH

CO2: 75, pH: 7.12
Acute

CO2: 55, pH: 7.30

Chronic

CO2: 78, pH: 7.28

Chronic
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ABG Interpretation

Respiratory Acidosis
Causes include:
CNS depression
Sedation CNS disease Obesity

Respiratory Acidosis
Lung disease
COPD Pneumonia

Musculoskeletal disorders
Kyphoscoliosis Guillian-Barre Polio Myasthenia Gravis
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Pleural disease
Pneumothorax
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Respiratory Alkalosis
Low CO2 level causes alkalosis Results from hyperventilation
Causes elimination of CO2 from blood Consequent rise in blood pH
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Respiratory Alkalosis
Causes include:
Catastrophic CNS event
CNS hemorrhage

Drugs
Salicylates Progesterone

Pregnancy
Especially the 3rd trimester 27
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Respiratory Alkalosis
Decreased lung compliance
Interstitial lung disease

HCO3Metabolic component Alkaline

Liver cirrhosis Anxiety

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ABG Interpretation

Metabolic Acidosis
Low bicarb level causes acidosis Results from accumulation of acids or a loss of bicarbonate
Low HCO3 Consequent drop in blood pH
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Anion Gap
Assists in determining which type of metabolic acidosis Formula: (Na++K+)-(HCO3-+Cl-)
Lactic/diabetic acidosis Bicarb losing acidosis
Normal gap = 3-11 mEq/L 31 32 Increased gap = >11 mEq/L

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Metabolic Acidosis
Uremia Ketoacidosis
Diabetic hyperglycemia ETOH withdrawal Starvation

Causes include (Gap acidosis):

Metabolic Acidosis
Causes include (Non-Gap acidosis):
GI loss of bicarb
Diarrhea

Renal loss of bicarb

Compensation for respiratory alkalosis Carbonic anhydrase inhibitor (Diamox) Renal tubular acidosis Ureteral diversion

Alcohol poisons or drug intoxication

Methanol, Ethylene glycol intoxication Ethanol Salicylates, paraldehyde and other drugs

Other:
Hyperalimentation Acid infusions 33
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Lactic acidosis
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Metabolic Alkalosis
High bicarbonate level causes alkalosis Results from elevation of serum bicarb
High HCO3Consequent elevation of blood pH

Metabolic Alkalosis
Causes include:
Volume contraction
Vomiting Overdiuresis Ascites

Hypokalemia

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ABG Interpretation

Metabolic Alkalosis
Alkali ingestion
Bicarbonate

Recap of pH and Cause

If the pH is low (acidotic)
The cause is respiratory if the CO2 is elevated The cause is metabolic if the HCO3- is low
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Excess gluco- or mineralocorticoids Bartters syndrome

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Recap of pH and Cause

If the pH is high (alkalotic)
The cause is respiratory if the CO2 is low The cause is metabolic if the HCO3- is elevated
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Compensation
The body attempts to normalize pH
Compensates for respiratory problems with bicarbonate Compensates for metabolic problems by altering ventilation

The body NEVER overcompensates

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Compensation
In metabolic acidosis, the CO2 will acidosis decrease In metabolic alkalosis, the CO2 will alkalosis increase In respiratory acidosis, the HCO3- will acidosis increase In respiratory alkalosis, the HCO3- will alkalosis decrease
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Compensation
Respiratory compensation is rapid
minutes

Metabolic compensation is slow

hours to days

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ABG Interpretation

Compensation
No compensation
Opposing parameter remains WNL Acute problem

Determine the Oxygen Status

Normal oxygenation decreases with age
Subtract 1/3 of patients age from 100

Partial compensation
Opposing parameter abnormal, but pH remains abnormal

Full or Complete compensation

Opposing parameter abnormal, and pH is normal
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PO2 PO2 PO2 PO2

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of of of of

80 100 is within normal limits 60 80 is mild hypoxemia 40 60 is moderate hypoxemia <40 is severe hypoxemia
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Oxygen Facts
Supplemental oxygen will increase the PO2
For each liter of nasal oxygen, the FIO2 is increased by .04 (4%) 1L = .24 2L = .28 3L = .32 4L = .36 5L = .40 6L = .44
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Oxygen Facts
To determine the anticipated PO2, multiply the FI02 by 5
On RA, the anticipated PO2 is approximately 100 On 3L NC, the PO2 should be 160 On a .40 VM, the PO2 should be 200

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Rule of 7s
For every decrease in FIO2 of 1%, the PO2 will decrease by 7 For every increase in FIO2 of 1%, the PO2 will increase by 7

Rule of 7s
PO2 is 380 on 90% FIO2. What change will you make in the FIO2 to attain a PO2 of 100? 380-100=280 (want to drop 280 points) 280/7= 40 (can decrease FIO2 by 40) FIO2 = .50
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ABG Interpretation

A-a Gradient
Normal 20-65 Severe distress >400 The larger the gradient, the worse the respiratory failure

Eval of Hypoxemia Using the A-a Gradient

Normal A-a gradient = hypoventilation High A-a gradient
V/Q imbalance (ventilation without perfusion) Shunting (perfusion without ventilation)

Give 100% O2
Increased PO2 = V/Q abnormality No change in PO2 = shunt

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Example #1
pH PCO2 HCO3BE PO2 7.34 33.9 18.2 -6.2 85.2
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Acidotic Low Low Low Normal

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#1 Partially Compensated Metabolic Acidosis with Normal Oxygenation

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Example #2
pH PCO2 HCO3BE PO2 7.44 27.8 19.2 -4.0 100
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Normal Low Low Low Normal

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#2 Fully Compensated Respiratory Alkalosis with Normal Oxygenation

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ABG Interpretation

Example #3
pH PCO2 HCO3BE PO2 7.59 49.0 48.2 +21.6 58.7
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Alkalotic High High High Low

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#3 Partially Compensated Metabolic Alkalosis with Moderate Hypoxemia

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Example #4
pH PCO2 HCO3BE PO2 7.17 69.3 21.0 -5.5 40.9
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Acidotic High Low Low Low

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#4 Combined Metabolic and Respiratory Acidosis with Moderate Hypoxemia

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Example #5
pH PCO2 HCO3BE PO2 7.28 79.5 37.1 +8.4 30.0
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Acidotic High High High Low

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#5 Partially Compensated Respiratory Acidosis with Severe Hypoxemia

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ABG Interpretation

Example #6
pH PCO2 HCO3BE PO2 7.39 39.0 23.4 -1.0 61.2
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Normal Normal Normal Normal Low

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#6 Normal Acid/Base Balance with Mild Hypoxemia

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Hooray!!! Youve done it!!

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