ABGs

Relevance of ABG
Important clinical assessment
tool
Vital to assess patient
regularly
Gives patient’s current state
or condition
Guides your management –
appropriate and accurate
Normal Values

pH 7.35 to 7.45
pCO2 35 to 45 mm Hg
HCO3 22 to 26 meq/L
Review basic physiology
Interpret ABG step by step by
answering principal guide
questions
Correlate to patient to come up
with complete, accurate clinical
interpretation and analysis

Practical Guide in Interpretation

 Guide Question No. 1

First, does the patient have

an ACIDOSIS or an
ALKALOSIS?
Acidosis vs. Alkalosis
LOOK at the pH
ACIDOSIS
• pH <7.35 (metabolic and/or
respiratory)

ALKALOSIS
• pH >7.45 (metabolic and/or
respiratory)
 Second, what is the
Guide Question No. 2
PRIMARY PROBLEM –
Metabolic or Respiratory?
Look at pCO2 and HCO3
ACIDOSIS
 pH <7.35 (metabolic and/or respiratory)
 Metabolic HCO3 <22
 Respiratory pCO2 >45

ALKALOSIS
 pH >7.45 (metabolic and/or respiratory)
 Metabolic HCO3 >26
 Respiratory pCO2 <35
Third, is there appropriate
COMPENSATION
Guide Question No. 3for
primary disturbance?
COMPENSATION
Compensated or
Uncompensated?
Compensatory mechanism
of body in response to acid-
base disorder
Body mechanism with goal to
COMPENSATION
ATTEMPT return acid/base status
to normal (i.e. pH closer to 7.4)
Compensation does NOT return
the pH to normal
Compensation is NOT equivalent
to normal pH
For Metabolic Acidosis or
Alkalosis:
COMPENSATION
RESPIRATORY COMPENSATION
IMMEDIATE, begins within
minutes
Acidosis: Hyperventilation
Alkalosis: Hypoventilation
(Note: only PARTIAL occurs)
For Respiratory Acidosis or
Alkalosis:
COMPENSATION
RENAL COMPENSATION
Compensation takes LONGER
Begins AFTER 12-24 hours
Takes several DAYS to reach
maximum compensation
For Respiratory Acidosis:
COMPENSATION
• Increase in serum HCO3 due to
increased H+ excretion in urine as
acid and ammonium
• HCO3 rarely >32 mEq/L
For Respiratory Alkalosis:
• Excretion of HCO3 in urine
 Disorder pH Primary Compensati
problem on
Metabolic ↓ ↓ in HCO3- ↓ in PaCO2
acidosis
Metabolic ↑ ↑ in HCO3- ↑ in PaCO2
alkalosis
Respiratory ↓ ↑ in PaCO2 ↑ in [HCO3-]
acidosis
Respiratory ↑ ↓ in PaCO2 ↓ in [HCO3-]
alkalosis
Standard Acid-Base
Approach: Observational
Standard Acid-Base Patterns
PRIMARY EXPECTED EXPECTED EXPECTED
DISORDER CHANGES CHANGES CHANGES
HCO3 pCO2 SBE
Metabol <22 = (1.5 X ≤5
ic HCO3) +
Acidosis (8 ± 2)
 PRIMARY EXPECTED EXPECTED EXPECTED
DISORDER CHANGES CHANGES CHANGES
HCO3 pCO2 SBE

Metaboli >26 = (0.7 X ≥5

c HCO3) +
Alkalosis (21 ± 2)
 PRIMARY EXPECTED EXPECTED EXPECTED
DISORDER CHANGES CHANGES CHANGES
HCO3 pCO2 SBE
Acute 0.1-1 >45 =0
Respirator mEq/liter AND
y Acidosis per 10 ∆ pH =
mm Hg 0.008 X
pCO2
(pCO2 - 40)
OR
= [(pCO2 -
40)÷10] +
24
 PRIMARY EXPECTED EXPECTED EXPECTED
DISORDER CHANGES CHANGES CHANGES
HCO3 pCO2 SBE

Chronic 1.1-3.5 >45 =0.4 X

Respirator mEq/liter AND (pCO2 –
y Acidosis per 10 ∆ pH = 40)
mm Hg 0.003 X
pCO2 (pCO2 -
OR 40)
= [(pCO2
-40)÷ 3] +
24
 PRIMARY EXPECTED EXPECTED EXPECTED
DISORDER CHANGES CHANGES CHANGES
HCO3 pCO2 SBE

Acute 0-2 <35 =0

Respirator mEq/liter AND
y Alkalosis per 10 ∆ pH =
mm Hg 0.008 X
pCO2 (40-pCO2)
OR
= [(40 -
pCO2)÷5]
+ 24
 PRIMARY EXPECTED EXPECTED EXPECTED
DISORDER CHANGES CHANGES CHANGES
HCO3 PCO2 SBE
Chronic 2.1-5 <35 =0.4 X
Respirator mEq/liter AND (PCO2 –
y Alkalosis per 10 ∆ pH = 40)
mm Hg 0.017 X
paCO2 (40-PCO2 )
OR
= [(40 -
PCO2 )÷10]
+ 24
Why do these
computations?
Is it single acid base disorder with
expected compensation?
Either metabolic or respiratory
OR
Is it mixed acid-base disorder?
Both metabolic and respiratory
Will guide clinical management

Why do these
computations?
pH<7.35
ACIDOSIS
HCO3 <22
METABOLIC ACIDOSIS
COMPENSATION?
 RESPIRATORY – Compute for expected
pCO2
 If actual pCO2 = expected pCO2
COMPENSATED METAB ACIDOSIS
 If actual pCO2 < expected pCO2
METAB ACIDOSIS WITH RESP ALKALOSIS
 If actual pCO2 > expected pCO2
METAB ACIDOSIS WITH RESP ACIDOSIS
pH <7.35
HCO3 <22
Respiratory compensation?
Calculate for expected pCO2
Expected pCO2 = (1.5 X HCO3) + (8 ±
2)
Compute Anion Gap (AG)
AG = ([Na+] + [K+]) – ([Cl-] + [HCO3])
Normal = 16 ± 2-4 mEq/L (if K+ included)
= 12 ± 2-4 mEq/L (without K+)
Metabolic Acidosis
Metabolic Acidosis
Normal Anion Gap
Metabolic Acidosis
High Anion Gap Metabolic
Acidosis
There are MANY and VARIOUS
etiologies and reasons for
metabolic acidosis
Management of metabolic
acidosis is dependent and guided
by PARTICULAR etiology of
metabolic acidosis
pH>7.45
ALKALOSIS
HCO3 >26
METABOLIC ALKALOSIS
COMPENSATION?
 RESPIRATORY – Compute for what?
 If actual pCO2 = expected pCO2
COMPENSATED METAB ALKALOSIS
 If actual pCO2 < expected pCO2
METAB ALKALOSIS WITH RESP ALKALOSIS
 If actual pCO2 > expected pCO2
METAB ALKALOSIS WITH RESP ACIDOSIS
Metabolic Alkalosis
pH >7.45
HCO3 >26
Respiratory compensation?
Calculate for expected pCO2
Expected pCO2 = (0.7 X HCO3) +
(21 ± 2)
pH <7.35
ACIDOSIS
pCO2 >45
RESPIRATORY ACIDOSIS
Acute or Chronic? – determine ∆ pH
COMPENSATION?
 RENAL – changes in HCO3
Remember that this TAKES TIME
 First, Compute for expected ∆ pH
ACUTE OR CHRONIC?
 If actual ∆ pH = 0.008 X ∆ pCO2
(expected pH in acute resp acidosis)
ACUTE RESPIRATORY ACIDOSIS
 If actual ∆ pH = 0.003 X ∆ pCO2
(expected pH in chronic resp acidosis)
CHRONIC RESPIRATORY ACIDOSIS

Respiratory Acidosis
 If actual ∆ pH >0.003 but <0.008 X ∆
pCO2
Respiratory Acidosis
PARTIAL RENAL COMPENSATION
(Partially compensated resp acidosis)
 If actual ∆ pH >0.008 X ∆ pCO2
Overlapping Metabolic derangement:
RESP ACIDOSIS WITH METABOLIC
ACIDOSIS OR RESP ACIDOSIS WITH
METABOLIC ALKALOSIS
If actual ∆ pH >0.008 X ∆ pCO2 -
Respiratory
Overlapping MetabAcidosis
acidosis or alkalosis?
So, Compute for expected HCO3
 If actual HCO3 < expected HCO3
RESP ACIDOSIS WITH METABOLIC
ACIDOSIS
 If actual HCO3 > expected HCO3
RESP ACIDOSIS WITH METABOLIC
ALKALOSIS
pH <7.35
pCO2 > 45
Respiratory Acidosis∆ pH: Does it
Compute for expected
account for pCO2 change?
If YES: Acute respiratory acidosis OR
Chronic respiratory acidosis
If NO: Partial compensation or
concomitant metabolic disorder
(acidosis or alkalosis)
Compute for expected HCO3
Remember in ACUTE Respiratory
acidosis:
Respiratory Acidosis
Renal compensation has NOT
occurred or NOT maximized
HCO3 within normal value (22-26)
pH >7.45
ALKALOSIS
pCO2 <35
RESPIRATORY ALKALOSIS
Acute or Chronic? – determine ∆ pH
COMPENSATION?
RENAL – changes in HCO3
Remember that this TAKES TIME
First, Compute for expected ∆ pH
Respiratory Alkalosis
• If actual ∆ pH = 0.008 X ∆ pCO2
(expected ∆ pH in acute resp
alkalosis)
• ACUTE RESPIRATORY ALKALOSIS
• If actual ∆ pH = 0.017 X ∆ pCO2
(expected ∆ pH in chronic resp
alkalosis)
• CHRONIC RESPIRATORY
ALKALOSIS
• If actual ∆ pH >0.008 but <0.017 X ∆
pCO2
Respiratory Alkalosis
• PARTIAL RENAL COMPENSATION
(Partially compensated resp
alkalosis)
• If actual ∆ pH >0.017 X ∆ pCO2
• Overlapping Metabolic
derangement: RESP ALKALOSIS
WITH METABOLIC ACIDOSIS OR
RESP ALKALOSIS WITH METABOLIC
ALKALOSIS
• If actual ∆ pH >0.017 X ∆ pCO2 -
Overlapping Metab acidosis or
alkalosis?
• So, Compute for expected HCO3
• If actual HCO3 < expected HCO3
 RESP ALKALOSIS WITH
METABOLIC ACIDOSIS
• If actual HCO3 > expected HCO3
 RESP ALKALOSIS WITH
METABOLIC ALKALOSIS
pH >7.46
pCO2 <35
Respiratory
Compute Alkalosis∆ pH: does it
for expected
account for change for pCO2?
If YES: Acute respiratory alkalosis OR
Chronic respiratory alkalosis
If NO: Partial compensation or
concomitant metabolic acidosis or
alkalosis
Compute for expected HCO3
Does the patient have an
ACIDOSIS
Guide Questionor
No.an
1
ALKALOSIS?
Look at the pH
 What is the PRIMARY
Guide Question No. 2
PROBLEM, Metabolic or
Respiratory?
Look at pCO2 and HCO3
 Is there appropriate
COMPENSATION for primary
disturbance?
Do your Computations –
Expected pCO2, pH, HCO3

Guide Question No. 3

 Disorder pH Primary Compensati
problem on
Metabolic ↓ ↓ in HCO3- ↓ in PaCO2
acidosis
Metabolic ↑ ↑ in HCO3- ↑ in PaCO2
alkalosis
Respiratory ↓ ↑ in PaCO2 ↑ in [HCO3-]
acidosis
Respiratory ↑ ↓ in PaCO2 ↓ in [HCO3-]
alkalosis
PRIMARY EXPECTED EXPECTED EXPECTED
DISORDER CHANGES CHANGES CHANGES
HCO3 pCO2 SBE
Metabol <22 = (1.5 X ≤5
ic HCO3) +
Acidosis (8 ± 2)
 PRIMARY EXPECTED EXPECTED EXPECTED
DISORDER CHANGES CHANGES CHANGES
HCO3 pCO2 SBE

Metaboli >26 = (0.7 X ≥5

c HCO3) +
Alkalosis (21 ± 2)
 PRIMARY EXPECTED EXPECTED EXPECTED
DISORDER CHANGES CHANGES CHANGES
HCO3 pCO2 SBE
Acute 0.1-1 >45 =0
Respirator mEq/liter AND
y Acidosis per 10 ∆ pH =
mm Hg 0.008 X
pCO2
(pCO2 - 40)
OR
= [(pCO2 -
40)÷10] +
24
 PRIMARY EXPECTED EXPECTED EXPECTED
DISORDER CHANGES CHANGES CHANGES
HCO3 pCO2 SBE

Chronic 1.1-3.5 >45 =0.4 X

Respirator mEq/liter AND (pCO2 –
y Acidosis per 10 ∆ pH = 40)
mm Hg 0.003 X
pCO2 (pCO2 -
OR 40)
= [(pCO2
-40)÷ 3] +
24
 PRIMARY EXPECTED EXPECTED EXPECTED
DISORDER CHANGES CHANGES CHANGES
HCO3 pCO2 SBE

Acute 0-2 <35 =0

Respirator mEq/liter AND
y Alkalosis per 10 ∆ pH =
mm Hg 0.008 X
pCO2 (40-pCO2)
OR
= [(40 -
pCO2)÷5]
+ 24
 PRIMARY EXPECTED EXPECTED EXPECTED
DISORDER CHANGES CHANGES CHANGES
HCO3 PCO2 SBE
Chronic 2.1-5 <35 =0.4 X
Respirator mEq/liter AND (PCO2 –
y Alkalosis per 10 ∆ pH = 40)
mm Hg 0.017 X
paCO2 (40-PCO2 )
OR
= [(40 -
PCO2 )÷10]
+ 24
10/M, CGN

pH7.5
pCO2 42
HCO3 29

What is the acid-base disorder?

Is it compensated or not?
Single or mixed?
Metabolic alkalosis
Expected pCO2 = 39-43
Actual or reported pCO2 = 42
Compensated

Metabolic alkalosis,
compensated, single acid-
base disorder
3/F, MRSA Sepsis
pH7.12
pCO2 38
HCO3 12

What is the acid-base disorder?

Is it compensated or not?
Single or mixed?
Metabolic acidosis
3/F, MRSA
Expected Sepsis
pCO2 = (1.5 X HCO3) + (8
± 2)
Expected pCO2 = 24-28
Actual or reported pCO2 = 38
Uncompensated, Mixed

Metabolic acidosis with

respiratory acidosis
pH 7.29
2 mos/F,
pCO 2 30 VSD
HCO3 15

What is the acid-base disorder?

Is it compensated or not? Single or
mixed?
Metabolic acidosis
2 mos/F, pCO2?
Expected VSD
Expected pCO2 = 28-32
Actual or reported pCO2 = 30
Compensated

Metabolic acidosis,
compensated, single acid
base disorder
pH 7.31
10 mos/M,
pCO2 80 ILD
HCO3 37

What is the acid-base disorder?

Is is compensated or not? Single or
mixed?
Respiratoryacidosis, chronic
∆ pH = 0.003 X (PCO2 - 40)
∆ pH = 0.12
 7.35/7.4/7.45 – 0.12 = 7.23/7.28/7.33
Soexpected pH = 7.23 – 7.33
Reported pH = 7.31
Compensated

Chronic respiratory acidosis,

10single acid-base
mos/M, ILD disorder
pH7.44
1/M, Pneumonia
pCO2 24
HCO3 15

What is the acid-base disorder?

Is it compensated or not? Single or
mixed?
Respiratoryalkalosis, acute
∆ pH = 0.008 X (40 - PCO2)
∆ pH = 0.128
 7.35/7.4/7.45
+ 0.12 =
7.478/7.528/7.578
So expected pH = 7.478 – 7.578
Reported pH = 7.44
Compute Expected HCO3
Expected HCO3 = 27
Reported HCO3 = 15
7/F, Pneumothorax

pH7.12
pCO2 77
HCO3 23

What is the acid-base disorder?

Is it compensated or not?
Single or mixed?
Respiratoryacidosis, acute
∆ pH = 0.008 X (PCO2 - 40)
∆ pH = 0.296
 7.35/7.4/7.45 – 0.29 = 7.05/7.104/7.154
Soexpected pH = 7.05 – 7.154
Reported pH = 7.12

Acute respiratory acidosis, single

acid-base disorder
ABG guide to appropriate
clinical assessment and
management.
Always CORRELATE ABG results
with patient’s clinical status
Clinical conditions are
DYNAMIC – Monitor!
Do NOT treat the ABG – Treat
the patient!
Important Reminders