APPROACH TO ABG

Presenter: Dr. Manish Shrestha

NAMS, resident
 Introduction

Acid base
disorders
oxygenation
status

Arterial
Blood Gas
(ABG):

Decisive
Critical
tool in
illness
emergency
 Physiology of Acid Base Balance
• pH of the body controlled by three systems

Acid Base
Buffering

Respiratory Renal
Buffering Buffering
 Physiology of Acid Base Balance

Buffers
- Primarily weak acids
- Take or release H+
- Prevents changes in free
H+ concentration

Extracellular Buffers:
Intracellular Buffers:
HCO3- most important buffer
Proteins
Phosphate and plasma proteins
Organic and inorganic phosphates
H2SO4 + 2NaHCO3 → NA2SO4 +
Haemoglobin (HB-) in the RBC
2H2CO3 →2CO2 + 2H2O + NA2SO4
Respiratory Buffering

Decreased plasma pH

Peripheral chemoreceptor detect and

respond

Increased ventilation

Decreased pCO2

Increased plasma pH
 Renal Regulation

Excrete the daily acid

load
Titratable
Acid
Reabsorption of all
filtered bicarbonate Ammonium
Excretion
 INDICATIONS
• Identification of acid-base disorders with or
without physiologic compensation
• Measurement of partial pressures of
respiratory gases involved in oxygenation
and ventilation
• Assessment of the response to therapeutic
interventions such as mechanical
ventilation in a patient with respiratory
failure
 Contraindications
• Absolute
– Abnormal modified Allen test (consider
different puncture site)
– Local infection or distorted anatomy
– Presence of arteriovenous fistulas or vascular
grafts
– Known or suspected severe peripheral
vascular disease of the limb involved
 Sampling
Superficial artery with collateral circulation

• Radial, Brachial, Femoral

Modified Allen’s test

Mix well
• Remove any air bubbles
• Cap the syringe

Sood P, Paul G, Puri S. Interpretation of arterial blood gas. Indian J Crit Care Med 2010;14:57-64
 Sampling
Analyze within 30 min
If expected to be greater than 30 min, use glass syringe and ice
slurry

Blood gases drawn 20 to 30 minutes after

change in ventilator settings

Anticoagulant
• Amount of Heparin recommended Is 50U/ml of blood drawn
• That is 0.05ml of heparin(1ml=1000U) for 1 ml blood

Sood P, Paul G, Puri S. Interpretation of arterial blood gas. Indian J Crit Care Med 2010;14:57-64
 ABG Parameters
Parameter Range

pH 7.35 – 7.45

PaCO2 35 – 45 mmHg

PaO2 80 – 100 mmHg

HCO3 22 – 26 mmol /L

Base Excess -2 to +2

SaO2 > 95%

FiO2 0.21
 What can we know from ABG
ABG

Oxygenation Ventilation Acid base

Disorder

Simple Acid
Adequacy of Hypoventilation base Disorder
oxygen

Hyperventilation Mixed Acid

Causes of base Disorder
Hypoxemia
Alveolar-arterial Oxygen Gradient
(A-a gradient)
Not enough oxygen getting into Not enough oxygen transferred
the alveoli into the capillary blood
A-a gradient
i) low atmospheric pressure= PAO2- PaO2
i) ventilation-perfusion
ii) hypoventilation mismatch
ii) right-to-left shunting
PAO2= (Patm - Pwater) FiO2iii)- PaCO2/0.8
diffusion defects

Normal A-a Increased A-a

Gradient Patm= the atmospheric pressure(760 mm Hg)
gradient
Pwater = the vapour pressure of water at body temp (47mm Hg)
FiO2= the fraction of O2 in the inspired gas (21% in room air)
PaCO2= the partial pressure of CO2 in arterial blood (from ABG)
O.8 = respiratory quotient
 TERMS
• Acidemia : pH less than 7.35
• Acidosis : a process that would cause
acidemia, if not compensated
• Alkalemia : pH greater than 7.45
• Alkalosis : a process that would
alkalemia, if not compensated
• Simple acid base disorder: a single
primary process of acidosis or alkalosis

• Mixed acid base disorder: presence of

more than one acid base disorder
simultaneously
 Acid base Disorder
Metabolic acidosis

Metabolic alkalosis

Respiratory acidosis: acute/chronic

Respiratory alkalosis: acute/chronic

 Analysis of simple acid base
disorder
Arterial blood sample

<7.35 >7.45
pH?

HCO3- Acidemia PaCO2 HCO3- Alkalemia PaCO2

<24meq/L >40mmHg >24meq/L <40mmHg

Metabolic Respiratory Metabolic Respiratory

Respiratory Renal Respiratory Renal

compensation compensation compensation compensation

PaCO2 HCO3- PaCO2 HCO3-

<40mmHg >24meq/L >40mmHg <24meq/L
 Expected compensation

Metabolic Metabolic
acidosis alkalosis
PaCO2= (1.5 x HCO3-) + 8 ± 2 PaCO2= (0.7 x HCO3-) + 21
(Winter’s formula) ±2

1.25 mmHg of PaCO2 decreases 0.75 mmHg of PaCO2

per mmol/L decreases [HCO3-]
increases per mmol/L
increases [HCO3-]

PaCO2=[HCO3-]+15 PaCO2=[HCO3-]+15

Harrisons principle if Internal Medicine, 18th edition, vol 1, p.g. 363-371

Expected compensations: Respiratory
For 10 mm Hg change in PCO2:
Change in HCO3 is given by

Respiratory acidosis Respiratory alkalosis

Acute 1 2

Chronic 4 4
 Respiratory disturbance
Acute/Chronic
ΔH+/ΔPaCO2

• <0.3 – Chronic

• >0.8 – Acute

• 0.3 to 0.8 – Acute on chronic

• H+= 24 x [(PaCO2) /(HCO3-)]

• pH (7.4)  H+ (40)

Sood P, Paul G, Puri S. Interpretation of arterial blood gas. Indian J Crit Care Med 2010;14:57-
64
 Anion Gap (AG)
• Represents the concentration of unmeasured anions in the plasma

• AG= Unmeasured anions- Unmeasured cations

• AG = [Na+] - ([Cl-] + [HCO3-])

• Normal: 10 ± 2mmol/L

• Increased AG
Increased anions
Decreased cations

Kraut JA & Madias NE. Serum Anion Gap: Its Uses and Limitations in Clinical Medicine Clin J Am Soc
Nephrol 2007; 2: 162-174
 Anion Gap and Albumin
• The normal AG is affected by patients plasma albumin
concentration.

• For every 1g/dl reduction in plasma albumin concentration

the AG increases by 2.5

• Corrected AG = Calculated AG + [2.5 × (4 – albumin)]

Kraut JA & Madias NE. Serum Anion Gap: Its Uses and Limitations in Clinical Medicine Clin J
Am Soc Nephrol 2007; 2: 162-174
 Urinary Anion Gap
• Differentiate cause of non AG metabolic acidosis

• Calculated as:
UAG=(UNa+ + UK+)-UCl-

UAG (negative) =
UAG (positive) =
Gastrointestinal
Renal Cause
cause

Sood P, Paul G, Puri S. Interpretation of arterial blood gas. Indian J Crit Care Med 2010;14:57-64
 Building concepts – ΔHCO3
• Only necessary if there is an AG metabolic acidosis.
• Does the increase in AG completely explain the ABG?

PRINCIPLE
• Bicarbonate is decreased due to the presence of unmeasured
anions
• For one molecule of anion, one molecule bicarbonate lost
• Bicarbonate level can be therefore be predicted
 Delta Gap
Known case of CKD 4, presents to casualty with vomiting for past
2 days. ABG reveals pH=7.08, Na=143, Cl= 100 and HCO3=8

• AG= 143 - (100+8)= 35 (Normal AG=10±2)

• High AG metabolic acidosis
• Excess AG= 35-12 = 23

• Hence HCO3 should have fallen by 23 (from 24 to 1)

• But it is 8
• So there must an underlying co-existent mechanism for this
HCO3- level which can be predicted by delta gap

Sood P, Paul G, Puri S. Interpretation of arterial blood gas. Indian J Crit Care Med 2010;14:57-64
 Delta Gap

Delta gap = (AG – 12)- (24- HCO3)

• If < 24, patient has an additional non-anion gap metabolic

acidosis

• If >24, patient has an additional metabolic alkalosis

Sood P, Paul G, Puri S. Interpretation of arterial blood gas. Indian J Crit Care Med 2010;14:57-64
 Delta Ratio
ΔAG/ΔHCO3- = (AG-12)/(24-HCO3-)

• ΔAG/ΔHCO3- = (Increase in AG)/ (Decrease in bicarbonate)

• ΔAG/ΔHCO3- = 1-2 (Pure High AG Metabolic Acidosis)

• ΔAG/ΔHCO3- > 2 (Associated Metabolic Alkalosis)

• ΔAG/ΔHCO3- < 1 (Associated Non AG Metabolic Acidosis)

Sood P, Paul G, Puri S. Interpretation of arterial blood gas. Indian J Crit Care Med 2010;14:57-64
Stepwise Interpretation
Validate ABG

Assess oxygenation, P/F ratio

pH: Acidemic or Alkalemic?

Primary disorder : Metabolic or Respiratory?

If respiratory disorder: Acute or Chronic?

Expected compensation.

Calculate Anion Gap

For high-AG metabolic acidosis: Calculate ΔGap?

 PREREQUISITE: VALIDATE

[H+] = 24 × PCO2 / [HCO3-]

pH from Kassirer-Bleich equation Calculate [H+] from pH
=
 RULE OF THUMB FOR PH
Subtract from 80 rule
• Drop the 7 and
subtract from 80

• i.e pH 7.38→ [H+]= 42

• pH 7.45→ [H+]= 35

• For range pH 7.25-7.55

 LETS GET STARTED

35 year old
woman,
community
acquired TLC-24000
pneumonia,
brought with
confusion.

Na-137, K-3.9, Cl- Urea-15mg/dl, Cr-

106 0.8 mg/dl
Na-137,Cl-106, HCO3- 8,pH- 7.20, paCO2 -
21, paO2- 90,SaO2: 94%, FiO2 - 0.21.
Validate ABG

1. Validate:
H+ = 80-20 = 60 nmol/L(thumb rule) Assess oxygenation

H+ = 63 nmol/l (from chart)

pH: Acidemic or Alkalemic?
H+ = 24 X pCO2 / HCO3= 24x21/8= 63
Primary disorder : Metabolic or Respiratory?

If respiratory disorder: Acute or Chronic?

2. Assess oxygenation:
pO2> 80mmHg, ADEQUATE Expected compensation.

For metabolic acidosis: Calculate Anion Gap

For high-AG metabolic acidosis: Calculate

ΔGap?
Na-137,Cl-106, HCO3- 8,pH- 7.20, paCO2 -
21, paO2- 90,SaO2: 94%, FiO2 - 0.21
3. Is the patient acidemic or alkalemic? Validate ABG

Acidemic
Assess oxygenation

4. Metabolic or respiratory? pH: Acidemic or Alkalemic?

(pH low, pCO2 low)

Primary disorder : Metabolic or Respiratory?
Metabolic
If respiratory disorder: Acute or Chronic?

5. Is there an increased anion gap?

AG= 137 –(106+8)= 23 Expected compensation.

Increased anion gap

For metabolic acidosis: Calculate Anion Gap
metabolic acidosis
For high-AG metabolic acidosis: Calculate
ΔGap?
Na-137,Cl-106, HCO3- 8, pH-7.2, paCO2
-21, paO2- 90 ,SaO2-94%, FiO2 - 0.21.
6. Are there other metabolic disturbances present in this
patient?
AG= 23
Excess anions= 23-12= 11
Hence, HCO3 should be 25-11 = 14
But HCO3 is 8, or 6 less than predicted
Delta Gap = Bicarb + (AG-12) = 5 + (23-12)= 16 (<24)
5 11 23 alkalosis
acidosis

6 14

coexisting non anionic gap metabolic acidosis present

Na-138,Cl-107, HCO3- 5, pH- 7.08, paCO2 -
21, paO2-90,SaO2: 94%, FiO2 - 0.21.

7. Is the respiratory system compensating for a

metabolic acidosis?
Expected PaCO2 = 1.5 (HCO3-) + 8 + 2
= 1.5 (8) + 8 + 2
= 17 + 2 = 15-19
Here PaCO2 is 21

Additional respiratory acidosis

Na-137,Cl-106, HCO3- 8, pH- 7.20, paCO2 -
21, paO2- 90, SaO2: 94%, FiO2 - 0.21.
Final diagnosis
Anion gap metabolic acidosis
Non–anion gap metabolic acidosis
Respiratory acidosis
Adequate oxygenation
 CASE 2
FiO2: 0.4

40 year old male comes

with acute exacerbation of
COPD.
 Na-137,Cl-105, HCO3- 30,pH- 7.16, pCO2 -
72, paO2- 58, FiO2 - 0.4, SaO2: 78%
Validate ABG
1. Validate:
H+ = 80-16 = 64 nmol/L(thumb rule)
H+ = 63 nmol/l (from chart) Assess oxygenation
H+ = 24 X pCO2 / HCO3= 24x72/30= 60
(from Kassirer Bleich’s equation)
pH: Acidemic or Alkalemic?

2. Assess oxygenation: Primary disorder : Metabolic or Respiratory?

pO2= 58mmHg, INADEQUATE

Moderate hypoxemia
If respiratory disorder: Acute or Chronic?
P/F Ratio= 58/0.4=145
A-a gradient = 714x(FiO2)-0.8x (pCO2)
= (713x 0.4) – 0.8 x 72
Expected compensation.
= 228 (N< 20 mm Hg)
=RESPIRATORY SHUNT
Calculate Anion Gap

For high-AG metabolic acidosis: Calculate

ΔGap?
 Na-137,Cl-105, HCO3- 30,pH- 7.16, paCO2
-72, paO2- 58, FiO2 - 0.4, SaO2: 78%
3. Is the patient acidemic or alkalemic? Validate ABG

Acidemic
Assess oxygenation
4. Metabolic or respiratory?
(pH low, pCO2 high)
pH: Acidemic or Alkalemic?
Respiratory

5. Acute or chronic? Primary disorder : Metabolic or Respiratory?

∆H+/ ∆paCO2 = (64- 40) / (72-40)

= 24 / 32 = 0.6 (ACUTE ON If respiratory disorder: Acute or Chronic?
CHRONIC)

Expected compensation.

6. Is there an increased anion gap?

Calculate Anion Gap
AG= 137–( 105+30)= 2
No anion gap
For high-AG metabolic acidosis: Calculate
ΔGap?
Na-137,Cl-105, HCO3- 30,pH- 7.16, pCO2 -
72, paO2- 58, FiO2 - 0.4, SaO2: 78%

7. Is the metabolic system compensating for a

respiratory acidosis?
Expected HCO3 = 0.1x(∆pCO2) + 24
= 0.1 (72-40) + 24
= 27
Here HCO3 = 30

ADEQUATE METABOLIC COMPENSATION

Na-137,Cl-105, HCO3- 30,pH- 7.16, pCO2 -
72, paO2- 58, FiO2 - 0.4, SaO2: 78%
Final diagnosis
• This patient has
– Acute Respiratory Acidosis with adequate
metabolic compensation
– Moderate hypoxemia
– Respiratory shunt
 CASE 2
40 year old female comes with tachypnea, lethargy,
tinnitus and a h/o drug overdose with the following
ABG:

 PaCO2 : 16
 pH: 7.32
 PaO2 : 95
 Na: 148
 Cl: 112
 HCO3-: 8
PaCO2 - 16, pH- 7.32, PaO2 - 95, Na- 148, Cl-
112, HCO3- 8, Sao2- 97%, FiO2- 0.21
Validate ABG

1. Validate:
H+ = 80-32 = 48 nmol/L(thumb rule) Assess oxygenation

H+ = 47 nmol/l (from chart)

H+ = 24 X pCO2 / HCO3= 24x16/8= 48 pH: Acidemic or Alkalemic?

(from Kassirer Bleich’s equation)

Primary disorder : Metabolic or Respiratory?

If respiratory disorder: Acute or Chronic?

2. Assess oxygenation:
pO2= 95mmHg, ADEQUATE Expected compensation.

P/F Ratio= 95/0.2=475

Calculate Anion Gap

For high-AG metabolic acidosis: Calculate

ΔGap?
PaCO2 - 16, pH- 7.32, PaO2 - 95, Na- 148, Cl-
112, HCO3-8, Sao2- 97%, FiO2- 0.21
3. Is the patient acidemic or alkalemic? Validate ABG

Acidemic
Assess oxygenation

4. Metabolic or respiratory? pH: Acidemic or Alkalemic?

(pH low, pCO2 low)

Metabolic Primary disorder : Metabolic or Respiratory?

5. Is there an increased anion gap? If respiratory disorder: Acute or Chronic?

AG= 148–( 112+8)= 28

Expected compensation.
High anion gap
Calculate Anion Gap

6. Delta ratio = 1 ( pure HAGMA)

For high-AG metabolic acidosis: Calculate
ΔGap?
PaCO2 - 16, pH- 7.32, PaO2 - 95, Na-
148, Cl- 112, HCO3- 8, Sao2- 97%, FiO2-
0.21

6. Is the respiratory system compensating for a

metabolic acidosis?
Expected PaCO2 = 1.5 ( 16) + 8
= 32

Here paCO2 = 16
Added respiratory alkalosis
PaCO2 - 16, pH- 7.32, PaO2 - 95, Na- 148, Cl-
112, HCO3- 8, Sao2- 97%, FiO2- 0.21

Final diagnosis
• This patient has
– Elevated anion gap metabolic acidosis
– Respiratory alkalosis

Patient was later confirmed to have salicylate

intoxication
 40 year old with CASE 3
pneumonia and low BP on
dopamine. She has been FiO2!!!
having vomiting over the
last three days. She is on
0.4
high flow oxygen with
nasal canula.
 pH = 7.26
 pCO2 = 18
 PaO2 = 65
 Na = 130
 Cl = 90
 HCO3 = 8
 Spo2= 79%
 pH - 7.26, pCO2 - 18, PaO2 -65, Na - 130, Cl -
90, HCO3 - 8, Spo2-79%, FiO2- 0.4
Validate ABG
1. Validate:
H+ = 80-26 = 54 nmol/L(thumb rule)
H+ = 57 nmol/l (from chart) Assess oxygenation
H+ = 24 X pCO2 / HCO3= 24x18/8= 54
(from Kassirer Bleich’s equation)
pH: Acidemic or Alkalemic?

2. Assess oxygenation: Primary disorder : Metabolic or Respiratory?

pO2= 65mmHg, INADEQUATE

Mild hypoxemia
If respiratory disorder: Acute or Chronic?
P/F Ratio= 58/0.4=145
A-a gradient = 714x(FiO2)-0.8x (pCO2)
= (713x 0.4) – 0.8 x 18
Expected compensation.
= 266 (N< 20 mm Hg)
=RESPIRATORY SHUNT
Calculate Anion Gap

For high-AG metabolic acidosis: Calculate

ΔGap?
pH - 7.26, pCO2 - 18, PaO2 -65, Na - 130, Cl -
90, HCO3 - , Spo2-79%, FiO2- 0.4
3 Is the patient acidemic or alkalemic?
. Validate ABG

Acidemic
Assess oxygenation

4. Metabolic or respiratory?
(pH low, pCO2 low) pH: Acidemic or Alkalemic?

Metabolic
Primary disorder : Metabolic or Respiratory?

5. Is there an increased anion gap? If respiratory disorder: Acute or Chronic?

AG= 130–( 90+8)= 32

High anion gap metabolic acidosis Expected compensation.

6. Delta ratio ? AG/HCO3 Calculate Anion Gap

2 (metabolic alkalosis)
For high-AG metabolic acidosis: Calculate
ΔGap?
pH - 7.26, pCO2 - 18, PaO2 -65, Na - 130, Cl -
90, HCO3 - 8, Spo2-79%, FiO2- 0.4

7. Is the respiratory system compensating for a

metabolic acidosis?
Expected PaCO2 = 1.5x(HCO3) + 8
= 1.5 (8) + 8
= 17
Here pCO2 = 18

ADEQUATE RESPIRATORY COMPENSATION

pH - 7.26, pCO2 - 18, PaO2 -65, Na - 130, Cl -
90, HCO3 - 8, Spo2-79%, FiO2- 0.4

Final diagnosis
This patient has
• Elevated anion gap metabolic acidosis
• Adequate respiratory compensation
• Additional metabolic alkalosis
 CASE 4
• 50 year old male with history of CKD presents to the casualty,
he is confused and lethargic. He has vomitus stains on his
clothes. His ABG shows
 pH: 7.40
 pCO2: 40 mmHg a) Normal
 HCO3-:24 b) Metabolic acidosis with
respiratory alkalosis
 Na:145 c) Metabolic acidosis with
metabolic alkalosis
 Cl:100 d) Metabolic acidosis with
respiratory compensation
 pH-7.40, pCO2-40, HCO3-24,
Na-145, Cl-100
• Anion gap: 145-(100+24)= 21 AG Metabolic
acidosis

>24
• Delta gap: 24+(21-12)= 33 Metabolic
alkalosis
 CAUTION
• Even with normal pH patient can have mixed
acid base disorder

• Step wise approach

THANK YOU