ABG Interpretation 7
ABG Interpretation 7
Dr. M. Sreelatha
Prof & Head of Nephrology
Govt Medical College, Calicut
Arterial blood Gases
20 7.70
30 7.52
40 7.40
50 7.30
60 7.22
80% method:-
For an in pH by 0.1 unit multiply H+ by 0.8
eg: 7.00 = 100 nmol
7.10 = 100 x 0.8 = 80
7.20 = 100 x 0.8 x 0.8 = 64 nmol
H+ in the body
H+ 40 44 48 100
HCO3 24 28 22 12
PCO240 46 44 50
Buffer systems
Plasma Phosphate
=
Buffer ratio 4:1
(0.8 -1.45 mmol/L)
Plasma Protein
(30 - 55 g/L)
(15%) K+ H+
H+ Na+ (36%)
(6%) H+ + A-
H+ + IC proteins
(1%)
EC : BBS (43%)
Handling of an acid or alkali load
1. Buffer systems
2. Lungs – CO2 wash out
3. Kidneys – a) increasing /decreasing HCO3 reabsorption
b) ammoniagenesis
c) distal tubular H+ secretion
d) excretion of titratable acids
Acid (H+) excretion by the kidneys – NH3 + H+ NH4+
HPO4-- + H+ H2PO4 -Titra.acid
NH4+ & H2PO4- NAE
Role of Kidneys in acid-base
regulation
HCO3 reabsorption
Ammoniagenesis
Distal H+ secretion
1 glutamine malate
H+ ATPase
2 major domains : V1 & V0
V1 three A & three B subunits ; 6
B1 & B2 isoforms : B1 specific to kid, placenta & inner
ear
ATP6B1 gene on chr 2p13
H+ ion secreted NH3 + H+ NH4+
HPO4 -- + H+ H2 PO4-
(titratable acidity)
HCO3 Bicarbonate
Normal ABG values
pH 7.35 – 7.45
PCO2 35 – 45 mmHg
HCO3 22 – 26 mmol/L
HCO3
BE -2 - +2
SaO2 >95%
Measured values : pH, PCO2, PO2
Calculated values : O2 sat, HCO3, BE
Sampling : percutaneous arterial puncture – radial artery
Alternative to arterial bld : arterialized cap / venous bld
• Ear lobe, dorsum of hand(warm at 45oC x 10 mts), lateral
margin of foot
Collection :
• always glass syringe
• Heparinised, anaerobically, cooled to 4oC
ABG : Errors
In venous sample:-
[H+] = 24 x PCO2
[HCO3]
5
Steps for
Successful
Blood Gas
Analysis
Danish Chemist – Sorrenson 1909
Clinical scenario : Case 1
PH 7. 24 Acidosis
PaCO2
PaCO2 pH RESP
Opposite direction
No click
PaCO of 10
2
p
Acute change H
.08
PaCO2 pH RESP
Opposite direction
HCO3
Base Excess:
D base to normalise HCO3 (to 24)
with PaCO2 at 40 mm Hg
(Sigaard-Andersen)
Normal value : -3 to +3
> -5 Met acidosis, > +5 Met alk
Case 1
pH 7.30
HCO3 15
PaCO2 40
Metabolic Alkalosis
pH 7.50
HCO3 30
PaCO2 40
Four-step ABG Interpretation
Step 4:
PCO2
+
CO2+H20=H2CO3 = H + HCO3 pH
HIGH
+
H
HIGH
HCO3
HCO3 HCO3
ACUTE RISE : PCO2 10 : pH .08
CHRONIC RISE : PCO2 10 : pH .03
Six clicks
pH
CO2
SERUM
+
LOW H IONS HCO3
Bicarbonate
…LOW HCO3
Is compensation adequate ?
Compensation for MA
pH 7.32 : acidosis
HCO3 6.0 : Met acidosis
Expected PCO2 : 40 – (18 x 1.2) = 18 mmHg
considered
complete
when the pH
returns to
normal range
Clinical blood gases by Malley
When to suspect mixed acid-base disorder ?
pH 7.1, HCO3 6, PCO2 30
pH 7.1 acidosis
HCO3 6.0 Met acidosis
PCO2 30
Expected PCO2 only 18 CO2 retention
Actual PCO2 is 30
Resp acidosis
So Met acidosis + Resp acidosis
pH 7.1, HCO3 6.0, PCO2 10
pH 7.1 acidosis
HCO3 6.0 met acidosis
Expected PCO2 : 18 CO2 washout
Actual PCO2 : 10
Resp alk
So Met acidosis + Resp alk
Case 1 ABG : PH 7.24, HCO3 12, PaCO2 26,
HCO3 12 meq/L;
Expected PCO2 will be 26
Pt’s PaCO2 is also 26
18 yr old boy with h/o PUV fulgrated at the age of 3 yrs, now
presented with severe breathlessness following UTI
ABG : PH 7.1, HCO3 10, PCO2 23
Na 130, K 6, Cl 106, HCO3 10
BU 130mg, s.cr 5.8 mg
USG : BUO, B/L HUN
‘Hybrid acidosis’
AGP > HCO3 MA + Met alk
A pt with CKD admitted with several days of
vomiting
PaO2 = 90 mmHg
FiO2 × 5 = PaO2
20 × 5 = 100
No click
5
th step
Clinical correlation
Case 8,,,,,,,,,,,,,,,,,,
What is the
Diagnosis ?
pH 7.583
PCO2 19.8
Click for answer
HCO3 18.7 Respiratory
Alkalosis
Is it acute ?
One click for answer
Case 1
Blood Gas Report
o 16 year old female with
Measured 37.0 C
pH 7.523 sudden onset of dyspnea.
PaCO2 30.1 mm Hg
PaO2 105.3 mm Hg No Cough or Chest Pain
Calculated Data
HCO3 act 22 mmol / L Vitals normal but RR 56,
O2 Sat 98.3% anxious.
PO2 (A - a) 8 mm Hg D
PO2 (a / A) 0.93
O2 Sat 78 %
PO2 (A - a) 9.5 mm Hg D
PO2 (a / A) 0.83
Entered Data
FiO2 21 %
Chronic respiratory acidosis
Hypoxemia
Normal A-a gradient With hypoxia due to hypoventilation
Hypoventilation
8-year-old male asthmatic with resp. distress
Six clicks
Measured 37.0 C
o PaCO8-year-old male
2 >45; respiratory asthmatic;
acidemia
pH 7. 32 D CO2 = 349days
- 40 = 9of cough, dyspnea
PaCO2 49.1 mm Hg
Expectedand
D pHorthopnea
( Acute ) = 9/10not
x 0.08 = 0.072
PaO2 66.3mm Hg
Expectedresponding to usual
pH ( Acute ) = 7.40 - 0.072 = 7.328
Calculated Data Acute resp. acidosis
bronchodilators.
HCO3 act 18.0 mmol / L
WITH INCREASE IN CO2 BICARB MUST RISE ?
BicarbonateO/E: Respiratory distress;
O2 Sat 92 %
153-66= 87 D is low………
PO2 (A - a) mm Hg
suprasternal
Metabolic acidosis + respiratoryand
acidosis
PO2 (a / A)
intercostal retraction;
Entered Data tired looking; on 4 L NC.
FiO2 30 %
Hypoxia
piO2 = 715x.3=214.5 / palvO2 = 214-49/.8=153 Wide A / a gradient
Case 4 8 year old diabetic with resp. distress, fatigue and loss of appetite.
Three clicks
pH <7.35 ; acidemia
Blood Gas Report
Measured 37.0 C
o
Last two digits of pH
pH 7.23 Correspond with co2
PaCO2 23 mm Hg
PaO2 110.5 mm Hg
Calculated Data
HCO3 act 14 mmol / L
HCO3 <22; metabolic acidemia
O2 Sat %
PO2 (A - a) mm Hg D
PO2 (a / A)
If Na = 130,
Entered Data Cl = 90
FiO2 21.0%
Anion Gap = 130 - (90 + 14)
= 130 – 104 = 26
Case 5 : 10 year old child with encephalitis
Four clicks
Measured 37.0 C
o
pH almost within normal range
pH 7.46 Mild alkalosis
PaCO2 28.1 mm Hg
PaO2 55.3mm Hg PaCO2 is low , respiratory
Calculated Data low by around 10
HCO3 act 19.2 mmol / L ( Acute ) by .08
(Chronic ) by .03
O2 Sat %
PO2 (A - a) mm Hg D Bicarb looks low ?
PO2 (a / A) Is it expected ?
Entered Data
FiO2 24.0%
BICARBINATURIA
Treatment of MA
Mol wt 84
1 gm NaHCO3 contain 12 mmol of NaHCO3
1 ml 8.4% NaHCO3 contain 1 meq of NaHCO3
25 ml 7.5% NaHCO3 contain 22 mEq NaHCO3
Oral preparation - 600 mg / tablet
Rx of Metabolic alkalosis
Rx of underlying cause
pH 7.39
PCO2 l5mmHg
HCO3 8mmol/L
PaO2 90 mmHg
What is the probable cause for the above findings ? Are they OK
as far as oxygenation is concerned ?
No click
Patient was hypo volumic , received Normal Saline bolus...
Corrected acidosis
He was operated ….but post-op became drowsy
His ABG……..
FiO2….30%
pH 7.38
PaCO2 38
PaO2 60
1) Why hypoxemia ?
2) Were the lungs bad to begin with ? ( Pre OP PaO2 90 mmHg )
3) Micro atelectesis during surgery ? Anesthetist goofed up the case
4) Pure and simple hypoventilation …..Sedation ?
Case study No. 4
Step 2
Who is responsible for this change in pH ( culprit )?
CO2 will change pH in opposite direction
Bicarb. will change pH in same direction
Acidemia: With HCO3 < 20 mmol/L = metabolic
With PCO2 >45 mm hg = respiratory
Step 3
If there is a primary respiratory disturbance, is it
acute ?
10 mm
Change = .08 change in pH ( Acute )
.03 change in pH ( Chronic )
PaCO2
Step 4 No click
If the disturbance is metabolic is the respiratory
compensation appropriate?
For metabolic acidosis:
Expected PaCO2 = (1.5 x [HCO3]) + 8 ) + 2
or simply…
expected PaCO2 = last two digits of pH
Suspect if .............
actual PaCO2 is more than expected : additional
…respiratory acidosis
actual PaCO2 is less than expected : additional …
No click
Step 4 cont.
If there is metabolic acidosis, is there a wide anion gap ?