Arterial Blood Gas

Analysis ..1
Dr Satish Deopujari
Pediatrician
Hon. Prof. ( Pediatrics) JNMC
Chairman National
Intensive care chapter
Indian academy of pediatrics
deopujari@rediffmail.com
Visit us at. http://rdsoxy.org

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The Goal :

To provide Bedside approach to

ABG analysis

H ION CONC.
OH ION 14
N.MOLS / L.
20

pH
7.70

pH stand for "power of hydrogen"

30
40

H ION

7.52
H+ = 80 - last two digits of pH

7.40

50

7.30

60

7.22

Dont click wait ..till

Last message .. H = 80-last two digits of pH

Bicarbonate:

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Henderson - Hasselbach equation:

pH = pK + Log

HCO3
Dissolved

CO2

Standard Bicarbonate:
Plasma HCO3 after equilibration
to a PaCO2 of 40 mm Hg
: Reflects non-respiratory acid base change
: No quantification of the extent of the
buffer base abnormality

Base Excess:

base to normalise HCO3 (to 24)

with PaCO2 at 40 mm Hg
(Sigaard-Andersen)

: Reflects metabolic part of acid base

: No info. over that derived from pH,
pCO2 and HCO3
: Misinterpreted in chronic or mixed
disorders

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Oxygenation
Indices:

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O2 Content of blood:

Hb. x O2 Sat + Dissolved O2

(Dont forget hemoglobin)

Oxygen Saturation: reported as ABG report
( Derived from oxygen dis. curve
not a measured value )
Alveolar / arterial gradient:
( Useful to classify respiratory failure )

Normal arterio/venous difference

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0 10 20 30 40 50 60 70 80 90 100 PaO2
100
80

Rt. Shift

Oxygen delivered
to tissues
with normally placed curve

60
Delivered oxygen
with Rt. Shift curve

40
20

Normal

Shift of the curve changes saturation for a given PaO2

Alveolar-arterial Difference
Inspired O2 = 21 %
piO2 = (760-45) x . 21

O2
CO2

150 mmHg

palvO2 = piO2 pCO2 / RQ

= 150 40 / 0.8
= 150 50 =
100 mm Hg
PaO2 = 90 mmHg

palvO2 partO2 = 10 mmHg

One click and wait

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Alveolar- arterial Difference

Oxygenation Failure
WIDE GAP
piO2 = 150
pCO2 = 40
palvO2= 150 40/.8
=150-50
=100
PaO2 = 45
= 100 - 45 = 55

760 45 = 715 : 21 % of 715 = 150

Ventilation Failure
NORMAL GAP
piO2 = 150
pCO2 = 80

O2
CO2

palvO2= 150-80/.8
=150-100
= 50
PaO2 = 45
= 50 - 45 = 5

PAO2 (partial pres. of O2. in the alveolus.)

= 150 - ( PaCO2 / .8 )

Expected PaO2 =
Normal situation

FiO2 5 = PaO2
20 5 = 100

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The essentials
The Blood Gas Report:
normals

HCO3

pH
PaCO2
PaO2

7.40 + 0.05
40 + 5
80 - 100

mm Hg
mm Hg

HCO3

24 + 4

mmol/L

O2 Sat
>95
Always mention and see

FIO2

The

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Steps for
Successful
Blood Gas
Analysis

Step 1

Look at the pH
Is the patient
or

acidemic
alkalemic

pH < 7.35
pH > 7.45

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

Alkalemia:

With HCO3 >28 mmol/L = metabolic

With PCO2 <35 mm Hg = respiratory

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Step 3

If there is a primary respiratory disturbance, is it

acute ?

10 mm
Change
PaCO2

= .08 change in pH ( Acute )

.03 change in pH ( Chronic )

Step 4

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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
For metabolic alkalosis:
Expected PaCO2 = 6 mm for 10 mEq. rise in Bicarb.
Suspect if .............
actual PaCO2 is more than expected : additional
respiratory acidosis
actual PaCO2 is less than expected : additional
respiratory alkalosis

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Step 4 cont.

If there is metabolic acidosis, is there a wide anion gap ?

Na - (Cl-+ HCO3-) = Anion Gap usually <12
If >12, Anion Gap Acidosis :
Common pediatric causes
1) Lactic acidosis
2) Metabolic disorders
3) Renal failure

M ethanol
U remia
D iabetic Ketoacidosis
P araldehyde
I nfection (lactic acid)
E thylene Glycol
S alicylate

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th step

Clinical correlation

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Same direction
HCO3

pH

META.

pH

RESP.

Same direction

PaCO2
Opposite direction

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Remember the format

pH
PaCO2
PaO2

Three clicks
pH

HYPER VENTILATION

PaCO2
BICARB CHANGES
pH in same direction
Compensation
Bicarbonate

Low
Alkali

Primary lesion
Primary lesion

METABOLIC ACIDOSIS

Three clicks
pH

HYPO VENTILATION

PaCO2
BICARB CHANGES
pH in same direction
Compensation
Bicarbonate

High
Alkali

Primary lesion

METABOLIC ALKALOSIS

pH

Three clicks
Wait for red circle
CO 2 CHANGES
pH in opposite direction

BICARB

compensation
PaCO 2

High
CO2

Primary lesion

Respiratory acidosis

Three clicks
Wait for red circle
pH

PaCO 2 CHANGES
pH in opposite direction

BICARB

compensation
PaCO 2

Low
PaCO2

Primary lesion
Primary lesion

Respiratory alkalosis

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PaCO of 10

pH

Acute change

.08

Chronic change .03

INTERPRETATION OF A.B.G.
FOUR STEP METHOD OF DEOSAT
1) LOOK FOR pH

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2) WHO IS THE CULPRIT ?

3) IF RESPIRATORY ACUTE / CHRONIC ?
4) IF METABOLIC / COMP. / ANION GAP
CLINICAL CORRELATION

compensation

considered
complete
when the
pH returns
to
normal
range

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Clinical blood gases by Malley

COMPENSION LIMITS

METABLIC ACIDOSIS
PaCO2 = Up to 10 ?

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METABOLIC ALKALOSIS
PaCO2 = Maximum 6O
RESPIRATORY ACIDOSIS
BICARB = Maximum 40
RESPIRATORY ALKALOSIS
BICARB = Up to 10

One click for answer

Blood

Gas

Case 1

Report
o

Measured
pH
PaCO2
PaO2

37.0 C
7.523
30.1
mm Hg
105.3
mm Hg

Calculated
HCO3 act

Data
22

O2 Sat
PO2 (A - a)
PO2 (a / A)

98.3
8
0.93

Entered
FiO2

Data
21.0

mmol / L
%
mm Hg

16 year old female with

sudden onset of dyspnea.
No Cough or Chest Pain
Vitals normal but RR 56,
anxious.
Acute respiratory alkalosis
And why acute ?

Case 2
Blood

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6 year old male with progressive respiratory distress

Muscular dystrophy .
pH <7.35 :acidemia
Gas

Report

Res. Acidemia : High PaCO2 and low pH

Measured
pH
PaCO2
PaO2

37.0 C
7.301
CO2 =76-40=36
76.2
mm Hg Expected pH for ( Acute ) = .08 for 10
45.5
mm Hg Expected ( Acute ) pH = 7.40 - 0.29=7.11

Calculated
HCO3 act

Data
35.1

O2 Sat
PO2 (A - a)
PO2 (a / A)

78
9.5
0.83

Entered
FiO2

Data
21

Hypoxemia
Normal A-a gradient
Hypoventilation

Chronic resp. acidosis

mmol / L
%
mm Hg

Chronic respiratory acidosis

With hypoxia due to hypoventilation

80 PaCO2

PaCO2
70
60
50
40
30
20

Last two digits

pH
pH
7.10
7.20
7.30
7.40
7.50
7.60

Acute respiratory change

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8-year-old male asthmatic with resp. distress

Blood

Gas

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Case 3

pH <7.35 ; acidemia

Report

PaCO >45; respiratory acidemia

Measured
pH
PaCO2
PaO2

28-year-old male asthmatic;

37.0 C
7. 24
CO2 = 493-days
40 = 9 of cough, dyspnea
49.1
mm Hg
Expectedand
pH orthopnea
( Acute ) = 9/10not
x 0.08 = 0.072
66.3
mm Hg

Calculated
HCO3 act

Data
18.0

O2 Sat
PO2 (A - a)
PO2 (a / A)
Entered
FiO2

Expectedresponding
pH ( Acute ) = 7.40
- 0.072 = 7.328
to usual
Acute resp.
acidosis
bronchodilators.

mmol / L

WITH INCREASE IN CO2 BICARB MUST RISE ?

% 5 = 150 O/E: Respiratory

30
Bicarbonate is low
153-66= 87
mm Hg
92

distress;

suprasternal
andacidosis
Metabolic acidosis
+ respiratory

Data
30

intercostal retraction;
tired looking; on 4 L NC.

Hypoxia
piO2 = 715x.3=214.5 / palvO2 = 214-49/.8=153 Wide A / a gradient

Case 4 8 year old diabetic with respi. distress fatigue and loss of appetite.
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Blood

Gas

pH <7.35 ; acidemia

Report

Measured
pH
PaCO2
PaO2

o
Last two digits of pH
37.0 C
Correspond with co2
7.23
23
mm Hg
110.5
mm Hg

Calculated
HCO3 act

Data
14

O2 Sat
PO2 (A - a)
PO2 (a / A)
Entered
FiO2

mmol / L

HCO3 <22; metabolic acidemia

%
mm Hg
Data
21.0

If Na = 130,
Cl = 90
Anion Gap = 130 - (90 + 14)
= 130 104 = 26

Case 5 : 10 year old child with encephalitis

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Blood

Gas

Report
o

Measured
pH
PaCO2
PaO2

37.0 C
7.46
28.1
mm Hg
55.3
mm Hg

Calculated
HCO3 act

Data
19.2

O2 Sat
PO2 (A - a)
PO2 (a / A)
Entered
FiO2

mmol / L
%
mm Hg

Data
24.0

BICARBINATURIA

pH almost within normal range

Mild alkalosis
PaCO2 is low , respiratory
low by around 10
( Acute ) by .08
(Chronic ) by .03
Bicarb looks low ?
Is it expected ?

Case 6.
pH 7.39
PCO2 l5mmHg
HCO3 8mmol/L
PaO2 90 mmHg

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These findings are most consistent with.

a) Metabolic acidosis with compensatory Hypocapnia.
b) Primary metabolic acidosis with
respiratory alkalosis.
c) Acute respiratory alkalosis fully compensated.
d) Chronic respiratory alkalosis fully compensated.
For metabolic acidosis: FULL COMPENSATION
Expected PaCO2 = (1.5 x [HCO3]) + 8 ) + 2
(Winters equation)
PCO 2 SHOULD BE 20

Case 7.

Adolescent boy with appendicitis , posted for surgery , he is a known

case of SLE.
His pre-op ABG shows
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: Room air
pH 7.39
pCO2 l5mmHg
paO2 90 mmHg
HCO3 8mmol/L
These findings are most consistent with.
a) Metabolic acidosis with compensatory Hypocapnia.
b) Primary metabolic acidosis with respiratory alkalosis.
c) Acute respiratory alkalosis fully compensated.
d) Chronic respiratory alkalosis fully compensated.
What is the probable cause for the above findings ? Are they OK
as far as oxygenation is concerned ?

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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 ?

Why hypoxemia ?
Lungs were bad to begin with ?
Micro atelectesis during surgery
Pure and simple hypoventilation ? sedation

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PRE OP .ABG on room air

pH 7.39
PaCO2 l5mmHg
Oxygenation status good ..?
PaO2 90 mmHg
HCO3 8mmol/L
Pre OP .....A/a gradient
palvO2 = PiO2 PaCO2 / RQ
= 150 15 / 0.8
= 150 18 =
132 mm Hg
132 90= 42 WIDE A / a gradient

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Apparently the lungs looked good with PaO2 of 90.

But have a good look at the ABG again
With wash out of CO 2 .
The expected PaO2 should have been more than 90 .
This coupled with correction of acidosis
( normalizing PaCO2 )
Lowered the PaO2 post operatively.
Conclusion ..
Lungs were not normal to begin with ( SLE )..

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Learning point

Correlate PaO2 with FiO2

But please also correlate with PaCO2

Case 8,,,,,,,,,,,,,,,,,,

What is the
Diagnosis

pH 7.583
PCO2
19.8
HCO3
18.7

Respiratory
Click
for answer
Alkalosis
Is it acute ?

THANKS