ABG INTERPRETATION

ABG INTERPRETATION

Determine
1. 2. 3. 4. 1. 2.

If acidosis or alkalosis Primary disorder is respiratory or metabolic If respiratory whether acute or chronic If Metabolic acidosis

Anion gap present or not

If metabolic respiratory compensation adequate or not For anion gap acidosis any concomitant disturbance present or

NORMAL VALUES
pH

7.40
3

HCO PCO
2

: 24

: 40

METABOLIC ACIDOSIS

First step is to see the anion gap AG = Na (Cl + HCO3) Then to see if respiratory compensation is adequate Use Winters formula Expected PCO2 : [1.5 x HCO3] + 8 (+/2) If PCO2 is > expected additional resp acidosis If PCO2 is < expexted additional resp alkalosis For AG metabolic acidosis see if there is additional disorder

RULES FOR COMPENSATION

Metabolic Acidosis

PaCO2 should fall by 1 - 1.5 mm Hg x the fall in plasma [HCO3]

Metabolic Alkalosis

PaCO2 should rise by 0.25 - 1 mm Hg x the rise in plasma [HCO3]

CASE NO. 1

Na: 123 Cl: 99 HCO3- : 5 PaCO2 : 10 pH: 7.31

STEP 1

ACIDOSIS OR ALKALOSIS

pH : 7.31 Normal pH : 7.40 This pt is ACIDOTIC

STEP 2

REPIRATORY OR METABOLIC
PCO2 : 10 Normal PCO2: 40 HCO3 : 5 Normal HCO3: 24 METABOLIC ACIDOSIS

Skip step 3 as the disorder is not respiratory

STEP 4

IF METABOLIC DISORDER WHAT IS THE ANION GAP

Na : 123 Cl : 99 HCO3 : 5 Anion gap: Na (Cl HCO) = 123 (99+5) = 19 Normal anion gap = 8 12 Pt has ANION GAP METABOLIC ACIDOSIS

STEP 5

IF METABOLIC PROB RESPIRATORY COMPENSATION ADEQUATE

Expected PCO2: (+/- 2) = 1.5 x 5 + 8 = 7.5 + 8 = 15.5 (+/- 2) = 13.5 17.5 PCO2 in our pt : expected)

[1.5 x (HCO3)] + 8

10 (lower than

STEP 6

FOR ANION GAP ACIDOSIS ANY OTHER METABOLIC PROBLEMS

Corrected HCO3 = measured HCO3 + (AG 12) = 5 + (19 12) = 5 + 7 = 12 Pts AG is 19 (normal 12) so 7 mEq of HCO3 was used to generate AG Add 7 to pts current HCO3 (7 + 5 = 12) which gives the pts HCO3 before AG acidosis developed. Meaning this pt has a additional NON-ANION GAP METABOLIC ACIDOSIS

CASE NO 2

Na : 125 mEq/L Cl : 100 mEq/L HCO3- : 8 mEq/L PaCO2 : 28 mmHg pH : 7.07

STEP 1

ACIDOSIS OR ALKALOSIS
pH : 7.07 So this is acidosis

STEP 2

REPIRATORY OR METABOLIC
PCO2 : 28 HCO3 : 8 Low HCO3 and low PCO2 Metabolic acidosis

STEP 4

IF METABOLIC DISORDER WHAT IS THE ANION GAP

Na : 125 Cl : 100 HCO3 : 8 AG : Na (Cl + HCO3) = 125 (100+8)

= 17

STEP 5

IF METABOLIC PROB RESPIRATORY COMPENSATION ADEQUATE

Expected PCO2: 8 (+/- 2)

[1.5 x (HCO3)] +

[1.5 x 8] + 8 +/- 2 12 + 8 +/- 2 18 22

Pts PCO2 : 28 So there is additional PRIMARY

STEP 6

FOR ANION GAP ACIDOSIS ANY OTHER METABOLIC PROBLEMS Delta gap = measured HCO3 + (AG 12)

= = =

8 + ( 17 12) 8+5 13

So pt has additional NON ANION GAP METABOLIC ACIDOSIS also

CASE 3
Na = 128 Cl = 90

HCO3 = 4 7.0/14/90/4/95%

PH = acidemia AG = 128 (90 + 4) = 34 Winters formula 1.5(4) + 8 = 14 Delta gap = 4 + (34 12) = 26

RESPIRATORY ACIDOSIS

Determine if the event is Acute or Chronic Acute : for every 10 rise in PCO2, pH drops by a factor of 0.08 Chronic : for every 10 rise in PCO2, pH drops by a factor of 0.03 Expected decrease in pH for acute resp acidosis = 0.08 x (measured PaCO2 40) 10 Expected decrease in pH for chronic resp acidosis

RESPIRATORY ACIDOSIS

Acute Respiratory Acidosis

Plasma [HCO3] should rise by ~1mmole/l for each 10 mm Hg increment in PaCO2

Chronic Respiratory Acidosis

Plasma [HCO3] should rise by ~4mmoles/l for each 10 mm Hg increment in PaCO2

Determine if the event is Acute or Chronic Acute : for every 10 drop in PCO2, pH rises by a factor of 0.08 Chronic : for every 10 drop in PCO2, pH rises by a factor of 0.03 Expected decrease in pH for acute resp alkalosis = 0.08 x (40 measured PaCO2) 10 Expected decrease in pH for chronic resp alkalosis = 0.03 x (40 measured PaCO2)

RESPIRATORY ALKALOSIS

RESPIRATORY ALKALOSIS

Acute Respiratory Alkalosis

Plasma [HCO3] should fall by ~1-3 mmole/l for each 10 mm Hg decrement in PaCO2, usually not to less than 18 mmoles/l Plasma [HCO3] should fall by ~2-5 mmole/l for each 10 mm Hg decrement in PaCO2, usually not to less than 14 mmoles/l

Chronic Respiratory Alkalosis

CASE 4

Na : 135 Cl : 93 HCO3 : 30 PCO2 : 80 pH : 7.18

Step 1: pH: 7.18, Acidosis Step 2: PCO2-80, HCO3-30 (Respiratory) Step 3 : Acute or chronic
Rise in PCO2 = 80 40 = 40 Drop in pH = 7.40 7.18 = 0.22 If it was acute = PCO2 (rose by a factor of 4), pH would have dropped by factor of four (4 x 0.08) = 0.32 (7.40 0.32 = 7.08) If it was chronic = pH would have dropped by 4 x 0.03 = 0.12 (7.40

CASE 5

56 y/o with COPD exacerbation and hypotension and associated diarrhea x 7 days presents with the following 139 110 20 ABG: 120 4.0 10 1.5 7.22/30/65/10/90% , PH(7.22) = acidemia Low HCO3 and low PCO2 = Met Acidosis AG = 139 (10 + 110) = 19 Winters formula PaCO2 = 1.5 (HCO3) + 8 = 1.5 (10) + 8 = 23

CASE 5

This pateint has Anion gap metabolic acidosis Respiratory acidosis Non-anion gap metabolic acidosis

CASE 6

40 y/o with pneumonia and low BP on dopamine. She has been having N/V over the last three days Na = 130, Cl = 90, HCO3 = 10 ABG = 7.26/15/65/10/90% PH = acidemia Low HCO3 / Low PCO2 = Met acidosis AG = 130 (90 + 10) = 30 Expected PCo2 = 1.5(10) + 8 = 23 Delta HCo3 = 10 + (30 12) = 28

CASE 6

Anion gap metabolic acidosis Respiratory alkalosis Metabolic alkalosis

CASE 7

A 3 year old is brought to the pedes ER at ~3am, stuporous and tachypneic. History is remarkable for his parents having cleaned out their medicine cabinet earlier that day. An ABG and electrolytes have been accidentally drawn by the nurse.

CASE 7

Available data: pH=7.53, PaCO2=12; Na+=140, K+=3.0, Cl-=106, HCO3=10 Which variable (PaCO2, HCO3) is deranged in a direction consistent with alkalosis? ed PaCO2, ed HCO3; so Respiratory Alkalosis Acute respiratory alkalosis Plasma [HCO ] should fall by ~1-3 mmole/l 3 for each 10 mm Hg decrement in PaCO2, usually not to less than 18 mmoles/l PaCO2 ed by ~30 mm Hg; HCO3 should fall by 3-9 mmole/l; HCO3 is too great, so

CASE 7

What is the anion gap? 140 - (106 + 10) = 24; elevated anion gap consistent with metabolic acidosis What is the differential diagnosis? Combined (true) respiratory alkalosis and metabolic acidosis seen in sepsis, or salicylate intoxication

CASE 8

A 5 year old with Bartters Syndrome is brought to clinic, where she collapses. She has recently been febrile, but history is otherwise unremarkable. An ABG and serum electrolytes are obtained: pH=6.9, PaCO2=81; Na+=142, K+=2.8, Cl-=87, HCO3=16

CASE 8

What is the primary disturbance? _________ Acidosis Which variable (PaCO2, HCO3) is deranged in a direction consistent with acidosis? Both; pick most abnormal value-Respiratory Acidosis Is compensation appropriate?

CASE 8

Acute Respiratory Acidosis

Plasma [HCO3] should rise by ~1mmole/l for each 10 mm Hg increment in PaCO2

Since HCO3 is inappropriately depressed, compensation is not appropriate, and there is a concomitant metabolic acidosis as well What is the anion gap?

CASE 8

Combined Respiratory Acidosis and Metabolic Acidosis; are there other disorders present? What about the dx of Bartters Syndrome? Bartters Syndrome characterized by hypokalemic metabolic alkalosis Does this patient have a concealed metabolic alkalosis?

CASE 8

Anion gap is 39, or 25-27 greater than normal Typically, increases in anion gap correlate with decreases in HCO3 Assuming a 1:1 relationship, as anion gap increases by 25, HCO3 should fall by 25 Starting HCO3 must have been 16 + 25 = 41

CASE 8

Therefore, starting HCO3 was ~41 mmol/l, consistent with expected chronic metabolic alkalosis. This metabolic alkalosis was concealed by the supervening profound metabolic and respiratory acidoses associated with her arrest event. Final diagnosis: Metabolic alkalosis, metabolic acidosis, &