Analysis of ABG

Dr. Ashwinikumar Aiyangar

Dept of Nephrology
Kamineni Hospital
Why Order an ABG?

• Aids in establishing a diagnosis

• Helps guide treatment plan

• Aids in ventilator management

• Improvement in acid/base management allows for
optimal function of medications
• Acid/base status may alter electrolyte levels
critical to patient status/care
 Acid Base Balance

• The body produces acids daily

– 15,000 mmol CO2

– 50-100 mEq Nonvolatile acids

• The lungs and kidneys attempt to maintain

balance
 Acid Base Balance
• Assessment of status via bicarbonate-carbon
dioxide buffer system

– CO2 + H2O <--> H2CO3 <--> HCO3- + H+

– ph = 6.10 + log ([HCO3] / [0.03 x PCO2])

 The Terms
• BASES
ACIDS
– Alkalemia
Acidemia
– Alkalosis
Acidosis
• Respiratory

CO2
CO

• Metabolic

HCO3
HCO
 Respiratory Acidosis
• ph, CO2, Ventilation
• Causes
– CNS depression
– Pleural disease
– COPD/ARDS
– Musculoskeletal disorders
– Compensation for metabolic alkalosis
 Respiratory Alkalosis

• pH, CO2, Ventilation

•  CO2   HCO3 (Cl to balance charges  hyperchloremia)

• Causes
– Intracerebral hemorrhage
– Salicylate and Progesterone drug usage

– Anxiety  lung compliance

– Cirrhosis of the liver

– Sepsis
 Metabolic Acidosis
• High AGAG
Normal Acidosis
Metabolic Acidosis
–
–M - Methanol
Hyperalimentation
–
–U - Uremia
Acetazolamide
–
–D - DKA
RTA (Calculate urine anion gap)
– P - Paraldehyde
– Diarrhea
– I - INH
– Pancreatic Fistula
– L - Lactic Acidosis
– E - Ehylene Glycol
– S - Salicylate
 Metabolic Alkalosis
• pH, HCO3

• Causes
– Vomiting
– Diuretics
– Chronic diarrhea
– Hypokalemia
– Renal Failure
 Normal Values (in ABG)

• pH – 7.4

• HCO3 – 24

• pCO2 - 40
 Types of Acid Base Disorders

• Simple

• Compound

• Complex
Prediction of Compensation for Simple Acid-
Base Disorders

• Metabolic Acidosis (fall in HCO3) –

• Pco2 = 1.5[HCO3] + 8 ± 2  
• Pco2 = last 2 digits of pH × 100  
• Pco2 = 15 + [HCO3]

• Metabolic Alkalosis (rise in HCO3) –

• Pco2 = + 0.6 mm Hg for Δ[HCO3] of 1 mEq/L  
• Pco2 = 15 + [HCO3]
• Respiratory Acidosis (rise in pCO2) –
• Acute   Δ[HCO3-] = +1 mEq/L for each ↑ ΔPco2 of 10
mm Hg
• Chronic   Δ[HCO3-] = +4 mEq/L for each ↑ΔPco2 of 10
mm Hg

• Respiratory Alkalosis (fall in pCO2) –

• Acute   Δ[HCO3-] = - 2 mEq/L for each ↓ ΔPco2 of 10
mm Hg
• Chronic   Δ[HCO3-] = - 5 mEq/L for each ↓ ΔPco2 of 10
mm Hg
Step by Step analysis
 Step 1
• Is there acidosis or alkalosis ?

• Look at pH – (normal between 7.35 and 7.45)

• pH<7.35 – acidosis
• pH>7.45 - alkalosis
 Step 2
• Determine the primary acid base defect

• If pH < 7.35 (acidosis)

• Metabolic – low HCO3
• Respiratory – high pCO2

• If pH > 7.45 (alkalosis)

• Metabolic – high HCO3
• Respiratory – low pCO2
• pH - 7.30
• HCO3 – 14
• pCO2 - 32
• pH - 7.28
• HCO3 – 30
• pCO2 - 55
• pH - 7.50
• HCO3 – 30
• pCO2 - 45
• pH - 7.50
• HCO3 – 21
• pCO2 - 25
 Step 3
• Calculate the expected compensation

• Use the rules

• If expected and actual compensation match –

confirms primary disorder – simple acid base
disorder
 • pH - 7.3
• HCO3 – 14
• pCO2 – 29

• Diabetic – h/o fever since 1 week, c/o

breathlessness
Prediction of Compensation for Simple Acid-
Base Disorders

• Metabolic Acidosis (fall in HCO3) –

• Pco2 = 1.5[HCO3] + 8 ± 2  
• Pco2 = last 2 digits of pH × 100  
• Pco2 = 15 + [HCO3]

• Metabolic Alkalosis (rise in HCO3) –

• Pco2 = + 0.6 mm Hg for Δ[HCO3] of 1 mEq/L  
• Pco2 = 15 + [HCO3]
 • pH - 7.32
• HCO3 – 30
• pCO2 – 55

• Obese male, BMI 44, admitted for sleep study

• Respiratory Acidosis (rise in pCO2) –
• Acute   Δ[HCO3-] = +1 mEq/L for each ↑ ΔPco2 of 10
mm Hg
• Chronic   Δ[HCO3-] = +4 mEq/L for each ↑ΔPco2 of 10
mm Hg

• Respiratory Alkalosis (fall in pCO2) –

• Acute   Δ[HCO3-] = - 2 mEq/L for each ↓ ΔPco2 of 10
mm Hg
• Chronic   Δ[HCO3-] = - 5 mEq/L for each ↓ ΔPco2 of 10
mm Hg
 • pH - 7.50
• HCO3 – 30
• pCO2 – 45

• 40 yr male, c/o vomiting since 1 week

Prediction of Compensation for Simple Acid-
Base Disorders

• Metabolic Acidosis (fall in HCO3) –

• Pco2 = 1.5[HCO3] + 8 ± 2  
• Pco2 = last 2 digits of pH × 100  
• Pco2 = 15 + [HCO3]

• Metabolic Alkalosis (rise in HCO3) –

• Pco2 = + 0.6 mm Hg for Δ[HCO3] of 1 mEq/L  
• Pco2 = 15 + [HCO3]
 • pH - 7.50
• HCO3 – 21
• pCO2 – 25

• 25 year old girl, admitted with sudden onset

breathlessness
• Respiratory Acidosis (rise in pCO2) –
• Acute   Δ[HCO3-] = +1 mEq/L for each ↑ ΔPco2 of 10
mm Hg
• Chronic   Δ[HCO3-] = +4 mEq/L for each ↑ΔPco2 of 10
mm Hg

• Respiratory Alkalosis (fall in pCO2) –

• Acute   Δ[HCO3-] = - 2 mEq/L for each ↓ ΔPco2 of 10
mm Hg
• Chronic   Δ[HCO3-] = - 5 mEq/L for each ↓ ΔPco2 of 10
mm Hg
 Step 4
• Determine presence of mixed disorder

• ‘Rule of same direction’ – HCO3 and pCO2

change in the same direction in simple
disorders, opposite directions – think of mixed
disorder

• If expected and actual compensation DO NOT

match – there is a mixed disorder
• pH - 7.26
• HCO3 – 16
• pCO2 - 26
Prediction of Compensation for Simple Acid-
Base Disorders

• Metabolic Acidosis (fall in HCO3) –

• Pco2 = 1.5[HCO3] + 8 ± 2  
• Pco2 = last 2 digits of pH × 100  
• Pco2 = 15 + [HCO3]

• Metabolic Alkalosis (rise in HCO3) –

• Pco2 = + 0.6 mm Hg for Δ[HCO3] of 1 mEq/L  
• Pco2 = 15 + [HCO3]
• pH - 7.25
• HCO3 – 26
• pCO2 - 55
• Respiratory Acidosis (rise in pCO2) –
• Acute   Δ[HCO3-] = +1 mEq/L for each ↑ ΔPco2 of 10
mm Hg
• Chronic   Δ[HCO3-] = +4 mEq/L for each ↑ΔPco2 of 10
mm Hg

• Respiratory Alkalosis (fall in pCO2) –

• Acute   Δ[HCO3-] = - 2 mEq/L for each ↓ ΔPco2 of 10
mm Hg
• Chronic   Δ[HCO3-] = - 5 mEq/L for each ↓ ΔPco2 of 10
mm Hg
 Step 5
• Calculate anion gap

• If there is presence of metabolic acidosis

• If HCO3, pCO2 are normal and yet there is suspicion of

acid base disorder – eg. Sick patients in ICU
 Anion Gap
• AG = Na – (Cl + HCO3)
• (N – 10 to 12)
• >12 - high anion gap

• High AG is a “foot print” of metabolic acidosis

– sometimes in mixed acid base disorders pH,
HCO3 and pCO2 are normal
 Step 6
In case AG is high

• Compare the fall in HCO3 (ΔHCO3) with rise in

AG (ΔAG)

• If ΔAG = ΔHCO3, then pure HAGMA

• If ΔAG > ΔHCO3, it is HAGMA + asso. Met Alk

• If ΔAG < ΔHCO3, it is HAGMA + NAGMA

• 43 yr male, alcoholic, not
eaten for 3 days, came
with increased RR and Na – 136
vomiting K – 3.8
Cl – 95

• pH - 7.24 AG = 23
Δ AG = 23-12 = 11
• HCO3 - 18
• pCO2 - 28 Δ HCO3 = 24-18 = 6
• 28 yr female, diarrhea
since 4 days came with
• Na – 132
oliguria and creatinine
of 4.0 • K – 3.4
• Cl – 104
• pH - 7.24
• HCO3 – 11 • AG – 17
• pCO2 - 25 • Δ AG = 17-12 = 5

• Δ HCO3 = 24-11 = 13
THANK YOU