ARTERIAL BLOOD GASES INTERPRETATION PATHWAY (revised and updated march 2019)

STEP:1:IDENTIFY PRIMARY ACID-BASE DISORDER:

A. WHEN BOTH PCO2 & pH ABNORMAL:-

If both change in same direction i.e, both low or both raised,primary disorder is METABOLIC.

If both change in opposite direction i.e, one raised & other low: primary disorder is
RESPIRATORY.

B. WHEN ONE OF PCO2 - pH is NORMAL:MIXED

DISORDER:

One is METABOLIC & other is RESPIRATORY. One is acidosis & other is alkalosis.

If PCO2 is normal, direction of change of pH identifies metabolic disorder, ie,low pH-metabolic

acidosis & raised pH-metabolic alkalosis.

If pH is normal, direction of change of pCO2 identifies respiratory disorder, ie,raised PCO2

respiratory acidosis & low PCO2- respiratory alkalosis.

STEP:2: COMPENSATION MECHANISMS:-

I)METABOLIC DISORDERS:

PRIMARY METABOLIC ACIDOSIS:

PCO2exp = 1.5 x HCO3 + 8 or PCO2exp = 40 -1.2 (24 - HCO3)

if blood PCO2 < PCO2exp;

partial compensated secondary resp.alkalosis ,

if blood PCO2 > PCO2exp;

partial compensated secondary resp.acidosis.

If blood PCO2 = PCO2exp: fully compensated.

PRIMARY METABOLIC ALKALOSIS:

PCO2exp = 0.7 x HCO3 + 21 or PCO2exp=40+0.7(HCO3-24)

if blood PCO2 < PCO2exp;

partial compensated secondary resp.alkalosis ,

if blood PCO2 > PCO2exp;

partial compensated secondary resp.acidosis.

If blood PCO2 = PCO2exp: fully compensated.

II) RESPIRATORY DISORDERS

ACUTE or CHRONIC?

If HCO3 is normal or near-normal, its acute respiratory disorder ie, HCO3 is 21-28.

40 - PCO2/24 - HCO3

If value <0.005 or close to 0.003, its chronic respiratory disorder, if value >0.005 or close to 0.008
; its acute respiratory disorder.

ACUTE RESP.ACIDOSIS:

pHexp = 7.4 - 0.008 (PCO2 - 40)

HCO3exp = 24 + (0.1 x {PCO2 – 40})

CHRONIC RESP.ACIDOSIS:

pHexp = 7.4 - 0.003 (PCO2 - 40)

HCO3exp = 24 + (0.4 x {PCO2-40})

If pH < pHexp or if HCO3 < HCO3exp;

partial compensated secondary metabolic acidosis,

if pH > pHexp or if HCO3 > HCO3exp;

partial compensated secondary metabolic alkalosis.

If pH = pHexp or HCO3 = HCO3exp : fully compensated.

ACUTE RESPIRATORY ALKALOSIS:

pHexp = 7.4 + 0.008(40-PCO2)

HCO3exp = 24 + (0.2 × {40 - PCO2})

CHRONIC RESPIRATORY ALKALOSIS:

pHexp = 7.4 + 0.003 (40 - PCO2)

HCO3exp = 24 + (0.4 x {40 - PCO2})

if blood HCO3 < HCO3exp;

partial compensated secondary metabolic acidosis,

if blood HCO3 > HCO3exp;

partial compensated secondary metabolic alkalosis.

If blood HCO3 = HCO3exp: fully compensated.

STEP:3: IDENTIFY & CORRECT GAPS:

Anion Gap:

Na-(Cl+HCO3)

normal 12+/-4

Corrected AG for hypoalbuminemia

AG+2.5(4-albumin)
Corrected Na for AG in hyperglycemia

Na+0.016(BSR-100)

Gap-gap or delta gap:

AG -12/24 - HCO3

<0.4 ~ low/normal AGMA

0.4-0.8~normal/high AGMA

0.8-2~high AGMA

>2~ MA + Metabolic alkalosis/Respiratory Acidosis

Standard Base Excess SBE

SBE = 0.93 (HCO3+14.84 x {pH-7.4} -24.4)

SBE < -3 ....metabolic acidosis

SBE > 3 .....metabolic alkalosis

STEP:4: INDICES OF OXYGENATION:

A-a gradient=PAO2-PaO2

PAO2 = (713 x fiO2) - (PCO2 x 1.25) {normal <20mmHg}

CaO2 =1.34 x Hb x SaO2 + 0.003 x PaO2 {normal 16-22ml/dl}

O2.ER = SaO2 - ScVO2/ SaO2 {normal 0.25-0.35}

PF=PaO2/fiO2 {Normal >300}

ref: Marino 4th ed, Fink 7th ed, Civetta 5th ed, OHs 8th ed, Irwin Rippe 8th ed, Hall 4th ed.