Interpret the ABGs in a stepwise manner:

1. Determine the adequacy of oxygenation (PaO2)

 Normal range: 80–100 mmHg (10.6–13.3 kPa)
Determine pH status
 Normal pH range: 7.35–7.45 (H+ 35–45 nmol/L)
 pH <7.35: Acidosis is an abnormal process that increases the serum hydrogen ion concentration,
lowers the pH and results in acidaemia.
 pH >7.45: Alkalosis is an abnormal process that decreases the hydrogen ion concentration and
results in alkalaemia.
Determine the respiratory component (PaCO2)
Primary respiratory acidosis (hypoventilation) if pH <7.35 and HCO3– normal.
 Normal range: PaCO2 35–45 mmHg (4.7–6.0 kPa)
 PaCO2 >45 mmHg (> 6.0 kPa): Respiratory compensation for metabolic alkalosis if pH >7.45 and
HCO3– (increased).
 PaCO2 <35 mmHg (4.7 kPa): Primary respiratory alkalosis (hyperventilation) if pH >7.45 and
HCO3– normal. Respiratory compensation for metabolic acidosis if pH <7.35 and HCO3–
(decreased).
Determine the metabolic component (HCO3–)
 Normal HCO3– range 22–26 mmol/L
 HCO3 <22 mmol/L: Primary metabolic acidosis if pH <7.35. Renal compensation for respiratory
alkalosis if pH >7.45.
 HCO3 >26 mmol/L: Primary metabolic alkalosis if pH >7.45. Renal compensation for respiratory
acidosis if pH <7.35.
Additional definitions

 Osmolar Gap
 Use: Screening test for detecting abnormal low MW solutes (e.g. ethanol, methanol & ethylene
glycol [Reference])
 An elevated osmolar gap (>10) provides indirect evidence for the presence of an abnormal solute
which is present in significant amounts [Reference]
 Osmolar gap = Osmolality – Osmolarity
 Osmolality (measured)
 Units: mOsm/kg
 Measured in laboratory and returned as the plasma osmolality
 Osmolarity (calculated)
 Units: mOsm/l
 Osmolarity = (1.86 x [Na+]) + [glucose] + [urea] + 9 (using values measured in mmol/l)
 Osmolarity = (1.86 x [Na+]) + glucose/18 + BUN/2.8 + 9 (using US units of mg/dl)
 NOTE: even though the units of measured (mOsm/kg) and calculated (mOsm/l) are different
[Reference], strictly they cannot be subtracted from one another… However, the value of the
difference is clinically useful so the problem is usually overlooked!
Rules and Resources

 Acid Base disorders worksheet – Joshua Steinberg MD

 ABG walk though (2003 FACEM exams) below
Arterial Blood Gas (ABG) Interpretation Chart

1 2 3 4 5 Rule

Simple table to calculate metabolic compensation in respiratory acidosis and alkalosis (aka the 1-2-3-4-5 rule)

Simple calculation to predict changes in HCO3– from PaCO2

HCO3 (Baseline 24 mmol/L)
Every 10 mmHg change in ACUTE CHRONIC
PaCO2 from baseline 40 mmHg
↑PaCO2 1 4
↓PaCO2 2 5
 Neonatal hypoxemia is an inadequate oxygen level in the neonate to meet its metabolic
demands. This may be different levels of oxygen depending on the age of the neonate. In utero,
a normal partial pressure of oxygen from the umbilical artery is 20 mmhg (O2 saturation 40%)
and the umbilical vein is 31 mmhg (O2 saturation 72%). With delivery and the transition from
fetal circulation to neonatal circulation the oxygen saturation and PaO2 rise. This transition
may take several hours. Five minutes after delivery, the PaO2 is approximately 35-40 and the
oxygen saturation is in the mid 80’s. One hour after delivery the PaO2 increases to 60-65 mmhg
and the oxygen saturation rises to 90-95%. It will take a few weeks for the neonatal PaO2 to
approximate the adult values (90-100 mmhg).
The response to hypoxia varies on the age of the neonate. During the first 2 to 3 weeks of life,
hypoxia during the neonatal period will cause a transient hyperventilation that is then followed
by ventilator depression. The transient hyperventilation will be abolished if the neonate is
hypothermic. Once the neonate is older than 3 weeks, hypoxemia induces a sustained
hyperventilation which is the response observed in older children and adults.
There are several causes of hypoxia during the neonatal period. These include congenital heart
disease, pulmonary disease (bronchopulmonary dysplasia), pulmonary hypertension, airway
obstruction, and sepsis.

Contraindications for hypothermia included

1. a moribund state,
2. refractory severe pulmonary hypertension, and
3. Refractory bleeding.

A-a gradient is calculated as PAO2 – PaO2

PAO2 is the ‘ideal’ compartment alveolar PO2 determined from the

alveolar gas equation
 PAO2 = PiO2 – PaCO2/0.8
 A normal A–a gradient for a young adult non-smoker breathing air, is
between 5–10 mmHg.
 However, the A–a gradient increases with age (see limitations)
CLASSIFICATION OF HYPOXIA BASED ON A-a GRADIENT
Normal A-a gradient

1. Alveolar hypoventilation (elevated PACO2)

2. Low PiO2 (FiO2 < 0.21 or barometric pressure < 760 mmHg)
Raised A-a gradient
1. Diffusion defect (rare)
2. V/Q mismatch
3. Right-to-Left shunt (intrapulmonary or cardiac)
4. Increased O2 extraction (CaO2-CvO2)
LIMITATIONS
 Gradient varies with age and FiO2:
FiO2 0.21 – 7 mmHg in young, 14 mmHg in elderly
FiO2 1.0 – 31 mmHg in young, 56 mmHg in elderly
 For every decade a person has lived, their A–a gradient is expected to
increase by 1 mmHg – a conservative estimate of normal A–a gradient
is < [age in years/4] + 4.
 an exaggerated FiO2 dependence in intrapulmonary shunt (PAO2 vs
PAO2/PaO2 difference diagram with regard to increasing percentage of
shunt) and even more so in V/Q mismatch.

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A-a gradient

The Alveolar-arterial gradient is used to evaluate causes of hypoxemia. Enter values and press
'calculate' button to calculate the gradient between the alveolar and arterial oxygen tensions.
Patient's Age 30

Fraction of Inspired Oxygen (FiO2): 21

Percent
Atmospheric Pressure: 760
mm Hg (760)
pH2O (mmHg) 47
mmHg (47)
RQ 0.8
0.8
PaCO2 (partial pressure of arterial CO2):
mmHg
PaO2 (partial pressure of arterial O2):
mmHg
Clear

A-a Gradient =
mmHg
Estimated normal gradient= (Age/4) + 4
mmHg

A-a (O2) = (FiO2%/100) * (Patm - 47 mmHg) - (PaCO2/0.8) - PaO2

Where:
FiO2 Room Air = 21 %
Atmospheric Pressure= 760 mm Hg at sea level
Water vapor pressure pH2O (mmHg) = 47 mm Hg at 37 degrees Celsius
Respiratory quotient RQ (VCO2/VO2) = 0.8 (usual)

Normal range increases with age. 5 to 20 is normal up to middle age

Hypoxemia with a normal gradient suggests:

  Hypoventilation (decreased respiratory drive or neuromuscular disease)
 Low FiO2

Hypoxemia with an increased gradient suggests:

 Ventilation-perfusion imbalance -also known as V/Q mismatch (asthma, COPD)

 Shunt : Cardiac right to left shunt such as patent foramen ovale, alveolar collapse, (atelectasis),
intraalveolar filling (pneumonia, pulmonary edema), or intrapulmonary shunt.

Supplemental O2 will help to correct the hypoxemia in hypoventilation and V/Q mismatch but not
hypoxemia resulting from a shunt.