THE IMPORTANCE OF

ACID-BASE PHYSIOLOGY
“ABG Simplified for M3”

Dr Adrian Kee

Consultant

Respiratory & Critical
Care Medicine

NUH

26 June 2015

 Stuff to cover

n  Methods of Acid-Base interpretation (boring)

n  Mind-boggling ABG exercises

 Why is it important?

n  Very common esp in acutely ill and critically ill
patients

n  Underlying pathophysiological mechanism

n  Severe metabolic derangements can directly result

in organ dysfunction

n  Anticipates potential complications

 Analytic methods

n  Traditional = HCO3, PACO2, AG

n  Base excess (deficit)

n  Differs in how the metabolic component is quantified

n  Yield almost identical results

 Traditional Method

1.  Evaluate pH

2.  Determine primary process (HCO3/PACO2)

3.  If respiratory, acute or chronic?

4.  If metabolic, determine respiratory compensation

5.  Calculate anion gap

 Evaluate pH & determine
primary disorder

First parameter
pH
Primary disorder
Compensation

change

Acidosis
Metabolic
HCO3
PaCO2

Alkalosis
Metabolic
HCO3
PaCO2

Acidosis
Respiratory
PaCO2
HCO3

Alkalosis
Respiratory
PaCO2
HCO3

 Traditional Method

1.  Evaluate pH

2.  Determine primary process (HCO3/PACO2)

3.  If respiratory, acute or chronic?

4.  If metabolic, determine respiratory compensation

5.  Calculate anion gap

 Base Excess method

n  BE is the quantity of metab acidosis or alkalosis
that is defined as the amount of acid or base that
must be added to a sample of whole blood in vitro
to restore the pH to 7.4 while the PCO2 is held at
40mmHg

 Base Excess Method

n  Calculated by normograms/algorithms (accurate in
vitro)

n  Standardised for Hb and PACO2 for in vivo:

n  SBE = 0.9287 x (HCO3 - 24.4 + 14.83 x [pH - 7.4])

n  Negative BE = acidosis; Positive BE = alkalosis

n  Pitfalls:

n  Does not explain the mechanisms of the metab acid-

base disorder

Which method is the best?

n  Traditional approach: applicable at bedside, reliable
with corrections for albumin

n  Base Excess: Easy because reported on ABG

results

Traditional Method

 Traditional Method

1.  Evaluate pH (acidaemic vs alkalaemic)

2.  Determine primary process (HCO3/PACO2)

3.  If respiratory, acute or chronic?

4.  If metabolic, determine respiratory compensation

5.  Calculate anion gap

 Traditional Method

1.  Evaluate pH (acidaemic vs alkalaemic)

2.  Determine primary process (HCO3/PACO2)

Primary First parameter

pH
Compensation

disorder
change

Acidosis
Metabolic
HCO3
PaCO2

Alkalosis
Metabolic
HCO3
PaCO2

Acidosis
Respiratory
PaCO2
HCO3

Alkalosis
Respiratory
PaCO2
HCO3

 Traditional Method

1.  Evaluate pH (acidaemic vs alkalaemic)

2.  Determine primary process (HCO3/PACO2)

3. If respiratory, acute 4. If metabolic, calculate

or chronic
resp compensation

Expected PaCO2 =
1.5xHCO3- + 8

Expected PaCO2 =
0.7xHCO3- + 21

 Traditional Method

1.  Evaluate pH (acidaemic vs alkalaemic)

2.  Determine primary process (HCO3/PACO2)

3.  If respiratory, acute or chronic?

4.  If metabolic, determine respiratory compensation

5.  Calculate anion gap

n  Anion gap = [Na+] - [Cl-] - [HCO3-] = 10 ± 4

 Limitations of AG

n  Need to correct for hypoalbuminaemia

n  About 2.5 for every 10 g/L decrease in albumin

n  Normal gap ≠ no acidosis (Beware of normal gap

metabolic acidosis)

n  High gap ≠ acidosis (beware of high gap without

acidosis -- mainly due to negative charges on
albumin)

 Traditional Method

1.  Evaluate pH (acidaemic vs alkalaemic)

2.  Determine primary process (HCO3/PACO2)

3.  If respiratory, acute or chronic?

4.  If metabolic, determine respiratory compensation

5.  Calculate anion gap

Some exercises

 Question 1

n  A 80 y/o man with HPT, DM and malnutrition was admitted with cough,
fever, hypotension BP 90/52

n  pH 7.35 PaCO2 32 PaO2 68 (RA)

n  Na 132 K 4.0 Cl- 103 HCO3- 17 Alb 15 Urea 7.1 Cr 123

n  Which is correct?

n  A. High anion gap metab acidosis

n  B. Normal gap metab acidosis

n  C. Normal gap metab acidosis + respiratory alkalosis

n  D. High and normal gap metab acidosis

 Question 1

n  A 80 y/o man with HPT, DM and malnutrition was admitted with cough,
fever, hypotension BP 90/52

n  pH 7.35 PaCO2 32 PaO2 68 (RA)

n  Na 132 K 4.0 Cl- 103 HCO3- 17 Alb 15 Urea 7.1 Cr 123

 Question 1

n  A 80 y/o man with HPT, DM and malnutrition was admitted with cough,
fever, hypotension BP 90/52

n  pH 7.35 PaCO2 32 PaO2 68 (RA)

n  Na 132 K 4.0 Cl- 103 HCO3- 17 Alb 15 Urea 7.1 Cr 123

Primary First parameter

pH
Compensation

disorder
change

Acidosis
Metabolic
HCO3
PaCO2

Alkalosis
Metabolic
HCO3
PaCO2

Acidosis
Respiratory
PaCO2
HCO3

Alkalosis
Respiratory
PaCO2
HCO3

 Question 1

n  A 80 y/o man with HPT, DM and malnutrition was admitted with cough,
fever, hypotension BP 90/52

n  pH 7.35 PaCO2 32 PaO2 68 (RA)

n  Na 132 K 4.0 Cl- 103 HCO3- 17 Alb 15 Urea 7.1 Cr 123

 Question 1

n  A 80 y/o man with HPT, DM and malnutrition was admitted with cough,
fever, hypotension BP 90/52

n  pH 7.35 PaCO2 32 PaO2 68 (RA)

n  Na 132 K 4.0 Cl- 103 HCO3- 17 Alb 15 Urea 7.1 Cr 123

 Question 1

n  A 80 y/o man with HPT, DM and malnutrition was admitted with cough,
fever, hypotension BP 90/52

n  pH 7.35 PaCO2 32 PaO2 68 (RA)

n  Na 132 K 4.0 Cl- 103 HCO3- 17 Alb 15 Urea 7.1 Cr 123

n  Which is correct?

n  A. High anion gap metab acidosis

n  B. Normal gap metab acidosis

n  C. Normal gap metab acidosis + respiratory alkalosis

n  D. High and normal gap metab acidosis

 Question 1

n  A 80 y/o man with HPT, DM and malnutrition was admitted with cough,
fever, hypotension BP 90/52

n  pH 7.35 PaCO2 32 PaO2 68 (RA)

n  Na 132 K 4.0 Cl- 103 HCO3- 17 Alb 15 Urea 7.1 Cr 123

n  Which is correct?

n  A. High anion gap metab acidosis

n  B. Normal gap metab acidosis

n  C. Normal gap metab acidosis + respiratory alkalosis

n  D. High and normal gap metab acidosis

 Question 1

n  A 80 y/o man with HPT, DM and malnutrition was
admitted with cough, fever, hypotension BP 90/52

n  pH 7.35 PaCO2 32 PaO2 68 (RA)

n  Na+ 132 K+ 4.0 Cl- 103 HCO3- 17 Alb 15 Urea

7.1 Cr 123

n  AG = 132-103-17 = 12 (but AG 18.25 corr for alb)

 Metabolic Acidosis

n  Expected compensation:

n  PaCO2 = 1.5 x [HCO3-] + 8

n  Anion gap = [Na+] - [Cl-] - [HCO3-] = 10 ± 4

n  For AG, need to correct for hypoalbuminaemia

n  About 2.5 for every 10 g/L decrease in albumin

 Causes of metab acidosis

High Gap

Normal Gap

 Question 2

n  39 Malay Female with poorly controlled asthma presenting with
a severe asthmatic exacerbation. Her ABG is shown:

n  pH 7.22 PaCO2 65 PaO2 200

n  Na+ 138 K+ 3.2 Cl- 109 HCO3- 26 Alb 42 Urea 4.5 Cr 80

 Question 2

n  39 Malay Female with poorly controlled asthma presenting with
a severe asthmatic exacerbation. Her ABG is shown:

n  pH 7.22 PaCO2 65 PaO2 200

n  Na+ 138 K+ 3.2 Cl- 109 HCO3- 26 Alb 42 Urea 4.5 Cr 80

Primary First parameter
pH
Compensation

disorder
change

Acidosis
Metabolic
HCO3
PaCO2

Alkalosis
Metabolic
HCO3
PaCO2

Acidosis
Respiratory
PaCO2
HCO3

Alkalosis
Respiratory
PaCO2
HCO3

 Question 2

n  39 Malay Female with poorly controlled asthma presenting with
a severe asthmatic exacerbation. Her ABG is shown:

n  pH 7.22 PaCO2 65 PaO2 200

n  Na+ 138 K+ 3.2 Cl- 109 HCO3- 26 Alb 42 Urea 4.5 Cr 80

 Question 2

n  39 Malay Female with poorly controlled asthma presenting with
a severe asthmatic exacerbation. Her ABG is shown:

n  pH 7.22 PaCO2 65 PaO2 200

n  Na+ 138 K+ 3.2 Cl- 109 HCO3- 26 Alb 42 Urea 4.5 Cr 80

n  Which is correct?

n  A. Acute respiratory acidosis

n  B. Chronic respiratory acidosis

n  C. Acute on chronic respiratory acidosis

n  D. High gap metabolic acidosis

 Question 2

n  39 Malay Female with poorly controlled asthma presenting with
a severe asthmatic exacerbation. Her ABG is shown:

n  pH 7.22 PaCO2 65 PaO2 200

n  Na+ 138 K+ 3.2 Cl- 109 HCO3- 26 Alb 42 Urea 4.5 Cr 80

n  Which is correct?

n  A. Acute respiratory acidosis

n  B. Chronic respiratory acidosis

n  C. Acute on chronic respiratory acidosis

n  D. High gap metabolic acidosis

 Question 2

n  39 Malay Female with poorly controlled asthma presenting with
a severe asthmatic exacerbation. Her ABG is shown:

n  pH 7.22 PaCO2 65 PaO2 200

n  Na+ 138 K+ 3.2 Cl- 109 HCO3- 26 Alb 42 Urea 4.5 Cr 80

Primary First parameter

pH
Compensation

disorder
change

Acidosis
Metabolic
HCO3
PaCO2

Alkalosis
Metabolic
HCO3
PaCO2

Acidosis
Respiratory
PaCO2
HCO3

Alkalosis
Respiratory
PaCO2
HCO3

 Question 2

n  39 Malay Female with poorly controlled asthma presenting with
a severe asthmatic exacerbation. Her ABG is shown:

n  pH 7.22 PaCO2 65 PaO2 200

n  Na+ 138 K+ 3.2 Cl- 109 HCO3- 26 Alb 42 Urea 4.5 Cr 80

n  Expected HCO3- = [(65-40)/10]+24 = 26.5

n  Expected HCO3- = [(65-40)/3]+24 = 32

 Selected causes of respiratory
acidosis

n  Obstructive airway disorders eg asthma, chronic
obstructive pulmonary disease, bronchiectasis,
bronchiolitis obliterans

n  Stroke

n  Drugs eg sedatives, opioids, muscle relaxants

n  Chest wall restriction

n  Neuromuscular disorders

 Question 3

n  63 Chinese Male, chronic smoker, with baseline mild breathless
and wheeze. This is his ABG in clinic:

n  pH 7.35 PaCO2 76 PaO2 75.9

n  Na+ 144 K+ 3.5 Cl- 109 HCO3- 37 Alb 28 Urea 3.5 Cr 30

n  Which is the correct answer?

n  A. Acute respiratory acidosis

n  B. Compensated chronic respiratory acidosis

n  C. Normal gap metabolic acidosis

n  D. No abnormality

 Question 3

n  63 Chinese Male, chronic smoker, with baseline mild breathless
and wheeze. This is his ABG in clinic:

n  pH 7.35 PaCO2 76 PaO2 75.9

n  Na+ 144 K+ 3.5 Cl- 109 HCO3- 37 Alb 28 Urea 3.5 Cr 30

First
Primary
pH
parameter Compensation

disorder

change

Acidosis
Metabolic
HCO3
PaCO2

Alkalosis
Metabolic
HCO3
PaCO2

Acidosis
Respiratory
PaCO2
HCO3

Alkalosis
Respiratory
PaCO2
HCO3

 Question 3

n  63 Chinese Male, chronic smoker, with baseline mild breathless
and wheeze. This is his ABG in clinic:

n  pH 7.35 PaCO2 76 PaO2 75.9

n  Na+ 144 K+ 3.5 Cl- 109 HCO3- 37 Alb 28 Urea 3.5 Cr 30

 Question 3

n  63 Chinese Male, chronic smoker, with baseline mild breathless
and wheeze. This is his ABG in clinic:

n  pH 7.35 PaCO2 76 PaO2 75.9

n  Na+ 144 K+ 3.5 Cl- 109 HCO3- 37 Alb 28 Urea 3.5 Cr 30

n  Which is the correct answer?

n  A. Acute respiratory acidosis

n  B. Compensated chronic respiratory acidosis

n  C. Normal gap metabolic acidosis

n  D. No abnormality

 Question 3

n  63 Chinese Male, chronic smoker, with baseline mild breathless
and wheeze. This is his ABG in clinic:

n  pH 7.35 PaCO2 76 PaO2 75.9

n  Na+ 144 K+ 3.5 Cl- 109 HCO3- 37 Alb 28 Urea 3.5 Cr 30

First
Primary
pH
parameter Compensation

disorder

change

Acidosis
Metabolic
HCO3
PaCO2

Alkalosis
Metabolic
HCO3
PaCO2

Acidosis
Respiratory
PaCO2
HCO3

Alkalosis
Respiratory
PaCO2
HCO3

 Question 3

n  63 Chinese Male, chronic smoker, with baseline mild breathless
and wheeze. This is his ABG in clinic:

n  pH 7.35 PaCO2 76 PaO2 75.9

n  Na+ 144 K+ 3.5 Cl- 109 HCO3- 37 Alb 28 Urea 3.5 Cr 30

n  Expected HCO3- = [(76-40)/3]+24 = 36

n  Expected HCO3- = [(76-40)/10]+24 = 27.5

 Main disorders

n  Metabolic

n  Metabolic acidosis (High & Normal gap)

n  Metabolic alkalosis

n  Respiratory

n  Respiratory acidosis (acute & chronic)

n  Respiratory alkalosis

Confused?

Hope not!