Arterial Blood Gas Analysis Made Easy

with Tic-Tac-Toe Method

Interpretation of arterial blood gases (ABGs) is a crucial skill that a lot of student nurses and
medical practitioners need to learn. In this guide, we’ll help you understand the concepts
behind arterial blood gas and teach you the easiest and most fun way to interpret ABGs using
the tic-tac-toe method.

 What is arterial blood gas? 

 What are the components of arterial blood gas? 
o pH
o PaCO2 (Partial Pressure of Carbon Dioxide)
o PaO2 (Partial Pressure of Oxygen)
o SO2 (Oxygen Saturation)
o HCO3 (Bicarbonate)
o BE (Base Excess)
 Normal Values in Arterial Blood Gas 
 Interpreting Arterial Blood Gas Imbalances
o Goals of Arterial Blood Gas analysis
o Steps in ABG analysis using the tic-tac-toe method
 1. Memorize the normal values. 
 2. Create your tic-tac-toe grid. 
 3. Determine if pH is under NORMAL, ACIDOSIS, or ALKALOSIS.  
 4. Determine if PaCO2 is under NORMAL, ACIDOSIS, or ALKALOSIS.  
 5. Determine if HCO3 is under NORMAL, ACIDOSIS, or ALKALOSIS.  
 6. Solve for goal #1: ACIDOSIS or ALKALOSIS.  
 7. Solve for goal #2: METABOLIC or RESPIRATORY. 
 8. Solve for goal #3: COMPENSATION. 
o Application and Examples
 How to draw Arterial Blood Gas? 
 Acid-Base Balance and Imbalances
o Respiratory Acidosis
o Respiratory Alkalosis 
o Metabolic Acidosis
o Metabolic Alkalosis 
 Arterial Blood Gas Interpretation Quiz
 References and Sources
What is arterial blood gas? 
Collection of arterial blood for arterial blood gas (ABG) test.

An arterial blood gas is a laboratory test to monitor the patient’s acid-base balance. It is used
to determine the extent of the compensation by the buffer system and includes the
measurements of the acidity (pH), levels of oxygen, and carbon dioxide in arterial blood.
Unlike other blood samples obtained through a vein, a blood sample from an arterial blood
gas (ABG) is taken from an artery (commonly on radial or brachial artery). 

What are the components of arterial blood

gas? 
There are six components of arterial blood gas (ABGs):

pH
The pH is the concentration of hydrogen ions and determines the acidity or alkalinity of body
fluids. A pH of 7.35 indicates acidosis and a pH greater than 7.45 indicates alkalosis. The
normal ABG level for pH is 7.35 to 7.45.

PaCO2 (Partial Pressure of Carbon Dioxide)

PaCO2 or partial pressure of carbon dioxide shows the adequacy of the gas exchange
between the alveoli and the external environment (alveolar ventilation). Carbon dioxide (CO2)
cannot escape when there is damage in the alveoli, excess CO2 combines with water to form
carbonic acid (H2CO3) causing an acidotic state. When there is hypoventilation in the alveolar
level (for example, in COPD), the PaCO2 is elevated, and respiratory acidosis results. On the
other hand, when there is alveolar hyperventilation (e.g., hyperventilation), the PaCO 2 is
decreased causing respiratory alkalosis. For PaCO2, the normal range is 35 to 45 mmHg
(respiratory determinant).

PaO2 (Partial Pressure of Oxygen)

PaO2 or partial pressure of oxygen or PAO2 indicates the amount of oxygen available to
bind with hemoglobin. The pH plays a role in the combining power of oxygen with
hemoglobin: a low pH means there is less oxygen in the hemoglobin. For PaO2, the normal
range is 75 to 100 mmHg

SO2 (Oxygen Saturation)

SO2 or oxygen saturation, measured in percentage, is the amount of oxygen in the blood
that combines with hemoglobin. It can be measured indirectly by calculating the PAO2 and
pH Or measured directly by co-oximetry. Oxygen saturation, the normal range is 94–100%

HCO3 (Bicarbonate)
HCO3 or bicarbonate ion is an alkaline substance that comprises over half of the total buffer
base in the blood. A deficit of bicarbonate and other bases indicates metabolic acidosis.
Alternatively, when there is an increase in bicarbonates present, then metabolic alkalosis
results. 

BE (Base Excess)
BE. Base excess or BE value is routinely checked with HCO 3 value. A base excess of less than –2
is acidosis and greater than +2 is alkalosis. Base excess, the normal range is –2 to +2 mmol/L

Normal Values in Arterial Blood Gas 

To determine acid-base imbalance, you need to know and memorize these values to
recognize what deviates from normal. The normal range for ABGs is used as a guide, and the
determination of disorders is often based on blood pH. If the blood is basic, the HCO 3 level is
considered because the kidneys regulate bicarbonate ion levels. If the blood is acidic, the
PaCO2 or partial pressure of carbon dioxide in arterial blood is assessed because the lungs
regulate the majority of acid. The normal ABG values are the following:

 For  pH, the normal range is 7.35 to 7.45

 For PaCO2, the normal range is 35 to 45 mmHg (respiratory determinant)
 For PaO2, the normal range is 75 to 100 mmHg
 For HCO3, the normal range is 22 to 26 mEq/L (metabolic determinant)
 Oxygen saturation, the normal range is 94–100%
 Base excess, the normal range is –2 to +2 mmol/L

Interpreting Arterial Blood Gas Imbalances

Interpreting arterial blood gases is used to detect respiratory acidosis or alkalosis, or
metabolic acidosis or alkalosis during an acute illness. To determine the type of arterial blood
gas the key components are checked. The best (and fun) way of interpreting arterial blood gas
is by using the tic-tac-toe method below:

Goals of Arterial Blood Gas analysis

To simplify this technique even further, keep these goals in mind.

For the purpose of this guide, we have set three (3) goals that we need to accomplish when
interpreting arterial blood gases. The goals are as follows:

1. Based on the given ABG values, determine if values interpret ACIDOSIS or ALKALOSIS.
2. Second, we need to determine if values define METABOLIC or RESPIRATORY.
3. Lastly, we need to determine the compensation if it is: FULLY COMPENSATED,
PARTIALLY COMPENSATED, or UNCOMPENSATED.
We need to keep these goals in mind as they’ll come up later in the steps for the ABG
interpretation technique.

Steps in ABG analysis using the tic-tac-toe method

There are eight (8) steps simple steps you need to know if you want to interpret arterial blood
gases (ABGs) results using the tic-tac-toe technique.

1. Memorize the normal values. 

The first step is you need to familiarize yourself with the normal and abnormal ABG values
when you review the lab results. They are easy to remember:

For  pH, the normal range is 7.35 to 7.45

 For PaCO2, the normal range is 35 to 45
 For HCO3, the normal range is 22 to 26
Normal Blood pH Scale Diagram for the Tic-Tac-Toe Method for ABG Analysis

The recommended way of memorizing it is by drawing the diagram of normal values above.
Write it down together with the arrows indicating ACIDOSIS or ALKALOSIS. Note that PaCO 2 is
intentionally inverted for the purpose of the Tic-Tac-Toe method.

2. Create your tic-tac-toe grid. 

Make a 3×3 grid and label it as follows.
Once you’ve memorized the normal values and the diagram, create a blank your tic-tac-toe
grid and label the top row as ACIDOSIS, NORMAL, and ALKALOSIS. Based on their values, we
need to determine in which column we’ll place pH, PaCO 2, and HCO3 in the grid.

3. Determine if pH is under NORMAL, ACIDOSIS, or ALKALOSIS. 

The third step of this technique is to determine the acidity or alkalinity of the blood with the
given value of the pH as our determining factor. Remember in step #1 that the normal pH
range is from 7.35 to 7.45.

 If the blood pH is between 7.35 to 7.39, the interpretation is NORMAL but SLIGHTLY
ACIDOSIS, place it under the NORMAL column.
 If the blood pH is between 7.41 to 7.45, interpretation is NORMAL but SLIGHTLY
ALKALOSIS, place it under the NORMAL column.
 Any blood pH below 7.35 (7.34, 7.33, 7.32, and so on…) is ACIDOSIS, place it under the
ACIDOSIS column.
 Any blood pH above 7.45 (7.46, 7.47, 7.48, and so on…) is ALKALOSIS, place it under the
ALKALOSIS column.
Please use the diagram below to help you visualize whether the normal value is ACIDOSIS or
ALKALOSIS.

Now we need to determine where we’ll plot pH in the tic-tac-toe grid.

Once you’ve determined whether the pH is under the ACIDOSIS or ALKALOSIS, plot it on your
tic-tac-toe grid under the appropriate column.

4. Determine if PaCO2 is under NORMAL, ACIDOSIS, or

ALKALOSIS. 
Do the same for the PaCO . (Click to enlarge)
2

For this step, we need to interpret if the value of PaCO 2 is within the NORMAL range, ACIDIC,
or BASIC and plot it on the grid under the appropriate column. Remember that the normal
range for PaCO2 is from 35 to 45:

 If PaCO2 is below 35, place it under the ALKALOSIS column.

 If PaCO2 is above 45, place it under the ACIDOSIS column.
 If PaCO2 is within its normal range, place it under the NORMAL column.
5. Determine if HCO3 is under NORMAL, ACIDOSIS, or
ALKALOSIS. 
In the fifth step, we need to know where HCO3  is placed in the ABG tic-tac-toe grid.
3

Next, we need to interpret if the value of HCO 3 is within the NORMAL range, ACIDIC, or BASIC
and plot it under the appropriate column in the tic-tac-toe grid. Remember that the normal
range for HCO3 is from 22 to 26:

 If HCO3 is below 22, place it under the ACIDOSIS column.

 If HCO3 is above 26, place it under the ALKALOSIS column.
 If HCO3 is within its normal range, place it under the NORMAL column.
6. Solve for goal #1: ACIDOSIS or ALKALOSIS. 
Solving for goal #1. Determining if the set of ABG values interpret as ACIDOSIS or ALKALOSIS.

Now, we will start solving for our goals. Looking at the tic-tac-toe grid, determine whether in
what column the pH is placed and interpret the results:

 If pH is under the ACIDOSIS column, it is ACIDOSIS.

 If pH is under the ALKALOSIS column, it is ALKALOSIS.
 If pH is under the NORMAL column, determine whether the value is leaning towards
ACIDOSIS or ALKALOSIS and interpret accordingly.
In this step, we can accomplish goal #1 of determining ACIDOSIS or ALKALOSIS.

7. Solve for goal #2: METABOLIC or RESPIRATORY. 

Solving for goal #2, we analyze where pH lines up with. If it lines up with PaCO , it’s
2

RESPIRATORY. If it lines up with HCO , it’s METABOLIC.

3

Looking back again on the tic-tac-toe grid, determine if pH is under the same column as
PaCO2 or HCO3 so we can accomplish our goal #2 of determining if the ABG is RESPIRATORY
or METABOLIC. Interpret the results as follows:

 If pH is under the same column as PaCO2, it is RESPIRATORY.

 If pH is under the same column as HCO3, it is METABOLIC.
 If pH is under the NORMAL column, determine whether the value is leaning towards
ACIDOSIS or ALKALOSIS and interpret accordingly.
8. Solve for goal #3: COMPENSATION. 
Solving for goal #3 where we determine the compensation of the ABG result.

Lastly, we need to determine the compensation to accomplish our goal #3. Interpret the
results as follows:
  It is FULLY COMPENSATED if pH is normal.
 It is PARTIALLY COMPENSATED if all three (3) values are abnormal.
 It is UNCOMPENSATED if PaCO2 or HCO3 is normal and the other is abnormal.
Application and Examples
Let’s solve for the ABG interpretation with the examples below:

Practice Problem #1:

pH=7.26 | PaCO2=32 | HCO3=18

1. Remember the normal values.

2. Make your tic-tac-toe grid.
3. pH of 7.26 ABNORMAL and under ACIDOSIS, so we place pH under ACIDOSIS.
4. PaCO2 of 32 is ABNORMAL and under ALKALOSIS, so we place PaCO 2 under ALKALOSIS.
5. HCO3 of 18 is ABNORMAL and under ACIDOSIS, so we place HCO 3 under ACIDOSIS.
6. pH is under ACIDOSIS, therefore solving for goal #1, we have ACIDOSIS.
7. pH is on the same column as HCO3, therefore solving for goal #2, we have METABOLIC.
8. All three values are ABNORMAL, therefore solving for goal #3, we have a PARTIALLY
COMPENSATED ABG.
The answer to Practice Problem #1:
Metabolic Acidosis, Partially Compensated

Practice Problem #2:

pH=7.44 | PaCO2=30 | HCO3=21

1. Remember the normal values.

2. Make your tic-tac-toe grid.
3. pH of 7.44 is NORMAL but slightly leaning towards ALKALOSIS, so we place pH under
the NORMAL column with an arrow pointing towards the ALKALOSIS column.
4. PaCO2 of 30 is ABNORMAL and ALKALOSIS, so we place PaCO2 under the ALKALOSIS
column.
 5. HCO3 of 21 is ABNORMAL and ACIDOSIS, so we place HCO 3 under the ACIDOSIS
column.
6. pH of 7.44 is NORMAL but leaning towards ALKALOSIS, therefore solving for goal #1,
we have ALKALOSIS.
7. pH is NORMAL but is leaning towards ALKALOSIS, therefore under the same column as
PaCO2. Solving for goal #2, we have RESPIRATORY.
8. pH is NORMAL, therefore solving for goal #3, we have a FULLY COMPENSATED ABG.
The answer to Practice Problem #2:
Respiratory Alkalosis, Fully Compensated

Practice Problem #3:

pH=7.1 | PaCO2=40 | HCO3=18

1. Remember the normal values.

2. Make your tic-tac-toe grid.
3. pH of 7.1 is ABNORMAL and ACIDOSIS, therefore, we place pH under the ACIDOSIS
column in the tic-tac-toe grid.
4. PaCO2 of 40 is NORMAL, therefore, place it under the NORMAL column.
5. HCO3 of 18 is ABNORMAL and ACIDOSIS, so we place HCO 3 under the ACIDOSIS
column.
6. pH of 7.1 is ACIDOSIS, therefore, solving for goal #1, we have ACIDOSIS.
7. pH is under the same column as HCO3, therefore, solving for goal #2, we have
determined that it is METABOLIC.
8. pH is ABNORMAL so as HCO3, but PaCO3 is under the NORMAL column. Solving for
goal #3, we can interpret it as UNCOMPENSATED.
The answer to Practice Problem #3:
Metabolic Acidosis, Uncompensated

How to draw Arterial Blood Gas? 

Arterial blood is usually drawn via the brachial or radial artery. 

1. Inform that client about the procedure and that there is no food or fluid restriction
imposed. 
2. Note if the client is taking anticoagulant therapy or aspirin as this may affect results. 
 3. Note if the client is receiving oxygen therapy (flow rate, type of administration device),
and the client’s current temperature. 
4. Using a heparinized needle and syringe, collect 1 to 5 mL of arterial blood. Common
sites for drawing arterial blood are the radial and brachial artery. 
5. Put the syringe with arterial blood in an ice-water bag to minimize the metabolic
activity of the sample. 
6. Deliver the blood sample immediately to the laboratory. 
7. Apply pressure to the puncture site for 5 minutes or longer. 

Acid-Base Balance and Imbalances

Acid-base imbalances develop when a person’s normal homeostatic mechanisms are
dysfunctional or overwhelmed. One type of acid-base imbalance is acidosis wherein the
blood is relatively too acidic (low pH). The body produces two types of acid, therefore, there
are two types of acidosis: respiratory acidosis and metabolic acidosis. On the
contrary, alkalosis is a condition wherein the blood is relatively too basic (high pH), there are
also two types of alkalosis: respiratory alkalosis and metabolic alkalosis. 

When acid-base imbalances occur, the body activates its compensatory mechanisms (the
lungs and kidneys) to help normalize the blood pH. The kidneys compensate for respiratory
acid-base imbalances while the respiratory system compensates for metabolic acid-base
imbalances. This does not correct the root cause of the problem, if the underlying condition is
not corrected, these systems will fail. 

Respiratory Acidosis
Respiratory acidosis occurs when breathing is inadequate (alveolar hypoventilation) and the
lungs are unable to excrete enough CO2 causing PaCO2 or respiratory acid builds up. The
extra CO2 combines with water to form carbonic acid, causing a state of acidosis — a
common occurrence in emphysema. The kidneys activate its compensatory process (albeit
slow, often 24 hours or more) by increasing the excretion of metabolic acids through
urination, which increases blood bicarbonate. 

Types of Respiratory Acidosis

There are two forms of respiratory acidosis: Acute and Chronic.

 Acute respiratory acidosis. This form of respiratory acidosis occurs immediately. Left

untreated, symptoms will get progressively worse. It’s a medical emergency and can
become life-threatening.
  Chronic respiratory acidosis. This form of respiratory acidosis develops through time.
It doesn’t cause symptoms. Instead, the body adapts to the increased acidity. For
example, the kidneys produce more bicarbonate to help maintain balance. Chronic
respiratory acidosis may not cause symptoms. Developing another illness may cause
chronic respiratory acidosis to worsen and become acute respiratory acidosis.
Risk Factors

Respiratory acidosis is typically caused by an underlying disease or condition. This is also

called respiratory failure or ventilatory failure.

 Hypoventilation. A decrease in ventilation increases the concentration of carbon

dioxide in the blood and decreases the blood’s pH (brain trauma,
coma, hypothyroidism: myxedema).
 Chronic Obstructive Pulmonary Disease (COPD). In chronic respiratory acidosis in
COPD patients, the body tries to compensate by retaining more bicarbonate to
overcome acidosis.
 Respiratory Conditions. The lungs are not able to eliminate enough of the carbon
dioxide produced by the body. Excess carbon dioxide causes the pH of the blood and
other bodily fluids to decrease, making them too acidic. (pneumothorax, pneumonia,
status asthmaticus)
 Drug Intake. Overdose of an opiate or opioid, such as morphine,
tramadol, heroin, fentanyl, or magnesium sulfate (MgSO4) can cause respiratory
acidosis.
Signs and Symptoms

Signs and symptoms of respiratory acidosis are as follows:

Altered level of consciousness. Respiratory acidosis may be the result of an altered

level of consciousness caused by encephalopathy or cerebral edema.
 Confusion. Acute respiratory acidosis may also cause symptoms involving the brain,
including confusion, stupor, drowsiness, and muscle jerks.
 Disorientation. Respiratory acidosis may result in disorientation, headache, or even
focal neurologic signs. 
 Coma. When the lungs can’t remove all of the carbon dioxide produced by the body
through normal metabolism, the blood becomes acidified, leading to increasingly
serious symptoms, from sleepiness to coma.
 Tremors. Manifest as shaking or jerking muscle movements.
 Asterixis. An inability to maintain the posture of part of the body.
Management of Respiratory Acidosis
Medical and nursing management of an arterial blood gas of respiratory acidosis includes the
following: 

 Treat underlying conditions. 

 Medications. Bronchodilator medicines and corticosteroids may be used to reverse
some types of airway obstruction, like those linked to asthma and COPD.
 Weight loss. In the case of obesity hypoventilation syndrome, significant weight loss
may be necessary to reduce abnormal compression of the lungs.
 Provide mechanical ventilation through oxygen supplementation. Additional
oxygen may be provided to alleviate the low oxygen level in the blood.
 Manage hyperkalemia through the use of Kayexalate. Acidosis causes potassium to
move from cells to extracellular fluid (plasma) in exchange for hydrogen ions, and
alkalosis causes the reverse movement of potassium and hydrogen ions. Kayexalate
increases fecal potassium excretion through the binding of potassium in the lumen of
the gastrointestinal tract.
 Maintain adequate hydration. Provide intravenous fluids and electrolytes as ordered. 
Respiratory Alkalosis 
Respiratory alkalosis can result from hyperventilation since the lungs excrete too much
carbonic acid which increases pH. Since respiratory alkalosis occurs quickly, the kidneys do not
have time to compensate. Neurological symptoms such as confusion, paresthesias, and cell
membrane excitability occur when the blood pH, CSF, and ICF increases acutely.

Risk Factors

Causes of hyperventilation include:

 Panic. Panic attacks and anxiety are the most common causes of hyperventilation.

 Hyperthermia. Fever may manifest as hyperventilation. The exact mechanism is not
known but is thought to be due to carotid body or hypothalamic stimulation by the
increased temperature.
 Brainstem damage. Central neurogenic hyperventilation (CNH) is the human body’s
response to reduced carbon dioxide levels in the blood. This reduction in carbon
dioxide is caused by the contraction of cranial arteries from damage caused by lesions
in the brain stem.
 Metabolic acidosis. Hyperventilation occurs most often as a response to hypoxia,
metabolic acidosis, increased metabolic demands, pain, or anxiety.
 Diabetic ketoacidosis (DKA). The only known compensatory response to metabolic
acidosis in DKA is hyperventilation with consecutive respiratory alkalosis.
 Pregnancy. Progesterone levels are increased during pregnancy. Progesterone causes
stimulation of the respiratory center, which can lead to respiratory alkalosis.
  Salicylate toxicity. Salicylate toxicity causes respiratory alkalosis and, by an
independent mechanism, metabolic acidosis.
Signs and Symptoms

Hyperventilation is a sign that respiratory alkalosis is most likely to occur. However, low
carbon dioxide levels in the blood also have a number of physical effects, including:

Numbness. Increased neuromuscular irritability in which a person loses feeling in a

particular part of their body. 
 Tingling sensation. Prickling sensation that is usually felt in the hands, arms, legs, or
feet, but can also occur in other parts of the body. 
 Palpitations. Palpitations are the perceived abnormality of the heartbeat characterized
by awareness of cardiac muscle contractions in the chest.
 Tetany. Tetany or tetanic seizure is a medical sign consisting of the involuntary
contraction of muscles.
 Convulsions. A medical condition where body muscles contract and relax rapidly and
repeatedly, resulting in uncontrolled actions of the body.
 Signs and symptoms of hypokalemia and hypocalcemia. Persistent respiratory
alkalosis can induce secondary hypocalcemia and hypokalemia that may cause cardiac
arrhythmias, conduction abnormalities, and various somatic symptoms such as
paresthesia, hyperreflexia, convulsive disorders, muscle spasm, muscle twitching,
positive Chvostek’s sign, and tetany.
Management of Respiratory Alkalosis

The treatment for respiratory alkalosis depends on the underlying cause. Treating the
condition is a matter of rising carbon dioxide levels in the blood. The following strategies and
tips are useful for respiratory alkalosis caused by over-breathing due to panic and anxiety.

 Breathe into a paper bag. Breathing through a paper bag fills it with carbon dioxide
helping in inhaling exhaled air back into the lungs. 
 Treat underlying condition: 
 Medications. Administering an opioid pain reliever or anti-anxiety medication to
reduce hyperventilation.
 Relaxation techniques. Breathing exercises that help relax and breathe from the
diaphragm and abdomen, rather than chest wall.
 Safety. Stay with the patient.
 Lavage. After massive aspirin ingestions, aggressive gut decontamination is
advisable, including gastric lavage. 
 Correction of hypokalemia and hypocalcemia. 
 Oxygenation as indicated. Providing oxygen to help keep a person from
hyperventilating.
Metabolic Acidosis
Metabolic acidosis is when there is a decrease in bicarbonates and a buildup of lactic acid
occurs. This happens in diarrhea, ketosis, and kidney disorders. It has three main root causes:
increased acid production, loss of bicarbonate, and a reduced ability of the kidneys to excrete
excess acids.

Risk Factors

 Diabetic Ketoacidosis (DKA). DKA develops when substances called ketone bodies

(which are acidic) build up during uncontrolled diabetes. DKA occurs mostly in Type
1 Diabetes Mellitus (DM).
 Chronic Renal Failure (CRF). This is due to reduced tubular bicarbonate reabsorption
and insufficient renal bicarbonate production in relation to the number of acids
synthesized by the body and ingested with food.
 Chronic Hypoxia. With chronic hypoxia, metabolic and hypercapnic acidosis develop
along with considerable lactate formation and pH falling to below 6.8.
 Obesity. Obesity, especially in conjunction with insulin resistance, can increase
metabolic acidosis and thus result in a reduction of urinary citrate excretion.
 Diarrhea. Loss of bicarbonate stores through diarrhea or renal tubular wasting leads to
a metabolic acidosis state characterized by increased plasma chloride concentration
and decreased plasma bicarbonate concentration.
 Dehydration. Electrolyte disturbances caused by prolonged vomiting or severe
dehydration can cause metabolic acidosis.
 Aspirin Toxicity. Aspirin overdose causes the body to not produce ATP, leading to
anaerobic metabolism with consequent raised lactate and ketone bodies. Acute aspirin
or salicylates overdose or poisoning can cause initial respiratory alkalosis through
metabolic acidosis ensues thereafter.
 Methanol Poisoning. Significant methanol ingestion leads to metabolic acidosis, which
is manifested by a low serum bicarbonate level. The anion gap is increased secondary to
high lactate and ketone levels. This is probably due to formic acid accumulation.
Signs and Symptoms

Altered level of consciousness

 Confusion
 Disorientation
 Lack of appetite
 Coma
 Jaundice
Management of Metabolic Acidosis
Patients with arterial blood gas indicating metabolic acidosis are managed and treated by: 

 Sodium bicarbonate. Indicated in the treatment of metabolic acidosis which may occur

in severe renal disease, uncontrolled diabetes, circulatory insufficiency due to shock or
severe dehydration, extracorporeal circulation of blood, cardiac arrest, and severe
primary lactic acidosis.
 Treat the underlying condition. 
 Hydration for diabetic ketoacidosis. The major treatment of this condition is the initial
rehydration.
 Dialysis for chronic renal failure. The control of metabolic acidosis in hemodialysis is
mainly focused on the supply of bicarbonate during the dialysis sessions.
 Use of diuretics.
 Initiate safety measures. 
 Kayexalate. Acidosis causes potassium to move from cells to extracellular fluid (plasma)
in exchange for hydrogen ions, and alkalosis causes the reverse movement of
potassium and hydrogen ions. Kayexalate increases fecal potassium excretion through
the binding of potassium in the lumen of the gastrointestinal tract.
Metabolic Alkalosis 
Metabolic alkalosis occurs when bicarbonate ion concentration increases, causing an elevation
in blood pH. This can occur in excessive vomiting, dehydration, or endocrine disorders.

Risk Factors

 Vomiting. Vomiting causes metabolic alkalosis by the loss of gastric secretions, which

are rich in hydrochloric acid (HCl). Whenever a hydrogen ion is excreted, a bicarbonate
ion is gained in the extracellular space.
 Sodium bicarbonate overdose. Administration of sodium bicarbonate in amounts that
exceed the capacity of the kidneys to excrete this excess bicarbonate may cause
metabolic alkalosis.
 Hypokalemia. Due to a low extracellular potassium concentration, potassium shifts out
of the cells. In order to maintain electrical neutrality, hydrogen shifts into the cells,
raising blood pH.
 Nasogastric suction. Just like in vomiting, nasogastric (NG) suction also generates
metabolic alkalosis by the loss of gastric secretions, which are rich in hydrochloric acid
(HCl).
Signs and Symptoms

Metabolic alkalosis may not show any symptoms. People with this type of alkalosis more often
complain of the underlying conditions that are causing it. These can include:
 Numbness
 Vomiting
 Diarrhea
 Swelling in the lower legs (peripheral edema)
 Fatigue
 Tingling sensation
 Agitation
 Disorientation
 Seizures
 Coma
Management of Metabolic Alkalosis

 Antiemetic. In the case of vomiting, administer antiemetics, if possible.

 Ammonium chloride. Ammonium chloride is a systemic and urinary acidifying agent
that is converted to ammonia and hydrochloric acid through oxidation by the liver.
Intravenous (IV) ammonium chloride is a treatment option for severe cases of metabolic
alkalosis.
 Acetazolamide (Diamox). Acetazolamide also appears to be safe and effective in
patients with metabolic alkalosis following treatment of respiratory acidosis from
exacerbations of chronic obstructive pulmonary disease (COPD).