1.

pH

2. Respiratory function – O2, CO2, SaO2

3. Metabolic measures – HCO3, base excess

4. Electrolytes and metabolytes

 pH 7.35 - 7.45
To convert kPa
PaO2 80-100 mmHg to mmHg
multiply by 7.5

PaCO2 35 – 45 mmHg

HCO3 20 – 24 mmol/L

Base Excess -2 - +2
Many modern gas machines also measure
K+ ,Na+ ,Cl- ,SaO2 ,Hb ,COHb ,MetHb ,Lactate
• Hypoxaemia - PaO2 of less than than 60 mmHg
• Acidaemia - pH of less than 7.35
• Alkalaemia - pH of greater than 7.45
• Acidosis
Respiratory : PaCO2 of greater than 45 mmHg
Metabolic : HCO3 of less than 20 mmol/L
• Alkalosis
Respiratory : PaCO2 of less than 35 mmHg
Metabolic : HCO3 of greater than 24 mmol/L
Mild : 60 - 79 mmHg
Moderate : 40 - 59 mmHg
Severe : < 40 mmHg
•Type I : Hypoxemic respiratory failure (type I)
is characterized by an arterial oxygen tension
(Pa O2) lower than 60 mm Hg with a normal
or low arterial carbon dioxide tension (Pa
CO2).

•Type II : Hypercapnic respiratory failure (type

II) is characterized by a PaCO2 higher than 50
mm Hg.
 pH

CO2 HCO3
 CO2 + H2O H+ + HCO3-

Excreted by Lungs Excreted by Kidneys

Less than 6.8 More than 7.8
•Cellular metabolism produces CO2
•Concentration of carbonic acid alter
blood pH
•pH changes results in lungs altering
rate and depth of ventilation
•Maintain blood pH by altering excretion
of HCO3
•When pH kidneys excrete HCO3
•When pH kidneys excrete H+
•Is there hypoxaemia?
•PaO2 of less than than 60 mmHg?
•Assess the pH for acidemia or alkalemia
•Acidaemia - a pH of less than 7.35
•Alkalaemia - a pH of greater than 7.45
•Is it a respiratory problem?

Alkalosis Acidosis
•Is it a metabolic problem?

HCO3
Acidosis Alkalosis
20-24
• Respiratory compensation is quick
• Metabolic compensation is slow
• Compensation is not usually complete
• Patients never over compensate
 Acid-Base Primary Secondary Expected Degree of
Disturbance Abnormality Response Compensatory Response
Respiratory  PaCO2  [HCO3-] Acute =
Acidosis [HCO3-]  1-2 mmol/L for 
PaCO2 10 mmHg

Respiratory  PaCO2  [HCO3-] Chronic =

Alkalosis [HCO3-]  4-5 mmol/L for  PaCO2
10 mmHg

Metabolic  [HCO3-]  PaCO2 PaCO2 = (1.5 X [HCO3-]) + 8

Acidosis +/- 2
Metabolic  [HCO3-]  PaCO2 PaCO2 = 0.6 X ( [HCO3- ] - 24) +
Alkalosis 40 mmHg
NORMAL pH

High PaCO2 + high HCO3‾ =

fully compensated respiratory acidosis
or fully compensated metabolic
alkalosis

Normal PaCO2 + normal HCO3‾ =

normal acid base

Low PaCO2 + low HCO3‾ =

fully compensated metabolic acidosis
or fully compensated respiratory
alkalosis
pH indicates ALKALOSIS
• High PaCO2 + high HCO3‾ =
partially compensated
metabolic alkalosis
• Normal PaCO2 + high HCO3‾ =
uncompensated metabolic
alkalosis
• Low PaCO2 + high HCO3‾ =
mixed respiratory and
metabolic alkalosis
• Low PaCO2 + normal HCO3‾ =
uncompensated respiratory
alkalosis
• Low PaCO2 + low HCO3‾ =
partially compensated
respiratory alkalosis
pH indicates ACIDOSIS
• High PaCO2 + high HCO3‾ =
partially compensated
respiratory acidosis
• High PaCO2 +
normal HCO3‾ =
uncompensated respiratory
acidosis
• High PaCO2 + low HCO3‾ =
mixed respiratory and
metabolic acidosis
• Normal PaCO2 + low HCO3‾
= uncompensated
metabolic acidosis
• Low PaCO2 + low HCO3‾ =
partially compensated
metabolic acidosis
Normal ABG
pH : 7.35 - 7.45
S02 : 95% - 100%
O2 : 80% - 100%
CO2 : 35% - 45 %
HCO3 : 20 – 24
BE : -2 - +2
1. Anion Gap ( AG ) : [ Na+ ] - [ HCO3 ] - [ Cl- ].
2. Normal gap 3-11 mmol/L.
3. Normally its either normal ( NAGMA ) or high ( HAGMA ).
4. If low ( <3 ),check for causes of low AG.
• hypoalbuminaemia ( AG decrease by 25 mmol/L for every 1 g/dl decrease )
• paraproteinemia
• hyponatraemia
• spurious hyperchloraemia
• lab error

5. The presence of very high anion gap (>20 ) suggest HAGMA even in the
presence of normal ph or normal HCO3 . The body does not generate an
elevated anion gap just to compensate for alkalosis.
• bicarbonate therapy more likely to benefit patient with
NAGMA because in NAGMA, it takes days before renal
recovery of bicarbonate ion can be significant.

• In HAGMA , treatment of underlying cause promotes

conversion of the excess anion to bicarbonate

• controversial usage of bicarbonate therapy nowadays.

• Treatment of metabolic acidosis is targeted at the underlying

cause
• Aim of treatment is targeted at the underlying cause.

• Supplemental oxygen ( airway adjunct --> NIPPV -->

Ventilatory support)

• supplemental oxygen to known Type II Respi Failure

patient should be delivered by fixed system to allow
accurate titration and prevent suppression of hypoxic
drive
Q1 : 38 years old male brought to ED at 6 PM c/o S.O.B.
The symptoms has been persistent for the past 3 days
Upon examination BP 110/70 , PR 100 bpm , RR 20 bpm ,
sO2 90%. Lung; Widespread rhonci
ABG :

• pH : 7.30
• S02 : 90%
• CO2 : 53%
• O2 : 65%
• HCO3 : 26
• BE : -2
Q2 : 64 years old male , chronic smoker was brought to
ED c/o cough and runny nose.
Upon examination BP 120/80 , HR 90 bpm, RR of 24 bpm
, sO2 88%. Lungs; Wide spread ronchi

ABG
• ph : 7.38
• SO2 : 88
• O2 : 70
• CO2 : 60
• HCO3 : 33
• BE : 0
Q3 :30 years old lady , refered from KK for high GM
she forget to take her insulin for the past 2 days
Upon examination : BP 120/80 , PR 70 bpm , RR 18 bpm ,
GM 20.3 , urine ketone +ve
ABG
• GM : 20.3
• Urine ketone : +ve
• Ph : 7.36
• So2 : 99%
• O2 : 90
• CO2 : 40
• HCO3 22
• BE : -2
Q4 : 30 years old lady , refered from KK for high GM
she forget to take her insulin for the past 2 days
Upon examination : BP 120/80 , PR 70 bpm , RR 18 bpm
, GM 33 , urine ketone +ve
ABG
• GM : 33
• Urine Ketone : +ve
• pH : 7.08
• SO2 : 99%
• O2 : 75
• C02 : 40
• HCO3 : 12
• BE : -10

I
Q5 :25 years old male c/o URTI sx with SOB, T:38
,Leucocyte count : 22,000 ,HR : 120 bpm , RR 24,
Lungs : creptation at Rt lower zone and dull on
percussion
ABG
• pH : 7.23
• So2 : 96%
• O2 : 77
• CO2 : 40
• HCO3 : 16
• BE : -5
Scenario 6
65 year old male with known COPD presents in A&E
complaining of increased breathlessness. The paramedics have
put him on a venturi mask to give an FI02 of 40% due to his
breathlessness and initial low saturations.
Significant findings on your examination is a drowsy patient with
a resp rate of 8, SpO2 of 85% and wide-spread coarse crackles

ABG

FiO2 0.4 (40%)

PaO2 52 mmHg
pH 7.18
PaCO2 65 mmHg
HCO3 22 mmol/L
Scenario 7
18 year old male with diabetes has been suffering from
diarrhoea and vomiting for 48 hours and because he has been
unable to eat he has not taken his insulin.
Significant findings on your examination are a resp rate of 40,
heart rate of120, BP 95/50, Blood glucose 30mmol/l
ABG

FiO2 0.3 (30%)

PaO2 160 mmHg
pH 7.25
PaCO2 22 mmHg
HCO3 10
Na 135
K 5.4
Cl 106
Scenario 8
17 year old male has taken his father’s BMW (without asking) to
impress his girlfriend and had an accident with a bus where the
BMW came off much the worse.
There is little abnormal to find on examination apart from
bruising, a resp rate of 24, a pulse of 110 and a BP of 120/85

ABG

FiO2 0.21 (21%)

PaO2 110 mmHg
pH 7.53
PaCO2 20 mmHg
HCO3 16.0
Scenario 9
A 75 year old female is on the surgical ward 2 days after a
laparotomy for a perforated sigmoid colon secondary to
diverticular disease. She has become hypotensive over the last
6 hours. A nurse has started 40% O2
On examination vital signs are:
RR 35/min, SpO2 92%, HR 120 bpm, warm peripheries,
BP 70/40 mmHg, Urine output 50 ml in the last 6 hours
ABG

FiO2 0.4 (40%)

PaO2 61 mmHg
pH 7.27
PaCO2 28 mmHg
HCO3- 12 mmol l-1
Scenario 10
A 75 year old man presents to the emergency department after a
witnessed out-of-hospital VF cardiac arrest.
The paramedics arrived after 5 minutes, during which CPR had
not been attempted. The paramedics had successfully restored
spontaneous circulation after 3 shocks but have been unable to
intubate him. He is breathing spontaneously with a re breathing
mask.

On arrival: comatose (GCS 3)

Resp rate 8 HR 120 bpm, BP 150/95 mmHg.
ABG

FiO2 0.85 (85%)

PaO2 75 mmHg
pH 7.05
PaCO2 52 mmHg
HCO3 14 mmol/L
BE - 10
 Practical considerations
1. Delayed analysis
• Continued O2 use and CO2 production in syringe
• Invalid after 15 min unless iced
• Iced sample can keep 1-2h
• May result in sedimentation of rbc – roll syringe in
hand before test

2. Heparin
• Necessary to prevent clotting
• Dilute blood unless > 50% of syringe volume filled
with blood
• Heparin acidic
3. Air bubbles
• PaO2 20kPa, PaCO2 0 in air
• Expel air and cap syringe immediately

4. WBC count
• O2 consumed by white cells and platelets

5. Pain on sampling
• Hyperventilation and breath holding due to pain of
arterial puncture can affect results

6. If the ABG does not make sense, check patients

clinically.
Reference