ROAD MAP

VENOUS BLOOD GAS ANALYSIS

Traditional Non-Trad
Amanda A Cavanagh, DVM, DACVECC Cases
Acid Base Acid Base
Consultant to Heska
April 28, 2022

HYDROGEN PH: TWO COMPONENTS

METABOLIC

H+ 40 nanomoles/L

145 MILLION
nanomoles/L RESPIRATORY
 STEP 1: EVALUATE
EVALU PH STEP 1: EVALU
EVALUATE PH

0 6.8 7.4 8 14 0 6.8 7.4 8 14

Acidemia Alkalemia

STEP 2: EVALUATE THE PCO2 RESPIRATORY DERANGEMENTS

Hyperventilation
Hypoxemia
Parenchymal Dz
Anxiety
Pain PCO2
Alkalosis PCO2 Acidosis Alkalosis 40mmHg
40mmHg
 RESPIRATORY DERANGEMENTS STEP 3: EVALUATE HCO3

Hypoventilation HCO3
CNS lesion Acidosis 24mg/dL Alkalosis
Muscle Weakness
NM Junction Dz
Airway Obs.
PCO2 Sedation
Acidosis
40mmHg

Need to add acid

To return pH
B ASE EXCESS

OSIS
ALKAL
The amount of ACID you need to add to one liter of blood to IDOSIS e BE =
e BE = AC Positiv
return the pH to normal Negativ
0

Need to take away acid

To return pH
 DEFINE PRIMARY DISTURB ANCE COMPENSATION

ACID BASE DISTURBANCE PH PRIMARY DISORDER ACID BASE PH PRIMARY DISORDER EXPECTED
DISTURBANCE COMPENSATION
RESPIRATORY ACIDOSIS DECREASED INCREASED PCO2
RESPIRATORY ACIDOSIS DECREASED INCREASED PCO2 INCREASED HCO3
RESPIRATORY ALKALOSIS INCREASED DECREASED PCO2

METABOLIC ACIDOSIS DECREASED DECREASED HCO3 RESPIRATORY ALKALOSIS INCREASED DECREASED PCO2 DECREASED HCO3

METABOLIC ALKALOSIS INCREASED INCREASED HCO3

METABOLIC ACIDOSIS DECREASED DECREASED HCO3 DECREASED PCO2

METABOLIC ALKALOSIS INCREASED INCREASED HCO3 INCREASED PCO2

COMPENSATION COMPENSATION

ACID BASE PH PRIMARY DISORDER EXPECTED

DISTURBANCE COMPENSATION ACID BASE PH PRIMARY EXPECTED ACTUAL
DISTURBANCE DISORDER COMPENSATION CHANGE in CO2
RESPIRATORY ACIDOSIS DECREASED INCREASED PCO2 INCREASED HCO3
METABOLIC DECREASED DECREASED DECREASED PCO2: INCREASED PCO2:
ACIDOSIS HCO3: Alkalosis Acidosis
RESPIRATORY ALKALOSIS INCREASED DECREASED PCO2 DECREASED HCO3 Acidosis

METABOLIC ACIDOSIS DECREASED DECREASED HCO3: DECREASED PCO2:

Acidosis Alkalosis

METABOLIC ALKALOSIS INCREASED INCREASED HCO3 INCREASED PCO2

 Gain HCO3
COMPENSATION

Lose Acid
ACID BASE PH PRIMARY EXPECTED ACTUAL
DISTURBANCE DISORDER COMPENSATION CHANGE in CO2

METABOLIC DECREASED DECREASED DECREASED PCO2: INCREASED PCO2:

ACIDOSIS HCO3: Alkalosis Acidosis
Acidosis

Mixed Metabolic and METABOLIC ALKALOSIS: HCO3

Respiratory Acidosis

Gain HCO3

Gain HCO3
Lose Acid

Selective GI acid loss Lose Acid Contraction Alkalosis

NG tube suction NaHCO3 Admin.
Renal loss: loop diuretic Metabolism of Anions
HypoK+
Lose HCO3

Lose HCO3
Add Acid

Add Acid
METABOLIC ACIDOSIS: HCO3 Hyperchloremia
Normal Anion Gap
Lose HCO3

Lose HCO3
Add Acid

Add Acid
SI Diarrhea
Proximal RTA
Distal RTA
Elevated Anion Gap
Normal Chloride
Compensation for Resp
Alkalosis
 Lose HCO3 METABOLIC ACIDOSIS:
UNMEASURED ANIONS

Add Acid
Anion Gap = Cations – Anions

Cations

Anions
Unmeasured Anions
Ketones
Uremia
Ethylene Glycol
(Na+ + K+) (HCO3- + Cl-)
Lactate
Salicylates

METABOLIC ACIDOSIS: METABOLIC ACIDOSIS:

UNMEASURED ANIONS UNMEASURED ANIONS
Alb- Alb –
Phos- Phos -
Anion Gap = Cations – Anions Anion Gap = Cations – Anions
UA -
Cations

Cations
Anions

Anions

(Na+ + K+) (HCO3- + Cl-) (Na+ + K+) (HCO3- + Cl-) UA-

 METABOLIC ACIDOSIS: METABOLIC ACIDOSIS:
UNMEASURED ANIONS UNMEASURED ANIONS
Alb – Alb –
Phos - Phos -
D - DKA D - DKA Blood Ketones
UA - UA -

U - Uremia U - Uremia
Cations

Cations
E - Ethylene glycol E - Ethylene glycol
Anions

Anions
L – Lactic acid L – Lactic acid
Salicylates, methanol, D lactic acidosis Salicylates, methanol, D lactic acidosis

METABOLIC ACIDOSIS: METABOLIC ACIDOSIS:

UNMEASURED ANIONS UNMEASURED ANIONS
Alb – Alb –
Phos - Phos -
D - DKA D - DKA
UA - UA -

U - Uremia Creatinine U - Uremia

Cations

Cations

Bedside EtOH
E - Ethylene glycol E - Ethylene glycol UA for CaOx
Anions

Anions

L – Lactic acid L – Lactic acid

Salicylates, methanol, D lactic acidosis Salicylates, methanol, D lactic acidosis
 METABOLIC ACIDOSIS:
METABOLIC ACIDOSIS
UNMEASURED ANIONS
Alb –
Phos -
D - DKA
If Acids added  anion gap is large and normal chloride
UA -

U - Uremia
D, U, E, L + other acids

Cations

E - Ethylene glycol
Anions

Lactometer
If Bicarbonate lost  normal anion gap and hyperchloremia

L – Lactic acid

Diarrhea or kidneys
Salicylates, methanol, D lactic acidosis

THE PROBLEM WITH AG THE STEWART APPROACH

Alb –
Alb – Alb – Phos -
Phos - Phos -
UA -

UA -

Total Weak Strong Ion

CO2 Acids Difference
Anions
Anions

Anions
Cations

Anions

ATOT SID
Respiratory Metabolic

CO2: Respiratory
Component
Total Weak Strong Ion
Strong Ion
CO2 Acids Difference ATOT
Difference
ATOT SID

ATOT: Weak Acids Strong Ion Difference

Albumin & Phosphorus Sodium and Chloride

Strong Ion
CO2 CO2 ATOT
Difference
 STRONG ION GAP STRONG ION GAP

AG

Hopper K. Small Animal Critical Care Medicine. 2015

STRONG ION GAP PH CONCLUSIONS

SIG simplified = ([albumin] x 4.9) – (AG + (2.53-(0.58 x [phos]))
Decreased SID acidosis

Increased SID alkalosis

Increased Atot acidosis
SIG simplified = ([albumin] x 7.94) – (AG + (2.53-(0.58 x [phos]))
Decreased Atot alkalosis

Increased strong ion gap acidosis
 COLLECTION LOC ATIONS EXTRA GOODIES

Significant differences between arterial and venous
(Hemoglobin Conc) x 3 = Estimated PCV

Differences between central and peripheral – especially if unstable

PVO2 – cannot evaluate oxygenation on venous blood gas

Elevated lactate

Elevated CO2
O2 Saturation – cannot evaluate on peripheral blood

Exposure to air

Creatinine – increases of 0.3mg/dL concerning for AKI

CO2 diffuses into the air and decreases value

Remove air bubbles and run within 15 minutes
Co-oximeter – evaluate dyshemoglobin concentrations

CLINICAL CASES
 STEP 1: EVALUATE THE PH STEP 2: EVALUATE THE CO2

pH 7.178 = Acidotic
pH 7.178 = Acidotic

pCO2 57.1 = Respiratory Acidosis

Compensation Hypoventilation

STEP 3: EVALUATE THE HOC3 METABOLIC CONTRIBUTIONS

pH 7.178 = Acidotic
HCO3 20.4 = Normal

pCO2 57.1 = Respiratory Acidosis
Base Excess = Negative (acidosis)

HCO3 20.4 = Normal
 METABOLIC CONTRIBUTIONS NORMAL AG WITH UNMEASURED
ANIONS

HCO3 20.4 = Normal Normal

Base Excess = Negative (acidosis)

Decreased

Anion Gap = Normal Elevated

DKA Uremia

Ethylene Glycol Lactate

METABOLIC CONTRIBUTIONS
35

HCO3 20.4 = Normal 32

Base Excess = Negative (acidosis)

Anion Gap = Normal, but unmeasured anions

Atot = likely decreased (alkalotic effect)
 PH CONCLUSION OTHER GOODIES

pH 7.178 = Acidotic
Hemoconcentration

Respiratory acidosis

Metabolic acidosis Hgb x 3 = approximate PCV = 75%

Acidosis secondary to gain of acids

Alkalosis secondary to hypoalbuminemia

OTHER GOODIES OTHER GOODIES

Venous Sample – ignore pO2
Electrolytes

Hyponatremia

Hyperkalemia

Hypochloremia
 OTHER GOODIES OTHER GOODIES

Electrolytes
Electrolytes

Ionized Ca = elevated
Hypoglycemia

Gow AG, et al., Calcium metabolism in eight dogs with hypoadrenocorticism. J Small Anim Pract. 2009 Aug;50(8):426-30.

FINAL DIAGNOSIS TREATMENT

Mixed respiratory and metabolic acidosis

with suspected hypoadrenocorticism
10-20ml/kg LRS to normalize

Suspect poor perfusion perfusion parameters

Hyperlactatemia
1ml/kg 50% dextrose diluted 1:4

Azotemia in LRS

Elevated CO2 (may not be a ventilation problem)

Dehydration
 TREATMENT TREATMENT

Check EKG
Recheck after perfusion
Fluid Therapy
parameters normalize
Calcium Gluconate 1mg/kg IV
diluted 1:4
Dextrose +/- Insulin
Steroids
Mineralocorticoids

CONCLUSION

ACTH Stim
CLINICAL CASE

Pre cortisol <1mg/dL

Post cortisol <1mg/dL
 STEP 1: EVALUATE PH

pH 7.473 = Mild Alkalosis

STEP 2: EVALUATE CO2 STEP 3: EVALUATE HCO3

pH 7.473 = Mild Alkalosis

pH 7.473 = Mild Alkalosis

pCO2 52mmHg = Respiratory Acidosis

pCO2 52mmHg = Respiratory Acidosis
HCO3 37.6 = Alkalosis
Gain HCO3

Compensation for
Compensation Hypoventilation
respiratory acidosis Loss of Acid
GI or Kidney
 METABOLIC CONTRIBUTIONS METABOLIC CONTRIBUTIONS

pH 7.473 = Mild Alkalosis
pH 7.473 = Mild Alkalosis

pCO2 52mmHg = Respiratory Acidosis
pCO2 52mmHg = Respiratory Acidosis

HCO3 37.6 = Metabolic Alkalosis
HCO3 37.6 = Metabolic Alkalosis

Base Excess = Positive = Alkalosis
Elevated Base Excess = Alkalosis

Elevated Anion Gap

DKA Ethylene Glycol Lactate Uremia

METABOLIC CONTRIBUTIONS STEP 4: DEFINE PRIMARY DISTURB ANCE

pH 7.473 = Mild Alkalosis
pH 7.473 = Mild Alkalosis

pCO2 52mmHg = Respiratory Acidosis

pCO2 52mmHg = Respiratory Acidosis

HCO3 37.6 = Metabolic Alkalosis

Elevated Base Excess = Alkalosis
HCO3 37.6 = Metabolic Alkalosis

Elevated Anion Gap
Metabolic Alkalosis (and a bit of acidosis)
DKA Ethylene Glycol Lactate Uremia with suspected respiratory compensation
 STEP 5: COMPENSATION THE STEWART APPROACH

Expected Compensation
Alkalosis

Increased PCO2 of 0.7mmHg per 1mEq/L Acidosis Acidosis

decrease in HCO3 (+/- 3mmHg)

Expected increase around 49.5mmHg +/- CO2 ATOT
Strong Ion
Difference
3mmHg
35

Appropriate compensation 68

STEP 6: CONCLUSION TREATMENT

Hypochloremic Metabolic alkalosis

Metabolic acidosis (Lactate and Uremia; Hyperphosphatemia) Respiratory acidosis should resolve
with resolution of metabolic disease

with respiratory compensation

 TREATMENT TREATMENT

Cannot evaluate 0.9% NaCl 10ml/kg IV boluses until perfusion parameters

oxygenation on a normalize
venous blood gas
Low SID Fluid

CLINIC AL PEARL: STRONG IONS TREATMENT

Check USG prior to fluid resuscitation

Recheck following fluid resuscitation to achieve

normovolemia

Modified from: https://navc.com/todaysveterinarynurse/wp-content/uploads/sites/3/2016/07/Table-1-Composition-of-Common-Vet-Fluids.jpg

 TREATMENT TREATMENT

Administer potassium supplementation in maintenance

fluids I would hesitate to correct iCa with
0.1 – 0.4 mEq/Kg/Hr calcium gluconate…
 QUESTIONS?

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amanda.cavanagh@colostate.edu
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