ABG ANALYSIS & ACID-

BASE DISORDERS
DR.ANITHA KS
 OUTLINE

1. DISCUSS SIMPLE STEPS IN ANALYZING ABGS

2. CALCULATE THE ANION GAP
3. CALCULATE THE DELTA GAP
4. DIFFERENTIALS FOR SPECIFIC ACID-BASE
DISORDERS
 STEPS FOR ABG ANALYSIS
1. WHAT IS THE PH? ACIDEMIA OR
ALKALEMIA?
2. WHAT IS THE PRIMARY DISORDER
PRESENT?
3. IS THERE APPROPRIATE COMPENSATION?
4. IS THE COMPENSATION ACUTE OR
CHRONIC?
5. IS THERE AN ANION GAP?
6. IF THERE IS A AG CHECK THE DELTA GAP?
7. WHAT IS THE DIFFERENTIAL FOR THE
CLINICAL PROCESSES?
 NORMAL VALUES

Variable Normal Range

pH 7.35 - 7.45
pCO2 35-45

Bicarbonate 22-26

Anion gap 10-14

Albumin 4
 STEP 1:
LOOK AT THE PH: IS THE BLOOD ACIDEMIC
OR ALKALEMIC?

EXAMPLE :
65YO M WITH CKD PRESENTING WITH NAUSEA,
DIARRHEA AND ACUTE RESPIRATORY DISTRESS
ABG :ABG 7.23/17/235 ON 50% VM
BMP NA 123/ CL 97/ HCO3 7/BUN 119/ CR
5.1
ACIDMEIA OR ALKALEMIA ????
 EXAMPLE ONE

ABG 7.23/17/235 ON 50% VM

NA 123/ CL 97/ HCO3 7/BUN 119/
CR 5.1
ANSWER PH = 7.23 , HCO3 7
ACIDEMIA
 STEP 2: WHAT IS THE PRIMARY
DISORDER?
What disorder is present? pH pCO2 or HCO3

Respiratory Acidosis pH low pCO2 high

Metabolic Acidosis pH low HCO3 low
Respiratory Alkalosis pH high pCO2 low
Metabolic Alkalosis pH high HCO3 high
 EXAMPLE

ABG 7.23/17/235 ON 50% VM

NA 123/ CL 97/ HCO3 7/BUN 119/ CR 5.

PH IS LOW , CO2 IS LOW

PH AND PCO2 ARE GOING IN SAME DIRECTIONS THEN ITS
MOST LIKELY PRIMARY METABOLIC WILL CHECK TO SEE IF
THERE IS A MIXED DISORDER.
 STEP 3-4: IS THERE APPROPRIATE
COMPENSATION? IS IT CHRONIC OR ACUTE?

RESPIRATORY ACIDOSIS
ACUTE: FOR EVERY 10 INCREASE IN PCO2 -> HCO3
INCREASES BY 1 AND THERE IS A DECREASE OF 0.08 IN
PH MEMORIZE
CHRONIC: FOR EVERY 10 INCREASE IN PCO2 -> HCO3
INCREASES BY 4 AND THERE IS A DECREASE OF 0.03 IN
PH

RESPIRATORY ALKALOSIS
ACUTE: FOR EVERY 10 DECREASE IN PCO2 -> HCO3
DECREASES BY 2 AND THERE IS A INCREASE OF 0.08 IN
PH MEMORIZE
CHRONIC: FOR EVERY 10 DECREASE IN PCO2 -> HCO3
DECREASES BY 5 AND THERE IS A INCREASE OF 0.03 IN
PH
 STEP 3-4: IS THERE APPROPRIATE
COMPENSATION? IS IT ACUTE OR CHRONIC ?

METABOLIC ACIDOSIS
WINTERS FORMULA: PCO2 = 1.5[HCO3] + 8 2
MEMORIZE
IF SERUM PCO2 > EXPECTED PCO2 -> ADDITIONAL
RESPIRATORY ACIDOSIS
METABOLIC ALKALOSIS
FOR EVERY 10 INCREASE IN HCO3 -> PCO2
INCREASES BY 6
 EXAMPLE

ABG 7.23/17/235 ON 50% VM

BMP NA 123/ CL 97/ HCO3 7/BUN 119/ CR 5.

WINTERS FORMULA : 17= 1.5 (7) +8 = 18.5

SO CORRECT COMPENSATION SO THERE IS ONLY
ONE DISORDER PRIMARY METABOLIC
 STEP 5: CALCULATE THE ANION GAP
AG = NA CL HCO3 (NORMAL 12 2)
AG CORRECTED = AG + 2.5[4 ALBUMIN]
IF THERE IS AN ANION GAP THEN CALCULATE
THE DELTA/DELTA GAP (STEP 6). ONLY NEED TO
CALCULATE DELTA GAP (EXCESS ANION GAP)
WHEN THERE IS AN ANION GAP TO DETERMINE
ADDITIONAL HIDDEN METABOLIC DISORDERS
(NONGAP METABOLIC ACIDOSIS OR METABOLIC
ALKALOSIS)
IF THERE IS NO ANION GAP THEN START
ANALYZING FOR NON-ANION ACIDOSIS
 EXAMPLE

CALCULATE ANION GAP

ABG 7.23/17/235 ON 50% VM
BMP NA 123/ CL 97/ HCO3 7/BUN 119/ CR 5/
ALBUMIN 4.

AG = NA CL HCO3 (NORMAL 12 2)
123 97 7 = 19

NO NEED TO CORRECT FOR ALBUMIN AS IT IS 4

 STEP 6: CALCULATE THE DIFFERENT
NEEDED FORMULAS

DELTA GAP = (ACTUAL AG 12) + HCO3

ADJUSTED HCO3 SHOULD BE 24 (+_ 6) {18-30}
IF DELTA GAP > 30 -> ADDITIONAL METABOLIC
ALKALOSIS
IF DELTA GAP < 18 -> ADDITIONAL NON-GAP
METABOLIC ACIDOSIS
IF DELTA GAP 18 30 -> NO ADDITIONAL
METABOLIC DISORDERS
 EXAMPLE : DELTA GAP
ABG 7.23/17/235 ON 50% VM
BMP NA 123/ CL 97/ HCO3 7/BUN 119/ CR 5/
ALBUMIN 4.

DELTA GAP = (ACTUAL AG 12) + HCO3

(19-12) +7 = 14
DELTA GAP < 18 -> ADDITIONAL NON-
GAP METABOLIC ACIDOSIS
SO METABOLIC ACIDOSIS ANION AND
NON ANION GAP
METOBOLIC ACIDOSIS: ANION GAP
ACIDOSIS
 EXAMPLE: WHY ANION GAP?

65YO M WITH CKD PRESENTING WITH NAUSEA,

DIARRHEA AND ACUTE RESPIRATORY DISTRESS
ABG :ABG 7.23/17/235 ON 50% VM
BMP NA 123/ CL 97/ HCO3 7/BUN 119/ CR
5.1
SO FOR OUR PATIENT FOR ANION GAP PORTION ITS DUE TO BUN OF
119 UREMIA
BUT WOULD STILL CHECK LACTIC ACID
 NONGAP METABOLIC ACIDOSIS
For non-gap metabolic acidosis, calculate the urine anion gap
UAG = UNA + UK UCL
If UAG>0: renal problem
If UAG<0: nonrenal problem (most commonly GI)

Causes of nongap metabolic acidosis - DURHAM

Diarrhea, ileostomy, colostomy, enteric fistulas

Ureteral diversions or pancreatic fistulas
RTA type I or IV, early renal failure
Hyperailmentation, hydrochloric acid administration
Acetazolamide, Addisons
Miscellaneous post-hypocapnia, toulene, sevelamer, cholestyramine ingestion
EXAMPLE : NON ANION GAP ACIDOSIS

65YO M WITH CKD PRESENTING WITH NAUSEA,

DIARRHEA AND ACUTE RESPIRATORY DISTRESS
ABG :ABG 7.23/17/235 ON 50% VM
BMP NA 123/ CL 97/ HCO3 7/BUN 119/ CR
5.1

MOST LIKELY DUE TO THE DIARRHEA

 METABOLIC ALKALOSIS

CALCULATE THE URINARY CHLORIDE TO DIFFERENTIATE SALINE

RESPONSIVE VS SALINE RESISTANT
MUST BE OFF DIURETICS IN ORDER TO INTERPRET URINE CHLORIDE

Saline responsive UCL<10 Saline-resistant UCL >10

Vomiting If hypertensive: Cushings, Conns, RAS,
renal failure with alkali administartion

NG suction If not hypertensive: severe hypokalemia,

hypomagnesemia, Bartters, Gittelmans,
licorice ingestion

Over-diuresis Exogenous corticosteroid administration

Post-hypercapnia
 RESPIRATORY ALKALOSIS
Causes of Respiratory Alkalosis

Anxiety, pain, fever

Hypoxia, CHF
Lung disease with or without hypoxia pulmonary embolus, reactive airway,
pneumonia
CNS diseases
Drug use salicylates, catecholamines, progesterone
Pregnancy
Sepsis, hypotension
Hepatic encephalopathy, liver failure
Mechanical ventilation
Hypothyroidism
High altitude
 RESPIRATORY ACIDOSIS

Causes of respiratory acidosis

CNS depression sedatives, narcotics, CVA
Neuromuscular disorders acute or chronic
Acute airway obstruction foreign body, tumor, reactive airway
Severe pneumonia, pulmonary edema, pleural effusion
Chest cavity problems hemothorax, pneumothorax, flail chest
Chronic lung disease obstructive or restrictive
Central hypoventilation, OSA
 STEPS FOR ABG ANALYSIS
1. WHAT IS THE PH? ACIDEMIC OR
ALKALEMIC?
2. WHAT IS THE PRIMARY DISORDER
PRESENT?
3. IS THERE APPROPRIATE COMPENSATION?
4. IS THE COMPENSATION ACUTE OR
CHRONIC?
5. IS THERE AN ANION GAP?
6. IF THERE IS A AG, WHAT IS THE DELTA GAP?
7. WHAT IS THE DIFFERENTIAL FOR THE
CLINICAL PROCESSES?