APPROACH TO BLOOD GAS

ANALYSIS
Dr. MANDAR HAVAL
D.C.H D.N.B
 How does the kidney do it?

• The kidney does it in three ways:

– Total reabsorption of filtered bicarbonate (proximal).

– Controlled secretion of H+ into filtrate (distal).

– Judicious use of urinary buffers.

FILTRATE TUBULAR CELL BLOOD
FILTRATE TUBULAR CELL BLOOD

H2O + CO2
CA II

H2CO3

H+ + HCO3-
FILTRATE TUBULAR CELL BLOOD

H2O + CO2
CA II

H2CO3

H+ + HCO3-
FILTRATE TUBULAR CELL BLOOD

H2O + CO2
CA II

H2CO3

H+ + HCO3-
Na+ Na

Na + Na K
ATPase
K
FILTRATE TUBULAR CELL BLOOD

H2O + CO2
CA II

H2CO3

HH
+ +
+ HCO
HCO33--
H+ATPase

Na+ / H+
Antiporter
Na+ Na
Na K
Na+ ATPase
K
FILTRATE TUBULAR CELL BLOOD

H2O + CO2
CA II

H2CO3
Na / K

H +
HCO3-
H+ATPase

Na+ / H+
Antiporter
Na+ Na
Na K
Na+ ATPase
K
 FILTRATE TUBULAR CELL BLOOD

H2O + CO2
H2O + CO2
H2CO3 CA II
CA IV
H2CO3
HCO3- Na / K

H +
HCO3-
H+ATPase

Na+ / H+
Antiporter
Na+ Na
Na K
Na+ ATPase
K
 FILTRATE TUBULAR CELL BLOOD

H2O
H2O + CO2
CA II
CA IV

H+ HCO3-
 COLLECTING
BLOOD TUBULE CELL FILTRATE

H2O + CO2
CA II

H2CO3

H+
HCO3- H+ ATPase
Cl- / HCO3-
Exchanger
Cl-
 COLLECTING
BLOOD TUBULE CELL FILTRATE

H2O + CO2
CA II

H2CO3

H+
HCO3- ATPase H+
Cl- / HCO3-
Exchanger
Cl-
 COLLECTING
TUBULE CELL FILTRATE

BLOOD

HPO4=

H+
ATPase H+
 COLLECTING
TUBULE CELL FILTRATE

BLOOD

H+
ATPase H+ HPO
H2PO4=4-
 COLLECTING
TUBULE CELL FILTRATE

BLOOD

SO4=

H+
ATPase H+ HSO4-
 COLLECTING
TUBULE CELL FILTRATE

BLOOD

NH3 NH3

H+
ATPase NH
H+ 4+
 Evaluation of
Systemic Acid Base Disorders
1. Comprehensive history and physical examination.
2. Evaluate simultaneously performed ABG & serum
electrolytes.
3. Identification of the dominant disorder.
4. Calculation of compensation.
5. Calculate the anion gap and the Δ.
1. Anion Gap
2. Δ AG
3. Δ Bicarbonate
 Step 3:
Identification of the dominant disorder
Primary pH Initial Compensatory
disorder change change
Metabolic ↓ ↓ HCO3 ↓ PCO2
acidosis
 Step 3:
Identification of the dominant disorder
Primary pH Initial Compensatory
disorder change change
Metabolic ↓ ↓ HCO3 ↓ PCO2
acidosis
Metabolic ↑ ↑ HCO3 ↑ PCO2
alkalosis
 Step 3:
Identification of the dominant disorder

Primary pH Initial Compensatory

disorder change change
Metabolic ↓ ↓ HCO3 ↓ PCO2
acidosis
Metabolic ↑ ↑ HCO3 ↑ PCO2
alkalosis
Respiratory ↓ ↑ PCO2 ↑ HCO3
acidosis
Respiratory ↑ ↓ PCO2 ↓ HCO3
alkalosis
• WHERE THE PROBLEM START
 Calculation of compensation
Mean "whole body" response equations for simple acid-base disturbances.
Disorder pH Primary Compensatory Equation
change Response
Metabolic   [HCO3-]  PCO2 ΔPCO2  1.2  ΔHCO3
Acidosis
Metabolic   [HCO3-]  PCO2 ΔPCO2  0.7  ΔHCO3
Alkalosis
Respiratory   PCO2  [HCO3-] Acute:
Acidosis ΔHCO3-  0.1  ΔPCO2
Chronic:
ΔHCO3-  0.3  ΔPCO2
Respiratory   PCO2  [HCO3-] Acute:
Alkalosis ΔHCO3-  0.2  ΔPCO2
Chronic:
ΔHCO3-  0.5  ΔPCO2
Note: The formula calculates the change in the compensatory parameter.
 Simple compensation
Disorder pH Primary problem Compensation

Metabolic acidosis ↓ ↓ in HCO3- PaCO2

=1.5xHCO3+8(+/-2)

Metabolic alkalosis ↑ 10↑ in HCO3- 7↑ in PaCO2

Respiratory acidosis ↓ ACUTE -10↑ in PaCO2 1↑ in [HCO3-]

CHRONIC -10↑ in PaCO2 3.5↑ in [HCO3-]

Respiratory alkalosis ↑ ACUTE-10↓ in PaCO2 2↓ in [HCO3-]

CHRONIC-10↓ in PaCO2 4↓ in [HCO3-]
 Calculate the “gaps”

Anion gap = Na+ − [Cl− + HCO3−]

Δ AG = Anion gap − 12

Δ HCO3 = 24 − HCO3

Δ AG = Δ HCO3 −, then Pure high AG Met. Acidosis

Δ AG > Δ HCO3 −, then High AG Met Acidosis + Met. Alkalosis

Note:Δ AG < Δ HCO3 , then High AG Met Acidosis + Normal AG Met A

−

Delta
 _
AG
Add Δ AG to measured HCO3− to obtain bicarbonate level  
 Pr
 e
_ 
existin
_
Bic
that would have existed IF the high AG metabolic acidosis 

 _ 
Current
Bicarb

were to be absent, i.e., “Pre-existing Bicarbonate.”
 SOME FORMULA

•THAT YOU SHOULD

KNOW
CALCULATION OF H+
PaCO2
H   24  HCO


3

20 – 7.70
30 – 7.50
40(H+) – 7.40 (PH)
50 – 7.30
65 – 7.20
pH H+ pH H+
6.70 200 7.40 40

6.75 178 7.45 35

6.80 158 7.50 32

6.85 141 7.55 28

6.90 126 7.60 25

6.95 112 7.65 22

7.00 100 7.70 20

7.05 89 7.75 18

7.10 79 7.80 16

7.15 71 7.85 14

7.20 63 7.90 13

7.25 56 7.95 11

7.30 50 8.00 10

7.35 45
 CAO2=  directly reflects the total number of oxygen molecules
in arterial blood, both bound and unbound to hemoglobin

• CaO2 = (1.34 x HB x SPO2) +(0.003 x PaO2)

Normal CaO2 ranges from 16 to 22 ml O2/dl

Which patient is more hypoxemic, and why?

• Patient A: • Patient B:
pH 7.48 pH 7.32
PaCO2 34 mm Hg PaCO2 74 mm Hg
PaO2 85 mm Hg PaO255 mm Hg
SaO2 95% SaO2 85%
Hemoglobin 7 gm% Hemoglobin 15 gm%
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 ANS CONT…..
• Patient A: Arterial oxygen content = .95 x 7 x
1.34 = 8.9 ml O2/dl
• Patient B: Arterial oxygen content = .85 x 15 x
1.34 = 17.1 ml O2/dl
• Patient A, with the higher PaO2 but the lower
hemoglobin content, is more hypoxemic

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 PaO2
• Factors affecting the PaO2 include alveolar
ventilation, FIO2, altitude, age, and the
oxyhemoglobin dissociation curve
• Relation between PaO2 and SaO2:
PaO2 corresponds to SaO2
60mm Hg 90%

50mm Hg 80%

40mm Hg 70%

30mm Hg 60%
 True or False:
The pO2 in a cup of water open to the
atmosphere is always higher than the arterial
pO2 in a healthy person (breathing room air)
who is holding the cup

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 ANS
• The PO2 in the cup of water is always higher. This is for several
reasons. First, there is no barrier to oxygen diffusing into the
water; thus the PO2 in the cup will be the same as the
atmosphere, at sea level approximately 160 mm Hg.
• Second, there is no CO2 coming from the cup to dilute the
oxygen, as there is in people.
• Third, there is no V-Q inequality or shunt; even healthy people
have a difference between alveolar PO2 and arterial PO2 for
this reason. Thus a healthy person and a cup of water exposed
to the atmosphere at sea level would have PO2 values of
about 100 mm Hg and 160 mm Hg, respectively.

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 A-a Gradient
• Determines the degree of lung function
impairment
• The A-a gradient is the partial pressure of
alveolar oxygen minus the partial pressure of
arterial oxygen (PAO2-PaO2)
• Normal is 2-10mm Hg or 10 plus one tenth the
person’s age
 A-a Gradient

• [(713*FIO2)-(PaCO2/0.8)] – PaO2
INTERPRETATION
NORMAL – 10-20
(>30 is SINGNIFICANT)
Seen in – Shunt
Low V/Q
Hypoventilation
 A-a Gradient
• PAO2-PaO2 of 20-30mm Hg on room air
indicates mild pulmonary dysfunction, and
greater than 50mm Hg on room air indicates
severe pulmonary dysfunction
• The causes of increased gradient include
intrapulmonary shunt, intracardiac shunt, and
diffusion abnormalities
 a/A Ratio
• Pao2/PAo2 NAORMAL LEVEL IS >0.75

• <0.60 IS INCOMPATIBLE WITH SPONTANIOUS

BREATHING
 PaO2/FIO2 Ratio
• To estimate the impairment of oxygenation, calculate
the PaO2/FIO2 ratio
• Normally, this ratio is 500-600
• Below 300 is acute lung injury*
• Below 200 is ARDS*

*Along with diffuse infiltrates, normal PCWP, and

appropriate mechanism
 OXYGEN INDEX

• OI =MAP X FIO2 x 100

POST DUCTAL
PAO2
 INTERPRETATION
• OI >40 that is unresponsive to iNO predict a
high mortality rate (>80%) and are indications
for ECMO.
 VENTILATORY INDEX

VI > 65% INDICATE

• VI =PIP X PCO2 X RR PREDICTIVE DEATH
1000 IN ARDS
 RELATION OF ALBUMIN IN ABG
AG corrected = AG + 2.5[4 – albumin]
(AG= Anion gap)
 DELTA GAP

 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
SOME CASE DISCUSSION
 Case 1
• A 15 yr old juvenile diabetic presents with abdominal
pain, vomiting, fever & tiredness for 1 day. He had
stopped taking insulin 3 days ago. Examination
revealed tachycardia, BP- 100/60, signs of
dehydration. Abdominal examination was normal.

• ABG:
pH 7.31 Serum Electrolytes:
PaCO2 26 mmHg Na 140 mEq/L
HCO3 12 mEq/L K 5.0 mEq/L
PaO2 92 mm Hg Cl 100 mEq/L

• Evaluate the acid-base disturbance(s)?

 Case 1: Solution
• Dominant disorder is Metabolic Acidosis
• Compensation formula: pH 7.31
Δ PaCO2 = 1.2 × Δ HCO3 PaCO2 26
HCO3 12
= 1.2 × 12 PaO2 92
= 14.4
Na 140
PaCO2 = 40 – 14 = 26 K 5.0
Compensation is appropriate. Cl 100

• Anion Gap = 140 – (100 + 12)

= 28
AG is high.
 Case 1: Solution
• Δ AG = 28 – 12
= 16
pH 7.31
PaCO2 26
• Δ HCO3 = 24 – 12 HCO3 12
PaO2 92
= 12
Na 140
K 5.0
• Δ AG > Δ HCO3- Cl 100

• Final Diagnosis:
High AG Met. Acidosis + Met. Alkalosis
 Case 2
• A 14 yr old boy presents with continuous vomiting of 3
days duration, mental confusion, giddiness, and
tiredness for 1 day.
• Examination revealed tachycardia, hypotension and
dehydration.
• ABG
pH 7.50 Serum Electrolytes:
PaCO2 48 Na 139
HCO3 32 K 3.9
PaO2 90 Cl 85

• Evaluate the acid-base disturbance(s)?

 Case 2: Solution
• Dominant disorder is Metabolic Alkalosis
• Compensation formula: pH 7.50
Δ PaCO2 = 0.7 × Δ HCO3 PaCO2 48
HCO3 32
= 0.7 × 8 PaO2 90
= 5.6
Na 139
PaCO2 = 40 + 6 = 46 K 3.9
Compensation is appropriate. Cl 85

• Anion Gap = 139 – (85 + 32)

= 22
AG is high.
 Case 2: Solution
• Δ AG = 22 – 12
= 10 pH 7.50
PaCO2 48
HCO3 32
• High AG metabolic acidosis PaO2 90

Na 139
K 3.9
• Final Diagnosis: Cl 85

Metabolic Alkalosis + High AG Met. Acidosis

 Case 3: Varieties of Metabolic Acidosis

Patient A B C
ECF volume Low Low Normal
Glucose 600 120 120
pH 7.20 7.20 7.20
Na 140 140 140
Cl 103 118 118
HCO3 -
10 10 10
AG 27 12 12
Ketones 4+ 0 0
High-AG Non-AG Non-AG
Met. Met. Met.
Acidosis Acidosis Acidosis
 Renal handling of Hydrogen in
Metabolic Acidosis

• In the setting of metabolic acidosis, normal kidneys try to

increase H+ excretion by increasing titratable acidity and
ammonia. The latter is excreted as NH4+.

• When NH4+ is excreted, it also causes increased chloride loss,

to maintain electrical neutrality.

• Chloride loss, therefore, will be in excess of Na and K.

• Urine Anion-Gap = Na + K – Cl

• In metabolic acidosis, if Urine anion gap is negative, it

suggests that the kidneys are excreting H+ effectively.
 Urine Electrolytes in Metabolic Acidosis

Patient A B C
U. Na 10 50
U. K 14 47
U. Cl 74 28
Urine AG –50 +69
Dx: Diarrhea RTA

Urine Anion Gap = (U. Na + U. K – U. Cl)

In Normal anion gap Metabolic Acidosis,
Positive Urine AG suggests distal Renal Tubular Acidosis

Negative Urine AG suggests non-renal cause for Metabolic Acidosis.

 Case 4
• A 17 yr old boy presented with history of
progressive dyspnoea with wheezing for 4 days.
• He also had fever, cough with yellowish
expectoration.
• He had increased sleepiness for 1 day.
• On examination, he was tachypnoeic, pulse-
100/min bounding, BP-160/96, central cyanosis +,
drowsy, asterixis +, RS – B/L extensive wheezing +.
• CXR- hyperinflated lung fields with tubular heart.
 Case 4: Laboratory data
• ABG:
pH 7.30
PaCO 60 mmHg2

HCO 28 mEq/L
3

PaO 68 mm Hg
2

• Serum Electrolytes:
Na 136 mEq/L
K 4.5 mEq/L
Cl 98 mEq/L

• Evaluate the acid-base disturbance(s)?

 Case 4: Solution
• Dominant disorder is Respiratory Acidosis
• Compensation formula: pH 7.30
Δ HCO3 = 0.3 × Δ PaCO2 =2 0.360
PaCO
HCO3 28
× 20 PaO2 68
=6
Na 136
HCO3 = 24 + 6 = 30 K 4.5
Cl 98
Compensation is appropriate.
• Anion Gap = 136 – (98 + 28)
= 10
AG is normal.
 Case 5
• 12 year old girl presented with complaints of
difficulty in breathing and upper abdominal
discomfort for the past 1 hr.

• On examination, vitals normal, patient

hyperventilating, RS – normal, Abdomen – normal.
 Case 5: Laboratory data
• ABG:
pH 7.50
PaCO 25 mmHg2

HCO 21 mEq/L
3

PaO 100 mm Hg
2

• Serum Electrolytes:
Na 137 mEq/L
K 3.9 mEq/L
Cl 99 mEq/L
Calcium 9.0 mEq/L

• Evaluate the acid-base disturbance(s)?

 Case 5: Solution
• Dominant disorder is Respiratory Alkalosis
• Compensation formula:
pH 7.50
Δ HCO3 = 0.2 × Δ PaCO2 PaCO= 0.2
25
2
× 15 HCO 3 21
=3 PaO 2 100

HCO3 = 24 – 3 = 21 Na 137
Compensation is appropriate. K 3.9
Cl 99
• Anion Gap = 137 – (99 + 21) Calcium 9.0
= 17
AG is slightly high which can be seen in respiratory
alkalosis.
 Case 7
• Explain the acid-base status of a 18-year-old boy
with history of chronic renal failure treated with high
dose diuretics admitted to hospital with pneumonia
and the following lab values:
ABG Serum Electrolytes
pH 7.52 Na+ 145 mEq/L
PaCO2 30 mm Hg K+ 2.9 mEq/L
PaO2 62 mm Hg Cl- 98 mEq/L
-
HCO3 21 mEq/L
 Case 7: Solution
• Dominant disorder is Respiratory Alkalosis
• Compensation formula:
pH 7.52
Δ HCO3 = 0.2 × Δ PaCO2 = 0.230
PaCO 2
× 10 HCO 3 21
=2 PaO 2 62

HCO3 = 24 – 2 = 22 Na 145
Compensation is appropriate. K 2.9
Cl 98
• Anion Gap = 145 – (98 + 21)
= 26
AG is very high suggestive of metabolic acidosis.
 Case 7: Solution
• Δ AG = 26 – 12
= 14
pH 7.52
• Δ HCO3 = 24 – 21 PaCO2 30
=3 HCO3 21
PaO2 62
• Δ AG > Δ HCO3-
Na 145
High AG Met Acidosis + Met. Alkalosis K 2.9
Cl 98
• Final Diagnosis:
Respiratory Alkalosis +
High AG Metabolic Acidosis +
Metabolic Alkalosis
 Case 8
• The following values are found in a 65-year-old
patient. Evaluate this patient's acid-base status?
ABG Serum Chemistry
pH 7.51 Na + 155 mEq/L
PaCO2 50 mm Hg K+ 5.5 mEq/L
HCO3- 40 mEq/L Cl- 90 mEq/L
CO2 40 mEq/L
BUN 121 mg/dl
Glucose 77 mg/dl
 Case 8: Solution
• Dominant disorder is Metabolic Alkalosis
• Compensation formula:
Δ PaCO2 = 0.7 × Δ HCO3 pH 7.51
= 0.7 × 16 PaCO2 50
HCO3 40
= 11.2 PaO2 62
PaCO2 = 40 + 11 = 51
Compensation is appropriate. Na 155
K 5.5
Cl 90
• Anion Gap = 155 – (90 + 40) BUN 121

= 25
AG is high.
 Case 8: Solution
• Δ AG = 25 – 12
= 13 pH 7.51
PaCO2 50
HCO3 40
• High AG metabolic acidosis PaO2 62

Na 155
K 5.5
• Final Diagnosis: Cl 90
BUN 121

Metabolic Alkalosis +
High AG Metabolic Acidosis
 Case 9
• A 52-year-old woman has been mechanically ventilated for
two days following a drug overdose. Her arterial blood gas
values and electrolytes, stable for the past 12 hours, show:

ABG Serum Chemistry

pH 7.45 Na + 142 mEq/L
PaCO2 25 mm Hg K+ 4.0 mEq/L
Cl- 100 mEq/L
HCO3- 18 mEq/L
 Case 9: Solution
• Dominant disorder is Chronic Respiratory Alkalosis
• Compensation formula:
Δ HCO3 = 0.5 × Δ PaCO2 pH =7.45
0.5
PaCO 25
× 15 HCO 18
2

= 7.5 3

HCO3 = 24 – 8 = 16 Na 142
K 4.0
Compensation is appropriate. Cl 100

• Anion Gap = 142 – (100 + 18)

= 24
AG is very high suggestive of metabolic acidosis.
 Case 9: Solution
• Δ AG = 24 – 12
= 12

• Δ HCO3 = 24 –18
=6
• Δ AG > Δ HCO3-
High AG Met Acidosis + Met. Alkalosis

• Final Diagnosis:
Chronic Respiratory Alkalosis +
High AG Metabolic Acidosis +
? Metabolic Alkalosis
 Case 11
• A 21 year old male with progressive renal insufficiency is
admitted with abdominal cramping. He had congenital
obstructive uropathy with creation of ileal loop for diversion.
On admission,

ABG Serum Chemistry

pH 7.20 Na + 140 mEq/L
PaCO2 24 mm Hg K+ 5.6 mEq/L
Cl- 110 mEq/L
HCO3- 10 mEq/L
 Case 11: Solution
• Dominant disorder is Metabolic Acidosis

• Compensation formula: pH 7.20

PaCO2 24
Δ PaCO2 = 1.2 × Δ HCO3 =HCO
1.23 × 10
14
= 16.8 Na 140
K 5.6
PaCO2 = 40 – 17 = 23 Cl 110
Compensation is appropriate.

• Anion Gap = 140 – (110 + 10)

= 20
High anion-gap metabolic acidosis.
 Case 11: Solution
• Δ AG = 20 – 12
=8
pH 7.20
PaCO2 24
• Δ HCO3 = 24 –10 HCO3 10
= 14
Na 140
K 5.6
• Δ AG < Δ HCO3- Cl 110

High AG Met Acidosis + Normal-AG Met. Acidosis

• Final Diagnosis:
Mixed Metabolic Acidosis
 Case 12
• A 15 year old female with Subseq
Parameter Initial
hypertension was treated with uent
low salt diet and diuretics. BP
135/85. Na 137 138
Otherwise normal.
See initial lab values. K+ 3.1 2.8

• She developed profound watery Cl -

90 102
diarrhea, nausea and weakness.
HCO3 35 25
• On exam, HR = 96, T=100.6 F, BP
115/70. Abdominal tenderness pH 7.51 7.42
with guarding on palpation.
PaCO2 47 39
 Case 12: Solution
• Initally, dominant disorder is Metabolic Alkalosis

• Compensation formula: pH 7.51

Δ PaCO2 = 0.7 × Δ HCO3 PaCO2 47
= 0.7 × 11 HCO3 35
= 7.7
Na 137
PaCO2 = 40 + 8 = 48 K 3.1
Compensation is appropriate. Cl 90

• Anion Gap = 137 – (90 + 35)

= 12
AG is normal.
 Case 12: Solution
• Subsequently, she has developed
pH HCO3 PaCO2
↓ ↓ ↓

pH 7.51  7.42
PaCO2 47  39
HCO3 35  25

Na 137  138
K 3.1  2.8
Cl 90  102
 Case 12: Solution
• Subsequently, she has developed
pH HCO3 PaCO2
↓ ↓ ↓ Metabolic acidosis

The decrease in bicarbonate is almost same as the

rise in chloride.
• Final Diagnosis:
Metabolic Alkalosis +
Hyperchloremic (non-AG) Metabolic Acidosis
 Case 13
• A patient with salicylate overdose.
pH = 7.45
PCO2 = 20 mmHg
HCO3 = 13 mEq/L

• Dominant disorder: Respiratory alkalosis

• Appropriate Compensation would have been HCO3 of
20 (24 – 4)

• Lower than expected HCO3 suggests presence of

metabolic acidosis as well.
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