Arterial Blood Gas Analysis

What is an ABG?
• The Components
• pH / PaCO2 / PaO2 / HCO3 / O2sat / BE
• Desired Ranges
• pH - 7.35 - 7.45
• PaCO2 - 35-45 mmHg
• PaO2 - 80-100 mmHg
• HCO3 - 21-27
• O2sat - 95-100%
• Base Excess - +/-2 mEq/L
 Why Order an ABG?
• Aids in establishing a diagnosis
• Helps guide treatment plan
• Aids in ventilator management
• Improvement in acid/base management allows for
optimal function of medications
• Acid/base status may alter electrolyte levels
critical to patient status/care
 Logistics
• When to order an arterial line --
• Need for continuous BP monitoring
• Need for multiple ABGs
• Where to place -- the options
• Radial
• Femoral
• Brachial
• Dorsalis Pedis
• Axillary
 Acid Base Balance
• The body produces acids daily
• 15,000 mmol CO2
• 50-100 mEq Nonvolatile acids

• The lungs and kidneys attempt to maintain

balance
 Acid Base Balance
• Assessment of status via bicarbonate-
carbon dioxide buffer system

• CO2 + H2O <--> H2CO3 <--> HCO3- + H+

• ph = 6.10 + log ([HCO3] / [0.03 x PCO2])

 The Terms
• ACIDS • BASES
• Acidemia • Alkalemia
• Acidosis • Alkalosis
• Respiratory • Respiratory
CO2 CO2
• Metabolic • Metabolic
HCO3 HCO3
 Respiratory Acidosis
• ph, CO2, Ventilation
• Causes
• CNS depression
• Pleural disease
• COPD/ARDS
• Musculoskeletal disorders
• Compensation for metabolic alkalosis
 Respiratory Acidosis
• Acute vs Chronic
• Acute - little kidney involvement. Buffering
via titration via Hb for example
• pH by 0.08 for 10mmHg  in CO2
• Chronic - Renal compensation via
synthesis and retention of HCO3 (Cl to
balance charges  hypochloremia)
• pH by 0.03 for 10mmHg in CO2
 Respiratory Alkalosis
• pH, CO2, Ventilation
•  CO2   HCO3 (Cl to balance charges 
hyperchloremia)
• Causes
• Intracerebral hemorrhage
• Salicylate and Progesterone drug usage
• Anxiety  lung compliance
• Cirrhosis of the liver
• Sepsis
 Respiratory Alkalosis
• Acute vs. Chronic
• Acute - HCO3 by 2 mmol/L for every
10mmHg  in PCO2
• Chronic - Ratio increases to 4 mmol/L of
HCO3 for every 10mmHg  in PCO2

• Decreased bicarb reabsorption and

decreased ammonium excretion to
normalize pH
 Metabolic Acidosis
• pH, HCO3
• 12-24 hours for complete activation of
respiratory compensation
• PCO2 by 1.2mmHg for every 1 mmol/L
HCO3
• The degree of compensation is assessed via
the Winter’s Formula
 PCO2 = 1.5(HCO3) +8  2 (estimated)

Compare the estimated & actual PCO2

 The Causes
• Metabolic Gap • Non Gap Metabolic
Acidosis Acidosis
• M - Methanol • Hyperalimentation
• U - Uremia • Acetazolamide
• D - DKA
• RTA (Calculate urine
• P - Paraldehyde
anion gap)
• I - INH
• Diarrhea
• L - Lactic Acidosis
• Pancreatic Fistula
• E - Ehylene Glycol
• S - Salicylate
 Metabolic Alkalosis
• pH, HCO3
• PCO2 by 0.7 for every 1mmol/L  in HCO3
• Causes
• Vomiting
• Diuretics
• Chronic diarrhea
• Hypokalemia
• Renal Failure
 Mixed Acid-Base Disorders
• Patients may have two or more acid-
base disorders at one time

• Delta Gap
Delta HCO3 = HCO3 + Change in anion gap
>24 = metabolic alkalosis
 The Steps
• Start with the pH
• Note the PCO2
• Calculate anion gap
• Determine compensation (Delta Gap)
Delta HCO3 = HCO3 + Change in anion gap
>24 = metabolic alkalosis
 Case 1
• An ill-appearing male presents with nausea
and vomiting.
• ABG – pH:7.4, PCO2: 41, PO2: 85, HCO3:
22mmol/l

• Na- 137 / K- 3.8 / Cl- 90 / HCO3- 22

 Sample Problem #1
• Anion Gap = 137 - (90 + 22) = 25
 anion gap metabolic acidosis
• Winters Formula = 1.5(22) + 8  2
= 39  2
 compensated
• Delta Gap = 25 - 10 = 15
15 + 22 = 37
 metabolic alkalosis
 Sample Problem #2
• 22 year old female presents for
attempted overdose. She has taken an
unknown amount of aspirin,
cinnamedrine, and caffeine. On exam
she is anxious.
 Sample Problem #2
• ABG - 7.45 / 35 / 123 / 14
• Na- 145 / K- 3.6 / Cl- 109 / HCO3- 14
• ASA level - 38.2 mg/dL
 Sample Problem #2
• Anion Gap = 145 - (109 + 17) = 19
 anion gap metabolic acidosis
• Winters Formula = 1.5 (14) + 8  2
= 29  2
 uncompensated
• Delta Gap = 19 - 10 = 9
9 + 17 = 26
 no metabolic alkalosis
 Sample Problem #3
• 47 year old male experienced crush
injury at construction site.
• ABG - 7.3 / 32 / 96 / 15
• Na- 135 / K-5 / Cl- 98 / HCO3- 15 / BUN-
38 / Cr- 1.7
• CK- 42, 346
 Sample Problem #3
• Anion Gap = 135 - (98 + 15) = 22
 anion gap metabolic acidosis
• Winters Formula = 1.5 (15) + 8  2
= 30  2
 compensated
• Delta Gap = 22 - 10 = 12
12 + 15 = 27
 mild metabolic alkalosis
 Sample Problem #4
• 1 month old male presents with
projectile emesis x 2 days.
• ABG - 7.49 / 40 / 98 / 30
• Na- 140 / K- 2.9 / Cl- 92 / HCO3- 32
 Sample Problem #4
• Metabolic Alkalosis, hypochloremic
• Winters Formula = 1.5 (30) + 8  2
= 53  2
 uncompensated