Practical Tips: How To Read ABG

Mohamad Hamim Mohamad Hanifah,M.D Moderator: Dr. Ida Zarina

Components of ABG
pH Respiratory function : PaCO2, PaO2, O2 sat Metabolic measures : HCO3, BE Electrolytes & metabolites

Normal Values
pH 7.35-7.45

PaCO2
HCO3 PaO2 O2 sat BE

35-45
22-26 80-100 95-100 % -2 to +2

Steps to ABG analysis

A. Identify the primary abnormality of acid-base disorder 1) Assess the pH - normal/acidosis/alkalosis 2) Compare pH & PaCO2 - If pH & PaCO2 are moving in opposite directions, then the problem is primarily respiratory in nature

3) Compare pH & HCO3 - If pH & HCO3 are moving in the same direction, then the problem is primarily metabolic in nature 4) Is there any (if any) compensation occurring?

No compensation: pH remains abnormal, and the other value (where the problem isnt occurring, i.e. CO2 or HCO3-) will remain normal or has made no attempt to help normalise the pH

Partial compensation: pH is still abnormal, and the other value is abnormal in an attempt to help normalise the pH
Full compensation: pH is normal, as the other value is abnormal and has been successful in normalising the pH.

 In compensated acid-base disorders, the pH will frequently fall either on the low or high side of neutral (7.40). Compensatory mechanisms do not overcompensate nor even fully compensate to normal.

5) Calculate Anion Gap

AG = Na HCO Cl (normal AG = 3 11 mmol/l)

* The presence of a very high AG (>20) suggests HAGMA, even in the presence of a normal pH or HCO3

Causes of HAGMA
C cyanide, CO A alcoholic ketoacidosis T toluene M methanol, methemoglobin U uremia D DKA P paraldehyde I INH/iron L lactic acidosis E ethylene glycol S salicylates

Causes of NAGMA
U ureterosigmoidostomy S small bowel fistula E extra chloride D diarrhea C carbonic anhydrase inhibitor A adrenal insufficiency R RTA P pancreatic fistula

B. Identify any secondary abnormality of acidbase disorder 1) Metabolic acidosis Winters formula: Expected PCO2 = (1.5 x HCO3) + 8 (2)
* if measured PCO is lower than expected concurrent respiratory alkalosis * if measured PCO is higher than expected concurrent respiratory acidosis

 For HAGMA, account for excess or missing anions by calculating the excess anion gap (delta gap)
Delta gap = AG 11 (normal AG) Delta gap then is added to measured HCO3

- If total = normal [ HCO] simple HAGMA - If total > normal [ HCO] there are too many [ HCO] = concurrent metabolic alkalosis - If total < normal [ HCO] there are not enough [HCO] = concurrent NAGMA

2) Metabolic alkalosis Expected PCO2 = 0.6(HCO3-24) + 40 * if measured pCO is lower than expected concurrent respiratory alkalosis * if measured pCO is higher than expected concurrent respiratory acidosis

3) Respiratory Acidosis or Respiratory Alkalosis

Acute - HCO changes 1-2 for every change in PCO2 by 10mmHg - pH changes 0.08 for every change in PCO2 by 10mmHg. Chronic - HCO changes 4-5 for every change in PCO2 by 10mmHg, - pH changes 0.03 for every change in PCO2 by 10mmHg. if measured HCO is lower than expected concurrent metabolic acidosis if measured HCO is higher than expected concurrent metabolic alkalosis

C. Check the oxygenation status Look at the PaO2 and the O2 sat. The PaO2 must always be interpreted in light of the oxygen concentration the patient is receiving.

A PaO2 of 85 mmHg when breathing room air (21%) indicates the lungs are functioning normally but a PaO2 of 85 when breathing 100% oxygen means the lungs are greatly impaired in their ability to move oxygen into the blood.

Alveolar-arterial O2 gradient (A-a gradient):

It is a useful tool in evaluating how well a patient is oxygenating. A-a gradient = PAO2 PaO2 (mmHg) ={(760-47)FiO2 - PaCO2/0.8}-PaO2 * Normal = 10-20 mmHg Or Normal =age/4 + 4

Elevated A-a gradient is caused by: V/Q mismatch (eg. Pneumonia, CHF, ARDS) R-L shunt (eg. PE) Diffusion abnormalities (eg. Interstitial lung dz)

PaO2/FiO2:
-Another tool for estimation of oxygenation, -Normal is 500-600. -Levels <300 suggest ALI, <200 suggest ARDS

Example 1
A patient admitted to CCU because of AMI. ABG sample was taken:
pH = 7.30 HCO3 = 20 mmol/L pCO2 = 32 mmHg

19

Interpretation
Partially compensated metabolic acidosis

20

Example 2
A 44 year old gentleman presented with severe diarrhea with moderate dehydration. Electrolyte results: Na+ 134, K+ 2.9, Cl- 108 Urea 31 ABG: pH 7.31 PaCO2 33 HCO3 16 PaO2 93

21

Interpretation
Partially compensated metabolic acidosis (NAGMA)

22

Example 3
A 22 year old female with Type I DM, presented to ED with hx of vomiting, polyuria & vague abd pain. O/E noted patient is tachypnoeic & dehydrated. Ix: CBS 19.0, Na 132 , K 6.0, Cl 93, Urea 38 Urine ketone + ABG: pH 7.27, HCO3 10, PCO2 32

23

Interpretation
HAGMA with concurrent respiratory acidosis

24

Example 4
60 year old lady was on a thiazide diuretic for 9 months following a previous admission with CHF. Currently was diagnosed to have lobar pneumonia ABG: pH 7.64, pCO2 32, pO2 75, HCO3 33

Interpretation
Mixed metabolic alkalosis & respiratory alkalosis with hypoxemia

26

Example 5
A 70 year old man with history of CHF presented with progressive SOB & leg swelling. ABG: pH 7.24, PCO2 60, PO2 52, HCO3 27

27

Interpretation
Acute respiratory acidosis with hypoxemia

28

Example 6
60 year old gentlemen, a chronic smoker presented with cough, SOB & wheezing ABG: pH 7.34, PaCO2 60, PaO2 80, HCO3 34

Interpretation
Chronic respiratory acidosis

30

Example 7
A vomiting, ill-appearing alcoholic patient has lab results showing: Na+ 137, K+ 3.8, Cl- 90 ABG: pH 7.40, pCO2 41, HCO3 22, pO2 85

Interpretation
HAGMA with concurrent metabolic alkalosis

32

Example 8
25 yo gentleman, post trauma D6 with hip dislocation and acetabular fracture scheduled for op but suddenly developed SOB. Noted tachycardic with HR 120 bpm ECG: Sinus tachycardia. ABG (on NP 3L/min): pH 7.442 PaO2 85 PaCO2 32. SaO2 96% What is the A-a gradient?

 110 mmHg

Thank You