ARTERIAL BLOOD

GASES
BASICS AND INTERPRETATION

Navin Kumar Mishra

Junior Resident
IMS-BHU
23-07-2018
OBJECTIVES
• Understand correct sample handling

• Outline an interpretation strategy

• Describe causes for acid-base disturbances

• Delineate a workup strategy for common disorders

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 ABG
• ABG is a very useful diagnostic tool in our day to day practice.

• The first arterial puncture was performed in 1912 by Hurter, a German

physician.

• Drawn from artery- Radial, Brachial, Femoral, Dorsalis pedis, Posterior

tibial
• It is an invasive procedure.

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 Acid-Base Physiology
• pH is the negative logarithm to the base 10 of the hydrogen ion
concentration in mmol/L

• pH = - log10[H+]

• An increase in pH indicates a proportionate decrease in the [H+] and a

decrease in the pH indicates a proportionate increase in the [H+].

• H2CO3 generates 12,500 mmol H+ per day.

• Normal metabolism of proteins and nucleotides generates about 100

23/07/18 mmol H+ per day in the form of@ sulphuric
NKMishra and phosphoric acids. 4
 Calculation of pH

• pH is calculated from Henderson-Hasselbalch

equation .
• pH = pK + log acid/bas
• pH = 6.1 + log HCO3-

H2CO3

Kassirer and Bliech modified equation

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• H+ = 24 x PCO2/HCO3- @ NKMishra 5
 Regulation of pH
pH is maintained in narrow range by

• 1) In seconds: buffer systems

• 2)In minutes: CO2 excretion by the lungs

• 3)In hours to days: renal excretion of H+,

reabsorption of HCO3

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 Regulation of arterial pH

• 1.BUFFERS –Buffer systems minimize the change in pH resulting from

production of acid .
• Main buffer system in humans is HCO3- in ECF and protein and
phosphate buffers in ICF.

2.ROLE OF THE RESPIRATORY SYSTEM–Elimination of volatile acid CO2.

• a. Respiratory centers in the brain respond to changes in pH of CSF
and blood to affect ventilatory rate.
• b. Ventilation directly controls the elimination of CO2.

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 ROLE OF KIDNEY
It retains and regenerate HCO3- thereby regenerating the
body buffer with the net effect of eliminating the non-
volatile acid load
a. H+ secretion
1. Free urinary H+ - minimal contribution
2. Ammonia
3. Phosphorus
b. HCO3- reabsorption
1. Proximal tubule – 90%
2. Distal tubule -10%
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Applications of ABG
• To document respiratory failure and assess its severity.

• To monitor patients on ventilators and assist in weaning.

• To assess acid base imbalance in critical illness.

• To assess response to therapeutic interventions and

mechanical ventilation.

• To assess pre-op patients.

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 VENTILATION
PaCO2 = VCO2 x K
VA
Hypercapnea > 45 mm Hg (Hypoventilation)
Respiratory Acidosis
Hypocapnea < 35 mm Hg (Hyperventilation)
Respiratory Alkalosis

VA=Portion of total ventilation participate in gas

exchange with pulmonary blood
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 OXYGENATION

• P(A-a)O2

• O2 content

• PaO2 / FiO2 ratio

• arterial-Alveolar O2 tension ratio

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 P(A-a)O2= PAO2- PaO2

• PAO2- partial pressure of oxygen in alveolar gas

pAO2 = pIO2 – (paCO2 / R)
PAO2= (PB-P h2o) x FiO2- (paCO2/R)
Eg.:
=(760-47) x .21- (40/0.8) =100
PAO2-Pao2= 100-80=20
N= <15

PAO2 = partial pressure of oxygen in alveolar gas, PB =

barometric pressure (760mmHg), Ph2o = water vapor
pressure (47 mm Hg), FiO2 = fraction of inspired oxygen,
23/07/18 PCO2 = partial pressure of CO2 in the ABG, R = respiratory
@ NKMishra 12
P(A-a)O2= PAO2- PaO2
• PaO2- partial pressure of oxygen in blood
PaO2 = FiO2 × 5
PaO2 = 109 - 0.4 (Age)
PaO2 is dependant upon Age, FiO2, Patm

HYPOXEMIA
Mild (60-80) mmHg

Moderate(40-60) mmHg

Severe <40 mmHg

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23/07/18 @ NKMishra 14
 Arterial Blood pH

7.35~7.45

6.8 7.8
7.4
Neutral
Academia Alkalemia
Acidosis? Alkalosis?

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TECHNIQUES of Sampling

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SAMPLE MANAGEMENT

• Sample needs to be iced

• At room temperature sample lasts 15 – 20 min

• PaCO2 increases

• PaO2 decreases

• pH decreases  Red cell glycolysis

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CAUTION

pH PaCO2 PaO2

Heparin ↓ ↓

Air Bubbles ↓ ↑

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Technical Errors
Risk of alteration of results with:
1)size of syringe/needle
2)vol of sample

 Syringes must have > 50% blood

 Use only 3ml or less syringe
25% lower values if 1 ml sample taken in 10 ml syringe (0.25 ml heparin in
needle)

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 Parameters Excessive Heparin Air bubbles
pH ↓ or remain the same ↑
PCO2 ↓ ↓
PO2 May altered May altered
HbO2% sat May altered May altered
HbCO2% sat Will not altered Will not altered

Hb content ↓ Is not altered

HCO3 ↓ ↓
Base Excess ↓ ↓

Oxygen content May be altered Maybe altered

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 Technical Errors
WBC Counts
0.01 ml O2 consumed/dL/min
Marked increase in high TLC/plt counts : dec.pO2
Chilling / immediate analysis

ABG Syringe must be transported earliest via COLD CHAIN

Change/10 min Uniced 370C Iced 40C

pH 0.01 0.001
pCO2 1 mm Hg 0.1 mm Hg
pO2 0.1% 0.01%

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 Site Selection

• Radial Artery – 45. insertion angle

• Brachial Artery – 60-90 .insertion angle

• Femoral Artery – 90 insertion angle

• Dorsalis Pedis Artery

• Posterior Tibial artery

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 45 DEGREE INSERTION
ANGLE FOR RADIAL
ARTERY

KK

60-90 DEGREE
INSERTION ANGLE FOR
BRACHAILARTERY

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 Contraindication

• No absolute contraindications

• Dialysis shunt – choose another site

• Patient on anticoagulant/aspirin therapy – may have to hold

pressure on puncture site longer than normal

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 Site specific contraindication
Radial : Buergers disease
Raynauds
Absent Ulnar collateral circulation
AV dialysis shunt

Femoral: Local infection

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23/07/18 @ NKMishra 32
 Arterial Venous

PH 7.35 - 7.45 7.36- 7.39

Pco2 35- 45 44 - 48

Po2 80 - 100 38 - 42

Hco3 24- 26 20 - 24

Sao2 95- 100 % 75%

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A Stepwise
Approach
to Solving
Acid-Base
Disorders
Step 1: Assess the internal consistency of the values using the Henderseon-Hasselbach equation:

• [H+] = 24(PaCO2)
[HCO3-]

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 If the pH and the [H+] are inconsistent, the ABG is probably not valid.

pH Approximate [H+]
(mmol/L)
7.00 100
7.05 89
7.10 79
7.15 71
7.20 63
7.25 56
7.30 50
7.35 45
7.40 40
7.45 35
7.50 32
7.55 28
7.60 25
7.65 22

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Step 2: Is there alkalemia or
acidemia present?
• pH < 7.35 acidemia
pH > 7.45 alkalemia
• This is usually the primary disorder
• Remember: an acidosis or alkalosis may be present even if the pH is in
the normal range (7.35 – 7.45)
• You will need to check the PaCO2, HCO3- and anion gap

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• Step 3: Is the disturbance respiratory or metabolic?
• What is the relationship between the direction of change in the pH and the
direction of change in the PaCO2?
• In primary respiratory disorders, the pH and PaCO2 change in opposite directions;
in metabolic disorders the pH and PaCO2 change in the same direction.
Acidosis Respiratory pH ↓ PaCO2 ↑ ROME

Acidosis Metabolic& pH ↓ PaCO2 ↓ ROME

Alkalosis Respiratory pH ↑ PaCO2 ↓ ROME

Alkalosis Metabolic pH ↑ PaCO2 ↑ ROME

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• Step 4: Is there appropriate compensation for the primary disturbance?
• Usually, compensation does not return the pH to normal (7.35 – 7.45) except….?

Disorder Expected compensation Correction factor

Metabolic acidosis PaCO2 = (1.5 x [HCO3-]) +8 ±2

Acute respiratory acidosis Increase in [HCO3-]= ∆ PaCO2/10 ±3

Chronic respiratory acidosis (3-5 days) Increase in [HCO3-]= 3.5(∆ PaCO2/10)

Metabolic alkalosis Increase in PaCO2 = 40 + 0.6(∆HCO3-)

Acute respiratory alkalosis Decrease in [HCO3-]= 2(∆ PaCO2/10)

Chronic respiratory alkalosis Decrease in [HCO3-] = 5(∆ PaCO2/10) to 7(∆

PaCO2/10)

If the observed compensation is not the expected compensation, it is likely that more than one acid-
base disorder is present.
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• Step 5: Calculate the anion gap (if a metabolic acidosis exists):
• AG= [Na+]-( [Cl-] + [HCO3-] )=12 ± 2

• A normal anion gap is approximately 12 meq/L.

• In patients with hypoalbuminemia, the normal anion gap is lower than 12 meq/L; the “normal”
anion gap in patients with hypoalbuminemia is about 2.5 meq/L lower for each 1 gm/dL decrease
in the plasma albumin concentration (for example, a patient with a plasma albumin of 2.0 gm/dL
would be approximately 7 meq/L.)

• If the anion gap is elevated, consider calculating the osmolal gap in compatible clinical situations.
• Elevation in AG is not explained by an obvious case (DKA, lactic acidosis, renal failure
• Toxic ingestion is suspected

• OSM gap = measured OSM – (2[Na+] - glucose/18 – BUN/2.8

• The OSM gap should be < 10
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• Step 6: If an increased anion gap is present, assess the relationship between
the increase in the anion gap and the decrease in [HCO3-].
• Assess the ratio of the change in the anion gap (∆AG ) to the change in
[HCO3-] (∆[HCO3-]): ∆AG/∆[HCO3-]
• This ratio should be between 1.0 and 2.0 if an uncomplicated anion gap
metabolic acidosis is present.
• If this ratio falls outside of this range, then another metabolic disorder is
present:
• If ∆AG/∆[HCO3-] < 1.0, then a concurrent non-anion gap metabolic acidosis is
likely to be present.
• If ∆AG/∆[HCO3-] > 2.0, then a concurrent metabolic alkalosis is likely to be
present.
• It is important to remember what the expected “normal” anion gap for your
patient should be, by adjusting for hypoalbuminemia (see Step 5, above.)
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Table 1: Characteristics of acid-base disturbances

Disorder pH Primary problem Compensation

Metabolic acidosis ↓ ↓ in HCO3- ↓ in PaCO2

Metabolic alkalosis ↑ ↑ in HCO3- ↑ in PaCO2

Respiratory acidosis ↓ ↑ in PaCO2 ↑ in [HCO3-]

Respiratory alkalosis ↑ ↓ in PaCO2 ↓ in [HCO3-]

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Table 2: Selected etiologies of respiratory acidosis
oAirway obstruction
- Upper
- Lower

o COPD
o asthma
o other obstructive lung disease
oCNS depression
oSleep disordered breathing (OSA or OHS)
oNeuromuscular impairment
oVentilatory restriction
oIncreased CO2 production: shivering, rigors, seizures, malignant hyperthermia,
hypermetabolism, increased intake of carbohydrates
oIncorrect mechanical ventilation settings

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 Table 3: Selected etiologies of respiratory alkalosis
oCNS stimulation: fever, pain, fear, anxiety, CVA, cerebral
edema, brain trauma, brain tumor, CNS infection
oHypoxemia or hypoxia: lung disease, profound anemia, low
FiO2
oStimulation of chest receptors: pulmonary edema, pleural
effusion, pneumonia, pneumothorax, pulmonary embolus
oDrugs, hormones: salicylates, catecholamines,
medroxyprogesterone, progestins
oPregnancy, liver disease, sepsis, hyperthyroidism
oIncorrect mechanical ventilation settings

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 Table 4: Selected causes of metabolic
alkalosis
oHypovolemia with Cl- depletion
o GI loss of H+
o Vomiting, gastric suction, villous
adenoma, diarrhea with chloride-rich
fluid
o Renal loss H+
o Loop and thiazide diuretics, post-
hypercapnia (especially after institution
of mechanical ventilation)
oHypervolemia, Cl- expansion
o Renal loss of H+: edematous states (heart
failure, cirrhosis, nephrotic syndrome),
hyperaldosteronism, hypercortisolism,
excess ACTH, exogenous steroids,
hyperreninemia, severe hypokalemia, renal
artery stenosis, bicarbonate administration

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Table 5: Selected etiologies of metabolic
oNormal anion gap: will have increase in [Cl-]
acidosis
oElevated anion gap: o GI loss of HCO3-
o Methanol intoxication o Diarrhea, ileostomy, proximal colostomy,
o Uremia ureteral diversion
o Diabetic ketoacidosisa, alcoholic o Renal loss of HCO3-
ketoacidosis, starvation ketoacidosis o proximal RTA
o Paraldehyde toxicity o carbonic anhydrase inhibitor
o Isoniazid (acetazolamide)
o Lactic acidosisa o Renal tubular disease
o Type A: tissue ischemia o ATN
o Type B: Altered cellular metabolism o Chronic renal disease
o Ethanolb or ethylene glycolb intoxication o Distal RTA
o Salicylate intoxication o Aldosterone inhibitors or absence
o NaCl infusion, TPN, NH4+ administration
a
Most common causes of metabolic acidosis with
an elevated anion gap
b
Frequently associated with an osmolal gap

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Table 6: Selected mixed and complex acid-base disturbances

Disorder Characteristics Selected situations

Respiratory acidosis with ↓in pH •Cardiac arrest
metabolic acidosis ↓ in HCO3 •Intoxications
↑ in PaCO2 •Multi-organ failure

Respiratory alkalosis with ↑in pH •Cirrhosis with diuretics

metabolic alkalosis ↑ in HCO3- •Pregnancy with vomiting
↓ in PaCO2 •Over ventilation of COPD

Respiratory acidosis with pH in normal range •COPD with diuretics, vomiting, NG suction
metabolic alkalosis ↑ in PaCO2, •Severe hypokalemia
↑ in HCO3-

Respiratory alkalosis with pH in normal range •Sepsis

metabolic acidosis ↓ in PaCO2 •Salicylate toxicity
↓ in HCO3 •Renal failure with CHF or pneumonia
•Advanced liver disease

Metabolic acidosis with metabolic pH in normal range •Uremia or ketoacidosis with vomiting, NG suction,
alkalosis HCO3- normal diuretics, etc.

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 ARTERIAL BLOOD GAS

MEASURES CALCULATES

• PaCO2 • Bicarbonate

• PaO2 • SaO2

• pH

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 INTERPRETATION
23/07/18 @ NKMishra 49
 Normal Values

• pH - 7.35 - 7.45

• PaCO2 - 35-45 mmHg

• PaO2 - 80-100 mmHg

• HCO3 - 22-26

• O2sat - 95-100%

• Base Excess - +/-2 m Eq/L

23/07/18 @ NKMishra 50
 Base excess and deficit

• The BE (or base deficit) is defined as the amount of acid (or base) required
to be added to whole blood to achieve a pH of 7.4 at 37˚C and paCO2 of
40mmHg.

If the base is in excess

• may be due to decrease in metabolic acids
• may be due to increase in buffers (e.g. HCO3-)

If the base is in deficit

• may be due to excess metabolic acids
23/07/18 @ NKMishra 51
  Step 1: is it reliable??
 STEP -2 : Comprehensive history and physical
examination.

 STEP -3 : Acidosis or alkalosis..???

See the pH (<7.35 or >7.45)

 STEP -4 : Identify the primary disorder

See the change in PCo2 & HCO3

 STEP -5 : Calculate the compensatory response

Is adequately compensated???

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  STEP -6 : Calculate anion gap

STEP -7 : Calculate the delta gap (unmask hidden

mixed disorders)

STEP -8 : Calculate the osmolar gap (for high AG

acidosis)

 STEP -9 : Calculate the urinary anion gap (Non AG

metabolic acidosis)

 STEP -10 : Formulate differential diagnosis

23/07/18 @ NKMishra 53
INTERPRETATION STEPS
pH PaCO2 Disorder

1. pH
↓ ↓ Metabolic Acidosis

2. PaCO2 ↑ ↑ Metabolic Alkalosis

3. Anion Gap ↓ ↑ Respiratory Acidosis

↑ ↓ Respiratory Alkalosis
- Delta ratio

4. Compensation
23/07/18 @ NKMishra 54
ANION GAP (AG)
• Normal value  8 – 12

• Primarily determined by negatively charged plasma proteins

• Albumin ↓ 1 g/dL (below 4/4.5)  AG ↓ 2.5

• AG needs correction for hypoalbuminemia

23/07/18 @ NKMishra 55
 UNADJUSTED AG ADJUSTED AG

Decreased 4.7 %
Decreased 26.7 %
Normal 22.0 %

Normal 36.4 %
Normal 62.6 %
Increased 26.3 %

Increased 10.7 % Increased 10.7 %

23/07/18 J Lab Clin Med 2005;146:317–20 @ NKMishra 56

Some quick clues:

• 1. if CO2 and HCO3 in opposite direction , it indicates mixed d/o

• 2. if pH and Co2 same direction, it indicates Metabolic d/o=ROME

• 3. if pH and Co2 same direction, it indicates Respiratory d/o= ROME

• If the difference between digits after decimal in PH and CO2 is

• <15= metabolic
• > 15= Respiratory
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 CASES

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Case 0
• pH 7.28
• PaCO2 27 mm Hg
• PaO2 105 mm Hg
• H+ 70 mmhg
• Na+ 134 mmol/L
• K+ 3.7 mmol/L
• Cl- 109 mmol/L
• HCO3- 13 mmol/L

• Albumin 4.0 g/dL

• AG 12
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• H+ = 24 X 27/ 13
• = 49.8

• Not Reliable test.

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 CASE 1

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CASE 1
• pH 7.28
• PaCO2 27 mm Hg
• PaO2 105 mm Hg
• H+ 50 mmhg
• Na+ 134 mmol/L
• K+ 3.7 mmol/L
ANION GAP = 12
• Cl- 109 mmol/L
• HCO3- 13 mmol/L

• Albumin 4.0 g/dL

23/07/18 @ NKMishra 62
 CASE 1
1. pH: ↓
NON-ANION GAP
2. PCO2: ↓
METABOLIC ACIDOSIS
Normal
3. Anion Gap: pH PaCO2 Disorder

↓ ↓ Metabolic Acidosis

- Delta ratio ↑ ↑ Metabolic Alkalosis

↓ ↑ Respiratory Acidosis

↑ ↓ Respiratory Alkalosis
4. Compensation
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COMPENSATION
PaCO2 = 1.5 x HCO3- + 8 ± 2

PaCO2 = 1.5 x 13 + 8 ± 2

PaCO2 = 19.5 + 8 ± 2

PaCO2 = 27.5 ± 2

PaCO2 = 25.5 - 29.5 PaCO2 = 27

23/07/18 @ NKMishra 64
 CASE 1
1. pH: ↓
NON-ANION GAP
2. PCO2: ↓
METABOLIC ACIDOSIS

3. Anion Gap: Normal

- Delta ratio
ADEQUATE
COMPENSATION
4. Compensation
23/07/18 @ NKMishra 65
 NON-ANION GAP ACIDOSIS
• NAG Acidosis:
• Hyperchloremic: Net
Bicarbonate loss
Diarrhea RTA
NAG M.Acidosis NAG M.Acidosis
• Two main different routes UAG= Neg UAG= Positive
K+= dec K+= Inc
• GI: diarrhea, fistulas
• Renal: RTAs, drugs
• What is used to differentiate?
Urine AG = Na+ + K+ - Cl-
UAG = Negative normally bcz CL- content is high in urine.

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 DIARRHEA

DIARRHEA

RTA
CONTROL
RTA

DIARRHEA

RTA

CONTROL

CONTROL

23/07/18 NEJM 1988;318:594-99 @ NKMishra 67

URINE ANION GAP

[Na ] + [K ] + [NH
+ +
4
+
?
] + [UC] ≈ [Cl ] +
-
[HCO3-] + [UA]

[Na+] + [K+] - [Cl-] ≈ [UA] - [UC]

UAG ≈ [Na+] + [K+] - [Cl-]

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HOW TO USE IT
NORMAL RESPONSE TO ACIDOSIS IF KIDNEYS UNABLE TO EXCRETE H+

NH4 +
Cl - NH4+
Cl
-

UAG ≈ [Na+] + [K+] - [Cl-]

UAG ≈ [Na+] + [K+] - [Cl ]
-

UAG < 0
UAG > 0

23/07/18 @ NKMishra 69
NON ANION GAP ACIDOSIS
RENAL
GASTROINTESTINAL - Hypokalemic
- Diarrhea * Proximal RTA (type 2)
- External pancreatic or bowel * Distal RTA (type 1)
drainage
- Ureterosigmoidostomy * Drugs: Acetazolamide, Amphotericin B
- Drugs - Hyperkalemic
* Calcium Chloride * Type 4 RTA
* Magnesium Sulfate * Mineralocorticoid deficiency
* Cholestyramine * Tubulointerstitial disease
* Ammonium excretion defect

* Drugs: K+ sparing diuretics, ACEi

ARBs, Trimethoprim, Pentamidine,
NSAIDs, Cyclosprine, tacrolimus, etc

23/07/18 @ NKMishra 70
 URINE ANION
GAP

NEGATIVE POSITIVE

Gastrointestinal
Diarrhea URINE pH > 5.5
Small bowel / pancreatic Type I RTA
drainage

IATROGENIC
URINE pH < 5.5
Parenteral nutrition
Saline
Low K+
Anion exchange resins Type II RTA

High K+
Aldosterone deficiency
Type IV RTA

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 CASE 2

23/07/18 @ NKMishra 72
CASE 2
• pH 7.30
• PaCO2 34 mm Hg
• PaO2 235 mm Hg
• H+ 48 mmhg

• Na+ 144 mmol/L

• K+ 4.5 mmol/L ANION GAP = 22
• Cl- 105 mmol/L
• HCO3- 17 mmol/L

• Albumin 4.0 g/dL

23/07/18 @ NKMishra 73
 CASE 2
1. pH: ↓
ANION GAP
2. PCO2: ↓
METABOLIC ACIDOSIS

3. Anion Gap: ↑ pH PaCO2 Disorder

↓ ↓ Metabolic Acidosis

- Delta Ratio ↑ ↑ Metabolic Alkalosis

↓ ↑ Respiratory Acidosis

↑ ↓ Respiratory Alkalosis
4. Compensation
23/07/18 @ NKMishra 74
DELTA RATIO
• Delta ratio = Δ anion gap / Δ bicarbonate

Actual AG – 12
Delta Ratio =
24 – HCO3-

22 – 12 12
Delta Ratio = = = 1.7
24 – 17 7

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 Δ AG (↑AG-12)
Delta Ratio = ------------- = -----------------
Δ HCO3- (24-↓HCO3)
1 (0.8-1.5)

NON-ANION GAP ACIDOSIS METABOLIC ALKALOSIS

(↑↑ AG – 12) (↑↑ AG – 12)

Delta Ratio = ----------------------- Delta Ratio = -----------------------
(24-↓↓↓HCO3) (24 - ≈↑HCO3)

• Delta Ratio < 0.8

• Delta Ratio > 1.5
23/07/18 @ NKMishra 76
 DELTA RATIO

Δ RATIO

< 0.8 0.8 - 1.5 > 1.5

Anion Gap metabolic acidosis Anion Gap metabolic acidosis

Anion Gap metabolic
acidosis
Non anion gap acidosis Metabolic alkalosis

23/07/18 @ NKMishra 77
 CASE 2
1. pH: ↓
ANION GAP
2. PCO2: ↓
METABOLIC ACIDOSIS

3. Anion Gap: ↑ METABOLIC

ALKALOSIS
- Delta Ratio = 1.7

4. Compensation
23/07/18 @ NKMishra 78
COMPENSATION
PaCO2 = 1.5 x HCO3- + 8 ± 2

PaCO2 = 1.5 x 17 + 8 ± 2

PaCO2 = 25.5 + 8 ± 2

PaCO2 = 33.5 ± 2

PaCO2 = 31.5 - 35.5 PaCO2 = 34

23/07/18 @ NKMishra 79
 CASE 2
1. pH: ↓
ANION GAP
2. PCO2: ↓
METABOLIC ACIDOSIS

3. Anion Gap: ↑ METABOLIC

ALKALOSIS
- Delta Ratio = 1.7
ADEQUATE
4. Compensation COMPENSATION
23/07/18 @ NKMishra 80
 HIGH ANION GAP
M ethanol

U remia

D iabetic Ketoacidosis: alcohol, starvation

P araldehyde, paracetamol

I ron, Isoniazid, inborn errors of metabolism

L actic Acidosis

E thylene glycol, Ethanol

S alicylates

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 CASE 3

23/07/18 @ NKMishra 82
CASE 3
• pH 7.24
• PaCO2 60 mm Hg
• PaO2 158 mm Hg

• Na+ 140 mmol/L

• K+ 4.4 mmol/L
• Cl- 103 mmol/L ANION GAP = 12
• HCO3- 25 mmol/L

• Albumin 4.0 g/dL

23/07/18 @ NKMishra 83
 CASE 3
ACUTE OR CHRONIC?
1. pH: ↓

RESPIRATORY
2. PCO2: ↑
ACIDOSIS
pH PaCO2 Disorder

↓ ↓ Metabolic Acidosis

↑ ↑ Metabolic Alkalosis

↓ ↑ Respiratory Acidosis

↑ ↓ Respiratory Alkalosis

23/07/18 @ NKMishra 84
RESPIRATORY DISORDERS

Δ10 PaCO2 ACUTE CHRONIC

Δ pH 0.08 0.03

23/07/18 @ NKMishra 85
ACUTE OR CHRONIC?
Δ 2x10 = 20 Δ10 PaCO2 ACUTE CHRONIC
• PaCO2 = 60
Δ 2x0.08 =0.16
• pH = 7.24 Δ pH 0.08 0.03

23/07/18 @ NKMishra 86
 CASE 3
1. pH: ↓
ACUTE
2. PCO2: ↑ RESPIRATORY
ACIDOSIS
3. Anion Gap: Normal

- Delta Ratio

4. Compensation
23/07/18 @ NKMishra 87
HCO3 ??? -

ACIDOSIS ALKALOSIS

ACUTE
1 2

Δ 10 PaCO2

CHRONIC
4 5

23/07/18 @ NKMishra 88
CASE 3
• pH 7.24
Δ 2x10=20
• PaCO2 60 mm Hg
Δ1
• HCO3 -
25 mmol/L
ACIDOSIS ALKALOSIS

ACUTE 1 2

Δ 10 PaCO2
CHRONIC
4 5

23/07/18 @ NKMishra 89
 CASE 3
1. pH: ↓
ACUTE
2. PCO2: ↑ RESPIRATORY
ACIDOSIS
3. Anion Gap: Normal

- Delta Ratio
ADEQUATE
4. Compensation COMPENSATION
23/07/18 @ NKMishra 90
 CASE 4

23/07/18 @ NKMishra 91
CASE 4
• pH 7.33
• PaCO2 60 mm Hg
• PaO2 158 mm Hg

• Na+ 146 mmol/L

• K+ 4.4 mmol/L
• Cl- 102 mmol/L ANION GAP = 12
• HCO3- 32 mmol/L

• Albumin 4.0 g/dL

23/07/18 @ NKMishra 92
 CASE 4
ACUTE OR CHRONIC?
1. pH: ↓

RESPIRATORY
2. PCO2: ↑
ACIDOSIS
pH PaCO2 Disorder

↓ ↓ Metabolic Acidosis

↑ ↑ Metabolic Alkalosis

↓ ↑ Respiratory Acidosis

↑ ↓ Respiratory Alkalosis

23/07/18 @ NKMishra 93
RESPIRATORY DISORDERS

Δ10 PaCO2 ACUTE CHRONIC

Δ pH 0.08 0.03

23/07/18 @ NKMishra 94
ACUTE OR CHRONIC?
Δ 2x10=20 Δ10 PaCO2 ACUTE CHRONIC
• PaCO2 = 60
Δ2x0.03= 0.06
• pH = 7.33 Δ pH 0.08 0.03

23/07/18 @ NKMishra 95
 CASE 4
1. pH: ↓
CHRONIC
2. PCO2: ↑ RESPIRATORY
ACIDOSIS
3. Anion Gap: Normal

- Delta Ratio

4. Compensation
23/07/18 @ NKMishra 96
CASE 4
• pH 7.33 ↑2 x 10 = 20
• PaCO2 60 mm Hg
↑2x4=8
• HCO3 -
32 mmol/L
ACIDOSIS ALKALOSIS

ACUTE 1 2

Δ 10 PaCO2
CHRONIC
4 5

23/07/18 @ NKMishra 97
 CASE 4
1. pH: ↓
CHRONIC
2. PCO2: ↑ RESPIRATORY
ACIDOSIS
3. Anion Gap: Normal

- Delta Ratio
ADEQUATE
4. Compensation COMPENSATION
23/07/18 @ NKMishra 98
 CASE 5

23/07/18 @ NKMishra 99
CASE 5
• pH 7.47
• PaCO2 45 mm Hg
• PaO2 146 mm Hg

• Na+ 143 mmol/L

• K+ 4.2 mmol/L
• Cl- 101 mmol/L ANION GAP = 9
• HCO3- 33 mmol/L

• Albumin 3.0 g/dL

23/07/18 @ NKMishra 100
 CASE 5
1. pH: ↑

2. PCO2: ↑
METABOLIC
ALKALOSIS
3. Anion Gap: Normal pH PaCO2 Disorder

↓ ↓ Metabolic Acidosis

- Delta Ratio ↑ ↑ Metabolic Alkalosis

↓ ↑ Respiratory Acidosis

↑ ↓ Respiratory Alkalosis
4. Compensation
23/07/18 @ NKMishra 101
COMPENSATION
PaCO2 = 0.7 x HCO3- + 21 ± 2

PaCO2 = 0.7 x 33 + 21 ± 2

PaCO2 = 23.1 + 21 ± 2

PaCO2 = 44.1 ± 2

PaCO2 = 42.1 - 46.1 PaCO2 = 45

23/07/18 @ NKMishra 102

 CASE 5
1. pH: ↑

2. PCO2: ↑
METABOLIC
ALKALOSIS
3. Anion Gap: Normal

- Delta Ratio
ADEQUATE
COMPENSATION
4. Compensation
23/07/18 @ NKMishra 103
METABOLIC ALKALOSIS
• Decreased H+ concentration

• Chloride responsive
• Chloride resistant

• Measure Urine Cl-

• IF Urine CL <20MEQ = Cl responsive M.Alk

• IF Urine CL >20MEQ = Cl resistant M.Alk

23/07/18 @ NKMishra 104

 URINE CHLORIDE

< 20 mEq/L > 20 mEq/L

CHLORIDE
CHLORIDE RESISTANT
RESPONSIVE

Laxative abuse
Gastric fluid loss Severe K+ depletion
Diuretics Diuretic abuse
Post hypercapnia Bartter or Gitelman Syndrome
Villous adenoma Primary aldosteronism
Congenital chloridorrhea Adrenal Hyperplasia
Cushing syndrome

23/07/18 @ NKMishra 105

 METABOLIC ALKALOSIS
GASTROINTESTINAL H+ LOSS RENAL HYDROGEN LOSS
- Vomiting or nasogastric suction - Primary mineralocorticoid excess
- Congenital chloride diarrhea
- Mineralocorticoid excess-like
states
INTRACELLULAR shift of H+
- Severe hypokalemia * Licorice ingestion

* Villous Adenoma * Liddle syndrome

* Laxative abuse - Loop or thiazide diuretics

- Bartter or Gitelman syndrome

ALKALI ADMINISTRATION WITH
REDUCED RENAL FUNCTION - Post-hypercapnic alkalosis

- Hypercalcemia and the milk-alkali

CONTRACTION ALKALOSIS syndrome

23/07/18 @ NKMishra 106

 CASE 6

23/07/18 @ NKMishra 107

CASE 6
• pH 7.40
• PaCO2 38 mm Hg
• PaO2 106 mm Hg

• Na+ 141 mmol/L

• K+ 4.8 mmol/L
• Cl- 97 mmol/L ANION GAP = 21
• HCO3- 23 mmol/L

• Albumin 4.0 g/dL

23/07/18 @ NKMishra 108
 CASE 6
1. pH: Normal
ANION GAP
2. PCO2: Normal
METABOLIC ACIDOSIS

3. Anion Gap: ↑ pH PaCO2 Disorder

↓ ↓ Metabolic Acidosis

- Delta Ratio ↑ ↑ Metabolic Alkalosis

↓ ↑ Respiratory Acidosis

↑ ↓ Respiratory Alkalosis
4. Compensation
23/07/18 @ NKMishra 109
DELTA RATIO
• Delta ratio = Δ anion gap / Δ bicarbonate

Actual AG – 12
Delta Ratio =
24 – HCO3-

21 – 12 9
Delta Ratio = = = 9
24 – 23 1

23/07/18 @ NKMishra 110

 DELTA RATIO

Δ RATIO

< 0.8 0.8 - 1.5 > 1.5

Anion Gap metabolic acidosis Anion Gap metabolic acidosis

Anion Gap metabolic
acidosis
Non anion gap acidosis Metabolic alkalosis

23/07/18 @ NKMishra 111

 CASE 6
1. pH: Normal
ANION GAP
2. PCO2: Normal
METABOLIC ACIDOSIS

3. Anion Gap: ↑ METABOLIC

ALKALOSIS
- Delta Ratio = 9

4. Compensation
23/07/18 @ NKMishra 112
COMPENSATION
PaCO2 = 1.5 x HCO3- + 8 ± 2

PaCO2 = 1.5 x 23 + 8 ± 2

PaCO2 = 34.5 + 8 ± 2

PaCO2 = 42.5 ± 2

PaCO2 = 40.5 - 44.5 PaCO2 = 38

23/07/18 @ NKMishra 113

 CASE 6
1. pH: Normal
ANION GAP
2. PCO2: Normal
METABOLIC ACIDOSIS

3. Anion Gap: ↑ METABOLIC

ALKALOSIS
- Delta Ratio = 9
RESPIRATORY
4. Compensation ALKALOSIS
23/07/18 @ NKMishra 114
Case 7
• pH: 7.4
• PCO2: 40MM/HG
• HCO3: 25MMOL/L
• AG: 30

• M.AC with M.Alk with R.Alk

23/07/18 @ NKMishra 115

• Case 8. A 54y/o male, Alcoholic presented to ER with c/o vomiting and
increased respiratory rate.

• PH: 7.4
• PCO2: 30
• HCO3:25
• AG: 30

• M. AC(Alcoholic Ketoacidosis)
• with M.Alk(Vomiting)
• with R. Alk( Hyperventilation due to hepatic dysfxn or alcohol withdrawal)
23/07/18 @ NKMishra 116
 SUMMARY

23/07/18 @ NKMishra 117

23/07/18 @ NKMishra 118
SUMMARY
pH PaCO2 Disorder
↓ ↓ Metabolic Acidosis
1. pH ↑ ↑ Metabolic Alkalosis

↓ ↑ Respiratory Acidosis

2. PaCO2 ↑ ↓ Respiratory Alkalosis

Δ RATIO
3. Anion Gap
< 0.8 0.8 - 1.5 > 1.5
- Delta ratio Anion Gap metabolic Anion Gap metabolic
acidosis acidosis
Anion Gap metabolic
acidosis
4. Compensation Non anion gap acidosis Metabolic alkalosis

DISORDER EXPECTED PCO2

Metabolic Acidosis PaCO2 = 1.5 x HCO3 + 8 ± 2

Metabolic Alkalosis PaCO2 = 0.7 x HCO3 + 21 ± 2

23/07/18 @ NKMishra 119

SUMMARY
Δ10 PaCO2 ACUTE CHRONIC
1. pH

Δ pH 0.08 0.03
2. PaCO2

3. Anion Gap
ACIDOSIS ALKALOSIS
- Delta ratio
ACUTE 1 2
4. Compensation
Δ 10 PaCO2
CHRONIC
4 5

23/07/18 @ NKMishra 120

 Treat the patient not the ABG.

Thank you!!

Have a Nice Day!!

23/07/18 @ NKMishra 121

 Case-1
• 60 years old M, presents to the ED with rapid
breathing and less responsive than usual. No other
history available.

ABG results
pH 7.31
PCO₂ 10
HCO₃ 5
Na 123
K 5
Cl 99
23/07/18 @ NKMishra 122
 Stepwise interpretation
1. At pH 7.3 H+ conc. Should be ≈50nmol/L
• Calculated H+ = 24 × 10/5 = 24 × 2 = 48
• Both values corroborate, hence result is valid.
2. pH is 7.3, i.e Acidosis
3. HCO₃ value has gone down, primary process is
metabolic
4. Respiratory compensation:
• Calculated PCO₂ = (1.5 × 5)+8 ± 2 = 13.5 to 17.5
• Partially compensated M.Acidosis a/w respiratory
alkalosis :- Mixed disorder

23/07/18 @ NKMishra 123

 5. Anion gap: (123+5) – (99 + 5) = 24
• High anion gap metabolic acidosis
Finally:- Mixed acid base disorder, with presence of high
AG metabolic acidosis and respiratory alkalosis.

23/07/18 @ NKMishra 124

 Case-2
• A k/c/o COPD with cor pulmonale on treatment
presented with progressive breathlessness.

ABG results
pH 7.42
PCO₂ 67
HCO₃ 42
Na 140
K 3.5
Cl 88
23/07/18 @ NKMishra 125
 • pH is normal; but PCO₂ & HCO₃ both are increased.
• Change in PCO₂ is 67-40 = 27
• Expected rise in HCO₃ should be 27 × 0.4 = 10.8
• Expected HCO₃ = 24+10.8 ≈ 35
• Actual HCO₃ = 42
• AG = 12 (N)
• Mixed disorder, both respiratory acidosis & metabolic
alkalosis.

23/07/18 @ NKMishra 126

 Case -3
• A known case of chronic kidney disease, discontinued
dialysis & presented to the emergency in an altered
state of sensorium. Attendants gave history of
repeated episodes of vomiting at home.

ABG results
pH 7.42
PCO₂ 40
HCO₃ 25
Na 140
K 3.0
Cl 95
23/07/18 @ NKMishra 127
 • pH, PCO₂, HCO₃ all WNL
• AG = 23 (↑)
• Delta gap = 13 – 1 = 12 (↑)
• AG >> HCO3–

• Mixed disorder with presence of both high AG

metabolic acidosis and metabolic alkalosis.

23/07/18 @ NKMishra 128

 Case-4
• 65 yrs old M, past h/o Acute MI on medication,
presented with high grade fever with, cough & yellowish
expectoration for 5 days. Acute increase in shortness of
breath.

ABG results
pH 7.3
PCO₂ 38
HCO₃ 16
Na 136
K 4
Cl 102
23/07/18 @ NKMishra 129
 • pH 7.3 = Acidosis
• HCO₃ is low ; primary disorder is metabolic acidosis
• Expected PCO₂ = (1.5 × 16) + 8 = 32
• Calculated PCO₂ < estimated PCO₂
• AG = 22
• Delta gap = (10-8) = 2
• Mixed disorder with metabolic acidosis & respiratory
acidosis

23/07/18 @ NKMishra 130

23/07/18 @ NKMishra 131
23/07/18 @ NKMishra 132
23/07/18 @ NKMishra 133
Case-6
• ABHG parameters are following:-
PH = 7.39
PaCO2 = 24
HCO3 = 14
Na = 140
K=4
Cl = 106
AG = 20

23/07/18 @ NKMishra 134

• Result:- High anion gap Metabolic Acidosis with Respiratory Alkalosis
• Examples- Lactic acidosis,Sepsis

23/07/18 @ NKMishra 135

Case-7
• ABHG parameters are following:-
PH = 7.42
PaCO2 = 67
HCO3 = 42
Na = 140
K = 3.5
Cl = 88
AG = 10

23/07/18 @ NKMishra 136

• Result:- Metabolic Alkalosis with Respiratory Acidosis
• Examples- COPD Patients

23/07/18 @ NKMishra 137

Case-8
• ABHG parameters are following:-
PH = 7.3
PaCO2 = 38
HCO3 = 18
Na = 140
K=4
Cl = 102
AG = 20

23/07/18 @ NKMishra 138

• Result:- Metabolic Acidosis with Respiratory Acidosis
• Examples- Pneumonia, Pulmonary Edema

23/07/18 @ NKMishra 139

Case-9
• ABHG parameters are following:-
PH = 7.42
PaCO2 = 40
HCO3 = 25
Na = 140
K=3
Cl = 95
AG = 23

23/07/18 @ NKMishra 140

• Result:- Mixed Disorder-Metabolic Acidosis with Metabolic Alkalosis
• Examples- Uremia with Vomiting

23/07/18 @ NKMishra 141

Case-10
• ABG parameters are following:-
PH = 7.2
PaCO2 = 25
HCO3 = 10
Na = 132
K=3
Cl = 110
AG = 15

23/07/18 @ NKMishra 142

• Result:- Normal AG Hyperchloremic Metabolic Acidosis
• Examples- DKA

23/07/18 @ NKMishra 143

 METABOLIC ACIDOSIS

23/07/18 @ NKMishra 144

 Causes of High AG Met
Acidosis
1. Ketoacidosis:
Diabetic
Alcoholic
Starvation
2. Lactic Acidosis:
Type A (Inadequate O2 Delivery to Cells)
Type B (Inability of Cells to utilise O2)
Type D (Abnormal bowel anatomy)
3. Toxicity:
Salicylates Paraldehyde
Methanol Toluene
Ethylene Glycol

4. Renal Failure
23/07/18
5. Rhabdomyolsis @ NKMishra 145
CAUSES OF NORMAL ANION GAP
METABOLIC ACIDOSIS

1. HCO3 loss:
GIT Diarrhoea
Pancreatic or biliary drainage
Urinary diversions (ureterosigmoidostomy)

Renal Proximal (type 2) RTA

Ketoacidosis (during therapy)
Post-chronic hypocapnia
23/07/18 @ NKMishra 146
 2. Impaired renal acid excretion:
Distal (type 1) RTA
Hyperkalemia (type 4) RTA
Hypoaldosteronism

3. Misc:
Acid Administration (NH4Cl)
Hyperalimentation
Cholestyramine Cl
HCl therapy (Rx of severe met alkalosis)
23/07/18 @ NKMishra 147
 METABOLIC ALKALOSIS

23/07/18 @ NKMishra 148

 CAUSES OF
METABOLIC ALKALOSIS
1. EXOGENOUS HCO3- LOADS
Acute alkali administration
Milk – alkali syndrome
2. Effective ECFV contraction, normotention, K+ deficiency and
secondary Hyperreninemic hyperaldosteronism:

GI LOSS: Vomiting
Gastric Aspiration
Villous adenoma

23/07/18 @ NKMishra 149

 RENAL LOSS : Diuretics
Post hypercapnic state
Hypercalcaemia
Recovery from LA/KA
Mg2+ deficiency
Bartters/Gitelmans syndr
Nonreabs anions – penicill
3. ECFV expansion, hypertension,K+ deficiency, and
mineralocorticoid excess:
HIGH RENIN : RAS
Accelerated hypertension
23/07/18
Renin sec@ tumor
NKMishra 150
 LOW RENIN :
PRIMARY ALDOSTERONISM –
Adenoma, hyperplasia , carcinoma
ADRENAL ENZYME DEFECTS –
11 b Hydroxylase
CUSHINGS SYNDROME OR DIS.

4. Gain of function mutation of renal sodium channel

with ECF expansion , hypertension , K+ deficiency
and hyporeninemic hypoaldosteronism : called as
LIDDLES SYNDROME

23/07/18 @ NKMishra 151

 RESPIRATORY ACIDOSIS

23/07/18 @ NKMishra 152

 Causes of Respiratory Acidosis
1. CENTRAL :
Drugs( anesthetics, morphine , sedatives)
Stroke
Infection
2. AIRWAY :
Obstruction
Asthma
3. PARENCHYMA :
Emphysema
Pneumoconiosis
Bronchitis
ARDS
23/07/18 @ NKMishra 153
Barotrauma
 • 4. NEUROMUSCULAR :
• Poliomyelitis
• Kyphoscoliosis
• Myasthenia
• Muscular dystrophies
5. MISCELLANEOUS
• Obesity
• Hypoventilation
• Permissive Hypercapnia

23/07/18 @ NKMishra 154

 Respiratory Alkalosis

23/07/18 @ NKMishra 155

 Causes of Respiratory Alkalosis

1.CENTRAL NERVOUS SYSTEM STIMULATION

Structural Causes Non Structural Causes

Head trauma Pain
Brain tumor Anxiety
CVA Fever
Meningitis, encephalitis Psychosis

2. HYPOXEMIA OR TISSUE HYPOXIA

Pneumonia, pulm oedema
Aspiration
23/07/18 High Altitude @ NKMishra 156
 3. STIMULATION OF CHEST RECEPTORS :
• Hemothorax
• Flail chest
• Cardiac failure
• Pulmonary embolism

4. MIXED/UNKNOWN MECHANISMS:
Drugs – Salicylates Nicotine
Progesterone Thyroid hormone
Catecholamines
Xanthines (Aminophylline & related compounds)
Cirrhosis
Gram –ve Sepsis
Pregnancy
23/07/18
Heat exposure @ NKMishra 157
 • ABG is a very useful diagnostic tool for our day to day
practice.

• Approach to interpret should be step wise & in a

systematic manner.

• Any abnormal result should be analyzed cautiously in

light of clinical context.

• Appropriate use of this tool using clinical judgment is of

paramount importance

23/07/18 @ NKMishra 158