Simple Method of Acid Base Balance Interpretation

A FOUR STEP METHOD FOR INTERPRETATION OF ABGS

Usefulness
This method is simple, easy and can be used for the majority of ABGs. It only addresses
acid-base balance and considers just 3 values.
pH,
PaCO2
HCO3-

Step 1. Use pH to determine Acidosis or Alkalosis.
ph
< 7.35 7.35-7.45 > 7.45
Acidosis
Normal or
Compensated
Alkalosis

Step 2. Use PaCO2 to determine respiratory effect.
PaCO2
< 35 35 -45 > 45
Tends toward
alkalosis
Causes high
pH
Neutralizes
low pH
Normal
or
Compensated
Tends toward
acidosis
Causes low pH
Neutralizes
high pH

Step 3. Assume metabolic cause when respiratory is ruled out.
You'll be right most of the time if you remember this simple table:
High pH Low pH
Alkalosis Acidosis
High PaCO2 Low PaCO2 High PaCO2 Low PaCO2
Metabolic Respiratory Respiratory Metabolic
If PaCO2 is abnormal and pH is normal, it indicates compensation.
o pH > 7.4 would be a compensated alkalosis.
o pH < 7.4 would be a compensated acidosis.
These steps will make more sense if we apply them to actual ABG values. Click here to
interpret some ABG values using these steps. You may want to refer back to these steps
(click on "linked" steps or use "BACK" button on your browser) or print out this page for
reference.

Step 4. Use HC03 to verify metabolic effect
Normal HCO3- is 22-26

Please note:
Remember, the first three steps apply to the majority of cases, but do not take into
account:
o the possibility of complete compensation, but those cases are usually less
serious, and
o instances of combined respiratory and metabolic imbalance, but those cases
are pretty rare.
"Combined" disturbance means HCO3- alters the pH in the same
direction as the PaCO2.
High PaCO2 and low HCO3- (acidosis) or
Low PaCO2 and high HCO3- (alkalosis).



Example 1
ABG Value Which step? Rationale
pH 7.39 Step 1 Normal pH
PaCO2 40 Step 2
Normal
PaCO2
Interpretation
Normal
ABG (acid
base is
balanced;
there are no
pH changes,
so if the
respiratory
acid is
normal, the
metabolic
base cannot
be causing
changes
either.)

Example 2
ABG Value Which step? Rationale
pH 7.2 Step 1
Low pH
indicates
acidosis
PaCO2 50 Step 2
High
PaCO2
indicates
respiratory
cause for
acidosis
Interpretation
respiratory
acidosis

Example 3
ABG Value Which step? Rationale
pH 7.49 Step 1
High pH
indicates
alkalosis
PaCO2 30 Step 2
Low PaCO2
indicates
respiratory
cause for
alkalosis (lo
respiratory
acid is
causing
higher pH)
Interpretation
respiratory
alkalosis

Example 4
ABG Value Which step? Rationale
pH 7.23 Step 1
Low pH
indicates
acidosis
PaCO2 31 Step 3
Low PaCO2
rules out
respiratory
cause for
acidosis,
therefore
metabolic
cause. Low
respiratory
acid is
compensating
for lower pH.
Interpretation
metabolic
acidosis

Example 5
ABG Value Which step? Rationale
pH 7.48 Step 1
High pH
indicates
alkalosis
PaCO2 47 Step 3
High PaC02
and High pH
indicates
metabolic
cause of
alkalosis.
Respiratory
acid is
compensating
for high pH.
Interpretation
Partially
compensated
metabolic
alkalosis

Example 6
ABG Value Which step? Rationale
pH 7.43 Step 1
pH is normal
but higher than
7.4, therefore
compensated
alkalosis.
PaCO2 33

Step 3
Low PaCO2
causes alkalosis
Interpretation
Compensated
respiratory
alkalosis


Case Studies

The following are examples of clinical situations and the ABGs that may result, as well as
causes and solutions for ABG abnormalities.

Case 1
Mrs. Puffer is a 35-year-old single mother, just getting off the night shift. She reports to the
ED in the early morning with shortness of breath. She has cyanosis of the lips. She has had a
productive cough for 2 weeks. Her temperature is 102.2, blood pressure 110/76, heart rate
108, respirations 32, rapid and shallow. Breath sounds are diminished in both bases, with
coarse rhonchi in the upper lobes. Chest X-ray indicates bilateral pneumonia.
ABG results are:
o pH= 7.44
o PaCO2= 28
o HCO3= 24
o PaO2= 54
Problems:
PaCO2 is low.
pH is on the high side of normal, therefore compensated respiratory alkalosis.
Also, PaO2 is low, probably due to mucous displacing air in the alveoli affected by the
pneumonia (see Shunting).
Solutions:
Mrs. Puffer most likely has ARDS along with her pneumonia.
The alkalosis need not be treated directly. Mrs. Puffer is hyperventilating to increase
oxygenation, which is incidentally blowing off CO2. Improve PaO2 and a normal
respiratory rate should normalize the pH.
High FiO2 can help, but if she has interstitial lung fluid, she may need intubation and
PEEP, or a BiPAP to raise her PaO2. (Click here to compare BiPAP to other respiratory
treatments.)
Expect orders for antibiotics, and possibly steroidal anti-inflammatory agents.
Chest physiotherapy and vigorous coughing or suctioning will help the patient clear
her airways of excess mucous and increase the number of functioning alveoli.

Case 2
Mr. Worried is a 52-year-old widow. He is retired and living alone. He enters the ED
complaining of shortness of breath and tingling in fingers. His breathing is shallow and
rapid. He denies diabetes; blood sugar is normal. There are no EKG changes. He has no
significant respiratory or cardiac history. He takes several antianxiety medications. He says
he has had anxiety attacks before. While being worked up for chest pain an ABG is done:
ABG results are:
o pH= 7.48
o PaCO2= 28
o HCO3= 22
o PaO2= 85
Problem:
pH is high,
PaCO2 is low
respiratory alkalosis.
Solution:
If he is hyperventilating from an anxiety attack, the simplest solution is to have him
breathe into a paper bag. He will rebreathe some exhaled CO2.This will increase
PaCO2 and trigger his normal respiratory drive to take over breathing control.
* Please note this will not work on a person with chronic CO2 retention, such as a
COPD patient. These people develop a hypoxic drive, and do not respond to CO2
changes.

Case 3
You are the critical care nurse about to receive Mr. Sweet, a 24-year-old DKA (diabetic
ketoacidosis) patient from the ED. The medical diagnosis tells you to expect acidosis. In
report you learn that his blood glucose on arrival was 780. He has been started on an
insulin drip and has received one amp of bicarb. You will be doing finger stick blood sugars
every hour.
ABG results are:
o pH= 7.33
o PaCO2= 25
o HCO3=12
o PaO2= 89
Problem:
The pH is acidotic,
PaCO2 is 25 (low) which should create alkalosis.
This is a respiratory compensation for the metabolic acidosis.
The underlying problem is, of course, a metabolic acidosis.
Solution:
Insulin, so the body can use the sugar in the blood and stop making ketones, which
are an acidic by-product of protein metabolism.
In the mean time, pH should be maintained near normal so that oxygenation is not
compromised




III. The Land of ABG *
*based on a concept by Laura Gasparis Vonfrolio, RN,PHD
Once upon a time there was a land known as ABG.
Everyone there was related with only a limited number of names for the population.
They were also very polite and had their own etiquette for learning each others names.
Now I would like to introduce you to your patient. Lets figure out what her name is:
All of the people in the land of ABG have a first name, a middle name, and a last name. You just have
to look at them one name at a time.

A. The Last Name
1. First, look at her pH. (Normal = 7.35-7.45)
2. If her pH is < (less than) 7.35; her last name is ACIDOSIS.
3. If her pH is > (greater than) 7.45; her last name is ALKALOSIS.
(Note: To be an absolutely perfect last name--her pH needs to be 7.40. So, keep in mind, that if her pH
is 7.35-7.39--shes thinking about marrying into the ACIDOSIS family. If her pH is 7.41-7.45--shes
thinking about marrying into the ALKALOSIS family.)

B. The First Name
Now that you know your patients last name, you would like to also learn her first name.
1. Look at her pH again.
2. If it is 7.35-7.45 (normal) then her first name is COMPENSATED.
3. If the pH is <7.35 or >7.45--then her first name is UNCOMPENSATED.

C. The Middle Name
Now that you know your patients first and last name, you would like to know
her middle name.
(Name Alert: These people are all related and you have many patients with the
same first and last name. A middle name will give you more information to go
on.)

1. First you need to look at the CO2 and HCO3.
(Remember: Normal CO2 = 35-45. Normal HCO3 = 22-26)
2. The middle name will either be Respiratory or Metabolic.
3. If the CO2 is <35 or >45--her middle name is RESPIRATORY.
4. If the HCO3 is <22 or >26--her middle name is METABOLIC.

D. The Family Feud
1. pH and HCO3 are "kissin cousins"--they like to go in the same direction.
2. But CO2 is the "black sheep"--pH runs the opposite direction when it sees him coming.
Therefore:
3. Decreased pH with Decreased HCO3 = ACIDOSIS.
4. Increased pH with Increased HCO3 = ALKALOSIS.
5. Decreased pH with Increased CO2 = ACIDOSIS.
6. Increased pH with Decreased CO2 = ALKALOSIS.


IV. Lets Practice

A. Respiratory Therapy gives you an ABG with the following numbers:
pH = 7.60 CO2 = 30 HCO3 = 22
1. What is her last name?
(Her pH is >7.45 so her last name is ALKALOSIS.)
2. What is her first name?
(Her pH is not in the normal range of 7.35-7.45 so her first name is UNCOMPENSATED.)
3. What is her middle name?
(Her CO2 is <35 and her HCO3 is normal so her middle name is RESPIRATORY.)
4. You have now been introduced to UNCOMPENSATED RESPIRATORY ALKALOSIS.


B. pH = 7.31 CO2 = 50 HCO3 = 25
1. What is her last name?
(Her pH is <7.35 so her last name is ACIDOSIS.)
2. What is her first name?
(Her pH is not in the normal range so her first name is UNCOMPENSATED.)
3. What is her middle name?
(Her CO2 is >45 and her HCO3 is normal so her middle name is RESPIRATORY.)
5. You have now been introduced to UNCOMPENSATED RESPIRATORY ACIDOSIS.


C. pH = 7.55 CO2 = 40 HCO3 = 30
1. What is her last name?
(Her pH is >7.45 so her last name is ALKALOSIS.)
2. What is her first name?
(Her pH is not in the normal range so her first name is UNCOMPENSATED.)
3. What is her middle name?
(Her CO2 is normal but her HCO3 is >26 so her middle name is METABOLIC.)
4. You have now been introduced to UNCOMPENSATED METABOLIC ALKALOSIS.


D. pH = 7.35 CO2 = 45 HCO3 = 21
1. What is her last name?
(Her pH is normal--but it is <7.40. So her last name might be ACIDOSIS. She hasnt decided if she wants
to get married yet.)
2. What is her first name?
(Her pH is normal so her first name is COMPENSATED.)
3. What is her middle name?
(Her CO2 is normal but her HCO3 is <22. So her middle name is METABOLIC. Note: Because she has a
middle name--she has decided to get married. Talk about a good reason to marry!)
4. You have been introduced to COMPENSATED METABOLIC ACIDOSIS