!

"##$ &'()(*
Not as Com||catoo as T|oy Soom
vors|on 1.8 May 25, 2OO6
Ko|t| Conovor, M.D., FACLP uoatos at: www.conovors.org
Attono|ng Statt, Morcy Hos|ta| ot P|ttsburg|, Doartmont ot Lmorgoncy Moo|c|no
C||n|ca| Ass|stant Protossor, Doartmont ot Lmorgoncy Moo|c|no, Un|vors|ty ot P|ttsburg|
Ass|stant Protossor, Duquosno Un|vors|ty, Pangos Sc|oo| ot Hoa|t| Sc|oncos, Dot. ot P|ys|c|an Ass|stant
Aojunct C||n|ca| Ass|stant Protossor, Doartmont ot lntorna| Moo|c|no / Lmorgoncy Moo|c|no,
La|o Lr|o Co||ogo ot Ostooat||c Moo|c|no
!"#$ $& '& (")* +&,)&*) "#*'+ -&. # /0&&' 1#+2
F|rst, DON'T PANlC. Ana|yz|ng an b|ooo gas, ovon |n t|o taco ot a com||catoo ac|obaso o|soroor, |s wo|| w|t||n t|o
scoo ot ovon a bog|nn|ng stuoont. T|oro |s so muc| wr|tton about b|ooo gasos ano ac|obaso o|soroors, |owovor,
ano trom so many orsoct|vos, t|at |t m|g|t |oo| |||o a |oo|oss tas|. Novor toar. \|t| a tow s|m|o gu|oo||nos t|at
you can |oo on a caro or |n a oc|ot notoboo|, you can taco t|o numbors w|t|out toar. T|o tr|c| |s to start t|o
r|g|t way. T|oro's |ots ot |ntormat|on an b|ooo gas. For s|m||c|ty's sa|o |gnoro |t a|| oxcot t|o O
2
, CO
2
, ano H,
aoo to t||s t|o b|carbonato ("b|carb," CO
2
) trom an SMA ano| or sot ot o|octro|ytos, ano you'ro a|| sot to ova|uato
oxygonat|on ano o|agnoso ac|obaso status.
34$)45#0 &4 6)*&.+7 689+ 4.0):
T|o t|rst quost|on, botoro wo ovon start oo|v|ng ooo |nto oquat|ons, ano tor t|at mattor ovon botoro you oroor a
gas, |s w|ot|or to oroor an !"#$"%!& or a '$()*+ gas. Yos, wo ta|| about A8Gs a|| t|o t|mo. Yos, |n commun|ty |os|ta|s
(ano somo toac||ng |os|ta|s tor t|at mattor), t|o PTs w||| say you want a w|at! A '$()*+ gas!" [as|oo to t|o ot|or
PT oo wo oo t|oso!"j
Yos, A8G" |s a muc| moro trao|t|ona| torm ano w|at wo a|ways usoo to oo.
*
8ut, |oy, oo ,)* want somoono
to st|c| a nooo|o |n your artory |t t|oy can st|c| a nooo|o |n your vo|n ano got t|o samo oxact |ntormat|on!
8ac| |n t|o o|o oays, wo got A8Gs most|y to t|no out |ow wo|| oxygonatoo oo|o woro. \|y! 8ocauso bac|
botoro t|o oays ot u|so ox|m|tors (you |now, t|o ov|| |umour" oays!), |t was t|o on|y way. 8ut now w|t| u|so
ox|motors ovoryw|oro (l ovon |avo ono |n my car t|rsta|o ||t), t|at's muc| |oss ot an argumont. lnoooo, wo |now
t|at u|so ox|motry, at |oast |t you'vo got a gooo wavo torm, |s qu|to accurato. lnoooo, |now|ng t|o contus|on about
A8G rosu|ts |n s|c|s|c| at|onts (|s t||s artor|a| or vonous!" maybo |t's a m|xoovonous gas. got anot|or ono,
OK!"), u|so ox|motry |s |||o|y, |n roa|, ract|ca| torms, -$##$" t|an an A8G. \o||, t||s |s truo at |oast |n t|o |n|t|a|
stagos ot ova|uat|on, ano as an omorgoncy |ys|c|an, t|at's my ma|n |ntorostbut |t's a|so truo w|on a at|ont on t|o
t|oor suooon|y oocomonsatos.
Yos, |t you |avo an |nowo|||ng artor|a| ||no |n t|o lCU, ano you'ro suro |t's wor||ng OK, t|on to||ow|ng A8Gs
ma|os sonso. 8ut t|at's a t|ny tract|on ot t|o at|onts w|o nooo t|o|r oxygonat|on c|oc|oo.
Ano, |t turns out t|at a '$()*+ b|ooo gas can g|vo you a|| t|o |ntormat|on you nooo to o|agnoso somoono's ac|o
baso status. OK, OK, t|oro aro a .$/ oxcot|ons, |||o somoono |n caro|ac arrost or w|o |s or|arrost (t|at moans
o|t|or you just got t|om bac| or t|oy'ro about to arrost). 8ut tor t|o major|ty ot at|onts w|o aro s|c|s|c| but not
c|rc||ng t|o ora|n r|g|t on t|o oogo, a 012 |s just t|no. lt's tastor ano oas|or to oraw, oas|or on t|o at|ont, ano |oss
|||o|y to causo artor|a| b|ooo|ng or artor|a| c|ots. (Lvor |oaro ot t|o A||on tost you'ro suosoo to oo botoro oraw|ng
an A8G at t|o wr|st! T|at's to ma|o suro t|o at|ont |as two artor|os to t|o |anoso |t you wroc| ono, t|o |ano
ooosn't turn b|ac| ano ta|| ott. T||n| about |t.)
As you wou|o oxoct, vonous b|ooo |as muc| |oss oxygon t|an artor|a| b|ooo. Norma| artor|a| O
2
(AO
2
) |s
about 8O1OO mm, t|o corrosono|ng oxygon saturat|on |s anyt||ng groator t|an 95 saturat|on.

*
Yos, yos, l |now t|o tootnoto on ago 3 ta||s about SMA6" ano ov|| |umours" as bo|ng gooo oxam|os ot trao|t|ona| torms l |||o to uso. So l'm |ncons|stont.
Conovor's A8G Hanoout 1.6
Pago 2 ot 9

Yos, t|oro aro tow t|mos w|on t|o u|so ox|motry ano t|o O2 oon't matc|, r|mar||y |n carbon monox|oo
o|son|ng, so tor carbon monox|oo o|son|ng, a s|ng|o A8G may ma|o sonso, at |oast tor at|onts w|o aro obv|ous|y
s|c|. Howovor, |t t|o at|ont |sn't s|c| ano you just want to ru|o out CO o|son|ng, you can just got a vonous CO
|ovo|t|oy aro just as gooo as artor|a| |ovo|s.
1

T|o '!+# major|ty ot t|o t|mo, as |ong as you can got a gooo u|so ox roao|ng, you oon't nooo an !"#$"%!& b|ooo
gas. T|o tab|o bo|ow |s a|so ava||ab|o on a caro at t|o ono ot t||s art|c|o, so you can |oo |t |n your oc|ot:
SaO2 PaO2@pH7.3 PaO2@pH7.4 PaO2@pH7.5
--------------------------------------------------
99 171 158 143
98 122 111 101
97 101 92 84
96 89 82 74
95 82 74 68
94 76 69 63
93 72 66 60
92 68 62 57
91 66 60 55
90 63 58 53
88 59 54 49
86 56 51 47
84 53 49 44
82 51 47 42
80 49 45 41
78 47 43 39
76 45 41 38
74 44 40 35
72 42 39 34

OK, so w|at aro norma| va|uos tor a '$()*+ b|ooo gas!
T|o vonous O
2
|s oasy. vonous O
2
|s norma||y ^O mm Hg. T||s |s t|o samo as t|o norma| artor|a| CO
2
, ma||ng |t
oasy to romombor.
T|o vonous CO
2
|s a|so rotty oasy. T|o vonous CO
2
|s 5.7 mm Hg ||g|or t|an artor|a|. For ract|ca| urosos,
ca|| |t 6 mm Hg. Norma| artor|a| CO
2
|s ^O (samo as t|o vonous O
2
romombor!), so norma| vonous CO
2
|s ^6.
S|m|o, roa||y.
Norma| H tor an artor|a| b|ooo gas |s 7.357.^5, ano norma| tor a vonous gas |s just a ||tt|o moro ac|oot|c, as you'o
oxoct: 7.327.^2. So t|o vonous H |s usua||y just O.O3 |owor t|an t|o artor|a|. So ta|o your vonous H ano aoo
O.O3 to |t to got t|o oqu|va|ont |n artor|a|H torms. 8ut, roa||y, O.O3 |s a vory sma|| numbor, ano robab|y not a|| t|at
c||n|ca||y s|gn|t|cant, so |t you just romombor t|at t|o vonous ano artor|a| H aro about t|o samo, t|at's gooo onoug|
tor govornmont wor|.
Venous Blood Gas:
pH - 0.03 lower than arterial pH unless low-flow state (basically the same)
pO2 - 40-50
pCO2 - 5.7 higher than arterial pCO2 (46 rather than 40)

So, |t you'ro worr|oo your at|ont |as ac|oos|s or carbon o|ox|oo rotont|on, just c|oc| a vonous gas. lt |t's OK, t|on
so's t|o at|ont's CO
2
|ovo| ano ac|obaso status.
25

Conovor's A8G Hanoout 1.6
Pago 3 ot 9

;.5<= #*' >54$-
Loo||ng to t|guro out somoono's ac|obaso status |n a |urry! lgnoro a|| t|o vorb|ago |n t||s |anoout oxcot w|at's |n
t|o two c|un|s ot boxoo toxt bo|ow. (Somot||ng o|so t|at's on t|o caro at t|o ono so you can |oo |anoy.)

Check the pH on the blood gas to tell whether the patient has an
Acidemia (pH) or Alkalemia (pH) or EupHemia (normal pH).

Check the bicarb on the SMA-6 and the pCO2 on the gas. pH with
[HCO3-], or pH with [HCO3-], indicates a primary metabolic acidosis
or alkalosis; pH with pCO2, or pH with pCO2, indicates a primary
respiratory acidosis or alkalosis.

Check for the expected degree of compensation. (Empiric Equations Below)

For metabolic acidosis, check to see if it is an anion gap acidosis, a
non-anion gap acidosis, or a mixed disorder. If all of the acidosis
is due to anion-gap acids, then the increase in the anion gap should
be the same as the decrease in the [HCO3-]. E.g., if the A.G. is 20
(normal 12), and the [HCO3-] is 19 (normal 27), then all of the
acidosis (all of the [HCO3-]) is due to the A.G. from excess organic
acids that form the anion gap.

T|oro aro about a z||||on om|r|c oquat|ons t|at ro|ato CO
2
, H, ano b|carbonato. T|oro aro a|so com||catoo
|oo||ng gra|s ("nomograms") t|at oo ossont|a||y t|o samo t||ng tor you.
|ust |c| a cou|o ot t|o s|m|o oquat|ons to momor|zo or wr|to oown. lgnoro a|| t|o rost un|oss somoono
torcos you to |oo| at t|om. My bost |c|s aro |n t|o box bo|ow.

For metabolic acidosis, Winters' equation:
pH = 1.5 ([HCO3-] + 8) 2
for good compensation except:
lactic acidosis may have overcompensation due to CNS effects.

For metabolic alkalosis or acidosis, with respiratory compensation:
pCO2 = last 2 digits of the pH = [HCO3-] + 15
(for [HCO3-] from 8 to 35)

For respiratory acidosis, every increase in pCO2 has an expected
decrease in pH:
pCO2 10 = pH .08 (acute)
pCO2 10 = pH .03 (later, with metabolic compensation)

For respiratory alkalosis, each decrease in pCO2 has an expected
increase in bicarbonate:
pCO2 10 = [HCO3-] 2 (acute)
pCO2 10 = [HCO3-] 5 (chronic/compensated)
*
*P|oaso noto t|at |n t|o rov|ous oo|t|on (1.7) t|oro was a tyo: t|o arrows |n tront ot t|o ros|ratory a||a|os|s
[HCO3j woro u arrows w|oro t|o s|ou|o |avo boon oown arrows. My ao|og|os tor any contus|on t||s causoo.

|
SMA6" |s t|o o|o namo tor c|om6" or bas|c motabo||c ano|." lt moans 8UN, Cr, o|octro|ytos, SMA7" aoos a g|ucoso. SMA" |s Soquont|a| Mu|t|
Ana|yzor" w||c| was t|o t|rst commorc|a| mu|t||otost |ab c|om|stry mac||no. Yos, |t's an o|o tas||onoo torm, but |oy, w|at's t|o mattor w|t| t|at! A sonso ot
trao|t|on |s |mortant, t|at's w|y l st||| uso woros |||o mon|||a| |ntortr|go" ano ov|| |umours."
|
Nono but ros|ratory a||a|os|s can |avo comonsat|on a|| t|o way bac| to a norma| H. A norma| H w|t| any ot|or o|soroor |no|catos a socono,
suor|mosoo, ac|obaso o|soroor. A|so, noto t|at SMA6 autoana|yzor may not accurato|y ootorm|no vory ||g| HCO3

, so t|o [HCO3

j must bo oono manua||y

by t|o |ab.
Conovor's A8G Hanoout 1.6
Pago ^ ot 9

Ano t|at's a|| you nooo to |now about b|ooo gas ana|ys|s.
\o||||, not roa||y... you m|g|t want to |now a b|t moro about w|at causos ano ma|nta|ns oac| ot t|o tour ma|n
abnorma||t|os, ano w|at to oo about t|o rob|oms you ootoct.
T|o roma|noor ot t||s |anoout |s a rotoronco to t|o tour r|mary ac|obaso o|sturbancos, ano t|o ossont|a| c||n|ca|
toaturos ot oac|, a|so w|t| ostscr|ts on t|o Aa grao|onts ano on b|ooo gasos ano |yot|orm|a. \o start w|t| t|o
s|m|o, ano movo to t|o moro com|ox. T|o |ntormat|on |n sma|| r|nt |s somow|at osotor|c, just somo ot my own
notos trom ast |octuros l'vo attonooo myso|t.
?)+@54#$&4- 3<5'&+5+
F|rst, romombor t|o troatmont tor ros|ratory ac|oos|s. lt |s not ca|cu|at|ons, |t |s not orugs, |t |s a|rway ano broat||ng.
(Pomombor your A8Cs!)
Socono, ros|ratory ac|oos|s tonos to causo C|

|oss ano vo|umo oo|ot|on by un|nown moc|an|sms. (Sourco:

8urton Dav|o Poso, 3&%(%4!& 67,+%)&)8, ). 9&$4#")&,#$ !(: ;4%:<1!+$ =%+)":$"+, w||c| |s a just outstano|ng boo|.)
?)+@54#$&4- 30=#0&+5+
Causos:
Sa||cy|ato ovorooso, osoc|a||y |n c|||oron (m|xoo w|t| an|onga motabo||c ac|oos|s, w||c| rooom|natos |n
|ator stagos).
C|rr|os|s ( rogostorono |n b|ooo!) ano ||vor ta||uro ( am|nos |n b|ooo!)
Lar|y stagos ot sos|s.
Psyc|ogon|c |yorvont||at|on.
Prognancy ( rogostorono).
Pont|no |os|ons.
Acuto |yox|a (o.g., PL).
Pos|ratory a||a|os|s w||| HCO3

s||g|t|y ouo to convors|on to CO

2
.
\||| |avo s||tt trom yruvato to |actato |n b|ooo, caus|ng m||o an|on ga comonsatory ac|oos|s.
Usua||y comonsatos tota||y ovor 23 oays.
May causo asymtomat|c PO^.
A)$#/&05< 3<5'&+5+
!"#$% '()$%"*+, "$ "% -.)'(-%)/0 1*23)+$-%).4
Uso ono ot t|o two tormu|as |n t|o box abovo.
5)1*+. '()$%"*+, "$ "% -+ 6+"*+ 7-3 *# - 8*+9-+"*+9:-3 ;<03)#1</*#)2"1= 2)%->*/"1 -1".*$"$4
[Na
+
j ([C|

j + [HCO3

j) >> 12 |s an|on ga ac|oos|s

[Na
+
j ([C|

j + [HCO3

j) 12 |s |yorc||orom|c (nonan|on ga) ac|oos|s

|n an|on ga s|ou|o bo samo as |n HCO3

, or |as 8OTH an|onga ano nonan|onga motabo||c

ac|oosos.
?":< 6+"*+ 7-3 @)%->*/"1 61".*$)$
Mnomon|c KUSMAL:
K |otoac|oos|s
Conovor's A8G Hanoout 1.6
Pago 5 ot 9

U urom|a
S sa||cy|atos
M mot|ano| (ano ot|y|ono g|yco|, ara|oo|yoo)
A a|co|o| (LtOH)
L |act|c ac|oos|s
Norma| An|on Ga (Hyorc||orom|c) Motabo||c Ac|oosos
o|v|ooo |nto ||g| K
+
vs. |ow K
+

!> 7%87 ?
@

1. |yora| ano |ncroasoo am|no ac|o catabo||sm
2. ost|yocan|c (|t ta|os a w|||o tor t|o HCO3

to r|so)
3. o||ut|ona|
^. |yoa|oo (o|t|or trom |ow ron|n or aorona| oystunct|on)
5. NH
^
C|, CaC|
2
, |ys|no, or arg|n|no (ottoct|vo|y aoos HC|)
-> &)/ ?
@

1. Gl: o|arr|oa, t|stu|as (K
+
|oss ano ||g| a|oo)
2. GU: surg|ca| urotora| conou|ts
3. PTA: Pona| Tubu|ar Ac|oos|s. Com|ox subjoct bost |ott to outs|oo roao|ng or a no|ro|ogy rotat|on.
A)$#/&05< 30=#0&+5+
Motabo||c a||a|os|s |s a com|ox o|soroor, ano unoorstano|ng ot motabo||c a||a|osos |as gonora||y boon an arcano art,
w|oso ract|t|onors aro susoctoo ot acts w|t| t|o oov||. Howovor, |t nooo not bo qu|to so com|ox. T||s
rosontat|on rov|oos t|roo o|ttoront v|ows ot motabo||c a||a|os|s: Pat|o|ys|o|ogy, C|ass|t|cat|on, ano Troatmont.
A-%<*3<0$"*/*:0 *B @)%->*/"1 6/C-/*$"$
!"#$%"& ()(*+
T|o r|mary ovont |s o|t|or |oss ot H
+
or ga|n ot HCO3

. Lxam|os: uor Gl |ossos trom vom|t|ng or NG suct|on,

H
+
|oss trom t|o ||onoy. Or, H
+
may movo |nto t|o co||s bocauso ot a |ow sorum K
+
. A||a|os|s may a|so rosu|t trom
aoo|t|on ot HCO3

or (urortoo|y) "contract|on" ot t|u|o vo|umo arouno a t|xoo amount ot HCO3

.
$%#*+(*%*,(
A||a|os|s w||| qu|c||y bo corroctoo by comonsatory moc|an|sms un|oss somo tactor |s act|ng to ma|nta|n t|o
a||a|os|s. Sovora| tactors may ma|nta|n an a||a|os|s, a|| by oocroas|ng HCO3

oxcrot|on (|ta||cs bo|ow):

; 7%87 !&:)+#$")($ +#!#$A $%#7$" B"%C!", )" +$4)(:!",
D

?
@
)" 3&
<

SLCONDAPY HYPLPALDO may bo ouo to: vo|umo, or ottoct|vo vo|umo (o.g. |n c|rr|os|s, CHF, no|rot|c synoromo), or C|

(or|as t|o ottoctor ot

oocroasoo vo|umo), bot| causo soconoary a|oo (w||c| causos soo|um av|o|ty |n t|o o|sta| tubu|o).
PPlMAPY HYPLPALDO may bo ouo to: tumor, ||cor|co (g|ycyrr||z|c ac|o |n ||cor|co |s s|m||ar to a|oo), or 8arttor's synoromo: congon|ta| |yortro|y ot
juxtag|omoru|ar aaratus w|t| ron|n ano |nab|||ty to roabsorb C|

.
H|g| a|oo (a|ong w|t| Na
+
oo||vory to t|o o|sta| a|oosons|t|vo aroas ot t|o tubu|o trom o|urot|cs or HCO3

ovor w|at t|o rox|ma| tubu|o can absorb)

causos Na
+
roabsorbt|on ano ob||gato K
+
or H
+
oxcrot|on. Attomts to rota|n Na
+
/HCO3

by t|o o|sta| tubu|o |oao to socrot|on ot H

+
to orm|t rocovory ot
t|o HCO3

, ot|orw|so, a |argo amount ot Na

+
wou|o bo |ost a|ong w|t| t|o HCO3

, rosu|t|ng |n vo|umo oo|ot|on.

Conovor's A8G Hanoout 1.6
Pago 6 ot 9

E7$ "$(!& EC .)" F3GH
<
C!, -$ "$+$# -, !&& ). #7$ !-)'$A !(: -, ')&*C$>
II

J)(<"$+)"-!-&$ !(%)(+ K$>8>A B$(%4%&&%(A 4!"-$(%4%&&%(L #!M$ F3GH
<
/%#7 #7$C>
B3G
N
+$4)(:!", #) !&M!&)+%+ 4!*+$+ ! E9OEP;OQ "$(!& F3GH
<
"$#$(#%)( K*B #) RST ). #7$ F3GH
<
%( C$#!-)&%4
!&M!&)+%+ C!, -$ +$4)(:!", #) #7%+L>
UU

O$(!& .!%&*"$ /%#7 :$4"$!+$: F3GH
<
.%&#"!#%)( K"!"$L
; C$#!-)&%4 !&M!&)+%+ K-*# ()# !&M!&$C%!L C!, -, ! 4)CB$(+!#)", &)++ ). F
@
:*$ #) B"%C!", "$+B%"!#)", )" C$#!-)&%4
!4%:)+%+> K3!*+$: -, F
@
%( "$(!& #*-*&$ 4$&&+>L
,-.//0102.3045 41 $63.74-02 %-8.-4/0/9
T||s soct|on |s |n sma||or r|nt bocauso |t's moro com||catoo t|an t|o rost ano robab|y not wort| roao|ng unt|| you
actua||y |avo a at|ont w|t| motabo||c a||a|os|s |n tront ot you. T|roo o|ttoront v|ows ot motabo||c a||a|os|s aro rosontoo.
Lac| c|ass|t|os a|| t|o a||a|osos |n a o|ttoront way. No ono c|ass|t|cat|on |s c|oar|y suor|or.
C|ass|t|cat|on #1: C||or|oorosons|vo vs. Nonc||or|oo rosons|vo Motabo||c A||a|os|s
a. C||or|oo Posons|vo Motabo||c A||a|os|s
Ur|nary C|

< 2O mLq/| moans c||or|oorosons|vo, w||c| w||| rosono to NaC|. Most a||a|osos aro |n t||s catogory
ano aro assoc|atoo w|t| norma| or |ow b|ooo vo|umos:
1. Gastr|c t|u|o |oss
2. D|urot|cs
3. Post|yorcan|c
^. D|arr|oa| |ossos ot C|

(congon|ta| or v|||ous aoonoma)

b. C||or|oo Unrosons|vo Motabo||c A||a|os|s
Ur|nary C|

> 2O mLq/| moans not c||or|oorosons|vo. T|oso a||a|osos aro raro, ano aro assoc|atoo w|t| norma| to
|ncroasoo |asma vo|umo. T|o rob|om |s vo|umo oxans|on soconoary to |yora|oo., sovoro K
+
, or sovoro C|

,
+ |oao|ng to HCO3

|oss, g|vo |onty ot K

+
, troat w|t| |argo oosos ot A|oactono (s|rono|actono) to |n||b|t t|o a|oo
ottoct. Causos:
1. Conn's o|soaso (r|mary |yora|oo)
2. Cus||ng's synoromo (cort|so| |as somo m|nora|ocort|co|o ottoct)
3. Congon|ta| aorona| |yor|as|a
^. 8arttor's synoromo (congon|ta| |yortro|y ot juxtag|omoru|ar aaratus w|t| ron|n ano |nab|||ty to
roabsorb C|

)
5. truo ||cor|co |ngost|on (g|ycyrr||z|c ac|o |n ||cor|co |s s|m||ar to a|oo)
6. ! rotouno K
+
oo|ot|on w|t| GFP
c. Unc|ass|t|oo Motabo||c A||a|os|s
1. a||a|| aom|n|strat|on
2. m|||a||a|| synoromo
3. g|ucoso |ngost|on attor starvat|on (un|nown moc|an|sm)
^. b|ooo transtus|on (c|trato)
5. |argo oosos ot on|c||||n or carbon|c||||n (causo |ncroasoo oxcrot|on ot K
+
ano H
+
ouo to |argo t||toroo |oao
ot |ons)
C|ass|t|cat|on #2: Motabo||c A||a|os|s by Poot Causos
a. Uor Gl H
+
|ossos (vom|t|ng or NG suct|on)
b. Pona| H
+
|ossos (o.g. o|urot|cs, |yora|oo)
1. D|urot|cs ("contract|on"), actua||y, o|urot|cs robab|y causo motabo||c a||a|os|s by moc|an|sms
ooscr|boo unoor "at|oys|o|ogy" rat|or t|an by contract|on arouno t|o HCO3

2. Pr|mary m|nora|ocort|co|o oxcoss
3. K
+
(sovoro) w|t| GFP
c. Co|on|c H
+
|ossos (o|arr|oa or v|||ous aoonoma or |axat|vo abuso w|t| soconoary rona| oystunct|on!)
o. A||a|| |ngost|on (lv or PO b|carb or CaCO3) (raro)
o. Post|yorcan|c: attor CO2 norma||zoo, ta|os a w|||o tor t|o comonsatory HCO3

to norma||zo.
t. Hyoarat|yro|o|sm: PTH causos HCO3

oxcrot|on, |ac| > rotont|on.

C|ass|t|cat|on #3 ot Motabo||c A||a|osos: An|on Ga vs. nonAn|on Ga

**
Moc|an|sm: |ncroasoo H
+
|n rona| tubu|o co||s (bocauso ot K
+
ott|ux |n K
+
) causos H
+
oxcrot|on.
||
"Motabo||c a||a|os|s", Harr|ngton, |o|n T., K|onoy lntornat|ona|, 26(198^) 8897.
Conovor's A8G Hanoout 1.6
Pago 7 ot 9

a. H|g| An|on Ga Motabo||c A||a|osos
1. + c|argos on |asma roto|ns trom H
2. |ncroasoo |actato roouct|on
3. oocroasoo |actato motabo||sm (o.g. |n ||vor ta||uro w|t| |yora||montat|on)
b. Norma| An|on Ga Motabo||c A||a|osos
1. Ca
++

2. Mg
++

3. araroto|ns
^. ||t||um
D#)-%2)+% *B @)%->*/"1 6/C-/*$"$
:; < =>?@ ./AB:34B.302 C2D-4E0F6GE6/:45/0H6 .//IB6FJ
vo|umo oo|otoo: g|vo lvNS ano K
+
(baso amount ot K
+
on ur|no C|

), soo bo|ow.
ooomatous but |ntravascu|ar|y oo|otoo (CHF, no|ros|s, c|rr|os|s): g|vo a|bum|n to |ntravascu|ar vo|umo
|t aror|ato, ro|oto K
+
aggross|vo|y, ano cons|oor D|amox (soo bo|ow)
vo|umo oxanooo (raro): 8%'$ ?3& B) )" P0
:; K =>?@ /AB:34B.302 C2D-4E0F6GE6/:45/0H6 .//IB6FJ
mon|toroo boo
NH
^
C| or HC| lv
o 2O^O mLq/|r ot O.1 N or O.15 N HC| t|roug| contra| ||no (NH
^
C| can bo g|von PO, but must bo
avo|ooo |n c|rr|os|s or rona| ta||uro bocauso ot NH
3
bu||ou)
o 1OO mLq H
+
s|ou|o HCO3

by 7 mLq/L
o to||ow |our|y H, CO
2
, HCO
3

o sto w|on H < 7.6 ano at|ont asymtomat|c
Acotazo|am|oo (D|amox)
o watc| tor K
+
, must su|omont w|t| mass|vo amounts KC|
o 25O mg lv Q8H
o sto w|on H < 7.6 ano at|ont asymtomat|c
!"#$%&'"()*+$(+,-"#,).+/
Ur|nary C|

> 2O mLq/| moans not c||or|oorosons|vo (raro), so rob|om |s robab|y r|mary |yora|oo, or sovoro
|ac| ot K
+
|oao|ng to HCO3

|oss, g|vo |onty ot K

+
, ano g|vo |argo oosos ot A|oactono (s|rono|actono) to b|oc| a|oo
rocotors.
B.4$")4 ?)#'5*1
lt you aro st||| uzz|oo by ac|obaso ba|anco, ano not too nausoatoo by t|o oonso |ntormat|on abovo, you s|ou|o |c|
u a gooo boo| on t|o to|c. T|oro's a boo| by Stryor t|at |s vory wo||t|oug|ot, but my orsona| tavor|to |s 3&%(%4!&
67,+%)&)8, ). ;4%: 1!+$ !(: 9&$4#")&,#$ =%+)":$"+ by 8urton Dav|o Poso. lt you can't t|no |t |n t|o boo|storo, got |t trom
www.amazon.com.
l |oo you t|no t||s ||tt|o |anoout usotu|. lt's just cobb|oo togot|or trom my own notos, ano |s rotty roug|, but
romombor, |t's at |oast wort| w|at you'ro ay|ng tor |t (not||ng).



Conovor's A8G Hanoout 1.6
Pago 8 ot 9

3@@)*'5C D2 EC-1)*#$5&*2 $") 3F# 14#'5)*$
Lva|uat|ng t|o O
2
on room a|r |s oasy: t|o |ab usua||y r|nts out norma| va|uos tor you, ano ovon uts a ||tt|o
astor|s| noxt to |ow va|uos. 8ut w|at |t t|o at|ont's O
2
|s |ow norma|, but t|o CO
2
|s bo|ow norma|. Cou|o t||s
moan t|o at|ont |s |av|ng to wor| |aro to |oo t|o O
2
u, caus|ng a |ow CO
2
! Cou|o t||s moan t|o at|ont |as a
b|g u|monary ombo||sm or a bao noumon|a, oos|to a "norma|" O
2
! You botc|a.
||

ls t|oro any sc|ont|t|c way to tactor t|o CO
2
|nto your t|gur|ng! Suro onoug|. T||s ca|cu|at|on |as t|o
|nt|m|oat|ng namo ot t|o Aa Grao|ont. Ano, oor|v|ng |t trom t|rst r|nc||os can bo o|tt|cu|t. 8ut us|ng t|o tormu|a |s
|ncroo|b|y s|m|o. |ust |oo |t wr|tton oown somow|oro so you can t|no |t w|on you nooo |t.
69- 7#-.")+% C%-H64-.EG.E36E0.- LMAN65 OE.F0653J
Uso: To quant|ty A8G rosu|ts to ost|mato t|o avorago grao|ont across t|o a|voo|ar mombrano. An |ncroasoo Aa
grao|ont |s soon |n u|monary ombo||sm, noumon|as, APDS, otc.
Norma| Aa grao|ont:
+,) -..)/ 01213 #4 5#/2'"
2O 17
3O 21
^O 2^
5O 27
6O 31
7O 3^
8O 38

From: Morr|s A, Kamor P, Crao P, ot a|. C||n|ca| u|monary tunct|on: a manua| ot un|torm |aboratory rocoouros,
2L. Sa|t La|o C|ty: lntorMounta|n T|orac|c Soc|oty, 198^:^5. Quotoo |n Lmorgoncy Moo|c|no Poorts, 12/1^/92.
Norma| va|uos |ncroaso w|t| ago, ano smo||ng or occuat|ona| noumocon|os|s w||| a|so |ncroaso t|o Aa grao|ont.
Lquat|on: Aa grao|ont (713 (FlO
2
) 1.2 (CO
2
)) (O
2
)
For room a|r: Aa grao|ont |s: 15O 1.2(CO
2
) O
2

Dor|vat|on:
(A|voo|arO
2
) (Fract|ona| lns|roo O
2
) * (Atmos|or|c Prossuro art|a| rossuro ot wator |n saturatoo a|r)
(A|voo|ar CO
2
/P) (w|oro P |s t|o ros|ratory coott|c|ont, t|o amount ot CO
2
rooucoo or mo|ocu|o ot O
2

usoo) or:
AO
2
(FlO
2
(76O^7)) (ACO
2
/P) or,
s|nco ra|o o|ttus|on ot CO
2
across t|o a|voo|ar mombrano moans t|at ACO
2
ano aCO
2
aro t|o samo:
AO
2
713(FlO
2
) 1.2(aCO
2
)

||
Ono noto: |t try|ng to o|agnoso u|monary ombo||sm |n a at|ont w|t| c|ost a|n, syncoo, or unox|a|noo tac|ycaro|a, oon't uso t|o Aa grao|ont, or a O2, or
ovon a u|so ox|motor roao|ng to |o| you ooc|oo |t |t's a PL. lt just ooosn't |o|. Yos, by a|| moans c|oc| t|o at|ont's oxygonat|on to soo |ow s|c| t|o at|ont |s
ano w|ot|or t|o at|ont nooos oxygon. 8ut t|o major|ty ot oo|o w|t| a PL w||| not |avo |ow oxygonat|on. lnoooo, |t's ovon sa|o (corroct|y) t|at, |t you |avo two
young |oa|t|y womon w|t| |our|t|c c|ost a|n, ano ono |as a norma| u|so ox ano t|o ot|or |as a |ow u|so ox, t|o ono w|t| t|o norma| u|so ox |s moro |||o|y
to |avo a PL. Truo. T|o ono w|t| t|o |ow u|so |s |s moro |||o|y to |avo a noumon|a.
Conovor's A8G Hanoout 1.6
Pago 9 ot 9

#7$"$.)"$: Aa O
2
(713(FlO
2
) 1.2(CO
2
)) O
2
3@@)*'5C DD2 G-@&$")4,5# #*' /0&&' 1#+)+
You may |oar about "corroct|ng b|ooo gasos tor |yot|orm|a." T|o b|ooo gas b|ooo |s warmoo to room
tomoraturo w|on t|o syr|ngo |s |njoctoo |nto t|o A8G mac||no. T|orotoro, t|o |ab wants to |now |t t|o at|ont |s
|yot|orm|c, so t|oy can "corroct" t|o numbors. Lab oo|o want to "corroct" t|o numbors so t|at t|oy g|vo you
oxact|y corroct numbors, rot|oct|ng oxact|y w|at t|o H ano CO
2
aro |n t|o at|ont's b|ooo. Dos|to t|oso gooo
|ntont|ons ot t|o |ab oo|o, LlL TO THLM. lt t|oy as| |t t|o at|ont |s |yot|orm|c, say no. lt somoono |s ta||ng t|o
gas to t|o |ab, ano m|g|t to|| t|o |ab t|o at|ont |s |yot|orm|c, uso ouct tao ovor t|o orson's mout| botoro
sono|ng ||m or |or to t|o |ab.
\|y! Ono vory |mortant roason.
You'vo |nvostoo cons|oorab|o t|mo ano onorgy |n |oarn|ng about room tomoraturo b|ooo gasos. 8ut, oo you
|avo any |ooa w|at a norma| H or CO
2
|s at 3OC! At 25C! l oon't, ano |yot|orm|a |s ono ot my soc|a|t|os.
8ut |t turns out t|at |t you warm t|o b|ooo gas to a norma| tomoraturo, ano oon't corroct tor |yot|orm|a, t|on t|o
numbors you got comaro a|most ortoct|y w|t| a roomtomoraturo gas. For oxam|o, t|o at|ont |s |yot|orm|c
to 25C. You got an uncorroctoo H ot 7.^. T||s moans t|o at|ont |s not ac|oot|c (ac|oom|c), ano not a||a|ot|c
(a||a|om|c). lt you got a "corroctoo" gas, you'o |avo to go |oo| u |n a tab|o w|at t|o norma| H |s tor a coro
tomoraturo ot 25 C. E7$ ()"C!& BF !# NV3 %+ ()# W>R> X!C$ t||ng tor CO
2
. E7$ ()"C!& B3G
N
!# NV3 %+ ()# RS>
Got |t!
T|oro |s ono oxcot|on, t|oug|. Corroct|ng tor tomoraturo |s aror|ato w|on you'ro cons|oor|ng O
2
on an
!"#$"%!& gas. Horo's t|o tr|c| l uso: sono t|o gas u w|t|out any mont|on ot |yot|orm|a, t|on uso t|o CO
2
ano H
to t|guro out t|o at|ont's ac|obaso status. T|on ca|| t|o |ab ano say "o|, by t|o way, t|o at|ont's coro tomoraturo
|s 25C, so you cou|o you to|| mo t|o corroctoo O
2
!" Ano w|on t|oy try to g|vo you t|o corroctoo H ano CO,
just ut your t|ngors |n your oars.
\o||, now you |now w|y you |oo t|o |ab oo|o |n t|o oar| about your at|ont's tomoraturo: to |oo t|om
trom contus|ng you, ano to |ot you uso your roomtom ac|obaso |now|oogo to roor|y manago your at|ont.

1. Tougor M, Ga||ag|or L|, Tyro|| |. Po|at|ons|| botwoon vonous ano artor|a| carboxy|omog|ob|n |ovo|s |n
at|onts w|t| susoctoo carbon monox|oo o|son|ng. Ann Lmorg Moo 1995,25(^):^813.
2. Gonn|s PP, S|ovron ML, Aronson ST, Ga||ag|or L|. T|o usotu|noss ot or||ora| vonous b|ooo |n ost|mat|ng
ac|obaso status |n acuto|y ||| at|onts. Ann Lmorg Moo 1985,1^(9):8^59.
3. \o|| MH, Pac|ow LC, Trov|no P, Gruno|or \, Fa|| |L, Gr|tto| Ml. D|ttoronco |n ac|obaso stato botwoon
vonous ano artor|a| b|ooo our|ng caro|ou|monary rosusc|tat|on. N Lng| | Moo 1986,315(3):1536.
^. Dur||n P, Gorg|ts MA, Pooo |F, 3ro, F|tzg|bbons |. T|o ro|at|ons|| botwoon t|o artor|ovonous carbon
o|ox|oo grao|ont ano caro|ac |noox. | Cr|t Caro 1993,8(^):21721.
5. Aoroguo H|, Pas|ao MN, Gor|n A8, Yacoub |, Mao|as NL. Assoss|ng ac|obaso status |n c|rcu|atory ta||uro.
D|ttoroncos botwoon artor|a| ano contra| vonous b|ooo. N Lng| | Moo 1989,32O(2O):13126.


B
l
o
o
d

G
a
s
/
A
c
i
d

B
a
s
e

R
e
f
e
r
e
n
c
e

C
a
r
d
K
e
i
t
h

C
o
n
o
v
e
r
,

M
.
D
.
,

F
A
C
E
P


w
w
w
.
c
o
n
o
v
e
r
s
.
o
r
g
P
a
g
e

1

o
f

2




V
e
r
s
i
o
n

1
.
1

5
/
2
6
/
0
6

Check the pH on the blood gas to tell whether the patient has an
Acidemia (pH) or Alkalemia (pH) or EupHemia (normal pH).

Check the bicarb on the SMA-6 and the pCO

2
on the gas. pH with
[HCO
3
-
], or pH with [HCO
3
-
], indicates a primary metabolic acidosis
or alkalosis; pH with pCO
2
, or pH with pCO
2
, indicates a primary
respiratory acidosis or alkalosis.

Check for the expected degree of compensation. (Empiric Equations Below)

For metabolic acidosis, check to see if it is an anion gap acidosis, a

non-anion gap acidosis, or a mixed disorder. If all of the acidosis
is due to anion-gap acids, then the increase in the anion gap should
be the same as the decrease in the [HCO
3
-
]. E.g., if the A.G. is 20
(normal 12), and the [HCO
3
-
] is 19 (normal 27), then all of the
acidosis (all of the [HCO
3
-
]) is due to the A.G. from excess organic
acids that form the anion gap.

For metabolic acidosis, Winters equation:

pH = 1.5 ([HCO
3
-
] + 8) 2
for good compensation except:
lactic acidosis may have overcompensation due to CNS effects.

For metabolic alkalosis or acidosis, with respiratory compensation:

pCO
2
= last 2 digits of the pH = [HCO
3
-
] + 15
(for [HCO
3
-
] from 8 to 35)

For respiratory acidosis, every increase in pCO2 has an expected

decrease in pH:
pCO
2
10 = pH .08 (acute)
pCO
2
10 = pH .03 (later, with metabolic compensation)

For respiratory alkalosis, each decrease in pCO2 has an expected

increase in bicarbonate:
pCO
2
10 = [HCO
3
-
] 2 (acute)
pCO
2
10 = [HCO
3
-
] 5 (chronic/compensated)

N
o
r
m
a
l

V
e
n
o
u
s

B
l
o
o
d

G
a
s

v
a
l
u
e
s
:
p
H
:

7
.
3
2
-
7
.
4
2

(
0
.
0
3

l
e
s
s

t
h
a
n

a
r
t
e
r
i
a
l
:

7
.
3
5
-
7
.
4
5
)
p
C
O
2
:

4
6

(
6

m
o
r
e

t
h
a
n

a
r
t
e
r
i
a
l
:

4
0
)
p
O
2
:

4
0
-
5
0
SaO
2
PaO
2
@pH 7.3 PaO
2
@pH 7.4 PaO
2
@pH 7.5
--------------------------------------------------
99 171 158 143
98 122 111 101
97 101 92 84
96 89 82 74
95 82 74 68
94 76 69 63
93 72 66 60
92 68 62 57
91 66 60 55
90 63 58 53
88 59 54 49
86 56 51 47
84 53 49 44
82 51 47 42
80 49 45 41
78 47 43 39
76 45 41 38
74 44 40 35
72 42 39 34
Blood Gas/Acid Base Reference Card
Keith Conover, M.D., FACEP www.conovers.org
Page 2 of 2 Version 1.1 5/26/06
High Anion Gap Metabolic Acidoses Mnemonic
KUSMAL:
K- ketoacidosis
U- uremia
S- salicylates
M- methanol (and ethylene glycol, paraldehyde)
A- alcohol (EtOH)
L- lactic acidosis
Normal Anion Gap (Hyperchloremic) Metabolic Acidoses
divided into high K
+
vs. low K
+
a. high K
+
1. hyperal and increased amino acid catabolism
2. post-hypocapnic (it takes a while for the HCO
3
-
to
rise)
3. dilutional
4. hypoaldo (either low renin or adrenal dysfunction)
5. NH
4
Cl, CaCl
2
, lysine, arginine (~= adds HCl)
b. low K+
1. GI: diarrhea, fistulas (K+ loss and high aldo)
2. GU: surgical ureteral conduits
3. RTA: Renal Tubular Acidosis. Complex.