Jason Hautala The Monster Method of ABG Interpretation Arterial blood gas (ABG) interpretation can be a scary thing to learn. hat !orries people the "ost about ABGs is that the patients that ha#e the" dra!n are usually pretty sic$. This can dra"atically increase the stress le#el. %ou then ha#e to thin$ bac$ to !hat the nor"al ranges are and !hether the results sho! an acidosis or an al$alosis& !hether it is co"pensated or not& and if so& by ho! "uch. All of this can be o#er!hel"ing. I re"e"ber the first fe! ABG results I got bac$ as a nurse. I loo$ed at the" as if they !ere so"e type of "onster. hat !ere these nu"bers trying to tell "e' I still loo$ at ABG results as if they !ere "onsters& but not the scary $ind. I loo$ at the" as the nice& soft& fury& colorful "onsters you !ill find in a children(s toy store. To use this "ethod of ABG interpretation& you ha#e to #isuali)e each ABG as if it !ere a fury "onster& and based on the color of his fur and clothing& you can figure out e#erything you need to $no! about his acid*base balance. Good luc$. Hello e#erybody+ I(" an ABG "onster. Many people are afraid of ABG "onsters& but I !ill sho! you that there is no reason to be afraid. All ABG "onsters can gi#e you infor"ation about their pH& ,a-./& and bicarb le#els. I(ll sho! you ho! easy it is to understand all of this data. The first piece of infor"ation you can get fro" an ABG "onster is his pH. The pH is a "easure"ent of ho! "uch acid and base is in a fluid. The lo!er the nu"ber is& the "ore acidic the fluid. The higher the nu"ber is& the "ore basic& or al$alotic& the fluid. The nor"al range for pH in arterial blood is 0.1230.42. If you !or$ s!ing shift in a busy unit& this !ill be an easy range to re"e"ber because it represents the 15 "inutes you ta$e to eat your lunch and #isit the restroo"& 061230642. The color of fur on an ABG "onster depends on his pH. My pH is perfect at 0.45& so "y fur is !hite. ABG "onsters !ith pH le#els less than 0.12 are acidic and !ill ha#e red fur. Monsters !ith pH le#els greater than 0.42 are al$alotic and !ill ha#e blue fur. This is easy to re"e"ber if you thin$ bac$ to your che"istry class. 7it"us paper turns red in an acid solution and blue in a basic& or al$alotic& solution. 7et us practice. If an ABG "onster has a pH of 0./& !hat is the color of his fur' A pH of 0./ is "ore acidic than the nor"al range of 0.1230.42& so his fur is red. If an ABG "onster has a pH of 0.2& !hat is the color of his fur' A pH of 0.2 is "ore al$alotic than nor"al& so his fur is blue. The ne8t piece of infor"ation you should loo$ at on your ABG is the ,a-./ le#el. The ,a-./ le#el is the partial pressure of -arbon 9io8ide& -./& in the arterial blood. -./ can be considered an acid !hen loo$ing at your ABG results. The "ore -./ in the blood& the "ore acidic the blood !ill be& and accordingly& the lo!er the pH. The lo!er the -./ le#el is& the higher the pH. -./ is a !aste product of cellular "etabolis" and is carried fro" the cells to the lungs by the blood. The a"ount of -./ in the blood is regulated by the respiratory syste". The capillaries and al#eoli in the lungs e8change -./ and .8ygen& ./. As you breathe& you increase the a"ount of ./ in your blood and decrease the a"ount of -./. This process is co""only called :blo!ing off; -./& since the -./ lea#es your body as you e8hale. The nor"al #alue for ,a-./ in arterial blood is 12342. This is an easy range to re"e"ber because it is the sa"e nu"bers found in the nor"al pH& 0.1230.42& !ithout the 0. To re"ind you that ,a-./ is regulated by the respiratory syste"& all ABG "onsters !ill !ear color coordinated shirts& depending on their ,a-./ le#el. Monsters !ith a nor"al ,a-./& 12342& !ill !ear !hite shirts& since their ,a-./ le#els are not "a$ing the blood "ore acidic nor al$alotic. Monsters !ith ,a-./ le#els abo#e 42 !ill !ear red shirts to sho! that their -./ le#els are "a$ing the blood "ore acidic& and "onsters !ith ,a-./ le#els belo! 12 !ill !ear blue shirts to sho! that their lac$ of -./ is "a$ing the blood "ore al$alotic. 7et(s practice this once. hat color shirt is an ABG "onster !earing if his ,a-./ le#el is 4<' =ince his ,a-./ le#el is abo#e nor"al& he has "ore -./& an acid& in his blood. Therefore& he is !earing a red shirt to indicate that his respiratory syste" is "a$ing his blood "ore acidic. The third piece of infor"ation to loo$ at on your ABG is the H-.1& (bicarbonate) (bicarb) le#el. Bicarb is a base that "a$es the blood "ore al$alotic. The higher the bicarb le#el is& the higher the pH. The nor"al range for the bicarb le#el "ay #ary slightly fro" one lab to another& but !e !ill use the #alues of //3/> for the standard range. This range for bicarb is also easy to re"e"ber because it is the ages you !ish you !ere& !hen you are no longer that age. The $idneys regulate the a"ount of bicarb in the blood. ?or ABG interpretation& this is called the "etabolic syste". To help you re"e"ber that the $idneys& or "etabolic syste"& regulate the a"ount of bicarb& ABG "onsters !ill !ear color coordinated pants based on their bicarb le#els. Monsters !ith bicarb le#els of //3/> !ill !ear !hite pants& since their bicarb le#els are not "a$ing the blood "ore acidic or al$alotic. Monsters !ith bicarb le#els of less than // !ill !ear red pants& since their lac$ of bicarb !ill allo! the blood to be "ore acidic. Monsters !ith bicarb le#els of "ore than /> !ill !ear blue pants since their e8tra bicarb !ill tend to "a$e the blood "ore al$alotic. 7et(s practice this once. hat color of pants !ould an ABG "onster !ear if his bicarb le#el !ere /5' This bicarb le#el !ould sho! that the $idneys& or "etabolic syste"& !ere e8creting too "uch bicarb into the urine. The loss of this e8tra base !ould "a$e the blood "ore acidic& so this ABG "onster !ould !ear red pants& to indicate the decrease in pH. This is all of the data you need to interpret ABG #alues. 7oo$ at the fur color& the shirt color& and the pants color& and the rest !ill fall into place. Ta$e a loo$ at "y friend here. His pH is 0.15& !hich is "ore acidic than the nor"al range of 0.1230.42. That is !hy his fur is red. @o! loo$ at his ,a-./& !hich is 21. He has "ore -./& !hich is an acid& than the nor"al range of 12342& so his respiratory syste" is "a$ing hi" "ore acidic. That is !hy he !ears a red shirt. 7astly& let(s loo$ at his bicarb le#el. His bicarb is />. The nor"al range of bicarb is //./>& so he !ears !hite pants& since his bicarb le#el is nor"al. Ha#e you figured out !hat type of ABG "onster he is yet' His fur is red& so you $no! he is so"e type of acidosis. @o! !e need to figure out if he is a respiratory or "etabolic acidosis. To do this& find the piece of clothing that "atches his fur color and this !ill tell you !hich syste" is causing the proble". In this case& it is his red shirt that "atches his red fur. The shirt co#ers the respiratory syste"& so he is a respiratory acidosis. 7et(s try another ABG "onster. This "onster(s #alues are6 pH 0.2& ,a-./ 1<& and bicarb 12. The pH is higher than the 0.1230.42 nor"al range& so he has the blue fur of al$alosis. His ,a-./ is in the nor"al range of 12342& so he has on a !hite shirt to indicate that his respiratory syste" is not "a$ing hi" acidic or al$alotic. His bicarb le#el is higher than the nor"al range of //3/>& so he has on blue pants to sho! his "etabolic syste" is raising his pH& "a$ing hi" "ore al$alotic. @o! !e find !hich clothes "atch his fur color& !hich is blue. e see that it is his blue pants& !hich co#er the "etabolic syste"& !hich "atches his blue& al$alotic fur. This is ho! !e $no! that he is a "etabolic al$alosis. 7et(s try one "ore& but be careful not to Au"p to conclusions because this one is a little bit different. This ABG "onster has a pH of 0./<& a ,a-./ of 2/& and a bicarb le#el of /1. hat type of "onster is he' e can see by his pH that he is acidic& so !e $no! !e !ill call hi" so"e type of acidosis& but !hich type' 7et(s see if either his pants or shirt "atch his red& acidic fur. His ,a-./ le#el is high at 2/& so !e $no! his respiratory syste" is not blo!ing off enough acid& so he !ill !ear a red shirt& indicating that it is his respiratory syste" that is "a$ing his blood "ore acidic. 9on(t stop here though+ %ou ha#e to loo$ at his bicarb le#el too. His bicarb le#el is only /1& !hich "eans that his $idneys are du"ping out too "uch base. ?or this reason he !ill also ha#e on red pants& to sho! that his "etabolic syste" is also "a$ing his blood "ore acidic. 7astly& !e loo$ to see !hich articles of clothing "atch his fur& and !e see that both his pants and shirt "atch his red fur color. In this case !e !ill ha#e a respiratory and "etabolic acidosis. Both syste"s are "a$ing his blood "ore acidic. In the last case& both the "etabolic syste" and the respiratory syste" !ere each !or$ing& or not !or$ing& as the case "ay be& to "a$e the blood too acidic. @or"ally though& if one syste" is "a$ing the pH too high or too lo!& the other syste" !ill try to counteract it& so that the pH !ill stay !ithin the nor"al range. ?or this reason& you can ha#e ABG "onsters that ha#e all of their #alues out of the nor"al range& but only one syste" is causing the proble". The other syste" is out of the nor"al range to co"pensate for the proble". As a rule& the respiratory syste" can change the pH #ery Buic$ly by holding onto or blo!ing off -./. It ta$es the "etabolic syste" a longer ti"e to affect the pH by holding onto or e8creting bicarb. Ho! do you $no! !hat to call these ABG "onsters that ha#e one syste" raising the pH and the other syste" lo!ering the pH' 7et(s ta$e a loo$ at another ABG "onster. His pH is 0.4<& his ,a-./ is 4/& and his bicarb le#el is 1/. hat should !e call hi"' His pH is high& so he has the characteristic blue fur of al$alosis. His ,a-./ is also high& but this !ould tend to "a$e hi" "ore acidic& so he has on a red shirt. His bicarb le#el is high also& !hich gi#es hi" blue pants to indicate his "etabolic syste" is "a$ing hi" al$alotic. His fur tells us he is al$alotic and it is his pants that "atch his fur& so !e $no! that he is so"e type of "etabolic al$alosis. hat about his red shirt' In this case& his lungs are trying to hang onto "ore -./ in an effort to "a$e his pH co"e bac$ do!n into the nor"al range. His pH !ould be e#en higher than 0.4< if it !eren(t for the increase in the ,a-./ le#el. ?or this reason !e !ill call this ABG a partially co"pensated "etabolic al$alosis. If his ,a-./ le#el !ere nor"al& and he !as !earing a !hite shirt li$e in our other e8a"ples& he !ould be called a non3co"pensated "etabolic al$alosis& since the respiratory syste" !ouldn(t ha#e been !or$ing to bring the pH bac$ into the nor"al range. hat if one syste" !as able to co"pensate the other syste" enough to bring the pH bac$ into the nor"al range of 0.1230.42' This is often the case& so let(s ta$e a loo$ at another e8a"ple. An ABG "onster has a pH of 0.1>& ,a-./ of 4C& and bicarb of /<. His ,a-./ is higher than nor"al& "a$ing his blood "ore acidic& so he !ill be !earing a red shirt. His bicarb is also high& "a$ing his blood "ore al$alotic& so he !ill be !earing blue pants. His pH& ho!e#er& is nor"al at 0.1>& so !hat is going on' Is it a fully co"pensated respiratory acidosis or a fully co"pensated "etabolic al$alosis' To decide& !e need to loo$ "ore closely at the pH. @or"al pH is 0.1230.42. A pH that is in this range& but closer to 0.12& can be considered to be on the acidic side of nor"al. A pH that is closer to the 0.42 can be considered to be on the al$alotic side of nor"al. The pH in our e8a"ple& 0.1>& is in the nor"al range& but on the acidic side. Therefore& !e are dealing !ith a fully co"pensated acidosis. @o! !e need to loo$ at the syste" that !ould be causing the acidosis. In this case& it !ould be the respiratory syste" that is causing the acidosis& so !e ha#e a fully co"pensate respiratory acidosis. D#en though the "etabolic syste" !as able to bring the pH bac$ up into the nor"al range& it !ill ne#er be able to o#er co"pensate and bring the pH o#er 0.45. In fact& !hen co"pensating for an acidic syste"& it !ould be difficult& if not i"possible& for the other syste" to bring the pH abo#e 1.1C. It !ould be eBually hard for a syste" to co"pensate an al$alotic syste" enough to bring the pH do!n belo! 0.4/. hat color fur do you thin$ this ABG "onster ought to ha#e' To "a$e things si"ple& and to gi#e a little "ore color to our red& !hite& and blue !orld. e !ill say that the fur of an ABG "onster that has a pH bet!een 0.12 and 0.1< !ill be light red& or pin$. This !ill indicate that it is in the nor"al range& but tending to be "ore acidic. e !ill also say that a pH bet!een 0.41 and 0.42 !ill be a light blue& to indicate that it is in the nor"al range& but tending to be "ore al$alotic. 7et(s practice this ne! bit of infor"ation a fe! ti"es. hat color !ould the ABG "onster be if he had a pH of 0./' The correct ans!er !ould be red& since 0./ is lo!er than the nor"al range& "a$ing hi" acidic. hat color !ould an ABG "onster be if he had a pH of 0.4/' In this case& the fur color !ould be a light blue. @ot dar$ blue fur li$e in an al$alotic ABG "onster& but a light blue& indicating that he !as on the basic side of nor"al. hat color !ould a "onster be if he had a pH of 0.10' =ince the nor"al range is 0.123 0.42& this "onster !ould be pin$& or light red& to indicate that he !as on the acidic side of nor"al. In order to $eep all of this straight& Aust re"e"ber that if one syste" is causing the change in the pH and the other syste" is nor"al& then it is an unco"pensated change& based on the color of fur and !hich article of clothing "atches it. If both syste"s are outside the nor"al range& one being red& the other being blue& and the pH is outside the nor"al range& then it is a partially co"pensated proble"& based on the "onster(s pH and !hich syste" is causing that change. If both syste"s are outside nor"al& one acidic and the other al$alotic& and the pH is !ithin the nor"al range& then !e ha#e a fully co"pensated state& and !ill base the na"e on the fact that the pH !ill either be on the acidic or basic side of nor"al& and on !hich syste" is causing that de#iation. Just re"e"ber& if both syste"s are "a$ing the blood "ore acidic or basic& then it is not co"pensated& e#en though both are outside the nor"al range. In these cases it !ould be a respiratory and "etabolic acidosis or a respiratory and "etabolic al$alosis. 7et(s try a fe! "ore& no! that !e ha#e all of the facts. A "onster has a pH of 0.1>& a ,a-./ of 25& and a bicarb le#el of 15. To use a syste"atic "ethod& let(s first loo$ at the pH. In this case& the pH is on the acidic side of nor"al& so his fur color !ill be pin$& or light red. @e8t& his ,a-./ is too high& "a$ing the blood "ore acidic& so his shirt !ill be red& "atching the reddish tint of his fur. 7astly& his bicarb le#el is also too high& but this is a base& so his pants !ill be blue& since his "etabolic syste" is "a$ing his blood "ore al$alotic. =ince it is his shirt that "atches his acidic fur& !e can call this a respiratory acidosis. =ince his "etabolic syste" is going in the opposite direction& trying to fi8 the proble"& and in fact& has brought the pH bac$ into the nor"al range& !e can call this a fully co"pensated respiratory acidosis. If the bicarb and the ,a-./ le#els stayed the sa"e and the pH !as lo!er than 0.12& such as 0.1/& then he !ould ha#e red fur& instead of pin$& and !e !ould call hi" a partially co"pensated respiratory acidosis. hat !ould you call an ABG "onster !ith a pH of 0.4C& a ,a-./ of 4C& and a bicarb le#el of 11' The pH is higher than nor"al& so his fur !ill be a dar$ blue& indicating so"e type of al$alosis. The ,a-./ is high& "a$ing the blood "ore acidic& so his shirt !ill be red. The bicarb le#el is high& "a$ing the blood "ore al$alotic& so his pants !ill be blue. His fur is blue& his shirt is red& and his pants are blue. It is the pants that "atch the blue fur& so !e ha#e a "etabolic al$alosis. His shirt clashes !ith his pants& so there is so"e type of co"pensation going on& but not enough to bring the pH bac$ into the nor"al range& so !e ha#e a partially co"pensated "etabolic al$alosis. If the pH had co"e bac$ into the high end of nor"al and the other #alues re"ained the sa"e& then !e !ould ha#e had a fully co"pensated "etabolic al$alosis and light blue fur. 7et(s try one "ore e8a"ple& pH of 0./<& ,a-./ of 25& and a bicarb le#el of 11. The fur !ill be red& since the pH is belo! nor"al. The shirt !ill be red& since the ,a-./ is abo#e nor"al& and the pants !ill be blue& since the bicarb is abo#e nor"al. Eed fur and red shirt "a$es this a respiratory acidosis. =ince the pants clash !ith the shirt& !e !ill call it a partially co"pensated respiratory acidosis. Had the $idneys been able to bring the pH bac$ into the nor"al range& !e !ould ha#e had a fully co"pensated respiratory acidosis and pin$ fur. %ou should be able to !or$ so"e of these on your o!n no!. Here are a fe! ABG "onsters for you to na"e yourself. The correct ans!ers !ill follo! if you get stuc$. 1. pH F 0.25& ,a-./ F /5& bicarb F />. /. pH F 0./1& ,a-./ F 15& bicarb F 1<. 1. pH F 0.1>& ,a-./ F 21& bicarb F 11. 4. pH F 0.4<& ,a-./ F 11& bicarb F 15. Ans!ers6 1. Blue fur& blue shirt& !hite pants. This gi#es us a respiratory al$alosis !ith no co"pensation. A non3co"pensated respiratory al$alosis. /. Eed fur& blue shirt& red pants. This gi#es us a "etabolic acidosis& !ith so"e respiratory co"pensation. A partially co"pensated "etabolic acidosis. 1. ,in$ fur& red shirt& and blue pants. This gi#es us a respiratory acidosis that is fully co"pensated by the "etabolic syste". A fully co"pensated respiratory acidosis. 4. Blue fur& blue shirt& and blue pants. This gi#es us an al$alosis that is caused by both the respiratory and "etabolic syste"s. A co"bination respiratory*"etabolic al$alosis. Ho! did you do' If you still need !or$& you can "a$e up your o!n ABG #alues and use this syste" to figure out !hat to call your "onsters. Just re"e"ber to loo$ at the fur color first& and then the shirt color& and lastly the pants color& to find !hich ones "atch. %ou can use the attached color coded reference sheet to chec$ your results. But !ait a "inute+ I told you that "y color !as !hite because "y pH !as 0.45. hat should you do if you co"e across an ABG "onster !ith a pH of 0.45' %ou should be happy& because your ABG !ould be nor"al. There is #ery little chance that you !ill e#er see an ABG !ith a perfect pH li$e "ine& and e#en less of a chance if one or "ore of the other le#els are not nor"al. There is one last piece of infor"ation gi#en on the ABG lab report& but don(t !orryG this one is e#en easier than the rest. This piece of datu" is the p./ or the partial pressure of .8ygen in the arterial blood. The nor"al #alue for this is C53155. If your ABG has a nor"al p.// le#el& you call it !hate#er you !ould ha#e called it based on the other ABG #alues. If the p./ is less than C5& then you call it !hate#er the fur and clothes dictate& but you add the !ords& :!ith hypo8e"ia&; to indicate that the blood does not ha#e as "uch .8ygen as it should. If the p./ is greater than 155& you add the !ords& :!ith hypero8e"ia; to your ABG na"e. %ou no! $no! e#erything you need to fully interpret any ABG "onster. They "ay loo$ scary& but they are really there to help you figure out !hat is !rong !ith the patient and !hich syste" is causing the proble". Good luc$+