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
Normal or
Acidosis Alkalosis
Compensated

Step 2. Use PaCO2 to determine respiratory effect.

PaCO2
< 35 35 -45 > 45
• Tends • Tends
toward toward
Normal
alkalosis acidosis
• Causes • Causes low
or
high pH pH
Compensated
• Neutralizes • Neutralizes
low pH 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
Normal
PaCO2 40 Step 2
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

Low pH
pH 7.2 Step 1 indicates
acidosis
High
PaCO2
PaCO2 50 Step 2 indicates
respiratory
cause for
acidosis
respiratory
Interpretation
acidosis

• Example 3

ABG Value Which step? Rationale

High pH
pH 7.49 Step 1 indicates
alkalosis
Low PaCO2
indicates
respiratory
cause for
PaCO2 30 Step 2
alkalosis (lo
respiratory
acid is causing
higher pH)
respiratory
Interpretation
alkalosis

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

• Example 5

ABG Value Which step? Rationale

High pH
pH 7.48 Step 1 indicates
alkalosis
High PaC02
and High pH
indicates
PaCO2 47 Step 3 metabolic cause
of alkalosis.
Respiratory acid
is compensating
for high pH.
Partially
compensated
Interpretation
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.

Low PaCO2
PaCO2 33
causes alkalosis
Step 3
Compensated
Interpretation 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 other’s names.
Now I would like to introduce you to your patient. Let’s 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--she’s thinking about marrying into the ACIDOSIS family. If her pH is 7.41-7.45--she’s
thinking about marrying into the ALKALOSIS family.)

B. The First Name

Now that you know your patient’s 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 patient’s 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. Let’s 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 hasn’t 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