ABG INTERPRETATION

Vicky Honkus MSN RN

2005
Education Department









OBJECTIVES:
Upon completion of this self learning module, the participant will be able to:
1. State the normal values for pH, pCO2 and HCO3.
2. Discuss the basic rules to follow in interpreting ABG results.
2. Explain how compensation is evaluated.
3. Correctly interpret the practice ABG sets in this self learning module.
4. List common causes of acid-base disorders.


































2
The chemical balance of body fluids is of
enormous clinical importance, since it is a
critical factor in all metabolic and cellular
functions. The body's own regulatory
mechanisms usually retain this balance
within normal limits, but certain disease
processes, illnesses and treatments can cause
imbalances that may even become life
threatening, unless appropriate interventions
are implemented. Acid base balance refers to
the hydrogen ion concentration of all body
fluids, which is determined by chemical
substances present in the blood and other
body fluids.

Arterial Blood Gas interpretation is an easy
skill to master. It simply requires an understanding of pH, the respiratory component (pCO2), a
metabolic component (HCO3 and/or Base Excess), what they represent, and what the normal
ranges are.

I. pH

In chemistry class we learned that pH describes the concentration of hydrogen ions, and that a
pH of 7.0 is perfectly neutral. The acceptable pH range of our blood is 7.35 7.45, which is
slightly alkaline. The body needs to maintain the pH of its chemical broth within fairly narrow
limits for proper body functioning. The bodys own regulatory mechanisms usually maintain
this balance, but certain disease processes, illnesses, and treatments can cause imbalances that
may become life threatening unless appropriate interventions are implemented. A pH that is less
than 7.0 or greater than 7.7 is not compatible with life.

The first step in interpreting ABG results is to determine if the pH represents acidosis or
alkalosis, or is perfectly normal. For purposes of ABG interpretation, we will consider the
middle of the acceptable range (7.4) as neutral for the blood, any value less than 7.4 as acidotic,
and any value higher than 7.4 as alkalotic.

pH

a c i d o t i c a l k a l o t i c

7.35 7.4 7.45



Acceptable
ranges:

pH 7.35-7.45

pCO2 35-45

HCO3 22-26

BE +2 to -2


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The following are some pH values for you to practice determining whether a pH is acidic or
alkalotic. Remember to base your decision on a pH of 4.0, which is neutral for blood. Cover up
the answers on the right, and check yourself after your interpretation.

pH 7.0 = _______________________________________acidic

pH 7.9 = _______________________________________alkalotic

pH 7.4 = _______________________________________neutral

pH 7.5 = _______________________________________alkalotic

pH 7.3 = _______________________________________acidic

The pH alone is not sufficient to tell us whether an imbalance is due to a respiratory or metabolic
problem. The other reported values enable us to determine the primary problem, and whether
any attempts are being made by the body to compensate for the imbalance.


II. Bicarbonate-carbonic acid buffer system

The body has several buffer systems that work to maintain the pH within acceptable limits. Of
these, the bicarbonate-carbonic acid buffer system is the most important, and is controlled by the
lungs and kidneys. Normal (aerobic) metabolism produces two forms
of acid: respiratory acid (carbonic acid) and metabolic acids.

In order to maintain proper pH balance, the body attempts to
maintain a ratio of 20:1 (bicarbonate to carbonic acid.) A wide
variety of pulmonary and metabolic problems can create an
imbalance, so it is necessary to look carefully at the respiratory and
metabolic components of ABG interpretation. 20 : 1
bicarbonate carbonic acid


III. Respiratory component

Carbon dioxide is an end product of metabolism, and when dissolved in blood
becomes carbonic acid. Carbonic acid is termed a volatile acid because it
dissociates into water and a gas, CO2 which is exhaled by the lungs. The
pCO2 or PaCO2 represents the partial pressure of carbon dioxide dissolved in
arterial blood, and provides an important measure of the adequacy of a patients
ventilation. The lungs normally maintain an acceptable balance of CO2 (which
is acidotic) in the bloodstream. The normal range for this respiratory component of ABGs, the
pCO2, is 35 45 mmHg, and is maintained by ventilation.

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When the patient is moving a normal volume of air in and out of the lungs, the pCO2 will stay
within the normal range. Hypoventilation will prevent sufficient removal of CO2 from the
bloodstream, causing a respiratory acidosis. Some causes of respiratory acidosis include
obstructive lung disease, restrictive lung disease and hypoventilation as a result of oversedation,
anesthesia or improper ventilator settings (e.g., tidal volume too low.) Respiratory acidosis
could also result from a drug overdose and neuromuscular diseases such as Guillain-Barre
syndrome or myasthenia gravis.

Hyperventilation, on the other hand, causes CO2 to be blown off or removed, causing a
respiratory alkalosis. The pCO2 falls below 35, and the acid-load decreases, causing an alkalosis.
Some possible causes of respiratory alkalosis include pain, panic attacks, anxiety, pulmonary
embolism, pregnancy, and a tidal volume that is too high for a ventilator patient.

The second step in ABG interpretation, is to evaluate the pCO2, to determine if it falls
within the acceptable range, falls below the lower limit (respiratory alkalosis) or is above
the upper limit (respiratory acidosis.)

Notice that a high value in pCO2 actually represents an acidosis (retention of CO2), whereas a
high value in pH represents an alkalosis. Do not try to memorize, but rather to understand the
concept of what the components represent. A high level of pCO2 simply means there is
retention of CO2 or hypoventilation. CO2 is acidotic in the blood, and too much causes
respiratory acidosis.

Practice with the values below, to determine the status for each pCO2 value. Cover over the
answers on the right, and then check your interpretation.

pCO2 of 22 = __________________________________respiratory alkalosis

pCO2 of 32 = ___________________________________respiratory alkalosis

pCO2 of 35 = ___________________________________low normal

pCO2 of 40 = ___________________________________normal

pCO2 of 45 = ___________________________________high normal

pCO2 of 50 = ___________________________________respiratory acidosis

pCO2 of 60 = ___________________________________respiratory acidosis


IV. Metabolic components
HCO3 represents the metabolic component of ABG interpretation, with a
normal range of 22-26 mEq/L. Bicarbonate (HCO3) is a weak base that is
regulated by the kidneys.
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When there is a loss of acid in the body, or an excess of base, the HCO3 will be greater than 26,
resulting in metabolic alkalosis. Some causes of metabolic alkalosis include loss of stomach acid
and potassium from vomiting or gastric suction, and ingestion of large amounts of bicarbonate.
Prolonged therapy with potassium-wasting diuretics, steroid therapy, Cushing's disease, and
aldosteronism can also deplete potassium, chloride, and hydrogen levels, resulting in metabolic
alkalosis.

When there is an excess of metabolic acid, or not enough base, the HCO3 will be less than 22,
causing metabolic acidosis. Conditions that increase acid-load include diabetic ketoacidosis or
prolonged fasting, lactic acidosis, and renal failure. Actual loss of bicarbonate ions through
severe diarrhea leads to metabolic acidosis. During cardiac arrest, or when low cardiac output
states (as in external cardiac compression) are present, anaerobic metabolism occurs and there is
an increase in the [production of lactic acid. Metabolism of lactic acid is normally effected
through the Krebs cycle, and oxygen is the essential element for this metabolic process. In the
absence of adequate tissue oxygenation, lactic acid cannot be metabolized; its quantity increases
and the result is metabolic acidosis.

The third step in ABG interpretation is to determine the direction of the metabolic
component HCO3, whether it is within normal limits, is high (metabolic alkalosis), or low
(metabolic acidosis.) Simply think of HCO3 as a base, and too much causes metabolic
alkalosis, whereas too little causes metabolic acidosis. Practice and check your answers below:


HCO3 of 22 = ___________________________________low normal

HCO3 of 16 = ___________________________________metabolic acidosis

HCO3 of 30 = ___________________________________metabolic alkalosis

HCO3 of 25 = ___________________________________normal

HCO3 of 12 = ___________________________________metabolic acidosis

HCO3 of 27 = ___________________________________metabolic alkalosis


Base Excess (BE) is another metabolic component that is reported with our blood gas report.
This value is a calculation of the circulating buffer/base, and is reported as milliequivalents per
liter of base above or below the normal buffer base range. The normal range for BE is 2 to
+2.

A base excess value of 8 would represent a deficit of base and therefore metabolic acidosis.

A base excess value of +10 would represent an excess of base and therefore metabolic alkalosis.

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The base excess can be used to help determine the presence of a metabolic imbalance, whether
acidosis or alkalosis. For the rest of this self learning module however, bicarbonate will be the
only metabolic component used in interpreting arterial blood gases.

Practice interpreting the following results (check your interpretation with answers below):
pH pCO2 HCO3 Interpretation
#1 7.41 40 24
#2 7.5 42 35
#3 6.72 40 5
#4 7.26 63 25
#5 7.52 18 25

#1: normal
#2: metabolic alkalosis
#3: metabolic acidosis
#4: respiratory acidosis
#5: respiratory alkalosis

The acid-base imbalances above involved only one component (respiratory or metabolic.)
Sometimes it is possible to have both components reflect the same abnormality. For example,
the patient who is in respiratory distress, and not exchanging air sufficiently develops respiratory
acidosis due to retention of CO2 (and hypoxemia.) If that same patients condition should
deteriorate to the point where his cells are not receiving oxygen, and CO2 is building up in the
blood, anaerobic metabolism will take place, causing a metabolic acidosis as well. That patient
would be said to have a combined respiratory and metabolic acidosis, which is typically seen in
the arrest setting.


IV. Compensation

Maintenance of acid-base balance is normally accomplished by buffer systems which react to
changes in the hydrogen ion concentration of body fluids. The primary buffer system is the
bicarbonate (kidneys) - carbonic acid (lungs) buffer system. When there is an imbalance in one
parameter, the other tries to compensate for it by causing the opposite imbalance. The goal of
this compensation process is to restore the 20:1 ratio, and return the pH back to the
acceptable range of 7.35 7.45.






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The regulation of respiration is achieved mainly by chemoreceptors in the medulla, that are
stimulated or inhibited by an increase or decrease in the carbonic acid and hydrogen ion levels.
Normally an increase in carbonic acid or hydrogen ion concentration in the blood stimulates an
increase in the rate and depth of ventilations, cause more carbon dioxide to be removed. A
decrease in concentration of carbonic acid results in a decrease in rate and depth of breathing,
thus retaining more carbon dioxide. The lungs can begin to compensate for metabolic
imbalances immediately, but can only partially correct pH deviations (can return pH to normal
range, but never to perfectly normal 7.4).

The kidneys, on the other hand, take much longer to compensate, sometimes as long as 3-5 days
to fully compensate. An increase in hydrogen ion concentration is corrected by increasing the
amount of bicarbonate that is returned to the blood, and increasing the amount of acid that is
excreted. A decrease in hydrogen ion concentration is corrected by increasing the amount of
acid that is retuned to the blood, and increasing the amount of bases, particularly, bicarbonate,
that are excreted. The kidneys may be slower to compensate, but they are much more powerful,
and can return the pH to perfectly normal 7.4.

The fourth and final step in ABG interpretation, then is to determine if compensation is
present, and to what extent.

.





When compensation is present,
we will see two imbalances. The question then
becomes, which is the primary problem, and which imbalance is
due to compensation. The clue is the pH. If the pH is leaning
toward acidosis or alkalosis, then the parameter with the matching
imbalance is the primary problem, and the other is due to
compensation.







Look at the following examples:

One patient has chronic pulmonary problems, and is in a chronic respiratory acidosis. His
kidneys will compensate by retaining bicarbonate, creating a metabolic alkalosis to balance his
chronic respiratory acidosis.
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A diabetic patient goes into ketoacidosis and develops Kussmaul breathing, causing him to blow
off CO2, creating a respiratory alkalosis to help balance his pH.

Below are some examples of ABG results with compensation:
pH PCO2 HCO3 Interpretation
7.30


(acidosis)
70

(respiratory
acidosis)
30
(mild
metabolic
alkalosis)
Respiratory acidosis with partial
compensation by the kidneys. The kidneys
have only begun to compensate, because the pH
is not back to acceptable limits yet.
7.43
(within
acceptable
range, but not
perfectly
normal 7.4)
20

(respiratory
alkalosis)

15

(metabolic
acidosis)
The pH is alkaline, so the primary problem is
alkalosis. Respiratory alkalosis with nearly
complete compensation by the kidneys.
7.36
(within
acceptable
range, but not
perfectly
normal 7.4)
10
(respiratory
alkalosis)
5
(metabolic
acidosis)
The pH is acidotic, so the primary problem is
acidosis. Metabolic acidosis with
compensation by the kidneys.
7.4
(perfectly
normal)
60
(respiratory
acidosis)
30
(metabolic
alkalosis)
The pH is perfectly normal in this case, with 2
very distinct imbalances. The primary problem
has to be respiratory acidosis, because only the
kidneys can compensate completely, and bring
the pH back to perfectly normal. This
respiratory problem is probably chronic, since it
takes the kidneys several days to completely
compensate for a respiratory problem. So this is
respiratory acidosis with complete
compensation by the kidneys.


BELOW ARE SOME PRACTICE ABG RESULTS FOR YOU TO DO, AND THE ANSWERS
ARE AT THE END OF THIS SELF LEARNING MODULE.


Practice:


#1 pH 7.52 = ___________________________________
pCO2 40 = ____________________________________
HCO3 35 = ____________________________________
Interpretation_______________________________________________

9
#2 pH 7.25 = ___________________________________
pCO2 60 = ____________________________________
HCO3 27 = ____________________________________
Interpretation_______________________________________________


#3 pH 7.25 = __________________________________
pCO2 40 = ___________________________________
HCO3 12 = ___________________________________
Interpretation______________________________________________


#4 pH 7.55 = _________________________________
pCO2 20 = ___________________________________
HCO3 26 = ___________________________________
Interpretation______________________________________________


#5 pH 7.29 = _________________________________
pCO2 20 = __________________________________
HCO3 18 = __________________________________
Interpretation______________________________________________


#6 pH 7.48 = _________________________________
pCO2 50 = ___________________________________
HCO3 34 = ___________________________________
Interpretation_______________________________________________


#7 pH 7.5 = __________________________________
pCO2 20 = __________________________________
HCO3 30 = __________________________________
Interpretation_____________________________________________


#8 pH 7.18 = _________________________________
pCO2 60 = _________________________________
HCO3 26 = _________________________________
Interpretation_____________________________________________


#9 pH 7.29 = ________________________________
pCO2 60 = __________________________________
HCO3 35 = __________________________________
Interpretation_____________________________________________
10
#10 pH 7.48 = _________________________________
pCO2 20 = __________________________________
HCO3 34 = __________________________________
Interpretation______________________________________________


#11 pH 7.43 = ________________________________
pCO2 35 = __________________________________
HCO3 23 = __________________________________
Interpretation _____________________________________________


#12 pH 7.4 = _________________________________
pCO2 60 = __________________________________
HCO3 30 = __________________________________
Interpretation:_____________________________________________




ABG studies are very helpful to reveal numerous underlying problems, and provide clues to a
patients ventilatory status, hypoxemic state, and tissue oxygenation. This is an important skill
to have and is invaluable when looking at the clinical picture.



Answers to practice ABG's:

#1 pH 7.52 = alkalosis
pCO2 40 = normal
HCO3 35 =metabolic alkalosis
Metabolic alkalosis (no compensation)

#2 pH 7.25 = acidosis
pCO2 60 = respiratory acidosis
HCO3 27 = slight metabolic alkalosis
Respiratory acidosis, and kidneys are beginning to compensate (retain
bicarb. Note that the pH has a long way to go before it comes back into
normal range, so compensation has just begun.)

#3 pH 7.25 = acidosis
pCO2 40 = normal
HCO3 12 = metabolic acidosis
Metabolic acidosis (no compensation)

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#4 pH 7.55 = alkalosis
pCO2 20 = respiratory alkalosis
HCO3 26 = normal
Respiratory alkalosis (no compensation)

#5 pH 7.29 = acidosis
pCO2 20 = respiratory alkalosis
HCO3 18 = metabolic acidosis
Metabolic acidosis with some compensation by the lungs (not very effective;
has not returned pH to acceptable range yet)

#6 pH 7.48 = alkalosis
pCO2 50 = respiratory acidosis
HCO3 34 = metabolic alkalosis
Metabolic alkalosis with almost complete compensation by the lungs

#7 pH 7.5 = alkalosis
pCO2 20 = respiratory alkalosis
HCO3 30 = metabolic alkalosis
Combined respiratory & metabolic alkalosis

#8 pH 7.18 = acidosis
pCO2 60 = respiratory acidosis
HCO3 26 = normal
Respiratory acidosis

#9 pH 7.29 = acidosis
pCO2 60 = respiratory acidosis
HCO3 35 = metabolic alkalosis
Respiratory acidosis with some compensation from kidneys

#10 pH 7.48 = alkalosis
pCO2 20 = respiratory alkalosis
HCO3 34 = metabolic alkalosis
Combined respiratory and metabolic alkalosis

#11 pH 7.43 = normal
pCO2 35 = normal
HCO3 23 = normal
Normal

#12 pH 7.4 = perfectly normal
pCO2 60 = respiratory acidosis
HCO3 30 = metabolic alkalosis
Two imbalances with complete compensation, so it is difficult to tell which is
the problem and which is the compensation. However, since only the kidneys
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are strong enough in compensation to bring the pH back to perfectly normal,
the primary problem has to be respiratory acidosis, with complete
compensation by the kidneys.











Now, print a copy of the revised Evaluation Form, which is
the last page of this module. Then, exit this module, and
on the Old Glory list of modules, select & print the
"Instructions for Taking Module Exam in Healthstream."
To print the evaluation form, scroll to the last page and
make sure your cursor is on that page. Go to File, and select
Print. Select Current Page, and then OK.




REFERENCES:

Dennison R. Pass CCRN!. Second edition. 2000:221-222.

Guyton A. Human Physiology and Mechanisms of Disease. 1992:233-240.

Kirksey, KM, et al. An Easy Method for Interpreting the Results of Arterial Blood Gas Analysis.
Critical Care Nurse. 21(5):49-54.

Lanford A. Name that Acid Base. Critical Care Nurse. March/April 1981:10-12.

McCance K, Huether S. Pathophysiology: The Biologic Basis for Disease in Adults and
Children. 1994:110-120.

Mims, BC. Interpreting ABG's. RN. March 1991:42-47.

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SELF LEARNING MODULE EVALUATION

Professional Title: RN LPN RT OTHER Date:__________


NAME: (PRINT)____________________________________ REQUIRED
LICENSE # ____________________________ INFO
Self Learning Module: ____ABG Interpretation___________
Score on Module Post-Test:_____________________


Circle your choice: (1 = Strongly Disagree, 2 = Disagree, 3 = Agree, 4 = Strongly Agree)

1. Overall, was the program worthwhile? 1 2 3 4

2. Did the program meet your personal objectives? 1 2 3 4

3. Regarding content:
Was the information presented clearly? 1 2 3 4
Was the information pertinent to your professional needs? 1 2 3 4

4. Was the information that was presented:
New and Useful Review but Useful
New and Necessary Review but Necessary

5. Was the information presented at the level of your understanding?
1 2 3 4
6. Comments:_______________________________________________________________
_____________________________________________________________________

7. Recommendations for future topics:____________________________________________
_____________________________________________________________________

8. Actual time spent completing this self learning module: ____________________________

SELF STUDY MODULE ATTESTMENT STATEMENT

I _______________________________ attest that I have read and understand the information
presented in the ______ABG Interpretation_______________________ self learning module.
Signature:________________________________________ Date:_________________
Employee #:_____________________________ License # (REQUIRED):_____________