ABG

Acid/Base and ABG Interpretation Made Simple

A-a Gradient ƒ FIO2 = PA O2 + (5/4) PaCO2 ƒ FIO2 = 713 x O2% ƒ A-a gradient = PA O2 - PaO2 ƒ Normal is 0-10 mm Hg ƒ 2.5 + 0.21 x age in years

ƒ With higher inspired O2 concentrations, the A-a gradient will also increase

PaO2-FiO2 ratio ƒ Normal PaO2/FiO2 is 300-500 ƒ 8 = Anion Gap metabolic acidosis

Metabolic Acidosis…continued ƒ Add delta gap back to CO2 = corrected bicarb ƒ if corrected bicarb = 24-26 then no other ƒ ƒ ƒ

disturbance if corrected bicarb < 24-26 then non-anion gap acidosis is superimposed (or chronic resp alkalosis) if corrected bicarb >24-26 then met alkalosis is superimposed (or chronic resp acidosis) if 31 = superimposed mild metabolic acidosis

EXAMPLE 3 ƒ ƒ ƒ ƒ

85 year old male with bloody diarrhea 7.32/33/80/20 Na 138, K 4, Cl 104, CO2 20, Cl 104, Cr 8.4, Gl 129 GO STRAIGHT TO BICARB!!! = 20 (too low)

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Compensation? Last two digits of pH 32 pretty close to pCO2 33 Anion gap? 14 = Anion gap met acidosis = uremia Delta gap? 14-8 = 6 Corrected bicarb = 6 + 20 = 26 (fairly close) = no other dist

ƒ Low pH, low bicarb = Metabolic Acidosis

EXAMPLE 4 ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ

71 year old diabetic male who is weak Na 135, K 6.9, Cl 108, CO2 19, BUN 63, Cr 2.2, Gl 152 >> HCO3 low at 19!! Don’t know about compensation yet because no ABG Metabolic Acidosis : what is gap? Gap 8: non anion gap acidosis: etiology? Diarrhea vs RTA = do urinary anion gap = positive Which RTA gives you hyperkalemia in a diabetic with renal insuffiency? ƒ Type IV = hyporeninemic hypoaldosteronism

EXAMPLE 5 ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ

88 yo female with lethargy and weakness Na 141, K 3, Cl 95, CO2 36, BUN 51, Cr 3.4, Gl 112 Ca 15.4 High CO2 = metabolic alkalosis or chronic resp acidosis? Further hx reveals taking too much tums and Oscal D =Metabolic Alkalosis and hypercalcemia =Metabolic Alkalosis + High Ca + renal dysfxn = ??? Milk-Alkali syndrome

EXAMPLE 6 ƒ ƒ ƒ ƒ ƒ

31 year old AAM took too many pills for suicide attempt Na 139, K 5.2, Cl 110, CO2 16, BUN 47, Cr 6.8, Glu nl What is disturbance? Met acidosis or chronic resp alkosis ABG 7.30/30/80/15 = appropriate resp compensation

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What is Gap? = 13 = Anion Gap Met Acidosis Delta Gap 13-8 = 5 Corrected Bicarb = 21 Still too low = second met acidosis superimposed Non Anion Gap Acidosis = likely RTA secondary to ARF

ƒ No other disturbance present

EXAMPLE 7 ƒ 21 year old WF with SLE ƒ Na 136, K 4.7, Cl 117, CO2 14, BUN 102, Cr 4.1, G nl ƒ Last Cr was 0.6 two months PTA

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What is the disturbance? Met acidosis or chronic resp alkalosis: What is Gap? Gap = 5 = Non Anion Gap Met Acidosis : likely from RTA secondary to ARF ƒ Albumin 1.3 = so unmeasured anions LOW which can make anion gap low (or increase in UC) ƒ So likely anion gap met acidosis secondary to ARF + non anion gap met acidosis secondary to RTA

EXAMPLE 8 ƒ ƒ ƒ ƒ ƒ ƒ

AIDS patient c/o dyspnea OFF HAART Na 121, Cl 88, CO2 13, BUN 116, Cr 7.8 ABG 7.31/22/63 START with BICARB = 13 = too low Low pH, Low bicarb = Metabolic acidosis Compensation? PCO2 should be 31, it is 22, so superimposed Resp Alkalosis ƒ Anion Gap? = 20, so AG metabolic acidosis ƒ Delta Gap = 20-8 = 12, cHCO3 = 25 (OK) ƒ Etiology?

EXAMPLE 9 ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ

74 year old WF with AMS and h/o quadriplegia Na 121, K 5.3, Cl 84, CO2 18, BUN 15, Cr 0.5, Gl nl What is disturbance? Met acidosis or chronic resp alk Compensation? 7.42/29/75/19 pCO2 should be 42 = 29 too low = addnl Resp Alkalosis What is gap? = 19 = Anion Gap met Acidosis Delta Gap = 19-8 = 11 Correctected Bicarb = 18 + 11 = 29 = too high = superimposed met alkalosis TRIPLE D/O!!! What causes met acidosis + resp alk ? SALICYLATES vs infection Infection in her case with likely urosepsis syndrome

EXAMPLE 10 ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ ƒ

82 year old hypotensive transfer with massive GI bleed Na 148, K 4.7, Cl 123, CO2 16, BUN 158, Cr 3, Glc nl ABG 7.22/39/34/16 >>HCO3 16 with low pH = met acidosis Compensation? PCO2 should be 22, it is 39, so superimposed RESP ACIDOSIS = ?etiology? Gap? 9 so Anion Gap Acidosis = ?etiology? Delta gap? 9-8=1, so cHCO3 = 17 = too low, so… Superimposed non-anion gap acidosis = ?etiology? TRIPLE D/O!!

CONCLUSIONS… ƒ Don’t get overwhelmed, identify the primary (or even just an obvious) disorder and build from that. ƒ When answering the question about compensation, you may often uncover a second disorder. ƒ When calculating the delta gap, you may even uncover a third disorder!

CONCLUSIONS… ƒ Now did you ever think in medical school that ƒ ƒ

you would be able to interpret a triple acid/base disorder? If you use this method to tease out the disturbances, you will NOT get stumped. You can then use these interpretations to better understand the patient and possibly entertain diagnoses that you might not have considered using your differential lists for the various acid/base disorders!

The End…