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j Arterial blood gas analysis

 is an essential part of diagnosing and
managing a patient¶s oxygenation status and
acid-base balance
 measures the acidity (pH) and the levels of
oxygen and carbon dioxide in the blood from
an artery
 This test is used to check how well your lungs
are able to move oxygen into the blood and
remove carbon dioxide from the blood.
Acid Base Balance

r The pH is a measurement of the acidity or

alkalinity of the blood.
rIt is inversely proportional to the number of
hydrogen ions (H+) in the blood.
rThe more H+ present, the lower the pH will be.
rThe fewer H+ present, the higher the pH will be.
Acid Base Balance

j Normal blood pH range is 7.35 to 7.45

 In order for normal metabolism to take place, the body must maintain this
narrow range at all times.

 decreasein the force of cardiac contractions
 decrease in the vascular response to catecholamines
 diminished response to the effects and actions of certain medications

j pH > 7.45
 r erferesrrssue
e ar a dnormal neurological and muscular functioning.

j Extreme acid-base derangements

 will interfere with cellular functioning, and if uncorrected, will lead to death.
maintenance of Acid Base Balance

j So how is the body able to self-regulate acid-base

balance in order to maintain pH within the
normal range?

Respiratory Buffer System

j A normal by-product of cellular metabolism is carbon

dioxide (CO2). CO2
j CO2 is carried in the blood to the lungs, where excess
CO2 combines with water (H2O) to form carbonic acid
(H2CO3). CO2 + H2O = H2CO3
j `e d r ca eaccrdr e eve f
car  rcacrdrese 
j This triggers the lungs to either increase or decrease the
rate and depth of ventilation until the appropriate
amount of CO2 has been re-established.
j Activation of the lungs to compensate for an imbalance
starts to occur within 1 to 3 minutes.
Renal Buffer System

j In an effort to maintain the pH of the blood within

its normal range, the kidneys excrete or retain
bicarbonate HCO3
j blood pH decreases (acidic) - the kidneys will
compensate by retaining HCO3
j blood pH rises (alkalotic) - the kidneys excrete
HCO3 through the urine
 measurement of acidity or alkalinity, based on the hydrogen
(H+) ions present.
 The normal range is 7.35 to 7.45
 The partial pressure of oxygen that is dissolved in arterial
 It measures how well oxygen is able to move from the airspace
of the lungs into the blood.
 The normal range is 80 to 100 mm Hg

 Desired aO2
 80 ± YEARS ABOVE 60
w Example 75 y/o Female

w aO2 = 80 ± (75-60) = 65
 The arterial oxygen saturation.

 Oxygen saturation measures how much of the hemoglobin in

the red blood cells is carrying oxygen (O2
 The normal range is 95% to 100%.
 The amount of carbon dioxide dissolved in arterial blood.

 how well carbon dioxide is able to move out of the body

 The normal range is 35 to 45 mm Hg

 The calculated value of the amount of bicarbonate in the
 The normal range is 22 to 26 mEq/liter
Respiratory Acidosis

j Low pH
j High aCO2
j rimary increase in pCO2 resulting from alveolar
Respiratory Acidosis

j Respiratory center depression

 Brainstem lesions
 narcotics, sedatives, or anesthesia

j Neuromuscular failure
 Impaired respiratory muscle function related to spinal cord injury,
neuromuscular diseases, or neuromuscular blocking drugs
j Decreased compliance
 arenchymal (e.g pulmonary fibrosis, ARDS)
 Extraparenchymal (e.g. Abdominal distention, severe kyphoscoliosis)

j Increased airway resistance

j Increased dead space
 Large pulmonary embolus
Respiratory Alkalosis

j High pH
j Low pCO2
j rimary decreased in pCO2 resulting from alveolar
Respiratory Alkalosis

j Central nervous system stimulation

 Hepatic encephalopathy

j Hypoxemia
 moderate asthma exacerbation
 Acute pulmonary edema
 ulmonary embolus
 High altitude
Respiratory Alkalosis

j Drugs

 Salicylate poisoning


j miscellaneous

 mechanical hyperventilation

metabolic Acidosis

j Low pH
j low HCO3
j rimary decreased in plasma HCO3 due to either
HCO3 loss or accumulation of acid
metabolic Acidosis

j High anion gap

 etoacidosis ± diabetic, alcoholic, starvation
 Lactic Acidosis
 Intoxications ± e.g. Ethylene glycol, methanol, salicylate
 Advanced Renal Failure
 Severe rhabdomyolysis
j Normal anion gap
 GI HCO3 loses (lower GI fistulas, diarrhea, ureterosigmoidostomy)
 Renal tubular acidosis
 moderate renal insufficiency
 Acetazolamide use
 Large volume saline resuscitation
metabolic Alkalosis

j High pH
j High HCO3
j rimary increase in the plasma HCO3 due to either
H+ loss or HCO3 gain
metabolic Alkalosis

j Chloride Responsive
 Upper GI losses

 revious diuretic use

 Recovery from chronic hypercapnia

j Chloride unresponsive
 Effective mineralocorticoid excess

 Current diuretic use

 Bartter¶s or Gitelman¶s syndrome

 Severe hypokalemia

 Excessive alkali administration

Steps on Dissecting Acid ± Base Disorder

j Step 1 : redict what underlying mechanisms might

be present based on the clinical scenario.
Steps on Dissecting Acid ± Base Disorder

j Step 2: Verify that the ABG values are internally

 Simplified form of the Henderson-Hasselbach Equation:
 [H+] (nmol/L) = 24 x pCO2 (mmHg) / [HCO3-] (meq/L)
Steps on Dissecting Acid ± Base Disorder

j Step 3:
If the blood is alkalotic or acidotic, we now need to
determine if it is caused primarily by a respiratory or metabolic

A. Assess the aCO2 level.

Remember that with a respiratory problem, as the pH
decreases below 7.35, the aCO2 should rise. If the pH rises
above 7.45, the aCO2 should fall.

Compare the pH and the aCO2 values. If pH and aCO2

are indeed moving in sre drrecr s, e e r em rs
r aure
Steps on Dissecting Acid ± Base Disorder

j Step 3:

B. Assess the HCO3 value. Recall that with a

metabolic problem, normally as the pH increases,
the HCO3 should also increase. Likewise, as the pH
decreases, so should the HCO3.

Compare the two values. If they are moving r 

esamedrrecr ,e er emrsprimarily
metabolic in nature.

j Jane Doe is a 45-year-old female admitted to the

nursing unit with a severe asthma attack. She has
been experiencing increasing shortness of breath
since admission three hours ago.
j Her arterial blood gas result is as follows:
j X  

1. Clinical rediction
2. Assess the pH.
3. Assess the aCO2.
4. Assess the HCO3.
?crdsrsrsrese decreased reaCO2 er r creased,
reflecting a primary resrrar
r em
rrsare ,e eedrmrveeve r ar status by
providing oxygen therapy, mechanical ventilation, pulmonary toilet or by
administering bronchodilators.

j John Doe is a 55-year-old male admitted to your

nursing unit with a recurring bowel obstruction. He
has been experiencing intractable vomiting for the
last several hours despite the use of antiemetics.
j X  

1. Clinical rediction
2. Assess the pH.
3. Assess the aCO2.
4. Assess the HCO3.
? a srsrsrese r creased re COr creased,
ref ecr a primary mea  rcr em`reame frsare mr 
r c udeeadmr rsrar ffluids and measures to reduce the excess

j body attempts to restore the normal blood pH during

an acid-base disorder
j compensation can be metabolic or respiratory in
Respiratory Compensation

j Respiratory compensation
 rapid process in which ventilation is adjusted to alter the pCO2
in response to a primary alteration in the [HCO3-].
 Increased HCO3- levels will stimulate hypoventilation and a
subsequent rise in pCO2.
 Decreased HCO3- levels will produce the opposite effect.

 begins within seconds and can reach maximum effectiveness

within 12-24 hours
cme sar ca  evercm ee
re ar a
rma  d  Oerfacrsr v vedr ve r ar 
c r ,esecra
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cme sar 

j metabolic compensation
 is a slower process
 Occurs in two phases
 First phase
w involves intracellular non-bicarbonate buffers
w responsible for the first phase, which occurs immediately
 Second phase
w kidneys are responsible
w begins within hours, but takes 2 to 5 days to reach maximal
w kidneys achieve compensation by altering net bicarbonate
reabsoprtion and net acid excretion into the urine.
w Given enough time (up to 4 weeks) metabolic compensation may
be able to return the blood pH to normal in chronic respiratory
j metabolic disturbance ± lungs compensate
j Respiratory disturbance ± kidney regulate

j mrs. L is a thin, elderly-looking 61 year old CO D

patient. She has an ABG done as part of her routine
care in pulmonary clinic.
j Her ABG shows the following results

 pH : 7.37
 CO2: 63

 pO2 : 58

 HCO3: 35

 SaO2: 89%
j X  

1. Clinical rediction
2. Assess the pH.
3. Assess the aCO2.
4. Assess the HCO3.
Clinical rediction

j Thin
 Decreased muscle mass leading to poor respiratory muscle
j CO D
 Interstitial damage/ bronchoconstriction decreased gas
exchanges increase CO2 retention
 Interstitial damage/bronchoconstriction decreased gas
exchnages decrease o2 entry


1. pH - acidic
2. Assess the aCO2 - increased
3. Assess the HCO3 - increased

j pH : 7.37
j CO2: 63
j HCO3: 35
 Simple compensated respiratory acidosis
 Full compensation is evidenced by the normal pH in spte of her
acid/base disorder
 This is her baseline and doesn¶t require treatment
Actual atient

j JL 35y/o female came in to the ER due to shortness of breath

j Desired Fio2
 A= pCO2/ 0.8
 B = (713 x del FiO2/100) ± A
 C = p02/B
 Des FiO2 = (des O2/C) + A/ 713 x 100
 Del FiO2
 NC = (# L m x 4) + 20
 Fm = (# L m ± 1) x 10
j mechanical ventilator with the following settings: TV: 450, FiO2:60, F:60
and BUR:20. Dormicum was discontinued.
j Arterial blood gas
 pH 7.64
 pCO2 29.8
 pO2 109.1
 HCO3 21.6
mechanical ventilation settings were adjusted to FiO2:40%, eak flow 45 and BUR:14.