Müller-Plathe: Acid-base diagnostic nomogram 795

J. Clin. Chem. Clin. Biochein.

Vol. 25, 1987, pp. 795-798
© 1987 Walter de Gruyter & Co.
Berlin · New York

A Nomogram for the Interpretation of Acid-Base Data

By O. Müller-Plathe
Allgemeines Krankenhaus Altona, Zentrallabor

(Received May 4, 1987)

Summary: A diagnostic nomogram based on log pCO2 and log cHCO J äs coordinates is presented. The
significance areas for compensated acid-base disorders are indicated. The nomogram facilitates the recognition
of mixed acid-base disorders. The graph is being used for on-line plotting.

Introduction Areas
Print-outs of modern blood gas analysers are becom- The oval area around pCO2 = 40 mmHg and
ing increasingly complicated. This does not facilitate cHCO J = 24 mmol/1 marks the reference ränge for
the Interpretation of acid-base data for the clinician, males and females (l, 2). The limits of the six signifi-
äs the single data of the acid-base Status cannot be cance areas for the acid-base disturbances were cälcu-
interpreted without consideration of the other results. lated and drawn according to data from the literature
In this Situation, characterized by highly complex and our own observations. Each area is based on
data, the clinical chemical laboratory has the duty experimental or clinical investigations and approxi-
not only to provide accurate figures, but also to mately represents the 95 percent area.
present the findings in a form that is understandable
by the clinician. The following publications were taken into account
for the significance areas:

Description and Use of the Nomogram Acute respiratory acidosis and alkalosis:
Arbus, G. S. et al. (3)
Coordinates
Bracken, N. C. et al. (4)
Ön the abscissa pCO2 and on the ordinate Siggaard-Andersen, O. (5)
are indicated logarithmicaUy. This arrarigement en-
ables the presentatiori of pH äs a System of strictly Chronic respiratory acidosis and alkalosis:
parallel straight lines which are cälculated with the Brackett, N. C. et al. (6)
following transformation of the Henderson-Hassel- Müller-Plathe et al, (7)
balch equation: Siggaard-Anderson, O. (5)
(mmol/1) = Metabolie acidosis and alkalosis:
0.0307 pC02 (mmHg)
Albert, M. S. et al. (8)
correspoiiding to Kildeberg, P. (9)
(mmol/1) = 0.230 pCO2 (kPa) · Siggaard-Andersen, O. (5)
With the ranges chosen, pCQ2 from 10 to 100 mmHg
(1.3 - 13.0 kPa) and cHCO^ from 6 to 60 mmol/1, Table l demonstrates the calculation of the signifi-
the pH 7.4 isopleth almost exactly forms the diagonal cance area for chronic respiratory acidosis äs an
of the graph. example for this procedure.

J. Clin. Chem. Clin. Biochem. / Vol. 25,1987 / No. 11

 796 Müller-Plathe: Acid-base diagnostic nomogram

Tab. l. Establishment of the significance area for chronic res- Nunierous acid-base nomograms with different com-
piratory acidosis. binations of coordinates have been designed in the
Refer- />C02 cHCOj (mmol/1) past (10 — 15), preferably for the calculation of
ence
mmHg kPa values limits in derived quantities. Frorn some of these graphs inter-
from l. c. the present pretational nomograms were developed. The Sig-
nomogram gaard-Andersen "acid-base chart" (5) with the coordi-
nates pH and log pCO2 is higbly suitable for diag-
6 50.0 6.7 26.8-35.3
7 48.0-50.9 6.4- 6.8 23.7-32.7 -33.2 nostic and therapeutic interpretations. But it is
5 50.0 6.7 26.4-31.7 strictly directed to the base excess concept, and
6 60.0 8.0 30.7-39.5 plasma bicarbonate which is preferred by many clinir
7 60.0-62.9 8.0- 8.4 29.4-38.2 30.1-37.7 cians can only be entered or read indirectly. The
5 60.0 8.0 30.2-35.5 Arbus diagram (16) with the coordinates pCO2 and
6 70.0 9.3 33.4-44.0 cHCO^ has the disadvantage of non-parallel pH
7 67.0-75.9 8.9-10.1 33.5-44.9 33.4-42.5
5 70.0 9.3 33.3-38.7
isopleths. The nomogram of Cogan et al. (17) with
pH and cHCOj äs coordinates shows a bündle of
6 80.0 10.7 36.5-47.0
7 76.0-84.9 10.1-11.3 34.6-47.8 35.7-45.2 curved non-parallel pCÖ2 lines hindering exact read-
5 80.0 10.7 35.9-40.8 ing of this important qüantity.
7 85.0-95.0 11.3-12.7 38.2-49.8 38.0-47.0
6 100.0 13.3 41.6-53.5
7 104.0 13.9 42.3-53.3 39.0-48.7 Remarks on the present iiömogjram
5 100.0 10.3 38.2-43.9
The acid-base equilibrrüm äs expressed in terms of
the carbonic acid-bicarbonate System is determined
by pCO2 (abscissa in the present nomogram) and
cHCOj (ordinate in the present nöniogram). The
Directions for use result of the two determinants is pH. Status marks
Enter the results for pCO2 (abscissa) and cHCOj superior to and left of the emphasized diagonal (pH
(ordinate) and find the Status mark, which mäy be = 7.4) indicate an alkalotic tendency, while marks
located inferior to and right of this line indicate an acidotic
tendency.
— In the normal area:
No acid-base abnormality present. The areas for metabolic acidosis and.alkalosis refef to
— In one of the six shaded areas: disorders with a duration of at least 24 h, allowing
Status typical for the indicated "pure" disturbance the respiratory centre to respoüd. If the Status mark
with a normal degree of compensation. is beyond these areas it is necessary to exclude or to
— In one of the free parts of the graph between the verify an additional respiratory dysfunction. Conf
shaded areas: cerning metabolic alkalosis it should be meütioned
Status typical for the indicated "mixed" distur- that some authors (9, 16) assume a greäter Variation
bance. in compensatory CO? retention than can be read from
the present graph.

Alternative use The areas for acute respiratory disturbances, natur*

ally, show a strong deviation. from the pH 7.4 line
One of the quantities indicated on the coordinates because they are predöminantly cpmpensated by
may be replaced by pH if this is preferred for any blood buffer reactiöns. After 5 to 7 days the renal
reason. pH values, too, can be entered precisely be- compensation for hypo- or hypercapnia is coinpleted.
cause of the parallelity of the pH isopleths. Only at this stage can a Status mark inside the äreas
for chronic respiratory acidosis or alkalosis be ex-
pected. A Status mark situated between the acute and
Discussion chronic respiratory areas or even remaining inside
the field for the acute disorder means that either renal
A nomogram for the Interpretation of acid-base data function is iinpaired by disease or drugs or that the
should fulfill the following requirements time interval for the tubülar respönse ^as too short.
— easily understandable There are two areas which are indicated for a combi^
— universally applicable hation of counteracting disturbances. Those constella-
— suitable for on-line plotting tioiis with a pH close to 7.4 mimic "overcompensa-

J. Clin. Chem, Clin, Biochem. / Vol. 25, 1987 / No. 11

Müller-Plathe: Acid-base diagnostic nomogram 797

ACID BASE DIAGNOSTIC NOMOGRAM ((Malier-piathe. m?)

9.3 10.7 12.0
70 80 90

10 12 14 16 1 20 mm Hg 30 40 50 60 70 80 90 100
1.3 1.6 1.9 2.1 2 2.7 kPq 4.0 5.3 6.7 . 9.3 10.7 12.0 13.0

Fig. 1. The acidUbase diagnostic nomogram.

tion", a term which shotild be avoided. A cpmbina- Combined acidosis or alkalosis leads to very high pH
tion of respiratory alkalosis and metabolic acidpsis deviations, because respiratory and metabolic causes
may be caused by hyperventilatiön with subsequent influence pH in the same direction. Examples: Mixed
lactic aeidösis. Respiratory acidosis and metabolic acidosis by cardiac arrest with acute hypercapnia and
alkalosis are frequently encountered together, e.g. hypoxic lactacidosis; combined alkalosis in patients
in pbstructive emphysema with cardiac failufe and with artificial respiration and additional drug therapy
diuretic therapy. Residual hyperbicarbonataeniiä (corticoids, diuretics). The term non-compensated
after rapid improvement of severe hypereapnia is acidosis or alkalosis is used for combined acid-base
another example, disorders, if one of the two disturbances is regarded

J. Clin. Chem. Clin. Biochem. / Vol. 25,1987 / No. 11

798 Müller-Plathe: Acid-base diagnostic nomogram

äs predominant. But in these cases, too, at least two and mixed äcid-base disorders, mainly for those who
impairments are present. Thus, "non-compensation" consider cHCO^ äs the most relevant base quantity.
represents a graded difference, at best. The nomogram proves to be very helpful. Therefore,
on-line plotting from a Corning 178 blood gas ana-
lyser was started*.
Conclusion
·r
This paper does not contain new data! Clinical and Acknowledgement
experimental data mainly from the sixties have been
re-evaluated. An attempt has been made to present * We are indebted to Cibä-Corning Diagnpstics GmbH,
D-6301 Fernwald 2, Federal Republic of Germany, whp devel-
these data in an easily understandable diagram to oped a Computer program for on4ine plotting on this nomp*
facilitate the recognition of pure ("compensated") gram which runs on a HP85 calcülator.

References
1. Siggaard-Andersen, O. (1974) The acid-base Status of the 10. Singer, R. B. & Hastmgs, A. B. (1948) Mediane (Baltimore)
blood, Munksgaard, Copenhagen. 27,223-242.
2. Müller-Plathe, O. (1982) Säure-Basen-Haushalt und Blut- 11. Davenport, H. W. (1958) The ABC of acid-base chemistry,
gase, Thieme, Stuttgart—New York. The University of Chicago Press.
3. Arbus, G. S., Hebert, M. D., Levesque, P. R., Etsten, B. 12. Siggaard-Andersen, O. (1962) Scand. J. Clin. Lab. Invest.
E. & Schwartz, W. B. (1969) New Engl. J. Med. 280, 117- 14, 598-604.
123. 13. Siggaard-Andersen, O. (1963) Scand. J. Clin. Lab. Invest.
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New Engl. J. Med. 272, 5-12. 14. thews, G. (1967) Pflügers Arch. Ges. Physiol. 296, 212-
5. Siggaard-Andersen, O. (1971) Scand. J. Clin. Lab. Invest. 214.
27, 239-245. 15. Thews, G. (1971) Nomogramme zum Säure-Basen-Status
6. Brackett, N. C., Wingo, C. F., Muren, O. & Solano, J. T. des Blutes und zum Atemgastransport, Springer, Heidel-
(1969) New Engl. J. Med. 280, 124-130. berg—New York.
7. Müller-Plathe, O. & Meinekat, E. (1966) Dtsch. Med. 16. Arbus, G. S. (1973) Canad. Med. Ass. J. 709, 291-292.
Wochenschr. 91, 2284-2289. 17. Cogan, M. G., Rector, F. C. & Seidin, D. W. (1981) Acid-
8. Albert, M. S., Dell, R. B. & Winters, R. W. (1967) Ann. base disorders. In: The Kidney (Brenner, B. M. & Rector,
Intern. Med. 66, 312-322. F. C., eds.) Saunders, Philadelphia.
9. Kildeberg, P. (1963) Acta Med. Scand. 174, 515-522.

Prof. Dr. O. Müller-Plathe

Allgemeines Krankenhaus Altona
Paul-Ehrlich-Str. l
2000 Hamburg 50

J. Clin. Chem. Clin. Biochein. / Vol. 25,1987 / No. 11