Arterial blood gas interpretation

In advanced life support training, a 5 step approach to arterial blood gas interpretation is advocated.

1. How is the patient?

2. Is the patient hypoxaemic? The Pa0 2 on air should be 10.0-13.0 kPa
3. Is the patient acidaemic (pH <7.35) or alkalaemic (pH >7.45)?
4. What has happened to the PaCO2? If there is acidaemia, an elevated PaCO2 will account for this
5. What is the bicarbonate level or base excess?

A metabolic acidosis will have a low bicarbonate level and a low base excess (< -2 mmol)
A metabolic alkalosis will have a high bicarbonate and a high base excess (> +2 mmol)

Disorders of acid - base balance

Metabolic acidosis
 This is the most common surgical acid - base disorder.
 Reduction in plasma bicarbonate levels.
 Two mechanisms:
1. Gain of strong acid (e.g. diabetic ketoacidosis)
2. Loss of base (e.g. from bowel in diarrhoea)
- Classified according to the anion gap, this can be calculated by:
+ + - -
(Na + K ) - (Cl + HCO3 ).
- If a question supplies the chloride level then this is often a clue that the anion gap should be calculated. The normal
range = 10-18 mmol/L

Normal anion gap ( = hyperchloraemic metabolic acidosis)

 Gastrointestinal bicarbonate loss: diarrhoea, ureterosigmoidostomy, fistula
 Renal tubular acidosis
 Drugs: e.g. acetazolamide
 Ammonium chloride injection
 Addison's disease

Raised anion gap

 Lactate: shock, hypoxia
 Ketones: diabetic ketoacidosis, alcohol
 Urate: renal failure
 Acid poisoning: salicylates, methanol

Metabolic acidosis secondary to high lactate levels may be subdivided into two types:
 Lactic acidosis type A: (Perfusion disorders e.g.shock, hypoxia, burns)
 Lactic acidosis type B: (Metabolic e.g. metformin toxicity)

Metabolic alkalosis
 Usually caused by a rise in plasma bicarbonate levels.
 Rise of bicarbonate above 24 mmol/L will typically result in renal excretion of excess bicarbonate.
 Caused by a loss of hydrogen ions or a gain of bicarbonate. It is due mainly to problems of the kidney or
gastrointestinal tract
Causes
 Vomiting / aspiration (e.g. Peptic ulcer leading to pyloric stenosis, nasogastric suction)
 Diuretics
 Liquorice, carbenoxolone
 Hypokalaemia
 Primary hyperaldosteronism
 Cushing's syndrome
 Bartter's syndrome
 Congenital adrenal hyperplasia
Mechanism of metabolic alkalosis
 Activation of renin-angiotensin II-aldosterone (RAA) system is a key factor
 Aldosterone causes reabsorption of Na+ in exchange for H+ in the distal convoluted tubule
 ECF depletion (vomiting, diuretics) --> Na+ and Cl- loss --> activation of RAA system --> raised aldosterone
levels
 In hypokalaemia, K+ shift from cells --> ECF, alkalosis is caused by shift of H+ into cells to maintain neutrality

Respiratory acidosis
 Rise in carbon dioxide levels usually as a result of alveolar hypoventilation

1
  Renal compensation may occur leading to Compensated respiratory acidosis
Causes
 COPD
 Decompensation in other respiratory conditions e.g. Life-threatening asthma / pulmonary oedema
 Sedative drugs: benzodiazepines, opiate overdose
Respiratory alkalosis
 Hyperventilation resulting in excess loss of carbon dioxide
 This will result in increasing pH
Causes
 Psychogenic: anxiety leading to hyperventilation
 Hypoxia causing a subsequent hyperventilation: pulmonary embolism, high altitude
 Early salicylate poisoning*
 CNS stimulation: stroke, subarachnoid haemorrhage, encephalitis
 Pregnancy
*Salicylate overdose leads to a mixed respiratory alkalosis and metabolic acidosis. Early stimulation of the respiratory
centre leads to a respiratory alkalosis whilst later the direct acid effects of salicylates (combined with acute renal failure)
may lead to an acidosis

1 2/3 Question 15-17 of 172

Theme: Interpretation of aterial blood gas results

A. pH 7.19, pCO2 10.2, pO2 16 (FiO2 85%), Bicarbonate 23.8, Base excess -2.2 mmol
B. pH 7.57, PaCO2 3.5, Pa O2 24.5 (FiO2 85%), Bicarbonate 23.5, Base excess +1.8
mmol
C. pH 7.14, PaCO2 7.4, PaO2 8.9 (FiO2 40%), Bicarbonate 14 mmol, Base excess -
10.6
D. pH 7.36, PaCO2 7.3, PO2 8.9 (FiO2 40%), Bicarbonate 30.2, Base excess 5.3
E. pH 7.32, PCO2 3.8, PaO2 22.2 (FiO2 40%), Bicarbonate 19.1, Base excess -7.9
Which of the following arterial blood gases fit with the description below?

15. Acute respiratory acidosis

pH 7.19, pCO2 10.2, pO2 16 (FiO2 85%), Bicarbonate 23.8, Base excess -2.2 mmol

16. Metabolic acidosis with a compensatory respiratory alkalosis

The correct answer is pH 7.32, PCO2 3.8, PaO2 22.2 (FiO2 40%), Bicarbonate 19.1, Base excess -7.9

17. Chronic respiratory acidosis with a compensatory metabolic alkalosis

pH 7.36, PaCO2 7.3, PO2 8.9 (FiO2 40%), Bicarbonate 30.2, Base excess 5.3

2 Question 18 of 172 April 2012

A 67 year old male is admitted to the surgical unit with acute abdominal pain. He is found to have a right sided
pneumonia. The nursing staff put him onto 15L O2 via a non rebreathe mask. After 30 minutes the patient is found
moribund, sweaty and agitated by the nursing staff. An arterial blood gas reveals:

pH 7.15

pCO2 10.2

pO2 8

Bicarbonate 32

Base excess 5.2

What is the most likely cause for this patients deterioration?

A. Acute respiratory alkalosis secondary to hyperventilation

B. Over administration of oxygen in a COPD patient

2
 C. Metabolic acidosis secondary to severe pancreatitis

D. Metabolic alkalosis secondary to hypokalaemia

E. Acute respiratory acidosis secondary to pneumonia

This patient has an acute respiratory acidosis, however this is on a background of chronic respiratory acidosis (due to
COPD) with a compensatory metabolic alkalosis (the elevated bicarbonate is the main clue to the chronic nature of the
respiratory acidosis). This blood gas picture is typical in a COPD patient who has received too much oxygen; these
patients lose their hypoxic drive for respiration, therefore retain CO2 and subsequently hypoventilate leading to
respiratory arrest. If the bicarbonate was normal, then the answer would be acute respiratory acidosis secondary to
pneumonia.

3 Question 49 of 172
A 53 year old man is on the intensive care unit following an emergency abdominal aortic aneurysm repair. He develops
abdominal pain and diarrhoea and is profoundly unwell. His abdomen has no features of peritonism. Which of the
following arterial blood gas pictures is most likely to be present?

A. pH 7.45, pO2 10.1, pCO2 3.2, Base excess 0, Lactate 0

B. pH 7.35, pO2 8.0, pCO2 5.2, Base excess 2, Lactate 1

C. pH 7.20, pO2 9.0, pCO2 3.5, Base excess -10, Lactate 8

D. pH 7.29, pO2 8.9, pCO2 5.9, Base excess -4, Lactate 3

E. pH 7.30, pO2 9.2 pCO2 4.8, Base excess -2, lactate 1

This man is likely to have a metabolic acidosis secondary to a mesenteric infarct.

4 1/3 Question 50-52 of 172

Theme: Acid - base disorders

A. pH 7.64 pO2 10.0 kPa pCO2 2.8 kPa HCO3 20

B. pH 7.25 pO2 8.9 pCO2 3.2 HCO3 10
C. pH 7.20 pO2 6.2 pCO2 8.2 HCO3 27
D. pH 7.60 pO2 8.2 pCO2 5.8 HCO3 40
E. pH7.45 pO2 7.2 pCO2 2.5 HCO3 24
Please match the diagnosis with the arterial blood gas result.

50. Pulmonary embolus

The correct answer is pH7.45 pO2 7.2 pCO2 2.5 HCO3 24
A combination of hypoxia and respiratory alkalosis should suggest a pulmonary embolus. The respiratory
alkalosis is due to hyperventilation associated with the pulmonary embolism.

51. Ureterosigmoidostomy
pH 7.25 pO2 8.9 pCO2 3.2 HCO3 10
There is acidosis. To compensate the patient will attempt to reduce the pH level in the blood by hyperventilating,
hence the low CO2 level .

52. Peptic ulcer causing pyloric stenosis

The correct answer is pH 7.60 pO2 8.2 pCO2 5.8 HCO3 40

5 Question 53 of 172
Which of the following does not cause an increased anion gap acidosis?

A. Uraemia

3
 B. Paraldehyde

C. Diabetic ketoacidosis

D. Ethylene glycol

E. Acetazolamide

Causes if increased anion acidosis: MUDPILES

M - Methanol
U - Uraemia
D - DKA/AKA
P - Paraldehyde/phenformin
I - Iron/INH
L - Lactic acidosis
E - Ethylene glycol
S – Salicylates

6 Question 54 of 172
Which of the following does not cause a normal anion gap acidosis?

A. Pancreatic fistula

B. Acetazolamide

C. Uraemia

D. Ureteric diversion

E. Renal tubular acidosis

Normal Gap Acidosis: HARDUP

H - Hyperalimentation/hyperventilation
A - Acetazolamide
R - Renal tubular acidosis
D - Diarrhoea
U - Ureteral diversion
P - Pancreatic fistula/parenteral saline
Uraemia will typically cause a high anion gap acidosis. It is one of the unmeasured anions.

2/3 Question 12-14 of 67 from perioperative care

Theme: Acid - base disorders

A. Respiratory alkalosis
B. Type 1 respiratory failure
C. Type 2 respiratory failure
D. Metabolic alkalosis
E. Metabolic acidosis with normal anion gap
F. Metabolic acidosis with increased anion gap

12. pH 7.48, pO2 10.1, Bicarbonate 30, pCO2 4.5, Chloride<10meq

Metabolic alkalosis
This would be typical result of prolonged vomiting.

13. pH 7.49, pO2 7.1, pCO2 2.4, Bicarbonate 22, Chloride 12meq
Respiratory alkalosis
The hyperventilation results in decreased carbon dioxide levels, causing a respiratory alkalosis (non
compensated).

14. pH 7.20, pO2 7.5, Bicarbonate 22, pCO2 8.1, Chloride 10

4
The correct answer is Type 2 respiratory failure

This is a sign of acute type 2 respiratory failure (non compensated). This is the result of carbon dioxide retention.