ABG interpretation made easy

So you are an intelligent RT student or RN who wishes to learn more about how to interpret ABGs. That in mind, and based on popular demand, here is ABG interpretations made easy (For simplicity reasons I will only refer to the three basic ABG values in this post: pH (acid base balance), CO2 (carbon dioxide) and HcO3 (bicarbonate). Normal ABG values are as follows: 1. pH (acid base balance) = 7.35 to 7.45 2. CO2 (carbon dioxide) = 35 to 45 3. HcO3 (bicarbonate) = 22 to 26 You also must note the following: 1. CO2 greater than 45 is acidotic 2. HcO3 less than 22 is acidotic 3. Co2 less than 35 is alkalotic 4. HcO3 greater than 26 is alkalotic How to interpret ABGs: All you have to do is memorize four basic questions and then answer them in order: A. Is the ABG normal? If all of them are, then you have a normal ABG and you can stop here. If any one of the values is out of the normal range, then you must move on to the next question. B. Is the pH Acidotic or Alkalotic?: To determine this you look only at the pH. 1. Alkalotic: If the pH is greater than 7.45 the patient is Alkalotic. 2. Acidotic: If the pH is below 7.35 the patient is acidotic. C. Is the cause respiratory or metabolic?: To determine this, you look at pH and compare it with HcO3 and CO2. If the pH is acidotic, you look for whichever value (HcO3 or CO2) that is also acidotic. If the pH is alkalotic, you look for whichever value (HcO3 or CO2) is also alkalotic. In this sense, you match the pH with HcO3 and CO2. If the pH matches with the CO2, you have respiratory. If the pH matches with the HcO3, you have metabolic. Or, put more simply: 1. Metabolic Alkalosis: If the pH is alkatotic and the HcO3 alkalotic. 2. Respiratory Alkalosis: If the pH is alkalotic and the CO2 is alkalotic 3. Metabolic Acidosis: If the pH is acidotic and the HcO3 acidotic. 4. Respiratory Acidisis: If the pH is acidotic and the CO2 is acidotic. D. Is the cause compensated or uncompensated? 1. Uncompensated: if the pH is anywhere outside the normal ranges (greater than 7.45 or less than 7.35) 2. Compensated: pH is anywhere inside the normal ranges (Anything between 7.35 to 7.45) So, here are some examples: 1. Ph 7.40, CO2 37, HcO3 23

What do you have here? All the number are within normal range, so you have a normal ABG. That was easy enough. You need to go no further in analyzing this ABG. 2. ph 7.23, CO2 50, HcO3 22 What do you have here? A. Is the ABG normal? You can see right away that the pH and CO2 are out of the normal range, so you must move on to the next question. B. Is the pH acidotic or alkalotic? Since the pH is less than 7.35 it is acidotic. C. Is is metabolic or respiratory? Since the pH is acidotic and the CO2 also acidotic, then you have respiratory acidosis. D. Is it compensated or uncompensated? Well, the pH is outside the normal range of 7.35 to 7.45, so it is uncompensated. You don't have to look at any other values. You are done. The ABG is uncompensated respiratory acidosis 2. pH 7.36, CO2 50, HcO3 29, A. Is the ABG normal? You can see right away that both CO2 and HcO3 are out of the normal range, so you move on to the next question. B. Is is acidotic or alkalotic: The pH is less than 7.39, so it is acidotic C. Is the cause respiratory or metabolic?: The pH is acidotic and the CO2 is also acidotic, so you have respiratory acidosis. D. Is it compensated or uncompensated? Since the pH is within normal limits, it is compensated. In this example you have compensated respiratory acidosis. 3. pH 7.50, CO2 42, HcO3 33 A. Is the ABG normal? No. Some of the values are outside the normal ranges. B. Is it acidotic or alkalotic? The pH is greater than 7.41, so it is alkalotic. C. Is the cause respiratory or metabolic?: You know the pH is alkalotic, so you look for the matching value. The HcO3 is alkalotic, so it matches the pH. So, what you have is a metabolic problem. D. Is it compensated or uncompensated? Since the pH is outside the normal range of 7.35 to 7.45, it is uncompensated. Thus, you have uncompensated metabolic alkalosis. 4. pH 7.50, CO2 18, HcO3 24 A. Is the ABG normal? No, pH and CO2 are both out of the normal range. B. Is it acidosis or alkalosis? Since the pH is greater than 7.45 it is alkalosis

C. Is is respiratory or metabolic? Since the pH is alkalotic and the CO2 is also alkalotic, you have a respiratory problem D. Is is compensated or uncompensated: It is uncompensated because the pH is outside the normal range of 7.35 to 7.45. What you have here is uncompensated respiratory alkalosis. Once you practice these for a few days or weeks, you will be able to do these automatically in your head in only a few seconds just by looking at the numbers.

ABG interpretation made easy (part 2)

Other than using an ABG to determine whether a patient is acidotic or alkalotic, and whether or not the patient is compensated or uncompensated, ABGs are also used to determine level of hypoxemia. To do this we need a basic definition of hypoxemia. Hypoxemia: This refers to a low level of oxygen in your blood. This means that less oxygen may be delivered to your tissues. (A low level of oxygen to your tissues is called Hypoxia.) According to the Mayo Clinic, "The main symptom of hypoxemia is shortness of breath, but depending on how quickly hypoxemia develops, you may experience a reduced capacity for exercise, fatigue and confusion." There are two ways to measure Hypoxemia, and these are by using a pulse oximeter and by drawing a blood gas. A pulse oximeter measures SpO2, or the percentage of oxygen that a patient is breathing in that gets to the blood. Your SpO2 is a calculation. This is a non-invasive tool to help you adjust the level of oxygen a patient is receiving. A blood gas measures the actual SaO2, which is the actual level of oxygen in the lungs. If you are not confident you are getting an actual SpO2 reading, or if you just want to check the severity of hypoxemia, a blood gas is necessary. To confirm the SpO2 you can check to see that it is close to the SaO2 on the blood gas. A better way of checking hypoxemia is by looking at the PaO2 on the blood gas. This is the partial pressure of oxygen in the lungs. Level of hypoxemia is determined this way: 80-106 torr = normal 60-79 torr = mild hypoxemia 40-59 torr = moderate hypoxemia less than 40 torr = severe hypoxemia

The level of hypoxemia is also determined by the FiO2 the patient was on at the time of the ABG draw. So, we need to define FiO2:

Fio2: This is the fraction of inspired oxygen. The FiO2 of room air is 21%, so currently you and I are breathing in 21% FiO2. Thus, if a patient is breathing room air, and has a PO2 of 80, then that patient has a normal oxygen level. However, if a patient is breathing room air, and his PO2 is 40, then he is severely hypoxic. If a patient is hypoxic, you will want to increase his oxygen. How much oxygen to place the patient on is dependent on the patient. Ideally, you'll want to place the patient on enough oxygen to get the SaO2 or SpO2 up to at least 90, and the PO2 above 60. So, without drawing another ABG, how do you know the PaO2 is at least 60? If you have ever studied the oxyhemoglobin disassociation curve, you'll know that PaO2 and SpO2 correspond to each other in the following fashion (for most patients): If the SpO2 is 90, the SaO2 is 60 If the SpO2 is 80, the SaO2 is 50 If the SpO2 is 70, the SaO2 is 40

Therefore, it's easy to use the pulse ox reading (SpO2) to determine approximate level of hypoxemia, how much FiO2 the patient needs. If the level of hypoxemia is mild, usually 2lpm nasal cannula works great. If the level of hypoxemia is mild, usually a venturi mask is required, or perhaps even a non-rebreather. Ideally, you will want use the lowest FiO2 possible to obtain the desired SpO2. For example, if the patient is on 2lpm and the SpO2 is 92%, than that's the perfect about of oxygen. However, if the patient is on a 75% non-rebreather, and his SpO2 is 100%, it might be time to try a 50% venturi mask. If the SpO2 is 100% on 50%, it might be time to try 40%. Now, say a patient is receiving an FiO2 of 60% or greater when the ABG was drawn, and the SpO2 is less than 60 torr. While 60 torr is usually acceptable, this particular patient is requiring a lot of supplemental oxygen to reach this level. In this case, an SpO2 of 60 would be considered as severe. Refractory Hypoxemia: This is when a patient has a low O2 that does not improve with increasing the oxygen. Generally, it is described as a PO2 of 60 torr or less with an FiO2 of 60% or greater. Another thing you can consider is to use a formula to determine the appropriate FiO2 setting for the given ABGs. The formula is as such: Desired FiO2 = Desired PaO2 + Known FiO2 divided by known PaO2 Ideally, however, this formula is not really needed, because (for the average patient), FiO2 should be adjusted to maintain an SpO2 of at least 90%. Exceptions are if the hemoglobin is less than 10, or if the patient has carbon monoxide poisoning. In these cases you'll want to maintain 100% SpO2 and monitor blood gas PaO2 to make sure it is at an appropriate level (at least 60). To determine if the FiO2 the patient is receiving is generating the appropriate PaO2, or to determine if the patient is oxygenating, you can use this formula: FiO2 * 5

Thus, if a patient is given 100% FiO2, you should expect a PaO2 of about 500. If the PaO2 is only 200, you know the patient is not oxygenating well. Of course you should already know this, yet sometimes a formula like this comes in handy. A PaO2, therefore, of 200 is still high, so if we use the formula above to determine appropriate FiO2 for this patient, we know we need at least 50% FiO2. To monitor if a patient is improving over time, you can use the following formulas: 1. Expected PaO2 = FiO2 x5 Even though normal PaO2 is 105 on room air, a PaO2 of 200 on 100% FiO2 is not necessarily good. It should be 500. Therefore you know patient still not oxygenating effectively. 16. Actual PaO2/ Expected PaO2 = % of patient expected PaO2: a. Should be recorded daily b. Shows if patient is oxygenating better c. Better indicator than simply looking at actual PaO2 and FiO2 d. Normal = zero (patient requiring no supplememtal oxygen)

Examples of % expected PaO2: (Despite lower PaO2, patient still oxygenating better) e. January 1 PaO2 40 on 100% FiO2 = 80% f. January 5 PaO2 60 on 40% FiO2 = 30% g. January 6 PaO2 55 on 50% FiO2 = 20%

Another example of % expected PaO2 (PaO2 look good, but is patient really oxygenating?) h. January 1 PaO2 200 on 100% FiO2 = 40% i. January 5 PaO2 100 on 100% = 20% j. January 6 PaO2 100 on 90% = 22% k. January 10 PaO2 55 on 80% = 13%

You don't necessarily need to use these formulas to see if patient oxygenating well or is getting better. However, sometimes, on the more complicated cases, it helps to see the numbers and the trends.