by "Grog" (Alan W. Grogono), Professor Emeritus, Tulane University Department of Anesthesiology
This page describes the interpretation of the acid-base component of blood gas results. Designing the interactive acid-base diagram necessitated the development of a logical approach. This page converts the logic back into a human process.
In a Perfect World complete information about a patient is available before acid-base values are analyzed. What follows is a logical framework for looking at acid-base values with no patient. A report may invite you to "Consider" a single clinical problem. However, identical results could also be obtained from a complex combination of clinical problems and therapy.
Step 1: Is the pH normal, acid, or alkaline – critical because it governs all the subsequent thinking. In acute problems the change is usually more acidic - a low pH - e.g., 7.2 or 7.1. This is because failure, either respiratory or metabolic, results in the accumulation of acids. The following paragraphs assume acidemia. However, also look at the Table of Details which follows the paragraphs below.
Step 2: If the respiratory change is also acid (raised PCO2), then the cause is respiratory, unless the metabolic component is also acidic – in which case both are contributing to the acidic pH.
If the PCO2 is not like the pH, i.e., the PCO2 is low (alkaline), then the primary problem must be metabolic and the low PCO2 is compensating for the metabolic acidosis.
Step 3: If the Standard Base Excess (SBE) is acidic (a negative SBE), then the cause is metabolic. The exception, as above, is when the respiratory component is also acid when both are contributing to the acid pH.
If the SBE is not like the pH, i.e., the SBE is alkaline, then the primary problem is not metabolic; the high SBE is a compensation for the respiratory acidosis.
Step 4: Few adjectives are used to characterize magnitude in casual conversation. The interactive diagram necessitated a disciplined sequence: No, Minimal, Mild, Moderate, Marked, Severe. In the diagram, these adjectives are applied to both the respiratory and metabolic components and, at pH=7.4, they "balance" with the PCO2 and the SBE being equal and opposite. If at pH 7.4 the PCO2 is described as a marked acidosis then the SBE must be a marked alkalosis. The steps actually used are shown in the following table (approximate for SBE):
|Alkalosis||Severe||< 10||> 16.5|
|Marked||10 to 19||12 to 16.5|
|Moderate||19 to 26||8 to 12|
|Mild||26 to 32||4.5 to 8|
|Minimal||32 to 37||2 to 4.5|
|Normal||Normal||37 to 43||2 to -2|
|Acidosis||Minimal||43 to 48||-2 to -4.5|
|Mild||48 to 54||-4.5 to -8|
|Moderate||54 to 61||-8 to -12|
|Marked||61 to 70||-12 to -16.5|
|Severe||> 70||< -16.5|
A pure, or acute, respiratory disturbance is found close to the SBE=0 line: the change in ventilation has occurred too rapidly for metabolic compensation to occur.
A pure metabolic disturbance would lie close to PCO2 = 40 mmHg (5.33 kPa). In practice, however, this is rare because partial respiratory compensation occurs even as the metabolic change develops.
Step 5: Characteristic compensation zones indicate where someone with a prolonged single problem is likely to lie (see the Acid-Base Diagram). These zones of partial compensation lie roughly half way between no compensation and complete compensation.
A respiratory acidosis with a PCO2 of 60 mmHg (raised by 20mmHg) would require for "complete compensation" an SBE = 12 mEq/L. An SBE=0 mEq/L would suggest "no compensation". A value in the middle (SBE = 6 mEq/L) is typical "compensation for chronic respiratory acidosis".
A metabolic acidosis with SBE of -12 (reduced by 12 mEq/L) would require for "complete compensation" a PCO2 = 20 mmHg. A normal PCO2 would indicate "no compensation". A value in the middle (30 mmHg) is typical "compensation for metabolic acidosis".
The first table below summarizes the six classical acid-base disturbances to be recognized.
The second table shows four combinations that are occasionally encountered: two pure uncompensated metabolic disturbances and the two combined disturbances.
1. Six Classical Acid-Base Disturbances
|Acid||Acid||Alk||Resp. Acid. Comp||SBE Half way - Normal Met. Comp.|
|Norm||Resp. Acid. Pure||SBE Normal - No Met. Comp|
|Alk||Acid||Met. Acid. Comp||PCO2 Half way - Normal Resp. Comp.|
|Alk||Alk||Acid||Resp. Alk. Comp||SBE Half way - Normal Met. Comp.|
|Norm||Resp. Alk. Pure||SBE Normal - No Met. Comp|
|Acid||Alk||Met. Alk. Comp||PCO2 Half way - Normal Resp. Comp|
2. Four Other Acid-Base Disturbances
|Acid||Norm||Acid||Met. Acid. Pure||PCO2 Normal - No Resp. Comp|
|Acid||Acid||Combined Acidosis||No Compensation - Both Acid|
|Alk||Norm||Alk||Met. Alk. Pure||PCO2 Normal - No Resp. Comp|
|Alk||Alk||Combined Alkalosis||No Compensation - Both Alkaline|
Recognize typical zones: The pink and blue zones represent the characteristic zones where patients with a single problem are typically found. The grey colored zones are less important for recognition:
Logical Approach to an Acid pH: The following section was added in March 2003 at the request of a reader:
The examples allow a logical analysis sequence to be followed:
"Thank you readers!" I appreciate feedback and would enjoy hearing from you and considering your suggestions. Thank you.
Alan W. Grogono
|Copyright Mar 2018.|
All Rights Reserved