Objectives

 Identify normal arterial blood gas (ABG) parameters

 List two mechanisms by which the body can balance the blood pH
 Identify the method of compensation based on the lab values

Please note. This CE educational offering has been developed for the DaVita Acute Nurse.

Nurses in the acute setting frequently encounter dialysis patients

presenting with acidosis. Whether the patient is a chronic renal failure
patient in distress, or a true acute kidney injury patient, the dialysis
team’s response is critical in the patient’s successful recovery. With this
in mind, let’s take a closer look at arterial blood gases, and what we can
learn about our patients from these results.

Definitions Defining the terms related to arterial blood gases and the relationship to
acid/base balance of the body will be helpful in facilitating this review. Multiple
resources offer simplistic ways to evaluate ABG results. The Romanski method
of analysis can be used by all levels of clinicians. The process examines whether
an acid-base disorder is present, the primary cause, and whether compensation
is present.

Let’s break it down:

 pH: refers to the concentration of hydrogen ions in a solution. In other
words, it is the measurement of acidity or alkalinity (base) of a solution. For
example, the pH of pure water is about 7.0 and is considered neutral,
Some pH examples meaning the acid (H+, or hydrogen ions) and the base (OH-, or hydroxide
 Lemon juice: pH ions) are equal.
of 2  A pH below 7 indicates an increase in hydrogen ion concentration
 Wine: pH of 4 and is acidic
 Baking soda: pH  A pH above 7 indicates a decrease in hydrogen ion concentration
of 8.7 and is alkalotic.
 Bleach: pH of
 Normal body pH is slightly alkaline with a range of 7.35 to 7.45.
12.5

Authors/Contributors/Reviewers  This free Continuing Education (CE) offering is provided

 Joanne Brady, RN, CDN, MBA by DaVita’s Clinical Education & Training.
 Carol Farthing BSN, RN, CNN  To receive a CE certificate for 1.0 contact hours, complete the
 Robert Provenzano, MD online posttest.
 Donna Swartzendruber, RN, CNN, MSN  Thank you for your interest in learning!
 Carol Weygant BSN, RN, CNN, MBA

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 Increasing concentration of hydrogen

Neutral (Water)
0 1 2 3 4 5 6 7.0 8 9 10 11 12 13 14
← More Acidic More Alkaline (Basic) →

 Acid: Any substance with a pH below 7.0. An acid has a free hydrogen ion
available to donate to a base. Examples include hydrochloric acid, nitric
acid, lactic acid, acetic acid and carbonic acid.
 Base: Any substance with a pH above 7.0. A base can accept or bind a
hydrogen ion. Examples include ammonia, lactate, acetate, and
bicarbonate.

Step 1: Is there an acid/base disorder? The presence of an acid or base disorder depends on
whether the patient’s blood pH is less than 7.35 or more than 7.45.
 Acidemia: condition when there is too much hydrogen in the blood, which
causes the pH to fall below below 7.35 (patient is acidotic).
 Alkalemia: condition of the blood when the concentration of hydrogen ions
falls, causing the pH to rise above 7.45 (patient is alkalotic).

To understand the underlying cause of the patient’s acid/base imbalance, we must first understand how
normal metabolic and respiratory processes impact the body’s pH.

 Acidosis: The process, whether metabolic or respiratory, that causes the

acidemia.
 Alkalosis: The process, whether metabolic or respiratory, that causes the
alkalemia.
In a healthy body, three buffering systems help maintain a normal, almost
constant pH. These include:
1. Chemical buffers
o The main chemical buffers are bicarbonate (HCO3-), phosphate and
protein.
2. The respiratory system
o Receptors in the brain sense pH changes and vary the rate and
depth of respirations to regulate the oxygen (O2) and carbon
dioxide (CO2) levels in the blood.
3. The renal system
 The kidneys maintain an acid/base balance by reabsorbing acids or
bases back into the bloodstream or by excreting acids and bases
through the urine. They produce HCO3- to replenish its supply as
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 needed. It may take 24 hours for the kidneys to restore a pH to
normal. These are metabolic processes.

“A blood gas is
exactly that...it
Normal arterial adult blood gas values (at sea level)
measures the pH 7.40 (7.35-7.45)
dissolved gases PaCO2 35-45 mm Hg pressure
in your HCO3- 22-26 mEq/L
bloodstream.” PaO2 80-100 mm Hg
Lopez SaO2 95% to 100%

Base excess -2 to +2

When ABNORMAL Step 2 of the Romanski method: What is the primary cause of the patient’s
academia or alkalemia? If the patient’s arterial blood gas lab values are
abnormal, the underlying cause may be either respiratory or metabolic in
origin.

Definitions I. The respiratory parameter of the ABG is the PaCO2 (see definition box).
PaCO2: The PaCO2 is a reflection of alveolar ventilation. If the PaCO2 is out of range
The partial the patient is said to have a respiratory disturbance. Each type is
pressure of carbon discussed below.
dioxide that is a. Respiratory acidosis (when PaCO2 is elevated) is caused by the
dissolved in
inability to breath off excess CO2, i.e. hypoventilation. Treatment
arterial blood.
generally consists of improving alveolar ventilation. Some common
PaO2: etiologies include:
The partial  Obstructive lung disease, sleep apnea, and other lung disease
pressure of  Over sedation, head trauma, anesthesia, and drug overdose
oxygen that is  Neuromuscular disorders, such as Guillain-Barre syndrome or
dissolved in myasthenic crisis
arterial blood.  Pneumothorax, flail chest, or other types of chest wall trauma
that interfere with breathing mechanics
SaO2:
The saturation of
 Inappropriate mechanical ventilator settings
oxygen in the b. Respiratory alkalosis (a low PaCO2) is caused by breathing off too
blood. much CO2, i.e., hyperventilation. Treatment consists of correcting
the underlying cause. Some common etiologies include:
 Nervousness and anxiety
 Pulmonary embolus, pulmonary edema
 Pregnancy
 Excessive ventilation with mechanical ventilator
 Interstitial lung disease
 Response to metabolic acidosis (i.e., diabetic ketoacidosis)
 Bacteremia (sepsis), liver disease, or fever
 CNS disturbances, such as brain tumors and infections
 Respiratory stimulant drugs, such as salicylates, theophylline,
catecholamines, and progesterone

II. The metabolic parameter of the ABG reading is the HCO3-. When the
primary disturbance affects the bicarbonate level, the problem is defined
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 as metabolic, not respiratory, in nature. A decrease in HCO3- leads to
metabolic acidosis while an increase in HCO3- leads to metabolic alkalosis.
Each is discussed below.
a. Metabolic alkalosis occurs when the body has more base than acid
in the system. Causes may include:
 Chloride depletion (vomiting, prolonged NG suctioning, diuretic
therapy)
 Cushing’s syndrome, hyperaldosteronism, potassium
deficiency, renal artery stenosis, licorice
 Exogenous administration of alkali (massive blood transfusions
containing citrate, bicarbonate administration, ingestion of
antacids)
b. Metabolic acidosis is the result of a high anion gap. Causes may
include:
Anion gap: the difference  Diabetic ketoacidosis, starvation
between the sum of serum  Drugs: salicylates, ethylene glycol, methanol alcohol,
anions (chloride and paraldehyde
bicarbonate) and the sum of  Shock, sepsis – resulting in lactic acidosis from hypoperfusion
serum cations (sodium and  Renal Failure, uremia, renal tubular acidosis
potassium). A normal anion gap  Diarrhea
is between 3 and 10 mEq/L  Drainage of pancreatic Juices
 Ureterosigmoidostomy (placement of ureters into the sigmoid
colon)
 Long or obstructed ileal conduit
 Rapid intravenous infusion of non-bicarbonate containing
solutions causing a dilutional acidosis
 Hyperalimentation causing a possible hyperchloremic acidosis

Step 3: Is there compensation present?

Maintaining pH balance: The body attempts to minimize pH changes by maintaining a normal

Compensation HCO3- to PaCO2 ratio (20:1). When imbalances occur, the pH can often be
returned to a near normal level when the component not initially affected
adapts to the imbalance.

Both the lungs and the kidneys can be involved in this compensatory process --
the lungs step in to compensate for metabolic problems and the kidneys
provide relief for respiratory causes.
 The lungs can be stimulated to make adjustments in as rapidly as 1-
12 minutes for acute situations and 1-2 days for a chronic
condition.
 The kidneys are slower to respond, however, but if kidney function
remains, this response can continue to infinity.

Acid-base disorder Compensation Speed of response

Respiratory Acidosis Kidneys increase their reabsorption of Slow (days)
HCO3- and increase their excretion of
acid.

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 Respiratory Alkalosis Kidneys increase their excretion of Slow (days)
HCO3-.
Metabolic Acidosis Respiration rate increases Rapid (in 1-2 hours,
(hyperventilation) maximizes in 12-24
hours)
Metabolic Alkalosis Respiration rate decreases Rapid (in 1-2 hours,
(hypoventilation) maximizes in 12-24
hours)

Analyzing arterial blood gas results: Job Aid

The following steps take a simple, systematic approach to assessing ABG results.

1st: Analyze the pH

Summary
 7.35-7.45 is normal range
Test name If lower If higher
 Below 7.35 is acidic (normal than than
 Above 7.45 is alkalotic range) normal normal
 Between 7.35 – 7.4 is normal/acidotic pH (7.35- Acidosis Alkalosis
 Between 7.4 – 7.45 is normal/alkalotic 7.45)
PaCO2 (35- Alkalosis Acidosis
nd 45)
2 : Analyze the PaCO2*
HCO3- (22- Acidosis Alkalosis
 35-45-mmHg is normal range
26)
 Below 35 mmHg is alkalotic PaO2 (80- Hypoxemia From O2
 Above 45 mmHg is acidotic 100) therapy
SaO2 (95- Hypoxemia ---
3rd: Analyze the HCO3- (bicarbonate) 100%
 22-26 is normal range
 Below 22 is acidotic
 Above 26 is alkalotic

4th: Determine the cause of acid-base disorder by matching the pH with the PaCO2 or the
HCO3
 If the pH is acidotic and the PaCO2 is acidotic, the acid-base disturbance is caused
by the respiratory system.
 If the pH is alkalotic and the HCO3- is alkalotic, the acid-base disturbance is caused
by the metabolic (renal) system.

5th: Determine if either the PaCO2 or the HCO3 is going in the opposite direction of the pH
 If yes, this indicates compensation is occurring.
 For example, both the pH and HCO3 are alkalotic but the PaCO2 is acidotic. Since the
HCO3 matches the pH, the primary acid-base disorder is metabolic alkalosis. The low
CO2 indicates the respiratory system’s attempt to compensate for this alkalosis.
 If the pH remains abnormal (as in the above example), only partial compensation is
present. When the pH returns to normal, the compensation is considered complete.

6th: Lastly, analyze the PaO2 and the O2 saturation

 Arterial PaO2: 80 or greater is normal
 Arterial oxygen saturation SaO2: 95 to 100%
 When these numbers are low, it indicates hypoxemia.
* The PaCO2 versus the CO2 content blood test
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  The PaCO2 (partial pressure arterial CO2) reading is part of an arterial blood gas report. This test measures
the pressure exerted by the dissolved CO2 within the blood. Its reading reflects gas exchange within the
lungs.
 The CO2 content (also called “total CO2”) is often part of an electrolyte blood panel. It measures the total
dissolved CO2 in the patient’s blood and reflects blood bicarbonate levels. It typically decreases between
dialysis treatments and then increases/improves during dialysis due to movement of bicarbonate from the
dialysate to the blood.

Test Your Knowledge

Use the preceding job aid to answer the follow ABG questions. Begin by
determining if each individual value is considered normal, acidotic or alkalotic.
Then select the best answer.

Question 1
pH of 7.27  normal,  acidotic, alkalotic

PaCO2 of 53  normal,  acidotic, alkalotic

HCO3 of 24  normal,  acidotic, alkalotic

These numbers indicate?

pH 7.27
A. Respiratory acidosis
CO2 30
B. Metabolic acidosis
HCO3 24
Answer: Both the pH and PaCO2 are acidotic. This indicates that the
acid-base disturbance was initiated by the respiratory system. The
correct answer is A.

Question 2
pH of 7.47  normal,  acidotic, alkalotic

PaCO2 of 39  normal,  acidotic, alkalotic

HCO3 of 31  normal,  acidotic, alkalotic

These numbers indicate?

A. Respiratory alkalosis pH 7.27
B. Metabolic alkalosis CO2 30
HCO3 24
Answer: Both the pH and HCO3 are alkalotic. This indicates metabolic
alkalosis is occurring and that this acid-base disturbance was initiated
by the metabolic system.

Question 3
pH of 7.32  normal,  acidotic, alkalotic

PaCO2 of 53  normal,  acidotic, alkalotic

HCO3 of 28  normal,  acidotic, alkalotic

These readings indicate?

pH 7.27
A. Partially compensated respiratory acidosis
CO2 30
B. Partially compensated metabolic acidosis
HCO3 24
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 Answer: Since both the pH and PaCO2 are acidotic yet the HCO3 is
alkalotic, this indicates that the metabolic system is attempting to
compensate for the initial respiratory acidosis. The best answer is A.

The numbers to the right are an example of a fully pH of 7.35

compensated respiratory acidosis (the pH is within PaCO2 of 50
the normal range). HCO3 of 32

Question 4 Select the correct answer for pH of 7.30  normal,  acidotic, alkalotic
each lab value. Is this set of PaCO2 of 30  normal,  acidotic, alkalotic
readings reflective of: HCO3 of 18  normal,  acidotic, alkalotic
A. Partially compensated meta- pO2 of 68  normal,  high,  low
bolic alkalosis with hypoxemia O 2 sat of 79%  normal,  high,  low
B. Partially compensated respiratory acidosis with hypoxemia.
Answer: Both the pH and the HCO3 are acidotic, indicating metabolic
acidosis. Since the PaCO2 is alkalotic, this indicates compensation is
occurring. Hypoxemia is also present. The correct answer is A.

More practice with compensation

Test Your Knowledge

Arterial blood gas readings Interpretations

1. pH of 7.30, PaCO2 of 50 mm Hg, HCO3 of 22 mEq/L A. Uncompensated metabolic

alkalosis
2. pH of 7.32, PaCO2 of 50 mm Hg, HCO3 of 28 mEq/L B. Respiratory acidosis with partial
compensation
3. pH of 7.52, PaCO2 of 29 mm Hg, HCO3 of 23 mEq/L
C. Uncompensated metabolic
4. pH of 7.18, PaCO2 of 44 mm Hg, HCO3 of 16 mEq/L acidosis
D. Respiratory acidosis without
5. pH of 7.60, PaCO2 of 37 mm Hg, HCO3 of 35 mEq/L compensation
E. Uncompensated respiratory
alkalosis
Answers: 1. D; 2. B; 3. E; 4. C; 5. A.

The patient How does all of this affect the dialysis patient? First let’s look at patient with
chronic kidney failure who is usually somewhat acidotic at the beginning of the
treatment.
 Pre-treatment some compensatory mechanism with an increase in
respirations may be present.
 During the treatment, the bicarbonate deficit is corrected (via the
movement of bicarbonate from the dialysate to the blood) and the
respiratory compensation slows.
 At the completion of the treatment the blood gas values would
probably be either close to normal or leaning slightly toward metabolic
alkalosis.
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 In the patient with acute kidney failure, the correction of the acidosis is variable
and depends on the cause and severity of the acidosis. For example, the acid-
base balance of a patient in profound septic shock who is producing large
amounts of lactate from hypoperfused tissues will probably not correct as
quickly or easily as in a patient who has stable chronic kidney disease. This is
partly due to the fact that lactate is not easily removed with dialysis, and partly
because more acid may be produced by the body than can be removed within a
dialysis treatment. In this case, the patient would probably remain acidotic
until the underlying cause of the acidosis is corrected.

Obtaining ABG sample Most hospitals have a respiratory therapy team or trained nurses who obtain
ABG specimens. Generally, specimens will be drawn from the radial artery or
from an existing arterial line. When drawn during a treatment it should be
noted that the results will be a reflection of that moment in time since the acid/
base balance will continue to be altered by the progression of the dialysis
treatment. If the patient is heparinized, extra precaution should be taken to
assure homeostasis at the site.

If asked to draw a specimen from an AV graft or fistula, the acute dialysis nurse
is to draw the sample from the arterial needle and the specimen should be
labeled as “mixed venous blood.”

Summary For normal enzyme and cell function and normal metabolism, the blood must
remain in a very narrow pH range (7.35 to 7.45). If the blood pH falls below 6.8
or climbs above 7.8 it is usually fatal. While a pH lower than 7.35 is indicative of
an acidosis and a pH higher than 7.45 is indicative of an alkalosis, it is important
to note that a patient may experience multiple abnormalities, and mixed acid-
base disturbances may be present.

References
 Acidosis. Available at http://commons.wikimedia.org/wiki/File:Symptoms_of_acidosis.png. Accessed on October 12, 2009.
 Alspach, J. G (1998) Core Curriculum for Critical Care Nursing, 5th Edition. Philadelphia: W. B. Saunders
 Anatomy and Physiology. Available at
http://rds.yahoo.com/_ylt=A9G_bF5GrtNKTP8A4jyjzbkF/SIG=12svu33nh/EXP=1255473094/**http%3A//www.fccj.org/campus
es/north/lac/urinary_system/kidney_cross2.html. Accessed on October 12, 2009.
 Counts, et al (2008) Core Curriculum for Nephrology Nursing, 5th Edition, Pitman, New Jersey, A. Janetti
 Fournier, M. (2009) Perfecting your acid-base balancing act. American Nurse Today. 4. (1): 17-22.
 Hartshorn, Sole, Lamborn (1997) Introduction to Critical Care Nursing, 2nd Edition. Philadelphia: W. B. Saunders Jupiter Science
Water Ionizers. Available at http://www.mallorcaspirit.com/ionizer/ Jupiter Science Water Ionizers. Accessed on October 12,
2009.
 Kurtz, I (2004) Acid-Base Case Studies. Victoria, Canada: Trafford Publishing
 Lytes – Acid Base Guide. Available at www.medicalinfosystems.com (2003) Accessed September, 2009.
 Nursing 331 Nursing Notes and Lecture Handouts. Available at
http://www.mac.edu/faculty/ChristineStaake/331%20Notes%20and%20Handouts%20Home.htm. Accessed on October 12,
2009.
 Preston, R. A. (2002) Acid-Base, Fluids, and Electrolytes Made Ridiculously Simple. Miami: MedMaster. Inc.
 Update in Anaesthesia. Available at http://www.nda.ox.ac.uk/wfsa/html/u13/u1312_03.htm Media Publishing Company,
Media House, 41 Crayford Way, Crayford, Kent, DA1 4JY, UK. Accessed on October 12, 2009
 Woodruff, D., (2003) 6 Easy Steps to ABG Analysis, Ed4Nurses.com
 https://www.ncbi.nlm.nih.gov/books/NBK536919/ accessd on October 2, 2019
 https://www.healthline.com/health/low-anion-gap Accessed on October 8, 2019.

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Post Test Questions (to be completed in StarLearning)

1. The normal body pH range is

A. 7.30 - 7.40
B. 7.40 - 7.55
C. 7.35 - 7.45
D. 7.25 - 7.40

2. The body’s main chemical buffers are

A. Potassium and sodium
B. Bicarbonate, phosphate, and protein
C. Hemoglobin and hematocrit
D. Temperature regulator and fluid balance

3. The respiratory system buffers pH by adjusting respiratory rates to regulate ____ in the blood.
A. PaCO2
B. PaO2
C. HCO3
D. O2 saturation

4. The kidneys maintain acid/base balance by producing ____ to replenish the supply.
A. CO2
B. Phosphate
C. HCO3
D. Hemoglobin

5. When the pH is elevated, the body is in a(n) __________ state.

A. Alkalotic
B. Acidotic
C. Balanced

6. A blood specimen drawn from an AV graft or fistula is a(n) ___________specimen.

A. Arterial
B. Venous
C. Mixed venous

7. Some common causes of Respiratory Acidosis include:

A. Nausea, vomiting, diarrhea
B. COPD, Guillain-Barre, or over-sedation
C. A and B

8. Blood gas values of pH 7.20, PaCO2 of 44 and HCO3 of 18 indicate:

a. Respiratory acidosis
b. Respiratory alkalosis
c. Metabolic acidosis
d. Metabolic alkalosis

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9. At the beginning of a treatment, a dialysis patient’s acid/base status would most likely be ___________ .
a. Normal
b. Acidotic
c. Alkalotic

10. A patient with a PaO2 of less than 80 is:

a. Hyperventilating
b. Hypoventilating
c. Hypoxic
d. Anoxic

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