AM Report Pearls: Approach to the Difficult ABG

AM Report Pearls: Six Step Approach to the Challenging ABG

Step 1: Acidemic (pH < 7.35) or alkalemic (pH > 7.45) on ABG?

Step 2: Is the primary disturbance respiratory or metabolic?

*Hint: Whichever side of 7.4 the pH is on, the process that caused it to shift to that side is the primary abnormality!*

Step 3: For metabolic acidosis, is there an increased anion gap?

*Hints: Remember to correct for albumin, and remember NS as cause of non-gap metabolic acidosis*

Step 4: For primary respiratory causes, is it acute or chronic?

Step 5: Is there appropriate respiratory compensation for a metabolic acidosis?

*Hint: Winter’s formula gives you expected PCO2 = 1.5 x HCO3 + 8 +/- 2*

Step 6: Are there other superimposed disturbances?

*Hint: Calculate the delta gap = calculated AG – 12 (normal AG) and add this delta gap to the HCO3 to get corrected HCO3*

 For more detailed information, check out the classic UCSF Dr. Haber paper on acid-base attached and a helpful handout from UC-Denver here:

Here is also a newer NEJM paper on Acid-Base disturbances that’s pretty helpful as well


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