Professional Documents
Culture Documents
Vishram Buche
Om Child Trust Hospital
NAGPUR
The Goal :
In detail
…A respiratory component
CO2 …A respiratory acid
…Moves opposite to the direction of pH.
…A metabolic component
…It is a base (Metabolic)
HCO3 …Moves in the same direction of pH.
OH 20 7.60
ion
30 AlkalineH1
pH 7.50
50 7.30
+
H 0 60
Acidic 7.20
ion
CO2
HYPERCO
VENTILATION
2 CHANGES
pH in opposite direction
compensation
LOW HCO3
pH
LOW pH CHANGES
BICARB
pH in same direction
LOW pCO2
HCO3
compensation
HIGH HCO3
pH
HIGH pH
BICARB CHANGES
HIGH CO2
pH in same direction
HCO3
compensation
HIGH pCO2
pH
LOW pH
HIGH HCO3
CO 2
High
CO2
Primary lesion Respiratory acidosis
BICARB
CO 2 CHANGES
pH in opposite direction
LOW pCO2
pH
HIGH pH
Full compensation
Partial compensation
No compensation…. (uncompensated)
7.20 15 40 Un Compensated
O.
PaO2
2 % Dissolved
Oxygen
Delivery
Of
CaO2 Oxygen
Content of oxygen
Ml/100 of blood
To
O2
Tissues
Cardiac output
A.C.I.( Alveolar capillary interface)
DaO2
----- XXXX Diagnostics ------
Calculated Data
HCO3 act 31.1 mmol / L
HCO3 std 30.5 mmol / L
BE
O2 CT
6.6
14.7
mmol / L
mL / dl output
O2 Sat 98.3 %
ct CO2 32.4 mmol / L
pO2 (A - a) 32.2 mm Hg
pO2 (a / A) 0.79
Entered Data
Temp 38.6 o
C
ct Hb 10.5 g/dl
FiO2 30.0 %
-----XXXX Diagnostics-----
Measured 37.0 0C
pH 7.452 Measured values…
pCO2 45.1 mm Hg
pO2 112.3 mm Hg most important
Corrected 38.6 0C
pH
pCO2
7.436
47.6 mm Hg
Temperature Correction :
pO2 122.4 mm Hg Is there any value to it ?
Calculated Data
HCO3 act 31.2 mmol / L
HCO3 std
BE
30.5
6.6
mmol / L
mmol / L
Calculated Data :
O2 ct 15.8 mL / dl Which are useful one?
O2 Sat 98.4 %
ct CO2 32.5 mmol / L
pO2 (A -a) 30.2 mm Hg
pO2 (a/A) 0.78
Entered Data
Entered Data :
Temp 38.6 0C Important
FiO2 30.0 %
ct Hb 10.5 gm/dl
Uncorrected pH & pCO2 are reliable reflections of
in-vivo acid base status
Measured 37.0 0C
pH 7.452 Bicarbonate is calculated on the basis
pCO2 45.1 mm Hg
pO2 112.3 mm Hg of the
Corrected 38.6 0C Henderson equation:
pH 7.436
pCO2 47.6 mm Hg
pO2 122.4 mm Hg + -
[H ] = 24 pCO2 / [HCO3 ]
Calculated Data
HCO3 act 31.2 mmol / L
or
HCO3 std
BE
30.5
6.6
mmol / L
mmol / L
for the
Mathematically
O2 ct 15.8 mL / dl
O2 Sat 98.4 %
ct CO2 32.5 mmol / L
inclined…
pO2 (A -a) 30.2 mm Hg
pO2 (a/A) 0.78
Entered Data
Temp 38.6 0C
FiO2 30.0 %
ct Hb 10.5 gm/dl
-----XXXX Diagnostics-----
Calculated Data
Base Excess:
HCO3 act 31.2 mmol / L
HCO3 std 30.5 mmol / L D base to normalise HCO3 (to 24) with
BE 6.6 mmol / L
O2 ct 15.8 mL / dl PCO2 at 40 mm Hg
O2 Sat 98.4 % (Sigaard-Andersen)
ct CO2 32.5 mmol / L
pO2 (A -a) 30.2 mm Hg
: reflects metabolic part of acid base D
pO2 (a/A) 0.78 : no info. over that derived from pH, pCO2 and
Entered Data HCO3
Temp 38.6 0C : Misinterpreted in chronic or mixed disorders
FiO2 30.0 %
ct Hb 10.5 gm/dl
-----XXXX Diagnostics-----
Measured 37.0 0C
pH 7.452
pCO2 45.1 mm Hg
pO2 112.3 mm Hg
Corrected 38.6 0C
pH 7.436
pCO2 47.6 mm Hg
pO2 122.4 mm Hg
Calculated Data
HCO3 act 31.2 mmol / L
HCO3 std 30.5 mmol / L
BE 6.6 mmol / L
O2 ct 15.8 mL / dl
O2 Sat 98.4 %
ct CO2 32.5 mmol / L
pO2 (A -a) 30.2 mm Hg
pO2 (a/A) 0.78
Entered Data
Temp 38.6 0C
FiO2 30.0 %
ct Hb 10.5 gm/dl
Alveolar-arterial O2 Difference
………..PAO2 – PaO2 = ?
PAO2 = PiO2* -(PCO2/0.8)
PAO2
= 150 – 50 = 100 mm Hg
O2
CO2
PaO2 = 90 mmHg
PaO2
PAO2 – PaO2 = 10 mmHg
* When FiO2 = 21 % :
PiO2 = (760-45) x .21= 150 mmHg
Alveolar-arterial Difference
Oxygenation Failure Ventilation Failure
Wide Gap Normal Gap
PCO2 = 40 PCO2 = 80
PaO2 = 45 PaO2 = 45
PAO2 = 150 – 1.2 (40) O2 PAO2 = 150-1.2(80)
= 150 - 50 CO2 = 150-100
= 100 = 50
20 × 5 = 100
FiO2 × 5 = PaO2
-----XXXX Diagnostics----
Blood Gas Report
Measured 37.0 0C
pH 7.452
pCO2 45.1 mm Hg
pO2 112.3 mm Hg
Calculated Data
HCO3 act 31.2 mmol / L
O2 Sat 98.4 %
O2 ct 15.8
pO2 (A -a) 30.2 mm Hg
pO2 (a/A) 0.78
Entered Data
FiO2 %
Ct Hb gm/dl
Always mention and see… FiO2
ct Hb
Technical Errors
Glass vs. plastic syringe:
Changes in pO2 are not clinically important
No effect on pH or pCO2
Heparin (1000 u / ml):
Need <0.1 ml / ml of blood
pH of heparin is 7.0; pCO2 trends down
Avoided by heparin flushing & drawing 2-4 cc blood
Delay in measurement:
Rate of changes in pH, pCO2 and pO2 can be reduced to 1/10 by
o
cooling in ice slush(4 C)
No major drifts up to 1 hour
1. Consider the clinical settings! Anticipate the disorder
7 steps to analyze ABG
2. Look at pH?
3. Who is the culprit ?...Metabolic / Respiratory
4. If respiratory…… acute and /or chronic
5. If metabolic acidosis,
Anion gap ed and/or normal or both?
6. Is more than one disorder present?
7. Correlate clinically
Step 2
Look at the pH
Is the patient acidemic pH < 7.35
or alkalemic pH > 7.45
If pH = 7.4 …… Normal
Mixed
or Fully compensated
Step 3 ……. CULPRIT?
HCO3…… METABOLIC
HCO3 = Base
> 26 ….. Met. Alkalosis Normal…22-26
PCO2 ……RESPIRATORY
CO2 = ACID
> 45 …… Resp. Acidosis Normal…35-45
10 mm
Change = .08 change in pH ( Acute )
.03 change in pH (Chronic)
PaCO2
By Henderson-Hasselbach
H+ = 24 x pCO2/HCO3
= 24 x (38/30) = 30
80 - last two digit pH = H+
80 - H+ = last two digit pH (after 7)
pH should be 7.50
Ready Chart………
Limitations…..
SIMPLE DISORDERS LOOKS LIKE MIXED
. Not enough time lapsed for compensation
. 5% out of confidence Bands
.g. pH = 7.20, HCO3 = 18, PCO2 = 33
Partially compensated
Metabolic Acidosis
2
pH = 7.4
PaCO2 = 40
HCO3 = 24
Uncompensated
Metabolic Acidosis
3
pH = 7.4
PaCO2 = 40
HCO3 = 24
Partially compensated
Metabolic Alkalosis
4
pH = 7.4
PaCO2 = 40
HCO3 = 24
Fully compensated
Respiratory Alkalosis
5
pH = 7.4
PaCO2 = 40
HCO3 = 24
Partially compensated
Respiratory Acidosis
6
pH = 7.4
PaCO2 = 40
HCO3 = 24
Uncompensated
Metabolic Alkalosis
7
pH = 7.4
PaCO2 = 40
HCO3 = 24
Normal A.B.G.
8
pH = 7.4
PaCO2 = 40
HCO3 = 24
Uncompensated
Respiratory Acidosis
9
pH = 7.4
PaCO2 = 40
HCO3 = 24
Uncompensated
Respiratory Alkalosis
10
pH = 7.4
PaCO2 = 40
HCO3 = 24
Fully compensated
Respiratory Acidosis
11
pH = 7.4
PaCO2 = 40
HCO3 = 24
Combined Alkalosis
12
pH = 7.4
PaCO2 = 40
HCO3 = 24
Combined Acidosis
-----XXXX Diagnostics----
Blood Gas Report
pH <7.30 …Acidosis
Measured 37.0 C0
O2
O2Sat
Sat 92
92 30 %×
% 5 = 150 O/E: Respiratory distress;
pO2 153-66= 87 mm WITH INCREASE
IN CO2 BICARB MUST RISE ?
pO2(A
(A--a)a) Hg
mm Hg
pO2
pO2(a
(a/ /A)
A)
suprasternal
Metabolic acidosis and acidosis
+ respiratory
Entered
intercostal retraction;
Entered Data
Data
FiO2
FiO2 30
30 %
%
tired looking; on 4 L NC.
Hypoxia
Wide A / a gradient
Blood
Blood
-----
-----XXXX
Gas
Gas
XXXXDiagnostics
Diagnostics------
Report
Report
------
Case 3
pH <7.35 , Acidosis
Measured 37.0
o
Last two digits of pH
37.0 CC
o
Measured
pH
pH 7.23
7.23 Correspond with co2
pCO2
pCO2 23
23 mm
mmHg
Hg
pO2
pO2 110.5
110.5 mm
mmHg
Hg 8 year old diabetic
Calculated
Calculated Data
Data
HCO
HCO3 act
3act 14
14 mmol
mmol/ /LL with respi. distress
HCO3 <22; metabolic acidemia
O2
O2Sat
Sat %
%
pO2
pO2(A
pO2
(A--a)
pO2(a
a)
(a/ /A)
A)
mm Hg
mmHg fatigue and loss of
If Na = 130,
Entered
Entered Data
FiO2
FiO2
Data
21.0
21.0 %
%
appetite.
Cl = 90
Anion Gap = 130 - (90 + 14)
= 130 – 104 = 26
-----
-----XXXX
XXXXDiagnostics
Diagnostics------
------
Case 4
Blood
Blood Gas
Gas Report
Report Acidosis
o
o
Measured 37.0
37.0 CC
Measured
pH 7.34 16CO2..???
Low year old female with
LAB ERROR!
pH 7.34
pCO
pCO2 2 38.1
38.1 mm
mmHg
Hg sudden Honset
24 dyspnea.
of
PaCO
2
pO
pO2 2 90.3
90.3 mm
mmHg
Hg HCO3
High HCO3…???
CalculatedBy Henderson-Hasselbach
Data
Calculated Data No Cough or Chest Pain
HCO3 act H+ = 24
HCO act
3 30 x pCO2/HCO3
30 mmol / L
mmol / L
OO2 Sat
2 Sat
= 98.3
24
98.3x (38/30)
%% = 30
pO
pO2 2(A
(A--a)a) 80 10
10 mm
mm Hg
Hg Vitals normal but RR 56,
- last two digit pH
= H+
pO2
pO2(a(a/ /A)A) 0.93
0.93 anxious.
80 - H+ = last two digit pH (after 7)
Entered
Entered Data
Data
FiO
FiO2 2 pH should
21.0 be
21.0 %% 7.50
Blood
Blood
-----
-----XXXX
Gas
Gas
XXXXDiagnostics
Diagnostics------
Report
Report
------
Case 5 :
Measured 37.0
o
pH almost within normal range
37.0 CC
o
Measured
pH 7.46 Mild alkalosis
pH 7.46
pCO2
pCO2 28.1
28.1 mm
mmHg
Hg
pO2
pO2 55.3
55.3 mm
mmHg
Hg Co2 is low , respiratory
Calculated
Calculated Data
Data 10 year old child with
Co2 low by around 10
( Acute ) by .08
HCO
HCO3 act 19.2
19.2 mmol
mmol/ /LL
encephalitis
(Chronic ) by .03
3act
O2
O2Sat
Sat %
%
pO2
pO2(A
(A--a)a) mm Hg
mmHg Bicarb looks low ?
pO2
pO2(a
(a/ /A)
A) Is it expected ?
Entered
Entered Data
Data
FiO2
FiO2 24.0
24.0 %
%
Case 6……
6 yrs old girl having type 1 Diabetic with H/O persistant vomiting
pH ……..7.39
PaCO2 …38
PaO2 ……60
1) Why hypoxemia ?
2) Were the lungs bad to begin with ? ( Pre OP PaO2 … 90 mmHg )
3) Micro atelectesis during surgery ? Anesthetist goofed up the case
4) Pure and simple hypoventilation …..Sedation ?
Why hypoxemia ?
Lungs were bad to begin with ? One click
Micro atelectesis during surgery
Pure and simple hypoventilation ? sedation
PRE OP ….ABG on room air
pH 7.39
PaCO2 l5mmHg
PaO2 90 mmHg
HCO3 8mmol/L
Oxygenation status good …..?
Conclusion ……..
Lungs were not normal at the beginning
No click
Learning point