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Dr.

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.

…Moves in same direction


...Primary disorder
CO2 …Moves in opposite direction
HCO3 …Mixed Disorder
14 H+ nmoles /L. pH

OH 20 7.60
ion
30 AlkalineH1
pH 7.50

40 H+ = 80- last two digits of7.40


pH

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

Low Primary lesion


Alkali METABOLIC ACIDOSIS
CO2 HYPO CO
VENTILATION
2 CHANGES
pH in opposite direction

compensation
HIGH HCO3
pH
HIGH pH
BICARB CHANGES

HIGH CO2
pH in same direction

HCO3

High Primary lesion


Alkali METABOLIC ALKALOSIS
BICARB CO 2 CHANGES
pH in opposite direction

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

compensation LOW HCO3


CO 2

Low Primary lesion


CO2 Respiratory alkalosis
Body’s physiologic response to Primary disorder
in order to bring pH towards NORMAL limit

Full compensation
Partial compensation
No compensation…. (uncompensated)

BUT never overshoots,


If overcompensation is there,
Take it granted it is a MIXED disorder
How to identify the type of
compensation…..?
pH HCO3 CO2

7.20 15 40 Un Compensated

7.20 15 30 Partially Compensated

7.37 15 20 Fully Compensated


FiO2….21%....150 mm of Hg

PAO2 OXY (Sat) 98%


C. SaO2 HAEMOGLOBIN
A.C.I.
D.

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 ------

Blood Gas Report


248 05:36 Jul 22 2000
Pt ID 2570 / 00

Now that I 37.0o C


Measured
pH have7.463
this data,
pCO2 44.4 mm Hg
pO2
what does
113.2
it mm Hg
mean?
o
Corrected 38.6 C
pH 7.439
pCO2 47.6 mm Hg
pO2 123.5 mm Hg

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-----

Blood Gas Report


328 03:44 Feb 5 2006
Pt ID 3245 / 00

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

Temperature correction of pH & pCO2 do


not affect calculated bicarbonate
“ There is no scientific basis ... for applying temperature corrections to
blood gas measurements…”
Shapiro BA, OTCC, 1999.
o
pCO2 reference points at 37 C are well established
as a reliable reflectors of alveolar ventilation

Reliable data on DO2 and oxygen demand are


o
-----XXXX Diagnostics-----

Blood Gas Report


328 03:44 Feb 5 2006
Pt ID 3245 / 00

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-----

Blood Gas Report


Standard Bicarbonate:
328 03:44 Feb 5 2006 Plasma HCO3 after equilibration
Pt ID 3245 / 00
to a PCO2 of 40 mm Hg
Measured 37.0 0C
pH 7.452
pCO2 45.1 mm Hg : reflects non-respiratory acid base change
pO2 112.3 mm Hg
: does not quantify the extent of the buffer base
Corrected 38.6 0C abnormality
pH 7.436
pCO2 47.6 mm Hg : does not consider actual buffering capacity of blood
pO2 122.4 mm Hg

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-----

Blood Gas Report


328 03:44 Feb 5 2006
Pt ID 3245 / 00

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 – 1.2 (PCO2)


= 150 – 1.2  40

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

Alveolar – arterial G. Alveolar arterial G.


100 - 45 = 55 50 – 45 = 5
……………….Wide A-a …………….Normal A-a
Expected PaO2 =
Normal

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

< 22 ……Met. Acidosis

PCO2 ……RESPIRATORY
CO2 = ACID
> 45 …… Resp. Acidosis Normal…35-45

< 35 …… Resp. Alkalosis


Step 4

If there is a primary Respiratory disturbance,


is it acute ?

10 mm
Change = .08 change in pH ( Acute )
.03 change in pH (Chronic)
PaCO2

Remember………… relation of CO2 and pH


pH
Step 5
If it is a primary Metabolic disturbance,
whether respiratory compensation appropriate?
Remember If :
For metabolic acidosis:
Expected PCO2 = (1.5 x [HCO3]) + 8 + 2
CO is equal to
Suspect .............
(Winter’s equation)
2
actual PaCO2 is more than expected :
For metabolic alkalosis:
Last two digits
additional ...respiratory acidosis
Expected PCO2 = 6 mm… for 10 mEq. rise in
actual PaCO2 is less than expected :
Bicarb.
of pH
additional...respiratory
………UNCERTAIN COMPENSATION alkalosis
Step 5 cont.
If metabolic acidosis is there
How is anion gap ? Is it wide ...
- -
Na - (Cl + HCO3 ) = Anion Gap usually <12

If >12, Anion Gap Acidosis : M ethanol


U remia
Common pediatric causes D iabetic Ketoacidosis
P araldehyde
Lactic acidosis I nfection (lactic acid)
Metabolic disorders E thylene Glycol
Renal failure S alicylate
Step 6…
-- Clinical history
-- pH normal, abnormal PCO2 n HCO3
-- PCO2 n HCO3 moving opposite directions
-- Degree of compensation for primary
disorder is inappropriate
-- Rise of anion gap and Fall of HCO3…..
……..R/F equation
Validity of ABG report… a lab error
PCO2
H= 24 x
HCO3
e.g. pH = 7.30, PCO2 = 38.1, HCO3 = 30

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

MIXED DISORDERS LOOKS LIKE SIMPLE


.g. pH =7.24, PCO2 = 65, HCO3 = 26
hronic Resp acidosis + Metabolic Acidosis
hronic case …. History helps
1
pH = 7.4
PaCO2 = 40
HCO3 = 24

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

pH 7.301 Respiratory Acidosis


pCO2 75.1 mm Hg
pO2 45.3 mm Hg Case 1
 CO =75-40=35
2
Calculated Data Expected pH ( Acute ) = 7.11
Expected pH ( Chronic ) = 7.30
HCO3 act
O2 Sat
35.2 mmol / L
78.4 %
6 year old male
Chronic with progressive
resp. acidosis
O2 ct 15.8
pO2 (A -a) 9.5 mm Hg  Hypoxia….???
pO2 (a/A) 0.83 respiratory distress due to
Entered Data Normal A-a gradient
Hypoxia due to
FiO2 21 % Muscular dystrophy
Due to .
hypoventilation
Ct Hb 12 gm/dl
Blood
-----
-----XXXX
XXXXDiagnostics
Gas
Diagnostics------
Report
------
Case 2
pH <7.35 , acidosis
Blood Gas Report
Measured 37.0
o 8-year-old
pCO2 >45; male
respiratory asthmatic;
acidosis
37.0 CC
o
Measured
pH
pH 7.7.24
24  CO2 =349
days
- 40 of
= 9cough, dyspnea
pCO2
pCO2 49.1
49.1 mm
mmHg
Hg and pH
Expected orthopnea
( Acute ) =not
9/10 x 0.08 = 0.072
pO2
pO2 66.3
66.3 mm
mmHg
Hg Expected pH ( Acute to
responding ) =usual
7.40 - 0.072 = 7.328
Calculated
Calculated Data
Data Acute resp. acidosis
bronchodilators.
HCO
HCO3 act
act 18.0
18.0 mmol
mmol/ /LL
3

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

Lab: pH 7.37, pCO2 35 mm Hg, HCO3 22


Na 140, Cl 90,
Blood sugar : 300

Mild Metabolic acidosis ?


Should we send her Home?
NO !!
Anion gap = (140 - 112) = 28
Correlate Rise of Anion Gap with Fall of HCO3
Anion Gap ↑ed by 18, HCO3 should ↓ed by 18,
but ↓ed by 2 only
HCO3 retention (production) due to vomiting

Metabolic acidosis, metabolic alkalosis


Case 3……….
1 month baby having malrotation, (having intermitent
vomiting) posted for surgery .

His pre-op ABG shows on Room air


pH ………. 7.39
pCO2 ……..l5
paO2 ……...90
HCO3 ……..8

a) Primary metabolic acidosis with respiratory alkalosis


b) Metabolic acidosis with compensatory Hypocapnia
c) Acute
What respiratory
is the probablealkalosis
cause for fully compensated.
d) Chronic respiratory alkalosis fully compensated.
the above findings ? Are they OK ?
As far as oxygenation is concerned ?
Patient was hypo- volumic , received
Normal Saline bolus... Corrected acidosis
He was operated …but post-op… drowsy
His ABG……..FiO2….30%

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 …..?

Pre OP .....A/a gradient


PAO2 = PiO2 – 1.2 (PaCO2 )
= 150 – 1.2 x 90
= 150 – 18 = 132 mm Hg
132 – 90= 42 WIDE A / a gradient
Apparently the lungs looked good with PaO2 of
90…
But have a good look at the ABG again
With wash out of CO 2 ……….
The expected PaO2 should have been more
than 90 .

This coupled with correction of acidosis


( normalizing PaCO2 )
Lowered the PaO2 …post operatively.

Conclusion ……..
Lungs were not normal at the beginning
No click

Learning point

Correlate PaO2 with FiO2

But please also correlate with PaCO2


1. I shall use only minimal amount of heparin
to rinse the syringe.
(Excess heparin causes  pCO2 & shift pO2 to near 150. pH
remains unchanged.)
2. I shall do ALLEN’S test for collateral
circulation and, ALSO confirm that the
sample sent is arterial and not venous
3. I shall ensure there are no air bubbles in
the blood .
4. I shall send the sample in ice and analyze
it quickly, … and keep the TLC in mind,
esp. when there is a delay.
5. I shall always take FiO2 into consideration
when interpreting pO2 values. I shall also look at
the pCO2 values carefully.
6. I shall take the history into consideration
before instituting therapy for Chronic respiratory
failure.
7. I shall always remember the acronym
“ DOPE “ in situations of sudden deterioration
of ABG values
D- Displacement
O- Obstruction
P- Pneumothorax
E- Equipment failure
8. I shall practice gentle mechanical
ventilation and not try to bring ABG
to perfect normal.

9. I shall treat the patient not the ABG


report

10. I shall always correlate ABG report


clinically.
There is no copyright on this material….
please copy for educational purposes….
THANKS
For any queries
: vbuche@rediffmail.com

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