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P f A
Prof. A. K.
K Sethi
S hi
Head, Dept. of Anaesthesiology & Critical Care,
UCMS & GTB Hospital,
p , Delhi,, India
What is meant by interpreting ABG Reports ?
Prof. A. K. Sethi, UCMS, Delhi
• All BG
G machines
ac es
Measure pH, PaCO2, PaO2
Calculate
Ca CO3- +………
cu a e HCO
Hb HCT,
Hb, HCT FiO2, PaOP O2, PaCO
P CO2 , pH, H NaN + , K+ , SaOS O2(%)
RQ CO2 produced:O2 consumed, Set value, Can be fed
HCO3 A Parameter for non-respiratory
non respiratory component of acid-base
acid base balance
(Actual)
HCO3 S Parameter for non-respiratory
p y component
p of acid-base balance
(Standard) but reported after standardising at PCO2 at 40 mm Hg,
Temperature 37°C, SO2 100%
B
Base Diff
Difference between
b t normall quantity
tit off Total
T t l Buffer
B ff Base
B (BB)
excess or and the BB calculated from Blood Sample. (+) or (-).
deficit Depends upon entered Hb value,
value measured pH & PCO2 values.
values
Standard Difference between normal quantity of Total Buffer Base (BB)
Base and the BB calculated from Blood Sample. (+) or (-).
excess Calculated from a standard Hb value of 6 gm%, pH of 7.4 &
PCO2 of 40 mmHg.
BB (Buffer Sum of all buffer anions in blood
bases) (Hb, HCO3, Protein, Phosphate)
......Explanation of Terms
Prof. A. K. Sethi, UCMS, Delhi
O2 CT,
CT CaO2, O2 content Hb bound O2 + Plasma dissolved O2
Ca 7.4
74 Calcium ion concentration computed for pH 7.4
74
+ + ………. ………….
Know Normal & Reference Values for Interpretation
Prof. A. K. Sethi, UCMS, Delhi
pH 7 35 – 7.45
7.35 7 45 O2 CT (ml/dL) 16 – 22
HCO3 A (mEq/L) 22 – 26 P50 mmHg 27
Na+ 135 – 145 A-aDO2 mmHg 5 – 25
Arterial Blood Sampling
Prof. A. K. Sethi, UCMS, Delhi
Radial
Dorsalis Paedis
Femoral
B hi l
Brachial
Arterialized Tissues
Feed the
Sample &
Data
Prof. A. K. Sethi, UCMS, Delhi
D
Donot
t confuse
f b
between
t “N
“Normall pH”
H” and
d “N
“Neutral
t l pH”
H”
Prof. A. K. Sethi, UCMS, Delhi
3 basic mechanisms
2 Ventilatory
2. V til t responses (L
(Lungs))
3. Renal responses
p ((Kidneys)
y )
Prof. A. K. Sethi, UCMS, Delhi
All
ll Clinicians,
l n c ans, Intens
Intensivists,
v sts, Physicians,
hys c ans, Anaesthesiologists,
naesthes olog sts,
should
→ Know correct techniques involved in performing an ABG analysis
Know correct techniques involved in performing an ABG analysis
→ Have an understanding of the changes in ABGs in commonly
encountered clinical conditions
encountered clinical conditions
→ Know to interpret the ABG report systematically and correctly
→ Understand implications
Understand implications
Prof. A. K. Sethi, UCMS, Delhi
2. Establish the diagnosis and severity of respiratory failure
3 Guide therapy ‐
3. G id h O2 administration, mechanical ventilation, weaning
d i i i h i l il i i
4. Assess changes in acid‐base homeostasis
5. Guide treatment for acid‐base abnormalities
………When to do ABGs ………
Prof. A. K. Sethi, UCMS, Delhi
6. Manage patients in ICUs for
• Respiratory dysfunction or failure
• Cardiac failure
• Renal failure
Renal failure
• Hepatic failure
• Polytrauma
• Multi‐organ failure
Multi‐organ failure
• Diabetic ketoacidosis
• Sepsis
• Burns
• Various types of poisonings etc. ………
Prof. A. K. Sethi, UCMS, Delhi
………When to do ABGs
7. Monitor patients during
• Cardio-pulmonary
C di l surgery
• Cardio-pulmonary exercise testing
• Sleep studies
1. Ensure a Steady State of Oxygenation & Ventilation (3,20,30 min)
2. Precautions for arterial blood sampling – Site, Puncture, Cannula,
H
Heparin
i
3 Do not keep the sample exposed to air, Any air bubble in Syringe
3. Do not keep the sample exposed to air Any air bubble in Syringe
4. Do not delay the processing. Otherwise, keep sample in Ice.
5. Analyze Step‐by‐Step and completely
Prof. A. K. Sethi, UCMS, Delhi
Effect of keeping
Sample at room
temperature for 2 hours
Prof. A. K. Sethi, UCMS, Delhi
• (+) or (-)
• 0±2
R di the
Reading h R
Report – Step-by-Step
b
Prof. A. K. Sethi, UCMS, Delhi
Step
p1
Check if the required parameters have been correctly fed ?
Barometric pressure
Patient’s temperature
Haemoglobin
(if machine does not measure, does not calculate)
FiO2
• A
A‐aDO
aDO2 value will be wrong if P
value will be wrong if PB & FiO
& FiO2 (PiO2) is not fed correctly
) is not fed correctly
Alveolar gas equation : PAO2 = PiO2 – 1.2(PaCO2) [PiO2 = FiO2 (PB – 47)]
• Oxygenation Impairment (Assess.) ‐
Oxygenation Impairment (Assess ) Wrong if FiO
Wrong if FiO2 not fed correctly
not fed correctly
Machines always analyse blood at 37 °C
• Sample of Hyperthermic Patient = > 37 °C ‐
Sample of Hyperthermic Patient = > 37 °C Measured value of
Measured value of
PaO2 and PaCO2 will be less than actual
p yp
• Sample of Hypothermic Patient = < 37 °C ‐ Measured value of
PaO2 and PaCO2 will be more than actual
Temperature Change
Temperature Change Shifting of ODC
Shifting of ODC Calculated SO
Calculated SO2, 37 C, (ODC)
37°C
Increase Right Higher than actual
Decrease Left Lower than actual
than actual
True assessment of adequacy of O2 in arterial blood (CaO2)can
only be made if Hb values are entered. SaO
only be made if Hb values are entered SaO2 & PaO
& PaO2 do not.
do not
Hb – affects Buffer Base values (Base excess or deficit)
Prof. A. K. Sethi, UCMS, Delhi
Hypoxemia
PaO2 Refractory
Uncorrected < 60, on O2
O2 x 5 = PaO2
Inspired O2 % PaO2 mmHg
30 > 150 Corrected 60‐100, < predicted
40 > 200
50 > 250 Excessively
> 100 < predicted
> 100, < predicted
80 > 400 Corrected
100 > 500
Responsive
Prof. A. K. Sethi, UCMS, Delhi
manifest as initial changes in PaCO2 or HCO3ˉ
First
First Disorder Change Primary
Primary Effect pH
Change disorder
Rises Respiratory
Respiratory Acidemia Falls
PaCO2 Respiratory acidosis
Falls Respiratory
p y Alkalemia Rises
alkalosis
Rises Metabolic Alkalemia Rises
HCO3ˉ Metabolic alkalosis
Falls Metabolic Acidemia Falls
acidosis
Prof. A. K. Sethi, UCMS, Delhi
……Terminology
Compensation
when the acid-base imbalance exists over a period of time
S
Secondary changes in HCO
d h i HCO3ˉ or PaCO
ˉ P CO2
‐ occur in response to the primary event
‐ to normalize pH
Done by the organ system which is not primarily affected
‐ Respiratory compensation for metabolic disorders
Respiratory compensation for metabolic disorders
‐ Metabolic compensation for respiratory disorders
Step – 3 : Acid Base disturbances
Prof. A. K. Sethi, UCMS, Delhi
Acidemia (p
(pH < 7.35)) Alkalemia (p
(pH >7.45))
Mild 7.30 – 7.34 7.46 – 7.50
Moderate 7.20 – 7.29 7.51 – 7.54
S
Severe < 7.2
72 > 7.55
7 55
Incompatible with life < 6.8 > 7.8
Prof. A. K. Sethi, UCMS, Delhi
> 45 Respiratory acidosis
PaCO2 Respiratory
< 35 Respiratory alkalosis
......Step – 4
A l
Analyse th
the P Primary
i disorder
di d
- Respiratory or Metabolic ?
Metabolic
Change
h Disorder
i d HCO3ˉ pH Primary disorder
i di d
> 26 Metabolic alkalosis
HCO3ˉ Metabolic
(base) < 22 Metabolic acidosis
Step
p – 5 : Analyse
y if Compensation
p ?
Compensations
p –Acid for Base
(Formula for every 1 mEq/L change in HCO3)
Change in HCO3 Disorder Compensation (Lungs)
1 mEq/L
E /L fall
f ll M b li acidosis
Metabolic id i 1 25 mmHg
1.25 H ffallll iin P
PaCO
CO2
1 mEq/L rise Metabolic alkalosis 0.75 mmHg rise in PaCO2
Step
p–7:
Find out if the Disorder is “Mixed” ?
Bicarbonate Gap
Unmasks the co-existence of 2 metabolic disorders
BG = ∆ AG - ∆ CO2
Steps
p (Summary)
y
St – 3 : Analyse
Step A l s pHH – Acidemia
A id i or Alkalemia?
Alk l i ?
Examples
Prof. A. K. Sethi, UCMS, Delhi
Example 1
1 pH = Low (7
1. (7.35
35 - 7.45,
7 45 77.4)
4) = Acidosis
2. PaCO2 = High (35 - 45, 40), Opposite direction than pH = Respiratory
3. HCO3¯ = Within Normal range (22 - 26, 24) = Not Metabolic
4 No secondary change (rise) in HCO3¯ = No compensation
4.
Prof. A. K. Sethi, UCMS, Delhi
Example 2
1 pH = High (7
1. (7.35
35 - 7.45,
7 45 77.4)
4) = Alkalosis
2. PaCO2 = Normal (35 - 45, 40), = Not Respiratory
3. HCO3¯ = High (22 - 26, 24), Moving in same direction = Metabolic
4 No secondary change (rise) in PaCO2 = No compensation
4.
Prof. A. K. Sethi, UCMS, Delhi
Example 3
Report Change from N pH PaCO2 HCO3¯
pH 7.32 - 0.08
PaCO2 32 -8
Metabolic Acidosis,
HCO3¯ 18 -6
Partially
y compensated
p
1. pH = Low (7.35 - 7.45, 7.4) = Acidosis
2. PaCO2 = Low (35 – 45, 40), Moving in same direction as pH
- Not Respiratory = Metabolic ?
3 HCO3¯ = Low (22 – 26,
3. 26 24) = Moving in same direction as pH = Metabolic
4. Secondary changes (Fall) in PaCO2 = Compensation by Lungs is on
5. Metabolic Acidosis – 1 mEq/L fall in HCO3 ≈ 1.25 mmHg fall in PaCO2
6. Estimated compensation (PaCO2) = - 6 x 1.25 = - 7.50 (Actual = - 8 mmHg)
7. pH - Not in normal range = Partial compensation
Prof. A. K. Sethi, UCMS, Delhi
Example 4
R
Report
t Ch
Change f
from N pH
H P CO2
PaCO HCO3¯
pH 7.35 0.05 N Range
PaCO2 48 +8 Respiratory Acidosis,
HCO3¯ 27 +3 Fully compensated
1. pH = Normal but lower side of range (7.35 - 7.45) = Acidosis
2 PaCO2 = Raised (35 - 45),
2. 45) Moving in the opposite direction to pH
= Respiratory
3 HCO3¯ = Raised (22 – 26) = Should move in same direction as pH,
3. pH
Here, moving in opposite direction to pH = Not Metabolic, Respiratory
4. Secondary change (Rise) in HCO3 = Compensation by Kidneys
5. pH near neutral, in the normal range (7.35) = Fully compensated Acidosis
Estimate Compensation
Disorder Change in PaCO2 Compensation (Kidney)
Respiratory Acute fall by 10 mmHg 2 mEq/L fall in HCO3
Alkalosis Chronic fall by 10 mmHg 4 mEq/L fall in HCO3
P
Presumingi Acute
A t
Estimated HCO3 compensation for an acute 10 mmHg fall of PaCO2
= 2 x ((–10)/10
10)/10 = –22.00 ³
Presuming Chronic
Estimated HCO3 compensation for a chronic 10 mmHg fall of PaCO2
= 4 x (–10)/10 = – 4.0
Prof. A. K. Sethi, UCMS, Delhi
Equations needed
• BG = ∆ AG - ∆ CO2
• BG = (Measured AG – 12) – (27 – measured CO2)
Prof. A. K. Sethi, UCMS, Delhi
Estimate Compensation
Disorder Change in PaCO2 Compensation (Kidney)
Respiratory Acute fall by 10 mmHg 2 mEq/L fall in HCO3
Alkalosis Chronic fall by 10 mmHg 4 mEq/L fall in HCO3
P
Presumingi Acute
A t
Estimated HCO3 compensation for an acute 10 mmHg fall of PaCO2
= 2 x ((–10)/10
10)/10 = –22.00 ³
Presuming Chronic
Estimated HCO3 compensation for a chronic 10 mmHg fall of PaCO2
= 4 x (–10)/10 = – 4.0
Prof. A. K. Sethi, UCMS, Delhi
Same Example 7
Report
ppH 7.40 N • AG = ((149)) – ((100 + 24)) = 149 – 124 = +25
PaCO2 38 N • ∆ AG = 25 – 12 = +13 ( Metabolic Acidosis)
HCO3¯ 24 N • ∆ CO2 = 27 – 24 = +33
Na+ 149 N • BG = ∆ AG – ∆ CO
2
K+ 3.8 N = (+13) – (+3)
Cl¯ 100 N = +10 ((> +6 = Metabolic Alkalosis))
CO2 24 N
pH (N), PaCO2 (N), HCO3 (N)
M
Metabolic
b li Acidosis
id i (U(Uremia)
i )
BUN 110
Metabolic Alkalosis (Diuretic)
Creatinine 87
8.7
Prof. A. K. Sethi, UCMS, Delhi
Best of Luck