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The Goal :
To provide simple and bedside approach to ABG report
Not to:
In details
To teach physiology .
pH 7.70 7.52
30
40 50
H+ = 80 - last two digits of pH
H ION
60
Gas
05:36 2570 / 00
Report
Jul 22 2000
o
Measured
pH pCO2 pO2 7.463 44.4 113.2
37.0 C
mm Hg mm Hg
Corrected
pH pCO2 pO2 7.439 47.6 123.5
38.6 C
mm Hg mm Hg
Calculated Data
HCO3 act HCO3 std BE O2 CT O2 Sat ct CO2 pO2 (A - a) pO2 (a / A) 31.1 30.5 6.6 14.7 98.3 32.4 32.2 0.79 mmol / L mmol / L mmol / L mL / dl % mmol / L mm Hg
Calculated Data:
Which are the useful ones?
Entered Data:
As important
Entered Data
Temp ct Hb FiO2 38.6 10.5 30.0
oC
g/dl %
Bicarbonate:
Measured
pH pCO2 pO2 7.463 44.4 113.2
37.0 C
mm Hg mm Hg
Corrected
38.6 C
Calculated
HCO3 act HCO3 std BE O2 CT O2 Sat t CO2 pO2 (A - a) pO2 (a / A) 31.1 30.5 6.6 14.7 98.3 32.4 32.2 0.79
Data
mmol / L mmol / L mmol / L mL / dl % mmol / L mm Hg
Entered
Temp ct Hb FiO2 38.6 10.5 30.0
Data
oC
g/dl %
Standard Bicarbonate:
Plasma HCO3 after equilibration to a PCO2 of 40 mm Hg
: reflects non-respiratory acid base change : does not quantify the extent of the buffer base abnormality : does not consider actual buffering capacity of blood
Measured
pH pCO2 pO2 7.463 44.4 113.2
37.0 C
mm Hg mm Hg
Corrected
38.6 C
Calculated
HCO3 act HCO3 std BE O2 CT O2 Sat t CO2 pO2 (A - a) pO2 (a / A) 31.1 30.5 6.6 14.7 98.3 32.4 32.2 0.79
Data
mmol / L mmol / L mmol / L mL / dl % mmol / L mm Hg
Base Excess:
(Sigaard-Andersen)
Entered
Temp ct Hb FiO2 38.6 10.5 30.0
Data
oC
g/dl %
Oxygenation Parameters:
O2 Content of blood:
Hb x O2 Sat + Dissolved O2
Measured
pH pCO2 pO2 7.463 44.4 113.2
37.0 C
mm Hg mm Hg
Corrected
38.6 C
Calculated
HCO3 act HCO3 std BE O2 CT O2 Sat t CO2 pO2 (A - a) pO2 (a / A) 31.1 30.5 6.6 14.7 98.3 32.4 32.2 0.79
Data
mmol / L mmol / L mmol / L mL / dl % mmol / L mm Hg
Entered
Temp ct Hb FiO2 38.6 10.5 30.0
Data
oC
g/dl %
Rt. Shift
Lt.Shift
Alveolar-arterial Difference
Inspired O2 = 21 % piO2 = (760-45) x . 21 = 150 mmHg
O2 CO2
pO2 = 45
D = 100 - 45 = 55
760 45 = 715 : 21 % of 715 = 150
pO2 = 45
D = 50 - 45 = 5
PAO2 (partial pres. of O2. in the alveolus.) = 150 - ( PaCO2 / .8 )
Oxygenation:
Limitations of parameters: O2 Content of blood:
Useful in oxygen transport calculations Derived from calculated saturation
Measured
pH pCO2 pO2 7.463 44.4 113.2
37.0 C
mm Hg mm Hg
Corrected
38.6 C
Oxygen Saturation:
Ideally measured by co-oximetry Calculated values may be error-prone
Calculated
HCO3 act 31.1
Data
mmol / L
mL / dl % mmol / L mm Hg
Entered
Temp ct Hb FiO2 38.6 10.5 30.0
Data
oC
g/dl %
The essentials
The Blood Gas Report:
pH PCO2 PO2 HCO3 7.40 + 0.05 40 + 5 80 - 100 24 + 4 mm Hg mm Hg mmol/L
----- XXXX Diagnostics -----o Measured 37.0 C pH 7.463 Blood Gas Report pCO 44.4 mm Hg
2
pO2
113.2
mm Hg o
37.0 C o 38.6 C
mm Hg mm Hg mm Hg mm Hg
Data
FIO2
Entered Data
Temp ct Hb FiO2 38.6 10.5 30.0
oC
g/dl %
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 cooling in ice slush(4o C) No major drifts up to 1 hour
The
Steps for Successful Blood Gas Analysis
Step 1
Look at the pH
The culprit
Is the patient or acidemic alkalemic pH < 7.35 pH > 7.45
Step 2
Acidemia:
Alkalemia:
BICARB
Step 3
If there is a primary respiratory disturbance, is it acute? (Acute)change in pH = 0.08 for 10 mm change in PCO2 (Chronic)change in pH = 0.03 for 10 mm change in PCO2
Step 4
If the disturbance is metabolic is the respiratory compensation appropriate? For metabolic acidosis: Expected PCO2 = (1.5 x [HCO3]) + 8 ) + 2
(Winters equation) ( Last two digits of pH )
For metabolic alkalosis: Expected PCO2 = 6 mm for 10 mEq. rise in Bicarb. If : actual PCO2 more than expected : additional respiratory acidosis actual PCO2 less than expected : additional respiratory alkalosis
Step 4 cont.
If there is metabolic acidosis, is there a wide anion gap ? Na - (Cl-+ HCO3-) = Anion Gap usually <12 If >12, Anion Gap Acidosis : Common pediatric causes 1) Lactic acidosis 2) Metabolic disorders 3) Renal failure Methanol Uremia Diabetic Ketoacidosis Paraldehyde Infection (lactic acid) Ethylene Glycol Salicylate
th step
Clinical correlation
Same direction
HCO3 Same direction
pH
META.
PCO2
Opposite direction
pH
RESP.
24
CO2
= H ION CONC.
N.MOLS / L.
BICARBONATE 24 40 = 960
= H ION CONC.
BICARBONATE
960
N.MOLS / L.
= H ION CONC. = 40
24
N.MOLS / L.
H+
N.MOLS / L.
pH
HYPER VENTILATION
METABOLIC ACIDOSIS
pH
HYPO VENTILATION
Primary lesion
METABOLIC ALKALOSIS
pH
BICARB
compensation CO 2
Primary lesion
Respiratory acidosis
RESP. ACIDOSIS
PCO2
ALKALOSIS META.
CO2+H20=H2CO3 = H + HCO3
pH
HCO3
HCO3
ACUTE RISE : PCO2 10 : CHRONIC RISE : PCO2 10 : pH .08 pH .03
pH
BICARB
compensation CO 2
Respiratory alkalosis
RESP. ALK.
ACID. META.
+ +
HCO3
pH
CO2
+
HCO3
Pco2 of 10
pH
INTERPRETATION OF A.B.G.
FOUR STEP METHOD OF DEOSAT 1) LOOK FOR pH 2) WHO IS THE CULPRIT ?
compensation
METABLIC ACIDOSIS CO2 = Up to 10 ? METABOLIC ALKALOSIS CO2 = Maximum 6O RESPIRATORY ACIDOSIS BICARB = Maximum 40 RESPIRATORY ALKALOSIS BICARB = Up to 10
COMPENSION LIMITS
Blood
Gas
Report 37.0 C 7.523 30.1 mm Hg 105.3 mm Hg Data 22 98.3 8 0.93 Data 21.0 mmol / L % mm Hg D
o
Case 1
16 year old female with sudden onset of dyspnea.
Measured pH pCO2 pO2 Calculated HCO3 act O2 Sat pO2 (A - a) pO2 (a / A) Entered FiO2
Case 2
Muscular dystrophy .
----- XXXX Diagnostics ------
pH <7.35 :acidemia
Blood
Gas
Report
Measured pH pCO2 pO2 Calculated HCO3 act O2 Sat pO2 (A - a) pO2 (a / A) Entered FiO2
respiratory acidemia : co2 and pH 37.0 C 7.301 D CO2 =76-40=36 76.2 mm Hg Expected D pH ( Acute ) = .08 for 10 45.5 mm Hg
o
mmol / L
% mm Hg D
Blood
Gas
Report
o
pH <7.35 ; acidemia
Case 3
Measured pH pCO2 pO2 Calculated HCO3 act O2 Sat pO2 (A - a) pO2 (a / A) Entered FiO2
pCO2 >45; respiratory acidemia 8-year-old male asthmatic; 37.0 C 7. 24 3 - 40 = of D CO2 = 49 days 9 cough, dyspnea 49.1 mm Hg Expectedand orthopnea not D pH ( Acute ) = 9/10 x 0.08 = 0.072 66.3 mm Hg
Data 18.0 92
mmol / L
bronchodilators.
153-66= 87
Data 30
Case 4 8 year old diabetic with respi. distress fatigue and loss of appetite.
----- XXXX Diagnostics ------
Blood
Gas
Report
o
pH <7.35 ; acidemia
Measured pH pCO2 pO2 Calculated HCO3 act O2 Sat pO2 (A - a) pO2 (a / A) Entered FiO2
37.0 C Last two digits of pH 7.23 Correspond with co2 23 mm Hg 110.5 mm Hg Data 14 mmol / L
Blood
Gas
Report 37.0 C 7.46 28.1 mm Hg 55.3 mm Hg Data 19.2 mmol / L % mm Hg D Data 24.0
o
Measured pH pCO2 pO2 Calculated HCO3 act O2 Sat pO2 (A - a) pO2 (a / A) Entered FiO2
Co2 is low , respiratory Co2 low by around 10 ( Acute ) by .08 (Chronic ) by .03
Bicarb looks low ? Is it expected ?
More cases
The arterial blood gas report : Room air pH 7.39 PCO2 l5mniHg HCO3 8mmol/L PaO2 90 mmHg
24
BICARBONATE
= 45 nmol/lit
1)
These findings are most consistent with. a) Metabolic acidosis with compensatory Hypocapnia. b) Primary metabolic acidosis with respiratory alkalosis. c) Acute respiratory alkalosis fully compensated. d) Chronic respiratory alkalosis fully compensated.
For metabolic acidosis: FULL COMPENSATION Expected PCO2 = (1.5 x [HCO3]) + 8 ) + 2 (Winters equation) PCO 2 SHOULD BE 20
2) What is the oxygenation status a) Normal oxygenation status b) Hypoxemia c) None of the above
palvO2 = piO2 pCO2 / RQ = 150 15 / 0.8 = 150 18 = 132 mm Hg 132 90 = 42 WIDE A / a gradient
pCO2 70 60 50 40 30 20
When pH is normal and: Bicarbonate is high ( Metabolic alkalosis + respiratory acidosis ) Bicarbonate is low ( Metabolic acidosis + resp. alkalosis) Bicarbonate is normal and: anion gap is high ( Metabolic Acidosis + Metabolic alkalosis) When bicarbonate is normal and: pH is in acidic range ( Chronic resp. acidosis + resp alk.) pH is in alkalemic range ( Metab.alk. + resp alk.) Anion gap is elevated and: clinical and laboratory data suggest a diagnosis other than metabolic acidosis PCO2 level and bicarbonates are shifted from normal in opposing directions.
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