Presented By:

Ayaz Ahmed Ms. Mujahida

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Objectives:
1 Define Giardiasis 2 Discus signs and symptoms 3 Explain Transmission 4 Review Pathophysiology 5 Discus Diagnosis & Treatment 6 References

Giardiasis popularly known as beaver fever. it is a parasitic disease caused by the flagellate protozoan Giardia lambli (also sometimes called Giardia intestinalis and Giardia duodenalis). The giardia organism inhabits the digestive tract of a wide variety of domestic and wild animal species, as well as humans. It is a common cause ofgastroenteritis in humans, infecting approximately 200 million people .

Review of Acid Base physiology The Key to Blood Gas Interpretation: Four Equations, Three Physiologic Processes

contd.

Equation
1) 2) 3) 4) PaCO2 equation Alveolar gas equation Oxygen content equation Henderson-Hasselbalch equation

Physiologic Process
Alveolar ventilation Oxygenation Oxygenation Acid-base balance

These four equations, crucial to understanding and interpreting arterial blood gas data,

contd.

Transmission
Giardiasis is passed via the fecal-oral route. Primary routes are personal contact and contaminated comestibles. The more susceptible are institutional or day-care workers, travelers, those eating improperly treated food or drink, and people who have contact with individuals already infected.

Review of Acid Base physiology Alveolar Gas Equation

PAO2 = PIO2 - 1.2 (PaCO2)* Where PAO2 is the average alveolar PO2, and PIO2 is the partial pressure of inspired oxygen in the trachea PIO2 = FIO2 (PB 47 mm Hg)

contd.

FIO2 is fraction of inspired oxygen and PB is the barometric pressure. 47 mm Hg is the water vapor pressure at normal body temperature.
* Note: This is the abbreviated version of the AG equation, suitable for most clinical purposes. In the longer version, the multiplication factor 1.2 declines with increasing FIO2, reaching zero when 100% oxygen is inhaled. In these exercises 1.2 is dropped when FIO2 is above 60%.

Review of Acid Base physiology Acid-base Balance

Henderson-Hasselbalch Equation

contd.

pH = pK + log

[HCO3-] ---------------.03 [PaCO2]

For teaching purposes, the H-H equation can be shortened to its basic relationships:
HCO3pH ~ --------PaCO2

Review of Acid Base physiology pH is inversely related to [H+]; a pH change of 1.00 represents a 10-fold change in [H+]
pH
7.00 7.10 7.30 7.40 7.52 7.70 8.00

contd.

[H+] in nanomoles/L
100 80 50 40 30 20 10

Review of Acid Base physiology

Buffers

There are two buffers that work in pairs H2CO3 NaHCO3 Carbonic acid base bicarbonate These buffers are linked to the respiratory and renal compensatory system

Sample Source
HOW TO TAKE AN ARTERIAL SAMPLE Heparinised syringe Blood with drawn from radial, brachial, femoral artery Analyse as soon as possible Air bubble should be eliminated Sample should be capped and placed in an ice bag Excessive heparin in syringe lower pH and decrease PCO2, variable effect on PO2 Temp. and F1O2 be mentioned in request form
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contd.

Components of arterial blood gases

pH [H+]
PCO2 Partial pressure CO2

PO2

Partial pressure O2

HCO3 Bicarbonate BE Base excess

SaO2 Oxygen Saturation

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Components of the Arterial Blood Gas

pH Measurement of acidity or alkalinity, based on the hydrogen (H+) ions present. The normal range is 7.35 to 7.45 PaO2 The partial pressure of oxygen that is dissolved in arterial blood. The normal range is 80 to 100 mm Hg. SaO2 The arterial oxygen saturation.

contd.

The normal range is 95% to 100%.

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Components of the Arterial Blood Gas contd.

PaCO2 The amount of carbon dioxide dissolved in arterial blood. The normal range is 35 to 45 mm Hg. HCO3 The calculated value of the amount of bicarbonate in the bloodstream. The normal range is 22 to 26 mEq/liter B.E. The base excess indicates the amount of excess or insufficient level of bicarbonate in the system.

The normal range is 2 to +2 mEq/liter.

(A negative base excess indicates a base deficit in the blood.) 13

Normal ABG values

pH
PCO2

7.35 7.45
35 45 mmHg

PO2
HCO3

80 100 mmHg
22 26 mmol/L

BE
SaO2

-2 - +2
>95%
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Practical approach to diagnosing acid base disorders from the ABG

Step 1: Is PH normal? Step 2: Is the CO2 normal? Step 3: Is CO2 the HCO3 normal? Step 4: Match the CO2 or the HCO3 with the PH?

Step 5: Does the CO2 or the HCO3 go the opposite direction of the PH?
Step 6: Are the pO2 and the O2 saturation normal? 15

Acids based disorders

Respiratory acidosis
Respiratory alkalosis

Metabolic acidosis
Metabolic alkalosis

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Blood Gas Report

Acid-Base Information pH PCO2 HCO3 [calculated vs measured] Oxygenation Information PO2 [oxygen tension] SO2 [oxygen saturation]

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contd.

Respiratory Acidosis ( PaCO2)

It is defined as a pH < 7.35 with a PaCO2 > 45 mmHg.

Mechanism

Inadequate CO2 excretion (decreased alveolar ventilation) CO2 production e.g. Malignant hyperpyrexia, severe lung disease, high

carbohydrate diet.
Types

Acute Respiratory Acidosis ( 6-12 hours)

Plasma HCO3 conc. 1mEq/L for each 10mmHg in PaCO2 above 40mmHg

Chronic Respiratory Acidosis (Renal campensation 24 hours to 5 days) Plasma HCO3 4 mEq/L for each 10mmHg in PaCO2 above 40mmHg 18

Causes of respiratory acidosis

contd.

Central nervous system depression related to head injury or medications such as narcotics, sedatives, or anesthesia Impaired respiratory muscle function related to spinal cord injury, neuromuscular diseases,or neuromuscular blocking drugs

Pulmonary disorders such as atelectasis, pneumonia, pneumothorax, pulmonary edema, or bronchial obstruction
Massive pulmonary embolism

Hypoventilation due to pain, chest wall injury/deformity, or abdominal distension

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Respiratory Acidosis
Treatment

Increase alveolar ventilation (bronchodilatation, reversal of

narcosis, doxapram, diuresis)

Reduce CO2 production by dantrolene, muscle paralysis,

antithyroid medication or reduced carbohydrate intake

Mechanical ventilation,
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Respiratory Alkalosis
Respiratory alkalosis is defined as a pH > 7.45 with a PaCO2 <35 mm Hg. CAUSES: Any condition that causes hyperventilation can result in respiratory alkalosis

Psychological responses, such as anxiety or fear

Pain Increased metabolic demands, such as fever, sepsis, pregnancy, or thyrotoxicosis Medications, such as respiratory stimulants. Central nervous system lesions

MANAGEMENT:

Treat the underlying cause

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Metabolic acidosis is defined as a bicarbonate level of <22 mEq/L with a pH of < 7.35

Metabolic Acidosis

contd.

Types

High anion gap (nonvoltile acids) Normal anion gap (hyperchloremia)

Anion gap

Plasma cations plasma anion [Na- (Cl+ Hco3)]

Anion gap:

140 (104 + 24) = 12 mEq/L ( normal 12 18 mEq/L)

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The Causes

contd.

High Anion Gap Acidosis

M - Methanol U - Uremia D - DKA P - Paraldehyde I - INH L - Lactic Acidosis E - Ehylene Glycol S - Salicylate

Normal Anion Gap Acidosis

Hyperalimentation Acetazolamide RTA (Calculate urine

anion gap) Diarrhea Pancreatic Fistula

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Metabolic Acidosis
Treatment

NaHCO3 1 mEq/Kg Base deficit X 30% X b.w Give 50% calculated dose & repeat ABG

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Metabolic Alkalosis
with a pH >7.45.
CAUSES

contd.

Metabolic alkalosis is defined as a bicarbonate level > 26 mEq/liter

Either an excess of base or a loss of acid within the body can cause metabolic alkalosis. Excess base occurs from ingestion of antacids, excess use of bicarbonate, or use of lactate in dialysis. Loss of acids can occur secondary to protracted vomiting, gastric suction, hypochloremia, excess administration of diuretics, or high levels of aldosterone.
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Management of metabolic alkalosis

Metabolic alkalosis is one of the most difficult acid-base imbalances to treat.

Bicarbonate excretion through the kidneys can be stimulated with drugs such as acetazolamide (Diamox),

In severe cases, IV administration of acids may be used.

It is significant to note that metabolic alkalosis in hospitalized patients is usually iatrogenic in nature.
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The relationships between pH, PaCO2 and HCO3.

pH Respiratory Acidosis PaCo2 HCO3 Normal

Respiratory alkalosis
Metabolic Acidosis Metabolic Alkalosis

Normal Normal

Normal

Remember Acronym

ROME Respiratory opposite, Metabolic equivalent 27

Normal Compensatory Responses

Disturbance Response Expected Change 1 mEq/L/10mmHg

Contd:

Respiratory Acidosis
Acute Co2 HCO3 conc. HCO3 conc. increase in PaCO2 4 mEq/L/10mmHg increase in PaCO2 2 mEq/L/10mmHg decrease in PaCO2 4 mEq/L/10mmHg decrease in PaCO2

Chronic Co2

Respiratory Alkalosis Acute Co2 HCO3 conc

Chronic Co2

HCO3 conc

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Normal Compensatory Responses (Contd)

Disturbance Response Expected Change

Metabolic Acidosis HCO3 PaCO2 1.2 X the decrease in HCO3 conc.

Metabolic Alkalosis HCO3 PaCO2 0.7 X the increase in HCO3 conc.

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Fully Compensated States

pH Respiratory Acidosis
Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis

PaCO2

HCO3

Normal, but < 7.40

Normal, but < 7.40 Normal, but < 7.40 Normal, but < 7.40

Partially Compensated States

pH Respiratory Acidosis Respiratory Alkalosis Metabolic Acidosis Metabolic Alkalosis PaCO2 HCO3

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Take Home Message:

Valuable information can be gained from an ABG as to the patients physiologic condition Remember that ABG analysis if only part of the patient assessment. Be systematic with your analysis, start with ABCs as always and look for hypoxia (which you can usually treat quickly), then follow the four steps. A quick assessment of patient oxygenation can be achieved with a pulse oximeter which measures SaO2.

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contd.

Example 1

A 45-year-old female presents to ER with a severe asthma

attack. She has been experiencing increasing shortness of breath since admission three hours ago. Stat ABGs pH 7.22 PaCO2 55 HCO3- 25 32

Follow the steps:

1. Assess the pH. It is low (normal 7.35-7.45);

2. Assess the PaCO2. It is high (normal 35-45) and in the opposite

direction of the pH. 3. Assess the HCO3. It has remained within the normal range (22-26).

pH Respiratory Acidosis

PCO2

HCO3 Normal

Management

Improve the ventilation status

Oxygen therapy, Administering bronchodilators Mechanical ventilation

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contd.

Example 2

55-year-old male presented to ER with a recurring bowel

obstruction. He has been experiencing intractable vomiting for the last several hours despite the use of

antiemetics.
Stat ABGs pH 7.50 PaCO2 42 HCO3- 33
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Follow the three steps again: 1. Assess the pH. It is high (normal 7.35-7.45), therefore, indicating alkalosis. 2. Assess the PaCO2. It is within the normal range (normal 35-45). 3. Assess the HCO3. It is high (normal 22-26) and moving in the same direction as the pH.

pH Metabolic Alkalosis

PCO2 Normal

HCO3

Management: Administration of I.V.fluids and measures to reduce the excess base.

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contd.

Example 3

40 years old man with CRF on dialysis since 6 years is admitted to the hospital. He has missed his last two dialysis
Stat ABGs pH 7.32 PaCO2 32 HCO3- 18
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Follow the three steps:

1. Assess the pH. It is low (normal 7.35-7.45); therefore we have acidosis. 2. Assess the PaCO2. It is low. Normally we would expect the pH and PaCO2 to move in opposite directions, but this is not the case. Because the pH and PaCO2 are moving in the same direction, it indicates that the acid-base disorder is primarily metabolic. In this case, the lungs, acting as the primary acidbase buffer, are now attempting to compensate by blowing off excessive C02, and therefore increasing the pH. 3. Assess the HCO3. It is low (normal 22-26). We would expect the pH and the HCO3 - to move in the same direction, confirming that the primary problem is metabolic. 4. What is your interpretation? Partially compensated metabolic acidosis.

pH
Metabolic Acidosis

PaCO2

HCO3
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Example 4
70 year old man RR 50/min B.P 80/50 pH 7.1 PCO2 22mmHg SBE - 21

contd.

Metabolic Acidosis + Resp. Compensation

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Example 5
A 6 week old child with projectile vomiting. pH 7.5 PCO2 48mmHg BE + 11

Metabolic Alkalosis + Resp. Compensation

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Example 6
pH 7.08 Na 138, PCO2 80mmHg PaO2 37 HCO3 26, Cl 100

Respiratory Acidosis

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contd.

Example 7

60 years old man with history of COPD since 20 years is scheduled for laprascopic cholecystectomy stat ABGs pH 7.35 PaCO2 48 HCO3- 28
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Follow the three steps: 1. Assess the pH. It is within the normal range, but on the low side of neutral (<7.40). 2. Assess the PaCO2. It is high (normal 35-45). 3. Assess the HCO3. It is also high (22-26). Interpretation of this ABG a fully compensated respiratory

acidosis.
pH Respiratory Acidosis Normal, but < 7.40 PaCO2 HCO3

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contd.

Example 8

16 years old boy after an RTA presents in ER with mental status. Stat ABGs pH 7.33 PaC02 62 HC03 35

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Follow the three steps:

1. Assess the pH. It is low (normal 7.35-7.45). This indicates that an acidosis exists. 2. Assess the PaC02. It is high (normal 35-45). The pH and PaC02 are moving in opposite directions, as we would expect if the problem were primarily respiratory in nature. 3. Assess the HC03. It is high (normal 22-26). Normally, the pH and HC03 should move in the same direction. Because they are moving in opposite directions, it also confirms that the primary acid-base disorder is respiratory in nature. In this case, the kidneys are attempting to compensate by retaining HCO3 in the blood in an order to return the pH back towards its normal range. Because there is evidence of compensation occurring (pH and HC03 moving in opposite directions), and seeing that the pH has not yet been restored to its normal range,

ABG interpretation Partially compensated respiratory acidosis.

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contd.

Example 9

54-year-old female admitted for an ileus. She had been experiencing nausea and vomiting. An NG tube has been in place for the last 24 hours. Here are the last ABG results pH 7.43 PaC02 48 HC03 36:
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Follow the three steps:

1. Assess the pH. It is normal, but on the high side of neutral (>7.40). 2. Assess the PaC02. It is high (normal 35-45). Normally, we would expect the pH and PaC02 to move in opposite directions. In this case, they are moving in the same direction indicating that the primary acid-base disorder is metabolic in nature. In this case, the lungs, acting as the primary acid-base buffer system, are retaining C02 (hypoventilation) in order to help lower the pH back towards its normal range. 3. Assess the HC03. It is high (normal 22-26). Because it is moving in the same direction, as we would expect, it confirms the primary acid-base disorder is metabolic alkalosis pH Metabolic Alkalosis Interpretation Normal, but >7.40 PaCO2 HCO3

fully compensated metabolic alkalosis.

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Example 10
A 42 year female diabetic, Temp 38.8oC WBC 14000 disoriented. pH 7.23 PCO2 25mmHg,PO2118 Na 135, K 4.8, HCO3 12, Cl 99

Metabolic Acidosis + Resp. Compensation

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Example 11
A Female 23 years pH 7.54 PCO2 22mmHg PO2 115 room air HCO3 22

Acute Respiratory Alkalosis

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Thank you

Practice ABGs
1. PaO2 2. PaO2 3. PaO2 4. PaO2 5. PaO2 6. PaO2 7. PaO2 8. PaO2 9. PaO2 10. PaO2 90 60 95 87 94 62 93 95 65 110 SaO2 SaO2 SaO2 SaO2 SaO2 SaO2 SaO2 SaO2 SaO2 SaO2 95 90 100 94 99 91 97 99 89 100 pH 7.48 pH 7.32 pH 7.30 pH 7.38 pH 7.49 pH 7.35 pH 7.45 pH 7.31 pH 7.30 pH 7.48 PaCO2 32 PaCO2 48 PaCO2 40 PaCO2 48 PaCO2 40 PaCO2 48 PaCO2 47 PaCO2 38 PaCO2 50 PaCO2 40 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 HCO3 24 25 18 28 30 27 29 15 24 30

Answers to Practice ABGs

1. Respiratory alkalosis 2. Respiratory acidosis 3. Metabolic acidosis 4. Compensated Respiratory acidosis 5. Metabolic alkalosis 6. Compensated Respiratory acidosis 7. Compensated Metabolic alkalosis 8. Metabolic acidosis 9. Respiratory acidosis 10. Metabolic alkalosis