ARTERIAL BLOOD GASES ACID/BASE BALANCE

Nursing 232E

HOMEOSTASIS

The chemical reactions that sustain life depend on a delicate balance between acids and bases in the body.

HENDERSON-HASSELBALCH EQUATION
Describes the relationship of pH, acid (H2CO3) and base (HCO3) The equation reveals that a ratio of 20 parts base to one part acid must be present to yield a normal pH.

An increase in base = increase blood pH A decrease in base = decrease blood pH An increase in acid = decrease blood pH A decrease in acid = increase blood pH

UNDERSTANDING

PH

a measure of H+ ion concentration

pH < 7.35 = Acidosis (high H+ concentration) pH > 7.45 = Alkalosis (low H+ concentration)

pH reflects the net balance between acid and base Normal pH is 7.35 7.45

ACIDOSIS
pH < 7.35 Excess of {H+} or {CO2} Loss of {HCO3}

CO2 is a massive source of {H=}

ALKALOSIS

pH > 7.45 Caused by excess Bicarbonate intake or loss of {H+} or {CO2}

3 PHYSIOLOGIC SYSTEMS TO MAINTAIN NORMAL SERUM PH

1. Excretion of acid by the lungs 2. Excretion of acid or reclamation of base by the kidneys 3. buffering of excess acid or base by the blood buffer systems

RESPIRATION

ROLE OF LUNGS

Lungs regulate blood levels of CO2. CO2 combines with H2O to form carbonic acid. Increased carbonic acid leads to decreased pH. Chemoreceptors in the brain sense the change in the pH and vary the rate and depth of breathing to compensate. Breathing faster eliminates CO2, thus less carbonic acid is made and pH rises. Breathing slower conserves CO2, more carbonic acid is present and pH falls.

PACO2
To assess the effectiveness of ventilation, look at the partial pressure of CO2 in arterial blood. PaCO2 = partial pressure of arterial carbon dioxide

Normal PaCO2 = 35 to 45 mm Hg Represents the respiratory component of bodys acid base balance.

KIDNEY REGULATION
Kidneys reabsorb acids and bases or excrete them into the urine. Produce bicarbonate to replenish lost supplies

If blood contains too much acid or not enough base, pH drops and kidneys reabsorb more sodium bicarbonate.

The reabsorption of bicarbonate and increased excretion of {H+} causes more bicarb to be formed in the renal tubules and retained. The bicarb level rises and the pH level increases.

HC03
Bicarbonate Normal level is 22 to 26 mEq\L Represents the metabolic component of the bodys acid-base balance.

INTERPRETING ABG RESULTS

If every value is normal, then the person has normal ABGs. If the pH is normal, but any of the other values abnormal then it is compensated.

INTERPRETING ABG RESULTS

Step 1.

Check the pH

If pH is abnormal, determine whether it reflects acidosis (below 7.35) or alkalosis (above 7.45).

Then figure out if the cause is respiratory or metabolic.

INTERPRETING ABG RESULTS

Step 2. Look at the CO2

If PaCO2 is abnormal, determine whether its low (<35) or high (>45). Then determine if the abnormal result corresponds with the change in the pH.

pH high, PaCO2 low (hypocapnea) indicating Respiratory alkalosis pH low, PaCO2 high (hypercapnea) indicating Respiratory acidosis

INTERPETING ABG RESULTS

Step 3.

Look at Bicarbonate

If bicarb level is abnormal, determine if low (<22) or high (>26). If pH is high, bicarb is high = metabolic alkalosis If pH is low, bicarb is low = metabolic acidosis

INTERPRETING ABG RESULTS

Step 4. Look for Compensation. Sometimes you will see a change in both the PaC02 level and the bicarbonate level. One value indicates the primary source of the pH change; the other, the bodys effort to compensate.

COMPENSATION
Complete compensation occurs when the bodys ability to compensate is so effective that pH falls within normal range. Partial compensation occurs when pH remains outside of normal range.

If it is 7.35 - 7.45 (normal) then it is COMPENSATED. If the pH is < 7.35 or > 7.45 then it is UNCOMPENSATED.

PARTIAL COMPENSATION

This describes when you have abnormalities in both systems and your pH is abnormal. This shows that one system has tried to compensate for the other but is not yet successful.

pH = 7.09 PaCO2 = 50 HCO3- = 30 Partially compensated respiratory acidosis

pH = 7.67 PaCO2 = 60 HCO3- = 45 Partially compensated metabolic alkalosis

ANALYSIS OF OXYGEN (NOT PART OF ABG INTERPRETATION)

Step 5. Determine PaO2 and SaO2

If values are abnormal, determine if high PaO2 > 100 or low PaO2 < 80 (and SaO2 < 95%) PaO2 reflects the bodys ability to pick up oxygen from the lungs.

Low PaO2 represents hypoxemia and can cause hyperventilation. The value indicates when to make adjustments in the concentration of oxygen being administered.

PAO2
The O2 tells us if the patient has hypoxemia (decreased oxygen in the blood). Normal PaO2 = 80-100 (hypoxemia = PaO2 < 80) PaO2 assesses perfusion (gas exchange) PaCO2 assesses the adequacy of ventilation (breathing pattern) The PaO2 is very important in determining your patients oxygen status and needs but it is not necessary in determining ABG results

O2 SATURATION

What is saturation?
SaO2 (oxygen saturation) measures the percent of oxygen bound to hemoglobin. This tells whether the patient has hypoxia (decrease O2 in the tissue). Normal SaO2 = greater than 95% Acceptable SaO2 will vary between MD, but PaO2 dramatically drops when it is less than 92%. This is a noninvasive measurement via pulse oximetry and can be less accurate due to hypoxemia, hypotension, hypovolemia, or vasoactives.

REVIEW

Decreased pH with decreased HCO3-: ACIDOSIS Increased pH with increased HCO3-: ALKALOSIS

Decreased pH with increased CO2-: ACIDOSIS

Increased pH with decreased CO2-: ALKALOSIS

EXAMPLE

pH = 7.60; CO2 = 30; HCO3- =22

Is this acidosis, alkalosis, or normal

EXAMPLE

pH = 7.60; CO2 = 30; HCO3- =22 pH is high = alkalosis

EXAMPLE

pH = 7.60; CO2 = 30; HCO3- =22 Do you think compensated or uncompensated?

EXAMPLE

pH = 7.60; CO2 = 30; HCO3- =22 Uncompensated because ph is abnormal

EXAMPLE

pH = 7.60; CO2 = 30; HCO3- =22 Is this respiratory or metabolic?

Respiratory because the C02 is low. You have uncompensated respiratory alkalosis

EXAMPLE 2

pH = 7.35; CO2- = 50; HCO3- = 25 pH is normal (lower end closer to acidosis), but everything else is not normal so we know this is not normal ABGS. Thus this is compensated.

Compensated acidosis. It is Respiratory because the CO2 is high. This is compensated respiratory acidosis.

EXAMPLE 3

pH = 7.35; CO2- = 45; HCO3- = 21

pH is normal, but the HCO3 is not, so these are abnormal results. Thus, this is compensated. HCO3 is low.

This is compensated metabolic acidosis.

ACIDOSIS
Respiratory

Metabolic

Hypoventilation Respiratory depressants Impaired diagphragmatic movement Chest wall disorders (flail chest, pneumothorax) Disorders of the lung parenchyma (CHF, COPD pneumonia, aspiration, ARDS) Alteration in the function of the abdominal system (distension)

Renal failure DKA Lactic acidosis

Overproduction of organic acids (starvation, increased catabolism) Abnormal loss of HCO3(diarrhea, biliary fistula, Diamox) Ingestion of acid (salicylate overdose, oral anti-freeze)

ALKALOSIS
Respiratory

Metabolic

Hyperventilation

Psychogenic (fear, pain, anxiety) CNS stimulation (brain injury, ETOH, early salicylate poisoning, brain tumor) Hypermetabolic states (fever, thyrotoxicosis) Hypoxia (high altitude, pneumonia, heart failure, pulmonary embolism) Mechanical overventilation (ventilator rate too fast)

NG suction Loss of H+ or increased HCO3Loss of K+ (diarrhea, vomiting) Ingestion of large amounts of bicarbonate (antacids, resuscitation) Prolonged use of diuretics (distal tubule lose ability to reabsorb Na+ and Cltherefore NaCl); Ammonia is in the urine and then binds with H+