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Arterial Blood GasArterial Blood Gas
Jaime C. Tan,MD
Division of Pulmonary and Critical Care Medicine
Philippine Heart center
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Indications of ABGIndications of ABG
Determine acid-base or oxygenation problem
May indicate onset or culmination of cardiopulmonary crises
May serve as a gauge to the appropriateness or effectiveness of therapy
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Normal ABG ValuesNormal ABG Values
pH 7.35 – 7.45
PaCO2 35 – 45 mmHg
[BE] 0 2 meq/L
PaO2 80 – 100 mmHg
[HCO3] 24 2 meq/L
SaO2 97 – 98%
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Steps for the interpretation of Steps for the interpretation of acid base disturbanceacid base disturbance
Is the px acidemic or alkalemic? Is the disturbance respiratory or
metabolic? If the disturbance is respiratory, is it
acute or chronic? If the disturbance is metabolic, is
the anion gap normal or abnormal?
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If the disturbance is metabolic, is the respiratory system compensating?
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Severity of Generalized Severity of Generalized Acid-Base DisturbancesAcid-Base Disturbances
pH Degree of Impairment
< 7.20 Severe acidemia
7.20 – 7.29 Moderate acidemia
7.30 – 7.34 Mild acidemia
7.35 – 7.45 Normal pH
7.46 – 7.50 Mild alkalemia
7.51 – 7.55 Moderate alkalemia
> 7.55 Severe alkalemia
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Classification of PaOClassification of PaO22 in the Adultin the Adult
Classification PaO2 (mmHg)
Hyperoxemia >100
Normoxemia 80 – 100
Mild hypoxemia 60 – 79
Moderate hypoxemia 45 – 59
Severe hypoxemia < 45
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Room Air (Fio2=.21)Room Air (Fio2=.21)
Px < 60 y.o. = Po2 =80-100mhg Px >60 y.o. = subtract 1 from 80 for
every year above 60 years of age
example: 70 y.o.
Ideal PaO2= 80
- 10
- - - - - -
70 mmhg
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Supplemental O2Supplemental O2
Fio2= Lpm x 4 + 20 P/F ratio: PaO2/ FiO2 NV: <60 y.o.= 400-500 NV:>60 y.o.= multiply every year above 60 by
5 then subtract the total from 400
ex: 70y.o.
= 10x 5= 50
= 400-50
= 350
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Steps in analyzing the Steps in analyzing the oxygenation statusoxygenation status
Is the px hypoxemic or non hypoxemic ?PaO2, Fio2, P/F ratio
Ex: 75 yo, 2 lpmactual P/F= 296
expected P/F= 325Therefore the px is HYPOXEMIC
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If the px is hypoxemic, is it corrected, uncorrected or overcorrected?
Compute for pO2 expected for age:
ex: 75 y.o., PaO2: 80
expected Po2 for age:80-15=65
px has CORRECTED HYPOXEMIA
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If the px is non hypoxemic , is he receiving adequate oxygenation or more than adequate oxygenation?
Ex: 75y.o., actual Po2:109, Fio2: 0.28, P/F ratio:389 (expected:325)
px is NON HYPOXEMIC
expected Po2 for age:65, actual Po2: 109
Receiving MORE THAN ADEQUATE OXYGENATION
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Acid-Base ClassificationAcid-Base Classification
Acid-base disturbance pH PaCO2 HCO3
Respiratory acidosis N0 or
Respiratory alkalosis N0 or
Metabolic acidosis N0 or
Metabolic alkalosis N0 or
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CasesCases
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CaseCase
V.M., 59 year old male Moderate COPD; NIDDM 2-week cough with yellow sputum Intermittent low-grade fever Cefuroxime, Paracetamol,
Fenoterol+Ipratropium Br Sought consult at ER due to dyspnea
and pleuritic chest pain
x 3 days
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CaseCase At ER, he was agitated with the ff v/s:
BP 130/90mmHg HR 110/min
RR 28/min T 380C Chest/Lungs: increased breath
sounds and tactile fremitus at the right lower lung field, crackles on both lower lung fields
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CaseCase
Chest x-ray: lobar pneumonia at the
right lower lobe, hazy densities at the
left base and blunting of the right
costophrenic angle
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CaseCase ABG taken at room air
pH 7.50
PaCO2 31 mmHg
PaO2 60 mmHg
HCO3 20 meq/L
BE 1.6 meq/L
SaO2 90%
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What is the acid-base problem?A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosisA. Respiratory alkalosis
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Respiratory AlkalosisRespiratory Alkalosis
Hallmark
CompensationCellular bufferingRenal response: retention of
endogenous acids, excretion of HCO3
pH, PaCO2
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Respiratory AlkalosisRespiratory Alkalosis
Formula for compensation
HCO3 by 2 - 4 meq/L
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Respiratory AlkalosisRespiratory AlkalosisPrimary central disorders Hyperventilation
syndrome, anxiety Cerebrovascular disease Meningitis, encephalitisPulmonary disease Interstitial fibrosis Pneumonia Pulmonary embolism Pulmonary edema (some
patients)
Hypoxia
Septicemia, hypotension
Hepatic failure
Drugs Salicylates Nicotine Xanthines Progestational hormones
High altitude
Mechanical ventilators
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Respiratory AlkalosisRespiratory Alkalosis Treatment
Treat the primary cause Control the patient’s ventilation
Paralyze the patient CMV
Carbonic anhydrase inhibitor (acetazolamide)
To decrease HCO3 of limited value
* Most frequently, requires no specific therapy
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CaseCase Given O2 at 4L/min via nasal cannula
SaO2 98%
Given Ceftazidime, Amikacin
WBC 30 x 106/uL
Segmenters 98%; (+) toxic granules
Potassium 4 mmol/L
Sodium 135 mmol/L
Creatinine 0.12 mmol/L
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CaseCase Eight hours later drowsy with
labored breathing and cyanosis
ABG at 10L/min O2
pH 7.23
PaCO2 86 mmHg
PaO2 69 mmHg
HCO3 25 meq/L
BE - 4.8 meq/L
SaO2 91%
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CaseCase Repeat Chest X-Ray: progression of
hazy densities on the left lower lung field, with no significant interval change in the previously noted right lower lobe pneumonia.
Patient admitted to ICU
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What is the acid-base problem?A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosisB. Respiratory acidosis
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Respiratory Respiratory AcidosisAcidosis
Hallmark
CompensationCellular buffering: HCO3
Renal adaptation: H+ secretion, Cl- reabsorption, net acid excretion
pH, PaCO2
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Respiratory AcidosisRespiratory Acidosis
Formula for compensation
HCO3 by 3 - 4 meq/L
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Respiratory AcidosisRespiratory Acidosis COPD O2 excess in COPD Drugs
Barbiturates Anesthetics Narcotics Sedatives
Extreme ventilation-perfusion mismatch
Exhaustion Inadequate MV Neurologic disorders
Neuromuscular disease Poliomyelitis ALL G-B syndrome Electrolyte deficiencies
(K+, PO4-)
Myasthenia gravis Excessive CO2
production TPN Sepsis Severe burns NaHCO3 administration
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Respiratory AcidosisRespiratory Acidosis
Treatment:Correct precipitating causeRestore alveolar ventilationCorrect CO2 retention Intubation and assisted ventilationO2 administration
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CaseCase
Third ICU day blood C/S: Klebsiella pneumoniae
Sensitive: piperacillin/tazobactam,
meropenem, cefepime
Resistant: ceftazidime, amikacin
Decreasing urine output at 10ml/hr
Impression: acute renal failure
Referred to nephrologist
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CaseCase
sodium 145 mmol/L
potassium 5 mmol/L
chloride 106 mmol/L
creatinine 0.48 mmol/L
CBG 300 mg/dL
Laboratories
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CaseCase ABG at 40% FiO2, BUR 20/min
400ml VT, PEEP 5cmH2OpH 7.20
PaCO2 25 mmHg
PaO2 114 mmHg
HCO3 11 meq/L
BE - 15.9 meq/L
SaO2 98.4%
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What is the acid-base problem?A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosisD. Metabolic acidosis
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Metabolic Metabolic AcidosisAcidosis
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Metabolic AcidosisMetabolic Acidosis
Hallmark: pH HCO3
base deficit accumulation of fixed acids
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Metabolic AcidosisMetabolic Acidosis
Abnormalities: Overproduction of acids Loss of buffer stores Underexcretion of acids
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Metabolic AcidosisMetabolic Acidosis
Compensation pCO2 (hyperventilation) Pathway:
pCO2
HCO3
ratio H+ conc
Acidification of ECF ECF pH
Stimulation of brainstem RR pCO2
Normalization of pH
HCO3
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Metabolic AcidosisMetabolic Acidosis
Compensation Ionic shift
K+ moves extracellularly for H+
HCO3 generation, H+ excretion
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Metabolic AcidosisMetabolic Acidosis
Effects Stimulate epinephrine release Leukocytosis Hyperkalemia Hypercalcemia / hypercalciuria Myocardial failure
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Anion GapAnion Gap
Numerical difference between Na+ and HCO3, Cl-
Helpful tool in suggesting the presence and clarifying the differential diagnosis of metabolic acidosis
Anion Gap = [Na+] – [HCO3 + Cl-]
N0 value = 12 2 meq/L
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Normal vs. Elevated Anion GapNormal vs. Elevated Anion Gap
Normal Anion Gap Reduced HCO3 is counterbalanced by a
measurable anion GI disorders (diarrhea, pancreatic fistulas) Uterosigmoidoscopy, ileostomy Ingestion of acids, parenteral
hyperalimentation Carbonic anhydrase inhibitors Renal acidification defects
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Normal vs. Elevated Anion GapNormal vs. Elevated Anion Gap
Elevated Anion Gap Reduced HCO3 is replaced by an
unmeasurable organic anion Ketoacidosis (starvation, alcohol-induced) Lactic acidosis Chronic renal failure Methyl alcohol / ethyl alcohol ingestion Paraldehyde ingestion Salicylate overdose
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Metabolic AcidosisMetabolic Acidosis
Compensation
Expected pCO2 = HCO3 x 1.5 + 8.4
Limit = 10 mmHg
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Metabolic AcidosisMetabolic Acidosis
Management Sustain normality of blood acid base
parameters Maintain serum HCO3 = 10 to 15 meq/L
HCO3 administration for pH < 7.2 Treat the underlying cause
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HCO3 = (desired – actual HCO3) x 0.4 x wt (kg)
HCO3 = BE x 0.3 x wt (kg) 2
NaHCONaHCO33 Deficit Computation Deficit Computation
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CaseCase Urine output improved after fluid
challenge Few hours later tachypneic PEEP increased to 8 cmH2O
pH 7.36
PaCO2 34 mmHg
PaO2 89 mmHg
HCO3 18 meq/L
BE - 6.1 meq/L
SaO2 96.6%
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CaseCase
Furosemide drip started at 10mg/hr Laboratories:
sodium 140 mmol/L
potassium 2 mmol/L
chloride 100 mmol/L
creatinine 0.34 mmol/L
albumin 26 g/dL
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CaseCase Repeat ABG at 40% FiO2, VT 400ml,
BUR 20/min, PEEP 8cmH2O
pH 7.53
PaCO2 47 mmHg
PaO2 109 mmHg
HCO3 36 meq/L
BE 11.3 meq/L
SaO2 98.5%
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What is the acid-base problem?A. Respiratory alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis
D. Metabolic acidosisC. Metabolic alkalosis
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Metabolic AlkalosisMetabolic Alkalosis
Hallmark
Compensation PaCO2 (hypoventilation)
pH, HCO3
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Metabolic AlkalosisMetabolic Alkalosis
Pathway
HCO3PaCO2
HCO3
ratio H+ conc
Alkalinization of ECF PaCO2 with mild hypoxemia
Normalization of pH
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Metabolic AlkalosisMetabolic Alkalosis
Compensation
Every 1 mEq increase in HCO3 will increase PaCO2 by 0.5-1 mmHg
Expected PaCO2= ( O.8 x HCO3 ) + 16 4
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Causes of Metabolic Alkalosis
Hypokalemia*Ingestion of large amounts of alkali or licoriceGastric fluid loss: Vomiting, NG suctioning*Hyperaldosteronism 20 to nonadrenal factors Bartter’s syndrome Inadequate renal perfusion diuretics (inhibiting NaCl reabsorption)*Bicarbonate administration Sodium bicarbonate overcorrection Blood transfusionAdrenocortical hypersecretion (e.g tumor)Steroids*Eucapnic ventilation posthypercapnia
* Common in the ICU
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Treatment of Treatment of Metabolic AlkalosisMetabolic Alkalosis
Replace fluids (with Normal Saline) Replace electrolyte deficit
K supplementation (K > 4.5 mEq/L) Ammonium chloride Hydrochloric acid
Acetazolamide (carbonic anhydrase inhibitor) -promotes renal excretion of HCO3
-
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Sample problem:Sample problem:
68 y.o., male, w/ increasing SOB, admitted at ER, initial ABG: (32% fio2)
Ph: 7.25, Pco2: 75, Po2= 95,HCO3: 32, O2 sat: 94%
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Role of NursesRole of Nurses
Evaluation of symptoms
When to refer to MD
Administration of medications
Awareness of potential
complications of medications
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Evaluation of Evaluation of
SymptomsSymptoms Respiratory acidosis
Alteration of state of consciousness
Confusion
Stupor
Obtundation
Coma
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Evaluation of Evaluation of
SymptomsSymptoms Respiratory alkalosis
Cerebral vasoconstriction
Nausea, vomiting, lightheadedness
Carpopedal spasm
Circumoral, digital paresthesias
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Evaluation of Evaluation of
SymptomsSymptoms Metabolic alkalosis
Increase neuromuscular activity
Chvostek, Trousseau sign
Twitching, tetany
Arrhythmias
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Evaluation of Evaluation of
SymptomsSymptoms Metabolic acidosis
Kussmaul’s respiration
Hyperpnea, tachypnea
Hypotension
Arrhythmias
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Administration of Administration of
MedicationsMedications Sodium Bicarbonate
Given for correction of metabolic
acidosis
Bicarbonate deficit
HCO3 = BE x 0.3 x wt (kg) 2
HCO3 = (desired – actual HCO3) x 0.4 x wt (kg)
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Potential Complications of Potential Complications of
MedicationsMedications
Local site complication
Patent IV site
Bicarbonate overcorrection
Hypokalemia
Fluid overload or hypernatremia
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Thank You for Thank You for ListeningListening