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    abg presentation.ppt abg presentation.ppt Presentation Transcript

    • Arterial Blood Gas Analysis Vanessa Klee MSIV
    • What is an ABG?
      • The Components
        • pH / PaCO 2 / PaO 2 / HCO 3 / O 2 sat / BE
      • Desired Ranges
        • pH - 7.35 - 7.45
        • PaCO 2 - 35-45 mmHg
        • PaO 2 - 80-100 mmHg
        • HCO 3 - 21-27
        • O 2 sat - 95-100%
        • Base Excess - +/-2 mEq/L
    • Why Order an ABG?
      • Aids in establishing a diagnosis
      • Helps guide treatment plan
      • Aids in ventilator management
      • Improvement in acid/base management allows for optimal function of medications
      • Acid/base status may alter electrolyte levels critical to patient status/care
    • Logistics
      • When to order an arterial line --
        • Need for continuous BP monitoring
        • Need for multiple ABGs
      • Where to place -- the options
        • Radial
        • Femoral
        • Brachial
        • Dorsalis Pedis
        • Axillary
    • Acid Base Balance
      • The body produces acids daily
        • 15,000 mmol CO 2
        • 50-100 mEq Nonvolatile acids
      • The lungs and kidneys attempt to maintain balance
    • Acid Base Balance
      • Assessment of status via bicarbonate-carbon dioxide buffer system
        • CO 2 + H 2 O <--> H 2 CO 3 <--> HCO 3 - + H +
        • ph = 6.10 + log ([HCO 3 ] / [0.03 x PCO 2 ])
    • The Terms
      • ACIDS
        • Acidemia
        • Acidosis
          • Respiratory
          •  CO 2
          • Metabolic
          •  HCO 3
      • BASES
        • Alkalemia
        • Alkalosis
          • Respiratory
          •  CO 2
          • Metabolic
          •  HCO 3
    • Respiratory Acidosis
      •  ph,  CO 2,  Ventilation
      • Causes
        • CNS depression
        • Pleural disease
        • COPD/ARDS
        • Musculoskeletal disorders
        • Compensation for metabolic alkalosis
    • Respiratory Acidosis
      • Acute vs Chronic
        • Acute - little kidney involvement. Buffering via titration via Hb for example
          • pH  by 0.08 for 10mmHg  in CO 2
        • Chronic - Renal compensation via synthesis and retention of HCO 3 (  Cl to balance charges  hypochloremia)
          • pH  by 0.03 for 10mmHg  in CO 2
    • Respiratory Alkalosis
      •  pH,  CO 2,  Ventilation
      •  CO 2   HCO 3 (  Cl to balance charges  hyperchloremia)
      • Causes
        • Intracerebral hemorrhage
        • Salicylate and Progesterone drug usage
        • Anxiety   lung compliance
        • Cirrhosis of the liver
        • Sepsis
    • Respiratory Alkalosis
      • Acute vs. Chronic
        • Acute -  HCO 3 by 2 mEq/L for every 10mmHg  in PCO 2
        • Chronic - Ratio increases to 4 mEq/L of HCO 3 for every 10mmHg  in PCO 2
        • Decreased bicarb reabsorption and decreased ammonium excretion to normalize pH
    • Metabolic Acidosis
      •  pH,  HCO 3
      • 12-24 hours for complete activation of respiratory compensation
      •  PCO 2 by 1.2mmHg for every 1 mEq/L  HCO 3
      • The degree of compensation is assessed via the Winter’s Formula
          •  PCO 2 = 1.5(HCO 3 ) +8  2
    • The Causes
      • Metabolic Gap Acidosis
        • M - Methanol
        • U - Uremia
        • D - DKA
        • P - Paraldehyde
        • I - INH
        • L - Lactic Acidosis
        • E - Ehylene Glycol
        • S - Salicylate
      • Non Gap Metabolic Acidosis
        • Hyperalimentation
        • Acetazolamide
        • RTA (Calculate urine anion gap)
        • Diarrhea
        • Pancreatic Fistula
    • Metabolic Alkalosis
      •  pH,  HCO 3
      •  PCO 2 by 0.7 for every 1mEq/L  in HCO 3
      • Causes
        • Vomiting
        • Diuretics
        • Chronic diarrhea
        • Hypokalemia
        • Renal Failure
    • Mixed Acid-Base Disorders
      • Patients may have two or more acid-base disorders at one time
      • Delta Gap
        • Delta HCO 3 = HCO 3 + Change in anion gap
        • >24 = metabolic alkalosis
    • The Steps
      • Start with the pH
      • Note the PCO 2
      • Calculate anion gap
      • Determine compensation
    • Sample Problem #1
      • An ill-appearing alcoholic male presents with nausea and vomiting.
        • ABG - 7.4 / 41 / 85 / 22
        • Na- 137 / K- 3.8 / Cl- 90 / HCO 3 - 22
    • Sample Problem #1
      • Anion Gap = 137 - (90 + 22) = 25
      •  anion gap metabolic acidosis
      • Winters Formula = 1.5(22) + 8  2
      • = 39  2
      •  compensated
      • Delta Gap = 25 - 10 = 15
      • 15 + 22 = 37
      •  metabolic alkalosis
    • Sample Problem #2
      • 22 year old female presents for attempted overdose. She has taken an unknown amount of Midol containing aspirin, cinnamedrine, and caffeine. On exam she is experiencing respiratory distress.
    • Sample Problem #2
      • ABG - 7.47 / 19 / 123 / 14
      • Na- 145 / K- 3.6 / Cl- 109 / HCO 3 - 17
      • ASA level - 38.2 mg/dL
    • Sample Problem #2
      • Anion Gap = 145 - (109 + 17) = 19
      •  anion gap metabolic acidosis
      • Winters Formula = 1.5 (17) + 8  2
      • = 34  2
      •  uncompensated
      • Delta Gap = 19 - 10 = 9
      • 9 + 17 = 26
      •  no metabolic alkalosis
    • Sample Problem #3
      • 47 year old male experienced crush injury at construction site.
      • ABG - 7.3 / 32 / 96 / 15
      • Na- 135 / K-5 / Cl- 98 / HCO 3 - 15 / BUN- 38 / Cr- 1.7
      • CK- 42, 346
    • Sample Problem #3
      • Anion Gap = 135 - (98 + 15) = 22
      •  anion gap metabolic acidosis
      • Winters Formula = 1.5 (15) + 8  2
      • = 30  2
      •  compensated
      • Delta Gap = 22 - 10 = 12
      • 12 + 15 = 27
      •  mild metabolic alkalosis
    • Sample Problem #4
      • 1 month old male presents with projectile emesis x 2 days.
      • ABG - 7.49 / 40 / 98 / 30
      • Na- 140 / K- 2.9 / Cl- 92 / HCO 3 - 32
    • Sample Problem #4
      • Metabolic Alkalosis, hypochloremic
      • Winters Formula = 1.5 (30) + 8  2
      • = 53  2
      •  uncompensated