ABG  series<br />ANAS  SAHLE , MD<br />DAMASCUSE   HOSPITAL<br />
Acid-Base Disorders and the ABG 4<br />
Very important note:<br />Sodium should be corrected if glucose is high befor calculated AG<br />REF:high-yield(c):2007<br />
BREIF  PREVIEW<br />
Summary of the Approach to ABGs<br />Check the pH<br />Check the pCO2<br />Select the appropriate compensation formula<br ...
EXPECTED CHANGES IN <br />ACID-BASE DISORDERS <br />From: THE ICU BOOK - 2nd Ed. (1998) [Corrected]<br />
Gap:gap ratio??<br />
HIGH AG M.AC<br />Osmolal gap = measured serum osmolality -  (2 NA + gluco18 + bun2,8)<br />Corrected osmolal gap = <br />...
HIGH AG M.AC<br />High <br /> normal <br />
Expected PCO2 : Measured PCO2<br />
YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />
<5,5<br />>5,5<br />Urine AG = (UNA +UK) - UCL<br />
METABOLIC ALKALOSIS-1<br />
CAUSES (in short phrase)<br /><ul><li>Diuretics
Vomiting
Exogenous alkali
Hyper- aldosteronism
Post-hypercapneic state</li></li></ul><li>YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />YES<br />NO<...
< 20 mEqL<br />> 20 mEqL<br />HIGH<br />NORMAL<br />
Case: 1<br />An elderly woman from a nursing home was transferred to hospital because of profound weakness and areflexia. ...
LAB<br />
Comments<br />About 90% of cases of metabolic alkalosis are due to: <br />diuretic therapy <br />loss of gastric secretion...
What blood pressure ???</li></li></ul><li>CASE: 2<br />A 20 year old student presents with excessive vomiting after binge ...
YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />
CASE: 3<br />46 year old man with progressive CKD on conservative management <br />(baseline BUN 40, Creat 4.0) <br />is a...
CRF>>>>>>>HIGH  AG  M.AC<br />VOMITING>>>>>>>METABOLIC  ALKALOSIS<br />FROM tow above disorders<br />/ we can explanation ...
MIXED DISORDERS(PH:NORMAL)<br />
AG<br />
CASE:4<br />45 year old woman with long history of EtOH abuse comes into ED with 3 days of nausea and vomiting.<br />She l...
LAB:<br />Measured <br />osmolal serum=284<br />
What it etiology for each disorders<br />
HIGH AG M.AC<br />Osmolal gap = measured serum osmolality -  (2 NA + gluco18 + bun2,8)<br />Corrected osmolal gap = <br />...
Discussion <br />Osmolal GAP = 10<br />Normal osmolal gap.<br />Is there CRF?.<br />IS THERE KETON? <br />IS BLOOD GLUCOSE...
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ABG4 Series

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ABG4 Series

  1. 1. ABG series<br />ANAS SAHLE , MD<br />DAMASCUSE HOSPITAL<br />
  2. 2. Acid-Base Disorders and the ABG 4<br />
  3. 3. Very important note:<br />Sodium should be corrected if glucose is high befor calculated AG<br />REF:high-yield(c):2007<br />
  4. 4. BREIF PREVIEW<br />
  5. 5. Summary of the Approach to ABGs<br />Check the pH<br />Check the pCO2<br />Select the appropriate compensation formula<br />Determine if compensation is appropriate<br />Check the anion gap <br />AG=NA – (HCO3 + CL):12±4<br />If the anion gap is elevated, check the delta-delta<br />G:G Ratio =Δ AG (12-AG) Δ HCO3 (24-HCO3)<br />If a metabolic acidosis is present, check urine pH<br />Generate a differential diagnosis<br />
  6. 6. EXPECTED CHANGES IN <br />ACID-BASE DISORDERS <br />From: THE ICU BOOK - 2nd Ed. (1998) [Corrected]<br />
  7. 7.
  8. 8. Gap:gap ratio??<br />
  9. 9. HIGH AG M.AC<br />Osmolal gap = measured serum osmolality - (2 NA + gluco18 + bun2,8)<br />Corrected osmolal gap = <br /> measured serum osmolality - (2 NA + gluco18 + bun2,8 + ETOH4,6)<br />
  10. 10. HIGH AG M.AC<br />High <br /> normal <br />
  11. 11. Expected PCO2 : Measured PCO2<br />
  12. 12. YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />
  13. 13. <5,5<br />>5,5<br />Urine AG = (UNA +UK) - UCL<br />
  14. 14. METABOLIC ALKALOSIS-1<br />
  15. 15. CAUSES (in short phrase)<br /><ul><li>Diuretics
  16. 16. Vomiting
  17. 17. Exogenous alkali
  18. 18. Hyper- aldosteronism
  19. 19. Post-hypercapneic state</li></li></ul><li>YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />
  20. 20. < 20 mEqL<br />> 20 mEqL<br />HIGH<br />NORMAL<br />
  21. 21. Case: 1<br />An elderly woman from a nursing home was transferred to hospital because of profound weakness and areflexia. <br />Her oral intake had been poor for a few days. <br />Current medication was a sleeping tablet which was administered by nursing staff as needed.<br />
  22. 22. LAB<br />
  23. 23.
  24. 24. Comments<br />About 90% of cases of metabolic alkalosis are due to: <br />diuretic therapy <br />loss of gastric secretions (vomiting or nasogastric suction)<br />The urine chloride at 74mmol/l is <br /> very high in this patient<br /><ul><li>Chloride UN-responsive metabolic alkalosis.
  25. 25. What blood pressure ???</li></li></ul><li>CASE: 2<br />A 20 year old student presents with excessive vomiting after binge drinking.<br />ABG:<br /> pH= 7.50, <br />pCO2 =44, <br />pO2= 100<br />Metabolic panel:<br /> Na= 138,<br />Cl =100,<br /> HCO3= 30<br />
  26. 26.
  27. 27. YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />YES<br />NO<br />
  28. 28. CASE: 3<br />46 year old man with progressive CKD on conservative management <br />(baseline BUN 40, Creat 4.0) <br />is admitted after episode of vomiting attributed to food poisoning.<br />He is orthostatic on exam and appears “dehydrated”<br />Nephrology called to dialyze<br />Renal fellow: Why’s his HCO3 so high?<br />Resident: High? It’s 25, and the pH is 7.40. Now come in and dialyze him!<br />
  29. 29. CRF>>>>>>>HIGH AG M.AC<br />VOMITING>>>>>>>METABOLIC ALKALOSIS<br />FROM tow above disorders<br />/ we can explanation why PH,HCO3 in normal limites?<br />Thereby we should calculate AG in all cases<br />
  30. 30. MIXED DISORDERS(PH:NORMAL)<br />
  31. 31. AG<br />
  32. 32. CASE:4<br />45 year old woman with long history of EtOH abuse comes into ED with 3 days of nausea and vomiting.<br />She lives on the streets and is very disgeveled appearing.<br />She stopped drinking 3 days ago because she felt sick<br />
  33. 33. LAB:<br />Measured <br />osmolal serum=284<br />
  34. 34. What it etiology for each disorders<br />
  35. 35. HIGH AG M.AC<br />Osmolal gap = measured serum osmolality - (2 NA + gluco18 + bun2,8)<br />Corrected osmolal gap = <br /> measured serum osmolality - (2 NA + gluco18 + bun2,8 + ETOH4,6)<br />
  36. 36. Discussion <br />Osmolal GAP = 10<br />Normal osmolal gap.<br />Is there CRF?.<br />IS THERE KETON? <br />IS BLOOD GLUCOSE HIGH?.<br />What is diagnosis?<br />
  37. 37. HIGH AG M.AC<br />
  38. 38. Diagnosis <br />Alkoholicketoacidosis<br />
  39. 39. NEXT LECTURE<br />Metabolic alkalosis-2<br />Cases <br />
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