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Abg khare
Abg khare
Abg khare
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Abg khare

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  • 1.  Acidemia : Blood pH < 7.35  Alkalemia : Blood pH > 7.45  Acidosis : a physiologic process that tends to cause acidemia  Alkalosis : a physiologic process that tends to
  • 2. pH 7.35 - 7.45 PaCO2 35 - 45 mm Hg PaO2 70 - 100 mm Hg ** SaO2 93 - 98% HCO3 ¯ 22 - 26 mEq/L Base excess -2.0 to 2.0 mEq/L * At sea level, breathing ambient air ** Age-dependent Normal Arterial Blood Gas Values*
  • 3. Primary & Secondary Acid – Base Disorder Acid Base Disorder Primary Change Secondary Change Respiratory Acidosis  PaCO2  HCO3 - Alkalosis  PCO2  HCO3 - Metabolic Acidosis  HCO3 -  PCO2 Alkalosis  HCO3 -  PCO2
  • 4. Changes In Actual HCO3 - Levels Respiratory acidosis Acute: ↑0.1 mmol of HCO3- per 1 mm Hg ↑ Pco2 or HCO3- = 24 + 0.1 X Δ PCO2 Chronic: ↑ 0.35 mmol of HCO3- per 1 mm Hg ↑ Pco2 or HCO3- = 24 + 0.35 X Δ PCO2
  • 5. Changes In Actual HCO3 - Levels Respiratory alkalosis Acute: ↓ 0.2 mmol of HCO3- per 1 mm Hg ↓ Pco2 or HCO3- = 24 – 0.2X Δ PCO2 Chronic: ↓ 0.4 mmol of HCO3- per 1 mm Hg ↓ Pco2 or HCO3- = 24 – 0.4X Δ PCO2
  • 6. Metabolic acidosis ΔPCO2 = 1.3 X Δ HCO3- Or PCO2 = (1.5 X HCO3-) + 8 ± 2
  • 7. Metabolic alkalosis ΔPCO2 = 0.6 X Δ HCO3- Or PCO2 = (0.7 X HCO3-) + 21 ± 2
  • 8. • Acid – base interpretation is based on three variables - pH, PCO2 & HCO3 - • If outside normal range, it is abnormal Normal range pH 7.35 to 7.45 PaCO2 35 to 45 mm of Hg HCO3 - 22 to 26 mEq/L
  • 9. If pH ‹ 7.35 - acidosis If pH › 7.45 - alkalosis
  • 10. Look at Pco2 and HCO3- Primary Change Acid Base Disorder Secondary Change  PaCO2 (› 45mmhg ) Respiratory Acidosis  HCO3 -  PCO2 (‹35mmhg) Alkalosis  HCO3 -  HCO3 -(‹22mmol/L) Metabolic Acidosis  PCO2  HCO3 -(›26mmol/L) Alkalosis  PCO2
  • 11. If primary respiratory disorder  Acute: Expected pH= 0.008 × ∆ Pco2  Chronic: Expected pH= 0.003 × ∆ Pco2
  • 12. Respiratory acidosis Ac : ↑0.1 mmol of HCO3- per 1 mm Hg ↑ Pco2 or HCO3- = 24 + 0.1 X Δ PCO2 Chr : ↑ 0.35 mmol of HCO3- per 1 mm Hg ↑ Pco2 or HCO3- = 24 + 0.35 X Δ PCO2 Expected change in HCO3-
  • 13. Respiratory alkalosis Acute: ↓ 0.2 mmol of HCO3- per 1 mm Hg ↓ Pco2 or HCO3- = 24 – 0.2X Δ PCO2 Chronic: ↓ 0.4 mmol of HCO3-per 1 mm Hg ↓ Pco2 or HCO3- = 24 – 0.4X Δ PCO2 Expected change in HCO3-
  • 14. Metabolic acidosis ΔPCO2 = 1.3 X Δ HCO3- or PCO2 =(1.5 X HCO3-) + 8 ± 2 Metabolic alkalosis ΔPCO2 = 0.6 X Δ HCO3- or PCO2 = (0.7 X HCO3-) + 21 ± 2 Expected Change in pCO2
  • 15.  ABG : pH HCO3 PCO2  Obtain a minimum diagnosis Electrolyte (Na+, K+,Cl- and HCO3) Calculate the Anion gap K+ SO2 Hb.  Complete the diagnosis  Match with the clinical diagnosis and treat accordingly Step-5 : Calculate the Anion gap a. Check the anion gap (AG) : AG =Na+ -(HCO3 + Cl- ) (normal = 12 ± 2) Elevated AG = Acidosis
  • 16. Step 5 : b. Compare fall in HCO3 with increase in plasma anion gap.  i) In high AG metabolic acidosis, rise in the plasma AG (AG - 12) matches with fall in serum HCO3 ( 24 – HCO3) (Rise in AG = Fall in HCO3)  ii) If increase in AG exceeds the fall in HCO3 (Rise in AG > Fall in HCO3), it suggests co-existing metabolic alkalosis.  iii) If increase in AG is lesser than the fall of HCO3 (Rise in AG < Fall in HCO3), it suggests loss of HCO3 (diarrhoea) causing non-AG metabolic acidosis.
  • 17.  AG = Na+ – (Cl- + HCO3 -)=Normal value is 12 ± 2  Compare the rise in AG with the decrease in HCO3-is Useful to identify additional or hidden metabolic disorders 1. change(rise) in AG = the decrease in HCO3= simple metabolic acidosis 2.change(rise) in AG < the decrease in HCO3= hidden metabolic alkalosis, 3.change(rise) in AG > the decrease in HCO3= hidden non AG acidosis
  • 18.  Actual PCO2 = Expected PCO2  respiratory alkolosis  Actual PCO2 > Expected PCO2  hidden non AG acidosis  Actual PCO2 < Expected PCO2  hidden metabolic alkalosis
  • 19. Q. A 19 years old boy brought in emergency with history of injecting some drug. O/E respiration shallow 8/mt, responded to painful stimuli. Arterial blood gases shows: pH 7.14 PaO2 86 mm of Hg PaCO2 72 mm of Hg ABC 26 mmol/L BE 1.4 mmol/L
  • 20. pH 7.14  Acidosis PaCO2 72 mm of Hg  Respiratory ABC 26 mmol/L  0.008 X (72-40) = 0.256  7.4 – 0.256 = 7.144  0.003 X (72-40) = 0.096  7.4 – 0.096 = 7.304  HCO3- = 24 + 0.1 X Δ PCO2 = 24+ 0.1(72-40) = 27.2  Uncompensated  Uncompensated Acute Respiratory Acidosis Acute  Not Chr.
  • 21. Q. A 67 years old male with H/O cough and respiratory distress and chronic smoking came in emergency : Arterial blood gases shows: pH 7.34 PaO2 76 mm of Hg PaCO2 60 mm of Hg ABC 31 mmol/L BE +4 mmol/L
  • 22. pH 7.34  Acidosis PaCO2 60 mm of Hg  Respiratory ABC 31 mmol/L  0.008 X (60-40) = 0.16  7.4 – 0.16 = 7.24  0.003 X (60-40) = 0.06  7.4 – 0.06 = 7.34  HCO3- = 24 + 0.35 X Δ PCO2 = 24+ 0.35(60-40) = 31  Compensated  Compensated Chronic Respiratory Acidosis Not Acute  Chronic
  • 23. Q. A 18 years old girl was admitted in the hospital after an argument with her boy friend. She denied taking any medication. On examination chest clear, respiratory rate 34 / mt. Blood gas estimation shows : pH 7.51 PaO2 82 mm of Hg PaCO2 26 mm of Hg ABC 24 mmol/L BE -1 mmol/L
  • 24. pH 7.51  Alkalosis PaCO2 26 mm of Hg  Respiratory ABC 24 mmol/L  0.008 X (40-26) = 0.112  7.4 + 0.112 = 7.512  0.003 X (40-26) = 0.042  7.4 + 0.042 = 7.442  HCO3- = 24 – 0.2X Δ PCO2 = 24- 0.2(40-26) = 21.2  Uncompensated  Uncompensated Acute Respiratory Alkalosis Acute  Not Chr.
  • 25. Q. A 52 years old man brought in emergency with history of cough and pleuritic chest pain for few days increasingly becoming breathless: Arterial blood gases shows: pH 7.47 PaO2 67 mm of Hg PaCO2 14 mm of Hg ABC 15 mmol/L BE -8.2 mmol/L
  • 26. pH 7.47  Alkalosis PaCO2 14 mm of Hg  Respiratory ABC 15 mmol/L  0.008 X (40-14) = 0.208  7.4 + 0.208 = 7.608  0.003 X (40-14) = 0.078  7.4 + 0.078 = 7.478  HCO3- = 24 – 0.4X Δ PCO2 = 24- 0.4(40-14) = 13.6  Uncompensated  Uncompensated Chronic Respiratory Alkalosis Not Acute  Chronic
  • 27. Q.60 year old admitted with gluteal abscess, known diabetic pH 7.18 PCO2 18 HCO3- 9 Na 138 K 4.1 Cl 110 AG 23.1
  • 28.  pH <7.4  acidosis  Metabolic  low HCO3-  Expected PCO2 = 1.5 X HCO3- + 8 = 1.5 X 9 + 8 = 21.5  Actual PCO2 (18) < Expected PCO2 (21.5)  respiratory alkalosis  Diag : Metabolic acidosis with respiratory alkalosis  Increased AG (23) metabolic acidosis  Clinical Diag : Diabetic ketoacidosis with sepsis
  • 29. Q.50 – year old with CRF, smoker pH 7.1 PCO2 50 HCO3- 15 Na 140 K 5 Cl 105 AG 23
  • 30.  pH <7.4  acidosis  Metabolic  low HCO3-  Expected PCO2 = 1.5 X 15 + 8 = 30.5  Actual PCO2 (50) > Expected PCO2 (30.5)  respiratory acidosis  Diag : Metabolic acidosis with respiratory acidosis  Increased AG (23) metabolic acidosis  Clinical Diag : CRF with COPD and increased AG metabolic acidosis
  • 31. Q.35 – year old, collapsed on physical exertion was brought to hospital pH 6.99 PCO2 34 HCO3- 8 Na 141 K 6 Cl 105 AG 28
  • 32.  pH <7.4  acidosis  Metabolic  low HCO3-  Expected PCO2 = 1.5 X 8 + 8 = 20  Actual PCO2 (34) > Expected PCO2 (20)  respiratory acidosis  Diag : Metabolic acidosis and respiratory acidosis with hyperkalemia  Increased AG (28) metabolic acidosis  Clinical Diag : Cardiorespiratory arrest
  • 33. Q.70 – kg healthy male had acute airway obstruction during induction of anaesthesia pH 7.1 PCO2 70 HCO3- 21
  • 34.  pH <7.4  acidosis  Respiratory  high PaCO2 (>40)  Acute hypercapnia – HCO3- increases 0.1 mmol for every increase in 1 mm Hg of PCO2 above 40 mm Hg  HCO3- should be 3 mmol above 24, if PCO2 only is changed  Predicted HCO3- is 27, but actual is 21  deficit of 6 mmol/ L  Combined respiratory and metabolic acidosis
  • 35. Q.56 – year old male patient, with COPD having resting PCO2 of 70 sustains perioperative MI, BP is 80/60 mm Hg, is sweating, cool and clammy pH 7.1 PCO2 70 HCO3- 21
  • 36.  pH <7.4  acidosis  Respiratory  high PaCO2(>40)  Chronic hypercapnia – HCO3- increases 0.4 mmol for every increase in 1 mm Hg of PCO2 above 40 mm Hg  Predicted HCO3- is 36, but actual is 21  deficit of 15 mmol/ L  Combined respiratory and metabolic acidosis  Metabolic component much greater than previous case
  • 37. Step 1: Acidemic, alkalemic, or normal? Step 2: Is the primary disturbance respiratory or metabolic? Step 3: For a primary respiratory disturbance, is it acute or chronic? Step 4: For a metabolic disturbance, is the respiratory system compensating OK? Step 5: For a metabolic acidosis, is there an increased anion gap? Step 6: For an increased anion gap metabolic acidosis, are there other derangements?
  • 38. Useful Formulas for Acid Base Interpretations Metabolic Acidosis Expected PaCO2 = (1.5 × HCO3) + (8±2) PRIMARY DISORDER EXPECTED RESULTS Metabolic Alkalosis Expected PaCO2 = (0.7 × HCO3) + (21±2) Acute Respiratory Acidosis Acute Respiratory Alkalosis Chronic Respiratory Acidosis Chronic Respiratory Alkalosis DpH = 0.003 × DPaCO2 Expected pH = 7.40 + [0.003 × (40 – PaCO2)] DpH = 0.003 × DPaCO2 Expected pH = 7.40 – [0.003 × (PaCO2 – 40)] DpH = 0.008 × DPaCO2 Expected pH = 7.40 + [0.008 × (40 – PaCO2)] DpH = 0.008 × DPaCO2 Expected pH = 7.40 - [0.008 × (PaCO2 – 40)]
  • 39. ABG analysis is the stethoscope of ICU and is an integral part of management of critical care patients, however, one should always remember that ‘Treat the patient, not the
  • 40. THANK YOU
  • 41. Q. A 66 years old woman had cardiac arrest in casualty. Basic and advanced life support was started in casualty. While patient was being ventilated blood sample was taken: Arterial blood gases shows: pH 6.86 PaO2 6o mm of Hg PaCO2 38.9 mm of Hg ABC 6.6 mmol/L BE - 23.9 mmol/L Ans :Metabolic Acidaemia
  • 42. Q. A 33 years old man with insulin dependent diabetes brought to emergency department not well for 3 days c/o frequency of urination, fever, nausea, sweating had not been eating hence not taking insulin: Arterial blood gases shows: pH 7.2 PaCO2 22 mm of Hg ABC 5.4 mmol/L SBC 7.5 mmol/L BE -26 mmol/L Ans :Metabolic Acidaemia with poor compensation
  • 43. Q. A 68 years old man c/o severe chest pain and shortness of breath. O/E cold and clammy R/R 8 per mt. brought in emergency Arterial blood gases shows: pH 6.99 PaCO2 109.5 mm of Hg ABC 15.5 mmol/L SBC 15.3 mmol/L BE -12.4 mmol/L Ans :Combined respiratory and metabolic Acidaemia
  • 44. Q. A 40 years old woman who had taken overdose of Dothiepin (a tricyclic antidepressant) 2 hrs previously. She was unconscious with a shallow breathing RR 8 / mt. Arterial blood gases shows: pH 6.76 PaCO2 46.5 mm of Hg ABC 6.5 mmol/L SBC 6.2 mmol/L BE -29 mmol/L Ans :Mixed Respiratory and Metabolic Acidaemia
  • 45. Q. A patient admitted in surgical ward was on gastric aspiration through Ryle’s tube because of persistent vomitings: Arterial blood gases shows: pH 7.5 PaCO2 50 mm of Hg ABC 35 mmol/L SBC 32 mmol/L BE +8 mmol/L Ans : Metabolic Alkalaemia
  • 46. Q. A 26 years old man having vomiting and diarrhoea from 4 days came in emergency: Arterial blood gases shows: pH 7.48 PaCO2 43 mm of Hg ABC 31 mmol/L SBC 30 mmol/L BE +4.5 mmol/L Ans :Metabolic Alkalaemia
  • 47. Q. A 51 years old woman presented in emergency department c/o of shortness of breath. The symptoms were present from years. She had no other medical problems: Arterial blood gases shows: pH 7.48 PaCO2 17.9 mm of Hg ABC 12.5 mmol/L SBC 14.5 mmol/L BE -6.6 mmol/L Ans :Chronic Respiratory Alkalaemia
  • 48. Q. A 30 years old lady attempted to commit suicide by throwing herself into a canal having taken overdose of alcohol . Passing policeman saved her & brought her to casualty. O/E she was pale, cold and confused. Her tympanic temperature was 28.40C, R/R 18/mt, PR 108/mt, BP 136/90 chest – bilateral crepts and ronchi. Arterial blood gases on breathing room air shows: pH 7.23 PaCO2 41.5 mm of Hg ABC 16.7 mmol/L SBC 16.4 mmol/L BE -10.2 mmol/L PaO2 86.0 mm of Hg Ans :Combined metabolic and respiratory acidaemia
  • 49. Q. A patient having fever since 3 days, having some respiratory difficulty was admitted with PR=130/ minute and BP = 100/ 60 mm Hg pH 6.56 PaO2 60 mm of Hg PaCO2 80 mm of Hg ABC 25 mmol / L Ans: IS IT COMPATIBLE? TREAT THE PATIENT NOT THE ABG!

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