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Arterial Blood Gas  Analysis …..1Dr DeopujariPediatrician   Nagpur
The Goal :To provide simple and bedside approach to ABGreport             In detailsNot to:To teach physiology .To teach t...
A Systematic and pointed………approach Use of pH for Hydrogen Ion Activity …….. The credit (or Blame) for introducing the ter...
H ION CONC.OH ION 14                                             pH          N.MOLS / L.          20                      ...
----- XXXX Diagnostics ------                                            The AnatomyBlood         Gas         Report248Pt ...
----- XXXX Diagnostics ------Blood         Gas     Report                                 Bicarbonate:                    ...
----- XXXX Diagnostics ------                                 Standard Bicarbonate:Blood         Gas     Report     Plasma...
Oxygenation ----- XXXX Diagnostics ------Blood         Gas     Report                                 Parameters:         ...
Rt. ShiftLt.Shift
Alveolar-arterial Difference                    Inspired O2 = 21 %                    piO2 = (760-45) x . 21   =       150...
Alveolar- arterial Difference Oxygenation Failure                                      Ventilation Failure piO2 = 150     ...
----- XXXX Diagnostics ------Blood         Gas     Report                                 Oxygenation:                    ...
----- XXXX Diagnostics ------Blood         Gas     Report     The essentials ----- XXXX Diagnostics ------Measured        ...
Low PaO2 can be the result ofA ) low PAO2 ( Low Alveolar Pressure )1) low barometric pressure,2) low fraction of inspired ...
Technical ErrorsGlass vs. plastic syringe:Changes in pO2 are not clinically importantNo effect on pH or pCO2Heparin (1000 ...
The5      Steps for      Successful       Blood Gas        Analysis
Step 1Look at the pHThe culpritIs the patient         acidemic    pH < 7.35or                     alkalemic   pH > 7.45Ste...
Step 3If there is a primary respiratory disturbance, is it acute?(Acute)change in pH = 0.08 for 10 mm change in PCO2(Chron...
Step 4If the disturbance is metabolic is the respiratorycompensation appropriate?                                       Th...
Step 4 cont.  If there is metabolic acidosis, is there a wide anion gap ?  Na - (Cl-+ HCO3-) = Anion Gap usually <12  If >...
th step5Clinical correlation
Same direction  HCO3                pH   META.Same direction  PCO2                pH   RESP. Opposite direction
24        CO2                            = H ION CONC.BICARBONATE                         N.MOLS / L.24        40 = 960   ...
pH       HYPER VENTILATION CO2                         BICARB CHANGES                         pH in same directioncompensa...
pH         HYPO VENTILATIONCO2                           BICARB CHANGES                           pH in same directioncomp...
pH                        CO 2 CHANGES                        pH in opposite direction BICARBcompensation   CO 2     Prima...
RESP. ACIDOSIS              ALKALOSIS META.  PCO2                         +         CO2+H20=H2CO3 = H + HCO3      pH HIGH ...
pH       CO 2 CHANGES                        pH in opposite direction BICARBcompensation   CO 2     Primary lesion      Pr...
RESP. ALK.                 ACID. META.                     + +   CO2 + H20 = H2CO3 = H   HCO3      pH  CO2        +       ...
Pco of 10    2           pHAcute change .08Chronic change .03
INTERPRETATION OF A.B.G.FOUR STEP METHOD OF DEOSAT1) LOOK FOR pH2) WHO IS THE CULPRIT ?3) IF RESPIRATORY ACUTE / CHRONIC ?...
compensation   considered               complete               when the               pH returns               to         ...
METABLIC ACIDOSISCOMPENSION LIMITS                    CO2 = Up to 10 ?                    METABOLIC ALKALOSIS             ...
----- XXXX Diagnostics ------         ----- XXXX Diagnostics ------Blood GasBlood Gas            Report                   ...
Case 2   6 year old male with progressive respiratory distress         Muscular dystrophy .                pH <7.35 :acide...
----- XXXX Diagnostics ------       ----- XXXX Diagnostics ------Blood Gas          Report                                ...
Case 4 8 year old diabetic with respi. distress fatigue and loss of appetite.               ----- XXXX Diagnostics ------ ...
Case 5 : 10 year old child with encephalitis         ----- XXXX Diagnostics ------          ----- XXXX Diagnostics ------ ...
ABG OF THE DAY The arterial blood gas report : Room air pH 7.39 PCO2 l5mniHg HCO3 8mmol/L PaO2 90 mmHg                    ...
pH 7.39 PCO2 l5mniHg HCO3 8mmol/L PaO2 90 mmHg1)    These findings are most consistent with….      a) Metabolic acidosis w...
pH 7.39PCO2 l5mniHgHCO3 8mmol/LPaO2 90 mmHg  2) What is the oxygenation status     a) Normal oxygenation status     b) Hyp...
pCO2   pH70     7.1060     7.2050     7.3040     7.4030     7.5020     7.60
 When pH is normal and:   Bicarbonate is high ( Metabolic alkalosis + respiratoryacidosis )   Bicarbonate is low ( Metabo...
THANKS
Arterial Blood Gas : Analysis 1 by Dr. Deopujari
Arterial Blood Gas : Analysis 1 by Dr. Deopujari
Arterial Blood Gas : Analysis 1 by Dr. Deopujari
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Arterial Blood Gas : Analysis 1 by Dr. Deopujari

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  1. 1. Arterial Blood Gas Analysis …..1Dr DeopujariPediatrician Nagpur
  2. 2. The Goal :To provide simple and bedside approach to ABGreport In detailsNot to:To teach physiology .To teach theories on acid-base regulationTo look for alternative approaches tointerpretation
  3. 3. A Systematic and pointed………approach Use of pH for Hydrogen Ion Activity …….. The credit (or Blame) for introducing the term pH, the negative log of hydrogen ion (H+) concentration, goes to S. P. L. Sørensen (1868-1939), who apparently was tired of writing seven zeros in a paper on enzyme activity and wanted a simpler designation…..?.
  4. 4. H ION CONC.OH ION 14 pH N.MOLS / L. 20 7.70 pH stand for "power of hydrogen" 30 7.52 40 H+ = 80 - last two digits of pH 7.40 50 7.30 60 7.22H ION 0
  5. 5. ----- XXXX Diagnostics ------ The AnatomyBlood Gas Report248Pt ID 05:36 2570 / 00 Jul 22 2000 of a Blood Gas ReportMeasured 37.0 C o Measured Values the mostpHpCO2 7.463 44.4 mm Hg importantpO2 113.2 mm Hg o Temperature Correction:Corrected 38.6 CpH 7.439 Is there any value to it?pCO2 47.6 mm HgpO2 123.5 mm HgCalculated Data Calculated Data:HCO3 act 31.1 mmol / L Which are the useful ones?HCO3 std 30.5 mmol / LBE 6.6 mmol / LO2 CT 14.7 mL / dlO2 Sat 98.3 %ct CO2pO2 (A - a) 32.4 32.2 mmol / L mm Hg Entered Data:pO2 (a / A) 0.79 As importantEntered DataTemp 38.6 o Cct Hb 10.5 g/dlFiO2 30.0 %
  6. 6. ----- XXXX Diagnostics ------Blood Gas Report Bicarbonate: oMeasured 37.0 CpH 7.463pCO2 44.4 mm HgpO2 113.2 mm Hg oCorrected 38.6 CCalculated DataHCO3 act 31.1 mmol / LHCO3 std 30.5 mmol / LBE 6.6 mmol / LO2 CT 14.7 mL / dl Henderson - Hasselbach equation:O2 Sat 98.3 %t CO2 32.4 mmol / L pH = pK + Log HCO3pO2 (A - a) 32.2 mm HgpO2 (a / A) 0.79 Dissolved CO2Entered DataTemp 38.6 o Cct Hb 10.5 g/dlFiO2 30.0 %
  7. 7. ----- XXXX Diagnostics ------ Standard Bicarbonate:Blood Gas Report Plasma HCO3 after equilibration to a PCO2 of 40 mm Hg oMeasured 37.0 CpH 7.463 : reflects non-respiratory acid base changepCO2 44.4 mm HgpO2 113.2 mm Hg : does not quantify the extent of the buffer base abnormality oCorrected 38.6 C : does not consider actual buffering capacity of bloodCalculated Data Base Excess: ∆ base to normalise HCO3 (to 24)HCO3 act 31.1 mmol / LHCO3 std 30.5 mmol / LBE 6.6 mmol / LO2 CT 14.7 mL / dl with PCO2 at 40 mm HgO2 Sat 98.3 % (Sigaard-Andersen)t CO2 32.4 mmol / L : reflects metabolic part of acid base ∆pO2 (A - a) 32.2 mm HgpO2 (a / A) 0.79 : no info. over that derived from pH, pCO2 and HCO3Entered DataTemp 38.6 o C : Misinterpreted in chronic or mixedct Hb 10.5 g/dlFiO2 30.0 % disorders
  8. 8. Oxygenation ----- XXXX Diagnostics ------Blood Gas Report Parameters: oMeasured 37.0 CpH 7.463 O2 Content of blood:pCO2 44.4 mm HgpO2 113.2 mm Hg Hb x O2 Sat + Dissolved O2 oCorrected 38.6 C Oxygen Saturation: ( remember this is calculated )Calculated DataHCO3 act 31.1 mmol / LHCO3 std 30.5 mmol / L Alveolar / arterial gradient:BE 6.6 mmol / LO2 CT 14.7 mL / dlO2 Sat 98.3 %t CO2 32.4 mmol / LpO2 (A - a) 32.2 mm HgpO2 (a / A) 0.79 Arterial / alveolar ratio:Entered DataTemp 38.6 o Cct Hb 10.5 g/dlFiO2 30.0 %
  9. 9. Rt. ShiftLt.Shift
  10. 10. Alveolar-arterial Difference Inspired O2 = 21 % piO2 = (760-45) x . 21 = 150 mmHg palvO2 = piO2 – pCO2 / RQ O2 = 150 – 40 / 0.8 CO2 = 150 – 50 = 100 mm Hg partO2 = 90 mmHgpalvO2 – partO2 = 10 mmHg
  11. 11. Alveolar- arterial Difference Oxygenation Failure Ventilation Failure piO2 = 150 piO2 = 150 pCO2 = 40 pCO2 = 80 palvO2= 150 – 40/.8 palvO2= 150-80/.8 =150-50 =150-100 =100 O2 = 50 CO2 pO2 = 45 pO2 = 45  = 100 - 45 = 55  = 50 - 45 = 5 PAO2 (partial pres. of O2. in the alveolus.)760 – 45 = 715 : 21 % of 715 = 150 = 150 - ( PaCO2 / .8 )
  12. 12. ----- XXXX Diagnostics ------Blood Gas Report Oxygenation: Limitations of parameters:Measured 37.0 C o O2 Content of blood:pH 7.463pCO2 44.4 mm Hg Useful in oxygen transport calculationspO2 113.2 mm Hg Derived from calculated saturation oCorrected 38.6 C Oxygen Saturation: Ideally measured by co-oximetryCalculatedHCO3 act 31.1 Data mmol / L 20 × 5 = 100 Calculated values may be error-prone Alveolar / arterial gradient:O2 CT 14.7 mL / dl Reflects O2 exchange with fixed FiO2O2 Sat 98.3 % Impracticalt CO2 32.4 mmol / LpO2 (A - a) 32.2 mm Hg Differentiates hypoventilation as causepO2 (a / A) 0.79 Arterial / alveolar ratio:Entered DataTemp 38.6 o C Proposed to be less variablect Hb 10.5 g/dl Same limitations as A-a gradientFiO2 30.0 %
  13. 13. ----- XXXX Diagnostics ------Blood Gas Report The essentials ----- XXXX Diagnostics ------Measured 37.0 C o The Blood Gas Report:BloodpH Gas 7.463 ReportpCO2 44.4 mm HgpO2 113.2 mm Hg oMeasured 37.0 CpH 7.463CorrectedpCO2 44.4 38.6 C mm Hg o pH 7.40 + 0.05pH2pOpCO2 7.439 113.2 47.6 mm Hg mm Hg PCO2 40 + 5 mm HgpO2 123.5Calculated mm Hg Data PO2 80 - 100 mm HgHCO3 act 31.1 mmol / LCalculated DataHCO3 actO2 Sat 31.1 98.3 mmol / L % HCO3 24 + 4 mmol/LHCO3 stdpO2 (A - a) 30.5 32.2 mmol / L mm HgBE 6.6 mmol / LO2 CT 14.7 mL / dl O2 Sat >95EnteredO2 Sat 98.3 Data %t CO2FiO2 32.4 30.0 mmol / L % Always mention and see FIO2pO2 (A - a) 32.2 mm HgpO2 (a / A) 0.79Entered DataTemp 38.6 o Cct Hb 10.5 g/dlFiO2 30.0 %
  14. 14. Low PaO2 can be the result ofA ) low PAO2 ( Low Alveolar Pressure )1) low barometric pressure,2) low fraction of inspired oxygen (FiO2)3) Hypercarbia – elevated (PaCO2).B ) Wide A / a gradient ( Normal Alveolar pressure )1) Shunt ( cardiac or non cardiac )2) Diffusion abnormality
  15. 15. Technical ErrorsGlass vs. plastic syringe:Changes in pO2 are not clinically importantNo effect on pH or pCO2Heparin (1000 u / ml):Need <0.1 ml / ml of bloodpH of heparin is 7.0; pCO2 trends downAvoided by heparin flushing & drawing 2-4 ccbloodDelay in measurement:Rate of changes in pH, pCO2 and pO2 can bereduced to 1/10 by cooling in ice slush(4o C)No major drifts up to 1 hour
  16. 16. The5 Steps for Successful Blood Gas Analysis
  17. 17. Step 1Look at the pHThe culpritIs the patient acidemic pH < 7.35or alkalemic pH > 7.45Step 2 CO responsible for this change ( culprit )?Who is 2 pHAcidemia: With HCO3 < 20 mmol/L = metabolic With PCO2 >45 mm hg = respiratoryAlkalemia: With HCO3 >28 mmol/L = metabolicBICARB pH With PCO2 <35 mm Hg = respiratory
  18. 18. Step 3If there is a primary respiratory disturbance, is it acute?(Acute)change in pH = 0.08 for 10 mm change in PCO2(Chronic)change in pH = 0.03 for 10 mm change in PCO2
  19. 19. Step 4If the disturbance is metabolic is the respiratorycompensation appropriate? The last twoFor metabolic acidosis: digitsExpected PCO2 = (1.5 x [HCO3]) + 8 ) + 2(Winter’s equation)( Last two digits of pH )For metabolic alkalosis:Expected PCO2 = 6 mm for 10 mEq. rise in Bicarb.If :actual PCO2 more than expected : additionalrespiratory acidosisactual PCO2 less than expected : additional respiratoryalkalosis
  20. 20. Step 4 cont. If there is metabolic acidosis, is there a wide anion gap ? Na - (Cl-+ HCO3-) = Anion Gap usually <12 If >12, Anion Gap Acidosis : Methanol UremiaCommon pediatric causes Diabetic Ketoacidosis1) Lactic acidosis Paraldehyde2) Metabolic disorders Infection (lactic acid)3) Renal failure Ethylene Glycol Salicylate
  21. 21. th step5Clinical correlation
  22. 22. Same direction HCO3 pH META.Same direction PCO2 pH RESP. Opposite direction
  23. 23. 24 CO2 = H ION CONC.BICARBONATE N.MOLS / L.24 40 = 960 = H ION CONC. N.MOLS / L.BICARBONATE 960 = H ION CONC. = 40 24 N.MOLS / L. H+ N.MOLS / L. = 80 - last two digits of pH
  24. 24. pH HYPER VENTILATION CO2 BICARB CHANGES pH in same directioncompensation HCO3 Primary lesion Primary lesion METABOLIC ACIDOSIS
  25. 25. pH HYPO VENTILATIONCO2 BICARB CHANGES pH in same directioncompensation HCO3 Primary lesion METABOLIC ALKALOSIS
  26. 26. pH CO 2 CHANGES pH in opposite direction BICARBcompensation CO 2 Primary lesion Respiratory acidosis
  27. 27. RESP. ACIDOSIS ALKALOSIS META. PCO2 + CO2+H20=H2CO3 = H + HCO3 pH HIGH + H HIGH HCO3 HCO3 HCO3 ACUTE RISE : PCO2 10 : pH .08 CHRONIC RISE : PCO2 10 : pH .03
  28. 28. pH CO 2 CHANGES pH in opposite direction BICARBcompensation CO 2 Primary lesion Primary lesion Respiratory alkalosis
  29. 29. RESP. ALK. ACID. META. + + CO2 + H20 = H2CO3 = H HCO3 pH CO2 + HCO3LOW H IONS…LOW HCO3 ACUTE FALL : PCO2 10 : pH .08 CHRONIC FALL: PCO2 10 : pH .03
  30. 30. Pco of 10 2 pHAcute change .08Chronic change .03
  31. 31. INTERPRETATION OF A.B.G.FOUR STEP METHOD OF DEOSAT1) LOOK FOR pH2) WHO IS THE CULPRIT ?3) IF RESPIRATORY ACUTE / CHRONIC ?4) IF METABOLIC / COMP. / ANION GAP CLINICAL CORRELATION
  32. 32. compensation considered complete when the pH returns to normal range Clinical blood gases by Malley
  33. 33. METABLIC ACIDOSISCOMPENSION LIMITS CO2 = Up to 10 ? METABOLIC ALKALOSIS CO2 = Maximum 6O RESPIRATORY ACIDOSIS BICARB = Maximum 40 RESPIRATORY ALKALOSIS BICARB = Up to 10
  34. 34. ----- XXXX Diagnostics ------ ----- XXXX Diagnostics ------Blood GasBlood Gas Report Report o Case 1Measured Measured 37.0 oC 37.0 CpH pH 7.523 7.523pCO2 pCO2 30.1 30.1 mm Hg mm Hg 16 year old female withpO2 pO 105.3 105.3 mm Hg mm Hg 2 sudden onset of dyspnea.CalculatedCalculated Data DataHCO3 actHCO act 22 22 mmol / /L mmol L 3 No Cough or Chest PainO2 Sat O2 Sat 98.3 98.3 % %pO2 (A --a) pO2 (A a) 88 mm Hg ∆ mm Hg ∆ Vitals normal but RR 56,pO2 (a / /A) pO2 (a A) 0.93 0.93 anxious.Entered Entered Data DataFiO2 FiO 21.0 21.0 % % 2
  35. 35. Case 2 6 year old male with progressive respiratory distress Muscular dystrophy . pH <7.35 :acidemia ----- XXXX Diagnostics ------ ----- XXXX Diagnostics ------ Blood Gas Blood Gas Report Report o respiratory acidemia : co2 and pH Measured Measured 37.0 oC 37.0 C pH pH 7.301 7.301  CO2 =76-40=36 pCO2 pCO2 76.2 76.2 mm Hg mm Hg Expected  pH ( Acute ) = .08 for 10 pO2 pO 45.5 45.5 mm Hg mm Hg Expected ( Acute ) pH = 7.40 - 0.29=7.11 2 Calculated Data Chronic resp. acidosis Calculated Data HCO3 act HCO act 35.1 35.1 mmol / /L mmol L 3 O2 Sat O2 Sat 78 78 % % pO2 (A --a) pO2 (A a) 9.5 9.5 mm Hg ∆ mm Hg ∆ pO2 (a / /A) pO (a A) 0.83 0.83 2 Entered Entered Data Data FiO2 FiO 21 21 % % 2 Hypoxia Normal A-a gradient Due to hypoventilation
  36. 36. ----- XXXX Diagnostics ------ ----- XXXX Diagnostics ------Blood Gas Report Case 3 pH <7.35 ; acidemiaBlood Gas Report o pCO2 >45; respiratory acidemia 8-year-old male asthmatic;Measured Measured 37.0 oC 37.0 CpH pH 7. 24 7. 24  CO2 = 49 -days9of cough, dyspnea 3 40 =pCO2 49.1 mm Hg pCO2 49.1 Expectedand orthopnea not = 0.072 mm Hg  pH ( Acute ) = 9/10 x 0.08pO2 pO2 66.3 66.3 mm Hg mm Hg Expectedresponding 7.40 - 0.072 = 7.328 pH ( Acute ) = to usualCalculated Data Acute resp. acidosisCalculatedHCO3 act Data 18.0 mmol / /L bronchodilators.HCO act 3 18.0 mmol LO2 Sat 92 % 153-66= 87 mm Hg×∆5 = O/E:IN CO2 BICARB MUST RISE ? WITH∆INCREASE Respiratory distress; O2 Sat 92 % 30 150pO2 (A --a) pO2 (A a) mm HgpO2 (a / /A) pO2 (a A) suprasternal and Metabolic acidosis + respiratory acidosisEntered Data intercostal retraction; Entered DataFiO2 FiO2 30 30 % % tired looking; on 4 L NC.Hypoxia piO2 = 715x.3=214.5 / palvO2 = 214-49/.8=153 Wide A / a gradient
  37. 37. Case 4 8 year old diabetic with respi. distress fatigue and loss of appetite. ----- XXXX Diagnostics ------ ----- XXXX Diagnostics ------ pH <7.35 ; acidemia Blood Gas Blood Gas Report Report Measured o 37.0 oC Last two digits of pH Measured 37.0 C pH pH 7.23 7.23 Correspond with co2 pCO2 pCO2 23 23 mm Hg mm Hg pO2 pO2 110.5 110.5 mm Hg mm Hg Calculated Calculated Data Data HCO3 act HCO act 14 14 mmol / /L mmol L 3 HCO3 <22; metabolic acidemia O2 Sat O2 Sat % % pO2 (A --a) pO2 (A a) mm Hg ∆ mm Hg ∆ pO2 (a / /A) pO2 (a A) If Na = 130, Entered Entered Data Data Cl = 90 FiO2 FiO2 21.0 21.0 % % Anion Gap = 130 - (90 + 14) = 130 – 104 = 26
  38. 38. Case 5 : 10 year old child with encephalitis ----- XXXX Diagnostics ------ ----- XXXX Diagnostics ------ Blood Gas Blood Gas Report Report Measured o 37.0 oC pH almost within normal range Measured 37.0 C pH 7.46 Mild alkalosis pH 7.46 pCO2 pCO2 28.1 28.1 mm Hg mm Hg pO2 pO2 55.3 55.3 mm Hg mm Hg Co2 is low , respiratory Co2 low by around 10 Calculated Calculated Data Data ( Acute ) by .08 HCO3 act HCO act 19.2 19.2 mmol / /L mmol L 3 (Chronic ) by .03 O2 Sat O2 Sat % % pO2 (A --a) pO2 (A a) mm Hg ∆ mm Hg ∆ Bicarb looks low ? pO2 (a / /A) pO2 (a A) Is it expected ? Entered Entered Data Data FiO2 FiO2 24.0 24.0 % % More cases
  39. 39. ABG OF THE DAY The arterial blood gas report : Room air pH 7.39 PCO2 l5mniHg HCO3 8mmol/L PaO2 90 mmHg PCO2 24H ION CONCENTRATION = BICARBONATE = 45 nmol/lit
  40. 40. pH 7.39 PCO2 l5mniHg HCO3 8mmol/L PaO2 90 mmHg1) These findings are most consistent with…. a) Metabolic acidosis with compensatory Hypocapnia. b) Primary metabolic acidosis with respiratory alkalosis. c) Acute respiratory alkalosis fully compensated. d) Chronic respiratory alkalosis fully compensated. For metabolic acidosis: FULL COMPENSATION Expected PCO2 = (1.5 x [HCO3]) + 8 ) + 2 (Winter’s equation) PCO 2 ……SHOULD BE 20
  41. 41. pH 7.39PCO2 l5mniHgHCO3 8mmol/LPaO2 90 mmHg 2) What is the oxygenation status a) Normal oxygenation status b) Hypoxemia c) None of the above palvO2 = piO2 – pCO2 / RQ = 150 – 15 / 0.8 = 150 – 18 = 132 mm Hg 132 – 90 = 42 WIDE A / a gradient
  42. 42. pCO2 pH70 7.1060 7.2050 7.3040 7.4030 7.5020 7.60
  43. 43.  When pH is normal and: Bicarbonate is high ( Metabolic alkalosis + respiratoryacidosis ) Bicarbonate is low ( Metabolic acidosis + resp. alkalosis) Bicarbonate is normal and: anion gap is high ( Metabolic Acidosis + Metabolic alkalosis) When bicarbonate is normal and: pH is in acidic range ( Chronic resp. acidosis + resp alk.) pH is in alkalemic range ( Metab.alk. + resp alk.) Anion gap is elevated and: clinical and laboratory data suggest a diagnosis other thanmetabolic acidosis PCO2 level and bicarbonates are shifted from normal inopposing directions.
  44. 44. THANKS
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