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Abg 2014
1. APPROACH TO ARTERIALAPPROACH TO ARTERIAL
BLOOD GAS ANALYSISBLOOD GAS ANALYSIS
Gp Capt S Shankar
Clinical Immunologist
Command Hospital (Air Force)
2. A tale of two investigationsA tale of two investigations
ECG ABG
Step by step approach YES NO
Pattern recognition YES NO
Theory YES YES
Your eyes cannot see what your mind does not
know
5. Baseline assessmentBaseline assessment
35 yrs, woman, fever,
confusional state, community
acquired pneumonia,
TLC-24000
Na-138
K-3.4
Cl-107
Urea-15mg/dl, Cr-0.8 mg/dl
ABG
– pH- 7.08
– p CO2 –20 mmHg
– HCO3- 5 mEq/l
– PaO2- 90 mmHg
What is your diagnosis?
a) Anion gap metabolic acidosis
only
b) Non–anion gap metabolic
acidosis and respiratory
alkalosis
c) Metabolic alkalosis and
respiratory acidosis
d) Anion gap metabolic acidosis,
non–anion gap metabolic
acidosis, and respiratory
alkalosis
e) Anion gap metabolic acidosis,
non–anion gap metabolic
acidosis, and respiratory
acidosis
f) I’m in a confusional state now
7. Four basic valuesFour basic values
pH = arterial blood pH
PaCO2 (or PCO2)= arterial pressure of
CO2, in mm Hg
PaO2 (or PO2)= arterial pressure of O2, in
mm Hg
HCO3-
= serum bicarbonate concentration,
in mEq/liter
8. Hypoxia and HypoxemiaHypoxia and Hypoxemia
Hypoxia
– reduced oxygen pressure (partial pressure of
oxygen) in the alveolus
Hypoxemia
– reduced oxygen content in arterial blood
9. HypoxemiaHypoxemia
hypoxemic for two basic reasons
– oxygen may not be delivered to the alveolar air
sacs (hypoventilation)
– oxygen in the alveoli may not enter into the
blood stream. (V/Q mismatch)
Hypercarbic
– inability to normally exchange gas in the lungs.
10. acidosisacidosis andand alkalosisalkalosis
Processes that alter the acid-base status
Metabolic processes alter the pH
– by altering the bicarbonate concentration in the blood
metabolic acidosis = reduced serum bicarbonate
metabolic alkalosis = increased serum bicarbonate
Respiratory processes alter the pH
– by changing the carbon dioxide levels
respiratory acidosis= hypoventilation,CO2 retention
respiratory alkalosis= hyperventilation, CO2 loss
14. If hypoxia-If hypoxia-
checkcheck (A-a gradient)(A-a gradient)
alveolar arterial oxygen gradient
can determine if hypoxia is due to
– Hypoventilation OR
– Deficiency in oxygenation
15. (A-a gradient)(A-a gradient)
partial pressure of oxygen in the alveolus
(Alveolar gas equation)
– PAO2= FiO2 x (PB- PH2O) – PaCO2/R
– PAO2= 0.21 x (760-47) – PaCO2/0.8
– PAO2= 150-1.25( PACO2)
– PACO2 = PaCO2 (CO2 freely diffuses)
A-a gradient = PAO2 - PaO2
– = [ 150-1.25 (PaCO2) ] - PaO2
– Normal A-a gradient is 10-20 mm Hg
19. Metabolic or Respiratory?Metabolic or Respiratory?
pH <7.35 >7.45
HCO3 change Metabolic
acidosis
Metabolic
alkalosis
pCO2 change Respiratory
acidosis
Respiratory
alkalosis
pCO2 and HCO3 move in the same direction
What is the primary disorder?
21. Is the respiratory disturbanceIs the respiratory disturbance
Acute or Chronic?Acute or Chronic?
acute respiratory disturbances
– PaCO2 variation by 10 mm Hg
– accompanied by a pH shift of 0.08 units
– Both directions
chronic respiratory disturbances
– PaCO2 variation by 10 mm Hg
– accompanied by a pH shift of 0.03 units
renal mediated shifts of bicarbonate that alter
and partially compensate for the pH
23. For metabolic acidosis-For metabolic acidosis-
what is the anion gap?what is the anion gap?
AG = [Na+] - ([Cl-
] + [HCO3-
])
normal anion gap is 12
Unmeasured Anions Unmeasured Cations
Proteins, mostly albumin 15 mEq/L Calcium 5 mEq/L
Organic acids 5 mEq/L Potassium 4.5 mEq/L
Phosphates 2 mEq/L Magnesium 1.5 mEq/L
Sulfates 1 mEq/L
Totals: 23 mEq/L 11 mEq/L
Anion Gap = GAP between unmeasured anions and cations.
24. Metabolic acidosisMetabolic acidosis
High anion gap (AG >12)
– Methanol other alcohols, and ethylene glycol intoxication
– Uremia (renal failure)
– Lactic acidosis
– Ethanol
– Paraldehyde and other drugs
– Aspirin
– Ketones (starvation, alcoholic and diabetic ketoacidosis)
Normal anion gap (AG <12)
– Renal tubular acidosis
– GI fistula
25. Are there other metabolic processesAre there other metabolic processes
present with anion gap acidosispresent with anion gap acidosis??
only necessary if there is an AG metabolic acidosis.
Does the increase in AG completely explain the AB disorder?
PRINCIPLE
– bicarbonate is decreased due to the presence of unmeasured
anions
– For one molecule of anion, one molecule bicarbonate lost.
– Bicarbonate level can be therefore be predicted
– If level is less than predicted- additional non anionic gap
metabolic acidosis exists
– If level more than predicted- additional met alkalosis exists
Tricky concept
26. A. How much should HCO3 fall?A. How much should HCO3 fall?
If pH=7.08, Na=143, Cl= 98 and HCO3=10
AG= 143 - (98+10)= 35, (Normal AG=12)
Excess AG=23
Hence HCO3 should have fallen by 23
(from 25 to 2)
But it is 10
8 more than predicted
27. A. How much should HCO3 fall?A. How much should HCO3 fall?
If pH=7.08, Na=143, Cl= 98 and HCO3=10
AG= 143 - (98+10)= 35, (Normal AG=12)
Excess AG=23
Hence HCO3 should have fallen by 23 (from 25 to 2)
But it is 10 (8 more than predicted)
2 10 25
8
acidosis
alkalosis
23
coexistant metabolic alkalosis
28. B. How much should HCO3 fall?B. How much should HCO3 fall?
If pH=7.08, Na=136, Cl= 110 and HCO3=5
AG= 136- (110+5)= 21
Normal AG=12, Excess AG=9
Hence HCO3 should have fallen by 9
from 25 to 16
But it is 5
11 less than predicted
29. B. How much should HCO3 fall?B. How much should HCO3 fall?
If pH=7.08, Na=136, Cl= 110 and HCO3=5
AG= 136- (110+5)= 21
Normal AG=12, Excess AG=9
Hence HCO3 should have fallen by 9 from 25 to 16
But it is 5 (11 less than predicted)
acidosis alkalosis25165
11 9
coexistant non anion gap metabolic acidosis
31. Is the respiratory system compensatingIs the respiratory system compensating
adequately for a metabolic disturbance?adequately for a metabolic disturbance?
Mainly necessary if disturbance is primarily
metabolic.
Metabolic acidosis
– Expected PaCO2 = [1.5 x serum HCO3-] + 8 + 2.
(Winter’s formula)
– E.g If HCO3 = 10
– Paco2= 21-25
– If <21- then coexisatnt resp alkalosis
– If >25, coexistant resp acidosis
32. Other equationsOther equations
Metabolic acidosis
– Expected PaCO2 = 1-1.5 X (Δ HCO3)
Metabolic alkalosis
– Expected PaCO2 = 0.5-1 X (Δ HCO3)
For Primary respiratory disorders
– Metabolic compensation is not very predictable
33. For 10 mm Hg change in PCO2:For 10 mm Hg change in PCO2:
Change in HCO3 is given byChange in HCO3 is given by
RESPIRATORY
ACIDOSIS
RESPIRATORY
ALKALOSIS
ACUTE 1 2
CHRONIC 3 4
35. 25 year old male
IDDM for 12 years on insulin
Presents with pain abdo, vomiting , fever
Confusional state
Na+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/L
pH 7.20 ,PaCO2 25 mm Hg, PO2 58 mm Hg
36. Na+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/LNa+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/L
pH 7.20 ,PaCO2 25 mm Hg, PO2 68 mm HgpH 7.20 ,PaCO2 25 mm Hg, PO2 68 mm Hg
1. Assess oxygenation
PaO2 = 58 mm Hg
He has hypoxia
(A-a) gradient= [ 150 - 1.25 (PaCO2) ] - PaO2
= [150 - 1.25 (25)] - 58 = 61
there is a primary lung problem
Possibly aspiration pneumonia
37. Na+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/LNa+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/L
pH 7.20 ,PaCO2 25 mm Hg, PO2 58 mm HgpH 7.20 ,PaCO2 25 mm Hg, PO2 58 mm Hg
2. Acidemic or Alkalemic?
The pH is 7.20
which is less than normal (7.35-7.45)
acidosis
38. Na+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/LNa+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/L
pH 7.20 ,PaCO2 25 mm Hg, PO2 58 mm HgpH 7.20 ,PaCO2 25 mm Hg, PO2 58 mm Hg
3. Respiratory or Metabolic Disturbance?
HCO3 is low
So is pCO2
Metabolic acidosis
We skip step 4 as it is NOT a respiratory disorder
39. Na+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/LNa+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/L
pH 7.20 ,PaCO2 25 mm Hg, PO2 68 mm HgpH 7.20 ,PaCO2 25 mm Hg, PO2 68 mm Hg
5. Is there an increased anion gap?
AG= 130 –( 80+10)= 40
Yes it is
increased anion gap metabolic acidosis
40. Na+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/LNa+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/L
pH 7.20 ,PaCO2 25 mm Hg, PO2 58 mm HgpH 7.20 ,PaCO2 25 mm Hg, PO2 58 mm Hg
6. Are there other metabolic disturbances
present in this patient?
AG= 40
Excess anions= 40-12= 28
Hence, HCO3 should be 25-28 = (-3)
But HCO3 is 10, or 13 more than predicted
acidosis alkalosis
13
25
coexisting metabolic alkalosis present
41. Na+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/LNa+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/L
pH 7.20 ,PaCO2 25 mm Hg, PO2 68 mm HgpH 7.20 ,PaCO2 25 mm Hg, PO2 68 mm Hg
7. Is the respiratory system compensating for
a metabolic acidosis?
Expected PaCO2 = 1.5 (HCO3-) + 8 + 2
= 1.5 (10) + 8 + 2
= 23 + 2 = 21-25
Respiratory compensation
adequate
42. Na+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/LNa+ 130 mEq/L, Cl- 80 mEq, HCO3-10mEq/L
pH 7.20 ,PaCO2 25 mm Hg, PO2 58 mm HgpH 7.20 ,PaCO2 25 mm Hg, PO2 58 mm Hg
FINAL DIAGNOSIS
1. Hypoxemic from a primary lung process
2. Increased anion gap metabolic acidosis
3. Coexisting metabolic alkalosis
4. Adequate respiratory compensation
43. 24 year old student in Africa
Handles a poisoned arrow tip accidentally
(Curare)
Brought to ICU- weak and cyanosed
Na+ 138 mEq/L, Cl- 100 mEq, HCO3-26mEq/L
pH 7.08 ,PaCO2 80 mm Hg, PO2 37 mm Hg
44. Na+ 138 mEq/L, Cl- 100 mEq, HCO3-26mEq/LNa+ 138 mEq/L, Cl- 100 mEq, HCO3-26mEq/L
pH 7.08 ,PaCO2 80 mm Hg, PO2 37 mm HgpH 7.08 ,PaCO2 80 mm Hg, PO2 37 mm Hg
1. Assess oxygenation
Is the patient hypoxic?
YES
What is his (A-a) gradient?
A-a gradient = [ 150 - 1.25 (PaCO2) ] - PaO2
[150 - 1.25 (80)] - 37 = 10.
Hypoxia solely due to hypoventilation
45. Na+ 138 mEq/L, Cl- 100 mEq, HCO3-26mEq/LNa+ 138 mEq/L, Cl- 100 mEq, HCO3-26mEq/L
pH 7.08 ,PaCO2 80 mm Hg, PO2 37 mm HgpH 7.08 ,PaCO2 80 mm Hg, PO2 37 mm Hg
2. Is the patient acidemic or alkalemic?
Acidemic
46. Na+ 138 mEq/L, Cl- 100 mEq, HCO3-26mEq/LNa+ 138 mEq/L, Cl- 100 mEq, HCO3-26mEq/L
pH 7.08 ,PaCO2 80 mm Hg, PO2 37 mm HgpH 7.08 ,PaCO2 80 mm Hg, PO2 37 mm Hg
3. Is the acidemia from respiratory or
metabolic causes?
PaCO2= 80 mmHg
HCO3- raised
Respiratory acidosis
In this case we will go to step 4
47. Na+ 138 mEq/L, Cl- 100 mEq, HCO3-26mEq/LNa+ 138 mEq/L, Cl- 100 mEq, HCO3-26mEq/L
pH 7.08 ,PaCO2 80 mm Hg, PO2 37 mm HgpH 7.08 ,PaCO2 80 mm Hg, PO2 37 mm Hg
4. Is the respiratory acidosis acute or
chronic?
PaCO2 rise= 40 mmHg
Expected fall of pH
-in acute= 0.08x40=0.32 (from 7.4 to 7.08)
-in chronic= 0.03x40= 0.12 (from 7.4 to 7.28)
Acute respiratory acidosis
49. 71 year old male, 120 pack-year X 40 years
admitted with a history of increasing dyspnea, cough, and
sputum production
minimal air entry, accessory muscles prominent, has acral
cyanosis.
Na+ 135, Cl- 93, HCO3- 30
pH7.21 / P CO2 75 / pO2 41
50. Na+ 135, Cl- 93, HCO3- 30Na+ 135, Cl- 93, HCO3- 30
pH 7.21 / P CO2 75 / pO2 41pH 7.21 / P CO2 75 / pO2 41
1. Assess oxygenation
Hypoxemia present
A-a gradient = [ 150 - 1.25 (PaCO2) ] - PaO2
[150 - 1.25 (75)] - 41 = 15
Hypoxemia is due to
hypoventilation
51. Na+ 135, Cl- 93, HCO3- 30Na+ 135, Cl- 93, HCO3- 30
pH 7.21 / P CO2 75 / pO2 41pH 7.21 / P CO2 75 / pO2 41
2. Acidosis or alkalosis?
Acidosis
3. Metabolic or respiratory?
Respiratory
52. Na+ 135, Cl- 93, HCO3- 30Na+ 135, Cl- 93, HCO3- 30
pH 7.21 / P CO2 75 / pO2 41pH 7.21 / P CO2 75 / pO2 41
4. Acute or chronic RA?
PaCO2 rise= 35 mmHg
Expected fall of pH
-in acute= 0.08x35=0.28 (from 7.4 to 7.12)
-in chronic= 0.03x35= 0.10 (from 7.4 to 7.30)
Here pH is between 7.12 to 7.3
Acute on Chronic Respiratory acidosis
54. Same patient – ICU managementSame patient – ICU management
Patient is intubated and mechanically ventilated
During the intubation he vomits and aspirates
He is ventilated with
– FiO2 of 50%
– tidal volume 850cc
– PEEP of 5, rate of 10
One hour later his ABG
– pH 7.48 / paCO2 -37 / pO2 -215.
IS HE HYPOXIC?
55. Important pointImportant point
What is his (A-a) gradient?
A-a gradient = 150 - 1.25 (pCO2) - PaO2
assumes the patient is breathing room air, or 21% O2 "simplified"
equation is not valid for this patient who is breathing 50% oxygen
Correct alveolar gas equation=
PAO2 = (FiO2)(713) - 1.25 (PCO2)
A-a gradient = PAO2 - PaO2.
A-a gradient in this case
(.5)(713) - 1.25 (37) - 215 = 95 mm Hg
? Aspiration pneumonia
56. Baseline caseBaseline case
35, woman, community acquired pneumonia,
brought with confusion.
TLC-24000
Na-138, K-3.4, Cl-107
Urea-15mg/dl, Cr-0.8 mg/dl
ABG
– pH- 7.08
– p CO2 -20mmHg
– HCO3- 5 mEq/l
58. Na-138,Cl-107, HCO3- 5Na-138,Cl-107, HCO3- 5
pH- 7.08, p CO2 -20, paO2- 90pH- 7.08, p CO2 -20, paO2- 90
2. Is the patient acidemic or alkalemic?
Acidemic
59. Na-138,Cl-107, HCO3- 5Na-138,Cl-107, HCO3- 5
pH- 7.08, p CO2 -20, paO2- 90pH- 7.08, p CO2 -20, paO2- 90
3. Metabolic or respiratory?
HCO3 low, pCO2 Low
Metabolic
60. Na-138,Cl-107, HCO3- 5Na-138,Cl-107, HCO3- 5
pH- 7.08, p CO2 -20, paO2- 90pH- 7.08, p CO2 -20, paO2- 90
5. Is there an increased anion gap?
AG= 138 –( 107+5)= 26
Yes it is
Increased anion gap metabolic acidosis
61. Na-138,Cl-107, HCO3- 5Na-138,Cl-107, HCO3- 5
pH- 7.08, p CO2 -20, paO2- 90pH- 7.08, p CO2 -20, paO2- 90
6. Are there other metabolic disturbances
present in this patient?
AG= 26
Excess anions= 26-12= 14
Hence, HCO3 should be 25-14 = 11
But HCO3 is 5, or 6 less than predicted
62. Na-138,Cl-107, HCO3- 5Na-138,Cl-107, HCO3- 5
pH- 7.08, p CO2 -20, paO2- 86pH- 7.08, p CO2 -20, paO2- 86
6. Are there other metabolic disturbances
present in this patient?
AG= 26
Excess anions= 26-12= 14
Hence, HCO3 should be 25-14 = 11
But HCO3 is 5, or 6 less than predicted
25
115
6 14
acidosis
alkalosis
coexisting non anionic gap metabolic acidosis present
63. Na-138,Cl-107, HCO3- 5Na-138,Cl-107, HCO3- 5
pH- 7.08, p CO2 -20, paO2- 86pH- 7.08, p CO2 -20, paO2- 86
7. Is the respiratory system compensating for a
metabolic acidosis?
Expected PaCO2 = 1.5 (HCO3-) + 8 + 2
= 1.5 (5) + 8 + 2
= 15 + 2 = 13-17
Here PaCO2 is 20
Additional respiratory acidosis
64. Na-138,Cl-107, HCO3- 5Na-138,Cl-107, HCO3- 5
pH- 7.08, p CO2 -20, paO2- 86pH- 7.08, p CO2 -20, paO2- 86
FINAL DIAGNOSIS
Anion gap metabolic acidosis
non–anion gap metabolic acidosis
and respiratory acidosis
65. Baseline assessmentBaseline assessment
35, woman, community
acquired pneumonia,
TLC-24000
Na-138
K-3.4
Cl-107
Urea-15mg/dl, Cr-0.8 mg/dl
ABG
– pH- 7.08
– p CO2 -18mmHg
– HCO3- 5 mEq/l
What is your diagnosis?
a) Anion gap metabolic acidosis
only
b) Non–anion gap metabolic
acidosis and respiratory
alkalosis
c) Metabolic alkalosis and
respiratory acidosis
d) Anion gap metabolic acidosis,
non–anion gap metabolic
acidosis, and respiratory
alkalosis
e) Anion gap metabolic acidosis,
non–anion gap metabolic
acidosis, and respiratory
acidosis