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04abginterpdrdeopujari 100330213945 Phpapp02
04abginterpdrdeopujari 100330213945 Phpapp02
04abginterpdrdeopujari 100330213945 Phpapp02
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Dr Satish Deopujari Pediatrician Hon. Prof. ( Pediatrics) JNMC Chairman National Intensive care chapter Indian academy of pediatrics deopujari@rediffmail.com Visit us at. http://rdsoxy.org
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The Goal :
pH 7.70 7.52
30 40 50
H+ = 80 - last two digits of pH
H ION
60
Bicarbonate:
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Standard Bicarbonate:
Plasma HCO3 after equilibration to a PaCO2 of 40 mm Hg
: Reflects non-respiratory acid base change : No quantification of the extent of the buffer base abnormality
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Base Excess:
( base to normalise HCO3 (to 24) with PaCO2 at 40 mm Hg
(Sigaard-Andersen)
: Reflects metabolic part of acid base ( : No info. over that derived from pH, pCO2 and HCO3 : Misinterpreted in chronic or mixed disorders
Oxygenation Indices:
O2 Content of blood:
Hb. x O2 Sat + Dissolved O2
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(Dont forget hemoglobin) Oxygen Saturation: reported as ABG report ( Derived from oxygen dis. curve not a measured value ) Alveolar / arterial gradient: ( Useful to classify respiratory failure )
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Rt. Shift
Oxygen delivered to tissues with normally placed curve Delivered oxygen with Rt. Shift curve
60
40
Normal
20
Alveolar-arterial Difference
Inspired O2 = 21 % piO2 = (760-45) x . 21 = 150 mmHg
O2 CO2
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O2 CO2
Expected PaO2 =
Normal situation
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The essentials
The Blood Gas Report: normals
pH PaCO2 PaO2 HCO3 7.40 + 0.05 40 + 5 80 - 100 24 + 4 mm Hg mm Hg mmol/L
HCO3
FIO2
The
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Step 1
Look at the pH Is the patient or acidemic alkalemic pH < 7.35 pH > 7.45
Step 2
Who is responsible for this change in pH ( culprit )?
CO2 will change pH in opposite direction Bicarb. will change pH in same direction
Acidemia: With HCO3 < 20 mmol/L = metabolic With PCO2 >45 mm hg = respiratory With HCO3 >28 mmol/L = metabolic With PCO2 <35 mm Hg = respiratory
Alkalemia:
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Step 3
If there is a primary respiratory disturbance, is it acute ?
10 mm Change PaCO2
Step 4
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If the disturbance is metabolic is the respiratory compensation appropriate? For metabolic acidosis: Expected PaCO2 = (1.5 x [HCO3]) + 8 ) + 2 or simply expected PaCO2 = last two digits of pH For metabolic alkalosis: Expected PaCO2 = 6 mm for 10 mEq. rise in Bicarb. Suspect if ............. actual PaCO2 is more than expected : additional respiratory acidosis actual PaCO2 is less than expected : additional respiratory alkalosis
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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 : Common pediatric causes 1. Lactic acidosis 2. Metabolic disorders 3. Renal failure M ethanol U remia D iabetic Ketoacidosis P araldehyde I nfection (lactic acid) E thylene Glycol S alicylate
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th step
Clinical correlation
Same direction
HCO3 Same direction pH
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META.
pH
RESP.
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Three clicks pH
HYPER VENTILATION
PaCO2 BICARB CHANGES pH in same direction Compensation Bicarbonate Primary lesion Primary lesion
Low Alkali
METABOLIC ACIDOSIS
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HYPO VENTILATION
High Alkali
Primary lesion
METABOLIC ALKALOSIS
BICARB
compensation PaCO 2
High CO2
Primary lesion
Respiratory acidosis
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RESP. ACIDOSIS
PCO2 +
ALKALOSIS META.
CO2+H20=H2CO3 = H + HCO3
pH
HCO3
HCO3
pH .08 pH .03
Three clicks Wait for red circle pH PaCO 2 CHANGES pH in opposite direction
BICARB
compensation PaCO 2
Low PaCO2
Respiratory alkalosis
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RESP. ALK.
ACID. META.
pH
CO2
+
SERUM HCO3
Bicarbonate
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PaCO2 of 10
pH
INTERPRETATION OF A.B.G.
FOUR STEP METHOD OF DEOSAT 1) LOOK FOR pH 2) WHO IS THE CULPRIT ? 3) IF RESPIRATORY ACUTE / CHRONIC ? 4) IF METABOLIC / COMP. / ANION GAP CLINICAL CORRELATION
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compensation
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METABLIC ACIDOSIS PaCO2 = Up to 10 ? METABOLIC ALKALOSIS PaCO2 = Maximum 6O RESPIRATORY ACIDOSIS BICARB = Maximum 40 RESPIRATORY ALKALOSIS BICARB = Up to 10
COMPENSION LIMITS
Case 1
Blood Gas Report 37.0 C 7.523 30.1 mm Hg 105.3 mm Hg Data 22 98.3 8 0.93 Data 21.0 mmol / L % mm Hg (
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Measured pH PaCO2 PaO2 Calculated HCO3 act O2 Sat PO2 (A - a) PO2 (a / A) Entered FiO2
16 year old female with sudden onset of dyspnea. No Cough or Chest Pain Vitals normal but RR 56, anxious.
Case 2
Blood
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pH <7.35 :acidemia
Measured pH PaCO2 PaO2 Calculated HCO3 act O2 Sat PO2 (A - a) PO2 (a / A) Entered FiO2
mmol / L % mm Hg (
80 PaCO2
pH
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PaCO2 70 60 50 40 30 20
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Blood
Gas
Report
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pH <7.35 ; acidemia
Case 3
Measured pH PaCO2 PaO2 Calculated HCO3 act O2 Sat PO2 (A - a) PO2 (a / A) Entered FiO2
PaCO28-year-old male asthmatic; >45; respiratory acidemia 37.0 C 7. 24 3 days ( CO2 = 49 - 40 = 9of cough, dyspnea 49.1 mm Hg Expectedand orthopnea not = 0.072 ( pH ( Acute ) = 9/10 x 0.08 66.3 mm Hg
Data 18.0 92 mmol / L
% WITH INCREASE IN CO2 BICARB MUST RISE ? O/E: Respiratory distress; 30 mm = ( Bicarbonate 153-66= 87 5 Hg 150 is low
Data 30
Case 4 8 year old diabetic with respi. distress fatigue and loss of appetite.
Three clicks Blood Gas Report
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pH <7.35 ; acidemia
Measured pH PaCO2 PaO2 Calculated HCO3 act O2 Sat PO2 (A - a) PO2 (a / A) Entered FiO2
37.0 C Last two digits of pH 7.23 Correspond with co2 23 mm Hg 110.5 mm Hg Data 14 mmol / L
Measured pH PaCO2 PaO2 Calculated HCO3 act O2 Sat PO2 (A - a) PO2 (a / A) Entered FiO2
pH almost within normal range Mild alkalosis PaCO2 is low , respiratory low by around 10 ( Acute ) by .08 (Chronic ) by .03 Bicarb looks low ? Is it expected ?
BICARBINATURIA
Case 6.
pH 7.39 PCO2 l5mmHg HCO3 8mmol/L PaO2 90 mmHg One click
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 PaCO2 = (1.5 x [HCO3]) + 8 ) + 2 (Winters equation) PCO 2 SHOULD BE 20
Case 7.
Adolescent boy with appendicitis , posted for surgery , he is a known case of SLE. His pre-op ABG shows No click : Room air pH 7.39 pCO2 l5mmHg paO2 90 mmHg HCO3 8mmol/L 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. What is the probable cause for the above findings ? Are they OK as far as oxygenation is concerned ?
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Patient was hypo volumic , received Normal Saline bolus... Corrected acidosis He was operated .but post-op became drowsy His ABG.. FiO2.30%
Why hypoxemia ? Lungs were bad to begin with ? Micro atelectesis during surgery Pure and simple hypoventilation ? sedation
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PRE OP .ABG on room air pH 7.39 PaCO2 l5mmHg PaO2 90 mmHg Oxygenation status good ..? HCO3 8mmol/L
Pre OP .....A/a gradient palvO2 = PiO2 PaCO2 / RQ = 150 15 / 0.8 = 150 18 = 132 mm Hg 132 90= 42 WIDE A / a gradient
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Apparently the lungs looked good with PaO2 of 90. But have a good look at the ABG again With wash out of CO 2 . The expected PaO2 should have been more than 90 . This coupled with correction of acidosis ( normalizing PaCO2 ) Lowered the PaO2 post operatively. Conclusion .. Lungs were not normal to begin with ( SLE )..
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Learning point
Correlate PaO2 with FiO2 But please also correlate with PaCO2
Case 8,,,,,,,,,,,,,,,,,,
THANKS