Hand Out 2 ABG Interpretation ABG Interpretation First, does the patient have an acidosis or an alkalosis Second, what

hat is the primary problem metabolic or respiratory Third, is there any compensation by the patient respiratory compensation is immediate while renal compensation takes time Compensation The bodys attempt to return the acid/base status to normal (i.e. pH closer to 7.4) Primary Problem respiratory acidosis respiratory alkalosis metabolic acidosis metabolic alkalosis Compensation -metabolic alkalosis -metabolic acidosis -respiratory alkalosis -respiratory acidosis

ABG Interpretation It would be extremely unusual for either the respiratory or renal system to overcompensate The pH determines the primary problem After determining the primary and compensatory acid/base balance, evaluate the effectiveness of oxygenation Normal Values pH 7.35 to 7.45 paCO2 36 to 44 mm Hg HCO3 22 to 26 meq/L Abnormal Values pH < 7.35 Acidosis (metabolic and/or respiratory) pH > 7.45 Alkalosis (metabolic and/or respiratory) paCO2 > 44 mm Hg Respiratory acidosis (alveolar hypoventilation) paCO2 < 36 mm Hg Respiratory alkalosis (alveolar hyperventilation) HCO3 < 22 meq/L Metabolic acidosis HCO3 > 26 meq/L Metabolic alkalosis

Respiratory Alkalosis Causes Pain Anxiety Hypoxemia Restrictive lung disease Severe congestive heart failure Pulmonary emboli Drugs Sepsis Fever Thyrotoxicosis Pregnancy Overaggressive mechanical ventilation Hepatic failure Metabolic Acidosis Elevated Anion Gap Causes Ketoacidosis - diabetic, alcoholic, starvation Lactic acidosis - hypoxia, shock, sepsis, seizures Toxic ingestion salicylates, methanol, ethylene glycol, ethanol, isopropyl alcohol, paraldehyde, toluene Renal failure - uremia Metabolic Acidosis Normal Anion Gap Causes Renal tubular acidosis Post respiratory alkalosis Hypoaldosteronism Potassium sparing diuretics Pancreatic loss of bicarbonate Diarrhea Carbonic anhydrase inhibitors Acid administration (HCl, NH4Cl, arginine HCl) Sulfamylon Cholestyramine Ureteral diversions

Putting It Together Respiratory paCO2 > 44 with a pH < 7.35 represents a respiratory acidosis paCO2 < 36 with a pH > 7.45 represents a respiratory alkalosis For a primary respiratory problem, pH and paCO2 move in the opposite direction For each deviation in paCO2 of 10 mm Hg in either direction, 0. 08 pH units change in the opposite direction Metabolic HCO3 < 22 with a pH < 7.35 represents a metabolic acidosis HCO3 > 26 with a pH > 7.45 represents a metabolic alkalosis For a primary metabolic problem, pH and HCO3 are in the same direction, and paCO2 is also in the same direction

Summary First, does the patient have an acidosis or an alkalosis Look at the pH Second, what is the primary problem metabolic or respiratory Look at the pCO2 If the pCO2 change is in the opposite direction of the pH change, the primary problem is respiratory Assessing Oxygenation Normal value for arterial blood gas 80100mmHg Normal value for venous blood gas 40mmHg Normal SaO2 o Arterial: 97% o Venous: 75%

Case 2 Little Joy Z. has had vomiting and diarrhea for 3 days. In her moms words, She cant keep anything down and shes runnin out. She has had 1 wet diaper in the last 24 hours. She appears lethargic and cool to touch with a prolonged capillary refill time. After addressing her ABCs, her blood gas reveals: pH=7.34, pCO2=26, HCO3=12 Case 2 What is the acid/base abnormality? Compensated metabolic acidosis Case 3 You are evaluating a 15 year old female in the ER who was brought in by EMS from school because of abdominal pain and vomiting. Review of system is negative except for a 10 lb. weight loss over the past 2 months and polyuria for the past 2 weeks. She has no other medical problems and denies any sexual activity or drug use. On exam, she is alert and oriented, afebrile, HR 115, RR 26 and regular, BP 114/75, pulse ox 95% on RA.

Third, is there any compensation by the patient - do the calculations For a primary respiratory problem, is the pH change completely accounted for by the change in pCO2 if yes, then there is no metabolic compensation if not, then there is either partial compensation or concomitant metabolic problem

Case 3 What is the blood gas interpretation? Metabolic acidosis with respiratory compensation

For a metabolic problem, calculate the expected pCO2 if equal to calculated, then there is appropriate respiratory compensation if higher than calculated, there is concomitant respiratory acidosis if lower than calculated, there is concomitant respiratory alkalosis Next, dont forget to look at the effectiveness of oxygenation, (and look at the patient) your patient may have a significantly increased work of breathing in order to maintain a normal blood gas . metabolic acidosis with a concomitant respiratory acidosis is concerning

EXCERCISES 12 year old diabetic presents with Kussmaul breathing pH : 7.05 pCO2: 12 mmHg pO2: 108 mmHg HCO3: 5 mEq/L Ans: Severe partly compensated metabolic acidosis without hypoxemia due to ketoacidosis

SAMPLE CASES Case 1 Little Aaron Z. got into some of dads barbiturates. He suffers a significant depression of mental status and respiration. You see him in the ER 3 hours after ingestion with a respiratory rate of 4. A blood gas is obtained (after doing the ABCs, of course). It shows pH = 7.16, pCO2 = 70, HCO3 = 22 Case 1 What is the acid/base abnormality? Uncompensated respiratory acidosis Case 1 Uncompensated respiratory acidosis There has not been time for metabolic compensation to occur. As the barbiturate toxicity took hold, this child slowed his respirations significantly, pCO2 built up in the blood, and an acidosis ensued.

17 year old w/severe kyphoscoliosis, admitted for pneumonia pH: 7.37 pCO2: 25 mmHg pO2: 60 mmHg HCO3: 14 mEq/L Ans: Compensated respiratory alkalosis due to chronic hyperventilation secondary to hypoxia 9 year old w/hx of asthma, audibly wheezing x 1 week, has not slept in 2 nights; presents sitting up and using accessory muscles to breath w/audible wheezes pH: 7.51 pCO2: 25 mmHg pO2 35 mmHg HCO3: 22 mEq/L Ans: Uncompensated respiratory alkalosis with severe hypoxia due to asthma exacerbation

7 year old post op presenting with chills, fever and hypotension pH: 7.25 pCO2: 32 mmHg pO2: 55 mmHg HCO3: 10 mEq/L Ans: Uncompensated metabolic acidosis due to low perfusion state and hypoxia causing increased lactic acid References The ICU Book Paul L. Marino, 1991, Algorithms for acid-base interpretations, p415-426 Textbook of Pediatric Intensive Care 3rd Edition edited by Mark C. Rogers, 1996, Respiratory Monitoring: Interpretation of clinical blood gas values, p355-361 Pediatric Critical Care Bradley Fuhrman and Jerry Zimmerman, 1992, Acid-Base Balance and Disorders, p689-696 Critical Care Physiology Robert Bartlett, 1996, Acid-Base physiology p165-173.