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Interpreting ABGs. Suneel Kumar MD. Arterial Blood Gases. Written in following manner: pH/PaCO 2 /PaO 2 /HCO 3 pH = arterial blood pH PaCO 2 = arterial pressure of CO 2 PaO 2 = arterial pressure of O 2 HCO 3 = serum bicarbonate concentration. Oxygenation.
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Interpreting ABGs Suneel Kumar MD
Arterial Blood Gases • Written in following manner: pH/PaCO2/PaO2/HCO3 • pH = arterial blood pH • PaCO2 = arterial pressure of CO2 • PaO2 = arterial pressure of O2 • HCO3 = serum bicarbonate concentration
Oxygenation • Hypoxia: reduced oxygen pressure in the alveolus (i.e. PAO2) • Hypoxemia: reduced oxygen pressure in arterial blood (i.e. PaO2)
Hypoxia with Low PaO2 • Alveolar diffusion impairment • Decreased alveolar PO2 • Decreased FiO2 • Hypoventilation • High altitude • R L shunt • V/Q mismatch
Hypoxia with Normal PaO2 • Alterations in hemoglobin • Anemic hypoxia • Carbon monoxide poisoning • Methemoglobinemia • Histotoxic hypoxia • Cyanide • Hypoperfusion hypoxia or stagnant hypoxia
Alveolar—Arterial Gradient • Indirect measurement of V/Q abnormalities • Normal A-a gradient is 10 mmHg • Rises with age • Rises by 5-7 mmHg for every 0.10 rise in FiO2, from loss of hypoxic vasoconstriction in the lungs
Alveolar—Arterial Gradient A-a gradient = PAO2 – PaO2 • PAO2 = alveolar PO2 (calculated) • PaO2 = arterial PO2 (measured)
Alveolar—Arterial Gradient PAO2 = PIO2 – (PaCO2/RQ) • PAO2 = alveolar PO2 • PIO2 = PO2 in inspired gas • PaCO2 = arterial PCO2 • RQ = respiratory quotient
Alveolar—Arterial Gradient PIO2 = FiO2 (PB – PH2O) • PB = barometric pressure (760 mmHg) • PH2O = partial pressure of water vapor (47 mmHg) RQ = VCO2/VO2 • RQ defines the exchange of O2 and CO2 across the alveolar-capillary interface (0.8)
Alveolar—Arterial Gradient PAO2 = FiO2 (PB – PH2O) – (PaCO2/RQ) Or PAO2 = FiO2 (713) – (PaCO2/0.8)
Alveolar—Arterial Gradient • For room air: PAO2 = 150 – (PaCO2/0.8) • And assume a normal PaCO2 (40): PAO2 = 100
Acid-Base • Acidosis or alkalosis: any disorder that causes an alteration in pH • Acidemia or alkalemia: alteration in blood pH; may be result of one or more disorders.
Six Simple Steps • Is there acidemia or alkalemia? • Is the primary disturbance respiratory or metabolic? • Is the respiratory problem acute or chronic? • For metabolic, what is the anion gap? • Are there any other processes in anion gap acidosis? • Is the respiratory compensation adequate?
Henderson-Hasselbach Equation pH = pK + log [HCO3/PaCO2] x K (K = dissociation constant of CO2) Or [H+] = 24 x PaCO2/HCO3
pH 7.20 7.30 7.40 7.50 7.60 [H+] 60 50 40 30 20 Henderson-Hasselbach Equation
Step 1:Acidemia or Alkalemia? • Normal arterial pH is 7.40 ± 0.02 • pH < 7.38 acidemia • pH > 7.42 alkalemia
Step 2:Primary Disturbance • Anything that alters HCO3 is a metabolic process • Anything that alters PaCO2 is a respiratory process
Step 2:Primary Disturbance • If 6pH, there is either 5PaCO2 or 6HCO3 • If 5pH, there is either 6PaCO2 or 5HCO3
Step 4:For Metabolic, Anion Gap? Anion gap = Na+ - (Cl- + HCO3-) • Normal is < 12
Increased Anion Gap • Ingestion of drugs or toxins • Ethanol • Methanol • Ethylene glycol • Paraldehyde • Toluene • Ammonium chloride • Salicylates
Increased Anion Gap • Ketoacidosis • DKA • Alcoholic • Starvation • Lactic acidosis • Renal failure
Step 4:For Metabolic, Anion Gap? • If + AG, calculate Osm gap: Calc Osm = (2 x Na+) + (glucose/18) + (BUN/2.8) + (EtOH/4.6) Osm gap = measured Osm – calc Osm Normal < 10 mOsm/kg
Nongap Metabolic Acidosis • Administration of acid or acid-producing substances • Hyperalimentation • Nonbicarbonate-containing IVF
Nongap Metabolic Acidosis • GI loss of HCO3 • Diarrhea • Pancreatic fistulas • Renal loss of HCO3 • Distal (type I) RTA • Distal (type IV) RTA • Proximal (type II) RTA
Nongap Metabolic Acidosis • Calculate urine anion gap: Urine AG = (Na+ + K+) – Cl- • Positive gap indicates renal impaired NH4+ excretion • Negative gap indicates normal NH4+ excretion and nonrenal cause
Nongap Metabolic Acidosis • Urine Cl- < 10 mEq/l is chloride responsive and accompanied by “contraction alkalosis” and is “saline responsive” • Urine Cl- > 20 mEq/l is chloride resistant, and treatment is aimed at underlying disorder
Step 5: Any other process with elevated AG? • Calculate rgap, or “gap-gap”: rGap = Measured AG – Normal AG (12)
Step 5: Any other process with elevated AG? • Add rgap to measured HCO3 • If normal (22-26), no other metabolic problems • If < 22, then concomitant metabolic acidosis • If > 26, then concomitant metabolic alkalosis
Step 6: Adequate respiratory compensation? Winter’s Formula Expected PaCO2 = (1.5 x HCO3) + 8 ± 2 • If measured PaCO2 is higher, then concomitant respiratory acidosis • If measured PaCO2 is lower, then concomitant respiratory alkalosis
Step 6: Adequate respiratory compensation? • In metabolic alkalosis, Winter’s formula does not predict the respiratory response • PaCO2 will rise > 40 mmHg, but not exceed 50-55 mmHg • For respiratory compensation, pH will remain > 7.42
Clues to a Mixed Disorder • Normal pH with abnormal PaCO2 or HCO3 • PaCO2 and HCO3 move in opposite directions • pH changes in opposite direction for a known primary disorder
Case 1 • A 24 year old student on the 6 year undergraduate plan is brought to the ER cyanotic and profoundly weak. His roommate has just returned from a semester in Africa. The patient had been observed admiring his roommate's authentic African blowgun and had scraped his finger on the tip of one of the poison darts (curare).
Case 1 138 100 26 7.08/80/37
Case 1 • What is the anion gap? AG = 138 – (100 + 26) AG = 12
Case 1 • Acute respiratory acidosis
Case 2 • A 42 year old diabetic female who has been on insulin since the age of 13 presents with a 4 day history of dysuria which has progressed to severe right flank pain. She has a temperature of 38.8ºC, a WBC of 14,000, and is disoriented.
Case 2 135 99 4.8 12 7.23/25/113
Case 2 • What is the A-a gradient? A-a = [150 – 25/0.8] – 113 = 6 • Acidemia or alkalemia? • Primary respiratory or metabolic? • What is the anion gap? AG = 135 – (99 + 12) = 24
Case 2 • What is the rgap? rGap = 24 – 12 = 12 rGap + HCO3 = 12 + 12 = 24 • No other metabolic abnormalities • Is the respiratory compensation appropriate? Expected PCO2 = (1.5 x 12) + 8 ± 2 = 24 ± 2 • It is appropriate
Case 2 • Acute anion gap metabolic acidosis (DKA)
Case 3 • A 71 year old male, retired machinist, is admitted to the ICU with a history of increasing dyspnea, cough, and sputum production. He has a 120 pack-year smoking history, and quit 5 years previously. On exam he is moving minimal air despite using his accessory muscles of respiration. He has acral cyanosis.
Case 3 135 93 30 7.21/75/41
Case 3 • What is the A-a gradient? A-a = [150 – 75/.8] – 41 = 15 • Acidemic or alkalemic? • Primary respiratory or metabolic? • Acute or chronic? • Acute 5PCO2 by 35 would 6pH by 0.28 • Chronic 5PCO2 by 35 would 6pH by 0.105 • Somewhere in between
Case 3 • What is the anion gap? AG = 135 – (93 + 30) = 12
Case 3 • Acute on chronic respiratory acidosis (COPD)
Case 3b • This same patient is intubated and mechanically ventilated. During the intubation he vomits and aspirates. He is ventilated with an FiO2 of 50%, tidal volumes of 850cc, PEEP of 5, rate of 10. One hour later his ABG is 7.48/37/215.
Case 3b • What is the A-a gradient? A-a = [FiO2 (713) – 37/.8] – 215 A-a = 310 – 215 = 95 • Why is he alkalotic with a normal PCO2? • Chronic compensatory metabolic alkalosis and acute respiratory alkalosis
Case 4 • A 23 year old female presents to the Emergency Room complaining of chest tightness and light-headedness. Other symptoms include tingling and numbness in her fingertips and around her mouth. Her medications include Xanax and birth control pills, but she recently ran out of both.