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Resident ICU Course

Blood Gas Interpretation View the Lecture

Release Date: 1-1-2009


ACGME Competencies:
Patient Care
Medical Knowledge
Practice Based Learning and Improvement

Description Author Disclosures Topic Objectives Key Words

This presentation reviews acid-based balance and how to interpret blood gases in the PICU setting.

2008
Copyright: Society of Critical Care Medicine 2008
Privacy Statement Terms & Conditions

Resident ICU Course


Blood Gas Interpretation View the Lecture

Release Date: 1-1-2009


ACGME Competencies:
Patient Care
Medical Knowledge
Practice Based Learning and Improvement

Description Author Disclosures Topic Objectives Key Words

The author of this presentation is Jeff A Clark, M.D. - Critical Care Medicine Childrens Hospital of Michigan.

Revised from an original slide presentation by Marc D. Berg, M.D., and Rita R. Ongjoco, D.O.

2008
Copyright: Society of Critical Care Medicine 2008
Privacy Statement Terms & Conditions

Resident ICU Course


Blood Gas Interpretation View the Lecture

Release Date: 1-1-2009


ACGME Competencies:
Patient Care
Medical Knowledge
Practice Based Learning and Improvement

Description Author Disclosures Topic Objectives Key Words

DISCLOSURE STATEMENT: In accordance with ACCME standards for commercial support of continuing medical education, faculty members have been
asked to disclose any relations they may have with commercial supporters of this activity or with companies providing drugs, medical equipment, etc that
may have relevance to the content of the presentation. Such disclosure is intended to provide participants with sufficient information to evaluate whether any
given presentation has been influenced by the faculty relationship(s) or financial interests with said companies.
The following faculty reported having financial interests or affiliation from a commercial supporter(s) or from a corporate organization that: (a) has a direct
interest in the subject matter of the presentation or (b) has provided financial support to underwrite this activity.

Jeff A Clark, M.D.


No Disclosures

2008
Copyright: Society of Critical Care Medicine 2008
Privacy Statement Terms & Conditions

1
Resident ICU Course

Blood Gas Interpretation View the Lecture

Release Date: 1-1-2009


ACGME Competencies:
Patient Care
Medical Knowledge
Practice Based Learning and Improvement

Description Author Disclosures Topic Objectives Key Words

Upon completion of this presentation, the participant will be able to:


1. Present an organized approach to blood gas interpretation.
2. Assess the type and magnitude of the acid/base disorder.
3. Determine the type and magnitude of compensation.
4. Assess adequacy of oxygenation and ventilation.

2008
Copyright: Society of Critical Care Medicine 2008
Privacy Statement Terms & Conditions

Resident ICU Course


Blood Gas Interpretation View the Lecture

Release Date: 1-1-2009


ACGME Competencies:
Patient Care
Medical Knowledge
Practice Based Learning and Improvement

Description Author Disclosures Topic Objectives Key Words

acidosis
alkalosis
oxygenation
ventilation
metabolic acidosis
metabolic alkalosis,

2008
Copyright: Society of Critical Care Medicine 2008
Privacy Statement Terms & Conditions

Blood Gas Interpretation

Jeff A. Clark, MD
Critical Care Medicine
Childrens Hospital of Michigan
Revised from an original slide presentation by
Marc D. Berg, MD, and Rita R. Ongjoco, DO

2
Objectives
Present an organized approach to blood gas
interpretation
Assess the type and magnitude of the acid/base disorder
Determine the type and magnitude of compensation
Assess adequacy of oxygenation and ventilation

Slide 7

Core Competencies
This presentation will educate pediatric residents
about blood gas interpretation and address the
ACGME competencies of:
Medical knowledge
Patient care
Practice-based learning and improvement

Slide 8

Importance in
Medical Knowledge and Patient Care
Maintenance of a normal pH essential for optimum
cell function
Blood gas analysis often is critical in identifying and
localizing the pathologic condition present
Blood gas gives wealth of information about metabolic
derangements and pulmonary functioning

Slide 9

3
Blood Gas Interpretation
Acidosis or alkalosis
pH (7.35 7.45)
Metabolic or respiratory (or both)
PCO2 (36-44 mm Hg)
Compensated or uncompensated
Bicarbonate (20-25 mEq/L)
Oxygenation and ventilation
PO2 and PCO2

Slide 10

Bicarbonate Buffering
_
pH = 6.1 + log [HCO3 ]
0.03 x PCO2

_
H+ + HCO3 H2CO3 CO2 + H2O

Anion Gap
_
[Na+] [Cl- + HCO3 ] ~ 10-15

Slide 11

Metabolic Acidosis
Fall in pH as a result of increased acid or loss of
bicarbonate in the blood
Anion Gap Acidosis Non-Anion Gap Acidosis
Lactic acidosis Renal tubular acidosis
Ketoacidosis Post respiratory alkalosis
Toxic ingestion Hypoaldosteronism
Potassium-sparing diuretics
salicylates, methanol, ethylene
Diarrhea
glycol, ethanol, isopropyl
Carbonic anhydrase inhibitors
alcohol, paraldehyde, toluene
Acid administration (HCl, NH4Cl,
Renal failure - uremia arginine HCl)
Slide 12

4
Compensation
The bodys attempt to return the acid/base status to
normal (i.e., pH closer to 7.4)
Acute compensation respiratory (minutes)
Acutely compensated by minute ventilation and PCO2
_
PCO2 = 1.5 x (HCO3 ) + 8 ( 2 )
(Winters formula)
Chronic compensation occurs via excretion of H+ in
the urine
It would be extremely unusual for either the
respiratory or renal system to overcompensate
Slide 13

Example
Blood gas
_
pH / PCO2 / PO2 / SO2 / HCO3
7.0 / 25 / 50 / 86% / 6
Winters formula
6 x 1.5 + 8 + 2 = 15-19
Metabolic acidosis with incomplete respiratory
compensation or with respiratory acidosis

Slide 14

Metabolic Alkalosis
Occurs as a result of excess H+ secretion or loss, or
from excess accumulation of bicarbonate (e.g.,
exogenous)
e.g., - contraction alkalosis
7.49 / 43 / 68 / 94 / 31

paCO2 = 0.7(HCO3) + 20 (1.5)


paCO2 0.5-
0.5-1.0 torr per 1 mEq/L HCO3

Slide 15

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Acute Respiratory Acidosis
Overall alveolar hypoventilation
Respiratory pathology pH decreases 0.08 units for
Intoxications every 10 mm Hg increase in
CNS disease paCO2
Decrease in pH is accounted for entirely by the
increase in PCO2
Bicarbonate and base excess will be in the normal
range because the kidneys have not had adequate
time to establish effective compensatory mechanisms

Slide 16

Example
Blood gas
_
pH / PCO2 / PO2 / SO2 / HCO3
7.0 / 70 / 53 / 86% / 19

.08 x 3 = .24 HCO3 0.1-1 mEq/L per


7.4 - .24 = 7.16 10 mm Hg paCO2
Respiratory and metabolic acidosis

Slide 17

Chronic Respiratory Acidosis


Renal mechanisms increase the excretion of H+
within 24 hours and may partially correct the resulting
acidosis caused by chronic retention of CO2
7.31 / 65 / 51 / 85 / 31
Expected pH = 7.20 if acute
Respiratory acidosis with metabolic compensation

Slide 18

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Respiratory Alkalosis
PCO2 with a rise in pH
Bicarbonate and base excess will be in the normal range if
acute
_
Over time, kidneys will compensate by excretion of HCO3
Pain Drugs (early salicylate intox.)
Anxiety Sepsis
Hypoxemia Fever
Restrictive lung disease Hepatic failure
Severe congestive heart Thyrotoxicosis
failure Pregnancy
Increased ICP (early) Overaggressive mechanical
Pulmonary emboli ventilation
Slide 19

Example
7.56 / 20 / 71 / 91 / 21
The increase in pH is accounted for entirely by the
decrease in PCO2
pH increases 0.08 units for every 10 mm Hg decrease in
PCO2
0.08 x 2 = 0.16 7.4 + 0.16 = 7.56
Pure respiratory alkalosis
Compensation
_
HCO3 0.5-2 mEq/L per 10 mm Hg PCO2
Slide 20

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

Slide 21

7
Summary
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
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
Slide 22

Oxygenation and Ventilation


Perhaps most common use for a blood gas
Oxygenation
Identify impairment in oxygenation
Differentiate mechanisms of this impairment
Ventilation
Identifies impairment of ventilation
Localizes the site of pathology

Slide 23

Shift
Shift
Temp to
right
PCO2
pH
2,3-DPG

Temp

Slide 24

8
Oxygenation
Alveolar-arterial oxygen gradient (A-a) PB
atmospheric
Difference between alveolar and arterial PO2 pressure
gradient suggests shunting PH O
2
Alveolar gas equation water vapor
pressure
PAO2 = (PB PH O) x FiO2 PaCO2/R FiO2
2
fraction of
= (760 47 ) x .21 40 / 0.8 inspired oxygen
= 99 R
respiratory
quotient

Slide 25

Examples
4-mo infant with wheezing and SpO2
7.24 / 70 / 59 / 86%/ 23 on room air
(760 -47) x .21 70/.8
149 - 88 = 61 NO A-a GRADIENT!
on .25 FiO2: PO2 = 87 (SO2 = 99%)
2-year-old with status epilepticus and apnea
7.34 / 36 / 71 / 96%/ 19 on 50% O2
(760 47) x.5 36/.8 = 311
LARGE A-a GRADIENT (~240 torr)
Slide 26

Ventilation
Objective measure of ventilation
Arterial PCO2 and alveolar ventilation are inversely
and linearly related
If minute ventilation doubles, PCO2 by half
If minute ventilation is cut in half, PCO2 doubles

Slide 27

9
Normal Lungs

Alveolar-
Alveolar-capillary unit

PO-2 = 40
SO2 = 75% PO2 = 90 PO2 = 40 PO2 = 90
PCO2 = 45 SO2 = 100% SO2 = 75% SO2 = 100%
PCO2 = 35 PCO2 = 45 PCO2 = 35

Slide 28

Distal Airway Obstruction

PO-2 = 40
SO2 = 75% PO2 = 90 PO2 = 40
PCO2 = 45 SO2 = 100% SO2 = 75%
PCO2 = 40 PCO2 = 45

PO2 58
SO2 87%
PCO2 42.5
Slide 29

Distal Airway Obstruction

PO-2 = 40
SO2 = 75% PO2 = 600 PO2 = 40
PCO2 = 45 SO2 = 100% SO2 = 75%
PCO2 = 25 PCO2 = 45

PO2 61
SO2 89%

PCO2 Slide
35 30

10
Proximal Airway Obstruction
Overall alveolar hypoventilation

FiO2 = .3
PAO2 = 713 x .3 70/0.8 = 126

PO-2 = 40
SO2 = 75% PO2 = 59
PCO2 = 75 SO2 = 89%
PCO2 = 70

Slide 31

Summary
Evaluate oxygenation using the A-a gradient
Significant gradient implies intra- or extrapulmonary
shunting
Evaluate effectiveness of ventilation
If PCO2 is low or normal, overall alveolar hypoventilation
does not exist
If PCO2 is elevated, the presence of an A-a gradient helps
localize the problem to the small airways

Slide 32

References
Marino PL. Algorithms for acid-base interpretations. In: The ICU Book.
Baltimore, MD: Lippincott Williams and Wilkins;1991:415-426.
Cheifetz IM, Venkataraman ST, Hamel DS. Respiratory monitoring:
interpretation of clinical blood gas values. In: Rogers MC, ed. Textbook of
Pediatric Intensive Care. 3rd ed. Baltimore, MD: Lippincott Williams and
Wilkins;1996:355-361.
Jefferson LS, Bricker JT. Acid-base balance and disorders. In: Fuhrman B,
Zimmerman J. Pediatric Critical Care. Philadelphia, PA: Mosby;1992:689-
696.
Bartlett R. Acid-base physiology. In: Critical Care Physiology. Boston, MA:
Little Brown;1996:165-173.
Sharman M, Sarnaik AP. UpToDate: Approach to the child with metabolic
acidosis (2006). Available online at: www.uptodate.com.
Sarnaik AP, Heidemann S. Respiratory physiology. In: Nelson Textbook of
Pediatrics. Philadelphia, PA: Saunders, 2008.

Slide 33

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