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ABG INTERPRETATION
Tarek Abdel-Gawad MD AbdelHead of PICU Children Hospital Ain Shams University .
Acidosis
presence of a process which tends to lower pH by virtue of gain of H+ or loss of HCO3 presence of a process which tends to raise pH by virtue of loss of H+ or addition of HCO3HCO3-
Alkalosis
Respiratory
processes which lead to acidosis or alkalosis through a primary alteration in ventilation and resultant excessive elimination or retention of CO2
Metabolic
processes which lead to acidosis or alkalosis through their effects on the kidneys and the consequent disruption of H+ and HCO3HCO3- control
pH is maintained within a narrow range to preserve normal cell function Buffers minimize the change in pH resulting from production of acid provides immediate protection from acid The primary buffer system is HCO3HCO3HCO3HCO3- + H+ H2CO3 H2O + CO2
Simple
acidacid-base disorder a single primary process of acidosis or alkalosis acidacid-base disorder presence of more than one acid base disorder simultaneously
Mixed
Compensation the normal response of the respiratory system or kidneys to change in pH induced by a primary acid-base disorder acid
Kidneys slow, lungs fast No overcompensation ( except occasionally primary resp. alkalosis) Lack of compensation (or over) determines a second primary disorder The degree of appropriate compensation is predictable
Role of the kidney To retain and regenerate HCO3- thereby HCO3regenerating the buffer with the net effect of eliminating the acid H+ secretion HCO3- reabsorption HCO3Role of the respiratory system eliminate CO2
Primary
q [HCO3-] [HCO3o [HCO3-] [HCO3o Pco2 q Pco2
Compensated response
q Pco2 o Pco2 o [HCO3-] [HCO3q [HCO3-] [HCO3-
q o
pH
PCO2
HCO3
Interpretation
Alkalotic
Acid
Metabolic Acidosis
Acidotic
Alk
Metabolic Alkalosis
Alkali Alkalotic
Acid
Alk
STEPWISE APPROACH
Determine primary disorder Check the compensatory response Calculate the anion gap Identify specific etiologies for the acid-base aciddisorder Prescribe treatment
pH
pCO2
(Reference Value = 40)
HCO3
(Reference value = 24)
Check the trend of the pH, HCO3, pCO2 The change that produces the pH is the primary disorder
pH = 7.25 ACIDOSIS
HCO3 = 12 ACIDOSIS
pCO2 = 30 ALKALOSIS
METABOLIC ACIDOSIS
Check the trend of the pH, HCO3, pCO2 The change that produces the pH is the primary disorder
pH = 7.25 ACIDOSIS
HCO3 = 28 ALKALOSIS
pCO2 = 60 ACIDOSIS
RESPIRATORY ACIDOSIS
Check the trend of the pH, HCO3, pCO2 The change that produces the pH is the primary disorder
pH = 7.55 ALKALOSIS
HCO3 = 19 ACIDOSIS
pCO2 = 20 ALKALOSIS
RESPIRATORY ALKALOSIS
If the trend is the same, check the percent difference The bigger % difference is the 10 disorder (16-24)/24 = 0.33 (60-40)/40 = 0.5 pH = 7.25 HCO3 = 16 ACIDOSIS pCO2 = 60 ACIDOSIS
ACIDOSIS
RESPIRATORY ACIDOSIS
If the trend is the same, check the percent difference The bigger %difference is the 10 disorder (38-24)/24 = 0.58 (30-40)/40 = 0.25 pH = 7.55 HCO3 = 38 ALKALOSIS pCO2 = 30 ALKALOSIS
ALKALOSIS
METABOLIC ALKALOSIS
COMPENSATORY RESPONSE
HENDERSEN-HASSELBACH EQUATION HENDERSEN24 x pCO2 H = ---------------HCO3 Metabolic or Respiratory Acidosis
COMPENSATORY RESPONSE
HENDERSEN-HASSELBACH EQUATION HENDERSEN24 x pCO2 H = ---------------HCO3 Metabolic or Respiratory Alkalosis
HCO3 will increase 1 meq/L per 10 mmHg increase in PaCO2 ( pH by 0.08/10 mm Hg PaCO2) HCO3 will increase 4 meq/L per 10 mmHg increase in PaCO2 ( pH by 0.03/10 mm Hg PaCO2) HCO3 will decrease 2 meq/L per 10 mmHg decrease in PaCO2 HCO3 will decrease 4 meq/L per 10 mmHg decrease in PaCO2
COMPENSATORY RESPONSE
METABOLIC ACIDOSIS
PaCO2 = (1.5 X HCO3) + 8 2
COMPENSATORY RESPONSE
METABOLIC ALKALOSIS
PaCO2 will increase 0.75 mmHg per 1meq increase in HCO3 meq/L
HCO3 = 35 HCO3 = 40
COMPENSATORY RESPONSE
ACUTE RESPIRATORY ACIDOSIS HCO3 will increase 1 meq per 10 mmHg meq/L increase in PaCO2 pCO2 = 55 pCO2 =80 HCO3 = 55-40/10= 1.5 1.5 + 24 = 25.5 HCO3 = 80-40/10= 4 4+24 = 28
COMPENSATORY RESPONSE
CHRONIC RESPIRATORY ACIDOSIS
HCO3 will increase 4 meq per 10 mmHg meq/L increase in PaCO2
pCO3 = 55
COMPENSATORY RESPONSE
CHRONIC RESPIRATORY ACIDOSIS
HCO3 will increase 4 meq per 10 mmHg meq/L increase in PaCO2
pCO3 = 80
HCO3 = 80-40/10 x 4 = 16 + 24 = 40
COMPENSATORY RESPONSE
RESPIRATORY ALKALOSIS
Acute: HCO3 will decrease 2 meq per 10 mmHg meq/L decrease in PaCO2 Chronic: HCO3 will decrease 4meq meql/L per 10 mmHg decrease in PaCO2
ANION GAP
Na (HCO3 + Cl) = 10-12 mmol/L 10-
Na = 135 Cl = 97
ANION GAP
Na (HCO3 + Cl) = 10-12 10Na = 135 Cl = 97 HCO3 = 15 RBS = 500 mg%
Corrected Na = Na + RBS mg% -100 x 1.4 100 Anion Gap = 135 + 5.6 112 = 28.6
DELTA - DELTA
DELTA - DELTA
c/c = 1 c/c > 1 c/c < 1 Pure Anion gap metabolic acidosis AG Metabolic Acidosis + metabolic alkalosis AG Metabolic Acidosis + non-AG metabolic acidosis
CASE 1
6 years F with vomiting and diarrhea 3 days ago despite intake of loperamide. Her last urine output was 12 hours ago. PE showed BP = 80/60, HR = 110, RR = 28. There is poor skin turgor.
CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 42 crea = 2.0 RBS = 100 BUN / crea = 21 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90
PRE-RENAL AZOTEMIA
CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 42 crea = 2.0 RBS = 100 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90
Metabolic Acidosis
CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 42 crea = 2.0 RBS = 100 Expected pCO2 = (15 x 1.5) + 8 2 = 28.5-32.5 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90
CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 42 crea = 2.0 RBS = 100 Anion Gap = Na (HCO3+Cl) 130 (15+105) = 10 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90
NORMAL ANION GAP METABOLIC ACIDOSIS Diarrhea Renal Tubular Acidosis Interstitial nephritis External pancreatic or small-bowel drainage smallUrinary tract obstruction
CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 15 crea = 177 RBS = 100 c/c= (105-100)/(24-15) = 0.56 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90
NAGMA + HAGMA
CASE 1
5 years F with vomiting and diarrhea 3 days ago despite intake of loperamide. Her last urine output was 12 hours ago. PE showed BP = 80/60, HR = 110, RR = 28. There is poor skin turgor. pH 7.30, HCO3=15, pCO2=30, Na=130 K=2.5 How will you correct the acid base disorder?
CASE 1
1) 2) 3) 4) Hydrate Hydrate + IV NaHCO3 Hydrate + oral NaHCO3 Hydrate + correct hypokalemia
pH < 7.2 and HCO3 < 5 10 mmHg When there is inadequate ventilatory compensation Concurrent severe AG and NAGMA Severe acidosis with renal failure or intoxication
Volume overload Hypernatremia NaHCO3 50 ml = 45 mEq Na Hyperosmolarity NaHCO3 gr X tab = 7 mEq Na Hypokalemia Intracellular acidosis Causes overshoot alkalosis Stimulates organic acid production tissue O2 delivery
Osmolar Gap Normal Uremia Lactate Ketoacids Salicylate Increased Ethylene glycol Methanol
GI Fluid Loss? No Urine pH > 5.5 < 5.5 Serum K Low High Type 4 RTA
POTASSIUM CORRECTION
K deficit = {(4.0 2.5) X 350} / 3 + 60 = 235 mEq K to replace in 1 day 1 kalium durule = 10 mEq K 1 medium sized banana = 10 mEq K
CASE 2
12 years M with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2 = 40 K=4 HCO3 = 17 Cl = 98
Metabolic Acidosis
CASE 2
12Y with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2= 40 K=4 HCO3 = 17 Cl = 98 Metabolic & Respiratory Acidosis
CASE 2
12Y with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2= 40 K=4 HCO3 = 17 Cl = 98
HAGMA + RAc
- diabetic, alcoholic, starvation Lactic acidosis - hypoxia, shock, sepsis, seizures Toxic ingestion salicylates, methanol, ethylene glycol, ethanol, isopropyl alcohol, paraldehyde, toluene Renal failure - uremia
CASE 2
12Y with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2= 40 K=4 HCO3 = 17 Cl = 98
CASE 2
12Y with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2= 40 K=4 HCO3 = 17 Cl = 98
CASE 2
1) IV NaHCO3 using HCO3 deficit 2) oral NaHCO3 at 1 mEq/kg/day 3) intubate 4) no treatment
CASE 2
HCO3 DEFICIT = (D A) x 0.5 x kg BW HCO3 deficit = (20 17) x 0.5 x 32 = 48
How as you correct the acid base disorder? Give willbolus and the other as drip in 24 hrs
CASE 2
HCO3 DEFICIT = (D A) x 0.5 x kg BW HCO3 deficit = (18 17) x 0.5 x 30 = 16
As HCO3 < 5-10, the Vd increases; hence use 0.7 to 0.1 dHCO3 = 15 - 18 Maintenance 1 mEq/day
How as you correct the acid base disorder? Give willbolus and the other as drip in 24 hrs
PRINCIPLES OF THERAPY
LACTIC ACIDOSIS
HCO3
Primary effort should be improving O2 delivery Use NaHCO3 only when HCO3 < 5 mmol/L In states of CO, raising the CO will have more impact on the pH In cases of low alveolar ventilation, ventilation to lower the tissue pCO2
PRINCIPLES OF THERAPY
KETOACIDOSIS
HCO3
Rate of H+ production is slow; NaHCO3 tx may just provoke severe hypokalemia Should be given if 1) severe hyperkalemia despite insulin 2) HCO3 < 5 mmol/L 3) worsening acidemia inspite of insulin
CASE 3
14 years F, is surprised to find her K=2.7 mmol/L because she was normokalemic 6 months ago. She admits to being on a diet of fruit and vegetables but denies vomiting and the use of diuretics or laxatives. She is asymptomatic. BP = 90/55 with subtle signs of volume contraction.
CASE 3
serum Na K Cl HCO3 pH pCO2 Plasma 138 2.7 96 30 7.46 45 Urine 63 34 0 0 5.6
Metabolic Alkalosis
CASE 3
serum Na K Cl HCO3 pH pCO2 Plasma 138 2.7 96 30 7.46 45 Urine 63 34 0 0 5.6 Compensated Metabolic Alkalosis
PaCO2Expected PCO =mmHg will increase 0.75 2 per 1 mmol/L increase in HCO3 6 x 0.75 = 4.5+40 = 44.5 from 24
CASE 3
serum Na K Cl HCO3 pH pCO2 Plasma 138 2.7 96 30 7.46 45 Urine 63 34 0 0 5.6
NAG
CASE 3
1) diuretic intake 2) surreptitious vomiting 3) Bartters syndrome 4) Adrenal tumo
CASE 3
serum Na K Cl HCO3 pH pCO2 Plasma 138 2.7 96 30 7.46 45 Urine 63 34 0 0 5.6
CASE 3
1) correct hypokalemia 2) hydrate with NSS 3) administer acidyfing agent 4) give carbonic anhydrase inhibitor
METABOLIC ALKALOSIS Vomiting Remote diuretic use Cystic fibrosis Acute alkali administration
METABOLIC ALKALOSIS Bartters syndrome Severe potassium depletion Current diuretic use Hypercalcemia Hyperaldosteronism Cushings syndrome Gastric aspiration
Chloride repletion Potassium repletion Tx hypermineralocorticoidism Dialysis Carbonic anhydrase inhibitors Acidyfing agents HCl, NH4Cl
INDICATIONS OF HCl
pH > 7.55 and HCO3 > 35 with contraindications for NaCl or KCl use Immediate correction of metabolic alkalosis in the presence of hepatic encephalopathy, cardiac arrhythmias, digitalis intoxication When initial response to NaCl, KCl, or acetalozamide is too slow or too little
USE OF HCl
HCL requirement = (A D) x 0.5 x kg BW 0.1 0.2 N HCl solution = 100 200 mEq Do not exceed 0.2 mEq/kg/hour of HCl HCl = 1,380 mEq
HCO3 = 70 wt = 60 kg
CASE 4
15 years M with ILD (pCO2 stable at 52-58 52mmHg), cor pulmonale, and peripheral edema had been taking furosemide for 6 months. Five days ago, he had anorexia, malaise, and productive cough. He continued his medications until he developed nausea. Later he was found disoriented and somnolent
CASE 4
PE: BP 110/70, HR 110, RR 24, T=40 respiratory distress prolonged expiratory phase postural drop in BP drowsy, disoriented scattered rhonchi and rales BLFs distant heart sounds trace pitting edema
CASE 4
admission serum Na 136 K 3.2 Cl 78 HCO3 40 pH 7.33 pCO2 78 pO2 43 cpH = acidosis cpCO2 =acidosis, cHCO3 = alk after 48 hrs 139 3.9 86 38 7.42 61 56 Respiratory Acidosis
CASE 4
CASE 4
admission serum Na 136 K 3.2 Cl 78 HCO3 40 pH 7.33 pCO2 78 pO2 43 after 48 hrs 139 3.9 86 38 7.42 61 56
CASE 4
1) intubation and mechanical ventilation 2) low flow oxygenation by nasal prong 3) oxygen by face mask 4) sodium bicarbonate infusion with KCl
RESPIRATORY ACIDOSIS CHRONIC: COPD, intracranial tumors ACUTE: pneumonia, head trauma, general anesthetics, sedatives
Correct underlying cause for hypoventilation effective alveolar ventilation intubate, mechanically ventilate Antagonize sedative drugs Stimulate respiration (e.g. progesterone) Correct metabolic alkalosis
CASE 5
15 years M, brought to the ER intoxicated. He was found at park in a pool of vomitus. PE showed incoherent patient with a markedly contracted ECF volume. T=390 C with crackles on the chest.
CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 34 crea = 1.4 RBS = 15 mmol/L BUN/Crea = 24 pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38
PRE-RENAL
CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 34 crea = 1.4 RBS = 120 mmol/L pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38
Respiratory Alkalosis
Acute respiratory alkalosis: HCO3 will decrease 2 mmol/L per 10 mmHg decrease in PaCO2
CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 12 crea = 120 RBS = 120 mmol/L HCO3 = 40-25/10 x 2= 3 24 - 3 = 21
CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 12 crea = 120 RBS = 15 mmol/L Anion Gap = 130 (80 + 20) = 30 pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38 HAGMA + RAlk
CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 12 crea = 120 RBS = 15 mmol/L pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38
CASE 5
Correct underlying cause of hyperventilation Rebreathe carbon dioxide Mechanical control of ventilation increase dead space decrease back up rate decrease tidal volume paralyze respiratory muscles
QUESTIONS?
Thank You