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What is an ABG?
The
Components
pH / PaCO2 / PaO2 / HCO3 / O2sat / BE
Desired Ranges
pH - 7.35 - 7.45
PaCO2 - 35-45 mmHg
PaO2 - 80-100 mmHg
HCO3 - 21-27
O2sat - 95-100%
Base Excess - +/-2 mEq/L
in establishing a diagnosis
Helps guide treatment plan
Aids in ventilator management
Improvement in acid/base management
allows for optimal function of medications
Acid/base status may alter electrolyte levels
critical to patient status/care
Logistics
When
The
Normal values
pH
Uncompensated
acidosis
7.45 7.35
Uncompensated
alkalosis
Respiratory
alkalosis
CO2
45 - 35
Respiratory
acidosis
Metabolic
acidosis
HCO3
27 - 23
Metabolic
alkalosis
Compensation
7.4
7.35
Partial
compensated
7.45
Partial
Respiratory Acidosis
pH,
CO2, Ventilation
Causes
CNS depression
Pleural disease
COPD/ARDS
Musculoskeletal disorders
Compensation for metabolic alkalosis
Respiratory Acidosis
Acute
vs Chronic
Respiratory Alkalosis
pH,
CO2, Ventilation
CO2 HCO3 (Cl to balance charges
hyperchloremia)
Causes
Intracerebral hemorrhage
Salicylate and Progesterone drug usage
Anxiety lung compliance
Cirrhosis of the liver
Sepsis
Respiratory Alkalosis
Acute
vs. Chronic
in PCO2
Chronic - Ratio increases to 4 mEq/L of HCO3
for every 10mmHg in PCO2
Decreased bicarb reabsorption and decreased
Metabolic Acidosis
pH,
HCO3
12-24 hours for complete activation of
respiratory compensation
PCO2 by 1.2mmHg for every 1 mEq/L
HCO3
The degree of compensation is assessed via
the Winters Formula
PCO2 = 1.5(HCO3) +8 2
The Causes
Metabolic Gap Acidosis
M - Methanol
U - Uremia
D - DKA
P - Paraldehyde
I - INH
L - Lactic Acidosis
E - Ehylene Glycol
S - Salicylate
anion gap)
Diarrhea
Pancreatic Fistula
Metabolic Alkalosis
pH,
HCO3
PCO2 by
Causes
Vomiting
Chronic diarrhea
Hypokalemia
Renal Failure
Delta
Gap
at the pH if it is normal/acidotic/alkalotic
Look at the PaCO2 if it is normal/acidotic/alkalotic
Look at the HCO3 if it is normal/acidotic/alkalotic
If the pH match with the PCO2 or with the HCO3
If the value goes opposite direction of the pH
(determine the compensation).
Look at the Po2 and oxygen saturation
Sample problem
pH
7.49
PCO2 40
HCO3 28
Vomiting/dearrhea
In this example the Bicarb is
matching the pH
No compensation (Partial)
Sample problem
pH
7.10
PCO2 25
HCO3 7
DKA/Dearrhea/shock/bleeding
/sepsis
In this example the Bicarb is
matching the pH
No compensation (Partial)
Severe metabolic acidosis
Sample problem
pH
7.42
PCO2 18
HCO3 11
PO2
150
O2 sat 99%
Sample problem
pH
7.35
PCO2 60
HCO3 32
PO2
92
O2 sat 96%
No
Sample problem
pH
7.37
PCO2 33
HCO3 18
Metabolic
acidosis
Fully compensated
Sample problem
pH
7.36
PCO2 62
HCO3 34
PO2
70
O2 sat. 90%
Respiratory
acidosis
Fully compensated
E.g. COPD
Respiratory Alkalosis
Most
hypoxemia
Conditions
Danger a head
Hypoxemia
Respiratory
alkalosis
Increased
W.O.B
Muscle
fatigue
Respiratory
Acidosis
Danger a head
( Hypoxemia causing fatigue and respiratory
acidosis)
Respiratory
Alkalosis
Normal ABG
Respiratory
Acidosis
Case 1
A 26 year old man with unknown past medical history is brought in to the
ER by ambulance, after friends found him unresponsive in his apartment.
He had last been seen at a party four hours prior.
ABG:
pH
7.25
PCO2 60
Na+
K+
137
4.5
HCO3- 26
Cl-
100
PO2
HCO3-
25
55
Chem :
Case 2
A 67 year old man with diabetes and early diabetic nephropathy (without
overt renal failure) presents for a routine clinic visit. He is currently
asymptomatic. Because of some abnormalities on his routine blood
chemistries, you elect to send him for an ABG.
ABG:
Urine pH:
pH
7.35
PCO2 34
HCO3- 18
PO2 92
5.0
Chem :
Na+
K+
ClHCO3Cr
135
5.1
110
16
1.4
Case 3
A 68 year old woman with metastatic colon cancer presents to
the ER with 1 hour of chest pain and shortness of breath. She
has no known previous cardiac or pulmonary problems.
ABG:
pH
PCO2
HCO3PO2
7.49
28
21
52
Chem :
Na+
133
K+
3.9
Cl102
HCO3- 22
Definitions
Acidemia:
Definitions (Continued)
PH: - is a negative logarithm of Hydrogen
ion concentration; and it is the initials of
these two wards (puiessence Hydrogen)
that mean the power of hydrogen
Definitions (Continued)
An acid: - is a hydrogen ion or proton donor, and a
substance which causes a rise in H+
concentration on being added to water.
A base: - is a hydrogen ion or proton acceptor, and
a substance which causes a rise in OHconcentration when added to water.
Strength of acids or bases refers to their ability to
donate and accept H+ ions respectively.
Acidosis
6.9)
Alkalosis - CNS excitability, tetany,
siezures
Hydrogen ion concentration is most
commonly expressed as pH (= negative
logarithm of the H+ concentration)
ACID-BASE CALCULATIONS
The
ph
H+ (nmol/l)
7
7.1
7.2
7.3
7.36
7.4
7.44
7.5
7.6
7.7
100
80
63
50
44
40
36
32
25
20
Normal pH:
Arterial
Regulation of pH
Background
H+ + H+CO3- H2CO3 H2O + CO2
-Metabolic Disorders:
Affect HCO3-: (Normal 22-26 meq/L)
-Metabolic Acidosis
-Metabolic Alkalosis
H+ pH
Alkalosis
pCO2
Metabolic
Acidosis
Alkalosis
pCO2
pCO2
Metabolic
Acidosis
Alkalosis
pCO2
pCO2
H+CO3-
Acidosis
Alkalosis
pCO2
pCO2
H CO
+
H+CO3-
pH PaCO2 [HCO3]
pH PaCO2 [HCO3]
Metabolic Acidosis
Metabolic Alkalosis
Acute Respiratory Acidosis
Chronic Respiratory Acidosis
Acute Respiratory Alkalosis
Chronic Respiratory Alkalosis
pH PaCO2 [HCO3]
Metabolic Acidosis
Metabolic Alkalosis
Acute Respiratory Acidosis
Chronic Respiratory Acidosis
Acute Respiratory Alkalosis
Chronic Respiratory Alkalosis
pH PaCO2 [HCO3]
Metabolic Acidosis
Metabolic Alkalosis
Acute Respiratory Acidosis
pH PaCO2 [HCO3]
Metabolic Acidosis
Metabolic Alkalosis
Acute Respiratory Acidosis
pH PaCO2 [HCO3]
Metabolic Acidosis
Metabolic Alkalosis
Acute Respiratory Acidosis
Chronic Respiratory Acidosis
Acute Respiratory Alkalosis
pH PaCO2 [HCO3]
Metabolic Acidosis
Metabolic Alkalosis
Acute Respiratory Acidosis
Chronic Respiratory Acidosis
Acute Respiratory Alkalosis
pH PaCO2 [HCO3]
Metabolic Acidosis
Metabolic Alkalosis
Compensation
For
1 Respiratory
Compensation
Acidosis
Alkalosis
pCO2
pCO2
H+CO3-
1 Metabolic
H+CO3-
Compensation
pCO2
H+CO3 H+CO3-
pCO2
H+ + H+CO3- H2CO3 H2O + CO2
Compensation (Continued)
Formulas
Buffer Systems
A substance
H
O
C
O
H
C
O
H
H
C
O
2223
3
Plasma protein
*acid buffer
Respiratory Responses
Renal Responses
the
Primary
change
Predicted Compensatory
Response
Metabolic acidosis
HCO3
Metabolic Alkalosis
HCO3
Respiratory acidosis:
Acute
PaCO2
Respiratory acidosis:
Chronic
PaCO2
Primary
Defect
Effect
on
pH
Hypoventilati
on (PCO2)
Limits of
Compensatio
n
[HCO3-] =
[HCO3-] =
1-4 mEq/L for each 10 45 mEq/L
mm Hg PCO2
Respiratory
Alkalosis
Hyperventilati
on (PCO2)
HCO3Consumption
[HCO3-] =
2-5 mEq/L for each 10 12-15 mEq/L
[HCO3-] =
mm Hg PCO2
Metabolic
Acidosis
Metabolic
Alkalosis
Loss of
HCO3- or
gain of H+(
HCO3-)
Increase in
Ventilation
(PCO2)
PCO2 =
1.5[HCO3-] + 8
PCO2 =
12-14 mm
Hg
Gain of
HCO3- or loss
of H+
( HCO3-)
Decrease in
Ventilation
(PCO2 (
PCO2 =
0.6 mm Hg for each 1
mEq/L [HCO3-]
PCO2 =
55 mm Hg
GENERAL ASPECTS OF
ACID-BASE DISORDERS
A primary alteration in [H+], [HCO3-] or PCO2 results in
abnormal pH.
The body has several mechanisms to correct pH towards
the normal range.
-In the acute phase (minutes to hours), the extra- and intracellular buffer systems (most importantly the bicarbonate
system) minimize the pH changes.
- In the chronic phase (hours to days), renal or respiratory
compensation partially or completely restore pH towards
normal.
There are limits to both types of compensation.
Compensation does not result in over correction of pH.
NORMAL LABORATORY
VALUES
Arterial Blood Gas:
pH
[H+]
PCO2
[HCO3-]
Plasma Electrolytes
[Na+]
[K+ ]
[Cl-]
[total CO2]
7.35-7.45
35-45 nmol/L or neq/L
35-45 mm Hg
22-26 mmol/L or mEq/L
135-145 mEq/L
3.5-5.0 mEq/L
96-109 mEq/L
24-30 mEq/L
Metabolic Acidosis
Secondary
to
Acid production or
H+CO3- loss
Characterized
Anion Gap
The
14 +/- 2
Why
Acid production or
H+CO3- loss
and phosphates
Other organic acids
Lactic Acidosis
Fundamentally
acidosis?
Answer: Anaerobic metabolism
environmental O2
Inability to absorb O2
O2 unable to bind Hg
Unable to pump O2
Tissues unable to utilize
O2
High
altitude
Lung Disease
CO poisoning
Shock (cardiogenic)
Septic shock
Focal vascular obstruction
Cyanide poisoning
KetoAcidosis
Occurs
KetoAcidosis
Three
etiologies
Diabetic Ketoacidosis
Primarily in type 1 diabetes mellitus
Severe, life threatening
Often associated with precipitating illness
Starvation ketoacidosis
Mild acidosis
Alcoholic ketoacidosis
Mild acidosis
Metabolic
Acidosis
Anion Gap
Acidosis
Lactic
Acidosis
Lung Disease
CO poisening
Shock (cardiogenic)
Septic shock
Focal vascular
obstruction
Cyanide poisening
Ketoacidosis
DKA (Type 1)
Starvation
Alcoholic
NonAnion Gap
Acidosis
Uremic
Acidosis
Organic
Acidosis
Organic
acidosis
Methanol
Ethylene Glycol
Salicylates
Metabolic
Acidosis
Anion Gap
Acidosis
Lactic
Acidosis
Lung Disease
CO poisening
Shock (cardiogenic)
Septic shock
Focal vascular
obstruction
Cyanide poisening
Ketoacidosis
DKA (Type 1)
Starvation
Alcoholic
NonAnion Gap
Acidosis
Uremic
Acidosis
Organic
Acidosis
Methanol
Ethylene Glycol
Salicylate
intoxication
Bicarbonate loss
Diarrhea
Severe Burns
Urinary loss (renal tubular acidosis)
Metabolic
Acidosis
Anion Gap
Acidosis
NonAnion Gap
Acidosis
Diarrhea
Burns (severe)
RTA
Lactic
Acidosis
Lung Disease
CO poisening
Shock (cardiogenic)
Septic shock
Focal vascular
obstruction
Cyanide poisening
Ketoacidosis
DKA (Type 1)
Starvation
Alcoholic
Uremic
Acidosis
Organic
Acidosis
Methanol
Ethylene Glycol
Salicylate
intoxication
Clinical Manifestation
Headache
Confusion
Drowsiness
RR and depth
Nausea and vomiting
Peripheral vasodilation and decreased Cardiac
output (pH 7 )
BP
Hyperkalemias
Metabolic Alkalosis
Generation
Maintenance
Metabolic Alkalosis:
Generation
Acid
loss
gastrointestinal
losses
gastric acid loss
chloride diarrhea
Metabolic Alkalosis:
Generation
Alkali
gain
bicarbonate administration
milk alkali syndrome
infusion of organic anions
citrate
acetate
lactate
rapid correction of chronic hypercapnia
GFR
renal failure
Increased
chloride depletion
Increased
hypokalemia
responsive
saline
potassium repletion
Saline
resistant
potassium repletion
mineralocorticoid antagonists
acetazolamide
Respiratory Acidosis
Think
Respiratory Acidosis
Brain
Stroke
Drug
Spinal
Cord
Peripheral
Nerve
NeuroMuscular Junction
Lung and Pleural disease
Intoxication
C spine injury,
Guillan
Barre
Myasthenia Gravis
Asthma, COPD,
ARDS, etc
Clinical Manifestation
Hypercapnia
Pulse
RR
BP
Mental cloudiness
Feeling of fullness in the head
ICP
Headache
Hyperkalemia
Respiratory Alkalosis
Hyperventilation
PaCO2 pH
Etiologies
Fever
Pain
Anxiety
Pulmonary disease
Sepsis
Salicylate intoxication
Neurologic disorders
If
Check the pH
Check the pCO2
Select the appropriate compensation formula
Determine if compensation is appropriate
Check the anion gap
If the anion gap is elevated, check the delta-delta
If a metabolic acidosis is present, check urine pH
Generate a differential diagnosis
Putting it Together
Step 1
Step 2
Acidemia
Alkalemia
Step 3
Step 4
Step 5
Step 6
Case 1
A 26 year old man with unknown past medical history is
brought in to the ER by ambulance, after friends found him
unresponsive in his apartment. He had last been seen at a
party four hours prior.
ABG: pH
PCO2
HCO3PO2
7.25
60
26
55
Chem 7:
Na+
K+
Cl-
137
4.5
100
HCO3- 25
Case 2
A 67 year old man with diabetes and early diabetic
nephropathy (without overt renal failure) presents for a
routine clinic visit. He is currently asymptomatic. Because
of some abnormalities on his routine blood chemistries, you
elect to send him for an ABG.
ABG: pH
PCO2
HCO3PO2
Urine pH:
5.0
7.35
34
18
92
Chem 7:
Na+
K+
ClHCO3Cr
135
5.1
110
16
1.4
Case 3
A 68 year old woman with metastatic colon cancer presents
to the ER with 1 hour of chest pain and shortness of breath.
She has no known previous cardiac or pulmonary problems.
ABG: pH
PCO2
HCO3PO2
7.49
28
21
52
Chem 7:
Na+
K+
ClHCO3-
133
3.9
102
22
Primary
change
Predicted Compensatory
Response
Metabolic acidosis
HCO3
Metabolic Alkalosis
HCO3
Respiratory acidosis:
Acute
PaCO2
Respiratory acidosis:
Chronic
PaCO2
Case 1
A 52
Case 1: Answer
A 52
Case 2
Acidemic or Alkalemic?
Metabolic or Respiratory?
What is his acid base disorder?
Why is he alkalemic?
How would you fix it? Whats with the urine sodium?
Answer: Metabolic alkalosis. Correct with NaCL
Case 3
79
Case 3 (continued)
Labs:
WBC 18K, 82% neutrophils, 10% bands
HCT 37
Na 138, K 4.2 HCO3- 6 CL 106 BUN 45 Cr. 1.0
Glucose 110
ABG: pH 7.10, PaCO2 20mm Hg, PaO2 90
What
Metabolic
Acidosis
Anion Gap
Acidosis
NonAnion Gap
Acidosis
Diarrhea
Burns (severe)
RTA
Lactic
Acidosis
Lung Disease
CO poisening
Shock (cardiogenic)
Septic shock
Focal vascular
obstruction
Cyanide poisening
Ketoacidosis
DKA (Type 1)
Starvation
Alcoholic
Uremic
Acidosis
Organic
Acidosis
Methanol
Ethylene Glycol
Salicylate
intoxication
Step 1
Step 2
Acidemia
Alkalemia
Step 3
Step 4
Step 5
Step 6
Arterial puncture
obstruction
Infection
Allen's