Arterial Blood Gas Analysis ..

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Dr Satish Deopujari Pediatrician Hon. Prof. ( Pediatrics) JNMC Chairman National Intensive care chapter Indian academy of pediatrics deopujari@rediffmail.com Visit us at. http://rdsoxy.org

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The Goal :

To provide Bedside approach to ABG analysis

H ION CONC. OH ION 14 N.MOLS / L. 20

pH stand for "power of hydrogen"

pH 7.70 7.52

30 40 50
H+ = 80 - last two digits of pH

7.40 7.30 7.22

H ION

60

Dont click wait ..till Last message .. H = 80-last two digits of pH

Bicarbonate:

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Henderson - Hasselbach equation: pH = pK + Log HCO3 Dissolved CO2

Standard Bicarbonate:
Plasma HCO3 after equilibration to a PaCO2 of 40 mm Hg
: Reflects non-respiratory acid base change : No quantification of the extent of the buffer base abnormality

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Base Excess:
( base to normalise HCO3 (to 24) with PaCO2 at 40 mm Hg
(Sigaard-Andersen)

: Reflects metabolic part of acid base ( : No info. over that derived from pH, pCO2 and HCO3 : Misinterpreted in chronic or mixed disorders

Oxygenation Indices:
O2 Content of blood:
Hb. x O2 Sat + Dissolved O2

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(Dont forget hemoglobin) Oxygen Saturation: reported as ABG report ( Derived from oxygen dis. curve not a measured value ) Alveolar / arterial gradient: ( Useful to classify respiratory failure )

Normal arterio/venous difference 0 10 20 30 40 50 60 70 80 90 100 PaO2 100 80

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Rt. Shift

Oxygen delivered to tissues with normally placed curve Delivered oxygen with Rt. Shift curve

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40

Normal
20

Shift of the curve changes saturation for a given PaO2

Alveolar-arterial Difference
Inspired O2 = 21 % piO2 = (760-45) x . 21 = 150 mmHg

O2 CO2

palvO2 = piO2 pCO2 / RQ = 150 40 / 0.8 = 150 50 = 100 mm Hg PaO2 = 90 mmHg

palvO2 partO2 = 10 mmHg

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Alveolar- arterial Difference

Oxygenation Failure WIDE GAP piO2 = 150 pCO2 = 40 palvO2= 150 40/.8 =150-50 =100 PaO2 = 45 ( = 100 - 45 = 55 Ventilation Failure NORMAL GAP piO2 = 150 pCO2 = 80 palvO2= 150-80/.8 =150-100 = 50 PaO2 = 45 ( = 50 - 45 = 5

O2 CO2

760 45 = 715 : 21 % of 715 = 150

PAO2 (partial pres. of O2. in the alveolus.) = 150 - ( PaCO2 / .8 )

Expected PaO2 =
Normal situation

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FiO2 5 = PaO2 20 5 = 100

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The essentials
The Blood Gas Report: normals
pH PaCO2 PaO2 HCO3 7.40 + 0.05 40 + 5 80 - 100 24 + 4 mm Hg mm Hg mmol/L

HCO3

O2 Sat >95 Always mention and see

FIO2

The

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Steps for Successful Blood Gas Analysis

Step 1
Look at the pH Is the patient or acidemic alkalemic pH < 7.35 pH > 7.45

Step 2
Who is responsible for this change in pH ( culprit )?

 CO2 will change pH in opposite direction  Bicarb. will change pH in same direction
Acidemia: With HCO3 < 20 mmol/L = metabolic With PCO2 >45 mm hg = respiratory With HCO3 >28 mmol/L = metabolic With PCO2 <35 mm Hg = respiratory

Alkalemia:

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Step 3
If there is a primary respiratory disturbance, is it acute ?

10 mm Change PaCO2

= .08 change in pH ( Acute )

.03 change in pH ( Chronic )

Step 4

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If the disturbance is metabolic is the respiratory compensation appropriate? For metabolic acidosis: Expected PaCO2 = (1.5 x [HCO3]) + 8 ) + 2 or simply expected PaCO2 = last two digits of pH For metabolic alkalosis: Expected PaCO2 = 6 mm for 10 mEq. rise in Bicarb. Suspect if ............. actual PaCO2 is more than expected : additional respiratory acidosis actual PaCO2 is less than expected : additional respiratory alkalosis

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Step 4 cont.
If there is metabolic acidosis, is there a wide anion gap ? Na - (Cl + HCO3 ) = Anion Gap usually <12 If >12, Anion Gap Acidosis : Common pediatric causes 1. Lactic acidosis 2. Metabolic disorders 3. Renal failure M ethanol U remia D iabetic Ketoacidosis P araldehyde I nfection (lactic acid) E thylene Glycol S alicylate
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th step

Clinical correlation

Same direction
HCO3 Same direction pH

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META.

PaCO2 Opposite direction

pH

RESP.

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Remember the format pH PaCO2 PaO2

Three clicks pH

HYPER VENTILATION

PaCO2 BICARB CHANGES pH in same direction Compensation Bicarbonate Primary lesion Primary lesion

Low Alkali

METABOLIC ACIDOSIS

Three clicks pH

HYPO VENTILATION

PaCO2 BICARB CHANGES pH in same direction Compensation Bicarbonate

High Alkali

Primary lesion

METABOLIC ALKALOSIS

Three clicks Wait for red circle pH CO 2 CHANGES pH in opposite direction

BICARB

compensation PaCO 2

High CO2

Primary lesion

Respiratory acidosis

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RESP. ACIDOSIS
PCO2 +

ALKALOSIS META.

CO2+H20=H2CO3 = H + HCO3

pH

HIGH H+ HIGH HCO3

HCO3

HCO3
pH .08 pH .03

ACUTE RISE : PCO2 10 : CHRONIC RISE : PCO2 10 :

Three clicks Wait for red circle pH PaCO 2 CHANGES pH in opposite direction

BICARB

compensation PaCO 2

Low PaCO2

Primary lesion Primary lesion

Respiratory alkalosis

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RESP. ALK.

ACID. META.

CO2 + H20 = H2CO3 = H+ + HCO3

pH

CO2
+

LOW H IONS LOW HCO3

SERUM HCO3
Bicarbonate

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PaCO2 of 10

pH

Acute change .08 Chronic change .03

INTERPRETATION OF A.B.G.
FOUR STEP METHOD OF DEOSAT 1) LOOK FOR pH 2) WHO IS THE CULPRIT ? 3) IF RESPIRATORY ACUTE / CHRONIC ? 4) IF METABOLIC / COMP. / ANION GAP CLINICAL CORRELATION
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considered complete when the pH returns to normal range

compensation

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Clinical blood gases by Malley

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METABLIC ACIDOSIS PaCO2 = Up to 10 ? METABOLIC ALKALOSIS PaCO2 = Maximum 6O RESPIRATORY ACIDOSIS BICARB = Maximum 40 RESPIRATORY ALKALOSIS BICARB = Up to 10

COMPENSION LIMITS

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Case 1
Blood Gas Report 37.0 C 7.523 30.1 mm Hg 105.3 mm Hg Data 22 98.3 8 0.93 Data 21.0 mmol / L % mm Hg (
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Measured pH PaCO2 PaO2 Calculated HCO3 act O2 Sat PO2 (A - a) PO2 (a / A) Entered FiO2

16 year old female with sudden onset of dyspnea. No Cough or Chest Pain Vitals normal but RR 56, anxious.

Acute respiratory alkalosis And why acute ?

Case 2
Blood

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6 year old male with progressive respiratory distress Muscular dystrophy .

Gas Report
o Res. Acidemia : High PaCO2 and low pH 37.0 C 7.301 ( CO2 =76-40=36 76.2 mm Hg Expected ( pH for ( Acute ) = .08 for 10 45.5 mm Hg

pH <7.35 :acidemia

Measured pH PaCO2 PaO2 Calculated HCO3 act O2 Sat PO2 (A - a) PO2 (a / A) Entered FiO2

Data 35.1 78 9.5 0.83 Data 21

Expected ( Acute ) pH = 7.40 - 0.29=7.11 Chronic resp. acidosis

mmol / L % mm Hg (

Hypoxemia Normal A-a gradient

Hypoventilation

Chronic respiratory acidosis With hypoxia due to hypoventilation

80 PaCO2

Last two digits

pH
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PaCO2 70 60 50 40 30 20

pH 7.10 7.20 7.30 7.40 7.50 7.60

Acute respiratory change

8-year-old male asthmatic with resp. distress

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Blood

Gas

Report
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pH <7.35 ; acidemia

Case 3

Measured pH PaCO2 PaO2 Calculated HCO3 act O2 Sat PO2 (A - a) PO2 (a / A) Entered FiO2

PaCO28-year-old male asthmatic; >45; respiratory acidemia 37.0 C 7. 24 3 days ( CO2 = 49 - 40 = 9of cough, dyspnea 49.1 mm Hg Expectedand orthopnea not = 0.072 ( pH ( Acute ) = 9/10 x 0.08 66.3 mm Hg
Data 18.0 92 mmol / L

Expectedresponding 7.40usual = 7.328 pH ( Acute ) = to - 0.072 Acute resp. acidosis bronchodilators.

% WITH INCREASE IN CO2 BICARB MUST RISE ? O/E: Respiratory distress; 30 mm = ( Bicarbonate 153-66= 87 5 Hg 150 is low

suprasternal and Metabolic acidosis + respiratory acidosis

Data 30

intercostal retraction; tired looking; on 4 L NC.

Hypoxia piO2 = 715x.3=214.5 / palvO2 = 214-49/.8=153 Wide A / a gradient

Case 4 8 year old diabetic with respi. distress fatigue and loss of appetite.
Three clicks Blood Gas Report
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pH <7.35 ; acidemia

Measured pH PaCO2 PaO2 Calculated HCO3 act O2 Sat PO2 (A - a) PO2 (a / A) Entered FiO2

37.0 C Last two digits of pH 7.23 Correspond with co2 23 mm Hg 110.5 mm Hg Data 14 mmol / L

HCO3 <22; metabolic acidemia % mm Hg (

Data 21.0

If Na = 130, Cl = 90 Anion Gap = 130 - (90 + 14) = 130 104 = 26

Case 5 : 10 year old child with encephalitis

Four clicks Blood Gas Report 37.0 C 7.46 28.1 mm Hg 55.3 mm Hg Data 19.2 mmol / L % mm Hg ( Data 24.0
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Measured pH PaCO2 PaO2 Calculated HCO3 act O2 Sat PO2 (A - a) PO2 (a / A) Entered FiO2

pH almost within normal range Mild alkalosis PaCO2 is low , respiratory low by around 10 ( Acute ) by .08 (Chronic ) by .03 Bicarb looks low ? Is it expected ?

BICARBINATURIA

Case 6.
pH 7.39 PCO2 l5mmHg HCO3 8mmol/L PaO2 90 mmHg One click

These findings are most consistent with. a) Metabolic acidosis with compensatory Hypocapnia. b) Primary metabolic acidosis with respiratory alkalosis. c) Acute respiratory alkalosis fully compensated. d) Chronic respiratory alkalosis fully compensated.
For metabolic acidosis: FULL COMPENSATION Expected PaCO2 = (1.5 x [HCO3]) + 8 ) + 2 (Winters equation) PCO 2 SHOULD BE 20

Case 7.

Adolescent boy with appendicitis , posted for surgery , he is a known case of SLE. His pre-op ABG shows No click : Room air pH 7.39 pCO2 l5mmHg paO2 90 mmHg HCO3 8mmol/L These findings are most consistent with. a) Metabolic acidosis with compensatory Hypocapnia. b) Primary metabolic acidosis with respiratory alkalosis. c) Acute respiratory alkalosis fully compensated. d) Chronic respiratory alkalosis fully compensated. What is the probable cause for the above findings ? Are they OK as far as oxygenation is concerned ?

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Patient was hypo volumic , received Normal Saline bolus... Corrected acidosis He was operated .but post-op became drowsy His ABG.. FiO2.30%

pH 7.38 PaCO2 38 PaO2 60

1) Why hypoxemia ? 2) Were the lungs bad to begin with ? ( Pre OP PaO2 90 mmHg ) 3) Micro atelectesis during surgery ? Anesthetist goofed up the case 4) Pure and simple hypoventilation ..Sedation ?

Why hypoxemia ? Lungs were bad to begin with ? Micro atelectesis during surgery Pure and simple hypoventilation ? sedation

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PRE OP .ABG on room air pH 7.39 PaCO2 l5mmHg PaO2 90 mmHg Oxygenation status good ..? HCO3 8mmol/L
Pre OP .....A/a gradient palvO2 = PiO2 PaCO2 / RQ = 150 15 / 0.8 = 150 18 = 132 mm Hg 132 90= 42 WIDE A / a gradient

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Apparently the lungs looked good with PaO2 of 90. But have a good look at the ABG again With wash out of CO 2 . The expected PaO2 should have been more than 90 . This coupled with correction of acidosis ( normalizing PaCO2 ) Lowered the PaO2 post operatively. Conclusion .. Lungs were not normal to begin with ( SLE )..

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Learning point

Correlate PaO2 with FiO2 But please also correlate with PaCO2

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What is the Diagnosis

pH 7.583 PCO2 19.8 HCO3 18.7

Respiratory Click for answer Alkalosis Is it acute ?

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