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Analysis ..1
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 :
H ION CONC.
OH ION 14
N.MOLS / L.
20
pH
7.70
30
40
H ION
7.52
H+ = 80 - last two digits of pH
7.40
50
7.30
60
7.22
Bicarbonate:
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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
Base Excess:
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Oxygenation
Indices:
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O2 Content of blood:
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0 10 20 30 40 50 60 70 80 90 100 PaO2
100
80
Rt. Shift
Oxygen delivered
to tissues
with normally placed curve
60
Delivered oxygen
with Rt. Shift curve
40
20
Normal
Alveolar-arterial Difference
Inspired O2 = 21 %
piO2 = (760-45) x . 21
O2
CO2
150 mmHg
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Ventilation Failure
NORMAL GAP
piO2 = 150
pCO2 = 80
O2
CO2
palvO2= 150-80/.8
=150-100
= 50
PaO2 = 45
= 50 - 45 = 5
Expected PaO2 =
Normal situation
FiO2 5 = PaO2
20 5 = 100
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The essentials
The Blood Gas Report:
normals
HCO3
pH
PaCO2
PaO2
7.40 + 0.05
40 + 5
80 - 100
mm Hg
mm Hg
HCO3
24 + 4
mmol/L
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
Alkalemia:
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Step 3
10 mm
Change
PaCO2
Step 4
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Step 4 cont.
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
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Same direction
HCO3
pH
META.
pH
RESP.
Same direction
PaCO2
Opposite direction
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Three clicks
pH
HYPER VENTILATION
PaCO2
BICARB CHANGES
pH in same direction
Compensation
Bicarbonate
Low
Alkali
Primary lesion
Primary lesion
METABOLIC ACIDOSIS
Three clicks
pH
HYPO VENTILATION
PaCO2
BICARB CHANGES
pH in same direction
Compensation
Bicarbonate
High
Alkali
Primary lesion
METABOLIC ALKALOSIS
pH
Three clicks
Wait for red circle
CO 2 CHANGES
pH in opposite direction
BICARB
compensation
PaCO 2
High
CO2
Primary lesion
Respiratory acidosis
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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PaCO of 10
pH
Acute change
.08
INTERPRETATION OF A.B.G.
FOUR STEP METHOD OF DEOSAT
1) LOOK FOR pH
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compensation
considered
complete
when the
pH returns
to
normal
range
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COMPENSION LIMITS
METABLIC ACIDOSIS
PaCO2 = Up to 10 ?
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METABOLIC ALKALOSIS
PaCO2 = Maximum 6O
RESPIRATORY ACIDOSIS
BICARB = Maximum 40
RESPIRATORY ALKALOSIS
BICARB = Up to 10
Blood
Gas
Case 1
Report
o
Measured
pH
PaCO2
PaO2
37.0 C
7.523
30.1
mm Hg
105.3
mm Hg
Calculated
HCO3 act
Data
22
O2 Sat
PO2 (A - a)
PO2 (a / A)
98.3
8
0.93
Entered
FiO2
Data
21.0
mmol / L
%
mm Hg
Case 2
Blood
Five clicks
Report
Measured
pH
PaCO2
PaO2
37.0 C
7.301
CO2 =76-40=36
76.2
mm Hg Expected pH for ( Acute ) = .08 for 10
45.5
mm Hg Expected ( Acute ) pH = 7.40 - 0.29=7.11
Calculated
HCO3 act
Data
35.1
O2 Sat
PO2 (A - a)
PO2 (a / A)
78
9.5
0.83
Entered
FiO2
Data
21
Hypoxemia
Normal A-a gradient
Hypoventilation
80 PaCO2
PaCO2
70
60
50
40
30
20
pH
pH
7.10
7.20
7.30
7.40
7.50
7.60
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Blood
Gas
Six clicks
Case 3
pH <7.35 ; acidemia
Report
Measured
pH
PaCO2
PaO2
Calculated
HCO3 act
Data
18.0
O2 Sat
PO2 (A - a)
PO2 (a / A)
Entered
FiO2
Expectedresponding
pH ( Acute ) = 7.40
- 0.072 = 7.328
to usual
Acute resp.
acidosis
bronchodilators.
mmol / L
distress;
suprasternal
andacidosis
Metabolic acidosis
+ respiratory
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
pH <7.35 ; acidemia
Report
Measured
pH
PaCO2
PaO2
o
Last two digits of pH
37.0 C
Correspond with co2
7.23
23
mm Hg
110.5
mm Hg
Calculated
HCO3 act
Data
14
O2 Sat
PO2 (A - a)
PO2 (a / A)
Entered
FiO2
mmol / L
%
mm Hg
Data
21.0
If Na = 130,
Cl = 90
Anion Gap = 130 - (90 + 14)
= 130 104 = 26
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Blood
Gas
Report
o
Measured
pH
PaCO2
PaO2
37.0 C
7.46
28.1
mm Hg
55.3
mm Hg
Calculated
HCO3 act
Data
19.2
O2 Sat
PO2 (A - a)
PO2 (a / A)
Entered
FiO2
mmol / L
%
mm Hg
Data
24.0
BICARBINATURIA
Case 6.
pH 7.39
PCO2 l5mmHg
HCO3 8mmol/L
PaO2 90 mmHg
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Case 7.
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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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Learning point
Case 8,,,,,,,,,,,,,,,,,,
What is the
Diagnosis
pH 7.583
PCO2
19.8
HCO3
18.7
Respiratory
Click
for answer
Alkalosis
Is it acute ?
THANKS