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measured pH &PaCO2
are used to determine if an acid-base
disturbance is present and, if so, to
identify the primary acid-base disorder.
Rule 1
• An acid-base abnormality
is present if either the
PaCO2 or the pH is
outside the normal
range.
A normal pH or PaCO2 does not exclude the
presence of an acid-base abnormality.
Rule 2
•If the pH and PaCO2
are both abnormal,
compare the directional
change.
Rule 2
•A-If both change in the
same direction (both
increase or decrease),
the primary acid-base
disorder is metabolic.
Rule 2
•B-And if both change in
opposite directions,
the primary acid-base
disorder is
respiratory.
Example
•Consider a patient with
an arterial pH of 7.23
and a PaCO2 of 23 mm
Hg.
Example
• The pH and PaCO2 are both
reduced (indicating a
primary metabolic problem)
and the pH is low (indicating
acidemia), so the problem is
a primary metabolic
acidosis.
Rule 3:
• If the pH or PaCO2
one is normal and the
other is abnormal, there
is a mixed metabolic and
respiratory disorder.
Rule 3:
• A-If the pH is normal and
PCO2 is abnormal,
the direction of change in PaCO2
identifies the respiratory
disorder. And the
metabolic disorder will be
in the opposite direction.
Rule 3:
• B-And if the PaCO2 is
normal and PH is
abnormal, there is double
disorder, acidosis or
alkalosis according to the
direction of PH.
Example:
• Consider a patient with an arterial pH of
7.37 and a PaCO2 of 55 mm Hg.
• The pH is normal and PCO2 is abnormal,
so there is a mixed metabolic and
respiratory acid-base disorder.
• The PaCO2 is elevated, so the
respiratory disorder is an acidosis, and
thus the metabolic disorder must be an
alkalosis.
Example:
• Therefore, this is a combined
respiratory acidosis and
metabolic alkalosis.
• There is no primary acid-base
disorder in this situation; both
disorders are equivalent in
severity that is why the pH is
normal.
• Remember that the
compensatory responses
to a primary acid-base
disturbance are never
strong enough to correct
the pH, but act to reduce
the severity of the change
in pH.
• Therefore, a normal pH in the
presence of an acid-base
disorder always signifies a mixed
respiratory and metabolic acid-
base disorder.
• (It is sometimes easier to think of
this situation as a condition of
overcompensation for one of the
acid-base disorders.)
Step four: Compensated,
Uncompensated, or Partially
Compensated
• The step four of the approach is for cases
where a primary acid-base disorder has
been identified in Step three.
• The goal in Step four is to determine if the
compensatory responses are adequate and
if there are additional acid-base
derangements.
Rule 4:
• If there is a primary metabolic acidosis or
alkalosis, use the measured serum
bicarbonate concentration in Equations;
• Acidosis: Expected pCO2 = (1.5 × HCO3 ) + 8 ±
2.
• Alkalosis: Expected pCO2 = (0.7 × HCO3 ) + 21
± 2.
to identify the expected PaCO2 and
respiratory compensation.
Rule 4:
• If the measured and expected PaCO2 are
equivalent, the condition is fully
compensated.
• If the measured PaCO2 is higher than
the expected PaCO2, there is a
superimposed respiratory
acidosis(uncompensated).
• If the measured PCO2 is less than the
expected PCO2, there is a superimposed
respiratory alkalosis.
Example:
• Consider a patient with a PaCO2 of
23 mm Hg, an arterial pH of 7.32,
and a serum HCO3 of 15 mEq/L.
pH scale
7.24 7.34 7.4 7.5
acute chronic
• For respiratory alkalosis, if the
measured pH is higher than the
expected pH for the acute,
uncompensated condition, there is a
superimposed metabolic alkalosis, and
if the measured pH is below the
expected pH for the chronic,
compensated condition, there is a
superimposed metabolic acidosis.
Example
• Consider a patient with a PaCO2 of
23 mm Hg and a pH of 7.54.
• The PaCO2 and pH change in
opposite directions so the primary
problem is respiratory and, since the
pH is alkalemic, this is a primary
respiratory alkalosis.
• The expected pH for an acute
respiratory alkalosis is 7.40 + [0.008
× (40 - 23)] = 7.54.
• This is the same as the measured
pH, so this is an acute,
uncompensated respiratory
alkalosis.
• If the measured pH was higher than
7.55, this would be evidence of a
superimposed metabolic alkalosis.
Step five : Anion gap
• AG is a measure of the relative abundance of
unmeasured anions.
• Used to evaluate patients with metabolic
acidosis.
• Determinants of the Anion Gap:
AG= UA - UC = + -
[Na ]-([Cl ] + [HCO3 -])
Unmeasured Anions Unmeasured Cations
Cl-
(70-
110)
Normal ABG
• High AG metabolic acidosis is due to
the accumulation of [H+] plus an
unmeasured anion in the ECF.
–Most likely caused by organic acid
accumulation or renal failure with
impaired [H+] excretion.
The anion gap ↑H+
K+ (3.5-4.5)
Anion K+ (3.5-4.5)
Anion
Na+ Gap Na+ Gap
(135- (135-
145) 145)
HCO3-
(22-26) HCO3-
(<22)
Cl- Cl-
(70- (70-110)
110)
Normal or Low
High anion Gap
anion Gap
Lactic acidosis
Ketoacidosis Urinary Anion Gap
•Diabetes
•Alcohol Positive Negative
•Starvation
Toxins
•Salicylate,
•Methanol GIT (Diarrheal)
•Ethylglycol Renal (RTA)
Renal failure Fistula
Step six : Oxygenation
The situation in
tissues
Several factors can affect the
affinity of hemoglobin for oxygen
• Alkalosis, • Acidosis, hyperthermia,
hypothermia, hypercapnia and increased
hypocapnia, and 2, 3 DPG have the
decreased levels of 2, opposite effect.
3-diphosphoglycerate
(2, 3 DPG) • decreasing the affinity of
• increase the affinity hemoglobin for oxygen.
of hemoglobin for
oxygen.
• shifting to the right.
• Shift to left
• This characteristic of hemoglobin
facilitates oxygen loading in the lung
and unloading in the tissue where the
pH is lower and the PaCO2 is higher
• Fetal hemoglobin, which has a higher
affinity for oxygen than adult
hemoglobin, is more fully oxygenated
at lower PaO2 values, This is important
in utero.
ctO2 Arterial concentration of
total oxygen tO2
ctO2 = sO2 × 1.37 × ctHb + 0.003 × pO2
ml / dl.
In the same infant with IVH & Hb content. Drops to 10.5 g/dl
Cardiac output&
Lung function&
O2 delivery to tissue tissue perfusion
Breathing
O2 content in
blood
The key concept is that when
assessing a patient’s oxygenation,
more information than just PaO2 and
SaO2 should be considered.
PaO2 = 90 mmHg
pH 7.32
PaCO2 32
HCO3- 18
• pH 7.32 PaCO2 32 HCO3- 18