Blood Gas Analysis

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Primary & Compensatory changes

Primary change PaCO2 PaCO2 [HCO3] [HCO3] Compensation [HCO3] [HCO3] PaCO2 PaCO2
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Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis

THE SIX STEP APPROACH

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The 6 step approach

1) Acidemic or Alkalemic 2) Is the primary disturbance respiratory or metabolic 3) If Respiratory, is it acute or chronic 4) If Metabolic, is there an anion gap?

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The 6 step approach

5) Are there any other metabolic disturbances with the anion gap acidosis? 6) Assess normal respiratory compensation for a metabolic disturbance.
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Step - 1
Acidemic or Alkalemic Acidemic : pH < 7.35 Alkalemic : pH > 7.45

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Step - 2
Is the primary disturbance Respiratory or Metabolic Respiratory disorder will alter the PaCO2 High CO2 in acidosis ,Low CO2 in alkalosis Go to Step 3
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Step - 2
Metabolic disorder will alter the [HCO3] HCO3 < 22, metabolic acidosis Go to Step-4 HCO3 >26 ,metabolic alkalosis
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Step - 3
RESPIRATORY

ACUTE

CHRONIC

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Step - 3
Respiratory Acidosis Acute pH = 0.08 x (PaCO2 40 ) /10 Chronic = 0.03 x (PaCO2 40 ) /10
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pH

Step - 3
Respiratory Alkalosis Acute pH = 0.08 x (PaCO2 40 ) /10 Chronic = 0.03 x (PaCO2 40 ) /10
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pH

Respiratory Acidosis
Hypoventilation : PaCO2 CNS depression : Sedatives , CNS disease Lung disease : Asthma , Chronic lung disease Musculoskeletal disorders : GBS , A&E(VINAYAKA) Myasthenia

Respiratory Alkalosis
Hyperventilation : PaCO2 CNS events ( hemorrhage) Drugs ( salicylates) Anxiety

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Step - 4
METABOLIC ACIDOSIS

CHECK ANION GAP

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Step - 4
Anion Gap = Na- (Cl + HCO3)

Usually 12 +- 2
Anion Gap Metabolic acidosis : AG > 12 Non Anion Gap acidosis : AG < 12

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Anion Gap Metabolic Acidosis

HCO3 & AG

Methanol Uremia DKA Paraldehyde Infection Lactic acid Ethylene glycol Salicylates
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Non-Anion Gap Metabolic acidosis

Loss of HCO3, or external acid infusion Low HCO3 but AG < 12 GI loss of HCO3 (Diarrhea) Renal losses Renal tubular necrosis Carbonic anhydrase inhibitors Ureteral diversion

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Step - 5
Is there another metabolic disturbance co-existing with an anion gap acidosis Corrected HCO3 = HCO3 + (AG 12) Corrected HCO3 > 24 : Additional metabolic alkalosis Corrected HCO3 < 24 : Non AG acidosis co-exists .
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Example
Anion Gap Metabolic acidosis HCO3 10 , AG 26 Corrected HCO3 = 1O + (26-12) =24 No additional disturbance HCO3 15 , AG 26 Corrected HCO3 = 15 + (26-12) =29 Co-existing metabolic alkalosis
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Step-6
Assess normal respiratory compensation for a metabolic acidosis Winter s formula Expected PaCO2 = (1.5 X HCO3) + (8 +- 2)
If HCO3 is 10 , PaCO2 should be 21-25 If PaCO2 < 21, additional respiratory alkalosis If PaCO2 >25, additional respiratory acidosis
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Step - 6
Assess normal respiratory compensation for a metabolic disturbance In metabolic Alkalosis winters formula not applicable PaCO2 will rise, but not over 50-55

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Case 1
Measured pH 7.24 PCO2 60 mm Hg PO2 56 mm Hg Calculated HCO3 24mmol/L BE +2 SaO2 85 %

FiO2 70%

5 Month old baby with Bronchiolitis

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Case 1
Step-1

pH PCO2 PO2 HCO3

7.24 60 mm Hg 56 mm Hg 24mmol/L

Acidemia or Alkalemia ? Acidemia Step-2 Primary disturbance Respiratory Step-3 Acute or Chronic pH = 0.08 x (60-40) / 10 = 0.16 7.4 0.16 = 7.24 Acute Respiratory Acidosis Uncompensated
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Case 2
3 year old with severe diarrhea , diminished urine output, lethargy, Na-135 , Cl- 115
Measured pH 7.10 PCO2 20 mm Hg PO2 87 mm Hg Calculated HCO3 8 mmol/L

- 15 SaO2 96%
BE

FiO2 24%
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Case 2
Step-1

Acidemia or Alkalemia ? Acidemia Na-135 , Cl- 115 Step-2 Primary disturbance Metabolic Step-4 What is the Anion Gap ? Na- (Cl + HCO3) 135-(115 + 8) = 12 Step-6 What is the expected CO2 ? Expected PaCO2 = (1.5 x HCO3) +( 8 +- 2 ) =( 1.5 x 8 ) + ( 8 +- 2 ) = 18 22 Compensated metabolic acidosis
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pH 7.10 PCO2 20 mm Hg PO2 87 mm Hg HCO3 8 mmol/L

Case 3
Measured pH 7.1o PCO2 60 mm Hg PO2 60 mm Hg Calculated

HCO3 10 mmol/L BE - 15 SaO2 87 %

FiO2 100%

50 Year old resuscitated after a cardiac arrest. Na-142 , Cl- 108

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Case 3
Step-1

pH 7.1o PCO2 60 mm Hg PO2 60 mm Hg HCO3 10 mmol/L

Na-142 , Cl- 108

Acidemia or Alkalemia ? Acidemia Step-2 Primary disturbance Metabolic Step-4 What is the Anion Gap ? Na- (Cl + HCO3) 142-(108 + 10) = 24
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Case 3
Step 5 What is the corrected HCO3 Corrected HCO3 = HCO3 + (AG 12 ) 10 + ( 24 12 ) = 22 Step 6 What is the expected CO2 ? Expected PaCO2 = (1.5 x HCO3) +( 8 +- 2 ) ( 1.5 x 10 ) + ( 8 +- 2 ) = 21 25 Mixed metabolic and respiratory acidosis

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Case 4
Measured pH 7.52 PCO2 26 mm Hg PO2 112mm Hg

Calculated HCO3 22 mmol/L BE +2 SaO2 99%

FiO2 33%

4 year girl with lethargy, irritability, jaundice

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Case 4
Step-1 Step-2 Step-3

pH 7.52 PCO2 26 mm Hg PO2 112mm Hg HCO3 22 mmol/L

Acidemia or Alkalemia ? Alkalemia Primary disturbance Respiratory Acute or Chronic pH = 0.08 x (26-40) / 10 = 0.11 7.4 + 0.11 = 7.51 Acute Respiratory Alkalosis Uncompensated
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THANK YOU

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