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Prof. A. K.

Sethi, UCMS, Delhi

Interpretation of Blood Gas Reports (ABG reports)


- made
d easy

P f A
Prof. A. K.
K Sethi
S hi
Head, Dept. of Anaesthesiology & Critical Care,
UCMS & GTB Hospital,
p , Delhi,, India
What is meant by interpreting ABG Reports ?
Prof. A. K. Sethi, UCMS, Delhi

• ABG = Arterial Blood Gases


Gases ≡ Gases in the Blood
(O2,CO
CO2, CO,
CO HeHe, Kr
Kr, N2)

• All BG
G machines
ac es
Measure pH, PaCO2, PaO2
Calculate
Ca CO3- +………
cu a e HCO

• ABG 2 sets of Tests ≡


Acid Base Status + Gases

• Co oximetry ≡ Hb, SaO2,


Co-oximetry
%COHb, %MetHb, CaO2
Explanation of Terms
Prof. A. K. Sethi, UCMS, Delhi

Hb HCT,
Hb, HCT FiO2, PaOP O2, PaCO
P CO2 , pH, H NaN + , K+ , SaOS O2(%)
RQ CO2 produced:O2 consumed, Set value, Can be fed
HCO3 A Parameter for non-respiratory
non respiratory component of acid-base
acid base balance
(Actual)
HCO3 S Parameter for non-respiratory
p y component
p of acid-base balance
(Standard) but reported after standardising at PCO2 at 40 mm Hg,
Temperature 37°C, SO2 100%
B
Base Diff
Difference between
b t normall quantity
tit off Total
T t l Buffer
B ff Base
B (BB)
excess or and the BB calculated from Blood Sample. (+) or (-).
deficit Depends upon entered Hb value,
value measured pH & PCO2 values.
values
Standard Difference between normal quantity of Total Buffer Base (BB)
Base and the BB calculated from Blood Sample. (+) or (-).
excess Calculated from a standard Hb value of 6 gm%, pH of 7.4 &
PCO2 of 40 mmHg.
BB (Buffer Sum of all buffer anions in blood
bases) (Hb, HCO3, Protein, Phosphate)
......Explanation of Terms
Prof. A. K. Sethi, UCMS, Delhi

TCO2 Content HCO3 concentration + dissolved CO2 in plasma

O2 CT,
CT CaO2, O2 content Hb bound O2 + Plasma dissolved O2

A-aDO2 Difference between PO2 (Alv) and PO2 (art)

P50 Semisaturation pressure = Partial pressure of O2


at which Hb is 50% saturated
LAC Lactate concentration

GLU Glucose concentration

Ca 7.4
74 Calcium ion concentration computed for pH 7.4
74

Li Lithium ion concentration

+ + ………. ………….
Know Normal & Reference Values for Interpretation
Prof. A. K. Sethi, UCMS, Delhi

Hb (gm%) Measured, K+ 3.5 – 5.1


Calculated or Fed
Ca+ 1 12 – 1.32
1.12 1 32
(HCT/3)
HCT (%) Measured or Cl- 97 – 100
Calculated (3xHb) B
Base excess (mEq/L)
( E /L) 0±2
FiO2 Fed
TCO2 Content ((mEq/L)
q ) ≈ 27
RQ 0 85
0.85
BB (mEq/L) 48
PaO2 (mmHg) 80 – 100
PaCO2 (mmHg) 35 – 45 O2 Sat (%) >95%

pH 7 35 – 7.45
7.35 7 45 O2 CT (ml/dL) 16 – 22
HCO3 A (mEq/L) 22 – 26 P50 mmHg 27
Na+ 135 – 145 A-aDO2 mmHg 5 – 25
Arterial Blood Sampling
Prof. A. K. Sethi, UCMS, Delhi

Radial
Dorsalis Paedis
Femoral
B hi l
Brachial
Arterialized Tissues

Feed the
Sample &
Data
Prof. A. K. Sethi, UCMS, Delhi

Acid Base Homeostasis


H+ and HCO3‐ concentration (pH) in Plasma 
must be regulated precisely 
& constantly maintained at normal levels

Enzyme activity Tissue Oxygenation


Chemical reactions within cells Neurological & Muscular functioning
Vascular Response to Catecholamines
Force of Cardiac contraction
Response to effects of Medications
Hb Saturation with O2
and
and,
O2 delivery many more activities . . . . . .
Blood pH < 6
6.8
8 and > 7
7.8
8 - Not Compatible with life
(Irreversible cell damage, Death)
Prof. A. K. Sethi, UCMS, Delhi

H+ : Continuously being produced as substrates, oxidized


during production of ATP
Must be continuously eliminated
by Lungs and Kidneys
Kidneys, ultimately

Normal H+ conc. ((Arterial blood,, ECF)) = 35 – 45 nmol/L


≡ Arterial pH of 7.45 – 7.35 respectively (Normal Range)

Acidemia : Blood pH < 7.35


Alkalemia : Blood p
pH > 7.45
Life sustaining functions of Body Organs and Systems
are bound to be affected adversely
when Acidemia or Alkalemia

D
Donot
t confuse
f b
between
t “N
“Normall pH”
H” and
d “N
“Neutral
t l pH”
H”
Prof. A. K. Sethi, UCMS, Delhi

What does body do when Acidemia or Alkalemia ?

1. Tries to prevent changes in pHa

2. If pHa changes, tries to bring the pH to normal

3 basic mechanisms

1. Buffer systems (HCO3-, Hb, Protein, Phosphate)

2 Ventilatory
2. V til t responses (L
(Lungs))

3. Renal responses
p ((Kidneys)
y )
Prof. A. K. Sethi, UCMS, Delhi

Importance of Interpretation of ABG Report


To establish diagnosis
To ascertain severityy
To decide about intensity of monitoring
To further intervene in management
g

All
ll Clinicians,
l n c ans, Intens
Intensivists,
v sts, Physicians,
hys c ans, Anaesthesiologists,
naesthes olog sts,
should
→ Know correct techniques involved in performing an ABG analysis
Know correct techniques involved in performing an ABG analysis
→ Have an understanding of the changes in ABGs in commonly 
encountered clinical conditions
encountered clinical conditions
→ Know to interpret the ABG report systematically and correctly
→ Understand implications
Understand implications
Prof. A. K. Sethi, UCMS, Delhi

When to perform ABGs ?


1. Assess the adequacy of ventilation and oxygenation 
(whether the patient is on a ventilator or not !)

2. Establish the diagnosis and severity of respiratory failure

3 Guide therapy ‐
3. G id h O2 administration, mechanical ventilation, weaning
d i i i h i l il i i

4. Assess changes in acid‐base homeostasis

5. Guide treatment for acid‐base abnormalities
………When to do ABGs ………
Prof. A. K. Sethi, UCMS, Delhi

6. Manage patients in ICUs for 
• Respiratory dysfunction or failure
• Cardiac failure
• Renal failure
Renal failure
• Hepatic failure
• Polytrauma
• Multi‐organ failure
Multi‐organ failure
• Diabetic ketoacidosis
• Sepsis
• Burns
• Various types of poisonings etc.  ………
Prof. A. K. Sethi, UCMS, Delhi

………When to do ABGs
7. Monitor patients during
• Cardio-pulmonary
C di l surgery
• Cardio-pulmonary exercise testing
• Sleep studies

8. Determine prognosis in critically ill patients


Basic Precautions (Sampling)
Prof. A. K. Sethi, UCMS, Delhi

1. Ensure  a Steady State of Oxygenation & Ventilation (3,20,30 min)

2. Precautions for arterial blood sampling – Site, Puncture, Cannula, 
H
Heparin
i

3 Do not keep the sample exposed to air, Any air bubble  in Syringe
3. Do not keep the sample exposed to air Any air bubble in Syringe

4. Do not delay the processing.  Otherwise, keep sample in Ice.

5.   Analyze Step‐by‐Step and completely
Prof. A. K. Sethi, UCMS, Delhi

Effect of keeping
Sample at room
temperature for 2 hours
Prof. A. K. Sethi, UCMS, Delhi

Base Excess or Base Deficit


• Difference between normal quantity of Total Buffer Base (BB)
and the BB calculated from Blood Sample
p

• (+) or (-)

• 0±2

Positive (+) value (Excess Base) = Alkalosis (Non-respiratory


(Non respiratory or Metabolic)

Negative ((-)) value (Deficit Base) = Acidosis (Non


(Non-respiratory
respiratory or Metabolic)

Sodium Bicarbonate dosage


= Body weight (Kg) x Base Deficit (mmol/L) x 0.3
Prof. A. K. Sethi, UCMS, Delhi

Base Deficit (Metabolic Acidosis)

• Compensation for Primary Respiratory Alkalosis


• Diabetic Ketoacidosis (Acidic Ketone Bodies)
• Lactic Acidosis (Anaerobic metabolism - Hypoxia, Heavy exercise)
• Chronic Renal Failure (x Acid excretion, x HCO3 Resorption, Production)
• Diarrheoa ((HCO3 excreted))
• Poisoning (Methanol, Aspirin, Ethylene glycol)

Base Excess (Metabolic Alkalosis)


• Compensation for Primary Respiratory Acidosis
• Excessive Vomiting (Loss of HCl in gastric juice)
• Over production of HCO3
Prof. A. K. Sethi, UCMS, Delhi

R di the
Reading h R
Report – Step-by-Step
b
Prof. A. K. Sethi, UCMS, Delhi

Step
p1
Check if the required parameters have been correctly fed ?

Barometric pressure
Patient’s temperature
Haemoglobin
(if machine does not measure, does not calculate)

FiO2

Results in the report are bound to


change get incorrect and misleading
change,
if the above values are not correctly fed
Effects of Wrong “Feedings” Prof. A. K. Sethi, UCMS, Delhi

• A
A‐aDO
aDO2 value will be wrong if P
value will be wrong if PB & FiO
& FiO2 (PiO2) is not fed correctly
) is not fed correctly
Alveolar gas equation : PAO2 = PiO2 – 1.2(PaCO2)    [PiO2 = FiO2 (PB – 47)]
• Oxygenation Impairment (Assess.) ‐
Oxygenation Impairment (Assess ) Wrong if FiO
Wrong if FiO2 not fed correctly 
not fed correctly
Machines always analyse blood at 37 °C
• Sample of Hyperthermic Patient = > 37 °C ‐
Sample of Hyperthermic Patient = > 37 °C Measured value of 
Measured value of
PaO2 and PaCO2 will be less than actual
p yp
• Sample of Hypothermic Patient = < 37 °C ‐ Measured value of 
PaO2 and PaCO2 will be more than actual
Temperature Change
Temperature Change Shifting of ODC
Shifting of ODC Calculated SO
Calculated SO2, 37 C, (ODC)
37°C
Increase Right Higher than actual
Decrease Left Lower than actual
than actual
True assessment of adequacy of O2 in arterial blood  (CaO2)can 
only be made if Hb values are entered. SaO
only be made if Hb values are entered SaO2 & PaO
& PaO2 do not.
do not
Hb – affects Buffer Base values (Base excess or deficit)
Prof. A. K. Sethi, UCMS, Delhi

Total O2 attached Total Dissolved O2


to Hb Content + carried by Plasma
Hb content (gm%)
PaO2
O2 carried by 1 gm Hb (ml)
Solubility Coefficient
Saturation Hb (SaO2)
‘☺’
☺ 15 x 11.34
34 x 100 (say) = 20.10
20 10 + 100 x 0.003
0 003 = 00.30
30
= 20.40 ml / dL
‘ ’ 15 x 1.34
1 34 x 85 (say) = 17.09
17 09 + 50 (say) x 0.003
0 003 = 0.15
0 15
= 17.24 ml / dL
“ ” 8 x 1.34 x 100 (say) = 10.72 + 100 x 0.003 = 0.30
= 10.75 ml / dL
FiO2
Prof. A. K. Sethi, UCMS, Delhi

Most common mistake


− FiO2 not entered while the sample 
is fed in the machine
− % FiO2 written on the report later 
on manually
− Hb also not entered at the time of 
feeding sample but told later on

If FiO2 not fed properly


Interpretation of PO2 affected adversely
A-aDO
A aDO2 values are wrongly calculated
(PAO2 calculated from PiO2)
Interpretation of adequacy of Oxygenation
affected adversely if Hb not fed properly.
Step - 2
Prof. A. K. Sethi, UCMS, Delhi

Analyse the Adequacy of Oxygenation


(i) Look at PaO2 and SaO2 first
Healthy Adult ‐ Sea Level, Room Air, A‐a O2 = 4 mmHg, PAO2 = 101
PaO2 (mmHg) SaO2 (%)
N
Normal values (on air)
l l ( i) > 80 
80 > 95
95
Mild hypoxemia 60‐79 90‐94
Moderate hypoxemia 40‐59 75‐89
Severe hypoxemia < 40 < 75
PaO2, SaO2 - Important
Low PaO2, Low SaO2 = Surely something wrong in terms of Oxygenation
Low PaO2 = degree of hypoxemia
→ Saturation of Hb ((SaO2) is dependent
p upon
p PaO2
→ Never rely totally on PaO2 & SaO2 – Look at other parameters also (CaO2)
Prof. A. K. Sethi, UCMS, Delhi

(ii) Relate PaO2 with FiO2 – Classify Hypoxemia

Hypoxemia
PaO2 Refractory

Uncorrected < 60, on O2
O2 x 5 = PaO2
Inspired O2 % PaO2 mmHg
30 > 150 Corrected 60‐100, < predicted
40 > 200
50 > 250 Excessively
> 100 < predicted
> 100, < predicted
80 > 400 Corrected
100 > 500
Responsive
Prof. A. K. Sethi, UCMS, Delhi

(iii) Find if Oxygenation is adequate or not – CaO2


PaO2 and SO2 mayy not ggive true estimate.
Low PaO2 but Oxygen Content still adequate . (V/Q imbalance)
Normal PaO2, still profound hypoxemia. (Anaemia, Altered affinity of Hb for O2 )
Calculated SaO2 may mislead & show false “normal” results. (CO, MHb )
(If no Co-oximeter in the machine, SaO2 is calculated from PaO2 , ODC)

Total Oxygen Content


CaO2 measured directly or calculated by O2 content equation.
CaO2 = Hb(gm%)
(g ) x 1.34 x SaO2 + 0.003 x PaO2((mmHg).
g)
Prof. A. K. Sethi, UCMS, Delhi

PaO2 = 89.2 mmHgg : seems normal


SaO2 = 97.3 % : seems normal

Correlate FiO2 of 60% with PaO2.


P O2 off 89
PaO 89.22 - very less
l th
than predicted
di t d (300)
(300).
→ Oxygenation impaired.
PaO2 60-100 : Corrected Hypoxaemia

CaO2 = 4.2 ml/dl : Very low (16-20)


Oxygenation grossly inadequate
Terminology for Acid Base Homeostasis
Prof. A. K. Sethi, UCMS, Delhi

Acidemia : Blood pH < 7.35


Acidosis :
→ A primary physiologic process that,
→ occurringg alone, tends to cause acidemia
(e.g., respiratory acidosis from hypoventilation
or metabolic acidosis from decreased pperfusion or shock))

Alkalemia : Blood ppH > 7.45


Alkalosis :
→ A primaryy physiologic
y g process that,
→ occurring alone, tends to cause alkalemia
(e.g., respiratory alkalosis from acute hyperventilation
or metabolic alkalosis from excessive diuretic therapy)
Prof. A. K. Sethi, UCMS, Delhi
……Terminology

Primary acid-base disorders


Respiratory Acidosis, Respiratory Alkalosis, Metabolic Acidosis, Metabolic Alkalosis

manifest as initial changes in PaCO2 or HCO3ˉ

First 
First Disorder Change Primary 
Primary Effect pH
Change disorder
Rises Respiratory
Respiratory  Acidemia Falls
PaCO2 Respiratory acidosis
Falls Respiratory 
p y Alkalemia Rises
alkalosis
Rises Metabolic  Alkalemia Rises
HCO3ˉ Metabolic alkalosis
Falls Metabolic Acidemia Falls
acidosis
Prof. A. K. Sethi, UCMS, Delhi
……Terminology

Compensation
when the acid-base imbalance exists over a period of time

S
Secondary changes in HCO
d h i HCO3ˉ or PaCO
ˉ P CO2

‐ occur in response to the primary event

‐ to normalize pH 

Done by the organ system which is not primarily affected 

‐ Respiratory compensation for metabolic disorders
Respiratory compensation for metabolic disorders

‐ Metabolic compensation for respiratory disorders
Step – 3 : Acid Base disturbances
Prof. A. K. Sethi, UCMS, Delhi

Anal se pH (First Impressi


Analyse Impression)
n)
pH Analysis
na ys s
7.35 – 7.45 Normal No acid-base disorder
Or, Compensated disorder
(7.4) (Mixed disorder)
< 7.35 Acidemia Uncompensated Acidosis
Or Partially compensated
Or,
> 7.45 Alkalemia Uncompensated Alkalosis
Or Partially compensated
Or,

Acidemia (p
(pH < 7.35)) Alkalemia (p
(pH >7.45))
Mild 7.30 – 7.34 7.46 – 7.50
Moderate 7.20 – 7.29 7.51 – 7.54
S
Severe < 7.2
72 > 7.55
7 55
Incompatible with life < 6.8 > 7.8
Prof. A. K. Sethi, UCMS, Delhi

Step – 4 Know the Primary disorder


- Respiratory
Respirat r orr Metabolic
Metab lic ?
Respiratory

Change Disorder PaCO2 pH Primary disorder

> 45 Respiratory acidosis
PaCO2 Respiratory
< 35  Respiratory alkalosis

3 If pH & PaCO2 move in opposite directions


– Primary defect is Respiratory.
Respiratory
If pH is not moving in opposite direction as PaCO2
– Primary
P i defect
d f t iis Not
N tRRespiratory
i t (M
(Metabolic).
t b li )
Prof. A. K. Sethi, UCMS, Delhi

......Step – 4
A l
Analyse th
the P Primary
i disorder
di d
- Respiratory or Metabolic ?
Metabolic
Change
h Disorder
i d HCO3ˉ pH Primary disorder
i di d
> 26 Metabolic alkalosis
HCO3ˉ Metabolic
(base) < 22 Metabolic acidosis

3 If pH moves in same direction as HCO3¯


– Primary defect is Metabolic

If pH moves in opposite direction as HCO3¯


– Primary defect is not Metabolic (Respiratory)
Prof. A. K. Sethi, UCMS, Delhi

Step
p – 5 : Analyse
y if Compensation
p ?

• Compensation - Body tries to bring pH towards normal, with time

• Lungs and kidneys are primary buffer response systems

• pH outside normal range – Uncompensated or Partially compensated

• pH in normal range – Fully compensated, or Mixed disorder,


(or no acid base disturbance)
Step – 6 : Calculate the Expected Compensation
Prof. A. K. Sethi, UCMS, Delhi

- Match it with actual report


Compensations – Base for Acid
(Formula for every 10 mmHg change in PaCO2)
Change in PaCO2 Disorder Compensation (Kidney)
10 mmHg Acute rise 1 mEq/L rise in HCO3
Respiratory acidosis
10 mmHg Chronic rise 4 mEq/L rise in HCO3
10 mmHg Acute fall 2 mEq/L fall in HCO3
Respiratory alkalosis
10 mmHg Chronic fall 4 mEq/L fall in HCO3

Compensations
p –Acid for Base
(Formula for every 1 mEq/L change in HCO3)
Change in HCO3 Disorder Compensation (Lungs)
1 mEq/L
E /L fall
f ll M b li acidosis
Metabolic id i 1 25 mmHg
1.25 H ffallll iin P
PaCO
CO2
1 mEq/L rise Metabolic alkalosis 0.75 mmHg rise in PaCO2

Match the Calculated Compensation with the Actual (Report)


Prof. A. K. Sethi, UCMS, Delhi

Step
p–7:
Find out if the Disorder is “Mixed” ?

(1) Check relative movement of both pairs


pH ≈ PaCO2 and pH ≈ HCO3
If both pairs are moving & in correct directions
– Mixed disorder

(2) Presume the Primary disorder to be Respiratory or


Metabolic Then analyse compensation
Metabolic.
If analysis supports no compensation – Mixed disorder
Prof. A. K. Sethi, UCMS, Delhi

Step – 8 : Unmask Hidden Metabolic Disorders


Use concept of Serum Electrolytes
Do not interpret any ABG data without Serum Electrolytes
(Na+, K+, Cl-, CO2)

3 Parameters need to be determined

1. Anion Gap and its change from normal (∆ AG)

2. Venous CO2 and its change from normal (∆ CO2)

3. Bicarbonate Gap (BG)


……Hidden Metabolic Disorders
Prof. A. K. Sethi, UCMS, Delhi

Anion Gap and its change from normal


AG = (Routinely measured Cations – Routinely measured Anions)
AG = (Na+ + K+) – (Cl- + HCO3)
AG = (Na+) – (Cl- + CO2)
Normal AG = 16 ± 4 mEq/L (12 ± 4 )
Change in AG from normal (Δ AG) = Measured AG – 12

Positive (+) or Elevated AG (> 16)


• Metabolic Acidosis
Negative (-) or Low AG
• Reduction in unmeasured Anions (Hypoprotienemia)
• Excess unmeasured Cations (Lithium Toxicity)
• Excess abnormal ‘+’vely charged proteins (Multiple Myeloma)
• Halide ion measured as Chloride (Bromism, Cough syrups)
……Hidden Metabolic Disorders
Prof. A. K. Sethi, UCMS, Delhi

Venous CO2 and its change from normal

Index of Plasma HCO3


Total CO2 = Plasma HCO3 + Dissolved CO2 in Plasma

Normal = 24 – 30 mEq/L (27 mEq/L)

Change in Venous CO2 from normal

(Δ CO2 ) = 27 – measured CO2


……Hidden Metabolic Disorders
Prof. A. K. Sethi, UCMS, Delhi

Bicarbonate Gap
Unmasks the co-existence of 2 metabolic disorders

BG = ∆ AG - ∆ CO2

BG = (Measured AG – 12) – (27 – Measured CO2)

Positive (+) or Elevated BG = > + 6 mEq/L


• Metabolic
M t b li AlkAlkalosis
l i
• Bicarbonate retention as compensation for Respiratory Acidosis

Negative (-) or Low BG = < – 6 mEq/L


• Metabolic Acidosis
• Bicarbonate excretion as compensation for Respiratory Alkalosis
Prof. A. K. Sethi, UCMS, Delhi

Steps
p (Summary)
y

Step – 1 : Check if the required parameters have been correctly fed?

Step – 2 : Analyse the Adequacy of Oxygenation.

St – 3 : Analyse
Step A l s pHH – Acidemia
A id i or Alkalemia?
Alk l i ?

Step – 4 : Analyse the Primary disorder - Respiratory or Metabolic ?

Step – 5 : Find if Compensation ?

Step – 6 : Calculate the Expected Compensation. Match it with actual.

Step – 7 : Find out if the Disorder is “Mixed”


Mixed ?

Step – 8 : Unmask Hidden Metabolic Disorders.


Prof. A. K. Sethi, UCMS, Delhi

Examples
Prof. A. K. Sethi, UCMS, Delhi

Example 1

Report pH PaCO2 HCO3¯


pH 7.22 N
PaCO2 55
Respiratory Acidosis,
HCO3¯ 25
U
Uncompensated
t d

1 pH = Low (7
1. (7.35
35 - 7.45,
7 45 77.4)
4) = Acidosis
2. PaCO2 = High (35 - 45, 40), Opposite direction than pH = Respiratory
3. HCO3¯ = Within Normal range (22 - 26, 24) = Not Metabolic
4 No secondary change (rise) in HCO3¯ = No compensation
4.
Prof. A. K. Sethi, UCMS, Delhi

Example 2

Report pH PaCO2 HCO3¯


pH 7.50 N
PaCO2 42
Metabolic Alkalosis,
HCO3¯ 33
Uncompensated

1 pH = High (7
1. (7.35
35 - 7.45,
7 45 77.4)
4) = Alkalosis
2. PaCO2 = Normal (35 - 45, 40), = Not Respiratory
3. HCO3¯ = High (22 - 26, 24), Moving in same direction = Metabolic
4 No secondary change (rise) in PaCO2 = No compensation
4.
Prof. A. K. Sethi, UCMS, Delhi
Example 3
Report Change from N pH PaCO2 HCO3¯
pH 7.32 - 0.08
PaCO2 32 -8
Metabolic Acidosis,
HCO3¯ 18 -6
Partially
y compensated
p
1. pH = Low (7.35 - 7.45, 7.4) = Acidosis
2. PaCO2 = Low (35 – 45, 40), Moving in same direction as pH
- Not Respiratory = Metabolic ?
3 HCO3¯ = Low (22 – 26,
3. 26 24) = Moving in same direction as pH = Metabolic
4. Secondary changes (Fall) in PaCO2 = Compensation by Lungs is on
5. Metabolic Acidosis – 1 mEq/L fall in HCO3 ≈ 1.25 mmHg fall in PaCO2
6. Estimated compensation (PaCO2) = - 6 x 1.25 = - 7.50 (Actual = - 8 mmHg)
7. pH - Not in normal range = Partial compensation
Prof. A. K. Sethi, UCMS, Delhi
Example 4
R
Report
t Ch
Change f
from N pH
H P CO2
PaCO HCO3¯
pH 7.35 0.05 N Range
PaCO2 48 +8 Respiratory Acidosis,
HCO3¯ 27 +3 Fully compensated
1. pH = Normal but lower side of range (7.35 - 7.45) = Acidosis
2 PaCO2 = Raised (35 - 45),
2. 45) Moving in the opposite direction to pH
= Respiratory
3 HCO3¯ = Raised (22 – 26) = Should move in same direction as pH,
3. pH
Here, moving in opposite direction to pH = Not Metabolic, Respiratory
4. Secondary change (Rise) in HCO3 = Compensation by Kidneys
5. pH near neutral, in the normal range (7.35) = Fully compensated Acidosis

Calculate Compensation now


Prof. A. K. Sethi, UCMS, Delhi

Report Change from N pH PaCO2 HCO3¯


pH
H 7 35
7.35 0 05
0.05 N
PaCO2 48 +8 Respiratory
RespiratoryAcidosis,
Acidosis,
HCO3¯ 27 +3 Ch Fully
Chronic,
F i ll Fully
Fcompensated
ll compensated
t d t d
Estimate
m Compensation
mp
For every 10 mmHg change in PaCO2
Disorder Change in PaCO2 Compensation (Kidney)
Respiratory acidosis 10 mmHg Acute rise 1 mEq/L rise in HCO3
10 mmHg Chronic rise 4 mEq/L rise in HCO3
Presume Acute Rise and Calculate compensation
Estimated HCO3 compensation for an acute 8 mmHg rise of PaCO2
= 1 x (+8)/10 = + 0.8
08³
Presume Chronic Rise and Calculate compensation
E ti t d HCO3 compensation
Estimated ti ffor a chronic
h i 8 mmHgH rise
i off P
PaCO
CO2
= 4 x (+8)/10 = + 3.2 3
Prof. A. K. Sethi, UCMS, Delhi
Example 5
pH PaCO2 HCO3¯
Report Change from N
N Range
pH 7.43 + 0.03
PaCO2 48 +8 Metabolic Alkalosis,
Alkalosis
HCO3¯ 36 + 12 Fully Compensated
1. pH = Normal, higher side of range (7.35 - 7.45) = Alkalosis
2. PaCO2 = Raised (35 – 45) = Should move in opposite direction to pH –
Moving in the same direction = Not Respiratory, Metabolic
3. HCO3¯ = Raised ((22 – 26)) = Should move in same direction as ppH.
Here, moving in same direction to pH = Metabolic
4. Seco
Secondary
da y cchanges
a ges ((Rise)
se) in PaCO
aCO2 = Co
Compensation
pe sat o by Lungs
u gs ((Hypo)
ypo)
5. pH = In the range of normal = Fully Compensated Alkalosis

Estimate Compensation now


Prof. A. K. Sethi, UCMS, Delhi
Example 5
pH PaCO2 HCO3¯
Report Change from N
N
pH 7.43 + 0.03
PaCO2 48 +8 Metabolic Alkalosis,
Alkalosis
≈Fully
FullyCompensated
compensated
HCO3¯ 36 + 10
- Reconfirmed
Estimate Compensation
Formula for every 1 mEq/L change in HCO3
Disorder Change in HCO3 Compensation (Lungs)
Metabolic acidosis 1 mEq/L
q fall 1.25 mmHgg fall in PaCO2
Metabolic alkalosis 1 mEq/L rise 0.75 mmHg rise in PaCO2

Estimated PaCO2 compensation for a 10 mEq/L rise of HCO3


= 10 x 0.75 = + 7.5 mmHg 3
Prof. A. K. Sethi, UCMS, Delhi
Example 6 (Mixed disorders)
pH PaCO2 HCO3¯
Report Change from N
pH 7.6 + 0.2
PaCO2 30 – 10 Mixed
d Respiratory
R Alkalosis
lk l with
h
HCO3¯ 30 +6 Metabolic Alkalosis

1. pH = High, (7.35 – 7.45) = Alkalosis


2. PaCO2 = Low ((35 – 45)) = Movingg in opposite
pp direction to ppH = Respiratory
p y
(Respiratory Alkalosis)
3. HCO3¯ = High
g ((22–26)) = Moves in same direction as ppH if Metabolic.
Moving in same direction = Metabolic (Metabolic Alkalosis)

Mixed Disorder ≈ Correct movement of both pairs


Prof. A. K. Sethi, UCMS, Delhi

Diagnosing Hidden Mixed Metabolic Disturbances


C
Concept
t of
f Using
U i Serum
S Electrolytes
El t l t (Na (N +, K+, Cl
Cl¯, CO2¯))
Example 7    (Mixed disorders)
Report Change from N pH PaCO2 HCO3¯
pH 7 46
7.46 + 0.06
0 06
PaCO2 30 – 10 Partially compensated
HCO3¯ 20 –4 R s i t
Respiratory Alk
Alkalosis
l sis
1. pH = Raised, (7.35 – 7.45) = Alkalosis
2. PaCO2 = Low, Should move opposite to pH – Moving = Respiratory
3. HCO3¯ = Low,, Should move in same direction as ppH – Not movingg in
same direction = Not Metabolic, Respiratory
4 Secondary changes (Fall) in HCO3 = Compensation by Kidney
4.
5. pH not normalized, Still > Normal Range, > 7.45 = Partially compensated
Prof. A. K. Sethi, UCMS, Delhi

Report Change from N pH PaCO2 HCO3¯


pH 7.46 + 0.06
PaCO2 30 – 10 Partially compensated
HCO3¯ 20 –4 R
Respiratory
i t Alk l i
Alkalosis Ch
Chronic
i

Estimate Compensation
Disorder Change in PaCO2 Compensation (Kidney)
Respiratory Acute fall by 10 mmHg 2 mEq/L fall in HCO3
Alkalosis Chronic fall by 10 mmHg 4 mEq/L fall in HCO3
P
Presumingi Acute
A t
Estimated HCO3 compensation for an acute 10 mmHg fall of PaCO2
= 2 x ((–10)/10
10)/10 = –22.00 ³
Presuming Chronic
Estimated HCO3 compensation for a chronic 10 mmHg fall of PaCO2
= 4 x (–10)/10 = – 4.0
Prof. A. K. Sethi, UCMS, Delhi

Is there any thing else to be done ?

3 more Parameters need to be determined

1. Anion Gap and its change from normal (∆ AG)

2. Venous CO2 and its change from normal (∆ CO2)

3. Bicarbonate Gap (BG)


Prof. A. K. Sethi, UCMS, Delhi

Equations needed

• AG = (Na+) – (Cl- + CO2)


• Normal AG = 12 ± 4 mEq/L
• ∆ AG = Measured AG – 12

• Normal CO2 = 24 – 30 mEq/L (27 mEq/L)


• ∆ CO2 = 27 – measured CO2

• BG = ∆ AG - ∆ CO2
• BG = (Measured AG – 12) – (27 – measured CO2)
Prof. A. K. Sethi, UCMS, Delhi

Report Change from N pH PaCO2 HCO3¯


pH 7.46 + 0.06
PaCO2 30 – 10 Partially compensated
HCO3¯ 20 –4 R
Respiratory
i t Alk l i
Alkalosis Ch
Chronic
i

Estimate Compensation
Disorder Change in PaCO2 Compensation (Kidney)
Respiratory Acute fall by 10 mmHg 2 mEq/L fall in HCO3
Alkalosis Chronic fall by 10 mmHg 4 mEq/L fall in HCO3
P
Presumingi Acute
A t
Estimated HCO3 compensation for an acute 10 mmHg fall of PaCO2
= 2 x ((–10)/10
10)/10 = –22.00 ³
Presuming Chronic
Estimated HCO3 compensation for a chronic 10 mmHg fall of PaCO2
= 4 x (–10)/10 = – 4.0
Prof. A. K. Sethi, UCMS, Delhi
Same Example 7 

Report • AG = (Na+) – (Cl- + CO2)


pH 7.46 = (150) – (102 + 20) = 150 – 122
= + 28 ( > 16 = Metabolic
M t b li Acidosis,
A id i with
ith AG)
PaCO2 30
• ∆ AG = 28 – 12 = +16
HCO3¯ 20
• ∆ CO2 = 27 – measured CO2
Na+ 150
∆ CO2 = 27 – 20 = +7
K+ 35
3.5
• BG = ∆ AG – ∆ CO2
Cl¯ 102
= (+16) – (+7)
CO2 20 = +9 (> +6 = Metabolic Alkalosis)
Respiratory Alkalosis
Partially compensated Metabolic Acidosis
Chronic Respiratory Alkalosis Metabolic Alkalosis
Vomiting for several days Developed Hypotension Hyperventilated
Hyperventilated, Compensation
Metabolic Alkalosis Lactic Acidosis Respiratory Alkalosis
Prof. A. K. Sethi, UCMS, Delhi
Example  8 

Report
ppH 7.40 N • AG = ((149)) – ((100 + 24)) = 149 – 124 = +25
PaCO2 38 N • ∆ AG = 25 – 12 = +13 ( Metabolic Acidosis)
HCO3¯ 24 N • ∆ CO2 = 27 – 24 = +33
Na+ 149 N • BG = ∆ AG – ∆ CO
2
K+ 3.8 N = (+13) – (+3)
Cl¯ 100 N = +10 ((> +6 = Metabolic Alkalosis))
CO2 24 N
pH (N), PaCO2 (N), HCO3 (N)
M
Metabolic
b li Acidosis
id i (U(Uremia)
i )
BUN 110
Metabolic Alkalosis (Diuretic)
Creatinine 87
8.7
Prof. A. K. Sethi, UCMS, Delhi

Best of Luck