BLOOD GAS QUESTIONS WITH ANSWERS 1998

Lawrence Martin, M.D.

Chief, Division of Pulmonary and Critical Care Medicine Mr. Sinai Medical Center Cleveland, OH 44106 This Quiz ran from February through December, 1998. It is based on Dr. Martin's All You Really Need to Know to Interpret Arterial Blood Gases, 2nd edition, published February 1999 by Lippincott Williams & Wilkins. Click on the title to see the Preface and Table of Contents. The book is available for purchase from the publisher at 1-800-638-0672 or 1-410-528-4223 and at the following web sites:

Lippincott Williams & Wilkins Amazon.com

In these questions, the degree of difficulty ranges from 1 -5; (1 is easiest, 5 most difficult.) QUESTION FOR FEBRUARY 12, 1998 (degree of difficulty 2/5) Which patient is more hypoxemic, and why? Patient A: pH 7.48, PaCO 34 mm Hg, PaO 85 mm Hg, SaO 95%, Hemoglobin 7 gm%
2 2 2

Patient B: pH 7.32, PaCO 74 mm Hg, PaO 55 mm Hg, SaO 85%, Hemoglobin 15 gm%
2 2 2

Hint: Be specific -- this is not a question you guess at. ANSWER TO FEBRUARY 12 QUESTION The body needs oxygen molecules, so oxygen content takes precedence over partial pressure in determining degree of hypoxemia. In this problem the amount of oxygen molecules contributed by the dissolved fraction is negligible and will not affect the answer. Also, the PaCO2 and pH are not needed to answer the question. Patient A: Arterial oxygen content = .95 x 7 x 1.34 = 8.9 ml O2/dl Patient B: Arterial oxygen content = .85 x 15 x 1.34 = 17.1 ml O2/dl Patient A, with the higher PaO2 but the lower hemoglobin content, is more hypoxemic. Reference: O2 Content Equation QUESTION FOR FEBRUARY 18, 1998 True or False: The PO2 in a cup of water open to the atmosphere is always higher than the arterial PO2 in a healthy person (breathing room air) who is holding the cup.

ANSWER TO FEBRUARY 18 QUESTION (3/5) The PO2 in the cup of water is always higher. This is for several reasons. First, there is no barrier to oxygen diffusing into the water; thus the PO2 in the cup will be the same as the atmosphere, at sea level approximately 160 mm Hg. Second, there is no CO2 coming from the cup to dilute the oxygen, as there is in people. Third, there is no V-Q inequality or shunt; even healthy people have a difference between alveolar PO2 and arterial PO2 for this reason. Thus a healthy person and a cup of water exposed to the atmosphere at sea level would have PO2 values of about 100 mm Hg and 160 mm Hg, respectively. Reference: Alveolar Gas Equation QUESTION FOR FEBRUARY 25, 1998 (3/5) State which of the following situations would be expected to lower a patient's arterial PO2. There may be none, one, or more than one correct answer. a) anemia b) carbon monoxide poisoning c) an abnormal hemoglobin that holds oxygen with half the affinity of normal hemoglobin d) an abnormal hemoglobin that holds oxygen with twice the affinity of normal hemoglobin e) lung disease with intra-pulmonary shunting. ANSWER TO FEBRUARY 25 QUESTION Answer: Only e) lung disease. . . a) affects only content, not oxygen saturation or PO2. b) through d) affect only oxygen saturation and content, not PO2. Reference: O2 Content Equation QUESTION FOR MARCH 5, 1998 (Difficulty 5/5) A patient is admitted to the ICU with the following lab values: BLOOD GASES pH: 7.40 PCO2: 38 HCO3: 24 PO2: 72 ELECTROLYTES, BUN & CREATININE Na: 149 K: 3.8 Cl: 100 CO2: 24 BUN: 110 Creatinine: 8.7 What is(are) the acid-base disorder(s)? ANSWER TO MARCH 5 QUESTION

First, note that pH, PCO , calculated HCO and serum CO are all normal (and, in this case, the venous CO =
2 3 2 2

arterial HCO ). At first glance it appears there is no acid-base disorder, and that the only obvious abnormality is the markedly elevated BUN and creatinine. However, by going through the steps outlined in this section, a different picture emerges. Step 1: Anion gap AG = Na - (Cl + CO )= 149 - (100 + 24) = 25
2 + -

This high an AG indicates an anion gap metabolic acidosis. Step 2: Delta anion gap calculated AG 25 mEq/L normal AG = 12 mEq/L 25 - 12 = 13 mEq/L; this is the excess or delta anion gap Step 3: Delta serum CO
2

= normal CO - measured CO
2

2 2

=27 (average normal venous CO ) - 24 = 3 mEq/L Step 4: Bicarbonate Gap = delta AG - delta CO = 13 - 3 = 10 mEq/L This means the measured bicarbonate is 10 mEq/L higher than expected from the excess AG, indicating (in this case) a metabolic alkalosis. Thus this patient, with normal pH and PaCO , has BOTH metabolic acidosis and
2

metabolic alkalosis. The patient was both uremic (causing metabolic acidosis) and had been vomiting (metabolic alkalosis). Reference: "All You Really Need to Know to Interpret Arterial Blood Gases," 2nd Edition, Lippincott Williams & Wilkins. Anion Gap & Bicarbonate Gap QUESTION FOR MARCH 12, 1998 (Difficulty 1/5) What is the pH of a blood sample with HCO 24 mEq/L and PaCO 80 mm Hg?
3 2 -

a) 7.10 b) 7.30 c) 7.40 d) 7.50 e) 7.60 ANSWER FOR MARCH 12, 1998 This is a simple calculation from the Henderson-Hasselbalch equation; the answer is 7.1. Even without doing the calculation, it should be apparent that a very high PaCO2 and normal bicarbonate will give a very acidic pH, and that 7.10 is the closest fit.

Reference: Henderson-Hasselbalch Equation QUESTION FOR MARCH 19, 1998 (Difficulty 3/5). Since the early 1980s, climbers have summited Mt. Everest without supplemental oxygen. The barometric pressure on the summit has been measured at 253 mm Hg. Assuming a climber maintained normal PaCO2 of 40 mm Hg and a normal alveolar- arterial PO2 difference of 5 mm Hg, what would be his/her arterial PO2 at the summit breathing only pure mountain air? ANSWER FOR MARCH 19, 1998 Alveolar PO2 = PAO2 = .21(253-47) - 1.2 (40) PAO2 = 43.26 - 48 = - 4.74 or 5 mm Hg Alv-arterial PO2 difference of 5 mm Hg would give an arterial PO2 of -10 mm Hg, which means at this altitude all the arterial oxygen would diffuse out into the thin air and the climber would quickly succumb. The fact that the summit has been climbed without supplemental oxygen means that one or more of our assumptions is wrong. In fact there is profound HYPERventilation on the summit, to about 7.5 mm Hg PCO2. Plugging that value into the equation we get: PAO2 = 43.26 - 9 = 34.26 mm Hg. P(A-a)O2 = 34.26 - 5 = 29.26 mm Hg. While this PaO2 is incredibly low, it is survivable. So the estimated PaO2 of climbers at the summit is about 30 mm Hg; they are often dizzy, confused and short of breath, but several well-conditioned climbers have survived the summit without supplemental oxygen. Reference: Alveolar Gas Equation QUESTION FOR MARCH 29, 1998 (Difficulty 3/5). In the following completion statement about carbon monoxide, there may be none, one, or more than one correct response. Carbon monoxide: a) shifts the oxygen dissociation curve to the left b) lowers the PaO2 c) increases the P50 d) lowers the arterial oxygen content e) is always elevated in the blood of cigarette smokers ANSWER FOR MARCH 29, 1998 Correct responses are a), c), d) and e). Carbon monoxide does not lower the PaO2. QUESTION FOR APRIL 10, 1998 (Difficulty 3/5). Which statement is most correct about obtaining arterial blood gas in a patient with an acute asthma attack? a) Anyone coming to the emergency department with an acute asthma attack should have an arterial blood gas at the start of therapy. b) Peak flow or similar test of expiratory effort should be the guide, with a PF < 50% that doesn't improve with medication being one reasonable criterion to obtaining a blood gas. c) Blood gases should be obtained in any patient using accessory breathing muscles, irrespective of the peak flow. d) As long as pulse oximetry is adequate and the patient is alert, an arterial blood gas should not be necessary.

ANSWER FOR APRIL 10, 1998. b) Peak flow or similar test of expiratory effort should be the guide, with a PF < 50% that doesn't improve with medication being one reasonable criterion on when to obtain an arterial blood gas. As to a), not everyone being treated for asthma in the ER needs a blood gas; if the PF is above 50% of predicted, and the patient is improving, respiratory acidosis should not be present. Also, oxygenation can be assessed by pulse oximetry as long as there is no concern for carbon monoxide toxicity. As to c), the same answer applies. As to d) remember that pulse oximetry is an imperfect monitor of oxygenation, since the oxygen dissociation curve is almost flat above a PO2 of 60 mm Hg. When the patient is using nasal oxygen, the pulse oximetry saturation can be normal or near normal even though there is CO2 retention. One should use peak flow as the guide to air flow obstruction, not pulse oximetry or mental alertness. QUESTION FOR APRIL 20, 1998 (Difficulty 2/5). A physically-fit subject goes jogging for two miles. After 7 minutes and end of the first mile, her respiratory rate has doubled. She feels fine and anticipates no difficulty in completing the second mile. At the one mile point, based on your understanding of pulmonary physiology, you would expect her arterial blood to show: 1) Normal PCO2 and pH 2) Low PCO2 and high pH 3) High PCO2 and low pH 4) Low PCO2 and low pH 5) A low pH but the PCO2 can be either high or low, depending on her tidal volume. ANSWER FOR APRIL 20, 1998. 1) Normal PCO2 and pH. During the exercise described, both CO2 production and alveolar ventilation increase, keeping PCO2 and pH in the normal range. Reference: CO2 Equation QUESTION FOR MAY 25, 1998 (Difficulty 4/5). The bicarbonate gap is useful to determine if there is a mixed acid base disorder in patients with an elevated anion gap. It is the difference between the excess anion gap and the change in serum CO2. (NOTE: A useful shortcut to the bicarbonate gap is: BG = Na - Cl - 39.) Given the following set of electrolytes, calculate both the anion gap and the bicarbonate gap, then state the most likely acid-base disorder(s) from this information. Na: 153 K: 4.0 Cl: 100 CO2: 23 a) metabolic acidosis and metabolic alkalosis b) metabolic acidosis alone c) metabolic alkalosis alone d) chronic respiratory alkalosis e) normal acid-base state; need arterial blood gases to determine if there is an acid-base disorder ANSWER FOR MAY 25, 1998

a) metabolic acidosis and metabolic alkalosis Anion gap = Na - (Cl + CO2) = 153 - (100 + 23) = 30 mEq/L. Since normal anion gap is about 12 (+ or - 4) mEq/L, an AG of 30 indicates a definite anion gap metabolic acidosis. Bicarbonate gap determines if the measured serum CO2 is appropriate for the measured anion gap. The shortcut to the BG gives the following answer: Na - Cl - 39 = 153 - 100 - 39 = 14 mEq/L. Normal BG is about + or - 6 mEq/L. A value of 14 mEq/L indicates a serum CO2 inappropriately elevated for this anion gap, and therefore a concomitant metabolic alkalosis. For further explanation see Diagnosing Acid-Base Disorders from Serum Electrolytes: The Anion Gap and The Bicarbonate Gap QUESTION FOR JUNE 2, 1998 (Difficulty 3/5). State which of the following statements is true and which is false. Any of the five statements may be true or false. a) The fraction of inspired oxygen is the same at any altitude, from sea level to the summit of Mt. Everest. b) The barometric pressure is higher in a an open mine shaft 1000 feet below sea level than at sea level. c) Up to 10,000 feet altitude, the arterial PO2 of a mountain climber remains normal due to hyperventilation. d) The barometric pressure in the passenger cabin of airplanes is pressurized to sea level pressure. e) The PO2 of a scuba diver breathing compressed air at 60 foot depth is higher than at sea level. ANSWERS FOR JUNE 2, 1998 (Difficulty 3/5). a) True b) True c) False d) False; it is usually pressurized to an altitude of 7000-8000 feet. e) True QUESTION FOR FOR JUNE 10, 1998 (Difficulty 5/5). In the clinical setting, which of the following statements concerning blood gas physiology is(are) true? a) End-tidal PCO2 should always be higher than arterial PCO2. b) In a steady state situation, alveolar PO2 should always be higher than arterial PO2. c) The %oxyhemoglobin + %carboxyhemoglobin + %methemoglobin should never exceed 100%. d) The ratio of dead space to tidal volume should never exceed 1.0. e) The average airway pressure does not exceed barometric pressure in a spontaneously-breathing patient. ANSWERS FOR FOR JUNE 10, 1998. a) is false; End-tidal PCO2 should always be equal or lower than PaCO2. b) is true. c) is true. d) is true. e) is true; the average airway pressure is always equal to barometric pressure in a spontaneously-breathing patient. QUESTION FOR FOR JUNE 26, 1998 (Difficulty 2/5).

True or false: With aging, the alveolar-arterial PO2 difference normally increases, while the arterial PCO2 remains unchanged. ANSWER FOR JUNE 26, 1998. True. The arterial PO2 falls with age because of natural aging of the lung tissues and resulting ventilationperfusion imbalance. However, the alveolar PO2 is the same at any age, since it is a function of barometric pressure, PCO2, temperature and FIO2. Hence the alveolar-arterial PO2 difference increases with age. The arterial PCO2 doesn't change with age, since it is a function of the medullary brain stem, which stays intact. Reference: Alveolar Gas Equation QUESTION FOR JULY 6, 1998 (Difficulty 4/5). A patient has a PaO2 of 40 mm Hg and a measured SaO2 of 50%. Obviously, the SaO2 will be reduced to some extent because of the low PaO2. Is this the sole explanation for the SaO2 of 50%? If not, what else could contribute to cause an SaO2 of only 50% in this case? ANSWER FOR JULY 6, 1998 . No. If the low PaO2 was the only cause for the reduced SaO2, then the SaO2 should be about 75%, not 50%. Thus some other factor or factors are lowering the SaO2 besides the low PaO2. The list could include carbon monoxide poisoning, excess methemoglobin, or simply a right shift of the O2 dissociation curve. Reference: O2 Content Equation QUESTION FOR AUGUST 3, 1998 (Difficulty 4/5). You are scuba diving to a depth of 99 feet in the ocean. In this activity you are breathing compressed air from a tank. At this depth, compared to the surface, your arterial PO2 will be approximately: a) the same b) twice the surface value c) three times the surface value d) four times the surface value e) dependent on the amount of air pressure in the tank ANSWER FOR AUGUST 3, 1998. d) four times the surface value. This is because each 33 feet of sea water increases ambient pressure by one atmosphere. Thus at 33 feet the diver is under TWO atmospheres of pressure, at 66 feet THREE atmospheres, and at 99 feet FOUR atmospheres. Breathing compressed air at four atmospheres will approximately quadruple the sea level arterial PO2. QUESTION FOR AUGUST 17, 1998 (Difficulty 2/5). Which of the following conditions would be expected to derive THE LEAST benefit from hyperbaric oxygen therapy? a) Severe blood loss when transfusion cannot be given b) Cyanide poisoning c) Methemoglobin toxicity d) Severe respiratory acidosis e) Decompression sickness when the patient's PaO2 is normal ANSWER FOR AUGUST 17, 1998. d) Severe respiratory acidosis. Hyperbaric oxygen could even be detrimental by causing a reduction in minute ventilation and consequent worsening of respiratory acidosis. QUESTION FOR AUGUST 27, 1998 (Difficulty 1/5).

Which statement is most accurate concerning blood gases in pulmonary embolism (PE)? a) They are highly variable in PE and need not be obtained as long as SaO2 is adequate. b) A normal PaO2 rules out the diagnosis of PE for all practical purposes. c) A normal alveolar-arterial PO2 difference rules out the diagnosis of PE for all practical purposes. d) Five to 10% of patients with PE will have a normal alveolar-arterial PO2 difference, so the test can be an aid in ruling out the condition. e) A widened alveolar-arterial PO2 difference is one of the hallmarks of PE, and can help secure the diagnosis in difficult cases. ANSWER FOR AUGUST 27, 1998. d) Five to 10% of patients with PE will have a normal alveolar-arterial PO2 difference, so the test can be an aid in ruling out the condition. If the A-a PO2 difference is normal it serves as lab evidence arguing against - but not by itself ruling out pulmonary embolism. This is analagous to the popular D-Dimer test, which is positive in 90 to 95% of cases of PE. So a normal D-Dimer and normal A-a PO2 difference would argue strongly against the diagnosis of acute pulmonary embolism. Ultimately, lab tests (especially the V/Q scan) coupled with the clinical index of suspicion, will serve to make or discard the diagnosis in the vast majority of cases. QUESTION FOR SEPTEMBER 7, 1998 (Difficulty 5/5). The 'delta gap' or 'bicarbonate gap' is the difference between the change in anion gap and the change in serum CO2. Which of the following formulas can be used to quickly determine this useful 'gap'? a) Na - CO2 + 15 b) Na - Cl + 12 c) Na - Cl - 39 d) Na - CO2 + anion gap e) Na + CO2 - anion gap ANSWER FOR SEPTEMBER 7, 1998 (Difficulty 5/5). c) Na - CO2 - 39 The bicarbonate gap is the difference between the change in anion gap and the change in serum CO2. Thus bicarbonate gap = [Na - Cl - CO2 - 12] - [27 - CO2]. Cancelling out the CO2 values we get Na - Cl -139. Reference: "All You Really Need to Know to Interpret Arterial Blood Gases," 2nd Edition, Lippincott Williams & Wilkins. Anion Gap & Bicarbonate Gap QUESTION FOR SEPTEMBER 18, 1998 (Difficulty 4/5). A 54-year-old man with chronic obstructive pulmonary disease is seen in the Emergency Department for respiratory distress. He has the following arterial blood gases: pH 7.38, PCO2 70 mm Hg, PO2 35 mm Hg, SaO2 51%. At the same time, his oxygen saturation measured by pulse oximetry (SpO2) is 62%. Give TWO reasons why this patient likely has excess carbon monoxide in his blood. ANSWER FOR SEPTEMBER 18, 1998 . 1) His SaO2 of 51% is a direct measurement in the blood gas co-oximeter; as such it represents his true oxygen saturation. His SpO2 of 62% is from a pulse oximeter, which reads excess COHb as oxyhemoglobin. The fact that the SpO2 registers 62% vs. only 51% in the co-oximeter likely represents 11% COHb in this patient.

2) A PaO2 of 35 with a pH of 7.38 should give a true SaO2 of about 60%, not 51%. Thus the SaO2 is reduced for this PaO2, again most likely from excess COHb. Reference: All You Really Need to Know to Interpret Arterial Blood Gases, 2nd edition. QUESTION FOR OCTOBER 12, 1998 (Difficulty 5/5). A patient with acute respiratory distress syndrome (ARDS) is being managed with the following ventilator settings: Assist-Control Ventilation Ventilator set rate = 10 breaths/minute Total respiratory rate = 24 breaths/minute Exhaled tidal volume 750 ml PEEP 5 cm H20 FIO2 100% On these setting he has the following blood gases: pH 7.35 PaCO2 35 mm Hg PaO2 65 mm Hg SaO2 92% Because of patient agitation and some breathing discoordination, it is decided to paralyze the patient. Without changing any ventilator settings, what is the most likely scenario after paralysis? a) Oxygenation and ventilation will improve b) Oxygenation will be unpreditable but ventilation will stay the same c) Oxygenation will be unpredictable but ventilation will worsen d) Oxygenation will worsen but ventilation will be unpreditable. e) Oxygenation and ventilation will worsen. ANSWER FOR OCTOBER 12, 1998 e) Oxygenation and ventilation will worsen. By paralyzing the patient you effectively change respiratory rate from 24 full ventilator breaths/minute to 10 full ventilator breaths/minute. Thus it would be expected that both ventilation and oxygenation will worsen, i.e., his PaCO2 will go up and PaO2 will go down. QUESTION FOR OCTOBER 31, 1998 (Difficulty 2/5). Assuming a mountain climber ascends from sea level to 18,000 feet in a two day period. She does not use any supplemental oxygen. All of the following factors will change on ascent except one. a) Fraction of inspired oxygen (FIO2) b) Barometric pressure c) Climber's PaO2 d) Climber's PaCO2 e) Climber's pH ANSWER FOR OCTOBER 31, 1998 a) The FIO2 does not change with increasing altitude. People become hypoxemic and hyperventilate because of the steady decline in barometric pressure. QUESTION FOR November 16, 1998 (Difficulty 3/5). Which one of the following conditions, by itself, would not be expected to lead to a metabolic acidosis?

a) Severe diarrhea b) Acetazolamide therapy c) Hepatic encephalopathy d) Renal tubular acidosis e) Ethylene glycol poisoning ANSWER FOR November 16, 1998. c) Hepatic encephalopathy The other conditions classically give metabolic acidosis. QUESTION FOR December 31, 1998 (Difficulty 3/5). All of the following conditions can be managed without measuring arterial blood gases, except one. Which condition most requires measurement of arterial blood gases? a) A 40-year-old woman suffering an asthma attack. Her peak expiratory flow rate is 65% of predicted and pulse oximeter oxygen saturation is 95% on room air. b) A 17-year-old-high school student who presents to the ED with hyperpnea and tachypnea; history reveals he became "excited" during a church service. He has some tetanic contractions of his hands, his lungs are clear and pulse oxygen saturation is 98% on room air. c) A 68-year-old hypertensive patient has been feeling "weak" for a few days. She has been taking her antihypertensive medications. Electrolyte measurements show (all in mEq/L): Na 148 K 4.0 Cl 102 CO2 24 d) A 24-year-old insulin-dependent diabetic comes to the ED, complaining of lethargy; she has not used insulin in several days. Her pulse oximeter oxygen saturation on room air is 98%. Lab values show (electrolytes in mEq/L): Glucose 750 mg% Na 135 K 4.5 Cl 100 CO2 10 4+ ketones in urine ANSWER FOR December 31, 1998. c) A 68-year-old hypertensive patient has been feeling "weak" for a few days. She has been taking her anti-hypertensive medications. Electrolyte measurements show (all in mEq/L): Na 148 K 4.0 Cl 102 CO2 24 This patient has an elevated anion gap, of 24 mEq/L, indicating metabolic acidosis. In addition, she has an elevated bicarbonate gap: her serum CO2 of 24 is inppropriately elevated for this anion gap, so there is ALSO a lilely metabolic alkalosis. It is impossible to know which disorder is predominant, of if there is also a concomitant respiratory acidosis, without measuring arterial blood gases. Reference: "All You Really Need to Know to Interpret Arterial Blood Gases," 2nd Edition, Lippincott Williams & Wilkins. Anion Gap & Bicarbonate Gap Comment about the other choices: Answer 'a' is a mild asthmatic, who can be managed without blood gases. Answer 'b' is a young man with anxiety-hyperventilation syndrome, who should respond to rebreathing from a paper bag.

Answer 'd" is a patient with classic diabetic ketoacidosis, who can be managed without blood gases; what needs to be followed are the serum electrlytes, plus glucose.

END OF QUIZ. This Quiz ran from February through December, 1998. It is based on Dr. Martin's All You Really Need to Know to Interpret Arterial Blood Gases, 2nd edition, published February 1999 by Lippincott Williams & Wilkins. Click on the title to see the Preface and Table of Contents. The book is available for purchase from the publisher at 1-800-638-0672 or 1-410-528-4223 and at the following web sites:

Lippincott Williams & Wilkins Amazon.com

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Lawrence Martin, M.D.

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