TUTOR NOTES:

Add in your name and your hospital and date of tutorial.

TUTOR NOTES:

TUTOR NOTES:
You can give your own definition of an ABG. May be a good idea to
add in pictures of how ABG results are printed in your facility.

TUTOR NOTES:
May be worth mentioning that some books will give slightly different
normal values
For the purpose interpreting the metabolic component, HCO3 or
base excess can be used this lecture uses HCO3 as do most text
books
It may be useful to note importance of lactate particularly in
intensive care and sepsis.

TUTOR NOTES:
Although the definition of Hypoxia is 60 we tend to err on the
cautious side and aim for a pO2 of 75.
You may want to change the units to what is more common in your
facility.

TUTOR NOTES:
Base excess can be used as a quick guide for assessing progress in
acidosis and calculation of bicarbonate requirement.

TUTOR NOTES:
The balance of pH in the blood is maintained by buffers, the most
important of which is the CO2-HCO3 buffer system. This is
essentially an open system buffer where the body can control both
CO2 and HCO3 to manipulate the pH.

TUTOR NOTES:
CO2 levels can be altered by the respiratory system while the HCO3
levels can be altered by the renal system to control the amount of H
ion.

TUTOR NOTES:
With normal blood pH 7.35 to 7.45, it is really a very narrow range
for maintainence of physiological processes. It is fatal therefore
when blood pH falls in the extreme resulting in cessation of the
necessary physiological biochemical processes.

TUTOR NOTES:
Cellular metabolism produces CO2 which combines with water in
blood to produce carbonic acid which in turns lowers blood pH. By
controlling ventilation, we can control the amount of CO2 present in
blood and therefore to some extent the pH of blood.

TUTOR NOTES:
Blood pH can also be controlled by the kidneys by altering the
amount of HCO3 ion in the blood. HCO3 is a very effective buffer
against excess H ions and results in raised pH.

TUTOR NOTES:
Highlight that patients can tolerate certain amount of acidosis or
alkalosis, but almost certainly never hypoxia. And hypoxia have to
be interpreted with reference to the supplemental oxygen being
supplied. 75mmHg with HFM O2 15L/m would certainly indicate
need for intubation soon regardless of the other parameters.

TUTOR NOTES:
Quiz on normal values for pH here.

TUTOR NOTES:
Recall that CO2 becomes carbonic acid and therefore raised CO2 is
associated with acidosis and vice cersa.

TUTOR NOTES:
Remember that HCO3 is a base.

TUTOR NOTES:
Respiratory compensation taken place in a matter of moments.
Metabolic compensation starts within hours but takes days to
complete.
It is not often that compensation will return a pH to normal.
Patients never over compensate which means we can determine that
a patient with a pH of 7.37, pCO2 of 21 and HCO3 of 18 has a
metabolic acidosis with respiratory compensation rather than a
respiratory alkalosis with metabolic compensation (if it were that
way round then the pH would be ~ 7.45 or higher)

TUTOR NOTES:
It is not necessary for the house officers to memorise these formulas
but it would be good to highlight to them that using these formulas
we are able to come to conclusion regarding the adequacy of the
compensatory process and whether there are other ongoing process
for example metabolic acidosis from DKA and metabolic alkalosis
from dehydration and vomiting in the same patient.
You may use other formulas which you are more familiar with.

TUTOR NOTES:
The patient is hypoxic. A-a gradient of 250. Patient has a respiratory
acidosis with metabolic compensation however since metabolic
compensation is slow this must be because of his chronic condition
rather than a response to his acute rise in pCO2. Is the respiratory
acidosis being caused by the patient becoming tired or because of
suppression of hypoxic drive by the oxygen?
Treatment: Would turning down the O2 increase the respiratory
drive? The patient is already hypoxic (despite the O2), turning down
the oxygen at this point may be fatal. Get the students to think
about the general management of a patient like this,

TUTOR NOTES:
The patient is not hypoxic.
Metabolic acidosis with incomplete respiratory compensation. The
anion gap of 24 (n=10-18) gives an idea of the cause and the history
this is a classic case of DKA The pH in these patients can go even
lower. This patient will become tired with this respiratory rate if he is
not treated soon, the respiratory rate will slow down causing a rise in
pCO2 and the pH will get even worse as the attempt at
compensation fails.
Treatment: Fluids, fluids, fluids, correct the blood glucose with
insulin, observe the potassium! Restart substrate,i.e. glucose as the

TUTOR NOTES:
May help work out the cause of a metabolic acidosis.
Estimates the unmeasured anions by calculating the difference
between plasma cations and anions

TUTOR NOTES:
The patient is not hypoxic.
Respiratory alkalosis caused by hyperventilation brought on by
anxiety!!!
Treatment None.

TUTOR NOTES:
The patient is hypoxic (pO2<10) despite the O2. They have a
metabolic acidosis, there is an attempt at respiratory compensation
taking place which is incomplete.
This patient is also in shock get the students to think about what
type of shock this might be and how they would decide, could it be
cardiac, hypovolaemic, neuogenic, septic or anaphylactic. The
history is pointing us toward septic however this 75 year old could
just as easily have had a post operative MI, a reaction to antibiotics,
bleeding or had insufficient post op fluids.

TUTOR NOTES:
The patient is not hypoxic but does have a significant A-a gradient.
During the cardiac arrest the patient has been hypoperfused causing
a metabolic acidosis.
The acidosis is being compounded by the patients respiratory failure.
Treatment: The size of the A-a gradient might suggest aspiration
during the cardiac arrest. This with an unconscious patient and a
respiratory rate of 8 means this patient needs intubation and
ventilation. Why might the patient have arrested, might this happen
again? Have a discussion about the use of bicarbonate in acidosis,

TUTOR NOTES:
Very important since they must understand how delayed analysis
and heparin will affect the results. If you can, demonstrate with a
short video on point-of-care testing with the ICU ABG machine.

TUTOR NOTES:
Highlight the fact that most ABG taken in the wards by puncture of
artery in the awake, conscious patient tends to have some amount
of resp alkalosis. This worsens with multiple blood taking in difficult,
uncooperative patients.
Also, an ABG is a test result. We treat patients, not test results.