arterial blood gases2

8/8/2019 ARTERIAL BLOOD GASES2

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Z C HA R MA I NE L . Y UM A NGS E P T E M B E R 2 0 1 0

ARTERIAL BLOOD GAS



ABG???

y Arterial blood gas analysis

is an essential part of diagnosing andmanaging a patient¶s oxygenation status and

acid-base balancemeasures the acidity (pH) and the levels of

oxygen and carbon dioxide in the blood froman artery

This test is used to check how well your lungsare able to move oxygen into the blood andremove carbon dioxide from the blood.



Acid Base Balance

The pH is a measurement of the acidity oralkalinity of the blood.It is inversely proportional to the number of

hydrogen ions (H+) in the blood.The more H+ present, the lower the pH will be.The fewer H+ present, the higher the pH will be.



Acid Base Balance

y Normal blood pH range is 7.35 to 7.45

In order for normal metabolism to take place, the body must maintain thisnarrow range at all times.

y pH <7.35 decrease in the force of cardiac contractions

decrease in the vascular response to catecholamines

diminished response to the effects and actions of certain medications

y

pH > 7.45 int erferes with ti ssue oxygenati on and normal neurological and muscular functioning.

y Extreme acid-base derangements will interfere with cellular functioning, and if uncorrected, will lead to death.



Maintenance of Acid Base Balance

y So how is the body able to self-regulate acid-base balance in order to maintain pH within the

normal range?

BUFFER SYSTEMS



Respiratory Buffer System

y A normal by-product of cellular metabolism is carbondioxide (CO2). CO2

y CO2 is carried in the blood to the lungs, where excessCO2 combines with water (H2O) to form carbonic acid

(H2CO3). CO2 + H2O = H2CO3y T he blood pH wi ll change accord ing t o the l evel o f

carboni c aci d present .

y This triggers the lungs to either increase or decrease the

rate and depth of ventilation until the appropriateamount of CO2 has been re-established.

y Activation of the lungs to compensate for an imbalancestarts to occur within 1 to 3 minutes.



Renal Buffer System

y In an effort to maintain the pH of the blood withinits normal range, the kidneys excrete or retain

bicarbonate HCO3

y blood pH decreases (acidic) - the kidneys willcompensate by retaining HCO3

y blood pH rises (alkalotic) - the kidneys excreteHCO3 through the urine



COMPONENTS



y pH

Measurement of acidity or alkalinity, based on the hydrogen(H+) ions present.

The normal range is 7.35 to 7.45



y PaO2

The partial pressure of oxygen that is dissolved in arterial blood.

It measures how well oxygen is able to move from the airspaceof the lungs into the blood.

The normal range is 80 to 100 mm Hg

Desired PaO2

Ù 80 ± YEARS ABOVE 60

Example 75 y/o Female

PaO2 = 80 ± (75-60) = 65



y SaO2

The arterial oxygen saturation.

Oxygen saturation measures how much of the hemoglobin in

the red blood cells is carrying oxygen (O2 The normal range is 95% to 100%.



y PaCO2

The amount of carbon dioxide dissolved in arterial blood.

how well carbon dioxide is able to move out of the body

The normal range is 35 to 45 mm Hg



y HCO3

The calculated value of the amount of bicarbonate in the bloodstream.

The normal range is 22 to 26 mEq/liter



ACID BASE DISORDERS



Respiratory Acidosis

y Low pH

y High PaCO2

y Primary increase in pCO2 resulting from alveolar

hypoventilation



Respiratory Acidosis

y Respiratory center depression Brainstem lesions narcotics, sedatives, or anesthesia

y Neuromuscular failure Impaired respiratory muscle function related to spinal cord injury,

neuromuscular diseases, or neuromuscular blocking drugsy Decreased compliance

Parenchymal (e.g pulmonary fibrosis, ARDS) Extraparenchymal (e.g. Abdominal distention, severe kyphoscoliosis)

y Increased airway resistance

COPD OSA

y Increased dead space Large pulmonary embolus



Respiratory Alkalosis

y High pH

y Low pCO2

y Primary decreased in pCO2 resulting from alveolar

hyperventilation




y Central nervous system stimulation Pain

Meningoencephalitis

SAH

Hepatic encephalopathy

y Hypoxemia Moderate asthma exacerbation

Acute pulmonary edema

Pulmonary embolus High altitude

pneumonia




y Drugs

Progesteroneµ

Salicylate poisoning

Xanthinesy Miscellaneous

Sepsis

Mechanical hyperventilation

pregnancy



Metabolic Acidosis

y Low pH

y low HCO3

y Primary decreased in plasma HCO3 due to either

HCO3 loss or accumulation of acid



Metabolic Acidosis

y High anion gap K etoacidosis ± diabetic, alcoholic, starvation

Lactic Acidosis

Intoxications ± e.g. Ethylene glycol, methanol, salicylate

Advanced Renal Failure Severe rhabdomyolysis

y Normal anion gap GI HCO3 loses (lower GI fistulas, diarrhea, ureterosigmoidostomy)

Renal tubular acidosis

Moderate renal insufficiency Acetazolamide use

Large volume saline resuscitation



Metabolic Alkalosis

y High pH

y High HCO3

y Primary increase in the plasma HCO3 due to either

H+ loss or HCO3 gain



Metabolic Alkalosis

y Chloride Responsive

Upper GI losses

Previous diuretic use

Recovery from chronic hypercapniay Chloride unresponsive

Effective mineralocorticoid excess

Current diuretic use

Bartter¶s or Gitelman¶s syndrome Severe hypokalemia

Excessive alkali administration



Steps on Dissecting Acid ± Base Disorder

y Step 1 : Predict what underlying mechanisms might be present based on the clinical scenario.




y Step 2: Verify that the ABG values are internally accurate

Simplified form of the Henderson-Hasselbach Equation:

[H+] (nmol/L) = 24 x pCO2 (mmHg) / [HCO3-] (meq/L)




y Step 3:

If the blood is alkalotic or acidotic, we now need todetermine if it is caused primarily by a respiratory or metabolicproblem.

A. Assess the PaCO2 level.

Remember that with a respiratory problem, as the pHdecreases below 7.35, the PaCO2 should rise. If the pH risesabove 7.45, the PaCO2 should fall.

Compare the pH and the PaCO2 values. If pH and PaCO2are indeed moving in opposit e d i recti ons, then the probl em i s

pri mari ly res pi rat ory in nat ure.




y Step 3:

B. Assess the HCO3 value. Recall that with a

metabolic problem, normally as the pH increases,the HCO3 should also increase. Likewise, as the pHdecreases, so should the HCO3.

Compare the two values. If they are moving in the same d i recti on, then the probl em i s primarily metabolic in nature.



CASE 1

y Jane Doe is a 45-year-old female admitted to thenursing unit with a severe asthma attack. She has

been experiencing increasing shortness of breath

since admission three hours ago.y Her arterial blood gas result is as follows:



y Follow the steps:

1. Clinical Prediction

2. Assess the pH.

3. Assess the PaCO2.

4. Assess the HCO3.



Aci d osi s i s present ( decreased pH) with the P aCO2 being increased, reflecting a primary res pi rat ory probl em.

For thi s pati ent , we need t o i m prove the venti l ati on status by providing oxygen therapy, mechanical ventilation, pulmonary toilet or by administering bronchodilators.



CASE 2

y John Doe is a 55-year-old male admitted to yournursing unit with a recurring bowel obstruction. Hehas been experiencing intractable vomiting for the

last several hours despite the use of antiemetics.



y Follow the steps:


2. Assess the pH.


4. Assess the HCO3.



Alkalosi s i s present ( increased pH) with the H CO 3 increased, ref l ecting a primary met abol i c probl em. T reat ment o f thi s pati ent mi ght incl ude the admini st rati on o f IV fluids and measures to reduce the excess base.



Compensation



Compensation

y body attempts to restore the normal blood pH duringan acid-base disorder

y compensation can be metabolic or respiratory in

origin



Respiratory Compensation

y Respiratory compensation

rapid process in which ventilation is adjusted to alter the pCO2

in response to a primary alteration in the [HCO3-].

Increased HCO3- levels will stimulate hypoventilation and a

subsequent rise in pCO2.

Decreased HCO3- levels will produce the opposite effect.

begins within seconds and can reach maximum effectiveness within 12-24 hours

Res pi rat ory com pensati on can never com pl et ely regain a normal blood pH. Other fact ors invol ved in venti l ati on cont rol , es peci ally the need f or oxygen, wi ll not allow f or full com pensati on.



Compensation

y Metabolic compensation is a slower process Occurs in two phases

Ù First phase involves intracellular non-bicarbonate buffers responsible for the first phase, which occurs immediately

Ù Second phase kidneys are responsible begins within hours, but takes 2 to 5 days to reach maximal

effectiveness kidneys achieve compensation by altering net bicarbonate

reabsoprtion and net acid excretion into the urine. Given enough time (up to 4 weeks) metabolic compensation may

be able to return the blood pH to normal in chronic respiratory disorders.2



y Metabolic disturbance ± lungs compensate

y Respiratory disturbance ± kidney regulate



CASE 3

y Mrs. L is a thin, elderly-looking 61 year old COPDpatient. She has an ABG done as part of her routinecare in pulmonary clinic.

y Her ABG shows the following results

pH : 7.37

CO2: 63

pO2 : 58 HCO3: 35

SaO2: 89%



y Follow the steps:


2. Assess the pH.


4. Assess the HCO3.



Clinical Prediction

y Thin

Decreased muscle mass leading to poor respiratory musclefunction

y

COP

D Interstitial damage/ bronchoconstriction decreased gas

exchanges increase CO2 retention

Interstitial damage/bronchoconstriction decreased gasexchnages decrease o2 entry

RESPIRATORY ACIDOSIS



1. pH - acidic

2. Assess the PaCO2 - increased

3. Assess the HCO3 - increased

y pH : 7.37

y CO2: 63

y HCO3: 35 Simple compensated respiratory acidosis

Full compensation is evidenced by the normal pH in spte of heracid/base disorder

This is her baseline and doesn¶t require treatment



Actual Patient

y JL 35y/o female came in to the ER due to shortness of breathy Desired Fio2

A= pCO2/ 0.8 B = (713 x del FiO2/100) ± A C = p02/B Des FiO2 = (des PO2/C) + A/ 713 x 100

Del FiO2Ù NC = (# LPM x 4) + 20Ù FM = (# LPM ± 1) x 10

y Mechanical ventilator with the following settings: TV: 450, FiO2:60, PF:60and BUR:20. Dormicum was discontinued.

y Arterial blood gas pH 7.64

pCO2 29.8 pO2 109.1 HCO3 21.6mechanical ventilation settings were adjusted to FiO2:40%, Peak flow 45 and BUR:14.

arterial blood gases2

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