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1) Given the following arterial blood gas values: pH: 7.

56 PaCO2: 31 mm Hg HCO3: 27 mEq/l PaO2: 56 mm Hg What is(are) the most likely acid-base state(s) in the patient? a) acute respiratory alkalosis b) chronic respiratory alkalosis c) respiratory alkalosis and metabolic alkalosis d) respiratory acidosis and metabolic acidosis e) respiratory alkalosis and metabolic acidosis

The subject is hyperventilating with an elevated pH, indicating respriratory alkalosis. However, with hyperventilation bicarbonate goes down from the simple excretion of CO2 in the hydration equation; CO2 + H2O <----> HCO3- + H+. As CO2 is excreted both bicarbonate and hydrogen ion fall. With simple hyperventilation and no other acid base disorder the HCO3- should fall slightly from the normal value of 24 mEq/L, and be about 22-23 mEq/L. In this example it is 27 mEq/L, indicating a comcomitant mild metabolic alkalosis.

2) A healthy young woman, toward the end of a mile run in the gym, has increased her heart rate by 50% over baseline. At that point, which one of the following statements is least likely to be true. a) She is tachypneic and/or hyperpneic. b) She is hyperventilating. c) Her alveolar ventilation is increased above its resting baseline value. d) Her CO2 production is increased above its resting baseline value. e) Her PaO2 is normal.

Hyperventilation is defined excess alveolar ventilation for CO2 production, which always leads to a low PaCO2 (if the subject starts from normal value of @40 mm Hg). It is NOT the same as tachypnea or hyperpnea. Since this healthy young woman has increased her heart rate with exercise, she has surely increased her CO2 production as well, and as a result her respiratory rate to blow it off. Thus she is tachypneic and or hyperpneic in order to increase her alveolar ventilation, which is necessary to excrete her excess metabolic CO2 production. She should NOT be hyperventilating though, as her increase in CO2 production will be balanced by increased alveolar ventilation, leaving PaCO2 unchanged. All of this is explained in the 4 Most Important Equations in Clinical Medicine (PaCO2 Equation).

3) Which of the following changes will most increase arterial oxygen delivery? a) PaO2 from 60 to 95 mm Hg b) cardiac output from 4 to 5 L/min c) hemoglobin from 9 to 10 grams% d) atmospheric pressure from 1 to 2 atmospheres e) arterial pH from 7.30 to 7.50

Oxygen delivery is oxygen content x cardiac output. a) This change in PaO2 will increase SaO2 from about 90% to 98%, in effect increasing CaO2 about 9% and O2 delivery about the same. b) This is a 25% increase in cardiac output, which will increase oxygen delivery 25%. c) This is an 11% increase in oxygen content, which will increase O2 delivery the same percentage, 11%. d) This change will increase PaO2 from about 100 to 200 mm Hg, for a neglible increase in SaO2 and oxygen content. e) This change will shift the O2 dissociation curve to the left and increase SaO2 slightly, perhaps by 2-3%.

4) Given the following arterial blood gas values: pH: 7.40 PaCO2: 20 mm Hg HCO3: 12 mEq/l What is(are) the most likely acid-base state(s) in the patient?

a) metabolic acidosis with full compensation b) respiratory alkalosis with full compensation c) metabolic acidosis and respiratory alkalosis d) metabolic acidosis and metabolic alkalosis e) normal acid-base state

A normal pH with abnormal PaCO2 or HCO3 indicates two or more acid base disorders. Full compensation (back to baseline) is never achieved with a single acid-base disorder.

5) All of the following are true about SpO2 as measured by pulse oximeters that utilize two wavelengths of light (i.e., most pulse oximeters in use today) except: a) Can can be normal even when PaCO2 is >200 mm Hg. b) Is not affected by anemia. c) Does not differentiate oxyhemoglobin from carboxyhemoglobin. d) Is not affected by excess methemoglobin. e) Requires a detectable pulse.

SpO2 falls in the presence of excess methemoglobin, approimately 1/2 percent for every percent of MetHb. Thus 10% MetHb will give about a 5% decline in SpO2. All the other statements are true.

6) All of the following are true about non-arterial assessment of oxygenation and acid-base balance except: a) if venous CO2 (measured as part of standard electrolyte panel) is truly abnormal, the patient has some type of acid-base disorder. b) in a hemodynamically stable patient, venous blood gases measured from central venous blood can be used to assess acid-base status. c) venous blood can be used in lieu of arterial blood to measure blood carboxyhemoglobin.

d) the bicarbonate gap, which is (Na+ - Cl- - 39), can diagnose a metabolic alkalosis even when there is increased anion gap. e) in a stable patient with normal lungs, the difference between PaCO2 and end-tidal PCO2 is 10 to 15 mm Hg.

In a normal person end tidal PCO2 is equal to PaCO2. All other statements are true.

7) One or more of the following statements (A, B, C) about PaO2 may be correct. Choose the single letter answer (a - e) that reflects which statement(s) is(are) correct. A) If the lungs and heart are normal, then PaO2 is affected only by factors that affect alveolar PO2. B) In a person with normal heart and lungs, anemia should not affect PaO2. C) The reason PaO2 falls with increasing altitude is because barometric pressure falls. a) only A) is correct. b) A) and B) are correct. c) A) and C) are correct. d) B) and C) are correct e) A), B) and C) are correct.

All 3 statements are correct.

8) A patient presents with the following arterial blood gases, drawn on room air (FIO2 = .21). pH: 7.40 PCO2: 40 mm Hg PO2: 82 mm Hg HCO3: 24 mEq/L

Which of the following statements is most accurate? a) The patient does not have an acid-base disorder. b) To determine if there is an acid base disorder you need to know the measured serum bicarbonate, since the HCO3 from blood gases is only a calculation. c) Need to know patient's respiratory rate, as PaCO2 may be inappropriately "normal" and signify a respiratory acidosis. d) A patient can have normal blood gases if two metabolic acid-base disorders oppose to give normal bicarbonate. e) The PaO2 is lower than predicted for a patient breathing room air.

Metabolic acidosis and metabolic alkalosis can co-exist, so the patient ends up with a normal HCO3 and PaCO2. Serum electrolytes can make the diagnosis by showing increased anion gap; in the presence of normal HCO3, increased AG would indicate the two disorders. See also Question 14.

9) A patient with respiratory failure has the following arterial blood gases (FIO2 = .21, sea level): pH: 7.20 PCO2: 70 mm Hg PO2: 60 mm Hg SaO2: 86% Which of the following is the least likely cause of these abnormal blood gases? a) congestive heart failure b) narcotic overdose c) myasthenia gravis d) flail chest e) Guillain Barre' Syndrome

All of these conditions can lead to respiratory acidosis, but congestive heart failure would be least likely to do so without increasing the A-a O2 difference. Alveolar PO2 in this example is .21(760-43) 1.2(PaCO2) = 150-84 = 66. Thus the (PAO2 - PaO2), or so-called 'A-a gradient' is normal at about 6 mm Hg. Since the other conditions can cause respiratory acidosis without involving the lung parenchyma, and thus without raising (PAO2 - PaO2), CHF is the correct answer.

10) A 42-year-old man is admitted to the hospital with dehydration and hypotension. Electrolytes show: Na+ 165 mEq/L K+ 4.0 mEq/L CO2 32 mEq/L Cl112 mEq/L

No arterial blood gas is obtained. Which statement best applies about this patient's acid-base status? a) Electrolytes indicate the presence of metabolic acidosis. b) Electrolytes indicate the presence of metabolic alkalosis. c) Electrolytes indicate the presence of both metabolic acidosis and metabolic alkalosis. d) Need serum albumin to make any clinically useful assessment of his metabolic acid-base disorders. e) Need serum lactate to make any clinically useful assessment of his metabolic acid-base disorders.

His anion gap is Na - (CO2 + Cl) = 165 - (32+112) = 21, indicating a metabolic acidosis. His bicarbonate gap is (Na - Cl - 39) = 165 - 112 - 39 = 14, which indicates a metabolic alkalosis. Note that it is not necessary to actually calculate a bicarbonate gap, since the elevated serum CO2 (32 mEq/L) in the presence of anion gap acidosis is enought to signify concomitant metabolic alkalosis. Of course without blood gas measurements you don't know which process is predominant, but it is clear from the electrolytes that both metabolic disorders are present. You don't need to measure albumin nor lactate to make this determination.

11) A 30-year-old man, previously healthy, is brought to the ED after suffering smoke inhalation. Measured carboxyhemoglobin is 20% and hemoglobin content = 15 gm%. He has following blood gas values:

PaO2: 80 mm Hg (on room air at sea level) PaCO2: 32 mm Hg pH: 7.34 SaO2: 96% (calculated) Exam shows clear lungs to auscultation and his chest x-ray is normal. From this information alone, you can determine that: a) His actual SaO2 is much lower than the calculated value. b) There is no lung abnormality present, though pulmonary disease could develop in the ensuing 24 hours. c) He has a mild metabolic acidosis associated with an increased anion gap. d) His arterial oxygen content is in the normal range. e) None of the above.

Given 20% carboxyhemoglobin, his actual SaO2 (which is the % of hemoglobin bound to oxygen) cannot be more than 80%. As to: b), a lung abnormality could be present, especially since his (PAO2-PaO2) is somewhat increased; c) no electrolyte information is given, so you don't know if he has an increased anion gap; d) no hemoglobin content is given, so you don't know his oxygen content; e) is incorrect, since a) is the answer.

12) Below are two sets of blood gases: Patient A: pH 7.48, PaCO2 34 mm Hg, PaO2 85 mm Hg, SaO2 95%, Hemoglobin 7 gm% Patient B: pH 7.32, PaCO2 74 mm Hg, PaO2 55 mm Hg, SaO2 85%, Hemoglobin 15 gm% Which is the most correct statement? a) B is more hypoxemic because PaO2 is lower than A. b) B is more hypoxemic because SaO2 is lower than A. c) A is more hypoxemic because A-a gradient is higher than B. d) A is more hypoxemic because O2 content is lower than B. e) The differences balance out and neither A nor B is more hypoxemic than the other.

Hypoxemia means low oxygen content in the blood. If you don't have oxygen content, then you might use PaO2 and/or SaO2 as a surrogate for assessing hypoxemia, but here you do have oxygen content information. The oxygen contents are (excluding contribution of dissolved O2): Patient A: 1.34 x 7 x .95 = 8.91 ml O2/dl Patient B: 1.34 x 15 x .85 = 17.09 ml O2/dl Clearly, Patient A is more hypoxemic despite having a higher PaO2 and SaO2 than Patient B.

13) State which one of the following situations would be expected to lower a patient's arterial PO2. 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 more than a normal amount of ventilation-perfusion imbalance

PaO2 is unaffected by anemia or anything to do with hemoglobin binding. PaO2 is a function of what's inhaled (Alveolar PO2) and the state of lung architecture; the latter is defined by ventilation-perfusion abnormality (which includes right to left shunting) and diffusion barrier to oxygen transfer. By far the most common cause of low PaO2 is ventilation-perfusion imbalance -- the mechanism in virtually all acute and chronic lung diseases.

14) A 40 year-old patient is admitted to the ICU with the following lab values:

BLOOD GASES pH: 7.40 PCO2: 38 mm Hg HCO3: 24 mEq/L PO2: 88 mm Hg (on room air) ELECTROLYTES, BUN & CREATININE Na: 149 mEq/L

K: 3.8 mEq/L Cl: 100 mEq/L CO2: 24 mEq/L BUN: 110 mg% Creatinine: 8.7 mg% Which statement best describes the disorder(s)?

a) Normal electrolytes, normal blood gases b) Abnormal electrolytes and abnormal blood gases c) Metabolic acidosis d) Metabolic alkalosis e) Metabolic acidosis and metabolic alkalosis

Electrolytes are not normal, since the anion gap is increased: AG = 149 - (100+24) = 25. Thus, there is at least a metabolic acidosis. Furthermore, since CO2 is "normal" at 24, desite an increased anion gap, there must also be a metabolic alkalosis. See also Question 8.

15) All of the following are true about cyanosis except: a) For cyanosis to manifest there needs to be 5 gm% of deoxygenated hemoglobin in the capillaries. b) Patients with normal hemoglobin manifest cyanosis at higher SaO2 values than patients with anemia. c) Cyanosis can be caused by excess methemoglobin, which is HbFe+3. d) For methemoglobin to cause cyanosis, the PaO2 generally has to be <80 mm Hg. e) Some drugs may cause cyanosis without causing vasoconstriction, or any impairment in PaO2, SaO2, or oxygen content.

Methemoglobin can cause cyanosis with a normal PaO2. All the other statements are true. See emedicine topic on cyanosis

16) Since the early 1980s, climbers have summited Mt. Everest without supplemental oxygen. Since the barometric pressure on the summit is only 253 mm Hg, summiting (without extra O2) has only been possible due to prolonged acclimitization at altitude and profound hyperventilation. Indeed, if a a climber maintained PaCO2 of 40 mm Hg and an alveolar-arterial PO2 difference of 5 mm Hg, what would be his/her theoretical PaO2? a) 25 mm Hg b) 15 mm Hg c) 5 mm Hg d) -5 mm Hg e) -10 mm Hg

Here you use the alveolar gas equation: PAO2 = .21 (253-47) - 1.2 (40) = 43 - 48 = - 5 mm Hg Since the alveolar-arterial PO2 difference is 5 mm Hg, that would make the arterial PO2 (PaO2) = -10 mm Hg! Climbers have summited without supplemental O2 by virtue of profound, sustained hyperventilation, to level of @ 7 mm Hg. Thus PAO2 = .21 (253-47) - 1.2 (7) = 43 - 8 = 35 mm Hg Again, since the alveolar-arterial PO2 difference is 5 mm Hg, that would gives a PaO2 on the summit of @ 30 mm Hg - extremely low but survivable.

17) All are true about excess carbon monoxide except: a) shifts the oxygen dissociation curve to the left b) lowers the PaO2 c) lowers the oxygen saturation d) lowers the arterial oxygen content e) is not accounted for when SaO2 is calculated from arterial blood gas measurements

CO shifts the O2 dissociation curve left-ward, lowers SaO2 and oxygen content, and is not accounted for in the calcuation of SaO2 from PaO2 measurement. CO does not affect PaO2.

18) A mountain climber ascends from sea level to 18,000 feet over a two day period, without supplemental oxygen. With ascent all of the following factors will decrease except: a) Fraction of inspired oxygen (FIO2) b) Barometric pressure c) PaO2 d) PaCO2 e) Arterial hydrogen ion concentration

FIO2 is the same at all breathable altitudes. The barometric pressure falls with altitude, and as a consequence PaO2 falls and the climber hyperventilates. Hyperventilation results in low PaCO2 and increased pH (reduced hydrogen ion concentration).

19) You are scuba diving to a depth of 99 feet in the ocean, breathing compressed air from a tank. At this depth, compared to the surface, your arterial PO2 will be approximately: a) the same b) 2x the surface value c) 3x the surface value d) 4x the surface value e) dependent on amount of air pressure in the tank

Each 33 feet of depth in sea water doubles the ambient pressure; thus at 99 feet of depth the ambient pressure is 4x the surface pressure, and PaO2 will be about 4x that at sea level.

20) While all of the following conditions could possibly be managed without measuring arterial blood gases, in which one would blood gases be most helpful? a) A 40-year-old woman suffering an asthma exacerbation. Her peak expiratory flow rate is 65% of predicted and SpO2 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 anti-hypertensive medications. Electrolyte measurements show: Na+ 148 mEq/L K+ 4.0 mEq/L CO2 24 mEq/L

Cl-

102 mEq/L

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: Glucose 750 mg% Na+ 135 mEq/L K+ 4.5 mEq/L CO2 10 mEq/L Cl100 mEq/L Urine 4+ ketones

e) A 25 year old woman comes to the ED with chest pain. She does not smoke. SaO2 is 96% on room air and V/Q scan is read as low probability for pulmonary embolism. EKG is normal.

The patient has an anion gap metabolic acidosis and a metabolic alkalosis (see also Questions 8 and 14). Blood gases will be helpful to determine which disorder is predominant. Patients a, b, d and e can be treated without measuring blood gases. Patient d, in particular, reflects a typical case of diabetic ketoacidosis, with anion gap of 25 mEq/L. It is not necessary to measure or follow blood gases in such a patient, as long as there is response to insulin along with a rise in AG and fall in serum CO2.

21) The factor 0.863 in the PCO2 equation: a) equates dissimilar units for CO2 production and alveolar ventilation into mm Hg used for PCO2. b) accounts for the difference between alveolar ventilation and total or minute ventilation. c) accounts for the dissolved fraction of carbon dioxide. d) factors in base excess. e) is not explained by any of the above.

The PaCO2 equation, PaCO2=VCO2/VA, results in units of mm Hg. The factor 0.863 converts CO2 production units (ml/min) and alveolar ventilation units (L/min) into mm Hg.

22) The limit of human hyperventilation is a PaCO2 of about 8 mm Hg. What is the highest PaO2 (mm Hg) a patient with normal lungs could achieve breathing room air (FIO2=.21) at sea level? a) 100 b) 122 c) 135 d) 142

e) 150

The abbreviated alveolar gas equation gas be used to answer this question: PAO2 = FIO2 (BP - 47) - 1.2 (PaCO2) PAO2 = .21 (760-47) - 1.2 (8) PAO2 = 149.7 - 9.6 = 140.1. Thus the alveolar PO2 is 140, but arterial PO2 will be somewhat lower due to the normal PAO2 - PaO2 difference. Assuming a normal PAO2-PaO2 of 5 mm Hg, the highest value would be about 135 mm Hg.

23) A 45 year-old-man is treated in a hyperbaric chamber for severe carbon monoxide toxicity. Assume he is breathing 100% oxygen at 3 atmospheres of pressure, that he has normal lungs, and that hemoglobin=15 gm%, carboxyhemoglobin=40%. What is his approximate arterial oxygen content in ml/dl? a) 10 b) 13 c) 15 d) 20 e) 21

Here you use the oxygen content equation. In this situation you need to include the contribution by PaO2, since it is considerably higher in a hyperbaric environment. Since the subject has normal lungs, PaO2 should be 3x normal PaO2 while breathing 100% oxygen. PaO2 on 100% oxygen with normal lungs should be around 600 mm Hg. Therefore at 3 atmospheres, PaO2 should be around 1800 mm Hg. Also, with 3 atmospheres of pressure at 100% oxygen, all the available hemoglobin binding sites will be fully saturated. However, since 40% of the sites are bound with CO (COHb = 40%), the actual SaO2 will only be 60%. Thus: CaO2 = 1.34 x Hgb x SaO2 + (.003 x PaO2) CaO2 = 1.34 x 15 x .60 + (.003 x 1800) CaO2 = 12.06 + 5.4 = 17.46 ml O2/dl Because this is between 15 and 20, either answer is accepted as correct.

24) Which one of the following statements is not true? a) If nothing else changes, as PaCO2 goes up alveolar PO2 and arterial PO2 go down. b) PaO2 is inversely related to blood pH: as pH goes up PaO2 also increases. c) If PaCO2 increases while HCO3- remains unchanged, pH always goes down. d) A high bicarbonate could reflect metabolic alkalosis or respiratory acidosis or metabolic acidosis+metabolic alkalosis. e) The SaO2 is related to hemoglobin-bound arterial oxygen content on a linear scale (i.e., a straight-line relationship).

While all the other relationships are physiologic, there is no such physiologic relationship between PaO2 and pH. True, if pH went up because of hyperventilation and the subject has normal lungs, then you would expect PaO2 to also increase. However, pH could go up because of metabolic alkalosis, which might lead to increased PaCO2 and a decreased PaO2. Or, the patient could hyperventilate and PaO2 could go down because of lung disease. There is simply no physiologic relationship that can predict direction of PaO2 when pH changes.

25) Which one of the following sets of blood gas values most likely represents a lab or transcription error? (PaCO2 and PaO2 in mm Hg, HCO3 in mEq/L, SaO2 in %. Assume all blood gases drawn at sea level.) pH PaCO2 HCO3 PaO2 SaO2 FIO2 a) 7.40 75 45 70 75 0.21 b) 7.22 20 8 160 98 0.50 c) 7.59 25 23 60 90 0.28 d) 6.65 265 28 200 96 1.00 e) 7.48 33 24 90 60 0.21

Answer: c 1 Answer: b 2 Answer: b 3

Answer: c 4 Answer: d 5 Answer: e 6 Answer: e 7 Answer: d 8 Answer: a 9 Answer: c 10 Answer: a 11 Answer: d 12 Answer: e 13 Answer: e 14 Answer: d 15 Answer: b 16 Answer: a 17 Answer: e 18 Answer: d 19 Answer: c 20

Answer: a 21 Answer: c 22 Answer: c or d 23 Answer: b 24 Answer: a* 25

Clinical Problem 8-4. A 53-year-old man initially presents to the emergency department with the following blood gas values: ARTERIAL BLOOD GASES FIO2 .21 PaO2 40 mm Hg PaCO2 50 mm Hg pH 7.51 HCO3- 39 mEq/L

At this point his acid-base disorder is best characterized as: a) metabolic alkalosis alone b) metabolic alkalosis plus respiratory acidosis c) respiratory acidosis with metabolic compensation d) can't be certain without more information He is found to have congestive heart failure and is treated with supplemental oxygen and diuretics. Three days later he is clinically improved, with pH 7.38, PaCO2 60 mm Hg, HCO3- 34 mEq/L, and PaO2 73 mm Hg (on FIO2 24%). How would you characterize his acid-base status now?

Clinical Problem 8-5. The following values are found in a 65-year-old patient.ARTERIAL BLOOD GASES VENOUS BLOOD MEASUREMENTS pH 7.51 Na + 155 mEq/L PaCO2 50 mm Hg K+ 5.5 mEq/L HCO3- 39 mEq/L Cl- 90 mEq/L CO2 40 mEq/L BUN 121 mg/dl Glucose 77 mg/dl

Which of the following most closely describes this patient's acid-base status? a) severe metabolic acidosis b) severe respiratory acidosis c) respiratory acidosis plus metabolic alkalosis d) metabolic alkalosis plus metabolic acidosis

e) respiratory acidosis plus respiratory alkalosis

Clinical Problem 8-6. A 52-year-old woman has been mechanically ventilated for two days following a drug overdose. Her arterial blood gas values and electrolytes, stable for the past 12 hours, show:ARTERIAL BLOOD GASES VENOUS BLOOD MEASUREMENTS pH 7.45 Na + 142 mEq/L PaCO2 25 mm Hg K+ 4.0 mEq/L Cl- 100 mEq/L CO2 18 mEq/L

Based on this information, how would you assess her acid-base status?

Clinical Problem 8-7. An 18-year-old college student is admitted to the ICU for an acute asthma attack, after not responding to treatment received in the emergency department. ABG values (on room air) show: pH 7.46, PaCO2 25 mm Hg, HCO3- 17 mEq/L, PaO2 55 mm Hg, SaO2 87%. Her peak expiratory flow rate is 95 L/min (25% of predicted value). Asthma medication is continued. Two hours later she becomes more tired and peak flow is < 60 L/minute. Blood gas values (on 40% oxygen) now show: pH 7.20, PaCO2 52 mm Hg, HCO3- 20 mEq/L, PaO2 65 mm Hg. At this point intubation and mechanical ventilation are considered. What is her acidbase status?

Clinical Problem 8-8. A 72-year-old man is admitted in shock, with 70 mm Hg systolic blood pressure. He has a history of chronic obstructive pulmonary disease, and his baseline ABG is 7.34, PaCO2 68 mm Hg, PaO2 65 mm Hg (on supplemental oxygen), HCO3- 36 mEq/L. He takes medication for a heart condition. Initial arterial blood gas results on admission (FIO2 .40) show: ARTERIAL BLOOD GASES pH 7.10 PaO2 35 mm Hg PaCO2 70 mm Hg SaO2 58% HCO3- 21 mEq/L

He is intubated. Repeat blood gases (on the same FIO2) show:ARTERIAL BLOOD GASES pH 7.30 PaO2 87 mm Hg PaCO2 40 mm Hg SaO2 98% HCO3- 19 mEq/L

Assuming his anion gap is elevated at 23 mEq/L, how would you described the acid-base changes?

Clinical Problem 8-9. In review, state whether each of the following statements is true or false. a) Metabolic acidosis is always present when the measured serum CO2 changes acutely from 24 to 21 mEq/L. b) In acute respiratory acidosis, bicarbonate initially rises because of the reaction of CO2 with water and the resultant formation of H2CO3. c) If pH and PaCO2 are both above normal, the calculated bicarbonate must also be above normal. d) An abnormal serum CO2 value always indicates an acid-base disorder of some type. e) The compensation for chronic elevation of PaCO2 is renal excretion of bicarbonate. f) A normal pH with abnormal HCO3- or PaCO2 suggests the presence of two or more acid-base disorders. g) A normal serum CO2 value indicates there is no acid-base disorder. h) Normal arterial blood gas values rule out the presence of an acid-base disorder

Clinical Problem 8-4. Here the answer must be d, "can't be certain without more information." If an acid-base disorder is found (from blood gas, electrolyte data), the next logical step is to determine the clinical causes(s). Elevated PaCO2, pH and HCO3- certainly suggest a metabolic alkalosis, but there are other possibilities. Isolated blood gas values should be viewed as a single point on a plot that can be arrived at from various pathways, and not as diagnostic of any particular acid-base disorder. Making a diagnosis of "metabolic alkalosis" solely on the basis of blood gas values has two potential pitfalls. PITFALL 1. It suggests a final diagnosis, which is not the case. There are several causes of metabolic alkalosis and the clinical reason has to be found and corrected. Acidosis and alkalosis, with their adjectives metabolic and respiratory, are analogous to "anemia" or "fever." Acidosis and alkalosis should always be viewed as manifestations of underlying clinical problems and never as clinical diagnoses in themselves. PITFALL 2. The patient may not have metabolic alkalosis or may have metabolic alkalosis plus another serious acid-base disorder. In fact, this patient"s initial blood gas values represent several clinical possibilities: uncomplicated metabolic alkalosis, chronic respiratory acidosis followed by acute hyperventilation (acute respiratory alkalosis), and respiratory acidosis complicated by metabolic alkalosis. For example, suppose the patient's pulmonary function tests and blood gas values were normal one week earlier and in the interval he had taken diuretics; a primary metabolic alkalosis would then be the most likely diagnosis. On the other hand, he could be a patient with chronic CO2 retention, e.g., PaCO2 60 mm Hg and pH 7.41; he then develops pneumonia and hyperventilates, lowering PaCO2 from 60 to 50 mm Hg and raising pH above normal. This last situation would reflect a state of chronic respiratory acidosis plus an acute increase in ventilation (respiratory alkalosis), not a primary metabolic alkalosis. Thus the patient could have an isolated metabolic problem, an isolated respiratory problem, or a combination. Only by a detailed clinical and laboratory history, including previous blood gas data if available, can the actual cause be determined. After treatment for congestive heart failure, his baseline arterial blood gas values reflect a state of chronic respiratory acidosis plus a mild metabolic alkalosis. In retrospect, his blood gas values on admission were the result of acute hyperventilation on top of chronic respiratory acidosis. Clinical Problem 8-5. The answer is d: metabolic alkalosis plus metabolic acidosis. A patient can have both vomiting (causing metabolic alkalosis) as well as uremia (causing metabolic acidosis) at the same time. This patient has renal failure (BUN 121 mg/dl) with the diagnosis of metabolic acidosis confirmed by the elevated anion gap (25 mEq/L). Despite the AG acidosis, serum CO2 is elevated at 40 mEq/L (bicarbonate gap is 26 mEq/L) indicating metabolic alkalosis. In this patient alkalosis is the dominant condition, hence the blood is alkalemic (pH 7.51). From the information provided one cannot rule out a primary respiratory acidosis as an additional problem. (After this patient recovered he showed no evidence of underlying lung disease. Sometimes it requires days or weeks of follow up to fully characterize acid base disorders.) Clinical Problem 8-6. This patient's blood gas values suggest a state of chronic respiratory alkalosis: very low PaCO2, slightly elevated pH. However this assessment does not indicate a specific diagnosis but only suggests possibilities. Accurate diagnosis must be made in conjunction with the clinical picture plus other

laboratory studies. Could this patient have a mixed problem respiratory alkalosis plus metabolic acidosis? Her anion gap is Na+ - (Cl- + CO2) = 142 - 118 = 24 mEq/L. The anion gap is elevated and indicates a metabolic acidosis. However, the acid-base disorder is not just metabolic acidosis since the blood is alkalemic. There is good evidence she has both metabolic acidosis and respiratory alkalosis, the latter disorder from excessive mechanical ventilation. The cause of metabolic acidosis must be looked for since it is not apparent from the information provided. Since the anion gap is elevated, the possibilities include lactic acidosis from hypoperfusion and drug-induced metabolic acidosis.

Clinical Problem 8-7. The patient initially had chronic respiratory alkalosis, resulting from several days of hyperventilation, during which time her kidneys had a chance to excrete bicarbonate and return the pH toward normal. Now her asthmatic condition has worsened; she has acutely hypoventilated. The second set of blood gas values reflects acute respiratory acidosis on top of a chronic respiratory alkalosis. Although her bicarbonate is low, there is no primary metabolic process and treatment must be aimed at her respiratory disorders. Clinical Problem 8-8. This patient has more than respiratory acidosis because the initial calculated bicarbonate is low (21 mEq/L). There is a concomitant metabolic acidosis, confirmed by an elevated anion gap. He has two causes of metabolic acidosis: shock and severe hypoxemia. After intubation he is ventilated down to a "normal" PaCO2 of 40 mm Hg, a de facto respiratory alkalosis, yet remains acidemic because his metabolic process (lactic acidosis) has not been corrected. The last set of blood gas values still shows metabolic acidosis and inadequate respiratory compensation, or what some people would call respiratory acidosis. NOTE: The terms "respiratory alkalosis" for his change in PaCO2 from 70 mm Hg to 40 mm Hg, and "respiratory acidosis" when his PaCO2 is 40 mm Hg with metabolic acidosis, are technically correct. However, as long as you understand the changes, and how they came about, it is not important how they are labeled; you could just as well use "hyperventilation" instead of "respiratory alkalosis," and "inadequate respiratory compensation" instead of "respiratory acidosis". Clinical Problem 8-9. a) false

b) true c) true d) true e) false f) true g) false

h) false

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