ABG INTERPRETATION

STEPWISE APPROACH

Obtain clues from the clinical setting Determine primary disorder Check the compensatory response Calculate the anion gap Calculate the delta/deltas Identify specific etiologies for the acidbase disorder Prescribe treatment

DETERMINE CLUES FROM THE CLINICAL SETTING

CLUES FROM CLINICAL SETTING

HIGH ANION GAP METABOLIC ACIDOSIS
Ketoacidosis dm, alcohol, starvation INH, methanol, lactic acid Renal failure Hypotension

CLUES FROM CLINICAL SETTING

NORMAL ANION GAP METABOLIC ACIDOSIS
Diarrhea RTA Interstitial nephritis Early renal failure Urinary tract obstruction

CLUES FROM CLINICAL SETTING

METABOLIC ALKALOSIS (urine Cl < 10 mEq/d) Vomiting Remote diuretic use Post hypercapnea Chronic diarrhea Cystic fibrosis

CLUES FROM CLINICAL SETTING

METABOLIC ALKALOSIS (urine Cl > 10 mEq/d) Bartters syndrome Severe potassium depletion Current diuretic use Hypercalcemia

DETERMINE PRIMARY DISORDER

Check the trend of the pH, HCO3, pCO2 The change that produces the pH is the primary disorder Hyperaldosteronism pH = 7.55Cushings syndrome pCO = 20 HCO = 19
3 2

ALKALOSIS

ACIDOSIS

ALKALOSIS

RESPIRATORY ALKALOSIS

CLUES FROM CLINICAL SETTING

RESPIRATORY ACIDOSIS
CHRONIC: ACUTE: COPD pneumonia

RESPIRATORY ALKALOSIS Hyperventilation

DETERMINE THE PRIMARY DISORDER

DETERMINE PRIMARY DISORDER

Check the trend of the pH, HCO3, pCO2 The change that produces the pH is the primary disorder pH = 7.25 HCO3 = 12 ACIDOSIS pCO2 = 30 ALKALOSIS

ACIDOSIS

METABOLIC ACIDOSIS

DETERMINE PRIMARY DISORDER

Check the trend of the pH, HCO3, pCO2 The change that produces the pH is the primary disorder pH = 7.25 HCO3 = 28 ALKALOSIS pCO2 = 60 ACIDOSIS

ACIDOSIS

RESPIRATORY ACIDOSIS

DETERMINE PRIMARY DISORDER

If the trend is the same, check the percent difference The bigger %difference is the 10 disorder (16-24)/24 = 0.33 (60-40)/40 = 0.5 pH = 7.25 HCO3 = 16 ACIDOSIS pCO2 = 60 ACIDOSIS

ACIDOSIS

RESPIRATORY ACIDOSIS

DETERMINE PRIMARY DISORDER

If the trend is the same, check the percent difference The bigger %difference is the 10 disorder (38-24)/24 = 0.58 (30-40)/40 = 0.25 pH = 7.55 HCO3 = 38 ALKALOSIS pCO2 = 30 ALKALOSIS

ALKALOSIS

METABOLIC ALKALOSIS

CHECK THE COMPENSATORY RESPONSE

COMPENSATORY RESPONSE
HENDERSEN-HASSELBACH EQUATION 24 x pCO2 H = ---------------HCO3 Metabolic or Respiratory Acidosis

COMPENSATORY RESPONSE
HENDERSEN-HASSELBACH EQUATION 24 x pCO2 H = ---------------HCO3 Metabolic or Respiratory Alkalosis

COMPENSATORY RESPONSE
METABOLIC ACIDOSIS
pCO2 = HCO3 x 1.2 + 2 HCO3 =12 HCO3 =7 pCO2 =14.4 40 = 25.6 pCO2 =20.4 40 = 19.6

COMPENSATORY RESPONSE
METABOLIC ALKALOSIS pCO2 = HCO3 x 0.7 + 2

HCO3 =35 HCO3 =40

pCO2 =7.7 + 40 = 47.7 pCO2 =11.2 + 40 = 51.2

COMPENSATORY RESPONSE
ACUTE RESPIRATORY ACIDOSIS HCO3 = pCO2 x 0.1

pCO3 =55 pCO3 =80

HCO3 =1.5 + 24 = 25.5 HCO3 =4 + 24 = 28

COMPENSATORY RESPONSE
CHRONIC RESPIRATORY ACIDOSIS HCO3 = pCO2 x 0.35

pCO3 =55 pCO3 =80

HCO3 =5.25 + 24 = 29.25 HCO3 =14 + 24 = 38

COMPENSATORY RESPONSE
RESPIRATORY ALKALOSIS HCO3 = pCO2 x 0.2

pCO3 =25 pCO3 =32

HCO3 =3 - 24 = 21 HCO3 =1.6 - 24 = 22.4

CALCULATE THE ANION GAP

ANION GAP
Na (HCO3 + Cl) = 12 + 4 Na = 135 Cl = 97 HCO3 = 15 RBS = 100 mg%

AG = 135 112 = 23

ANION GAP
Na (HCO3 + Cl) = 12 + 4
Na = 135 Cl = 97 HCO3 = 15 RBS = 500 mg%

Corrected Na = Na + RBS mg% -100 x 1.6

100
AG = 135 + 6.4 112 = 29.4

CHECK THE DELTA / DELTA

DELTA - DELTA

If with high AG metabolic acidosis

AG

HCO3

If with normal AG metabolic acidosis Cl HCO3

A high AG always indicates the presence of a HAG metabolic acidosis

DELTA - DELTA
/ = 1 / > 1 / < 1

Simple NAG metabolic acidosis HAGMA/NAGMA + meta alk HAGMA+NAGMA

CASE 1
56F with vomiting and diarrhea 3 days ago despite intake of loperamide. Her last urine output was 12 hours ago. PE showed BP = 80/60, HR = 110, RR = 28. There is poor skin turgor.

CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 15 crea = 177 RBS = 100 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90

BCR = BUN / crea x 247.6 = 21

PRE-RENAL

CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 15 crea = 177 RBS = 100 pH = acidosis, pCO2 =alk, HCO3 = acidosis pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90

Metabolic Acidosis

CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 15 crea = 177 RBS = 100 pCO2 = 9 x 1.2 = 10.8 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90

Compensated Metabolic Acidosis

CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 15 crea = 177 RBS = 100 AG= 130 (105+15) = 10 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90

NAGMA

CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 15 crea = 177 RBS = 100 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90

/= (105-100)/(24-15) = 0.56

NAGMA + HAGMA

CASE 1
56F with vomiting and diarrhea 3 days ago despite intake of loperamide. Her last urine output was 12 hours ago.
PE showed BP = 80/60, HR = 110, RR = 28. There is poor skin turgor. pH 7.30, HCO3=15, pCO2=30, Na=130 K=2.5 How will you correct the acid base disorder?

CASE 1
1) 2) 3) 4) Hydrate Hydrate + IV NaHCO3 Hydrate + oral NaHCO3 Hydrate + correct hypokalemia

How will you correct the acid base disorder?

INDICATIONS FOR HCO3 THERAPY

pH < 7.2 and HCO3 < 5 10 mmHg When there is inadequate ventilatory compensation Elderly on beta blockers in severe acidosis with compromised cardiac function Concurrent severe AG and NAGMA Severe acidosis with renal failure or intoxication

COMPLICATIONS OF HCO3 THERAPY

Volume overload Hypernatremia NaHCO3 50 ml = 45 mEq Na Hyperosmolarity NaHCO3 gr X tab = 7 mEq Na Hypokalemia Intracellular acidosis Causes overshoot alkalosis Stimulates organic acid production tissue O2 delivery

POTASSIUM CORRECTION

K deficit = (3.5 K)/0.27 x 100 Give of the deficit in 24 hours

K deficit = (3.5 2.5)/0.27 x 100 = 370

1 cc oral KCL = 1.33 mEq K 1 potassium durule = 10 mEq K

CASE 2
30M with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2= 45 K=4 HCO3 = 17 Cl = 98 %pCO2 =13, %HCO3 = 29 Metabolic Acidosis

CASE 2
30M with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2= 45 K=4 HCO3 = 17 Cl = 98 pCO2 =7 x 1.2 = 8.4 Metabolic & Respiratory Acidosis

CASE 2
30M with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2= 45 K=4 HCO3 = 17 Cl = 98 AG = 140 (98+17) = 25

HAGMA + RAc

CASE 2
30M with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2= 45 K=4 HCO3 = 17 Cl = 98 /= (25-12)/(24-17) = 1.9

HAGMA + MAlk + RAc

CASE 2
30M with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2= 45 K=4 HCO3 = 17 Cl = 98

How will you correct the acid base disorder?

CASE 2
1) IV NaHCO3 using HCO3 deficit 2) oral NaHCO3 at 1 mEq/kg/day 3) intubate 4) no treatment

How will you correct the acid base disorder?

CASE 2
HCO3 DEFICIT = (D A) x 0.5 x kg BW HCO3 deficit = (18 17) x 0.5 x 60 = 30
As HCO3 < 5-10, the Vd increases; hence use 0.7 to 0.1 dHCO3 = 15 - 18 Maintenance 1 mEq/day

How as you and the other base disorder? Give willboluscorrect the acid as drip in 24 hrs

PRINCIPLES OF HCO3 THERAPY

LACTIC ACIDOSIS

Primary effort should be improving O2 delivery Use NaCO3 only when HCO3 < 5 mmol/L In states of CO, raising the CO will have more impact on the pH In cases of low alveolar ventilation, ventilation to lower the tissue pCO2

PRINCIPLES OF HCO3 THERAPY

KETOACIDOSIS

Rate of H+ production is slow; NaHCO3 tx may just provoke severe hypokalemia Should be given if 1) severe hyperkalemia despite insulin 2) HCO3 < 5 mmol/L 3) worsening acidemia inspite of insulin

CASE 3
19F, fashion model, is surprised to find her K=2.7 mmol/L because she was normokalemic 6 months ago. She admits to being on a diet of fruit and vegetables but denies vomiting and the use of diuretics or laxatives. She is asymptomatic. BP = 90/55 with subtle signs of volume contraction.

CASE 3
serum Na K Cl HCO3 pH pCO2

Plasma 138 2.7 96 30 7.45 45

Urine 63 34 0 0 5.6

pH = alk, pCO2 =acidosis HCO3 = alkalosis

Metabolic Alkalosis

CASE 3
serum Na K Cl HCO3 pH pCO2

Plasma 138 2.7 96 30 7.45 45

Urine 63 34 0 0 5.6 Compensated Metabolic Alkalosis

pCO2 = 6 x 0.7 = 4.2

CASE 3
serum Na K Cl HCO3 pH pCO2

Plasma 138 2.7 96 30 7.45 45

Urine 63 34 0 0 5.6

AG= 138 (96+30) = 12

NAG

CASE 3
serum Na K Cl HCO3 pH pCO2

Plasma 138 2.7 96 30 7.45 45

Urine 63 34 0 0 5.6

What is the cause of the acid base disorder?

CASE 3
1) diuretic intake 2) surreptitious vomiting 3) diuretic intake 4) Bartters syndrome 5) Adrenal tumor 6) nonreabsorbable anion How should her acid-base disorder be managed? What is the cause of the acid base disorder?

CASE 3
1) correct hypokalemia
2) hydrate with NSS 3) administer acidyfing agent 4) give carbonic anhydrase inhibitor

How should her acid-base disorder be managed?

MANAGEMENT OF METABOLIC ALKALOSIS

Chloride repletion Potassium repletion Tx hypermineralocorticoidism Dialysis Carbonic anhydrase inhibitors Acidyfing agents HCl, NH4Cl

INDICATIONS OF HCl

pH > 7.55 and HCO3 > 35 with contraindications for NaCl or KCl use Immediate correction of metabolic alkalosis in the presence of hepatic encephalopathy, cardiac arrhythmias, digitalis intoxication When initial response to NaCl, KCl, or acetalozamide is too slow or too little

USE OF HCl

HCL requirement = (A D) x 0.5 x kg BW 0.1 0.2 N HCl solution = 100 200 mEq Do not exceed 0.2 mEq/kg/hour of HCl HCl = 1,380 mEq

HCO3 = 70 wt = 60 kg

CASE 4
73M with long standing COPD (pCO2 stable at 52-58 mmHg), cor pulmonale, and peripheral edema had been taking furosemide for 6 months. Five days ago, he had anorexia, malaise, and productive cough. He continued his medications until he developed nausea. Later he was found disoriented and somnolent

CASE 4
PE: BP 110/70, HR 110, RR 24, T=40 respiratory distress prolonged expiratory phase postural drop in BP drowsy, disoriented scattered rhonchi and rales BLFs distant heart sounds trace pitting edema

admission serum Na 136 K 3.2 Cl 78 HCO3 40 pH 7.33 pCO2 78 pO2 43 pH = acidosis pCO2 =acidosis, HCO3 = alk

CASE 4

after 48 hrs 139 3.9 86 38 7.42 61 56 Respiratory Acidosis

Respiratory Acidosis & M. Alkalosis

CASE 4
serum Na K Cl HCO3 pH pCO2 pO2

admission 136 3.2 78 40 7.33 78 43

after 48 hrs 139 3.9 86 38 7.42 61 56 = 24 + HCO

3

HCO3 = (55-40) x 0.35 = 5.25 HCO3 = (78-55) x 0.1 = 2.3

5.25 + 2.3 = 31.55

CASE 4
serum Na K Cl HCO3 pH pCO2 pO2

admission 136 3.2 78 40 7.33 78 43

after 48 hrs 139 3.9 86 38 7.42 61 56

How should this patient be managed?

CASE 4
1) intubation and mechanical ventilation 2) low flow oxygenation by nasal prong 3) oxygen by face mask 4) sodium bicarbonate infusion with KCl

How should this patient be managed?

MANAGEMENT OF RESPIRATORY ACIDOSIS

Correct underlying cause for hypoventilation effective alveolar ventilation intubate, mechanically ventilate Antagonize sedative drugs Stimulate respiration (e.g. progesterone) Correct metabolic alkalosis

CASE 5
42M, alcoholic, brought to the ER intoxicated. He was found at Rizal park in a pool of vomitus. PE showed unkempt and incoherent patient with a markedly contracted ECF volume. T=390 C with crackles on the RULF.

CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 12 crea = 120 RBS = 15 mmol/L pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38

BCR = (12/120) x 247.6 = 24.76

PRE-RENAL

CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 12 crea = 120 RBS = 15 mmol/L %pCO2 =38, %HCO3 = 18 pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38

Respiratory Alkalosis

CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 12 crea = 120 RBS = 15 mmol/L HCO3 = (40-25) x 0.2 = 3 pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38 Compensated Respiratory Alkalosis

CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 12 crea = 120 RBS = 15 mmol/L AG = 130 (80 + 20) = 30 pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38 HAGMA + RAlk

CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 12 crea = 120 RBS = 15 mmol/L pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38

What are the causes of his acid base disturbance?

CASE 5
1) aspiration pneumonia 2) alcohol ketoacidosis 3) vomiting

What are the causes of his acid base disturbance?

MANAGEMENT OF RESPIRATORY ALKALOSIS

Correct underlying cause of hyperventilation Rebreathe carbon dioxide Mechanical control of ventilation increase dead space decrease back up rate decrease tidal volume paralyze respiratory muscles

QUESTIONS?

Thank You