Transcript
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Marc D. Berg, MD DeVos Childrens Hospital
Rita R. Ongjoco, DO Sinai Hospital of Baltimore
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ABG InterpretationABG Interpretation
First, does the patient have an acidosis or anFirst, does the patient have an acidosis or analkalosisalkalosis
Second, what is the primary problemSecond, what is the primary problem
metabolic or respiratorymetabolic or respiratory Third, is there any compensation by theThird, is there any compensation by the
patientpatient respiratory compensation isrespiratory compensation isimmediate while renal compensation takesimmediate while renal compensation takestimetime
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ABG InterpretationABG Interpretation
It would be extremely unusual for either theIt would be extremely unusual for either the
respiratory or renal system torespiratory or renal system to
overcompensateovercompensate
The pH determines the primary problemThe pH determines the primary problem
After determining the primary andAfter determining the primary and
compensatory acid/base balance, evaluatecompensatory acid/base balance, evaluate
the effectiveness of oxygenationthe effectiveness of oxygenation
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Normal ValuesNormal Values
pH 7.35 to 7.45pH 7.35 to 7.45
paCOpaCO22 36 to 44 mm Hg36 to 44 mm Hg
HCOHCO33 22 to 26 meq/L22 to 26 meq/L
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Abnormal ValuesAbnormal Values
pH < 7.35pH < 7.35
yy Acidosis (metabolic and/orAcidosis (metabolic and/or
respiratory)respiratory)
pH > 7.45pH > 7.45yy Alkalosis (metabolic and/orAlkalosis (metabolic and/or
respiratory)respiratory)
paCOpaCO22 > 44> 44 mmHgmmHg
yy Respiratory acidosisRespiratory acidosis
(alveolar hypoventilation)(alveolar hypoventilation)
paCOpaCO22 < 36< 36 mmHgmmHg
yy Respiratory alkalosisRespiratory alkalosis
(alveolar hyperventilation)(alveolar hyperventilation)
HCOHCO33 < 22 meq/L< 22 meq/Lyy Metabolic acidosisMetabolic acidosis
HCOHCO33 > 26 meq/L> 26 meq/L
yy Metabolic alkalosisMetabolic alkalosis
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Putting It TogetherPutting It Together -- RespiratoryRespiratory
SoSo
paCOpaCO22 > 44 with a pH < 7.35 represents a> 44 with a pH < 7.35 represents arespiratory acidosisrespiratory acidosis
paCOpaCO22 < 36 with a pH > 7.45 represents a< 36 with a pH > 7.45 represents arespiratory alkalosisrespiratory alkalosis
For a primary respiratory problem, pH andFor a primary respiratory problem, pH andpaCOpaCO22 move in the opposite directionmove in the opposite direction
yy For each deviation in paCOFor each deviation in paCO22 of 10 mm Hg in eitherof 10 mm Hg in eitherdirection, 0. 08 pH units change in the oppositedirection, 0. 08 pH units change in the oppositedirectiondirection
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Putting It TogetherPutting It Together -- MetabolicMetabolic
AndAnd
HCOHCO33 < 22 with a pH < 7.35 represents a< 22 with a pH < 7.35 represents ametabolic acidosismetabolic acidosis
HCOHCO33 > 26 with a pH > 7.45 represents a> 26 with a pH > 7.45 represents ametabolic alkalosismetabolic alkalosis
For a primary metabolic problem, pH andFor a primary metabolic problem, pH and
HCOHCO33 are in the same direction, and paCOare in the same direction, and paCO22is also in the same directionis also in the same direction
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CompensationCompensation
The bodys attempt to return the acid/baseThe bodys attempt to return the acid/base
status to normal (i.e. pH closer to 7.4)status to normal (i.e. pH closer to 7.4)
Primary ProblemPrimary Problem CompensationCompensation
respiratory acidosisrespiratory acidosis metabolic alkalosismetabolic alkalosis
respiratory alkalosisrespiratory alkalosis metabolic acidosismetabolic acidosis
metabolic acidosismetabolic acidosis respiratory alkalosisrespiratory alkalosis
metabolic alkalosismetabolic alkalosis respiratory acidosisrespiratory acidosis
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Expected CompensationExpected Compensation
Respiratory acidosisRespiratory acidosis
AcuteAcute
yy
thethe pH decreases 0.08 units for every 10 mm HgpH decreases 0.08 units for every 10 mm Hgincrease in paCOincrease in paCO22;;
yy HCOHCO33 oo0.10.1--1 mEq/liter per1 mEq/liter peroo10 mm Hg paCO10 mm Hg paCO22
ChronicChronic
yy thethe pH decreases 0.03 units for every 10 mm HgpH decreases 0.03 units for every 10 mm Hgincrease in paCOincrease in paCO22;;
yy HCOHCO33 oo1.11.1--3.5 mEq/liter per3.5 mEq/liter peroo10 mm Hg paCO10 mm Hg paCO22
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Expected CompensationExpected Compensation
Respiratory alkalosisRespiratory alkalosis
AcuteAcute
yy
thethe pH increases 0.08 units for every 10 mm HgpH increases 0.08 units for every 10 mm Hgdecrease in paCOdecrease in paCO22;;
yy HCOHCO33 qq00--2 mEq/liter per2 mEq/liter perqq10 mm Hg paCO10 mm Hg paCO22
ChronicChronic
yy thethe pH increases 0.17 units for every 10 mm HgpH increases 0.17 units for every 10 mm Hgdecrease in paCOdecrease in paCO22;;
yy HCOHCO33 qq2.12.1--5 mEq/liter per5 mEq/liter perqq10 mm Hg paCO10 mm Hg paCO22
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Expected CompensationExpected Compensation
Metabolic acidosisMetabolic acidosis
paCOpaCO22 = 1.5(HCO= 1.5(HCO33) + 8 () + 8 (ss2)2)
paCOpaCO22 qq11--1.5 per1.5 perqq1 mEq/liter HCO1 mEq/liter HCO33Metabolic alkalosisMetabolic alkalosis
paCOpaCO22 = 0.7(HCO= 0.7(HCO33) + 20) + 20 ((ss1.5)1.5)
paCOpaCO22oo
0.50.5--1.0 per1.0 peroo
1 mEq/liter HCO1 mEq/liter HCO33
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Classification of primary acidClassification of primary acid--basebase
disturbances and compensationdisturbances and compensation
Acceptable ventilatory and metabolic acidAcceptable ventilatory and metabolic acid--basebasestatusstatus
Respiratory acidosis (alveolar hypoventilation)Respiratory acidosis (alveolar hypoventilation) --
acute, chronicacute, chronic Respiratory alkalosis (alveolar hyperventilation)Respiratory alkalosis (alveolar hyperventilation)
-- acute, chronicacute, chronic
Metabolic acidosisMetabolic acidosis uncompensated,uncompensated,
compensatedcompensated Metabolic alkalosisMetabolic alkalosis uncompensated, partiallyuncompensated, partially
compensatedcompensated
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Acute Respiratory AcidosisAcute Respiratory Acidosis
paCOpaCO22 is elevated and pH is acidoticis elevated and pH is acidotic
The decrease in pH is accounted for entirelyThe decrease in pH is accounted for entirely
by the increase in paCOby the increase in paCO22
Bicarbonate and base excess will be in theBicarbonate and base excess will be in the
normal range because the kidneys have notnormal range because the kidneys have not
had adequate time to establish effectivehad adequate time to establish effective
compensatory mechanismscompensatory mechanisms
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Acute Respiratory AcidosisAcute Respiratory Acidosis
CausesCauses
yy Respiratory pathophysiologyRespiratory pathophysiology -- airway obstruction,airway obstruction,
severe pneumonia, chest trauma/pneumothoraxsevere pneumonia, chest trauma/pneumothorax
yyAcute drug intoxication (narcotics, sedatives)Acute drug intoxication (narcotics, sedatives)
yy Residual neuromuscular blockadeResidual neuromuscular blockade
yy CNS disease (head trauma)CNS disease (head trauma)
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Chronic Respiratory AcidosisChronic Respiratory Acidosis
paCOpaCO22 is elevated with a pH in theis elevated with a pH in the
acceptable rangeacceptable range
Renal mechanisms increase the excretion ofRenal mechanisms increase the excretion of
HH++ within 24 hours and may correct thewithin 24 hours and may correct the
resulting acidosis caused by chronicresulting acidosis caused by chronic
retention of COretention of CO22 to a certain extentto a certain extent
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Chronic Respiratory AcidosisChronic Respiratory Acidosis
CausesCauses
yy Chronic lung disease (BPD, COPD)Chronic lung disease (BPD, COPD)
yy Neuromuscular diseaseNeuromuscular disease
yy Extreme obesityExtreme obesity
yy Chest wall deformityChest wall deformity
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Acute Respiratory AlkalosisAcute Respiratory Alkalosis
paCOpaCO22 is low and the pH is alkaloticis low and the pH is alkalotic
The increase in pH is accounted for entirelyThe increase in pH is accounted for entirely
by the decrease in paCOby the decrease in paCO22
Bicarbonate and base excess will be in theBicarbonate and base excess will be in the
normal range because the kidneys have notnormal range because the kidneys have not
had sufficient time to establish effectivehad sufficient time to establish effective
compensatory mechanismscompensatory mechanisms
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Respiratory AlkalosisRespiratory Alkalosis
CausesCauses
yy PainPain
yy AnxietyAnxiety
yy HypoxemiaHypoxemiayy Restrictive lungRestrictive lung
diseasedisease
yy Severe congestiveSevere congestive
heart failureheart failure
yy Pulmonary emboliPulmonary emboli
yy DrugsDrugs
yy SepsisSepsis
yy FeverFever
yyThyrotoxicosisThyrotoxicosis
yy PregnancyPregnancy
yy OveraggressiveOveraggressive
mechanicalmechanical
ventilationventilation
yy Hepatic failureHepatic failure
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Uncompensated Metabolic AcidosisUncompensated Metabolic Acidosis
Normal paCONormal paCO22, low HCO, low HCO33, and a pH less, and a pH lessthan 7.30than 7.30
Occurs as a result of increased production ofOccurs as a result of increased production of
acids and/or failure to eliminate these acidsacids and/or failure to eliminate these acids Respiratory system is not compensating byRespiratory system is not compensating by
increasing alveolar ventilationincreasing alveolar ventilation(hyperventilation)(hyperventilation)
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Compensated Metabolic AcidosisCompensated Metabolic Acidosis
paCOpaCO22 less than 30, low HCOless than 30, low HCO33, with a pH of, with a pH of
7.37.3--7.47.4
Patients with chronic metabolic acidosis arePatients with chronic metabolic acidosis are
unable to hyperventilate sufficiently to lowerunable to hyperventilate sufficiently to lower
paCOpaCO22 for complete compensation to 7.4for complete compensation to 7.4
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Metabolic AcidosisMetabolic Acidosis
Elevated Anion GapElevated Anion Gap
CausesCauses
yy KetoacidosisKetoacidosis -- diabetic, alcoholic, starvationdiabetic, alcoholic, starvation
yy Lactic acidosisLactic acidosis -- hypoxia, shock, sepsis, seizureshypoxia, shock, sepsis, seizures
yy Toxic ingestionToxic ingestion salicylates, methanol, ethylenesalicylates, methanol, ethylene
glycol, ethanol, isopropyl alcohol, paraldehyde,glycol, ethanol, isopropyl alcohol, paraldehyde,
toluenetoluene
yy Renal failureRenal failure -- uremiauremia
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Metabolic AcidosisMetabolic Acidosis
Normal Anion GapNormal Anion Gap
CausesCausesyy Renal tubularRenal tubular
acidosisacidosis
yy Post respiratoryPost respiratoryalkalosisalkalosis
yy HypoaldosteronismHypoaldosteronism
yy Potassium sparingPotassium sparing
diureticsdiuretics
yy Pancreatic loss ofPancreatic loss of
bicarbonatebicarbonate
yy DiarrheaDiarrhea
yy Carbonic anhydraseCarbonic anhydrase
inhibitorsinhibitors
yy Acid administrationAcid administration
(HCl, NH(HCl, NH44Cl, arginineCl, arginine
HCl)HCl)
yy SulfamylonSulfamylon
yy CholestyramineCholestyramine
yy Ureteral diversionsUreteral diversions
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Effectiveness of OxygenationEffectiveness of Oxygenation
Further evaluation of the arterial blood gasFurther evaluation of the arterial blood gas
requires assessment of the effectiveness ofrequires assessment of the effectiveness of
oxygenation of the bloodoxygenation of the blood
HypoxemiaHypoxemia decreased oxygen content ofdecreased oxygen content ofbloodblood -- paOpaO22 less than 60 mm Hg and theless than 60 mm Hg and the
saturation is less than 90%saturation is less than 90%
HypoxiaHypoxia inadequate amount of oxygeninadequate amount of oxygen
available to or used by tissues for metabolicavailable to or used by tissues for metabolic
needsneeds
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Mechanisms of HypoxemiaMechanisms of Hypoxemia
Inadequate inspiratory partial pressure ofInadequate inspiratory partial pressure of
oxygenoxygen
HypoventilationHypoventilation
Right to left shuntRight to left shunt
VentilationVentilation--perfusion mismatchperfusion mismatch
Incomplete diffusion equilibriumIncomplete diffusion equilibrium
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Assessment of Gas ExchangeAssessment of Gas Exchange
AlveolarAlveolar--arterial Oarterial O22 tension differencetension differenceyy AA--a gradienta gradient
yy PAOPAO22--PaOPaO22
yy PAOPAO22 = FIO= FIO22(PB(PB -- PHPH22O)O) -- PaCOPaCO22/RQ*/RQ* arterialarterial--Alveolar OAlveolar O22 tension ratiotension ratio
yy PaOPaO22/PAO/PAO22
arterialarterial--inspired Oinspired O22 ratioratio
yy PaOPaO22/FIO/FIO22yy P/F ratioP/F ratio
*RQ=respiratory quotient= 0.8*RQ=respiratory quotient= 0.8
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Assessment of Gas ExchangeAssessment of Gas Exchange
ABGABG AA--a grada grad
PaOPaO22 PaCOPaCO22 RARA 100%100%
Low FIOLow FIO22 qq qq N*N* NN
Alveolar hypoventilationAlveolar hypoventilation qq oo NN NN
Altered gas exchangeAltered gas exchange
Regional V/Q mismatchRegional V/Q mismatch qq oo/N//N/qq oo N/N/oo
Intrapulmonary R to L shuntIntrapulmonary R to L shunt qq N/N/qq oo oo
Impaired diffusionImpaired diffusion qq N/N/qq oo NN
Anatomical R to L shuntAnatomical R to L shunt(intrapulmonary or intracardiac)(intrapulmonary or intracardiac) qq N/N/qq oo oo
* N=normal* N=normal
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SummarySummary
First, does the patient have an acidosis or anFirst, does the patient have an acidosis or an
alkalosisalkalosis
yy Look at the pHLook at the pH
Second, what is the primary problemSecond, what is the primary problem metabolic or respiratorymetabolic or respiratory
yy Look at the pCOLook at the pCO22
yy If the pCOIf the pCO22 change is in the opposite direction of thechange is in the opposite direction of the
pH change, the primary problem is respiratorypH change, the primary problem is respiratory
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SummarySummary
Third, is there any compensation by theThird, is there any compensation by thepatientpatient -- do the calculationsdo the calculationsyy For a primary respiratory problem, is the pHFor a primary respiratory problem, is the pH
change completely accounted for by the changechange completely accounted for by the changein pCOin pCO22 if yes, then there is no metabolic compensationif yes, then there is no metabolic compensation
if not, then there is either partial compensation orif not, then there is either partial compensation orconcomitant metabolic problemconcomitant metabolic problem
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SummarySummary
yy For a metabolic problem, calculate the expectedFor a metabolic problem, calculate the expectedpCOpCO22 if equal to calculated, then there is appropriateif equal to calculated, then there is appropriate
respiratory compensationrespiratory compensation
if higher than calculated, there is concomitantif higher than calculated, there is concomitantrespiratory acidosisrespiratory acidosis
if lower than calculated, there is concomitantif lower than calculated, there is concomitantrespiratory alkalosisrespiratory alkalosis
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SummarySummary
Next, dont forget to look at the effectivenessNext, dont forget to look at the effectiveness
of oxygenation, (and look at the patient)of oxygenation, (and look at the patient)
yy your patient may have a significantly increasedyour patient may have a significantly increased
work of breathing in order to maintain a normalwork of breathing in order to maintain a normalblood gasblood gas
yy metabolic acidosis with a concomitant respiratorymetabolic acidosis with a concomitant respiratory
acidosis is concerningacidosis is concerning
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Case 1Case 1
Little Billy got into some of dads barbiturates.Little Billy got into some of dads barbiturates.
He suffers a significant depression of mentalHe suffers a significant depression of mental
status and respiration. You see him in thestatus and respiration. You see him in the
ER 3 hours after ingestion with a respiratoryER 3 hours after ingestion with a respiratoryrate of 4. A blood gas is obtained (afterrate of 4. A blood gas is obtained (after
doing the ABCs, of course). It shows pH =doing the ABCs, of course). It shows pH =
7.16, pCO7.16, pCO22 = 70, HCO= 70, HCO33 = 22= 22
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Case 1Case 1
What is the acid/base abnormality?What is the acid/base abnormality?
1.1. Uncompensated metabolic acidosisUncompensated metabolic acidosis
2.2. Compensated respiratory acidosisCompensated respiratory acidosis3.3. Uncompensated respiratory acidosisUncompensated respiratory acidosis
4.4. Compensated metabolic alkalosisCompensated metabolic alkalosis
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Case 1Case 1
Uncompensated respiratory acidosisUncompensated respiratory acidosis
There has not been time for metabolicThere has not been time for metabolic
compensation to occur. As the barbituratecompensation to occur. As the barbiturate
toxicity took hold, this child slowed histoxicity took hold, this child slowed his
respirations significantly, pCOrespirations significantly, pCO22 built up in thebuilt up in the
blood, and an acidosis ensued.blood, and an acidosis ensued.
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Case 2Case 2
Little Suzie has had vomiting and diarrhea for 3Little Suzie has had vomiting and diarrhea for 3
days. In her moms words, She cant keepdays. In her moms words, She cant keep
anything down and shes runnin out. Sheanything down and shes runnin out. She
has had 1 wet diaper in the last 24 hours.has had 1 wet diaper in the last 24 hours.She appears lethargic and cool to touch withShe appears lethargic and cool to touch with
a prolonged capillary refill time. Aftera prolonged capillary refill time. After
addressing her ABCs, her blood gas reveals:addressing her ABCs, her blood gas reveals:pH=7.34, pCOpH=7.34, pCO22=26, HCO=26, HCO33=12=12
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Case 2Case 2
What is the acid/base abnormality?What is the acid/base abnormality?
1.1. Uncompensated metabolic acidosisUncompensated metabolic acidosis
2.2. Compensated respiratory alkalosisCompensated respiratory alkalosis3.3. Uncompensated respiratory acidosisUncompensated respiratory acidosis
4.4. Compensated metabolic acidosisCompensated metabolic acidosis
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Case 2Case 2
Compensated metabolic acidosisCompensated metabolic acidosis
The prolong history of fluid loss throughThe prolong history of fluid loss through
diarrhea has caused a metabolic acidosis. Thediarrhea has caused a metabolic acidosis. The
mechanisms probably are twofold. First there ismechanisms probably are twofold. First there islactic acid production from the hypovolemia andlactic acid production from the hypovolemia and
tissue hypoperfusion. Second, there may betissue hypoperfusion. Second, there may be
significant bicarbonate losses in the stool. Thesignificant bicarbonate losses in the stool. The
body has compensated by blowing off the CObody has compensated by blowing off the CO22with increased respirations.with increased respirations.
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Case 3Case 3
You are evaluating a 15 year old female in theYou are evaluating a 15 year old female in theER who was brought in by EMS from schoolER who was brought in by EMS from schoolbecause of abdominal pain and vomiting.because of abdominal pain and vomiting.
Review of system is negative except for a 10Review of system is negative except for a 10lb. weight loss over the past 2 months andlb. weight loss over the past 2 months andpolyuria for the past 2 weeks. She has nopolyuria for the past 2 weeks. She has noother medical problems and denies anyother medical problems and denies any
sexual activity or drug use. On exam, she issexual activity or drug use. On exam, she isalert and oriented, afebrile, HR 115, RR 26alert and oriented, afebrile, HR 115, RR 26and regular, BP 114/75, pulse ox 95% on RA.and regular, BP 114/75, pulse ox 95% on RA.
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Case 3Case 3
Exam is unremarkable except for mild abdominalExam is unremarkable except for mild abdominal
tenderness on palpation in the midepigastrictenderness on palpation in the midepigastric
region and capillary refill time of 3 seconds.region and capillary refill time of 3 seconds.
The nurse has already seen the patient and hasThe nurse has already seen the patient and hassent off routine blood work. She hands yousent off routine blood work. She hands you
the result of the blood gas. pH = 7.21 pCOthe result of the blood gas. pH = 7.21 pCO22==
24 pO24 pO22 = 45 HCO= 45 HCO33 = 10 BE == 10 BE = --10 saturation =10 saturation =
72%72%
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Case 3Case 3
What is the blood gas interpretation?What is the blood gas interpretation?
Uncompensated respiratory acidosis withUncompensated respiratory acidosis with
severe hypoxiasevere hypoxia
Uncompensated metabolic alkalosisUncompensated metabolic alkalosis
Combined metabolic acidosis and respiratoryCombined metabolic acidosis and respiratory
acidosis with severe hypoxiaacidosis with severe hypoxia
Metabolic acidosis with respiratoryMetabolic acidosis with respiratorycompensationcompensation
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Case 3Case 3
Metabolic acidosis with respiratory compensationMetabolic acidosis with respiratory compensation
This is a patient with new onset diabetesThis is a patient with new onset diabetes
mellitus in ketoacidosis. Her pulse oximetrymellitus in ketoacidosis. Her pulse oximetry
saturation and clinical examination do not revealsaturation and clinical examination do not revealany respiratory problems except for tachypneaany respiratory problems except for tachypnea
which is her compensatory mechanism for thewhich is her compensatory mechanism for the
metabolic acidosis. The nurse obtained themetabolic acidosis. The nurse obtained the
blood gas sample from the venous stick whenblood gas sample from the venous stick whenshe sent off the other labs.she sent off the other labs.
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ReferencesReferences
The ICU BookThe ICU Book Paul L. Marino, 1991,Paul L. Marino, 1991,Algorithms for acidAlgorithms for acid--base interpretations, p415base interpretations, p415--426426
Textbook of Pediatric Intensive Care 3Textbook of Pediatric Intensive Care 3rdrd EditionEdition edited by Mark C. Rogers, 1996, Respiratoryedited by Mark C. Rogers, 1996, RespiratoryMonitoring: Interpretation of clinical blood gasMonitoring: Interpretation of clinical blood gasvalues, p355values, p355--361361
Pediatric Critical CarePediatric Critical Care Bradley Fuhrman andBradley Fuhrman and
Jerry Zimmerman, 1992, AcidJerry Zimmerman, 1992, Acid--Base BalanceBase Balanceand Disorders, p689and Disorders, p689--696696
Critical Care PhysiologyCritical Care Physiology Robert Bartlett, 1996,Robert Bartlett, 1996,AcidAcid--Base physiology p165Base physiology p165--173.173.
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