Wanchai Wongkornrat Cardiovascular Thoracic Surgery Siriraj Hospital Mahidol University
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1 Wanchai Wongkornrat Cardiovascular Thoracic Surgery Siriraj Hospital Mahidol University
2 Assess adequacy of ventilation and oxygenation Aids in establishing a diagnosis and severity of respiratory failure Assess changes in acid- base homeostasis Helps in management of ICU patients
3 4 Steps in ABG analysis 1. ABG or VBG 2. Oxygenation 3. Ventilation 4. Acid-Base disorder
4 ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l VBG ph PvO mmhg PvCO mmhg O2 sat % HCO3 24 ± 2 meq/l O2 sat from ABG = O2 sat from pulse oximetry O2 sat from VBG
5 Usually this in patients with shock Should doubt when PO2 is significantly lower than O2 sat from pulse oximetry draw venous blood to check comparison redraw arterial blood
6 1. PaO2 (room air, FiO2=0.2) 2. A-a gradient (room air, FiO2=0.2) 3. PaO2 / FiO2
7 Normal room air PaO mmhg Normal room air PaO2 = 100 Age/4 Hypoxemia (room air, FiO2 = 0.2) PaO2 (mmhg) O2 sat (%) Mild Moderate (tachycardia, hypertension, cool extremities) Severe (severe arrhythmias, brain injury, death) < 40 <75
8 A = Alveoli a = arterial A-a gradient = PAO2 PaO2 PAO2 = 713 FiO2 PaCO2/0.8 Normal room air A-a gradient = 5 25 mmhg Normal room air A-a gradient = Age/4 Wide A-a gradient = lung parenchymal disease
9 Normal PaO2/FiO2 = 100/0.2 = 500 PaO2 / FiO2 < 300 = lung pathology (PaO2/FiO2)I = (PaO2/FiO2)II O2 flow (L/min) FiO2 Room air O2 nasal cannula O2 mask O2 mask with bag
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11 ARDS is characterized by an acute onset within 1 week, bilateral radiographic pulmonary infiltrates, respiratory failure not fully explained by heart failure or volume overload, and a PaO2/FiO2 ratio < 300 severity PaO2 / FiO2 ratio Mild ARDS Moderate ARDS < Severe ARDS
12 Hypoxemia Normal A-a gradient (FiO2=0.2) Normal PaO2/FiO2 (FiO2>0.2) Wide A-a gradient (FiO2=0.2) Low PaO2/FiO2 (FiO2>0.2) Decreased FiO2 FiO2 Hypoventilation minute ventilation (TV, RR) V/Q mismatch Dead space (PE, PHT) Intrapulmonary shunt (pneumonia, atelectasis) Extrapulmonary shunt (cyanotic heart disease, pulmonary AVF) Diffusion defect (defect at alveolar capillary membrane, pulmonary fibrosis, interstitial lung disease ) Low SvO2 Low O2 delivery (shock, anemia) High O2 consumption (fever, shivering, convulsion) 100% O2 Thrombolytic, anticoagulant, pulmonary vasodilator PEEP, inverse I:E ratio, prone position Disease specific treatment 100% O2 Disease specific treatment
13 30 YO male Fever RR 12/min Room air ph 7.28 PaO2 = 65 mmhg PaCO2 = 55 mmhg HCO3 = 27 meq/l Mild hypoxemia (PaO mmhg) PAO2 = 713 FiO2 PaCO2/0.8 = 713x0.2 55/0.8 = A-a gradient = PAO2 PaO2 = = 8.85 Normal A-a gradient = Age/4 = /4 = 10 No lung parenchymal disease PaCO2 > 45 mmhg = Hypoventilation Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
14 30 YO male Pneumonia RR 28/min Room air ph 7.50 PaO2 70 mmhg PaCO2 25mmHg HCO3 19 meq/l Mild hypoxemia (PaO mmhg) PAO2 = 713 FiO2 PaCO2/0.8 = 713x0.2 25/0.8 = A-a gradient = PAO2 PaO2 = = Normal A-a gradient = Age/4 = /4 = lung parenchymal disease (V/Q mismatch) PaCO2 < 35 mmhg = Hyperventilation Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
15 ARDS, FiO2 = 1.0 O2 sat 100%, PaO2 = 100 mmhg O2sat 90%, PaO2 =?, FiO2 =? O2sat 90%, PaO2 = 60 mmhg (PaO2/FiO2)I = (PaO2/FiO2)II (100/1) = (60/FiO2) FiO2 = 0.6
16 Normal PaCO mmhg PaCO2 < 35mmHg = Hyperventilation PaCO2 > 45 mmhg = Hypoventilation (PaCO2 x TV x RR)I = (PaCO2 x TV x RR)II PaCO2 = 0.8 x CO2 production RR (TV Dead space)
17 Normal PaCO mmhg PaCO2 < 35mmHg = Hyperventilation PaCO2 > 45 mmhg = Hypoventilation PaCO2 = 0.8 x CO2 production RR ( TV Dead space)
18 Normal PaCO mmhg PaCO2 < 35mmHg = Hyperventilation PaCO2 > 45 mmhg = Hypoventilation PaCO2 = 0.8 x CO2 production RR ( TV Dead space) Cut the ET tube shorter Longer expiratory time ( decrease auto PEEP )
19 Pneumonia, FiO2=0.6 TV=400 ml, RR=15/min, PaCO2=50 mmhg PaCO2=40 mmhg, TV=?, RR=? (PaCO2 x TV x RR)I = (PaCO2 x TV x RR)II 50x400x15 = 40xTVxRR TVxRR = 7500 ml/min (minute ventilation) TV, keep inspiratory < 35 mmhg RR, beware air trapping
20 1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis (acute, chronic) 4. Respiratory alkalosis (acute, chronic)
21 1. In seconds: buffer systems 2. In minutes: CO2 excretion by the lungs 3. In hours to days: renal excretion of H+, reabsorption of HCO3
22 H HCO3 RR PaCO2 Predicted PaCO2 = 1.5 HCO3 + 8 ± 2 Anion gap = Na Cl HCO3 Normal AG = 12 ± 4 AG (Corrected) = AG (4 Albumin) Wide anion gap (>16) metabolic acidosis Lactic acidosis Ketoacidosis (diabetic, starvation, alcoholic) Uremia Rhabdomyolysis Drug intoxication (salicylate, ethanol, ethylene glycol) Normal anion gap (<16) metabolic acidosis Diarrhea Renal tubular acidosis Early renal insufficiency Excessive saline loading Amino acid infusion ureterosigmoidostomy
23 HCO3 H RR PaCO2 Predicted PaCO2 = 0.7 HCO ± 2
24 Hypoventilation PaCO2 H kidney HCO3 Respiratory acidosis PaCO2 Predicted HCO3 Predicted ph acute 10 mmhg 1 meq/l 0.08 chronic 10 mmhg 4 meq/l 0.03
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26 Hyperventilation PaCO2 H kidney HCO3 Respiratory alkalosis PaCO2 Predicted HCO3 Predicted ph acute 10 mmhg 2 meq/l 0.08 chronic 10 mmhg 5 meq/l 0.03
27
28 ph = 7.20 PaCO2 = 20 mmhg HCO3 = 8 meq/l Acidosis (ph<7.40) Metabolic (HCO3 < 22 ) Predicted PaCO2 = 1.5 HCO3 + 8 ± 2 = 20 ± 2 Pure metabolic acidosis Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
29 ph = 7.15 PaCO2 = 30 mmhg HCO3 = 8 meq/l Acidosis (ph<7.40) Metabolic (HCO3 < 22 ) Predicted PaCO2 = 1.5 HCO3 + 8 ± 2 = 20 ± 2 Metabolic acidosis + Respiratory acidosis Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
30 ph = 7.25 PaCO2 = 15 mmhg HCO3 = 8 meq/l Acidosis (ph<7.40) Metabolic (HCO3 < 22 ) Predicted PaCO2 = 1.5 HCO3 + 8 ± 2 = 20 ± 2 Metabolic acidosis + Respiratory alkalosis Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
31 ph = 7.50 PaCO2 = 42 mmhg HCO3 = 30 meq/l alkalosis (ph>7.40) Metabolic (HCO3 > 26 ) Predicted PaCO2 = 0.7 HCO ± 2 = 41 ± 2 Pure metabolic alkalosis Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
32 ph = 7.45 PaCO2 = 50 mmhg HCO3 = 30 meq/l alkalosis (ph>7.40) Metabolic (HCO3 > 26 ) Predicted PaCO2 = 0.7 HCO ± 2 = 41 ± 2 Metabolic alkalosis + Respiratory acidosis Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
33 ph = 7.60 PaCO2 = 35 mmhg HCO3 = 30 meq/l alkalosis (ph>7.40) Metabolic (HCO3 > 26 ) Predicted PaCO2 = 0.7 HCO ± 2 = 41 ± 2 Metabolic alkalosis + Respiratory alkalosis Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
34 ph = 7.24 PaCO2 = 60 mmhg HCO3 = 28 meq/l acidosis (ph<7.40) respiratory (PaCO2 > 45 ) Respiratory acidosis Acute (ph ) Predicted HCO3 = (24 ± 2) + (60-40)/10 = 26 ± 2 Pure acute respiratory acidosis Respiratory acidosis PaCO2 Predicted HCO3 Predicted ph acute 10 mmhg 1 meq/l 0.08 chronic 10 mmhg 4 meq/l 0.03 Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
35 ph = 7.18 PaCO2 = 60 mmhg HCO3 = 22 meq/l acidosis (ph<7.40) respiratory (PaCO2 > 45 ) Respiratory acidosis Acute (ph ) Predicted HCO3 = (24 ± 2) + (60-40)/10 = 26 ± 2 + Metabolic acidosis Respiratory acidosis PaCO2 Predicted HCO3 Predicted ph acute 10 mmhg 1 meq/l 0.08 chronic 10 mmhg 4 meq/l 0.03 Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
36 ph = 7.30 PaCO2 = 60 mmhg HCO3 = 32 meq/l acidosis (ph<7.40) respiratory (PaCO2 > 45 ) Respiratory acidosis Acute (ph ) Predicted HCO3 = (24 ± 2) + (60-40)/10 = 26 ± 2 + Metabolic alkalosis Respiratory acidosis PaCO2 Predicted HCO3 Predicted ph acute 10 mmhg 1 meq/l 0.08 chronic 10 mmhg 4 meq/l 0.03 Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
37 ph = 7.56 PaCO2 = 20 mmhg HCO3 = 18 meq/l alkalosis (ph>7.40) respiratory (PaCO2 < 35 ) Respiratory alkalosis Acute (ph ) Predicted HCO3 = (24 ± 2) (40-20)2/10 = 20 ± 2 Pure acute respiratory alkalosis Respiratory alkalosis PaCO2 Predicted HCO3 Predicted ph acute 10 mmhg 2 meq/l 0.08 chronic 10 mmhg 5 meq/l 0.03 Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
38 ph = 7.50 PaCO2 = 20 mmhg HCO3 = 12 meq/l alkalosis (ph>7.40) respiratory (PaCO2 < 35 ) Respiratory alkalosis Acute (ph ) Predicted HCO3 = (24 ± 2) - (40-20)2/10 = 20 ± 2 + Metabolic acidosis Respiratory alkalosis PaCO2 Predicted HCO3 Predicted ph acute 10 mmhg 2 meq/l 0.08 chronic 10 mmhg 5 meq/l 0.03 Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
39 ph = 7.62 PaCO2 = 20 mmhg HCO3 = 25 meq/l alkalosis (ph>7.40) respiratory (PaCO2 < 35 ) Respiratory alkalosis Acute (ph ) Predicted HCO3 = (24 ± 2) - (40-20)2/10 = 20 ± 2 + Metabolic alkalosis Respiratory alkalosis PaCO2 Predicted HCO3 Predicted ph acute 10 mmhg 2 meq/l 0.08 chronic 10 mmhg 5 meq/l 0.03 Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
40 ph = 7.40 PaCO2 = 15 mmhg HCO3 = 12 meq/l Acidosis? Alkalosis? (ph =7.40) Metabolic acidosis (HCO3 < 22) Respiratory alkalosis (PaCO2 < 35 ) Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
41 ph = 7.40 PaCO2 = 60 mmhg HCO3 = 36 meq/l Acidosis? Alkalosis? (ph =7.40) Metabolic alkalosis (HCO3 > 26) Respiratory acidosis (PaCO2 > 45 ) Normal ABG ph PaO mmhg PaCO mmhg O2 sat % HCO3 24 ± 2 meq/l
42 Thank you
43
44 40 YO male, IE at AV S/P AVR and Ao root replacement for 2 days Post op pneumonia On ET tube, VCV mode, FiO2=0.8, TV=400ml, RR 18/min ph=7.14, PaCO2=50 mmhg, PaO2=60 mmhg Na=140, K=5.5, Cl=102, HCO3=15 meq/l BUN 50, Cr 3.0 CXR - bilateral pulmonary infiltration ABP 90/50 mmhg, P100/min regular Low dose inotropic drug CVP 8 mmhg, PA pressure 30/15 mmhg Oxygenation Ventilation Acid-Base disorder Management
45 40 YO male, IE at AV S/P AVR and Ao root replacement for 2 days Post op pneumonia On ET tube, VCV mode, FiO2=0.8, TV=400ml, RR 18/min ph=7.14, PaCO2=50 mmhg, PaO2=60 mmhg Na=140, K=5.5, Cl=102, HCO3=15 meq/l BUN 50, Cr 3.0 CXR - bilateral pulmonary infiltration ABP 90/50 mmhg, P100/min regular Low dose inotropic drug CVP 8 mmhg, PA pressure 30/15 mmhg Oxygenation FiO2=0.8, PaO2=60 mmhg, O2 sat 90% PO2/FiO2 = 60/0.8 = 75 severe ARDS FiO2 X, PEEP, inverse I:E ratio, prone position Ventilation PaCO2=50 mmhg, RR 18/min, hypoventilation? severe pneumonia mild form pneumonia hyperventilation, acute respiratory alkalosis) PEEP Acid-Base disorder Acidosis (ph<7.40) Metabolic (HCO3 < 22 ) Predicted PaCO2 = 1.5 HCO3 + 8 ± 2 = 30.5 ± 2 Metabolic acidosis + Respiratory acidosis Anion gap = Na Cl HCO3 = = 23 Wide anion gap (>16) metabolic acidosis Lactic acidosis, sepsis, ARF treatment
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