Wanchai Wongkornrat Cardiovascular Thoracic Surgery Siriraj Hospital Mahidol University

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Transcription:

Wanchai Wongkornrat Cardiovascular Thoracic Surgery Siriraj Hospital Mahidol University

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

4 Steps in ABG analysis 1. ABG or VBG 2. Oxygenation 3. Ventilation 4. Acid-Base disorder

ABG ph 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l VBG ph 7.32-7.42 PvO2 35-45 mmhg PvCO2 40-50 mmhg O2 sat 70-75 % HCO3 24 ± 2 meq/l O2 sat from ABG = O2 sat from pulse oximetry O2 sat from VBG

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

1. PaO2 (room air, FiO2=0.2) 2. A-a gradient (room air, FiO2=0.2) 3. PaO2 / FiO2

Normal room air PaO2 80-100 mmhg Normal room air PaO2 = 100 Age/4 Hypoxemia (room air, FiO2 = 0.2) PaO2 (mmhg) O2 sat (%) Mild 60-80 90-95 Moderate (tachycardia, hypertension, cool extremities) Severe (severe arrhythmias, brain injury, death) 40-60 75-90 < 40 <75

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 = 2.5 + Age/4 Wide A-a gradient = lung parenchymal disease

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 - 0.2 O2 nasal cannula 1-5 0.24-0.40 O2 mask 6-8 0.40-0.60 O2 mask with bag 6-10 0.60-0.99

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 200 300 - Mild ARDS 100 200 Moderate ARDS < 100 - Severe ARDS

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

30 YO male Fever RR 12/min Room air ph 7.28 PaO2 = 65 mmhg PaCO2 = 55 mmhg HCO3 = 27 meq/l Mild hypoxemia (PaO2 60-80 mmhg) PAO2 = 713 FiO2 PaCO2/0.8 = 713x0.2 55/0.8 = 73.85 A-a gradient = PAO2 PaO2 = 73.85 65 = 8.85 Normal A-a gradient = 2.5 + Age/4 = 2.5 + 30/4 = 10 No lung parenchymal disease PaCO2 > 45 mmhg = Hypoventilation Normal ABG ph 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

30 YO male Pneumonia RR 28/min Room air ph 7.50 PaO2 70 mmhg PaCO2 25mmHg HCO3 19 meq/l Mild hypoxemia (PaO2 60-80 mmhg) PAO2 = 713 FiO2 PaCO2/0.8 = 713x0.2 25/0.8 = 111.35 A-a gradient = PAO2 PaO2 = 111.35 70 = 41.35 Normal A-a gradient = 2.5 + Age/4 = 2.5 + 45/4 = 13.75 lung parenchymal disease (V/Q mismatch) PaCO2 < 35 mmhg = Hyperventilation Normal ABG ph 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

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

Normal PaCO2 35-45 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)

Normal PaCO2 35-45 mmhg PaCO2 < 35mmHg = Hyperventilation PaCO2 > 45 mmhg = Hypoventilation PaCO2 = 0.8 x CO2 production RR ( TV Dead space)

Normal PaCO2 35-45 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 )

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

1. Metabolic acidosis 2. Metabolic alkalosis 3. Respiratory acidosis (acute, chronic) 4. Respiratory alkalosis (acute, chronic)

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

H HCO3 RR PaCO2 Predicted PaCO2 = 1.5 HCO3 + 8 ± 2 Anion gap = Na Cl HCO3 Normal AG = 12 ± 4 AG (Corrected) = AG + 2.5 (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

HCO3 H RR PaCO2 Predicted PaCO2 = 0.7 HCO3 + 20 ± 2

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

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

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 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

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 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

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 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

ph = 7.50 PaCO2 = 42 mmhg HCO3 = 30 meq/l alkalosis (ph>7.40) Metabolic (HCO3 > 26 ) Predicted PaCO2 = 0.7 HCO3 + 20 ± 2 = 41 ± 2 Pure metabolic alkalosis Normal ABG ph 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

ph = 7.45 PaCO2 = 50 mmhg HCO3 = 30 meq/l alkalosis (ph>7.40) Metabolic (HCO3 > 26 ) Predicted PaCO2 = 0.7 HCO3 + 20 ± 2 = 41 ± 2 Metabolic alkalosis + Respiratory acidosis Normal ABG ph 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

ph = 7.60 PaCO2 = 35 mmhg HCO3 = 30 meq/l alkalosis (ph>7.40) Metabolic (HCO3 > 26 ) Predicted PaCO2 = 0.7 HCO3 + 20 ± 2 = 41 ± 2 Metabolic alkalosis + Respiratory alkalosis Normal ABG ph 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

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 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

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 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

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 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

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 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

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 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

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 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

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 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

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 7.35-7.45 PaO2 80-100 mmhg PaCO2 35-45 mmhg O2 sat 97-100 % HCO3 24 ± 2 meq/l

Thank you

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

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 = 140-102-15 = 23 Wide anion gap (>16) metabolic acidosis Lactic acidosis, sepsis, ARF treatment

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