Unexpected deterioration of sick patient Hypoxaemia on sats monitoring Reduced conscious level Exacerbation of COPD Monitoring of ventilated patient Sepsis Metabolic or electrolyte problem e.g. DKA Drug Overdose
Normal PaO kPa ON AIR › Correct hypoxaemia immediately (target SpO 2 ) Respiratory failure defined as PaO 2 <8kPa (SpO 2 <93%) › Type I – normal PaCO 2 › Type 2 – elevated PaCO 2 (ventilatory failure) Significant respiratory failure may be present despite ‘normal’ or high PaO 2 › Predicted PaO 2 normally ~10kPa below FiO 2 › e.g. 40% venturi, PaO 2 should be ~30kPa › Document oxygen use on ABG result!
Look at the pH (normal range ) pH <7.35 = acidaemia/acidosis pH >7.45 = alkaemia/alkalosis Acidosis or alkalosis may still be present with a ‘normal’ pH if the body has already buffered = compensation CO 2 is acidic and HCO 3 - is alkaline Normal compensation for acidosis is to decrease CO 2 (rapid) and increase HCO 3 - (takes longer) Normal compensation for alkalosis is to decrease HCO 3 - (and increase CO 2 )
Normal range for PaCO 2 is kPa Acidosis (pH <7.35) › PaCO 2 >6.0kPa = respiratory acidosis › PaCO 2 <6.0kPa = metabolic acidosis Alkalosis (pH >7.45) › PaCO 2 >4.5kPa = metabolic alkalosis › PaCO 2 <4.5kPa = respiratory alkalosis
Normal range for HCO 3 - is 22-26mmol/L › Normal range for base excess (BE) is -2 to +2 Acidosis (pH <7.35) › HCO 3 - <22mmol/L (BE < -2) = metabolic acidosis › HCO 3 - >22mmol/L (BE > -2) = respiratory acidosis Alkalosis (pH >7.45) › HCO 3 - >26mmol/L (BE > +2) = metabolic alkalosis › HCO 3 - <26mmol/L (BE < +2) = respiratory alkalosis
What is the primary disturbance? Is there any compensation? Is there a mixed picture? e.g. in acidosis (pH <7.35) › PaCO 2 >6.0kPa with HCO 3 - >26mmol/L = › Respiratory acidosis with partial metabolic compensation › PaCO 2 >6.0kPa with HCO3- <22mmol/L = › Mixed respiratory and metabolic acidosis
Lactate (normal range 0-2mmol/L) › Elevated levels often associated with acidosis › tissue hypoperfusion/anaerobic metabolism, liver/renal failure or drugs (e.g. metformin) › Degree of elevation correlates directly with mortality in sepsis › Response to fluids also important Haemoglobin (Hb) Potassium (K + ) and Sodium (Na + ) Glucose (not on AMU analyzer)
78-year-old male admitted with IECOPD becomes more drowsy and confused whilst on AMU. Oxygen is being delivered via a non-rebreathe bag and mask.
FiO2 0.4 (40%) 0.21 (air) pH PaO kPa kPa PaCO 2 8.9kPa kPa HCO mmol/L 22-26mmol/L BE to +2 Lactate 1.8mmol/L <2.0mmol/L
Relative hypoxaemia (PaO2 should be ~30kPa) Respiratory failure = type 2 (elevated PaCO2) Acidosis (pH <7.35) High PaCO 2 = respiratory acidosis High HCO 3 - = partial metabolic compensation (likely chronic) Acute-on-chronic type 2 respiratory failure with respiratory acidosis and partial metabolic compensation
29-year-old female with type 1 diabetes. Admitted with 48h history of diarrhoea and vomiting. Rapid respiratory rate. CBG 27mmol/L and blood ketones 4.9mmol/L.
FiO (21%) 0.21 (air) pH PaO kPa kPa PaCO 2 3.2kPa kPa HCO mmol/L 22-26mmol/L BE to +2 Lactate 2.8mmol/L <2.0mmol/L
Normal PaO 2 on air i.e. no respiratory failure Normal pH however; Low HCO 3 - and BE with high lactate and ketones = metabolic acidosis Low PaCO 2 = respiratory compensation (Kussmaul respiration) Fully compensated metabolic acidosis due to DKA
36-year-old male with alcohol dependence and ALD. Admitted to AMU following a staggered co-codamol overdose. GCS 8/15 with small pupils and respiratory rate of 10/min.
FiO (35%)0.21 (air) pH PaO kPa kPa PaCO 2 7.5kPa kPa HCO mmol/L22-26mmol/L BE-8-2 to +2 Lactate4.2mmol/L<2.0mmol/L
Relative hypoxaemia (PaO 2 should be ~25kPa) Respiratory failure = type 2 (elevated PaCO 2 ) Acidosis (pH <7.35) High PaCO 2 = respiratory acidosis Low HCO 3 - and BE = metabolic acidosis Mixed respiratory and metabolic (lactic) acidosis Hypoventilation due to reduced GCS (hepatic encephalopathy) and opiate overdose Lactic acidosis due to liver failure/drug overdose
56-year-old female admitted with acute breathlessness. Recent marital stress. Heart rate 120/min, respiratory rate 28/min, SpO 2 96% on air. Chest clear. Looks anxious ++
FiO (40%) 0.21 (air) pH PaO kPa kPa PaCO 2 3.8kPa kPa HCO mmol/L 22-26mmol/L BE to +2 Lactate 0.7mmol/L <2.0mmol/L
Hyperventilation with respiratory alkalosis No metabolic compensation May be due to anxiety/panic attack but relative hypoxaemia in this case suggests alternative cause e.g. PE, pneumonia, acute asthma
Cannot be used to assess pO 2 or pCO 2 › Normal pCO 2 on VBG excludes hypercapnia Good correlation with ABG for other parameters › pH, lactate, BE, HCO 3 -, electrolytes, Hb › except if patient shocked/peri-arrest VBG usually adequate in all other situations › Obtain VBG in all acutely unwell patients › Especially sepsis, DKA, UGIB, AKI, overdose
Sample must not be shaken and should be analysed immediately (<10min) to prevent haemolysis › lowers pH and increases K + K + up to 0.5mmol lower than lab value Na + up to 6mmol lower than lab value Hb 5g/L higher than lab value on average
Acid Base DisorderpHpCO 2 HCO 3 - Examples Metabolic Acidosis ↓↔↓ Sepsis, shock, AKI, drugs, DKA Metabolic Acidosis with Respiratory Compensation ↔↓↓ DKA with Kussmaul’s Respiratory Acidosis ↓↑↔ COPD, LVF, reduced GCS Respiratory Acidosis with Metabolic Compensation ↔↑↑ COPD with chronic T2RF Metabolic Alkalosis ↑↔↑ Prolonged vomiting Respiratory Alkalosis ↑↓↔ Anxiety, PE, pneumonia, asthma