Part II - Respiratory, Mixed Acid Base Disorders & ABG Interpretation - Dr. Gawad
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Part II - Respiratory, Mixed Acid Base Disorders & ABG Interpretation - Dr. Gawad
- 1. Acid-Base Balance & Disorders . Part II . Respiratory & Mixed Acid Base Disorders ABG Interpretation Presented By dr. Mohammed Abdel Gawad Nephrologist 2-2-2012
- 3. To download the lecture contact me drgawad@gmail.com More lectures on www.NephroTube.com
- 4. Acid Base Balance & Disorders • Normal Acid Base Balance • Metabolic Acidosis • Metabolic Alkalosis • Respiratory Acidosis • Respiratory Alkalosis • Mixed Acid Base Disorders • ABG Interpretation 4 Part I Part II
- 5. 5 CO2 Red Blood Cell Systemic Circulation H2O H+ HCO3- carbonic anhydrase Plasma CO2 CO2 CO2 CO2 CO2CO2 + + Tissues H+ Cl- Hb H+ is buffered by Hemoglobin Tissue side
- 6. 6 Red Blood Cell Pulmonary Circulation CO2 H2O H+ + + HCO3- Cl- Alveolus Plasma CO2 H2O Hb Lung side
- 7. Respiratory regulation of acid-base balance
- 8. Classification of Acid-basic Disorders pH PCO2 HCO3 Metabolic Acidosis ↓ ↓ (compensation) ↓ (1ry disorder) Metabolic Alkalosis ↑ ↑ (compensation) ↑ (1ry disorder) Respiratory Acidosis ↓ ↑ (1ry disorder) ↑ (compensation) Respiratory Alkalosis ↑ ↓ (1ry disorder) ↓ (compensation)
- 9. is PO2 low? PCO2 low is HCO3 low? NO 1ry hyperventilation YES Respiratory alkalosis high Type II respiratory impairment is HCO3 high? NO Acute YES pH normal Chronic pH low Acute on top of chronic PCO2 high Low/normal Type I respiratory impairment Acute or Chronic?
- 10. I- Approved respiratory acidosis: • pH < 7.35 • PCO2 > 45 mmHg • HCO3 > 26 mEq/L (compensation) • 1. Acute respiratory acidosis: ▫ HCO3 rises 1 mEq/L for each 10 mm Hg rise in PCO2 (in minutes). • 2. Chronic respiratory acidosis: ▫ HCO3 rises 3.5 mEq/L for each 10 mm Hg rise in PCO2 (over days). • In absence of full compensation, this is called: ▫ A- partial compensation ▫ or better called: II- Expected compensation:
- 13. Acid Base Balance & Disorders • Normal Acid Base Balance • Metabolic Acidosis • Metabolic Alkalosis • Respiratory Acidosis • Respiratory Alkalosis • Mixed Acid Base Disorders • ABG Interpretation 13 Part I Part II
- 14. I- Approved respiratory alkalosis: • pH > 7.45 • PCO2 < 35 mmHg • HCO3 < 22 mEq/L (compensation) • 1. Acute respiratory alkalosis: ▫ HCO3 falls 2 mEq/L for each 10 mm Hg fall in PCO2 (in minutes). • 2. Chronic respiratory alkalosis: ▫ HCO3 falls 5 mEq/L for each 10 mm Hg fall in PCO2 (over days). • In absence of full compensation, this is called: ▫ A- partial compensation ▫ or better called: II- Expected compensation:
- 17. Acid Base Balance & Disorders • Normal Acid Base Balance • Metabolic Acidosis • Metabolic Alkalosis • Respiratory Acidosis • Respiratory Alkalosis • Mixed Acid Base Disorders • ABG Interpretation 17 Part I Part II
- 18. All acid base disorders can be combined in a double or triple disorders BUT NEVER COMBINE respiratory acidosis with respiratory alkalosis
- 19. Acid Base Balance & Disorders • Normal Acid Base Balance • Metabolic Acidosis • Metabolic Alkalosis • Respiratory Acidosis • Respiratory Alkalosis • Mixed Acid Base Disorders • ABG Interpretation 19 Part I Part II
- 20. Step 1 - pH If it falls into the normal range: < 7.4 = normal/acidic, > 7.4 = normal/alkalotic.
- 21. Parameter Normal value PCO2 35 – 45 mmHg HCO3 22- 26 mEq/L Step 2 – PCO2 & HCO3 analysis pH PCO2 HCO3 Metabolic Acidosis ↓ ↓ ↓ Respiratory Alkalosis ↑ ↓ ↓ Metabolic Alkalosis ↑ ↑ ↑ Respiratory Acidosis ↓ ↑ ↑ Mixed Acidosis ↓ ↑ ↓ Mixed Alkalosis ↑ ↓ ↑
- 23. I- Approved metabolic acidosis: • pH < 7.35 • HCO3 < 22 mEq/L • PCO2 < 35 mmHg (compensation) • for each 1 HCO3 1.2 CO2↓ → ↓ ▫ or • Δ ↓ Pco2 = 1.2 x ΔHCO3 • In absence of full compensation, this is called: ▫ A- partial compensation ▫ or better called: ▫ B- mixed metabolic & respiratory acidosis: as the lung not washing enough CO2 as needed, which mean that it is actually accumulating CO2 II- Expected compensation:
- 25. III- Calculate Anion Gap • Equations: ▫ AG = (Na + K) – (Cl + HCO3) = 12 ± 4 mmol/l ▫ or ▫ AG = (Na) – (Cl + HCO3) = 12 ± 2 mmol/l • Corrected Anion Gap: ▫ anion gap is decreased by 4 mmol/l for each 1 g/dl decrease in the serum albumin concentration below normal. • The result: ▫ Wide (high) anion gap metabolic acidosis ▫ or ▫ Non (normal) anion gap metabolic acidosis
- 26. High AG acidosis • • • • • • • • K U S S M A L E Ketoacidosis (starvation, DM, alcohol) Uremia Sepsis Salicylate & other drugs e.g.paraldhyde Methanol Alcohol (Ethanol) Lactic acidosis Ethylene glycol Wide Anion Gap Causes Normocholeremic
- 27. 4- uretrosigmoid- ostomy Non Anion Gap Causes Hypercholeremic
- 28. To remember • I- Approved Metabolic Acidosis • II- Calculate Compensation • III- Calculate Anion Gap • IV- – a- if high anion gap calculate delta gap→ – b- if normal anion gap calculate urinary AG→
- 29. ● IV- a- if high anion gap calculate delta gap→ ∆ Gap = ∆AG / ∆HCO3 ▫ > 1 = high AG metabolic acidosis mixed with metabolic alkalosis ▫ < 1 = high AG metabolic acidosis mixed with non AG metabolic acidosis ▫ = 1 = simple high AG metabolic acidosis Ketoacidosis Uremia Sepsis Salicylate & other drugs Methanol Alcohol (Ethanol) Lactic acidosis Ethylene glycol AG HCO3 Cl 12 24 105
- 30. ● IV- b- if normal anion gap calculate urinary→ AG 4- uretrosigmoid- ostomy urine AG = u[Na + K] – u[Cl] If –ve: so the loss is non renal If zero or +ve: so the loss is renal N.B. Normally it is +ve ranging from +30 to +50 mmol/L
- 31. To remember • I- Approved Metabolic Acidosis • II- Calculate Compensation • III- Calculate Anion Gap • IV- – a- if high anion gap calculate delta gap→ – b- if normal anion gap calculate urinary AG→
- 32. Bicarbonate Deficit – Equation 1
- 33. Bicarbonate Deficit – Equation 2
- 35. I- Approved metabolic alkalosis: • pH > 7.45 • HCO3 > 26 mEq/L • PCO2 > 45 mmHg (compensation) • for each 1 HCO3 0.7 CO2↑ → ↑ ▫ or • Δ ↑ Pco2 = 0.7 x ΔHCO3 • In absence of full compensation, this is called: ▫ A- partial compensation ▫ or better called: ▫ B- mixed metabolic & respiratory alkalosis: as the lung can not retain enough CO2 as needed, which mean that it is actually washing CO2 even if the PCO2 is higher than normal. II- Expected compensation:
- 36. III- Causes • A- Chloride Depletion (urine Cl < 10 mEq/L) • B- Corticosteroid & Apparent Corticosteroid Induced (chloride resistant) (urine Cl > 10 mEq/L) • C- Alkali Administration or Ingestion
- 37. A- Chloride Depletion (urine Cl < 10 mEq/L)
- 38. B- Corticosteroid & Apparent Corticosteroid Induced (chloride resistant) (urine Cl > 10 mEq/L)
- 42. is PO2 low? PCO2 low is HCO3 low? NO 1ry hyperventilation YES Respiratory alkalosis high Type II respiratory impairment is HCO3 high? NO Acute YES pH normal Chronic pH low Acute on top of chronic PCO2 high Low/normal Type I respiratory impairment Acute or Chronic? NO YES
- 44. I- Approved respiratory acidosis: • pH < 7.35 • PCO2 > 45 mmHg • HCO3 > 26 mEq/L (compensation) • 1. Acute respiratory acidosis: ▫ HCO3 rises 1 mEq/L for each 10 mm Hg rise in PCO2 (in minutes). • 2. Chronic respiratory acidosis: ▫ HCO3 rises 3.5 mEq/L for each 10 mm Hg rise in PCO2 (over days). • In absence of full compensation, this is called: ▫ A- partial compensation ▫ or better called: II- Expected compensation:
- 47. I- Approved respiratory alkalosis: • pH > 7.45 • PCO2 < 35 mmHg • HCO3 < 22 mEq/L (compensation) • 1. Acute respiratory alkalosis: ▫ HCO3 falls 2 mEq/L for each 10 mm Hg fall in PCO2 (in minutes). • 2. Chronic respiratory alkalosis: ▫ HCO3 falls 5 mEq/L for each 10 mm Hg fall in PCO2 (over days). • In absence of full compensation, this is called: ▫ A- partial compensation ▫ or better called: II- Expected compensation:
- 51. Thank You
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