ACID BASE BALANCE FLUID BALANCE ABG IINTERPRETATION


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  Notes
 
 
1 : ACID BASE BALANCE&FLUID BALANCE&ABG IINTERPRETATION
2 : Delicate balance of fluid and electrolytes and acids and bases required to maintain good health?
3 : Homeostasis
4 : Fluid within cells of body is known as?
5 : ICF
6 : Major cation of ICF?
7 : K+
8 : Fluid located outside of cell is known as?
9 : ECF
10 : Major cation of ECF?
11 : Na+
12 : Movement of H2O across cell membranes from less concentrated to more concentrated?
13 : Osmosis
14 : Substances dissolved in a liquid are known as?
15 : Solutes
16 : The concentration within a fluid is known as?
17 : Osmolality
18 : Movement of molecules in liquids from an area of higher concentration to an area of lower concentration is known as?
19 : Diffusion
20 : Fluid and solute move together across a membrane from an area of psi to an area of lower psi?
21 : Filtration
22 : Substance moves across cell membranes from less concentrated solution to more concentrated solution – requires a carrier?
23 : Active transport
24 : List some routes of fluid loss?
25 : Urine Insensible fluid loss Feces Perspiration
26 : List major electrolytes?
27 : Sodium Potassium Chloride Phosphate Magnesium Calcium Bicarbonate
28 : Acid base balance is the regulation of ____ ions?
29 : Hydrogen
30 : The acidity or alkalinity of a solution is measured as ____?
31 : pH
32 : The more ____ a solution the lower the pH?
33 : Acidic
34 : The more ____ the solution the higher the pH?
35 : Alkaline
36 : H2O has a pH of ____ and is neutral?
37 : 7
38 : The ____ hydrogen ions, the more acidic the solution and the lower the pH?
39 : More
40 : The lower the hydrogen concentration, the more ____ the solution and the higher the pH?
41 : Alkaline
42 : Most important buffer system?
43 : Bicarbonate-carbonic acid buffer system?
44 : Lungs help regulate acid-base balance by eliminating or retaining ____?
45 : Carbon dioxide
46 : Normal CO2 level?
47 : 35-45
48 : Kidneys are the ____ regulators of acid base balance?
49 : Long-term
50 : Kidneys maintain pH balance by excreting or conserving ____ and ____ ions?
51 : Bicarbonate, hydrogen
52 : Normal bicarbonate levels?
53 : 22-26
54 : Factors affecting homeostasis?
55 : Age Gender Body size Environment Lifestyles
56 : List the acid base imbalances?
57 : Respiratory acidosis Respiratory alkalosis Metabolic acidosis Metabolic alkalosis
58 : Signs and symptoms of respiratory acidosis?
59 : Dyspnea Disorientation Coma Dysrythmias Ph <7.35 PaCo2 >45 Hypokalemia Hyporemia
60 : Treatment for respiratory acidosis?
61 : Treat underlying cause Support ventilation Correct electrolyte imbalance IV sodium bicarbonate
62 : Causes/etiology of respiratory acidosis?
63 : COPD Neuromuscular disease Respiratory center depression Late ARDS Inadequate mechanical ventilation Sepsis Burns Excess bicarb intake
64 : Respiratory alkalosis may be caused by hyperventilation due to?
65 : Anxiety Pain Increased body temp Overventilation with ventilator Hypoxia ASA overdose Hypoxemia CNS trauma/tumor Emphysema Pneumonia
66 : Signs and symptoms of respiratory alkalosis?
67 : Tachycardia SOB CP Syncope Coma Seizures Numbness/tingling of extremities Blurred vision pH >7.45 CO2 < 35
68 : Treatment for respiratory alkalosis?
69 : Treat underlying cause Assist client to breathe more slowly Breath in paper bag Sedation
70 : Conditions that may lead to metabolic acidosis?
71 : Renal failure DKA Starvation Lactic acidosis
72 : ____ diarrhea may lead to metabolic acidosis?
73 : Prolonged
74 : Signs and symptoms of metabolic acidosis?
75 : Kussmal’s respirations Lethargy HA Weakness N/V pH <7.35 Bicarb <22 CO2 >38
76 : Acid loss due to vomiting and gastric suction may lead to ____ alkalosis?
77 : Metabolic
78 : Overuse of ____ may lead to metabolic alkalosis?
79 : Antacids
80 : Signs and symptoms of metabolic alkalosis?
81 : Hyperventilation Dysrhythmias Dizziness Hypertonic muscle tetany pH >7.45 Bicarb >26 Hypokalemia hypocalcemia
82 : Treatment metabolic alkalosis?
83 : Give K+ Treat underlying cause
84 : List the normal values for Ph PaCO2 HCO3 PaO2 O2 sat
85 : 7.35-7.45 35-45 22-26 80-100 95-98%
86 : ROME stands for?
87 : R – respiratory O – opposite M – metabolic E – equal (arrows go same direction as pH arrow)
88 : ABG INTERPRETATION
89 : Objectives What’s an ABG? Understanding Acid/Base Relationship General approach to ABG Interpretation Clinical causes Abnormal ABG’s Case studies Take home
90 : What is an ABG Arterial Blood Gas Drawn from artery- radial, brachial, femoral It is an invasive procedure. Caution must be taken with patient on anticoagulants. Helps differentiate oxygen deficiencies from primary ventilatory deficiencies from primary metabolic acid-base abnormalities
91 : What Is An ABG? pH [H+] PCO2 Partial pressure CO2 PO2 Partial pressure O2 HCO3 Bicarbonate BE Base excess SaO2 Oxygen Saturation
92 : Acid/Base Relationship This relationship is critical for homeostasis Significant deviations from normal pH ranges are poorly tolerated and may be life threatening Achieved by Respiratory and Renal systems
93 : Case Study No. 1 60 y/o male comes ER c/o SOB. Tachypneic, tachycardic, diaphoretic and Cyanotic. Dx acute resp. failure and ABG’s Show PaCO2 well below nl, pH above nl, PaO2 is very low. The blood gas document Resp. failure due to primary O2 problem.
94 : Case Study No. 2 60 y/o male comes ER c/o SOB. Tachypneic, tachycardic, diaphoretic and Cyanotic. Dx acute resp. failure and ABG’s Show PaCO2 very high, low pH and PaO2 is moderately low. The blood gas document Resp. failure due to primarily ventilatory insufficiency.
95 : There are two buffers that work in pairs H2CO3 NaHCO3Carbonic acid base bicarbonate These buffers are linked to the respiratory and renal compensatory system Buffers
96 : Respiratory Component function of the lungs Carbonic acid H2CO3 Approximately 98% normal metabolites are in the form of CO2 CO2 + H2O ? H2CO3 excess CO2 exhaled by the lungs
97 : Metabolic Component Function of the kidneys base bicarbonate Na HCO3 Process of kidneys excreting H+ into the urine and reabsorbing HCO3- into the blood from the renal tubules 1) active exchange Na+ for H+ between the tubular cells and glomerular filtrate 2) carbonic anhydrase is an enzyme that accelerates hydration/dehydration CO2 in renal epithelial cells
98 : H2O + CO2 ? H2CO3 ? HCO3 + H+ Acid/Base Relationship
99 : Normal ABG values pH 7.35 – 7.45 PCO2 35 – 45 mmHg PO2 80 – 100 mmHg HCO3 22 – 26 mmol/L BE -2 - +2 SaO2 >95%
100 : Acidosis Alkalosis pH < 7.35 PCO2 > 45 HCO3 < 22 pH > 7.45 PCO2 < 35 HCO3 > 26
101 : Respiratory Acidosis Think of CO2 as an acid failure of the lungs to exhale adequate CO2 pH < 7.35 PCO2 > 45 CO2 + H2CO3 ? ? pH
102 : Causes of Respiratory Acidosis emphysema drug overdose narcosis respiratory arrest airway obstruction
103 : Metabolic Acidosis failure of kidney function ? blood HCO3 which results in ? availability of renal tubular HCO3 for H+ excretion pH < 7.35 HCO3 < 22
104 : Causes of Metabolic Acidosis renal failure diabetic ketoacidosis lactic acidosis excessive diarrhea cardiac arrest
105 : Respiratory Alkalosis too much CO2 exhaled (hyperventilation) ? PCO2, H2CO3 insufficiency = ? pH pH > 7.45 PCO2 < 35
106 : Causes of Respiratory Alkalosis hyperventilation panic d/o pain pregnancy acute anemia salicylate overdose
107 : Metabolic Alkalosis ? plasma bicarbonate pH > 7.45 HCO3 > 26
108 : Causes of Metabolic Alkalosis ? loss acid from stomach or kidney hypokalemia excessive alkali intake
109 : How to Analyze an ABG PO2 NL = 80 – 100 mmHg 2. pH NL = 7.35 – 7.45 Acidotic <7.35 Alkalotic >7.45 PCO2 NL = 35 – 45 mmHg Acidotic >45 Alkalotic <35 HCO3 NL = 22 – 26 mmol/L Acidotic < 22 Alkalotic > 26
110 : Four-step ABG Interpretation Step 1: Examine PaO2 & SaO2 Determine oxygen status Low PaO2 (<80 mmHg) & SaO2 means hypoxia NL/elevated oxygen means adequate oxygenation
111 : Step 2: pH acidosis <7.35 alkalosis >7.45 Four-step ABG Interpretation
112 : Step 3: study PaCO2 & HCO 3 respiratory irregularity if PaCO2 abnl & HCO3 NL metabolic irregularity if HCO3 abnl & PaCO2 NL Four-step ABG Interpretation
113 : Step 4: Determine if there is a compensatory mechanism working to try to correct the pH. ie: if have primary respiratory acidosis will have increased PaCO2 and decreased pH. Compensation occurs when the kidneys retain HCO3. Four-step ABG Interpretation
114 : ~ PaCO2 – pH Relationship 80 7.2060 7.3040 7.4030 7.5020 7.60
115 : Compensated Respiratory Acidosis CO2 More Abnormal Respiratory Acidosis CO2 Expected Mixed Respiratory Metabolic Acidosis CO2 Less Abnormal CO2 Change c/w Abnormality Metabolic Metabolic Acidosis CO2 Normal Compensated Metabolic Acidosis CO2 Change opposes Abnormality Acidosis ABG Interpretation
116 : Compensated Respiratory Alkalosis CO2 More Abnormal Respiratory Alkalosis CO2 Expected Mixed Respiratory Metabolic Alkalosis CO2 Less Abnormal CO2 Change c/w Abnormality Metabolic Alkalosis CO2 Normal Compensated Metabolic Alkalosis CO2 Change opposes Abnormality Alkalosis ABG Interpretation
117 : Respiratory Acidosis pH 7.30 PaCO2 60 HCO3 26
118 : Respiratory Alkalosis pH 7.50 PaCO2 30 HCO3 22
119 : Metabolic Acidosis pH 7.30 PaCO2 40 HCO3 15
120 : Metabolic Alkalosis pH 7.50 PCO2 40 HCO3 30
121 : What are the compensations? Respiratory acidosis ? metabolic alkalosis Respiratory alkalosis ? metabolic acidosis In respiratory conditions, therefore, the kidneys will attempt to compensate and visa versa. In chronic respiratory acidosis (COPD) the kidneys increase the elimination of H+ and absorb more HCO3. The ABG will Show NL pH, ?CO2 and ?HCO3. Buffers kick in within minutes. Respiratory compensation is rapid and starts within minutes and complete within 24 hours. Kidney compensation takes hours and up to 5 days.
122 : Mixed Acid-Base Abnormalities Case Study No. 3: 56 yo ? ? neurologic dz required ventilator support for several weeks. She seemed most comfortable when hyperventilated to PaCO2 28-30 mmHg. She required daily doses of lasix to assure adequate urine output and received 40 mmol/L IV K+ each day. On 10th day of ICU her ABG on 24% oxygen & VS:
123 : ABG Results pH 7.62 BP 115/80 mmHg PCO2 30 mmHg Pulse 88/min PO2 85 mmHg RR 10/min HCO3 30 mmol/L VT 1000ml BE 10 mmol/L MV 10L K+ 2.5 mmol/L Interpretation: Acute alveolar hyperventilation (resp. alkalosis) and metabolic alkalosis with corrected hypoxemia.
124 : Case study No. 4 27 yo retarded ? with insulin-dependent DM arrived at ER from the institution where he lived. On room air ABG & VS: pH 7.15 BP 180/110 mmHg PCO2 22 mmHg Pulse 130/min PO2 92 mmHg RR 40/min HCO3 9 mmol/L VT 800ml BE -30 mmol/L MV 32L Interpretation: Partly compensated metabolic acidosis.
125 : Case study No. 5 74 yo ? with hx chronic renal failure and chronic diuretic therapy was admitted to ICU comatose and severely dehydrated. On 40% oxygen her ABG & VS: pH 7.52 BP 130/90 mmHg PCO2 55 mmHg Pulse 120/min PO2 92 mmHg RR 25/min HCO3 42 mmol/L VT 150ml BE 17 mmol/L MV 3.75L Interpretation: Partly compensated metabolic alkalosis with corrected hypoxemia.
126 : Case study No. 6 43 yo ? arrives in ER 20 minutes after a MVA in which he injured his face on the dashboard. He is agitated, has mottled, cold and clammy skin and has obvious partial airway obstruction. An oxygen mask at 10 L is placed on his face. ABG & VS: pH 7.10 BP 150/110 mmHg PCO2 60 mmHg Pulse 150/min PO2 125 mmHg RR 45/min HCO3 18 mmol/L VT ? ml BE -15 mmol/L MV ? L . Interpretation: Acute ventilatory failure (resp. acidosis) and acute metabolic acidosis with corrected hypoxemia
127 : Case study No. 7 17 yo, 48 kg ? with known insulin-dependent DM came to ER with Kussmaul breathing and irregular pulse. Room air ABG & VS: pH 7.05 BP 140/90 mmHg PCO2 12 mmHg Pulse 118/min PO2 108 mmHg RR 40/min HCO3 5 mmol/L VT 1200ml BE -30 mmol/L MV 48L Interpretation: Severe partly compensated metabolic acidosis without hypoxemia.
128 : Case No. 7 cont’d This patient is in diabetic ketoacidosis. IV glucose and insulin were immediately administered. A judgement was made that severe acidemia was adversely affecting CV function and bicarb was elected to restore pH to ? 7.20. Bicarb administration calculation: Base deficit X weight (kg) 4 30 X 48 = 360 mmol/L Admin 1/2 over 15 min & 4 repeat ABG
129 : Case No. 7 cont’d ABG result after bicarb: pH 7.27 BP 130/80 mmHg PCO2 25 mmHg Pulse 100/min PO2 92 mmHg RR 22/min HCO3 11 mmol/L VT 600ml BE -14 mmol/L MV 13.2L
130 : Case study No. 8 47 yo ? was in PACU for 3 hours s/p cholecystectomy. She had been on 40% oxygen and ABG & VS: pH 7.44 BP 130/90 mmHg PCO2 32 mmHg Pulse 95/min, regular PO2 121 mmHg RR 20/min HCO3 22 mmol/L VT 350ml BE -2 mmol/L MV 7L SaO2 98% Hb 13 g/dL
131 : Case No. 8 cont’d Oxygen was changed to 2L N/C. 1/2 hour pt. ready to be D/C to floor and ABG & VS: pH 7.41 BP 130/90 mmHg PCO2 10 mmHg Pulse 95/min, regular PO2 148 mmHg RR 20/min HCO3 6 mmol/L VT 350ml BE -17 mmol/L MV 7L SaO2 99% Hb 7 g/dL
132 : Case No. 8 cont’d What is going on?
133 : Case No. 8 cont’d If the picture doesn’t fit, repeat ABG!! pH 7. 45 BP 130/90 mmHg PCO2 31 mmHg Pulse 95/min PO2 87 mmHg RR 20/min HCO3 22 mmol/L VT 350ml BE -2 mmol/L MV 7L SaO2 96% Hb 13 g/dL Technical error was presumed.
134 : Case study No. 9 67 yo ? who had closed reduction of leg fx without incident. Four days later she experienced a sudden onset of severe chest pain and SOB. Room air ABG & VS: pH 7.36 BP 130/90 mmHg PCO2 33 mmHg Pulse 100/min PO2 55 mmHg RR 25/min HCO3 18 mmol/L BE -5 mmol/L MV 18L SaO2 88% Interpretation: Compensated metabolic acidosis with moderate hypoxemia. Dx: PE
135 : Case study No. 10 76 yo ? with documented chronic hypercapnia secondary to severe COPD has been in ICU for 3 days while being tx for pneumonia. She had been stable for past 24 hours and was transferred to general floor. Pt was on 2L oxygen & ABG &VS: pH 7.44 BP 135/95 mmHg PCO2 63 mmHg Pulse 110/min PO2 52 mmHg RR 22/min HCO3 42 mmol/L BE +16 mmol/L MV 10L SaO2 86% . Interpretation: Chronic ventilatory failure (resp. acidosis) with uncorrected hypoxemia
136 : Case No. 10 cont’d She was placed on 3L and monitored for next hour. She remained alert, oriented and comfortable. ABG was repeated: pH 7.36 BP 140/100 mmHg PCO2 75 mmHg Pulse 105/min PO2 65 mmHg RR 24/min HCO3 42 mmol/L BE +16 mmol/L MV 4.8L SaO2 92% . Pt’s ventilatory pattern has changed to more rapid and shallow breathing. Although still acceptable the pH and CO2 are trending in the wrong direction. High-flow oxygen may be better for this pt to prevent intubation
137 : Take Home Message: Valuable information can be gained from an ABG as to the patients physiologic condition Remember that ABG analysis if only part of the patient assessment. Be systematic with your analysis, start with ABC’s as always and look for hypoxia (which you can usually treat quickly), then follow the four steps. A quick assessment of patient oxygenation can be achieved with a pulse oximeter which measures SaO2.
138 : It’s not magic understanding ABG’s, it just takes a little practice!
139 : Any Questions?
140 : References Shapiro, Barry A., et al; Clinical Application of BloodGases; 1994 2. American Journal of Nursing1999;Aug99(8):34-6 3. Journal Post Anesthesia Nursing1990;Aug;5(4)264-72 4. Irvine, David;ABG Interpretation, A Rough and DirtyProduction
141 : Practice ABG’s PaO2 90 SaO2 95 pH 7.48 PaCO2 32 HCO3 24 PaO2 60 SaO2 90 pH 7.32 PaCO2 48 HCO3 25 PaO2 95 SaO2 100 pH 7.30 PaCO2 40 HCO3 18 PaO2 87 SaO2 94 pH 7.38 PaCO2 48 HCO3 28 PaO2 94 SaO2 99 pH 7.49 PaCO2 40 HCO3 30 6. PaO2 62 SaO2 91 pH 7.35 PaCO2 48 HCO3 27 Pa

 

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