‫اﻟﻘﻮاﻋﺪ اﻟﺨﻤﺲ ﻟﻘﺮاءة ﻏﺎزات اﻟﺪم‬

‫د‪.‬ﺿﻴﺎء اﻟﺪﻳﻦ ﻋﻴــﺮان‬

‫أﺧﺼﺎﺋﻲ ﻓﻲ أﻣﺮاض اﻟﻜﻠﻴﺔ واﻟﻀﻐﻂ اﻟﺸﺮﻳﺎﻧﻲ‬
 ‫اﻟﻬﺪف‬

‫† ﻗﺮاءة أي ﻏﺎزات دم ﺑﺴﺮﻋﺔ وﻓﻌﺎﻟﻴﺔ‬

‫† ﺗﺒﺴﻴﻂ اﻟﻌﻘﺪة ﻣﻦ ﻏﺎزات اﻟﺪم‬
‫† وﺑﺎﻟﺘﺎﻟﻲ اﻻﺳﺘﻔﺎدة ﻣﻦ هﺬﻩ اﻟﻮﺳﻴﻠﺔ اﻟﻬﺎﻣﺔ ﻓﻲ اﻟﺘﺸﺨﻴﺺ‬
‫وﺗﺪﺑﻴﺮ اﻟﺤﺎﻻت اﻹﺳﻌﺎﻓﻴﺔ‬
‫ﻣﺎذا ﺗﺤﺘﺎج ﻟﻘﺮاءة اﻟﻐﺎزات؟‬

‫† ﻏﺎزات اﻟﺪم )‪(pH, PCO2‬‬

‫† اﻟﺸﻮارد ) ‪(Na,K,Cl,HCO3‬‬
‫† ﻓﺤﻮص أﺧﺮى ﻟﺘﺤﺪﻳﺪ اﻟﺴﺒﺐ‬
‫† ﻣﻌﺮﻓﺔ اﻟﻘﻴﻢ اﻟﻄﺒﻴﻌﻴﺔ‬
‫† ﻣﻌﺮﻓﺔ ﻧﺴﺐ اﻟﻤﻌﺎوﺿﺔ‬
 ‫اﻟﻘﻮاﻋﺪ اﻟﺨﻤﺲ‬

‫‪-1‬ﺣﺪد ‪) pH‬ﺣﻤﺎض‪ ,‬ﻗﻼء(‬

‫‪-2‬اﻵﻟﻴﺔ اﻷوﻟﻴﺔ )ﺗﻨﻔﺴﻴﺔ أو اﺳﺘﻘﻼﺑﻴﺔ(‬
‫‪-3‬اﺣﺴﺐ ﻓﺠﻮة اﻟﺼﻮاﻋﺪ ‪Anion Gap‬‬
‫‪-4‬اﺣﺴﺐ درﺟﺔ اﻟﻤﻌﺎوﺿﺔ‬
‫‪-5‬ﺗﺄآﺪ ﻣﻦ ﻋﻼﻗﺔ ‪1:1‬‬
 ‫اﻟﻘﺎﻋﺪة اﻷوﻟﻰ‬

‫† ﺣﺪد ال ‪:pH‬‬
‫‪ pH‬اﻟﻄﺒﻴﻌﻲ )‪(7.40-7.44‬‬
‫أﻗﻞ ﻣﻦ ‪ 7.40‬ﺣﻤﺎض دﻣﻮي ‪Acidemia‬‬
‫أآﺜﺮ ﻣﻦ ‪ 7.44‬ﻗﻼء دﻣﻮي ‪Alkalemia‬‬
‫اﻟﻘﺎﻋﺪة اﻟﺜﺎﻧﻴﺔ‪ :‬ﻣﺎهﻲ اﻵﻟﻴﺔ اﻷوﻟﻴﺔ؟‬

‫‪PCO2‬‬ ‫ﺗﻨﻔﺴﻴﺔ‬
‫اﺳﺘﻘﻼﺑﻴﺔ ‪HCO3‬‬

‫ﻣﺜﺎل ‪ pH 7.50 :‬ﻗﻼء دﻣﻮي‬

‫‪PCO2 25‬‬
‫‪HCO3 20‬‬
‫اﻵﻟﻴﺔ اﻷوﻟﻴﺔ ‪ :‬ﺗﻨﻔﺴﻴﺔ‬
 ‫ ﺣﺴﺎب ﻓﺠﻮة اﻟﺼﻮاﻋﺪ‬:‫اﻟﻘﺎﻋﺪة اﻟﺜﺎﻟﺜﺔ‬

† Anion Gap
Na –(HCO3+Cl)
12±2 Normal

AG>20 always mean Metabolic Acidosis

 ‫ﻣﺎ هﻲ ﻓﺠﻮة اﻟﺼﻮاﻋﺪ؟‬
‫اﻟﻔﺮق ﺑﻴﻦ اﻟﺸﻮارد اﻹﻳﺠﺎﺑﻴﺔ واﻟﺴﻠﺒﻴﺔ‬
‫اﻟﺠﺴﻢ ﻟﺪﻳﻪ ﺗﻮازن دﻗﻴﻖ ﺑﻴﻦ اﻟﺸﻮارد اﻹﻳﺠﺎﺑﻴﺔ واﻟﺴﻠﺒﻴﺔ‬
‫‪Na+K+Mg+Ca+ Ig +..etc=Cl+HCO3+ Alb+ PO4+ SO3+etc‬‬
‫‪Na+K+ UC= Cl+HCO3+ UA‬‬
‫)‪UA-UC= (Na+K)-( Cl+HCO3‬‬

‫)‪Anion Gap = Na –( Cl+HCO3‬‬

 ‫اﻟﻘﺎﻋﺪة اﻟﺮاﺑﻌﺔ ‪ :‬اﺣﺴﺐ اﻟﻤﻌﺎوﺿﺔ‬

‫اﻟﺤﻤﺎض اﻻﺳﺘﻘﻼﺑﻲ‪:‬‬
‫‪-‬أﺳﺮع ﻃﺮﻳﻘﺔ ‪ PCO2‬ﻳﺴﺎوي اﻟﺮﻗﻤﻴﻦ ﺑﻌﺪ اﻟﻔﺎﺻﻠﺔ ﻣﻦ ‪pH‬‬
‫‪-‬ﻃﺮﻳﻘﺔ أدق )↓‪(PCO2↓ =1.3 XHCO3‬‬

‫اﻟﻘﻼء اﻻﺳﺘﻘﻼﺑﻲ‪:‬‬
‫↑‪PCO2↑= 0.6 HCO3‬‬
 ‫اﻟﻘﺎﻋﺪة اﻟﺮاﺑﻌﺔ‪ :‬اﺣﺴﺐ اﻟﻤﻌﺎوﺿﺔ‬

‫† اﻟﺤﻤﺎض واﻟﻘﻼء اﻟﺘﻨﻔﺴﻲ‬

‫ﺣﺎد أو ﻣﺰﻣﻦ‬
‫ﻟﻜﻞ ‪ 10‬ﺗﻐﻴﺮ ﻓﻲ ‪ pCO2‬ﻳﺘﻐﻴﺮ ال ‪ HCO3‬ﺑﻤﻘﺪار‪:‬‬
‫ﺣﺎد ‪1‬‬
‫ﻣﺰﻣﻦ ‪4‬‬

‫ﺣﺎد ‪2-1‬‬
‫ﻣﺰﻣﻦ ‪5‬‬
 ‫اﻟﻘﺎﻋﺪة اﻟﺨﺎﻣﺴﺔ‪ :‬اﻟﻌﻼﻗﺔ ‪1:1‬‬

‫† أي زﻳﺎدة ﻓﻲ آﻤﻴﺔ اﻟﺸﻮارد اﻟﺴﻠﺒﻴﺔ )اﻟﺤﻤﺎض اﻻﺳﺘﻘﻼﺑﻲ(‬

‫ﻳﻘﺎﺑﻠﻬﺎ ﻧﻘﺺ ﻣﻤﺎﺛﻞ ﻓﻲ آﻤﻴﺔ ال‪HCO3‬‬
‫‪∆HCO3= ∆ AG‬‬
‫‪∆HCO3= ∆ Cl‬‬

‫إذا آﺎن اﻟﻨﻘﺺ ﻓﻲ ال ‪ HCO3‬أﻗﻞ ﻣﻦ اﻟﻤﺘﻮﻗﻊ ﻓﻬﻨﺎك ﻗﻼء‬

‫اﺳﺘﻘﻼﺑﻲ ﻣﺴﺘﺨﻒ‬
‫‪Case-1‬‬

‫ﻣﺮﻳﻀﺔ ‪ 60‬ﺳﻨﺔ‪ ,‬ﻟﺪﻳﻬﺎ ﺿﻌﻒ ﻋﺎم وارهﺎق ﻟﻤﺪة أﺳﺒﻮع‬

‫اﻋﺘﺮﻓﺖ أﻧﻬﺎ ﺗﻨﺎوﻟﺖ اﻟﻤﺴﻬﻼت ﻟﻤﻌﺎﻟﺠﺔ اﻻﻣﺴﺎك وﻟﺪﻳﻬﺎ اﺳﻬﺎل اﻻن ﻣﻨﺬ‬
‫ﺷﻬﺮ‪.‬‬
‫‪Na 133‬‬ ‫‪Acidemia‬‬
‫‪K 2.8‬‬ ‫‪Metabolic‬‬
‫‪Cl 118‬‬ ‫‪AG 10‬‬
‫‪pH 7.26‬‬ ‫‪(25-5)X 1.3=26‬‬
‫‪PCO2 13‬‬ ‫‪40-26=14‬‬

‫‪HCO3 5‬‬ ‫‪20≈18‬‬

‫‪Hyperchloremic (Non-AG) Metabolic Acidosis‬‬

 Case-2

‫ﺳﻨﺔ أدﺧﻞ ﻗﺴﻢ اﻻﺳﻌﺎف ﺑﻬﺒﻮط ﺿﻐﻂ‬74 ‫† رﺟﻞ‬

‫ ﺗﺤﻠﻴﻞ اﻟﺒﻮل أﻇﻬﺮ وﺟﻮد‬, c 38.5 ‫ ﺣﺮارة‬,(60\96)
‫اﻧﺘﺎن ﺑﻮﻟﻲ‬
Na 137 Alkalemia
K 3.2 Respiratory
AG10
Cl 105 ∆PCo2=15
Expected ∆ HCO3
pH 7.49 3
3≈5
PCO2 25
HCO3 22
Respiratory Alkalosis
 Case-3

‫ ﻟﺪﻳﻪ اﻟﺘﻬﺎب ﻗﺼﺒﺎت ﻣﺰﻣﻦ‬,‫ ﺳﻨﺔ‬52 ‫† رﺟﻞ ﻣﺪﺧﻦ‬

‫راﺟﻊ اﻟﻌﻴﺎدة ﻟﻔﺤﺺ روﺗﻴﻨﻲ‬
Na 136
Acidemia
K 3.8
Respiratory
Cl 92 AG 10
pH 7.34 ∆PCO2 25
PCO2 65 Exp.∆ bicarb 10

HCO3 34

Respiratory Acidosis (Chronic)

 Case-4

‫ﺗﺸﻤﻊ آﺒﺪي أدﺧﻞ ﻟﻘﺴﻢ اﻹﺳﻌﺎف‬,‫ ﺳﻨﺔ‬50 ‫† رﺟﻞ آﺤﻮﻟﻲ‬

,‫ ﺑﺎﻟﻔﺤﺺ هﻨﺎك ﺗﻐﻴﻢ ﺑﺎﻟﻮﻋﻲ‬.‫ﺑﺄﻟﻢ ﺑﻄﻨﻲ وإﻗﻴﺎء ﻣﻨﺬ ﻋﺪة أﻳﺎم‬
106/78 mmHg ‫ اﻟﻀﻐﻂ‬.‫ﺣﺒﻦ‬
Na 126
Alkalemia
K 2.8 Metabolic
Cl 80 AG 10
pH 7.60 Exp. PCO2 47
PCO2 34 Resp. Alkalosis

HCO3 36

Metabolic and Respiratory Alkalosis

 Metabolic Alkalosis
Urine Cl

<10 >20

Saline Responsive Saline resistant

Excess mineralocorticoid or similar

Upper GI loss Bartter’s Syn.
Lower GI Loss Gitelman’s Syn.
Posthypercapnia Liddle’s Syn.
Diuretic therapy Ingestion of Alkali
Treatment

† Treating the underlying Cause

† Saline in Saline sensitive
Respiratory Alkalosis

† Endotoxemia (Sepsis)
† Chronic liver disease
† CNS: Stroke, Tumor, infection
† Drugs: Aspirin
† Hyperthyroidism
† Pulmonary: Hyperventilation
 ‫‪Case 5‬‬

‫† رﺟﻞ ‪ 65‬ﺳﻨﺔ‪ ,‬اﻟﺘﻬﺎب ﻗﺼﺒﺎت ﻣﺰﻣﻦ ‪ ,‬دﺧﻞ ﻗﺴﻢ اﻹﺳﻌﺎف‬

‫ﺑﻘﺼﺔ اﺳﻬﺎل ﻟﻤﺪة أﺳﺒﻮع‪ .‬هﻨﺎك ﺻﻌﻮﺑﺔ ﻓﻲ اﻟﺘﻨﻔﺲ‬
‫واﺿﺤﺔ وﺗﺨﻠﻴﻂ ذهﻨﻲ‪ .‬اﻟﻀﻐﻂ اﻟﺸﺮﻳﺎﻧﻲ ‪100/60‬‬
‫‪Na 137‬‬
‫‪Acidemia‬‬
‫‪K2‬‬ ‫‪Respiratory and Metabolic‬‬
‫‪Cl 111‬‬ ‫‪AG 11‬‬
‫‪pH 7.15‬‬ ‫‪10≈11‬‬
‫‪PCO2 50‬‬
‫‪HCO3 15‬‬
‫‪Respiratory and Metabolic Acidosis‬‬
Respiratory Acidosis

† Pulmonary Parenchymal disease

† Laryngospasm
† Pleural Disease
† Impaired respiratory: Sedation, muscular
weakness, CNS ..etc
Metabolic Acidosis

† Anion Gap
† Non Anion Gap
Non- AG Metabolic Acidosis

† Bicarb Loss
† Renal or GI
† Urinary electrolytes ( Na,K,Cl)
† Urine Delta Gap ( Na+ K – Cl)
† Negative Gap means Extra (-) charges
which is Ammonia (normal kidney
response to acidemia)
Treatment

† Treating Underlying Cause

† Correcting Volume
† Supplementing Bicarb
Bicarb deficit
TBW X (desired Bicarb – current Bicarb)

Gradual correction
Don’t over correct
 ‫‪Case 5‬‬
‫† رﺟﻞ ‪ 65‬ﺳﻨﺔ‪ ,‬اﻟﺘﻬﺎب ﻗﺼﺒﺎت ﻣﺰﻣﻦ ‪ ,‬دﺧﻞ ﻗﺴﻢ اﻹﺳﻌﺎف‬
‫ﺑﻘﺼﺔ اﺳﻬﺎل ﻟﻤﺪة أﺳﺒﻮع‪ .‬هﻨﺎك ﺻﻌﻮﺑﺔ ﻓﻲ اﻟﺘﻨﻔﺲ‬
‫واﺿﺤﺔ وﺗﺨﻠﻴﻂ ذهﻨﻲ‪ .‬اﻟﻀﻐﻂ اﻟﺸﺮﻳﺎﻧﻲ ‪100/60‬‬
‫‪† Urine Na 10‬‬
‫‪† Urine K 30‬‬
‫‪† Urine Cl 100‬‬
‫‪Delta Gap -60‬‬
‫)‪( GI loss‬‬
‫‪Bicarb diff= 60X 0.5X (20-15)= 150 mEq‬‬
 Case 6

‫ ﺳﻨﺔ أدﺧﻠﺖ ﻗﺴﻢ اﻹﺳﻌﺎف ﺑﻀﻌﻒ ﻋﻀﻠﻲ ﻣﺘﺮق‬16 ‫† ﻓﺘﺎة‬

.‫ﺧﻼل أﺳﺒﻮع وﺣﺎﻟﻴﺎ ﻻ ﺗﺴﺘﻄﻴﻊ اﻟﺤﺮآﺔ‬
Na 136
K 1.8 Acidemia
Metabolic
Cl 114
AG 10
pH 7.25 Expec. PCO2 23
PCO2 28 1:1
HCO3 12

Metabolic Acidosis and respiratory Acidosis

‫)‪Case-6 (..cont‬‬

‫† ﺧﻼل وﺟﻮد اﻟﻤﺮﻳﻀﺔ ﻓﻲ ﻗﺴﻢ اﻻﺳﻌﺎف ﺑﺪأ ﺗﻨﻔﺴﻬﺎ ﻳﺴﻮء‪.‬‬

‫أﻋﻴﺪت ﻏﺎزات اﻟﺪم‬
‫‪Na 136‬‬
‫‪K 1.3‬‬
‫‪Cl 113‬‬
‫‪pH 7.05‬‬
‫‪PCO2 40‬‬
Case-6 treatment

† Intubation
† IV bicarb???
† K replacement 20 mEq/hr with cardiac
monitoring first until k>3
† Then carefully bicarb IV if pH <7.10
Case-7
‫ وﺟﺪ‬.110/50 mmHg ‫ أدﺧﻞ ﻟﻘﺴﻢ اﻹﺳﻌﺎف ﺑﻬﺒﻮط ﺿﻐﻂ‬.‫ آﺤﻮﻟﻲ‬,‫ ﺳﻨﺔ‬50 ‫رﺟﻞ‬
.(Antifreeze) ‫ﻓﻲ اﻟﺒﻴﺖ ﻓﺎﻗﺪ اﻟﻮﻋﻲ وأﻣﺎﻣﻪ ﻋﺒﻮة ﻟﻤﻀﺎد اﻟﺘﺠﻤﺪ‬
Na 139
K 6.5 Acidemia
Cl 84 Metabolic and respiratory
pH 6.86 AG 39
PCO2 81
Bicarb 16
Glucose 90 ∆AG=27
BUN 48 ∆bicarb= 9
Ethanol -

Anion gap Metabolic Acidosis, Respiratory acidosis

and Metabolic Alkalosis
Case 7- ..cont

Urine pH 5
U.Na 1
U.K 30
U. Cl 8
Saline responsive Met. Alkalosis
Case 7- ..cont

† Intubation
† IV fluids
† IV bicarb ????

What is the Cause of Metabolic Acidosis

 Anion Gap Metabolic Acidosis

† Ketoacidosis (DM, Alcohol-induced,..)

† Lactic Acidosis ( L, and D)
† Renal Failure
† Toxin ingestion- Ethylene glycol
- Methanol
Labs
Glucose, Ethanol, Lactic - Salicylates
Acid, BUN, creatinine
- Paraldehyde
Salicylate
Osmolar gap
Osmolar Gap

† Osmolar gap=
measured Osm- Calculated Osm

Calc. Osm= 2xNa+ glucose/18+

BUN/2.8+ethanol/4.6
Normally not greater than 10
 Case 8

† A 75 y. old lady with hx of arthritis was

found by family to be confused and
breathing rapidly .
Na 140
Acidemia
K 3.5 Metabolic
Cl 105 AG=18
HCO3 17 Exp.∆PCO2=1.3X8=11
pH 7.30 Respiratory Alkalosis

PCO2 20 1:1

AG Metabolic Acidosis and Respiratory Alkalosis (Salicylate Toxicity)

 Case 9
† A 15 y old boy, type 1 DM .admitted to ER with
coma. Family report to you that he has no
insulin since yesterday.
Na 130
K 6.5
Cl 95 Acidemia
HCO3 10 Metabolic
pH 7.10
AG 25
PCO2 20
Exp.PCO2 20
Glucose 1000
1:1
BUN ,creat NL
Keton body +

AG metabolic Acidosis (DKA)

Case 9 ..cont
† Pt was treated with Insulin/ IV fluid (Saline)
† Next morning, keton has been (-) on repeated
measures,
Na 140
Cl 115 Acidemia

K5 Metabolic
HCO3 18 AG 7
Keton (-) blood and urine Exp.PCO2 30
pH 7.30 1:1
PCO2 30
Glucose 200. pt on IV insulin drip

Hyperchloremic (Non-AG) Metabolic Acidosis

Case 9 ..cont

† Loss of bicarb in the Urine

† IV saline (Cl)
† Hyperkalemia suppress ammonium
production and excretion

Treatment
Change IV fluid to ½ normal + Bicarb
or D5W