— UNDERSTANDING BLOOD-GAS IMBALANCES A BRIEF GUIDE One of the most confusing tasks | faced as a young student was the understanding of blood gasses. The method described in this guide was introduced several years ago by Doreen A. Mays — a nurse from the VA Medical Center in Castle Point, New York. Even though | would like to claim this as my ‘own system, she deserves all the credit. | think you'll like the way she breaks- down the values and uses the tic-tac-toe method of evaluation. | have added samples and clinical conditions, ailments, and diseases to the fray. Once you work out a few cases, you'll have a better understanding of blood gas values and conditions that cause those imbalances - YOU WILL BE IMPRESSIVE! First of all, we must understand that the body works very hard to maintain the balance between Hydrogen ions (H+) and Hydroxyl ions (OH-). The normal concentration of H+ ions or “pH” is between 7.35 and 7.45 (many now suggest 7.38-7.42). Any pH value below 7.35 is considered to be “acidic” or “acidosis”. This can be caused by excess H+ ions OR by increases in alkaline (above 7.45) substances. A pH above 7.45 indicates that there are too many OH- ions or other “alkaline” substances OR not enough H+ ions. This condition (pH is above 7.45) is alkaline or “alkalosis”. Carbon Dioxide (CO2) combines with water in the blood to form Carbonic Acid (H2COs). This is the primary component in “Respiratory” conditions. The normal values of Carbon Dioxide are displayed as a “partial pressure”(PaCO2) are between 35 and 45 mm. Hg. If the PaCOz levels are high, the pH DROPS. This is a condition of “Respiratory Acidosis”. If the PaCOz levels decrease below 35 mm Hg,, the pH will rise and the condition will be “Respiratory Alkalosis”. So, HIGH CO2 = ACID, LOW CO2=ALKALINE The Bicarbonate ion (HCO3-) serves as the “metabolic” component. This ion binds with the H+ ion to reduce acidity. Normal serum concentrations range from 22 to 26 mEq/L. When the HCO3- levels rise, so do the pH values. This would be “Metabolic Alkalosis”. A fall in HCO3- concentration would lead to a drop in pH or “Metabolic Acidosis”.To Diagnose Acid-Base imbalances, we must consider three questions: 1. Does the pH indicate Acidosis or Alkalosis? 2. Is the cause of the imbalance Respiratory OR Metabolic? 3. Is there compensation for the imbalance? To answer these questions, use the following chart. [COMPONENT [ACID [NORMAL [ALKALINE | I i [Below 7.35 7.35-7.45 ‘Above 7.45 /pH HCO3 "| Below 22 22-26mEqiL ‘Above 26 | | | 35-45 mm Hg. Below 35 ' ‘PaCO2 | Above 45 Now, construct your own grid as follows: ACID ___NORMAL ____| ALKALINE i _ Alll you have to do now is simply plug-in the patient values. When any three items are aligned (including the heading), you are ready to diagnose!Now, let's try a problem in each of the major categories --- 1. Metabolic Acido: Patient Values: pH = 7.26, PaCO2 is 42, and HCO3 is 17 PH igoes into the acidic column, PaCO2 goes into the normal column, and HCO3 is low — going into the acidic column. BINGO - Metabolic Acidosis! | ACID | NORMAL ALKALINE [pH - [PaCOa | HCO3- _ T I Metabolic Acido: include — Diabetic Ketoacidosis Diarrhea Renal Failure Shock Sepsis Salicylate Overdose Intoxications- ethanol, methanol, ethylene glycol, etc. imply put, too much acid-not enough Bicarb. Possible causes Signs and Symptoms include: Chest pain, palpitations, headache, altered mental status, decreased visual acuity, nausea, vomiting, muscle weakness, altered appetite (long term), bone pain, Kussmaul breathing — rapid deep breathing 2. Metabolic alkalosis: Patient values: pH=7.48, PaCO2= 37, and HCO3 =29 [ACID NORMAL | ALKALINE Lo PACOz | pH [Hos L Causes of Metabolic Alkalosis include: Loss of H= ions due to Vomiting Renal loss of H+ ions (Conn’s syndrome) — Loss of H+ in the urine Loss of water from extracellular spaces - Hypokalemia Overuse of Antacids Retention of Bicarbonate3. Respiratory Alkalosis: Let's try another set of patient values: pH=7.49, PaCO2=30, and HCO3=23 ACID [NORMAL : [ALKALINE [ | HCO3 ‘pH CE | PaCO2 The values align on the alkaline side and the involved component is PaCO2. Therefore, it is a case of Respiratory Alkalosis. Possible causes would be—- Hyperventilation ~ related to one or some of the following Anxiety Hysteria Stress High Altitudes Pregnancy Fever Hypoxia Pulmonary embolism Hyperthermia Stroke Excessive Mechanical Ventilation Drug use ~ Doxapram, Aspirin, Caffeine, Pneumonia Sexual Activity Signs and Symptoms include: Dizziness, fainting, hand numbness, tetany, confusion, twitching, agitation 4. Respiratory Acidosis: In another case, patient values are: pH=7.26, PaCO2=52, and HCO3=24 [Acio NORMAL [ALKALINE ] pH HCO3 I | [Pacoz - i This would be a case of Respiratory Acidosis. General causes are: Hypoventilation Myasthenia gravis Amyotrophic lateral sclerosis G Barre syndrome Muscular dystrophy Depression of CNS due to damage or drugs coppNow, let's talk about compensation...... I think this handout is worth about $20..don’t you? NO, not that kind of compensation but what the body does to try and correct imbalances. Compensation can be Chemical, respiratory, or Renal related. Chemical compensation are quick-acting and generally not long-lasting. These include Bicarbonate, Phosphates, and Proteins Respiratory compensation responds to metabolic imbalances. Metabolic Acidosis causes an INCREASE in Respiratory rate to get rid of CO2. Metabolic Alkalosis causes a DECREASE in respiration ~ trying to keep C02. Renal Compensation responds to respiratory imbalances. Renal compensation is a slow and powerful way of restoring imbalances. Respiratory acidosis makes the kidneys excrete H+ (acid) and retain HCO3 (base). Respiratory alkalosis makes the kidneys excrete base (HCO3) and retain acid(H+). Also, the degree of compensation is important. in a “partially compensated” patient, the body is attempting to correct the problem but hasn’t succeeded. In a “fully compensated” Patient, the blood pH has been restored to normal. All the cases we've looked at so far have been “uncompensated” cases. PARTIALLY COMPENSATED: -32, PaCOz=33, HCO3=21_ NORMAL [ ALKALINE | Pacoz [acid [NORMAL | ALKALINE ] - __PH | LHCOs I Pacoz