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LEARNING OBJECTIVES
By the end of the session, the student will be able to: 1. Identify the causes of acid base imbalance in children. 2. Recognise the clinical manifestations that may be seen in a child with acid base imbalance. 3. Interpret blood gas analysis.
CAPILLARY BLOOD GASES: pH: Same as arterial or slightly lower (Normal = 7.35-7.40) pCO2: Same as arterial or slightly higher (Normal = 40-45) pO2: Lower than arterial (Normal = 45-60) O2 Saturation: >70% is acceptable.
pCO2 and pH
A change in pCO2 up or down 10 mm Hg is associated with an increase or decrease in pH of 0.08 units. As the pCO2 decreases, the pH increases; as the pCO2 increases, the pH decreases.
INTERPRETATION OF BLOOD GASES Step 2: determine if an acidemia (pH <7.37) or an alkalemia (pH >7.44) is present.
If both components act in the same direction (eg, both respiratory [pCO2 > 44 mm Hg] and metabolic [HCO3 - <22 mmol/L] acidosis are present), then this is a mixed acid-base problem. The primary disturbance will be the one that varies from normal the greatest, that is, with a [HCO3 -] = 6 mmol/L and pCO2 = 50 mm Hg, the primary disturbance would be a metabolic acidosis, the [HCO3 -] is about one-quarter normal, whereas the increase in pCO2 is only 25%.
Step 4:
Calculate the anion gap. Anion gap = Na+ - (Cl- + HCO3 -). Normal anion gap is 8-12 mmol.
Metabolic acidosis represents an increase in acid in body fluids . Reflected by a decrease in [HCO3 -] and a compensatory decrease in pCO2.
METABOLIC ALKALOSIS:
Metabolic alkalosis represents an increase in [HCO3 -] with a compensatory rise in pCO2.
Differential Diagnosis
1. Neuromuscular Abnormalities with Ventilatory Failure 2. Central Nervous System Drugs, Sedative,,Central sleep apnea 3. Airway Obstruction a. Chronic (COPD) b. Acute (asthma) c. Upper airway obstruction d. Obstructive sleep apnea 4. Thoracic/Pulmonary Disorders a. Bony thoracic cage: Flail chest, kyphoscoliosis b. Parenchymal lesions: Pneumothorax, pulmonary edema, c. Large pleural effusions d. Scleroderma e. Marked obesity (Pickwickian syndrome)
RESPIRATORY ALKALOSIS:
Respiratory alkalosis is a primary fall in pCO2 with a compensatory decrease in plasma [HCO3 -]. Respiratory alkalosis occurs with increased alveolar ventilation.
Differential Diagnosis
1. Central stimulation a. Anxiety, hyperventilation syndrome, pain b. Head trauma or CVA with central neurogenic hyperventilation c. Tumors d. Salicylate overdose e. Fever, early sepsis 2. Peripheral stimulation a. PE b. CHF (mild) c. Interstitial lung disease d. Pneumonia e. Altitude f. Hypoxemia: 3. Miscellaneous a. Hepatic insufficiency b. Pregnancy c. Progesterone d. Hyperthyroidism e. Iatrogenic mechanical overventilation
H+
HCO3KIDNEYS
PCO2 in
arterial blood
PCO2 in
CSF
PCO2 in
arterial blood
RESPONSE TO HYPERCAPNIA
H+ in CSF
expiration of PCO2
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Blood Gas Case Studies. 1. Anna is a 3 month old baby who has been in hospital for one week. She has been tested RSV +ve. She is having severe difficulty in breathing. PH Paco2 BE 7.15 9.25 kPa -1 mmol
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2. Badu is a 15 year old who has been involved in a RTA. He was driving a stolen car. He has been admitted to your ward awaiting police investigation. He is very anxious. He begins to hyperventilate. PH 7.6 Paco2 3.15 kPa BE +3 mmol What is Budus acid base status?
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3. Rani is a 10 year old newly diagnosed diabetic. She has presented to A & E. She has been acutely unwell since this morning. It is now 2pm. PH Paco2 BE 7.10 4.2 kPa -10 mmol
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4. Andrew is a 4 week old baby. He has vomited post feeds since 1 week old. This vomiting has worsened, he has come to your ward for investigation into pyloric stenosis. PH 7.75 Paco2 5.8 kPa BE +8.7 mmol What is Andrews acid base status?
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5. Jessica is a 10 year old newly diagnosed diabetic. She has presented to A & E. She has been acutely unwell since Monday morning but her parents felt she would get better today. It is now Tuesday 2pm. PH 7.3 Paco2 3.35 kPa BE -5.9 mmol What is Jessicas acid base status?
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