Blood Gases

Introduction
Oxygenation, ventilation and metabolic functions are routinely assessed in critically ill patients. A 10
second, disease oriented, approach is helpful. Blood gases tell us two things. Oxygenation and ventilation.
Oxygenation
The two questions are:
1) Is it safe?
• Safe SpO2 is over 90% (flat part of the oxy-hemoglobin curve)
• PaO2 of 60 corresponds to SpO2 of 90%
• If the PaO2 is <60mm Hg, stop and go fix it
2) Is it normal?
• Normal lungs breathing room air (FiO2 0.21) would have PaO2 100mm Hg. That person
with 100% FIO2 should have PaO2 500mm Hg. You can thus infer the expected PaO2
• A patient may have safe PaO2 of 65mm Hg but if they require FIO2 0.75, something is
wrong, but deal with that later
Ventilation
Next we assess ventilation. There are three steps, the first two of which are familiar.
1. What is the pH?
• To sound smart and for simplicity, consider normal pH 7.400000
• Anything less is acidosis, anything more is alkalosis
2. Does the CO2 explain it?
o A high CO2 would explain an acidosis
▪ If both are present they have a Respiratory Acidosis
o A low CO2 would explain an alkalosis
▪ If both present = Respiratory Alkalosis
3. What is Base Excess?
o This may be new. CO2 is the independent variable in blood gases, determined by the
brain, spine, chest wall and lungs. HCO3 just reflects changes in CO2
o The computer knows that for any CO2, the bicarb should be SOMETHING
o It then calculates how much MORE bicarb is present, than there ought to be for that CO2
▪ This is the base excess
o A positive base excess → MORE bicarb than expected ➔ Metabolic Alkalosis
o Negative base excess → LESS bicarb than expected ➔ Metabolic Acidosis
Practically
- Safe but not normal O2 → think atelectasis, edema, pneumonia, PE
- RAc → Drugs, COPD, neuromuscular disease
- RAlk → Same different as sinus tachycardia, does not matter
- MAlk → Always “contraction alkalosis” in ICU due to free water loss, diuresis, or diarrhea
- MAc → Almost always lactate. If not, think uremia or ketones. The list of things that cause
metabolic acidosis is very long but if it’s not lactate (which suggests shock), it can wait.