6 bước phân tích toan kiềm

Bước 1: Toan hay kiềm

pH < 7.35 = toan máu pH > 7.45 = kiềm máu

Bước 2: Chuyển hóa hay hô hấp

22 < HCO3- < 26 (mmol/L) 35 < PaCO2 < 45 (mmHg)

Bước 3: Nếu do hô hấp  cấp hay mãn

(PCO2 = 10)  pH = 0.08 (PCO2 = 10)  pH = 0.03
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 6 bước phân tích toan kiềm
Bước 4: Nếu toan chuyển hóa  tính anion gap
AG = Na+ - (Cl- + HCO3-)
AG > 12: toan CH có AG AG < 12: toan CH non AG

Bước 5: HCO3 hiệu chỉnh = HCO3 đo + (AG – 12)

> 24: kèm kiềm chuyển hóa < 24: kèm toan CH non AG

6. Bù trừ hô hấp: PaCO2 dự tính = (1,5 x HCO3) + (8 ± 2)

> PaCO2 đo: kèm kiềm HH < PaCO2 đo: kèm toan HH
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 Phân tích ca 1:

Trẻ 12t, nữ, hôn mê ketoacidosis do tiểu

đường type 1:
 Na = 128, Cl = 90, Glucose = 400

 Khí máu: 7.0/14/90/4

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 Trả lời: ca 1

 Bước 1: pH = 7.0  toan máu

 Bước 2: HCO3 = 4 (cùng chiều)  toan ch.hóa
 Bước 4: AG = 128 – (90 + 4) = 34  toan
chuyển hóa tăng anion gap
 Bước 5: HCO3 hiệu chỉnh = 4 + (34 – 12) = 26 
kèm kiềm chuyển hóa
 Bước 6: Winters formula: PaCO2 = (1.5 x 4) + 8
( 2) = 12 – 16  bù trừ hô hấp đủ
 KL: toan chuyển hóa tăng anion gap kèm kiềm
chuyển hóa, bù trừ hô hấp hoàn toàn
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 Phân tích ca 2

1 ông 56 tuổi, đợt cấp COPD và hạ HA do tiêu

chảy 7 ngày:

 Khí máu: 7.22/65/80/10

 Ion đồ: Na 139, Cl 110, K 4

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 Trả lời ca 2

Bước 1: pH = 7.22  toan máu

Bước 2: Hô hấp hay chuyển hóa:
 Hô hấp: (65 – 40):40 = 0,375
 Chuyển hóa: (24 – 10): 24 = 0,58
  toan chuyển hóa
Bước 4: AG = 139 – (10 + 110) = 19  toan chuyển
hóa có tăng anion gap
Bước 5: HCO3 hiệu chỉnh = 10 + (19 – 12) = 10 + 7
= 17
 Kèm toan chuyển hóa không anion gap
Bước 6: Winters formula
 PaCO2 dự tính = 1.5 x10 + 8 (2)= 21 – 25
 Kèm Toan hô hấp
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 Trả lời ca 2

Kết luận: bộ ba
 AG acidosis
 Non AG acidosis
 Respiratory acidosis
Cơ chế:
 AG acidosis: do lactic acidosis sau hạ huyết áp
 Non AG acidosis: tiêu chảy mất bicar qua đường tiêu
hóa
 Respiratory acidosis đợt cấp trên nền mãn do COPD.
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 Phân tích ca 3

Bé gái 6 tháng tuổi, viêm phổi + nhiễm

trùng huyết. Đang bị tụt huyết áp, phải
truyền dopamine. Ói nhiều lần từ 3 ngày
nay
 Na = 130, Cl = 90

 ABG = 7.26/15/65/10

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 Trả lời ca 3
 Bước 1: pH = toan
 Bước 2: HCO3 = 10 → toan chuyển hóa
 Bước 4: AG = 130 – (90 + 10) = 30 → toan chuyển hóa
có tăng anion gap (do HA thấp)
 Bước 5: HCO3 hiệu chỉnh = 10 + (30 –12) = 28 → kiềm
chuyển hóa (do ói nhiều, mất HCl)
 Bước 6: PCO2 = (1.5 x 10) + 8 (2)= 21 – 25 → bù trừ
toan chuyển hóa bằng kiềm hô hấp
 Kết luận
 AG acidosis
 Respiratory alkalosis
 Metabolic alkalosis
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 Arterial Blood Gases – test your
overall understanding
Case 1. A 55-year-old man is evaluated in the
pulmonary lab for shortness of breath. His regular
medications include a diuretic for hypertension and
one aspirin a day. He smokes a pack of cigarettes a
day.
FIO2 .21 HCO3- 30 mEq/L
pH 7.53 %COHb 7.8%
PaCO2 37 mm Hg Hb 14 gm%
PaO2 62 mm Hg CaO2 16.5 ml O2
SaO2 87%

How would you characterize his state of oxygenation,

ventilation and acid-base balance?

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 Arterial Blood Gases – test your
overall understanding
Case 1 - Discussion.
OXYGENATION: The PaO2 and SaO2 are both reduced on
room air. Since P(A-a)O2 is elevated (approximately 43 mm
Hg), the low PaO2 can be attributed to V-Q imbalance, i.e., a
pulmonary problem. SaO2 is reduced, mainly from elevated
carboxyhemoglobin, which in turn can be attributed to
cigarettes. The arterial oxygen content is adequate.
VENTILATION: Adequate for the patient's level of CO2
production; the patient is neither hyper- nor hypo-ventilating.
ACID-BASE: Elevated pH and HCO3- suggest a state of
metabolic alkalosis, most likely related to the patient's
diuretic; his serum K+ should be checked for hypokalemia.
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 Arterial Blood Gases – test your
overall understanding
Case 2. A 46-year-old man has been in the hospital two days,
with pneumonia. He was recovering but has just become
diaphoretic, dyspneic and hypotensive. He is breathing
oxygen through a nasal cannula at 3 l/min.
pH 7.40
PaCO2 20 mm Hg
%COHb 1.0%
PaO2 80 mm Hg
SaO2 95%
Hb 13.3 gm%
HCO3- 12 mEq/L
CaO2 17.2 ml O2

How would you characterize his state of oxygenation,

ventilation and acid-base balance?
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 Arterial Blood Gases – test your
overall understanding
Case 2 - Discussion.
OXYGENATION: The PaO2 is lower than expected for someone
hyperventilating to this degree and receiving supplemental
oxygen, and points to significant V-Q imbalance. The oxygen
content is adequate.
VENTILATION: PaCO2 is half normal and indicates marked
hyperventilation.
ACID-BASE: Normal pH with very low bicarbonate and PaCO2
indicates combined respiratory alkalosis and metabolic acidosis.
If these changes are of sudden onset the diagnosis of sepsis
should be strongly considered, especially in someone with a
documented infection.
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 Arterial Blood Gases – test your
overall understanding
Case 3. A 58-year-old woman is being evaluated in the
emergency department for acute dyspnea.
FIO2 .21
pH 7.19
PaCO2 65 mm Hg
%COHb 1.1%
PaO2 45 mm Hg
SaO2 90%
Hb 15.1 gm%
HCO3- 24 mEq/L
CaO2 18.3 ml O2

How would you characterize her state of oxygenation,

ventilation and acid-base balance?
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 Arterial Blood Gases – test your
overall understanding
Case 3 - Discussion.
OXYGENATION: The patient's PaO2 is reduced for two
reasons: hypercapnia and V-Q imbalance, the latter apparent
from an elevated P(A-a)O2 (approximately 27 mm Hg).
VENTILATION: The patient is hypoventilating.
ACID-BASE: pH and PaCO2 are suggestive of acute respiratory
acidosis plus metabolic acidosis; the calculated HCO3- is
lower than expected from acute respiratory acidosis alone.
.

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 Arterial Blood Gases – test your
overall understanding
Case 4. A 23-year-old man is being evaluated in the emergency
room for severe pneumonia. His respiratory rate is 38/min
and he is using accessory breathing muscles.
FIO2 .90 Na+ 154 mEq/L
pH 7.29 K+ 4.1 mEq/L
PaCO2 55 mm Hg Cl- 100 mEq/L
PaO2 47 mm Hg CO2 24 mEq/L
SaO2 86%
HCO3- 23 mEq/L
%COHb 2.1%
Hb 13 gm%
CaO2 15.8 ml O2

How would you characterize his state of oxygenation,

ventilation and acid-base balance?
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 Arterial Blood Gases – test
your overall understanding
OXYGENATION: The PaO2 and SaO2 are both markedly reduced on
90% inspired oxygen, indicating severe V-Q imbalance.
VENTILATION: The patient is hypoventilating despite the presence of
tachypnea, indicating significant dead space ventilation. This is a
dangerous situation that suggests the need for mechanical ventilation.
ACID-BASE: The low pH, high PaCO2 and slightly low calculated
HCO3- all point to combined acute respiratory acidosis and metabolic
acidosis. Anion gap is elevated to 30 mEq/L indicating a clinically
significant anion gap (AG) acidosis. With an of AG of 30 mEq/L his
serum CO2 should be much lower, to reflect buffering of the increased
acid. However, his serum CO2 is near normal, indicating a primary
process that is increasing it, i.e., a metabolic alkalosis in addition to a
metabolic acidosis. The cause of the alkalosis is as yet undetermined.
In summary this patient has respiratory acidosis, metabolic acidosis and
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metabolic alkalosis.