acid base disorders

Acid Base Disorders Acid Base Disorders

A Practical ApproachA Practical Approach

Ass. Lecturer critical care medicineAss. Lecturer critical care medicineCairo University HospitalCairo University Hospital

WALID KAMEL, MBChWALID KAMEL, MBCh

Regulation of acid-base balance:Regulation of acid-base balance:

Defense against the change in pH…

because H+ react highly with cellular

proteins resulting in alteration in their function.

Avoiding acidemia and alkalemia by tightly

regulation H+ is essential for normal cellular

function.

What information does ABG provide about the patient?What information does ABG provide about the patient?

ABG provide an assessment of the following:

1)PaO2: Amount of o dissolved in the blood, it give initial information on efficiency of oxygenation.

2)PaCO2: Adequacy of ventilation is inversely proportional to Paco2 (when ventilation increase PaCO2 decrease and vice verse).

3) Acid base status (pH, HCO3, base deficit, anion gap).

4) Hb, Hct, oxygen saturation.

5) Electrolyte e.g. Na+, K+.

Diagnosis of acid Base disorders Diagnosis of acid Base disorders

•Arterial blood sample is common utilized clinically

but venous blood may be useful in determining acid

base status. (Except in CHF and shock).

•Blood sample should be in heparin coated syringe.

•The sample should be analyzed as soon as possible.

•Air bubble should be eliminated.

•The syringe should be capped and placed in ice.

Acid Base -Basic ConceptsAcid Base -Basic Concepts

Hydrogen Ion Hydrogen Ion [H[H++]] is tightly controlled is tightly controlled [H[H++]] is determined by the balance between is determined by the balance between

PaCOPaCO22 and serum and serum HCOHCO33 (bicarbonate) (bicarbonate)

Henderson-Hasselbalch EquationHenderson-Hasselbalch Equation

[H[H++] = 24 (PaCO] = 24 (PaCO22 / HCO / HCO33--))

[H[H++] pH] pH

pH = 6.1 + log ([PaCO2] / [0.03 x HCO3-])pH = 6.1 + log ([PaCO2] / [0.03 x HCO3-])

pH [H+] pH [H+]

7.807.75

1618

7.307.25

5056

7.707.65

2022

7.207.15

6371

7.607.55

2528

7.107.00

7989

7.507.45

3235

6.956.90

100112

7.407.35

4045

6.856.80

141159

Normal ValuesNormal Values

[H+] = 40 nEq/L [H+] = 40 nEq/L pH = 7.40 pH = 7.40 (7.35-7.45)(7.35-7.45)PaCOPaCO22 = 40 mm Hg = 40 mm Hg (35-45)(35-45)

HCOHCO33 = 24 mEq/L = 24 mEq/L (22-26)(22-26)

Keep It SimpleKeep It Simple

PaCOPaCO22 = Acid = Acid PaCOPaCO22 = = pH (Acidemia) pH (Acidemia)

PaCOPaCO22 = = pH (Alkalemia) pH (Alkalemia)

HCOHCO33 = Base = Base HCOHCO33 = = pH (Alkalemia) pH (Alkalemia)

HCOHCO33 = = pH (Acidemia) pH (Acidemia)

Simple Acid-Base DisordersSimple Acid-Base Disorders

Type of Disorder pH PaCO2 [HCO3]

Metabolic Acidosis ↓ ↓ ↓Metabolic Alkalosis ↑ ↑ ↑Acute Respiratory Acidosis ↓ ↑ ↑Chronic Respiratory Acidosis ↓ ↑ ↑↑Acute Respiratory Alkalosis ↑ ↓ ↓Chronic Respiratory Alkalosis ↑ ↓ ↓↓

EXPECTED CHANGES IN ACID-BASE DISORDERSEXPECTED CHANGES IN ACID-BASE DISORDERS

Primary Disorder Primary Disorder Expected Expected ChangesChanges

Metabolic acidosis Metabolic acidosis PCO2 = 1.5 × HCO3 + (8 ± 2) PCO2 = 1.5 × HCO3 + (8 ± 2) Metabolic alkalosis Metabolic alkalosis PCO2 = 0.7 × HCO3 + (21 ± 2) PCO2 = 0.7 × HCO3 + (21 ± 2) Acute respiratory acidosis Acute respiratory acidosis delta pH = 0.008 × delta pH = 0.008 ×

(PCO2 - 40) (PCO2 - 40) Chronic respiratory acidosis Chronic respiratory acidosis delta pH = 0.003 × delta pH = 0.003 ×

(PCO2 - 40) (PCO2 - 40) Acute respiratory alkalosis Acute respiratory alkalosis delta pH = 0.008 × (40 - PCO2) delta pH = 0.008 × (40 - PCO2) Chronic respiratory alkalosis Chronic respiratory alkalosis delta pH = 0.003 × (40 - delta pH = 0.003 × (40 -

PCO2) PCO2)

Acid-Base AnalysisAcid-Base AnalysisWhat do You Need?What do You Need?

Arterial Blood gases (pH, COArterial Blood gases (pH, CO22))

Serum chemistry (Na, K, Cl, HCOSerum chemistry (Na, K, Cl, HCO33))

A 39 year old woman was admitted with a history of A 39 year old woman was admitted with a history of generalized weakness, dyspnea, continuous nausea generalized weakness, dyspnea, continuous nausea and diarrhea. Bowel motions were frequent and and diarrhea. Bowel motions were frequent and watery.watery.

ABG: pH 7.29, PaCO2 25.6, PaO2 98ABG: pH 7.29, PaCO2 25.6, PaO2 98 NaNa++=125, K=125, K++=2.8, Cl=2.8, Cl--=101, HCO=101, HCO33=14=14

Study CaseStudy Case

Metabolic Metabolic Acidosis

Simple Vs. MixedSimple Vs. MixedCompensation ConceptCompensation Concept


Is compensation appropriate?Is compensation appropriate? Must know “rules of thumb” of compensationMust know “rules of thumb” of compensation

Respiratory CompensationRespiratory Compensation

Compensate for metabolic Compensate for metabolic disordersdisorders

Prompt responsePrompt response

Metabolic acidosisMetabolic acidosis Hyperventilation - ↓ PaCOHyperventilation - ↓ PaCO2 2

Metabolic alkalosisMetabolic alkalosis Hypoventilation - ↑ PaCOHypoventilation - ↑ PaCO22

Respiratory CompensationRespiratory Compensation

Metabolic AcidosisMetabolic AcidosisPaCO2 = [1.5 x HCOPaCO2 = [1.5 x HCO33 + 8] ± 2 + 8] ± 2

Metabolic AlkalosisMetabolic Alkalosis∆∆PaCO2 = 0.9 ∆ HCOPaCO2 = 0.9 ∆ HCO33

Metabolic CompensationMetabolic Compensation

Compensation for respiratory disordersCompensation for respiratory disorders Slow response Slow response

Starts in 6-12 hoursStarts in 6-12 hours Steady state in few daysSteady state in few days

Respiratory acidosisRespiratory acidosis Stimulates HCOStimulates HCO33 reabsorption -- reabsorption --↑ HCO↑ HCO3 3

Respiratory alkalosisRespiratory alkalosis Inhibits HCOInhibits HCO33 reabsorption -- reabsorption -- ↓ HCO↓ HCO33

Metabolic CompensationMetabolic Compensation

Chronic Respiratory AcidosisChronic Respiratory Acidosis∆ ∆ HCOHCO33= 0.35 ∆ PaCO= 0.35 ∆ PaCO22

Chronic Respiratory AlkalosisChronic Respiratory Alkalosis∆ ∆ HCOHCO33= 0.5 ∆ PaCO= 0.5 ∆ PaCO22

Case Study - 1Case Study - 1 A 39 year old woman was admitted with a history of generalized A 39 year old woman was admitted with a history of generalized

weakness, dyspnea, continuous nausea and diarrhea. Bowel weakness, dyspnea, continuous nausea and diarrhea. Bowel motions were frequent and watery.motions were frequent and watery.


PaCO2 = [1.5 x HCO3 + 8] ± 2PaCO2 = [1.5 x HCO3 + 8] ± 2PaCo2=[1.5X12]+8 ± 2PaCo2=[1.5X12]+8 ± 2

PaCO2 = PaCO2 = 2525 ± 2 ± 2

Simple (compensated) metabolic acidosis

Metabolic AcidosisMetabolic AcidosisAnion GapAnion Gap

Metabolic acidosis is grouped Metabolic acidosis is grouped according to the anion gapaccording to the anion gap

Anion Gap (AG)Anion Gap (AG) The difference between measured cations The difference between measured cations

and measured anions in the serumand measured anions in the serum

AG= NaAG= Na++ - [Cl - [Cl-- + HCO + HCO33--]]

Normal (9 - 12 mEq/LNormal (9 - 12 mEq/L))

Wide Anion Gap AcidosisWide Anion Gap Acidosis

MethanolMethanol UremiaUremia Diabetic Ketoacidosis, KetoacidosisDiabetic Ketoacidosis, Ketoacidosis ParaldehydeParaldehyde Iron, Isoniazid (INH)Iron, Isoniazid (INH) Lactic AcidosisLactic Acidosis Ethanol, Ethylene glycolEthanol, Ethylene glycol SalicylatesSalicylates

Non (normal) Anion Gap Non (normal) Anion Gap AcidosisAcidosis

HyperalimentationHyperalimentation Acetazolamide, amphotericinAcetazolamide, amphotericin RTA –Renal Tubular AcidosisRTA –Renal Tubular Acidosis DiarrheaDiarrhea Ureteral DiversionsUreteral Diversions Pancreatic fistulaPancreatic fistula Saline resuscitationSaline resuscitation

Non anion gap metabolic acidosis:

Metabolic acidosis associated with normal AG is typically characterized by hyperchloremia.

Calculation of AG in urine:Urine AG = ( Na+ + K+) – CL-

In a patient with a hyperchloraemic metabolic acidosis:•A negative UAG GIT loss of bicarbonate (eg diarrhoea) •A positive UAG impaired renal distal acidification (ie renal tubular acidosis).

BASE EXCESSBASE EXCESS

It is an estimate of the amount of strong acid or It is an estimate of the amount of strong acid or

base needed to correct the met. component of an base needed to correct the met. component of an

acid base disorder (restore plasma pH to 7.40at a acid base disorder (restore plasma pH to 7.40at a

PacoPaco2 2 40 mmHg) 40 mmHg) represent only the metabolic

component of acid base disorders.

Its +ve value indicate metabolic alkalosis, wIts +ve value indicate metabolic alkalosis, while

–ve value indicate metabolic acidosis.

Study Case - 1Study Case - 1 A 39 year old woman was admitted with a history of A 39 year old woman was admitted with a history of

generalized weakness, dyspnea, continuous nausea generalized weakness, dyspnea, continuous nausea and diarrhea. Bowel motions were frequent and and diarrhea. Bowel motions were frequent and watery.watery.


AG = Na – (Cl+HCO3)

AG = 125 – (101+14) = 10

Normal anion gap metabolic acidosis

Metabolic AlkalosisMetabolic Alkalosis

Characterized byCharacterized by Primary Primary ↑↑ in HCO3 concentration in HCO3 concentration Compensatory Compensatory ↑↑ in PaCO2 in PaCO2

Classified according to urinary chlorideClassified according to urinary chloride Chloride responsiveChloride responsive Chloride resistantChloride resistant

Metabolic AlkalosisMetabolic AlkalosisChloride ResponsiveChloride Responsive

Urine ClUrine Cl-- >20 mEq/L >20 mEq/L Volume Contraction:Volume Contraction:

Nasogastric suctioningNasogastric suctioning VomitingVomiting DiureticsDiuretics

Post HypercapniaPost Hypercapnia HypokalemiaHypokalemia HypomagnesemiaHypomagnesemia PenicillinPenicillin

Metabolic AlkalosisMetabolic AlkalosisChloride UnresponsiveChloride Unresponsive

Mineralcorticoid excessMineralcorticoid excess Exogenous steroidsExogenous steroids Alkali IngestionAlkali Ingestion LicoriceLicorice Too much wineToo much wine Tobacco chewersTobacco chewers Bartter’s SyndromeBartter’s Syndrome

Urine Cl- < 20 mEq/LUrine Cl- < 20 mEq/L

Case Study - 2Case Study - 2

A 78 year old lady presented with at a 1 week A 78 year old lady presented with at a 1 week history of abdominal pain and vomiting.history of abdominal pain and vomiting.

ABG: pH 7.49, PaCO2 52, PaO2 78ABG: pH 7.49, PaCO2 52, PaO2 78 Na 137, K 2.2, CL 91, HCO3 38Na 137, K 2.2, CL 91, HCO3 38 Urine CI 43Urine CI 43 mEq/LmEq/L

Metabolic Alkalosis

Vomiting and hypokalemia

SolvingSolving Acid Base Disorders Acid Base Disorders

Rule 1Rule 1

Validate the ABGValidate the ABG


80 - [H80 - [H++]] ~ the last two digits of the pH ~ the last two digits of the pH

[H[H++] of 24: pH of (80-24=56) ~ 7.] of 24: pH of (80-24=56) ~ 7.5656 [H[H++] of 53: pH of (80-53=27) ~ 7.] of 53: pH of (80-53=27) ~ 7.2727

Another method

Determine if numbers fit:Determine if numbers fit:H+ = H+ =

3

2

HCO

PCO24×

H+ = (7.8-PH)×100.H+ = (7.8-PH)×100.

The Rt side of the equation should be The Rt side of the equation should be within 10% of the Lt Side. If not so another within 10% of the Lt Side. If not so another

ABG or chemistry panel for HCO3 should be ABG or chemistry panel for HCO3 should be done.done.

Rule 2Rule 2 What is the pH?What is the pH?

> 7.40 → 1° disorder is alkalosis> 7.40 → 1° disorder is alkalosis < 7.40 → 1° disorder is acidosis< 7.40 → 1° disorder is acidosis

Does the Does the PaCOPaCO22 explains the pH? explains the pH? Yes Yes → 1° disorder is respiratory→ 1° disorder is respiratory No → 1° disorder is metabolicNo → 1° disorder is metabolic

Rule 3Rule 3

Does the Does the PaCOPaCO22 explains the pH? explains the pH? Yes Yes → 1° disorder is respiratory→ 1° disorder is respiratory No → 1° disorder is metabolicNo → 1° disorder is metabolic

Rule 4Rule 4

Apply compensation rulesApply compensation rules

If calculated compensation:If calculated compensation: Within the expected range → simple Within the expected range → simple

acid/base disorderacid/base disorder Less or more than expected → 2° Less or more than expected → 2°

acid/base disorderacid/base disorder

There is no over correction or There is no over correction or compensation in acid base balance → compensation in acid base balance → if the compensatory response is more if the compensatory response is more

or less than expected → it is mixed or less than expected → it is mixed acid base disorderacid base disorder

Case Study - 1Case Study - 1 A 39 year old woman was admitted with a history A 39 year old woman was admitted with a history

of generalized weakness, dyspnea, continuous of generalized weakness, dyspnea, continuous nausea and diarrhea. Bowel motions were frequent nausea and diarrhea. Bowel motions were frequent and watery.and watery.

ABG: pH 7.29, PaCO2 26, PaO2 98ABG: pH 7.29, PaCO2 26, PaO2 98 NaNa++=125, K=125, K++=2.8, Cl=2.8, Cl--=101, HCO=101, HCO33=12=12

PaCO2 = [1.5 x HCO3 + 8] ± 2PaCO2 = [1.5 x HCO3 + 8] ± 2PaCO2 = 25 ± 2PaCO2 = 25 ± 2

Simple (compensated) metabolic acidosis


A 78 year old lady presented with at least a A 78 year old lady presented with at least a week history of abdominal pain and vomiting.week history of abdominal pain and vomiting.

ABG: pH 7.49, PaCO2 52, PaO2 78ABG: pH 7.49, PaCO2 52, PaO2 78 Na 137, K 2.2, CL 91, HCO3 38Na 137, K 2.2, CL 91, HCO3 38 Urine CI 43Urine CI 43 mEq/LmEq/L

Metabolic Alkalosis∆∆PaCO2 = 0.9 ∆ HCO3 : 0.9 X 14 = 17PaCO2 = 0.9 ∆ HCO3 : 0.9 X 14 = 17

PaCO2 = 53PaCO2 = 53

Simple

Mixed Acid-Base DisordersMixed Acid-Base Disorders

pH may be within normal (7.35-7.45)pH may be within normal (7.35-7.45) Cannot over-compensateCannot over-compensate Simultaneous co-existence of Simultaneous co-existence of

disordersdisorders 2 respiratory + 2 metabolic2 respiratory + 2 metabolic Acute on top of chronicAcute on top of chronic

The pH determines which is primary:The pH determines which is primary: pH < 7.40 – primary disorder is Acidosis pH < 7.40 – primary disorder is Acidosis pH > 7.40 – primary disorder is AlkalosispH > 7.40 – primary disorder is Alkalosis

A 21 year old MS is brought to the ER at ~3 A 21 year old MS is brought to the ER at ~3 am, stuporous and tachypneic. History is am, stuporous and tachypneic. History is remarkable for failing the respiratory module remarkable for failing the respiratory module in 2in 2ndnd year. An ABG and electrolytes have year. An ABG and electrolytes have been drawn by the ER nurse.been drawn by the ER nurse.

ABG: pH=7.38, PaCOABG: pH=7.38, PaCO22=18=18

NaNa++=140, K=140, K++=3.8, Cl=3.8, Cl--=106, HCO=106, HCO33=12=12


A 21 year old MS is brought to the ER at ~3 am, stuporous and tachypneic. A 21 year old MS is brought to the ER at ~3 am, stuporous and tachypneic. History is remarkable for failing the respiratory module in 2History is remarkable for failing the respiratory module in 2ndnd year. An ABG and year. An ABG and electrolytes have been drawn by the ER nurse.electrolytes have been drawn by the ER nurse.




AG = 143-106-12 = 25

Wide AG Metabolic acidosis

PaCO2 = 1.5 X 12 +8 = 26 ±2

Wide AG metabolic acidosis and Respiratory Alkalosis

Aspirin Overdose

Primary Respiratory DisordersPrimary Respiratory DisordersAcute vs. ChronicAcute vs. Chronic

ACUTE ACUTE Δ PCO2 = 10 → Δ pH=0.08 (~0.1)Δ PCO2 = 10 → Δ pH=0.08 (~0.1)

CHRONICCHRONIC Δ PCO2 = 10 → Δ pH=0.03Δ PCO2 = 10 → Δ pH=0.03

A 55 year old woman presented to the ER A 55 year old woman presented to the ER with dyspnea and wheezes. She is heavy with dyspnea and wheezes. She is heavy smoker. An ABG and electrolytes have been smoker. An ABG and electrolytes have been drawn by the ER nurse.drawn by the ER nurse.




A 55 year old woman presented to the ER with dyspnea and A 55 year old woman presented to the ER with dyspnea and wheezes. She is heavy smoker. An ABG and electrolytes have wheezes. She is heavy smoker. An ABG and electrolytes have been drawn by the ER nurse.been drawn by the ER nurse.




Chronic Respiratory Acidosis

Approach To ALL Acid/Base Approach To ALL Acid/Base ProblemsProblems

Don’t get overwhelmed by all the numbers Don’t get overwhelmed by all the numbers at once!at once!

Use a methodical system to dissect the Use a methodical system to dissect the numbers.numbers.

Don’t jump ahead when doing calculations.Don’t jump ahead when doing calculations.

METHODICAL SYSTEMMETHODICAL SYSTEM

Get all your numbers in front you first…Get all your numbers in front you first… Look at pH first: Acidotic or alkalotic?Look at pH first: Acidotic or alkalotic? Metabolic or Respiratory?Metabolic or Respiratory? Go straight to Bicarb!Go straight to Bicarb! Correlate bicarb with PCO2 and it should be Correlate bicarb with PCO2 and it should be

obviousobvious Calculate anion gap no matter what the Calculate anion gap no matter what the

disturbance is!disturbance is!

SYSTEM…continuedSYSTEM…continued

After you come up with “primary disturbance”, After you come up with “primary disturbance”, your next question should ALWAYS BE =your next question should ALWAYS BE =

““Is there compensation?”Is there compensation?” For metabolic acidosis… do last two digits of pH For metabolic acidosis… do last two digits of pH

equal PCO2 or notequal PCO2 or not For resp acidosis… is it acute or chronic, and is For resp acidosis… is it acute or chronic, and is

the HCO3 up appropriately?the HCO3 up appropriately? For resp alkalosis… is it acute or chronic, and is For resp alkalosis… is it acute or chronic, and is

the HCO3 down appropriately?the HCO3 down appropriately?

CompensationCompensation

The Two Given Rules of Compensation:The Two Given Rules of Compensation:

1.1. METABOLIC = BICARB (HCO3)METABOLIC = BICARB (HCO3)……So if you dealing with figuring out your So if you dealing with figuring out your

disturbance and it is metabolic (up or down disturbance and it is metabolic (up or down HCO3), then the compensation will be HCO3), then the compensation will be RESPIRATORY (is the PCO2 appropriately RESPIRATORY (is the PCO2 appropriately up or down)up or down)

Compensation…continuedCompensation…continued

2.2. RESPIRATORY = PCO2RESPIRATORY = PCO2

… …So if you are dealing with respiratory So if you are dealing with respiratory alkalosis or acidosis, you want to know if alkalosis or acidosis, you want to know if the METABOLIC (HCO3) compensation the METABOLIC (HCO3) compensation is appropriate or notis appropriate or not

SYSTEM…continuedSYSTEM…continued

If the compensation is INAPPROPRIATE, then If the compensation is INAPPROPRIATE, then you automatically have a SECOND you automatically have a SECOND superimposed acid/base disordersuperimposed acid/base disorder

Case 1Case 1 A 75-year-old man presents to the ED after a A 75-year-old man presents to the ED after a

witnessed out of hospital VF cardiac arrest. witnessed out of hospital VF cardiac arrest. Arrived after 10 minutes, CPR had not been Arrived after 10 minutes, CPR had not been

attempted. attempted. The paramedics had successfully restored The paramedics had successfully restored

spontaneous circulation after 6 shocks. spontaneous circulation after 6 shocks. On arrival the man is comatose with a GCS of 3 On arrival the man is comatose with a GCS of 3

and his lungs are being ventilated with 50% and his lungs are being ventilated with 50% oxygen via ET tube.oxygen via ET tube.

He has HR of 120/min and a blood pressure of He has HR of 120/min and a blood pressure of 150/95 mmHg.150/95 mmHg.

ABG Analysis reveals:ABG Analysis reveals:

FF iiOO22 0.5 0.5

pHpH 7.107.10 PaCOPaCO

22 45 mmHg45 mmHg

PaOPaO22 56 mmHg56 mmHg

HCOHCO33-- 14 mmol/l14 mmol/l

BEBE - 10 mmol/l- 10 mmol/l

Case 2Case 2

A 65-year-old man with severe COPD A 65-year-old man with severe COPD has just collapsed in the respiratory has just collapsed in the respiratory high-care unit.high-care unit.

On initial assessment he is found to be On initial assessment he is found to be apnoeic but has an easily palpable apnoeic but has an easily palpable carotid pulse at 90/min.carotid pulse at 90/min.

A nurse is ventilating his lungs with A nurse is ventilating his lungs with an Ambu bag and supplementary O2an Ambu bag and supplementary O2


FF iiOO22 0.85 (estimated)0.85 (estimated)

pHpH 7.207.20 PaCO2PaCO2 151 mmHg151 mmHg PaO2PaO2 147 mmHg147 mmHg HCO3-HCO3- 36 mmol/l36 mmol/l BEBE + 12 mmol/l+ 12 mmol/l

Case 3Case 3

A 75-year-old lady is admitted to the ED A 75-year-old lady is admitted to the ED following a VF cardiac arrest, which was following a VF cardiac arrest, which was witnessed by the paramedics. witnessed by the paramedics.

A spontaneous circulation was restored A spontaneous circulation was restored after 4 shocks, but the patient remained after 4 shocks, but the patient remained comatose and apnoeic. comatose and apnoeic.

The paramedics intubated her trachea, The paramedics intubated her trachea, and on arrival in hospital her lungs are and on arrival in hospital her lungs are being ventilated with an automatic being ventilated with an automatic ventilator using a tidal volume of 900 ml ventilator using a tidal volume of 900 ml and a rate of 18 breaths/min.and a rate of 18 breaths/min.


FF iiOO22 1.0 1.0


22 20 mmHg20 mmHg




Case 4Case 4 An 18-year-old male insulin dependent An 18-year-old male insulin dependent

diabetic is admitted to the ED. diabetic is admitted to the ED. He has been vomiting for 48 hours and He has been vomiting for 48 hours and

because he was unable to eat, he omitted because he was unable to eat, he omitted his insulin. his insulin.

He has HR of 130/min and his blood He has HR of 130/min and his blood pressure is 90/65 mmHg. pressure is 90/65 mmHg.

He is breathing spontaneously with deep He is breathing spontaneously with deep breaths at a rate of 35/min. His GCS is 12 breaths at a rate of 35/min. His GCS is 12 (E3, M5, V4(E3, M5, V4).).


FF iiOO22 0.40.4


22 11.3 mmHg11.3 mmHg

PaOPaO22 129.2 mmHg129.2 mmHg

HCOHCO33-- 4.7 mmol/l4.7 mmol/l

BEBE - 29.2 mmol/l- 29.2 mmol/l

Case 5Case 5

His vital signs are:His vital signs are: Heart rate Heart rate 120/min – sinus 120/min – sinus

tachycardia – warm peripheriestachycardia – warm peripheries Blood pressureBlood pressure 70/40 mmHg70/40 mmHg Respiratory rateRespiratory rate 35 breaths/min35 breaths/min SpOSpO

22 on oxygen on oxygen 92%92%

Urine outputUrine output 50 ml in the last 6 hours50 ml in the last 6 hours GCSGCS 13 (E3, M6, V4)13 (E3, M6, V4)


FF iiOO22 0.4 (approx)0.4 (approx)


22 36 mmHg)36 mmHg)




Any Any Question?Question?

Thank YouThank You

acid base disorders

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