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Arterial Blood Gas Cases

By Leon Simpson,2014-05-08 20:45
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Arterial Blood Gas Cases

    Arterial Blood Gas Cases

    In the space that follows you will find a series of cases that include arterial blood gases. Each case is then followed by an explanation of the acid-base status, the oxygenation status and a summary of the patient’s clinical picture.

    The explanations of the acid-base status utilize the 5-step approach to interpreting acid-base status that is laid out in the Arterial Blood Gas Primer, which you can access by clicking here. In some of the cases below, information

    is not available to calculate the anion gap or the delta delta. In such cases, you should focus solely on identifying the primary and compensatory processes.

Case 1:

    A 24 year-old woman is found down in Pioneer Square by some bystanders. The medics are called and, upon arrival, find her with an oxygen saturation of 88% on room air and pinpoint pupils on exam. She is brought into the Harborview ER where a room air arterial blood gas is performed and -reveals: pH 7.25, PCO 60, PO 65, HCO 26, Base Excess 1. On his 223

    chemistry panel, her sodium is 137, chloride 100, bicarbonate 27.

Acid-base status:

The patient has a low pH (acidemia)

     The PCOis high (respiratory acidosis) and the bicarbonate is at the upper 2

    end of normal. The low pH and high PCO imply that the respiratory acidosis 2

    is the primary process

     The anion gap is 10 and is, therefore, normal. The patient does not have an

    elevated anion gap acidosis.

     There is no compensatory process. Although the measured bicarbonate is

    just above normal, the base excess of 1 tells us that there is no metabolic

    alkalosis

     The delta gap is 10 -12 = -2 and the delta-delta is -2 + 27 = 25. There is,

    therefore, no metabolic process.

     Summary: An acute, uncompensated respiratory acidosis leading to acidemia.

Alveolar-arterial oxygen difference: The alveolar-arterial difference is 10

    mmHg, a normal value, which tells us that her hypoxemia is entirely due to hypoventilation.

Explanation for the clinical picture: The respiratory acidosis implies that the

    patient is hypoventilating. This fact, in combination with the pinpoint pupils suggests the patient is suffering from an acute narcotic overdose. In this case, the narcotic is most likely heroin.

Case 2:

    A 60 year-old man with amyotrophic lateral sclerosis is brought into clinic by his family who are concerned that he is more somnolent than normal. On further history, they report that he has been having problems with morning headaches and does not feel very refreshed when he wakes up. An arterial blood gas is performed and reveals: pH 7.37, PCO 57, PO 70, 22-HCO 32. 3

Acid-base status:

The patient has a low pH (acidemia)

     The PCO is high (respiratory acidosis) and the bicarbonate is high (metabolic 2

    alkalosis). The low pH in combination with the high PCO tells us that the 2

    respiratory acidosis is the primary process.

     The metabolic alkalosis is the compensatory process.

     Summary: A chronic respiratory acidosis with a compensatory metabolic

    alkalosis.

    Alveolar-arterial oxygen difference: The alveolar-arterial oxygen difference is 9 mmHg, a normal value, which tells us that the hypoxemia is entirely due to hypoventilation.

    Explanation for the clinical picture: The patient has a respiratory acidosis with a compensatory metabolic alkalosis. The respiratory acidosis tells us that the patient is hypoventilating while the compensatory metabolic alkalosis tells us that this is a chronic process. The patient is likely hypoventilating due to progression of his amyotrophic lateral sclerosis, a neurodegenerative disorder associated with progressive muscle weakness that eventually involves the muscles of respiration.

Case 3:

    A 65 year-old man is brought into the VA hospital with complaints of severe nausea and weakness. He has had problems with peptic ulcer disease in the past and has been having similar pain for the past two weeks. Rather than see a physician about this, he opted to deal with the problem on his own and, over the past week, has been drinking significant quantities of milk and consuming large quantities of TUMS (calcium carbonate). On his initial laboratory studies, he is found to have a calcium level of 11.5 mg/dL, a creatinine of 1.4 and bicarbonate of 35. The resident working in the ER decides to draw a room air arterial blood gas, which reveals: pH 7.45, PCO 2-49, PO 68, HCO 34. On his chemistry panel, the sodium is 139, chloride 95, 23-HCO 34. 3

Acid-base status:

The patient has a high pH (alkalemia)

     The PCO is high (respiratory acidosis) and the bicarbonate is high (metabolic 2

    alkalosis). The high pH and the high bicarbonate tell us that the metabolic

    alkalosis is the primary process.

     The anion gap is 10. This is a normal value

     The respiratory acidosis is the compensatory process

     The delta gap is 10 12 = -2. The delta delta is -2 + 34 = 32. This value is

    above 26 and tells us that a metabolic alkalosis is present. This is the same

    process that was identified in the second step above.

     Summary: A primary metabolic alkalosis with respiratory compensation.

Alveolar-arterial oxygen difference: The alveolar-arterial difference is 14

    mmHg. This value is mildly elevated but still within the normal range for someone of this age. This suggests that his hypoxemia is likely due to hypoventilation.

Explanation for the clinical picture: The patient has hypercalcemia and a

    metabolic alkalosis. In conjunction with a clinical history of heavy milk and calcium carbonate consumption, these abnormalities suggest the patient is suffering from milk-alkali syndrome. In response to metabolic alkaloses, patients develop hypoventilation. This explains his elevated PCO and respiratory 2

    acidosis that, in turn, explains his hypoxemia.

Case 4:

    A 45 year-old woman with a history of inhalant abuse presents to the emergency room complaining of dyspnea. She has an SO of 99% on room p2

    air and is obviously tachypneic on exam with what appears to be Kussmaul’s respirations. A room air arterial blood gas is performed and -reveals: pH 6.95, PCO 9, PO 128, HCO 2. A chemistry panel revealed 223-sodium of 130, chloride 98, HCO 2. 3

Acid-base status:

The patient has a very low pH (acidemia)

     The patient has a low PCO (respiratory alkalosis) and a very low bicarbonate 2

    (metabolic acidosis). The low pH in conjunction with the low bicarbonate tells

    us that the metabolic acidosis is the primary process

     The anion gap is elevated at 30. This tells us that the patient has a primary

    elevated anion gap metabolic acidosis.

     The respiratory alkalosis is the compensatory process, although in this case,

    despite a huge compensatory increase in minute ventilation, the patient still

    has a very low pH.

     The delta gap is 30-12 = 18 and the delta-delta is 18 + 2 = 20. Since the

    delta-delta is below 22, we know that there is an additional non-gap metabolic

    acidosis as well.

     Summary: Combined elevated anion gap and non-gap metabolic acidoses

    with compensatory respiratory alkalosis.

Alveolar-arterial oxygen difference: The alveolar-arterial oxygen difference is

    11 mmHg. This tells us that the patient does not have any shunt or low V/Q areas and, therefore, likely does not have any pulmonary parenchymal pathology as the source of her dyspnea. Her PO is actually well above 100 mmHg even a2

    though she is breathing room air at sea-level. This is a result of her extreme degree of hyperventilation, which leads to a rise in the alveolar PO. 2

Explanation for the clinical picture: The patient has concurrent elevated anion

    gap and non-gap acidoses with respiratory compensation. The acidoses are so severe that, despite the high minute ventilation, the pH remains very low. This patient has a history of inhalant abuse and one of the commonly abused inhalants, toluene, can present with severe elevated anion gap acidosis with respiratory compensation. The severe elevated anion gap acidosis is due to accumulation of one of the main toluene metabolites, hippuric acid.

Case 5:

    A 68 year-old man with a history of very severe COPD (FEV ~ 1.0L, < 25% 1

    predicted) and chronic carbon dioxide retention (Baseline PCO 58) 2

    presents to the emergency room complaining of worsening dyspnea and an increase in the frequency and purulence of his sputum production over the past 2 days. His oxygen saturation is 78% on room air. Before he is place on supplemental oxygen, a room air arterial blood gas is drawn and -reveals: pH 7.25, PCO 68, PO 48, HCO 31. 223

Acid-base status:

The patient has a low pH (acidemia)

     The patient has a high PCO(respiratory acidosis) and a high bicarbonate 2

    (metabolic alkalosis). The combination of the low pH and the high PCO tells 2

    us that the respiratory acidosis is the primary process.

     The metabolic alkalosis is the compensatory process. The pH is still low

    despite this metabolic compensation

     Summary: Primary respiratory acidosis with compensatory metabolic alkalosis.

Alveolar-arterial oxygen difference: The alveolar-arterial oxygen difference is

    17 mmHg. This value is elevated, suggesting that the hypoxemia is due to either shunt or areas of low V/Q (the more likely explanation in a patient with COPD) and cannot be explained by hypoventilation alone.

Explanation for the clinical picture: The patient has very severe COPD and

    chronic carbon dioxide retention. As a result, you expect that at baseline, they will have a chronic respiratory acidosis (his baseline PCO was 58) with a 2

    compensatory metabolic alkalosis. In this case, the clinical history suggests the patient is in an exacerbation. When the patient presents to the ER, his PCO is 2

    elevated above his baseline. Because this is an acute change, the bicarbonate has not had time to adjust and the pH falls. This case is, therefore, an example of an acute on chronic respiratory acidosis.

Case 6:

    A climber is coming down from the summit of Mt. Everest. At an altitude of 8,400 m (P ~ 272 mmHg), he has a blood gas drawn while breathing B

    ambient air as part of a research project. The blood gas reveals pH 7.55, -PCO 12, PO 30 and HCO 10.5. 223

Acid-base status:

The patient has a high pH (alkalemia)

     The PCO is low (respiratory alkalosis) and the bicarbonate is low (metabolic 2

    acidosis). The high pH in conjunction with the low PCO tells us that the 2

    respiratory alkalosis is the primary process.

     The metabolic acidosis is the compensatory process

     Summary: Primary respiratory alkalosis with metabolic compensation.

Alveolar-arterial oxygen difference: The alveolar-arterial oxygen difference is

    only 2.3! When you get to very low barometric pressures and low alveolar oxygen tensions like the values seen in this case, the alveolar-arterial oxygen difference can be very small. This is a normal value at this elevation. Hypoxemia with a normal alveolar-arterial oxygen difference is due to either hypoventilation or a low inspired PO. In this particular case, it is the low inspired PO that is 22

    responsible for the profound but well-tolerated hypoxemia.

Explanation for the clinical picture: The patient is climbing at extremely high

    altitude where the low oxygen tensions in the arterial blood trigger the hypoxic ventilatory response. This response is, in turn, responsible for the respiratory alkalosis. As the patient spends increasing time at these high altitudes, metabolic compensation occurs and allows the ventilatory response to increase even further in magnitude. It is important to note that the person could not achieve this degree of minute ventilation on acute exposure to this altitude and, as a result, would not be able to maintain an adequate PO to support life. It is only with a2

    long periods spent acclimatizing to the environment that the person can achieve sufficient levels of minute ventilation and maintain adequate levels or oxygenation.

Case 7:

    A 57 year-old woman presents with 2 days of fevers, dyspnea and a cough productive of rust-colored sputum. Her room air oxygen saturation in the emergency room is found to be 85% and the intern decides to obtain a room air arterial blood gas while they are waiting for the chest x-ray to be -done. The blood gas reveals: pH 7.54, PCO 25, PO 65, HCO 22, Base 223

    excess -1.

Acid-base status:

The patient has a high pH (alkalemia)

     The PCO is low (respiratory alkalosis). The high pH in conjunction with the 2

    low PCO tells us that the respiratory alkalosis is the primary process. 2

     Although the bicarbonate is on the low side, the base excess of -1 tells us that

    the patient does not have a metabolic acidosis. The patient, therefore, has not

    mounted a compensatory response yet.

     Summary: Acute, uncompensated respiratory alkalosis

Alveolar-arterial oxygen difference: The alveolar-arterial oxygen difference is

    54 mmHg. This value is elevated and tells us that the patient’s hypoxemia is due

    to either shunt or areas of low V/Q

Explanation for the clinical picture: The patient has a history suggestive of

    pneumonia. The pneumonia has led to areas of shunt and/or low V/Q that have led to her arterial hypoxemia. The arterial hypoxemia will, in turn, lead to the hypoxic ventilatory response that is responsible for her hyperventilation and respiratory alkalosis. Because the hypoxemia may have only been present for a short time, there has not been adequate time for metabolic compensation to occur.

Case 8:

    A 47 year-old man with a history of heavy alcohol use presents with a two-day history of severe abdominal pain, nausea and vomiting. On exam, his blood pressure is 90/50 and he is markedly tender in his epigastrum. His - initial laboratory studies reveal a sodium of 132, chloride 92, HCO16, 3

    creatinine 1.5, amylase 400 and lipase 250. A room air arterial blood gas is -drawn and reveals pH 7.28, PCO 34, PO 88, HCO 16. 223

Acid-base status:

The patient has a low pH (acidemia)

The PCO is low (respiratory alkalosis) and the bicarbonate is low (metabolic 2

    acidosis). The combination of the low pH and the low bicarbonate tells us that

    the metabolic acidosis is the primary process

     The anion gap is elevated at 24. This tells us that the patient has a primary

    elevated anion gap metabolic acidosis

     The respiratory alkalosis is the compensatory process

     The delta gap is 24-12 = 12. The delta delta is 12 + 17 = 29. Because the

    delta-delta is greater than 26, we know that the patient has a concurrent

    metabolic alkalosis.

     Summary: Primary elevated anion gap metabolic acidosis with respiratory

    compensation and a concurrent metabolic alkalosis.

Alveolar-arterial oxygen difference: The alveolar-arterial oxygen difference is

    27. This suggests that the patient’s hypoxemia is due to either shunt or areas of low V/Q.

Explanation for the clinical picture: A history of epigastric pain, nausea and

    vomiting in conjunction with elevated lipase and amylase on laboratory studies is consistent with the diagnosis of pancreatitis. As a result of the pancreatitis, the patient has developed an elevated anion gap acidosis with respiratory compensation. The concurrent metabolic alkalosis is likely due to vomiting, which leads to hydrogen ion loss via the upper gastrointestinal tract.

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