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Dka Abg Example

Blood Gas Interpretation

Blood Gas Interpretation

The body normally controls the pH of blood within a tight range. One must always remember that pH is a logarithmic scale and so a change from 8 to 7 is a ten-fold increase in H+ concentration. A normal intracellular pH is required for the functioning of many enzyme systems. When blood becomes profoundly acidotic (pH<7) then cellular function becomes impossible and death ensues. There are a lot of texts available describing the causes of the respiratory and metabolic acidosis and alkalosis. However the best way to learn how to interpret blood gases is to practice. Normal Blood gas. The only abnormal result here is the pO2, however this is a venous gas and so the pO2 should be low. This is therefore a normal blood gas. It is important to rule out a diabetic ketoacidosis in children with diabetes who are unwell with high blood sugars. The learning point here is that blood gas analysis doesn’t just have to be performed on arterial blood. A lot can be established from venous or capillary samples. Respiratory Acidosis – Respiratory failure (bronchiolitis). This baby has bronchiolitis. There is a respiratory acidosis. Notice the high oxygen secondary to aggressive oxygen therapy. Treatment of bronchiolitis is supportive, ie oxygen and fluids. Respiratory Acidosis – respiratory failure secondary to acute exacerbation of asthma This is a respiratory acidosis. This boy is in respiratory failure secondary to an acute exacerbation of his asthma. A “silent chest” where you can only just hear breath sounds is a very serious clinical sign. This boy will need aggressive treatment and likely intubation and transfer to PICU. Respiratory Acidosis with metabolic compensation– Respiratory failure (pneumonia) This boy has pneumonia associated with respiratory failure. There is a Continue reading >>

Diabetic Ketoacidosis And Hyperglycaemic Hyperosmolar State

Diabetic Ketoacidosis And Hyperglycaemic Hyperosmolar State

The hallmark of diabetes is a raised plasma glucose resulting from an absolute or relative lack of insulin action. Untreated, this can lead to two distinct yet overlapping life-threatening emergencies. Near-complete lack of insulin will result in diabetic ketoacidosis, which is therefore more characteristic of type 1 diabetes, whereas partial insulin deficiency will suppress hepatic ketogenesis but not hepatic glucose output, resulting in hyperglycaemia and dehydration, and culminating in the hyperglycaemic hyperosmolar state. Hyperglycaemia is characteristic of diabetic ketoacidosis, particularly in the previously undiagnosed, but it is the acidosis and the associated electrolyte disorders that make this a life-threatening condition. Hyperglycaemia is the dominant feature of the hyperglycaemic hyperosmolar state, causing severe polyuria and fluid loss and leading to cellular dehydration. Progression from uncontrolled diabetes to a metabolic emergency may result from unrecognised diabetes, sometimes aggravated by glucose containing drinks, or metabolic stress due to infection or intercurrent illness and associated with increased levels of counter-regulatory hormones. Since diabetic ketoacidosis and the hyperglycaemic hyperosmolar state have a similar underlying pathophysiology the principles of treatment are similar (but not identical), and the conditions may be considered two extremes of a spectrum of disease, with individual patients often showing aspects of both. Pathogenesis of DKA and HHS Insulin is a powerful anabolic hormone which helps nutrients to enter the cells, where these nutrients can be used either as fuel or as building blocks for cell growth and expansion. The complementary action of insulin is to antagonise the breakdown of fuel stores. Thus, the relea Continue reading >>

Episode 63 – Pediatric Dka

Episode 63 – Pediatric Dka

Pediatric DKA was identified as one of key diagnoses that we need to get better at managing in a massive national needs assessment conducted by the fine folks at TREKK – Translating Emergency Knowledge for Kids – one of EM Cases’ partners who’s mission is to improve the care of children in non-pediatric emergency departments across the country. You might be wondering – why was DKA singled out in this needs assessment? It turns out that kids who present to the ED in DKA without a known history of diabetes, can sometimes be tricky to diagnose, as they often present with vague symptoms. When a child does have a known history of diabetes, and the diagnosis of DKA is obvious, the challenge turns to managing severe, life-threatening DKA, so that we avoid the many potential complications of the DKA itself as well as the complications of treatment – cerebral edema being the big bad one. The approach to these patients has evolved over the years, even since I started practicing, from bolusing insulin and super aggressive fluid resuscitation to more gentle fluid management and delayed insulin drips, as examples. There are subtleties and controversies in the management of DKA when it comes to fluid management, correcting serum potassium and acidosis, preventing cerebral edema, as well as airway management for the really sick kids. In this episode we‘ll be asking our guest pediatric emergency medicine experts Dr. Sarah Reid, who you may remember from her powerhouse performance on our recent episodes on pediatric fever and sepsis, and Dr. Sarah Curtis, not only a pediatric emergency physician, but a prominent pediatric emergency researcher in Canada, about the key historical and examination pearls to help pick up this sometimes elusive diagnosis, what the value of serum Continue reading >>

Original Article Correlation Between Peripheral Venous And Arterial Blood Gas Measurements In Patients Admitted To The Intensive Care Unit: A Single-center Study

Original Article Correlation Between Peripheral Venous And Arterial Blood Gas Measurements In Patients Admitted To The Intensive Care Unit: A Single-center Study

Introduction The acid–base and respiratory status of critical patients are commonly ascertained by means of arterial blood gas (ABG) analysis. Nevertheless, the test can cause patients to experience discomfort, and its associated complications include arterial injury, thrombosis or embolization, hematoma, aneurysm formation, and reflex sympathetic dystrophy [1,2]. A further drawback for health care providers is the possibility of a needle stick injury when performing an ABG. A comparatively safer procedure is venous blood gas (VBG) analysis, which poses fewer risks to both the patients and health care professionals. VBG may eventually take the place of ABG analysis in determining acid–base status. In contrast to earlier studies, which questioned the precision of VBG values [3–5], more recent evidences indicate a concurrence of ABG and VBG values [6–14]. However, as far as we can determine, the correlation between all parameters typically used in arterial and peripheral VBG samples as found in a broad population of intensive care unit (ICU) patients has not been studied previously. An earlier study investigated whether the similarities between ABG and VBG values are sufficient for the respiratory and dynamic acid–base conditions. For this evaluation, each patient provided multiple paired ABG and VBG samples during the length of their ICU treatment. The purpose of this study was to investigate the correlation of ABG and peripheral VBG samples for all common parameters (bicarbonate, total CO2, pH, and PCO2) in an ICU patient population exhibiting a variety of pathologies. Specific attention was given to the analysis of each patient's multiple paired arterial and venous samples. Methods A single-center, prospective trial was performed from April 2010 to September Continue reading >>

Comparison Of Arterial And Venous Ph, Bicarbonate, Pco2 And Po2 In Initial Emergency Department Assessment

Comparison Of Arterial And Venous Ph, Bicarbonate, Pco2 And Po2 In Initial Emergency Department Assessment

Go to: Patients and method A convenience sample of adult patients presenting to the ED of a tertiary care 1000 bed teaching hospital in Northern India, from September to December 2006, were enrolled. Patients were eligible if the on‐duty emergency physician decided to obtain an ABG sample for the initial assessment. After having the study explained, a verbal consent was obtained from the patient or the relative, and patients were sampled for arterial and venous blood with minimum delay (always <2 min) between the samples. For arterial samples (0.5–1 ml), a minimally heparinised plastic syringe with 24 G needle was used to puncture the radial artery. For venous sampling, blood was obtained at the time of intravenous cannula placement or using peripheral venepuncture. The two samples were taken as close as possible in time and before the initiation of any form of treatment. The samples were analysed as quickly as possible using the blood gas analyser located in the ED. Data were analysed using SPSS version 10.0.1.299 and Prism 5 for Windows (Graph pad, version 5). The Bland‐Altman method was used to calculate agreement between arterial and venous measurements. The study was approved by the ethics committee of the All India Institute of Medical Sciences, New Delhi, India. Continue reading >>

Dka, “answers”

Dka, “answers”

1. When you are suspicious for DKA do you obtain a VBG or an ABG? How good is a VBG for determining acid/base status? Diabetic ketoacidosis (DKA) is defined by five findings: acidosis (pH < 7.30, serum bicarbonate (HCO3) < 18 mEq/L, the presence of ketonuria or ketonemia, an anion gap > 10 mEq/L, and a plasma glucose concentration > 250 mg/dl. It is one of the most serious complications of diabetes seen in the emergency department. The mortality rate of hospitalized DKA patients is estimated to be between 2-10% (Lebovitz, 1995). As a result, its prompt recognition is vital to improving outcomes in these patients. As a result, emergency physicians have long relied on the combination of hyperglycemia and anion gap metabolic acidosis to help point them in the correct diagnostic direction. In the assessment of the level of acidosis in a DKA patient, an arterial blood gas (ABG) has long been thought of as much more accurate than a venous blood gas (VBG) and thus necessary in evaluating a DKA patient’s pH and HCO3 level, two values often used to direct treatment decisions. An ABG is more painful, often time-consuming and labor intensive as it may involve multiple attempts. In addition, ABGs can be complicated by radial artery aneurysms, radial nerve injury and compromised blood supply in patients with peripheral vascular disease or inadequate ulnar circulation. A VBG is less painful, can obtained at the time of IV placement, and is therefore less time consuming. But is it good enough to estimate acid/base status in these patients? Brandenburg, et al. compared arterial and venous blood gas samples in DKA patients taken at the exact same time prior to treatment and found a mean difference in pH between the arterial and venous samples to be only 0.03, with a Pearson’s correl Continue reading >>

Abg Examples (abg Exam Questions For Medical Students And Paces)

Abg Examples (abg Exam Questions For Medical Students And Paces)

Below are some brief clinical scenarios with ABG results. Try to interpret each ABG and formulate a differential diagnosis before looking at the answer. Question 1. You are called to see a 54 year old lady on the ward. She is three days post-cholecystectomy and has been complaining of shortness of breath. Her ABG is as follows: pH: 7.49 (7.35-7.45) pO2: 7.5 (10–14) pCO2: 3.9 (4.5–6.0) HCO3: 22 (22-26) BE: -1 (-2 to +2) Other values within normal range Question 2. A 75 year old gentleman living in the community is being assessed for home oxygen. His ABG is as follows: pH: 7.36 (7.35-7.45) pO2: 8.0 (10–14) pCO2: 7.6 (4.5–6.0) HCO3: 31 (22-26) BE: +5 (-2 to +2) Other values within normal range Question 3. A 64 year old gentleman with a history of COPD presents with worsening shortness of breath and increased sputum production. pH: 7.21 (7.35-7.45) pO2: 7.2 (10–14) pCO2: 8.5 (4.5–6.0) HCO3: 29 (22-26) BE: +4 (-2 to +2) Other values within normal range Question 4. A 21 year-old woman presents feeling acutely lightheaded and short of breath. She has her final university exams next week. pH: 7.48 (7.35-7.45) pO2: 12.1 (10–14) pCO2: 3.5 (4.5–6.0) HCO3: 22 (22-26) BE: +2 (-2 to +2) Other values within normal range Question 5. A 32 year-old man presents to the emergency department having been found collapsed by his girlfriend. pH: 7.25 (7.35-7.45) pO2: 11.1 (10–14) pCO2: 3.2 (4.5–6.0) HCO3: 11 (22-26) BE: -15 (-2 to +2) Potassium: 4.5 Sodium: 135 Chloride: 100 Other values within normal range Question 6. A 67 year-old man with a history of peptic ulcer disease presents with persistent vomiting. pH: 7.56 (7.35-7.45) pO2: 10.7 (10–14) pCO2: 5.0 (4.5–6.0) HCO3: 31 (22-26) BE: +5 (-2 to +2) Other values within normal range Question 7. A seventeen year-old girl Continue reading >>

Common Laboratory (lab) Values - Abgs

Common Laboratory (lab) Values - Abgs

A B C D E F G H I J K L M N O P Q R S T U V W X Y Z Laboratory VALUES Home Page Arterial Blood Gases Arterial blood gas analysis provides information on the following: 1] Oxygenation of blood through gas exchange in the lungs. 2] Carbon dioxide (CO2) elimination through respiration. 3] Acid-base balance or imbalance in extra-cellular fluid (ECF). Normal Blood Gases Arterial Venous pH 7.35 - 7.45 7.32 - 7.42 Not a gas, but a measurement of acidity or alkalinity, based on the hydrogen (H+) ions present. The pH of a solution is equal to the negative log of the hydrogen ion concentration in that solution: pH = - log [H+]. PaO2 80 to 100 mm Hg. 28 - 48 mm Hg The partial pressure of oxygen that is dissolved in arterial blood. New Born – Acceptable range 40-70 mm Hg. Elderly: Subtract 1 mm Hg from the minimal 80 mm Hg level for every year over 60 years of age: 80 - (age- 60) (Note: up to age 90) HCO3 22 to 26 mEq/liter (21–28 mEq/L) 19 to 25 mEq/liter The calculated value of the amount of bicarbonate in the bloodstream. Not a blood gas but the anion of carbonic acid. PaCO2 35-45 mm Hg 38-52 mm Hg The amount of carbon dioxide dissolved in arterial blood. Measured. Partial pressure of arterial CO2. (Note: Large A= alveolor CO2). CO2 is called a “volatile acid” because it can combine reversibly with H2O to yield a strongly acidic H+ ion and a weak basic bicarbonate ion (HCO3 -) according to the following equation: CO2 + H2O <--- --> H+ + HCO3 B.E. –2 to +2 mEq/liter Other sources: normal reference range is between -5 to +3. The base excess indicates the amount of excess or insufficient level of bicarbonate in the system. (A negative base excess indicates a base deficit in the blood.) A negative base excess is equivalent to an acid excess. A value outside of the normal r Continue reading >>

The Abcs Of Abgs: Blood Gas Analysis

The Abcs Of Abgs: Blood Gas Analysis

A systematic and step-wise process based upon pH shift is the key to correct interpretation and application of arterial blood gas results In a previous article, “The Pitfalls of Arterial Blood Gases” (RT, April 2013), I described how simple pre-analytical, analytical, and post-analytical errors can produce arterial blood gas test results (ABGs) that are of little or no value, and perhaps even dangerous. In this article, I will assume that we have avoided all of those pitfalls and and will discuss how to interpret valid ABG results. (Some of the foundational information in this article is necessary for those new to interpreting. I encourage more experienced practitioners to bear with me.) This article will not attempt to discuss all of the possible causes or disease states that could relate to the results. Neither will it attempt to go into the interpretation of electrolytes or co-oximetry results. Adequate review of these subjects could require—in fact, have required—whole textbooks, and are beyond the scope of this article. What Is Normal? To interpret ABGs, we first need to know the normal values for the various analytes. Where do these normal values come from? They mostly come from collected results of volunteers or study subjects who appear to have uncompromised lungs and gas exchange. Researchers plotted the results of the various parameters, found the collective center of the bell-shaped curve of data, and declared the results shown in Table 1. Whichever range you and your facility prefer, it is important to think in terms of a normal range, not a single, specific, always “normal” value—except when it comes to pH for interpreting acid-base balance. We will get to why shortly. It is also vital to remember that the aggregate “normal” value is a con Continue reading >>

Respiratory Failure In Diabetic Ketoacidosis

Respiratory Failure In Diabetic Ketoacidosis

Go to: INTRODUCTION Ketoacidosis in subjects with type 1, or less frequently, type 2 diabetes mellitus remains a potentially life-threatening diabetic manifestation. The subject has justifiably attracted attention in the literature. Sequential reviews[1-9] have documented important changes in the clinical concepts that are related to diabetic ketoacidosis (DKA) and its management. A large number of case series of DKA have addressed various aspects of its clinical presentation and management. For this review, we selected representative studies focused on management, outcome, age differences, gender differences, associated morbid conditions, ethnicity and prominent clinical and laboratory features[10-35]. In recognition of the complexity of treatment, the recommendation to provide this care in intensive care units was made more than 50 years ago[36]. Severe DKA is treated in intensive care units today[31]. Evidence-based guidelines for the diagnosis and management of DKA have been published and frequently revised in North America[37,38] and Europe[39]. Losses of fluids and electrolytes, which are important causes of morbidity and mortality in DKA, vary greatly between patients. Quantitative methods estimating individual losses and guiding their replacement have also been reported[40,41]. The outcomes of DKA have improved with new methods of insulin administration[42] and adherence to guidelines[43-46]. The aim of treatment is to minimize mortality and prevent sequelae. One study documented that the target of zero mortality is feasible[42]. However, mortality from DKA, although reduced progressively in the early decades after the employment of insulin treatment[1], remains high. Up to fifty plus years ago, mortality from DKA was between 3% and 10%[1,16]. A recent review re Continue reading >>

Diabetic Emergencies, Part 5: Dka Case Studies

Diabetic Emergencies, Part 5: Dka Case Studies

Case Study 1 A 32-year-old male with type 1 diabetes since the age of 14 years was taken to the emergency room because of drowsiness, fever, cough, diffuse abdominal pain, and vomiting. Fever and cough started 2 days ago and the patient could not eat or drink water. He has been treated with an intensive insulin regimen (insulin glargine 24 IU at bedtime and a rapid-acting insulin analog before each meal). On examination he was tachypneic, his temperature was 39° C (102.2° F), pulse rate 104 beats per minute, respiratory rate 24 breaths per minute, supine blood pressure 100/70 mmHg; he also had dry mucous membranes, poor skin turgor, and rales in the right lower chest. He was slightly confused. Rapid hematology and biochemical tests showed hematocrit 48%, hemoglobin 14.3 g/dl (143 g/L), white blood cell count 18,000/ μ l, glucose 450 mg/dl (25.0 mmol/L), urea 60 mg/dl (10.2 mmol/L), creatinine 1.4 mg/dl (123.7 μ mol/L), Na+ 152 mEq/L, K+ 5.3 mEq/L, PO4 3−2.3 mEq/L (0.74 mmol/L), and Cl− 110 mmol/L. Arterial pH was 6.9, PO 2 95 mmHg, PCO 2 28 mmHg, HCO 3−9 mEq/L, and O 2 sat 98%. The result of the strip for ketone bodies in urine was strongly positive and the concentration of β-OHB in serum was 3.5 mmol/L. Urinalysis showed glucose 800 mg/dl and specific gravity 1030. What is your diagnosis? The patient has hyperglycemia, ketosis, and metabolic acidosis. Therefore, he has DKA. In addition, because of the pre-existing fever, cough, localized rales on auscultation and high white blood cell count, a respiratory tract infection should be considered. The patient is also dehydrated and has impaired renal function. Do you need more tests to confirm the diagnosis? Determination of the effective serum osmolality and anion gap should be performed in all patients presenti Continue reading >>

Arterial Blood Gases Not Helpful In Ed Management Of Dka

Arterial Blood Gases Not Helpful In Ed Management Of Dka

reviewing Ma OJ et al. Acad Emerg Med 2003 Aug This article requires a subscription for full access. NEJM Journal Watch articles published within the last six months are available to subscribers only. Articles published more than 6 months ago are available to registered users. Continue reading >>

Also, Pao2 Is Low, Probably Due To Mucous Displacing Air In The Alveoli Affected By The Pneumonia (

Also, Pao2 Is Low, Probably Due To Mucous Displacing Air In The Alveoli Affected By The Pneumonia (

Case Studies The following are examples of clinical situations and the ABGs that may result, as well as causes and solutions for ABG abnormalities. Case 1 Mrs. Puffer is a 35-year-old single mother, just getting off the night shift. She reports to the ED in the early morning with shortness of breath. She has cyanosis of the lips. She has had a productive cough for 2 weeks. Her temperature is 102.2, blood pressure 110/76, heart rate 108, respirations 32, rapid and shallow. Breath sounds are diminished in both bases, with coarse rhonchi in the upper lobes. Chest X-ray indicates bilateral pneumonia. ABG results are: pH= 7.44 PaCO2= 28 HCO3= 24 PaO2= 54 Problems: PaCO2 is low. pH is on the high side of normal, therefore compensated respiratory alkalosis. Also, PaO2 is low, probably due to mucous displacing air in the alveoli affected by the pneumonia (see Shunting). Solutions: Mrs. Puffer most likely has ARDS along with her pneumonia. The alkalosis need not be treated directly. Mrs. Puffer is hyperventilating to increase oxygenation, which is incidentally blowing off CO2. Improve PaO2 and a normal respiratory rate should normalize the pH. High FiO2 can help, but if she has interstitial lung fluid, she may need intubation and PEEP, or a BiPAP to raise her PaO2. (Click here to compare BiPAP to other respiratory treatments.) Expect orders for antibiotics, and possibly steroidal anti-inflammatory agents. Chest physiotherapy and vigorous coughing or suctioning will help the patient clear her airways of excess mucous and increase the number of functioning alveoli. Case 2 Mr. Worried is a 52-year-old widow. He is retired and living alone. He enters the ED complaining of shortness of breath and tingling in fingers. His breathing is shallow and rapid. He denies diabetes; blood sugar Continue reading >>

Arterial Blood Gas Analysis: Example Set 1

Arterial Blood Gas Analysis: Example Set 1

Case A A patient is brought back to the floor from the operating room on a patient controlled analgesia (PCA) pump with hydromorphone. The patient hits his PCA button several times in the first hour. Shortly thereafter, the nurse walks in the room and finds him somnolent and difficult to arouse. His SpO2 is only 88% so the nurse obtains a blood gas that reveals: Step 1: pH is low (acidemia) Step 2: The PCO2 is high (respiratory acidosis) and the bicarbonate is normal. A low pH with a high PCO2 indicates that the primary process is a respiratory acidosis. Summary In this case, the patient started hypoventilating because he had likely given himself too much narcotic pain medications. Case B A patient presents with a one-day history of productive cough, fevers and increasing dyspnea. In the ER, the chest x-ray shows a right middle lobe opacity. His oxygen saturation is 90% on room air. An arterial blood gas is obtained and it reveals a Step 1: The pH is high (alkalemia) Step 2: The PCO2 is low (respiratory alkalosis) and the bicarbonate is on the low side of normal. A high pH with a low PCO2 indicates that the primary process is a respiratory alkalosis. Summary In this case, the patient is likely hyperventilating because he is hypoxemic. This is a good example of the hypoxemic ventilatory response. Case C A patient with Type I diabetes presents to the ER complaining of feeling poorly two days after running out of his insulin. An arterial blood gas is obtained and shows Step 1: The pH is low (acidemia) Step 2: The PCO2 is low (respiratory alkalosis) and the bicarbonate is low (metabolic acidosis). A low pH and low bicarbonate signifies that the metabolic acidosis is the primary process. Summary In this case, the patient is likely in diabetic ketoacidosis because he was not Continue reading >>

Agreement Between Central Venous And Arterial Blood Gas Measurements In The Intensive Care Unit

Agreement Between Central Venous And Arterial Blood Gas Measurements In The Intensive Care Unit

Go to: Abstract Background and objectives: Venous blood gas (VBG) analysis is a safer procedure than arterial blood gas (ABG) analysis and may be an alternative for determining acid-base status. The objective of this study was to examine the agreement between ABG and central VBG samples for all commonly used parameters in a medical intensive care unit (ICU) population. Design, setting, participants, & measurements: We performed a single-center, prospective trial to assess the agreement between arterial and central VBG measurements in a medical ICU. Adult patients who were admitted to the ICU and required both a central venous line and an arterial line were enrolled. When an ABG was performed, a central venous sample was obtained to examine the agreement among the pH, Pco2, and bicarbonate. Data comparing central and peripheral VBG values were also obtained. Results: The mean arterial minus venous difference for pH, Pco2, and bicarbonate was 0.027, −3.8, and −0.80, respectively. Bland-Altman plots for agreement of pH, Pco2, and bicarbonate showed 95% limits of agreement of −0.028 to 0.081, −12.3 to 4.8, and −4.0 to 2.4, respectively. Regression equations were derived to predict arterial values from venous values as follows: Arterial pH = −0.307 + 1.05 × venous pH, arterial Pco2 = 0.805 + 0.936 × venous Pco2, and arterial bicarbonate = 0.513 + 0.945 × venous bicarbonate. The mean central minus peripheral differences for pH, Pco2, and bicarbonate were not clinically important. Conclusions: Peripheral or central venous pH, Pco2, and bicarbonate can replace their arterial equivalents in many clinical contexts encountered in the ICU. Figure 2. Bland-Altman plot of arterial and central venous blood Pco2 showing the regression line (solid line) and the 95% limits Continue reading >>

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