Download - Blood gases for nurses
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Blood gases
What is most likely to be wrong with the patient and how will
you manage them?
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Case 1: 75F
Arterial
FIO2 0.5
pH 7.289 7.35-7.43
pO2 147 69-116
pCO2 26.4 32-45
BXS 13.1 -2 - +2
HCO3 12.3 22-26
Na 155 136-146
K 4.4 3.5-5.0
Cl 120 99-106
Glucose 46 3.9-5.8
Lactate 4.3 0.5-1.6
Hb 163 130-180
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Case 1: 75F
Arterial
FIO2 0.5
pH 7.289 7.35-7.43
pO2 147 69-116
pCO2 26.4 32-45
BXS 13.1 -2 - +2
HCO3 12.3 22-26
Na 155 136-146
K 4.4 3.5-5.0
Cl 120 99-106
Glucose 46 3.9-5.8
Lactate 4.3 0.5-1.6
Hb 163 130-180
Give me a couple of diagnoses and tell me your management
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Case 1: 75F
Arterial
FIO2 0.5
pH 7.289 7.35-7.43
pO2 147 69-116
pCO2 26.4 32-45
BXS 13.1 -2 - +2
HCO3 12.3 22-26
Na 155 136-146
K 4.4 3.5-5.0
Cl 120 99-106
Glucose 46 3.9-5.8
Lactate 4.3 0.5-1.6
Hb 163 130-180
DKA or HHS + relative
hypoxia + hypoperfusion ?
septic
Rehydrate slowly
Add insulin and K+
replacement once K+
known
Seek and treat source
CXR
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Case 2 85F
Arterial
FIO2 1.0
pH 7.186 7.35-7.43
pO2 87.5 69-116
pCO2 37.8 32-45
BXS -12.9 -2 - +2
HCO3 13.7 22-26
Na 139 136-146
K 9.4 3.5-5.0
Cl 117 99-106
Glucose 8.6 3.9-5.8
Lactate 0.6 0.5-1.6
Hb 124 130-180
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Case 2 85F
Arterial
FIO2 1.0
pH 7.186 7.35-7.43
pO2 87.5 69-116
pCO2 37.8 32-45
BXS -12.9 -2 - +2
HCO3 13.7 22-26
Na 139 136-146
K 9.4 3.5-5.0
Cl 117 99-106
Glucose 8.6 3.9-5.8
Lactate 0.6 0.5-1.6
Hb 124 130-180
Give me a couple of diagnoses and tell me your
management
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Case 2 85F
Arterial
FIO2 1.0
pH 7.186 7.35-7.43
pO2 87.5 69-116
pCO2 37.8 32-45
BXS -12.9 -2 - +2
HCO3 13.7 22-26
Na 139 136-146
K 9.4 3.5-5.0
Cl 117 99-106
Glucose 8.6 3.9-5.8
Lactate 0.6 0.5-1.6
Hb 124 130-180
Life threatening
hyperkalaemia
Hypoxia
Severe acidosis with poor
respiratory compensation ?
Decr LOC
Salbutamol
Calcium gluconate
ECG
Repeat K+ sample
Find the cause
? Candidate for dialysis
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Case 3: 3 year old with tachypnoea,
floppy, parents don’t speak local
languagesVenous
FIO2 0.21
pH 7.22 7.35-7.43
pO2 48 69-116
pCO2 24 32-45
BXS -2 - +2
HCO3 10 22-26
Na 139 136-146
K 1.9 3.5-5.0
Cl 118 99-106
Glucose 4.1 3.9-5.8
Lactate 2.5 0.5-1.6
Hb 107 130-180
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Case 3: 3 year old with tachypnoea
Venous
FIO2 0.21
pH 7.22 7.35-7.43
pO2 48 69-116
pCO2 24 32-45
BXS -2 - +2
HCO3 10 22-26
Na 139 136-146
K 1.9 3.5-5.0
Cl 118 99-106
Glucose 4.1 3.9-5.8
Lactate 2.5 0.5-1.6
Hb 107 130-180
NB venous
Severe hypokalaemia
? diarrhoeal illness
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What's going on and what are you going to do?
Probable gastroenteritis with life threatening hypokalaemia.
Mx (lots of ways to do it)
If really shocked IV boluses eg Hartmann's (K = 5mmol/L) 20mmol/kg boluses
till clinically intravascularly euvolaemic.
Then
Eg 20mmolKCL in 1/2NS + 5% dextrose run at double maintenance
(Maintenance = 4ml/kg for 1st 10kg + 2ml/kg for next 10kg + 1ml/kg
thereafter, (but in Alice they use 5ml/kg if under ) 40 + 8 ml/hour. Double
maintenance = 96ml/hour
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Alternatively (RCH): 250ml/hour NS + KCL 20mmol/L for first 6 hours
if severely dehydrated (=5mmolKCL/hour), or 150ml/kg thereafter
Alternatively (CC) 280ml boluses of Hartmann's if shocked. Then or
otherwise: 250 0r 150ml/hour (depending on severity) NS + 5%
Dextrose + KCL 20mmol/L. Offer ORS. Stop IV fluid when taking >
10ml/kg/hour ORS.
ORS (liquid or icy pole) contains KCL 20mmol/kg.
Ondansetron 2mg SL wafer or IV
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Case 4 78F SOB
Arterial
FIO2 0.21
pH 7.421 7.35-7.43
pO2 41.9 69-116
pCO2 50.8 32-45
BXS 7.8 -2 - +2
HCO3 32.4 22-26
Na 140 136-146
K 2.7 3.5-5.0
Cl 99 99-106
Glucose 6.0 3.9-5.8
Lactate 0.9 0.5-1.6
Hb 104 130-180
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Is there an acid base disorder present? If so what?
No acidaemia or alkalaemia but probably respiratory acidosis (low HCO3, high CO2 and
hypoxia (or could be metabolic alkalosis with full compensation - but hypoxia
suggests respiratory process and don't usually get full compensation for metabolic
acidosis).
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HypoK
Most likley secondary to any or all of:
●Alkalosis
●Salbutamol
●Diuretics
●Vomiting
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Conclusion
Severely unwell patient who requires oxygen.
She has hypoxic and hypercapnic respiratory failure.
She is not acidaemic or alkalaemic probably on the basis of a compensated
chronic respiratory acidosis + another process eg
●metabolic alkalosis from vomiting or diuretics (also causing hypo K)
●acute respiratory acidosis
She is hypokalaemic from eg
●vomiting
●diuretics
●alkalosis
●salbutamol
She needs urgent correction of her hypoxia as first line therapy. She is likely
to require ventilatory support. Her K needs to be corrected.
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Case 5. 71F with persistent vomiting
Arterial
FIO2 0.21
pH 7.671 7.35-7.43
pO2 28.2 69-116
pCO2 43 32-45
BXS 25.7 -2 - +2
HCO3 49.1 22-26
Na 129 136-146
K 1.9 3.5-5.0
Cl 71 99-106
Glucose 6.0 3.9-5.8
Lactate 1.8 0.5-1.6
Hb 136 130-180
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Acid base disorder
Hypoxic +
Metabolic alkalosis
Causes
Most common GIT loss (vomiting) or diuretics
Chloride responsive
● GI loss
●Diuretics
●Chloride wasting disease
o cystic fibrosis
Non-chloride responsive
●hyperaldosteronism
oExpect hyperNa and hypoK
oeg renal artery stenosis, CCF, liver failure, nephrotic syndrome
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Severe hypoK: 1.9
Likely to be as a result of vomiting
●Kidneys retain H at expense of K
Needs urgent correction and cardiac monitoring
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Conclusion
Severe hypoxaemia requiring oxygen and probably ventilatory
support.
Hypoxaemia may be as a result of aspiration from vomiting
and exacerbated by respiratory compensation for metabolic
alkalosis
Given Hx of persistent vomiting, vomiting is probable cause of
metabolic alkalosis.
Needs volume, Na, Cl and K replacement eg NS + 40mmolKCL/
1 hour with cardiac monitoring
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Case 6 74M SOB
Arterial
FIO2 0.21
pH 7.49 7.35-7.43
pO2 38.4 69-116
pCO2 26.7 32-45
BXS -2.8 -2 - +2
HCO3 20.1 22-26
Na 139 136-146
K 4.2 3.5-5.0
Cl 108 99-106
Glucose 6.2 3.9-5.8
Lactate 1.4 0.5-1.6
Hb 121 130-180
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Conclusion
Severe hypoxic respiratory failure.
Patient requires oxygen and treatment of underlying process