Diseases, Disorders information

What are then the definitions? We’ll go briefly over them. But we have here acidosis and alkalosis and it can either be caused by the lungs - in which case it is called respiratory - or it can be caused by something else besides the lungs, in which it is called metabolic. Forget about all this. We’ll get back to that later. There’s just really four choices. Now, that’s not exactly true because on top of those four choices you have two more. Do you have a combined something-or-other? And number two, do you have a compensation? So when we are trying to solve these problems, after you’ve got them solved, you always have to remember to ask those two questions. Do we have more than one, and/or is there some compensation going on here? It’s reasonably easy if you ask the questions in order.
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Here’s what the Europeans are doing. This is the concentration of hydrogen ion and this is the pH and as you can see, as the hydrogen ion goes up the pH goes down. It’s easy to remember that because you know that’s what is happening but in reporting these things out, as soon as you get the normal ranges in your mind - and you really don’t have to do that anymore because the computers print out the normal ranges. If they don’t they are not doing their job - then it becomes fairly easy to say, “Hey, 25 is low and 80 is high” and it is going right in the direction that you want. But my guess is that we are stuck with pH, probably to your grandchildren. That’s progress. Unless maybe Bill Gates decides that Microsoft wants to get into the pH business, then we are okay.
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Now the last thing that I think you need to deal with is that specimens differ in where they came from. We can do all these things on arterial, venous, capillary or alveolar gas. I guess rather than remembering this, you always have to remember to look on the report and ask yourself, “Where did this come from?” where does it come from, because the normal values will be different. Again, if the computer is doing it’s job right it will tell you pH, it will tell you where it came from, and it will give you the normal range for those sources. Frankly I deal with them every day and I’m not sure, except in some of the major ones, that I could tell you what all the normal ranges are. So there’s not a real problem not knowing them. But there is a problem if you don’t ask yourself the question; “where did the stuff come from?”

One last concept that we will talk a little bit about is the concept of base excess. Now, bicarbonate is called a base and you can talk to your chemist as to why it’s called a base. Anyway it’s called a base. It’s not a pejorative name. It’s just base. So base excess or base deficit really means that you have too much or too little bicarbonate and you can say, “Okay, but we are going to measure serum bicarbonate, why isn’t serum bicarbonate alone? Why isn’t that okay?” and the answer is, mostly it is okay. But since the body is multiple compartments and since you’ve got two compartment that’s the blood, you have one compartment that’s the plasma and one compartment that is in the cells. There is not free motion between those three compartments that you can get some disparate results in chronic conditions. So we put the anion or base excess or deficit in there to give you a kind of a qualitative estimation as to how bad it is. You come down and you say, “This patient is acidotic, this patient is metabolic acidosis, this patient is diabetic.” So you’ve got that. Then this deficit then gives you a sort of a semi-quantitative estimate as to how bad it is. I’ll show you in a minute. It’s a little bit better than just using the plasma bicarb alone. Now this is a graph, it’s in your thing, you’ll probably never use it. I just wanted you to know that it exists because if your computers ever break, here is the PCO2, here’s the pH and here’s the CO2 content and right here is the base excess, and you can draw a line across here. For example, this is 40 mmHg which would be normal, this is 7.40 which would be normal, and this is 25 mmol/L of bicarb. That would be normal. If you had a normal patient and drew a line across there, this is the base excess grid and you hit zero. So it’s no excess, no deficit. So if ever someone gives you some numbers and they want to ask you “What’s the base excess or what’s the base deficit?” you just put the three points here, here and here and it’s on the grid. As I say, the only time anybody would ever use that is if the computerized method for calculating it would go bad.

Blood Gas Analysis

CO2 content, however, I measured and that’s the CO2 as it comes. It doesn’t matter what. Now the vast majority of CO2 is present in bicarbonate, like 95%. So most people use those terms interchangeably. CO2, CO2 content, bicarb. For practical purposes that’s okay. Unless somebody is trying to find out it you have deep scientific knowledge, it is okay to use them interchangeably because clinically we do use them. But CO2 content has a little bit more than bicarbonate, and you should know that. Finally, as far as oxygen is concerned, it won’t transfer it in any meaningful way unless it’s attached to hemoglobin. So two things: one, it’s the oxyhemoglobin that carries the overwhelming - 99.9% or some huge amount - of all the oxygen that goes from the alveoli to the tissues. So that means then that every time you are doing blood gases you have to ask, number one: what’s the hemoglobin, number two: is it normal? Is it some kind of abnormal hemoglobin? Has the patient been in a fire, this or that. Drinking bad well water, so does the patient have the right amount of hemoglobin? Is it abnormal? Something that would prevent the oxygen from jumping aboard? As you know, most smokers have enough carboxyhemoglobin to make a difference in marginal cases. People with arteriosclerotic heart disease can have enough carboxyhemoglobin to actually make a difference.
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The third thing is blood pressure, pulse and cardiac output. Again, most all of those things can be clinically estimated, but you can have all the hemoglobin you want, you can have all the oxygen you want, and if the pump isn’t working, you aren’t getting it where you want. It’s amazing when people sometimes look at the numbers that we provide, they sometimes leave the patient mentally and go back and look at the numbers only. And you can’t. You have to go back and forth and back and forth and each time ask all the other questions about hemoglobin. Pretty simple but if you don’t remember to do it you can make big errors.
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Now, the Henderson-Hasselbalch equation here - I just showed it to remind you that you saw it one time and you’ll probably never see it again - but it will show you what it really says. What it really says is the pH is directly related to the bicarbonate. In other words, as the bicarbonate goes up pH goes up and the pH is inversely related to the PCO2. So as the pH goes up, PCO2 goes down, and vice-versa. So if you want to remember Henderson-Hasselbalch, as a which way does it happen? This is the one to remember. The pH is directly related to the bicarbonate; pH is inversely related to PCO2. Once you start working with these numbers, which many of you do, you will find out that you are already accommodating to that. You’re just not thinking about it when you do it.

pH is the negative log of the hydrogen ion concentration. More hydrogen ion, more acid. Less acid, more alkaline. As the pH goes down you are more acidotic and as the pH goes up you are more alkalotic. So it is actually going inversely, negative log, but the Europeans have already switched over. I don’t think we are going to switch over, I wish we would, and they’ve gone to hydrogen ion concentrations so it is directly - it actually adds and subtracts with all the other ions and frankly I wish we would change over, but I don’t think we are.

Now partial pressure is another concept that is sometimes difficult to deal with and that is, it isn’t a real measurement of anything. It’s just a relationship to the total. Here the barometric pressure is about 730 mmHg or so. So that’s a partial pressure of 100%, whatever that is. And then partial pressures then are the part that a gas plays in that. So if a gas, an inert gas, is 80% then the partial pressure is 80% of whatever that is. If it’s 10% or 20%, it’s whatever that is. So if its partial pressure is 730 mmHg and somebody is 10%, it’s 73. If it’s 20% it’s 146. And since oxygen is right about 20% of room air - that’s approximately the PO2 of room air. It’s about 140 mmHg. It’s very important to remember that this is just a proportion. It doesn’t have any absolute value at all. There’s a lot of other things that come into play, including hemoglobin and so forth that we’ll get into, so it’s just the part that CO2 plays in the total. Same thing with O2, N2 whatever you are measuring.

Now bicarbonate, on the other hand, is something. It is an ion. The problem is, we can’t measure it. There has been no accurate way ever devised to measure it. So all of the bicarbonates that you get will be calculated. The good news is that the calculations are such that it is almost as good as a measured ion and I never even think twice about it. And it almost always works out right. So even though it’s calculated, not measured, it is a good value and is worthy of our attention.