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This patient is acidotic, without any question. So we have an acidotic patient. So it’s either respiratory acidosis or metabolic acidosis. Let’s just say for though purposes we are going to try to make this patient respiratory acidosis. If that’s true, the patient is hypoventilating, right? The patient is hypoventilating the PCO2 goes up. In this case, the PCO2 is down, not up. So even if you get taken down the wrong road, if you go in order you are immediately blocked. You can’t get there. So we thought maybe this was respiratory acidosis, and then we say, “No, it can’t be that. So it must be metabolic acidosis.” So what happens with metabolic acidosis, if you remember, is you lose hydrogen ion and then everything else you hyperventilate and everything else goes away to try to buffer up that extra hydrogen ion so the PCO2 is down, the bicarbonate is down and the patient obviously does not have a respiratory problem. PO2 is normal, saturation is normal for a patient who is on room air. So this patient is metabolic acidosis. It’s a 46-year-old lady who came in comatose with an unknown history. I think this one was a drug overdose if I remember correctly. I’m not positive about that.
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This patient, the pH is normal. So now if the pH is normal, either the gases are normal or the system is compensated completely. One or the other. Either it’s normal or compensated completely. We have those two choices. PCO2 is normal. Base excess normal. The arterial oxygen is a little bit up from what you want, doing room air, but it’s okay. But you wonder why does a person have all these? Have a saturation of 80%. So there’s a question when you look at those things. Is there something wrong? Was the saturation wrong? Or is there something wrong? So, 25-year-old person brought into the emergency room, narcotic overdose and possible aspiration. Repeat, at the end of a little while in the emergency room. So now we repeat them. The patient is still on room air so they haven’t done anything with the patient. The saturation is still 80%, so there’s still something going on here. The pH is now acidotic. So it’s either metabolic acidoses or respiratory acidosis. So now you maybe or maybe not, you don’t know if it’s narcotic overdose because this patient is in the ER, so I don’t remember when they found that out. Let’s say you don’t know it. Let’s say it’s respiratory acidosis then. If it’s respiratory acidosis, people quit breathing, PCO2 goes up. This is quite a bit up. 64. So this is compatible with respiratory acidosis. The base excess hasn’t changed very much so that’s a tip that this is acute rather than chronic. We’ll have some patients like that later on. So this is respiratory acidosis and there is a respiratory problem evolving. The patient is on room air, the PO2 is falling, the saturation is staying down. Something needs to be done. Those people, you either ventilate them or you don’t, depending on how serious they are and eventually that all goes away and you are left with only a suicide or a chronic drug problem. A nice little problem.
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Okay, here’s another case. Now we are going to step up the pace a little bit. We are going to ask you from now on to give us all what you know about it. Not just the acidosis, alkalosis but give us every bit of information that you learned just from these very simple tests. This is a patient, again breathing room air, but immediately you can see there’s a problem breathing room air. The PO2 is at 60 mmHg. So the patient has some kind of respiratory problem and you haven’t even gotten very far. And it’s severely acidotic. Again, very easy. Is it metabolic or is it respiratory? If you know this patient for instance and it’s one of your diabetics. So you’ve decided to go in and your mind is poisoned because you know the patient. So you decide it’s a metabolic acidosis and you remember metabolic acidosis is too my hydrogen ion and breathing too fast. Immediately you are blocked there because this PCO2 is way up. So this patient is having trouble breathing, not moving PCO2 and not moving O2 so it can’t be diabetic ketoacidosis. It could be a diabetic all right, but not ketoacidosis. So it’s respiratory acidosis. Here’s then the question. You know that it hasn’t been going on for very long because the bicarbonate isn’t up and the base excess is still normal - plus or minus 5 is what most people use - so you know this is an acute respiratory acidosis because the bicarb and the base excess have not moved. That is going to be important if you are dealing with any COPD patients in your practice.
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So here’s a 43-year-old man in an automobile accident with severe head trauma and he’s probably got a central hypoventilation and probably put him on a ventilator, and if the head trauma goes away there’s no reason that that can’t go away.

Okay, next case. This person is on room air, and saturation is normal and PO2 is pretty normal. So we don’t have any evidence at this point that there is any respiratory problem. But the pH is up, so the patient is alkalotic. So is it respiratory or is it metabolic? If the patient was hyperventilating the PCO2 would be down. In this case it is up. So it’s not respiratory alkalosis. It’s got to be metabolic alkalosis and again, it’s been going on for awhile because that bicarbonate is high. So this is metabolic alkalosis, chronic. Probably the most common thing that we see in clinical practice that produces this is what? Diuretics. You got it. That’s right. It’s very common. The problem is we don’t do gasses on these people unless we have another reason, so you don’t see it. But it’s very very common.
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This is a 32-year-old patient. Intestinal obstruction with a nasogastric tube in and so forth. And it has been on for too long.

Okay, last case. Here’s a patient on breathing room air and having trouble. The saturation is 52% and the PO2 is 39, so we’ve got a patient with a respiratory problem so there’s an acidotic and it’s pretty easy to say, well that’s a respiratory patient with an acidosis. It ought to be respiratory acidosis. If people who have a respiratory problem are hypoventilating, their PCO2 goes up. This is way up. The bicarb has not moved very much so this would then be an acute respiratory acidosis. This patient had a history of chronic bronchitis but you’d have to say from this standpoint the numbers look more acute than they do chronic. As you know, chronic bronchitis patients don’t necessarily have interval problems. They may, but they may not.

Take the reverse now, last hyperventilation: teenager, anxiety, the ventilator is going to fast, brain tumor, stroke, doesn’t matter. The person is hyperventilating. If you are hyperventilating into room air, there’s no problem that I know of on the oxygen side. So if you are hyperventilating you can forget about the oxygen. It will still stay mostly within limits. But then the hyperventilation, off goes the CO2 and drives everything from your right to your left: bicarbonates down, hydrogen ion is down, PCO2 is down and pH is obviously is then up. So now if the problem is respiratory the result is alkalosis. In the first case, the problem is acidosis and you have a bunch of results. In this case the problem is respiratory and then you have alkalosis or you have acidosis.
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I put a few of these things on the charts here. I don’t think we have any of them in there because I don’t think they are at all necessary. People have invented little schemes to help you do your work. I believe that if you understand what you are doing, you can survive any one of these charts. The reason I don’t like them is very simple, and that is; the lab is not that precise and if these little schemes are supposed to be different diagnostic categories - which they are - you see if your crosses are right there you get one answer, and if they are right there you get another answer. And that’s a very little lab error that does that. Here’s another one. It’s not so good to go in and tell the patient, “You know I think you have a J but you may have an E. The damn lab isn’t reliable so I can’t tell whether you’ve got a J or an E” and now they’ve got a new doctor after you tell them that. This one I’ve had now for about 15 years and I’ve never been able to figure out how anybody actually uses it. That makes it the best one of all. Then here’s the last one. But the point is, if you think about those points and you think about reasonable lab error, it’s very easy to go from one zone to another zone. Whereas if you are just thinking about them in abstract, it won’t take your diagnosis out of the place it should be. So, for those of you who look in the stratosphere or wherever, the Washington Post now predicts the next planet that is found again, so all of you from Nebraska rejoice.
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What I am going to do is I want you all to just take a quick - I’ve got some cases here - and we will take some quick goes through the cases and they are in order to kind of demonstrate how to do it. Now what I generally do, and I think most of you have your habits already, but the easiest thing to do is to go to the pH. It’s the most reliable. And if it is abnormal, it reduces your choices. So what I do is go to the pH and see whether you can reduce the choices from 4 or 6 down to 2 or 3, and then fill in the blanks. So here’s case two. I’ll give you a couple of minutes to think it over. This is the fraction of inspired oxygen and .21 is 21%. That means the patient here is on room air. If the patient is not on room air, there will be some other thing right there. These are all arterial values and this is the saturation of oxygen, and again, normal is going to be 95% or so.

Now these charts are all in your handout, but I have developed over the years a way of looking at what is going on that relates to the interface between the alveolus and the capillary. I think it’s the best way to think about it because you only have to have one picture in your mind and it’s almost impossible to forget how this picture looks. Because, I don’t care how you draw the alveolus. You can draw it any way you want, and I don’t care how you draw the capillary, you can draw it any way you want. But I think everybody knows that the air has got nitrogen coming in and out. The air has got oxygen coming in and out, and everybody knows that the oxygen goes in the blood and the CO2 comes out of the blood. So now you’ve got most of the thing drawn. Then, if you just know that the main buffer system in the plasma is the bicarbonate buffer system, which everybody pretty much knows that, then you just write it down. CO2 is in equilibrium with un-associated carbonic acid, which is in equilibrium with hydrogen ion and bicarbonate. This bicarbonate is what you measure for the bicarbonate level, this is what you measure for the pH level and over here, the physically dissolved stuff, this is what you measure for the PCO2. So you are metabolizing out here, producing hydrogen ion. You are breathing over here, getting off the CO2, back and forth, back and forth. So that’s what we are rolling off of, is this diagram. Then of course we can go quickly through this because I don’t think there’s a problem here, but if you have too much hydrogen ion, then by definition, that’s acidosis. If you just have this thing in mind then there’s no other way it can be. If you are pushing in hydrogen ion at this point and there’s nothing else wrong - if that’s all you are doing, is firing more hydrogen on in - diabetic acidosis, renal failure, doesn’t matter, then the bicarbonate is going to grab onto it. You are going to get more PCO2. The people are going to breathe faster and everything is going to go outside. In theory, nothing happens to the oxygen so it just keeps on breathing, and the result is the problem is too much hydrogen ion. Everything else is low. The problem is too much hydrogen ion and everything else is low because you just breathe it off.
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Now, let’s just reverse the charges. You’ve got a patient with a nasogastric tube in, or chronic vomiting, or you are taking some nonabsorbable antacids, or there’s too little hydrogen ion. Again, for our purposes it doesn’t matter what the cause. It does for the patient because we are going to have to eventually figure that out. But for our purposes it doesn’t matter. If our problem is loss of hydrogen ion, then everything stops. The PCO2 goes up, the carbonic acid goes up and bicarbonate goes up. Hydrogen ion is down because you just continue to lose it and it just keeps going toward your right. Therefore, your problem is alkalosis. Everything else is up. Now the body has a problem. You can’t stop breathing completely. So there is a limit to the hypoventilation you can do - that’s about 50, 55 mmHg but that’s irrelevant. You can look at the patient and tell whether they are breathing or not. That’s fairly easy in most cases. So the patient can only hypoventilate so much, in which to try to compensate for what’s going on, and then otherwise it just continues to produce alkalosis. So if you have alkalosis, everything is up.
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Now we’ll quickly go through the other two. Okay, now we have some trouble breathing. The patient has got a piece of steak in here or there’s pneumonia or there’s the hyaline membrane or there’s pulmonary edema, or the ventilator is going too slow. Again, it doesn’t matter if there is some reduction in respiration. Now you’ve got oxygen in play, because if you’ve got reduction in respiration, you’ve got the oxygen in play. The oxygen is down so therefor the PO2 is down, so therefor the oxyhemoglobin will be down. That’s over on the other side of the equation. But in this case, metabolism keeps going on but the CO2 backs up, backs up, backs up, backs up. So now you have hypoventilation which means it’s respiratory so the pH is down. But that’s the problem. That’s not the cause. The cause is respiratory. The problem now is acidosis down, everything else is up. Again, same diagram.
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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.

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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.