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Fa: Methods 2 > Acid Base Management > Flashcards

Acid Base Management Flashcards

1
Q

technical definition of blood gas

A

gas under ordinary conditions
dissolved to some extend in our bloodf

dissolved to some extent into our blood

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2
Q

clinical definition of blood gas

A

test that measures actual gases (PaO2, PaCO2) but includes values that aren’t blood gases

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3
Q

5 main things in arterial blood gas

A 
pH
HCO3-
base excess
PaCO2
PaO2
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4
Q

additional things that can be added to ABGs

A 
Hb/Hct
K
Glucose
Calcium
Carboxyhemoglobin
Methemoglobin
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5
Q

technical definition of base excess

A

amount of acid or base needed (at 100% SaO2 and 37C) to return:
pH to 7.4
PaCO2 to 40mmHg

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6
Q

clinical definition of base excess

A

ABG value that reveals if the pt has too much or not enough base

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7
Q

What type of base status does base excess refer to?

A

metabolic acid base status

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8
Q

normal base excess

A

-2 to 2 mmol/L

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9
Q

negative base excess

A

< -2 mmol/L
not enough base
metabolic acidosis

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10
Q

treatment for negative base excess?

A

bicarb

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11
Q

positive base excess

A

> 2mmol/L
too much base
metabolic alkalosis

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12
Q

how do you treat metabolic alkalosis

A

reversing the cause of alkalosis

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13
Q

what is pH defined as

A

H+ concentration

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14
Q

what is pH determined by?

A

HCO3-/PaCO2

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15
Q

normal pH range

A

7.35-7.45

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16
Q

pH >7.45

A

alkalosis

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17
Q

pH<7.35

A

acidosis

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18
Q

6 consequences of acidosis

A 
decrease cardiac contractility
decreases response to catecholamines
impairs coagulation and increases bleeding
increases PVR
lowers vfib threshold
increases plasma K concentration
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19
Q

why does acidosis increase K concentration in the plasma?

A

H+ enters cells and K+ leaves cells

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20
Q

5 consequences of alkalosis

A 
shifts oxyhemoglobin curve to left
increases SVR
cerebral vasoconstriction
decreases PVR
decreases plasma K concentration
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21
Q

venous measurement CO2

A

24-30mEq/L

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22
Q

arterial measurement HCO3-

A

22-26mEq/L

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23
Q

PaCO2

A

35-45mmHg

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24
Q

PvCO2

A

40-50mmHg

~5 higher than PaCO2

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25
Q

when does the PvCO2 to PaCO2 gradient increase

A

pt is poorly perfused

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26
Q

PaO2 of atmosphere

A

~160mmHg

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27
Q

PaO2

A

70-100mmHg

decreases with age

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28
Q

PvO2

A

30-40mmHg

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29
Q

CaO2

A

16-20mL/dL

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30
Q

CvO2

A

12-16mL/dL

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31
Q

SmvO2

A

60-80% in awake pts

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32
Q

SaO2

A

93-98%

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33
Q

use a decimal or percent for SaO2 in the equation?

A

decimal

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34
Q

on room air what is the A-a gradient

A

5-15mmHg

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35
Q

in elderly pts what does the A-a gradient increase to

A

15-25mmHg

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36
Q

on 100% FiO2 what can the A-a gradient be as high as?

A

10-110mmHg

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37
Q

minute ventilation

A

7-8L/min

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38
Q

Va

A

alveolar ventilation

2/3 minute ventilation

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39
Q

what is tissue perfusion primarily depended on?

A

SaO2

PaO2 has little effect on tissue perfusion

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40
Q

VCO2

A

CO2 production

200mL/min

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41
Q

how much is VCO2 decreased by with GA

A

60%

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42
Q

VO2

A

oxygen consumption

250mL/min (normothermic 70kg)

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43
Q

%MetHb normal

A

<2%

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44
Q

%COHb normal

A

<3%

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45
Q

HCO3-/PaCO2 ratio

A

20:1

abnormal ratio always leads to abnormal pH

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46
Q

PaO2/FiO2 ratio

A

480

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47
Q

Anion Gap

A

8-16mEq/L

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48
Q

Lances simple PiO2 equation

A

PiO2= (FiO2)(713)

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49
Q

serum lactate concentration

A

<2mmol/L

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50
Q

lactic acidosis

A

serum lactate >5mmol/L

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51
Q

CaO2 Equation

A

(SaO2)(Hb)(1.34)+(PaO2)(0.003)

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52
Q

what % of oxygen is bound to Hb?

A

98.5%

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53
Q

what % of oxygen is dissolved in plasma?

A

1.5%

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54
Q

T/F PaO2 makes up a large portion of the total oxygen content in the arteries.

A

False

it makes up a small portion

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55
Q

what is the primary determinant of CaO2?

A

SaO2

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56
Q

If SaO2 increased by 10% and Hb also increased by 10% which would have the greater effect on CaO2?

A

they would have the same effect

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57
Q

what are the units for 1.34 in the CaO2 equation?

A

mL O2/ 1g Hb

varrying capacity of Hb

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58
Q

use a decimal or percent for SaO2 in the equation?

A

decimal

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59
Q

CvO2 equation

A

(SvO2)(Hb)(1.34)+(PvO2)(0.003)

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60
Q

fick equation

A

VO2= (Cardiac Output)(CaO2-CvO2)(10)

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61
Q

units for the fick equation answer

A

mL/min

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62
Q

DO2

A

amount of oxygen available for tissue perfusion per minute

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63
Q

DO2 equation

A

DO2= (CaO2)(Cardiac Output)

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64
Q

what is tissue perfusion primarily depended on?

A

SaO2

PaO2 has little effect on tissue perfusion

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65
Q

PiO2 definition

A

pressure of inspired oxygen

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66
Q

3 things that determine PiO2

A

FiO2
pressure in the atmosphere
water vapor pressure

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67
Q

equation alveolar volume

A

Vt-Vd

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68
Q

if atmospheric pressure increasees then PiO2 _____?

A

increases

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69
Q

as water vapor pressure in the air increases PiO2 _____?

A

decreases

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70
Q

PiO2 equation

A

PiO2= (FiO2)(Barometric Pressure -Water Vapor Pressure)

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71
Q

sea level barometric pressure

A

760

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72
Q

sea level water vapor pressure

A

47

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73
Q

Lances simple PiO2 equation

A

PiO2= (FiO2)(713)

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74
Q

PAO2 equations

A

(PiO2)- (1.2)(PaCO2)
OR
(FiO2)(713)- (1.2)(PaCO2)

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75
Q

what changes about the PAO2 equation if the FiO2 is >60%?

A

leave out the 1.2
NEW=
(FiO2)(713)-(PaCO2)

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76
Q

if PaCO2 decreases what does that do to PAO2?

A

increases

exact mechanism unknown

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77
Q

is it possible to have a normal pH with abnormal bicarb and PaCO2 levels?

A

yes

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78
Q

PAO2 estimation

A

PAO2= 102- (age/3)

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79
Q

Vt

A

tidal volume

air expired in one breath

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80
Q

does Vt include dead space volume?

A

yes

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81
Q

MV

A

minute ventilation

total volume of air that we breath in 1 min

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82
Q

does MV include dead space?

A

yes

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83
Q

MV equation

A

MV = RR*Vt

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84
Q

Vd

A

volume of dead space in one breath

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85
Q

what amount of the Vt is dead space?

A

1/3

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86
Q

in a pt with pulm disease what amount of Vt is dead space?

A

> 1/3

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87
Q

dead space ventilation equation

A

Vd/Vt = VdxRR

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88
Q

PaO2/FiO2 <200 indicates what?

A

ARDS

acute respiratory distress syndrome

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89
Q

Which of the following is least likely to lower a patient’s alveolar PO2?

  • Increase in altitude
  • Elevated PaCO2
  • A left to right intracardiac shunt
  • None of the above
A

-A left to right intracardiac shunt

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90
Q

what is the amount of dead space proportional to?

A

difference in PaCO2 and etCO2

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91
Q

Alveolar Volume

A

amount of air in one breath that actually reaches the alveoli and participates in gas exchange

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92
Q

equation alveolar volume

A

Vt-Vd

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93
Q

Va

A

alveolar ventilation
Va = (Vt-Vd)RR

amount of air in one min that participates in gas exchange

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94
Q

equation for VA

A

VA= (Vt-Vd)(RR)

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95
Q

PaCO2 equation

A

(VCO2mL/min)(0.863)/ VA L/min

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96
Q

if alveolar ventilation is low then PaCO2 will be?

A

high

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97
Q

if CO2 production is high then PaCO2 will be?

A

high

98
Q

what can high levels of CO2 cause?

A

acidosis

99
Q

what can low levels of CO2 cause?

A

alkalosis

100
Q

clinical henderson hasselbalch equation

A

pH= HCO3-/PaCO2

101
Q

is it possible to have an abnormal pH with normal bicarb and PaCO2 levels?

A

no

102
Q

what % of CO2 is in the form of HCO3-?

A

90-95%

103
Q

what is the A-a gradient

A

difference between the PAO2 and PaO2

104
Q

what does an increase in A-a gradient indicate?

A

lung disease

105
Q

A-a gradient will increase with

A

impaired gas exchange (COPD)
age
supplemental oxygen
right to left intracardiac shunting

106
Q

disadvantages to A-a gradient

A

anesthetist must calculate PAO2

varies greatly in ppl breathing supplemental O2

107
Q

alternative to A-a gradient

A

PaO2/FiO2

108
Q

normal PaO2/FiO2 ratio?

A

> 400

109
Q

in health pts the PaO2 is ~ ___ greater than FiO2

A

5x

110
Q

the lower number we get for the PaO2/FiO2 ratio indicates what?

A

higher degree of lung disease

111
Q

PaO2/FiO2 <300 indicates what?

A

ALI

acute lung injury

112
Q

PaO2/FiO2 <200 indicates what?

A

ARDS

acute respiratory distress syndrome

113
Q

advantages to PaO2/FiO2 ratio

A

anesthetist doesnt have to calculate PAO2

this ratio doesnt vary as much with people on supplemental O2

114
Q

Which of the following is least likely to lower a patient’s alveolar PO2?

  • Increase in altitude
  • Elevated PaCO2
  • A left to right intracardiac shunt
  • None of the above
A

-A left to right intracardiac shunt

115
Q

What is the maximum value attainable by adding the values obtained for SaO2, %COHb, and %MetHb from a single blood sample?

A

100%

116
Q

If the PaCO2 and FiO2 of a patient both increase by 50%, what is most likely to happen to their PAO2?

A

increase

117
Q

If both barometric pressure and the PaCO2 of a patient fall by half, what is most likely to happen to their PAO2?

A

decrease

118
Q

At 10:00am, a patient has a PaO2 of 85mmHg, and SaO2 of 98%, and a Hb of 14g/dL. At 10:05am, she suffers a severe hemolytic reaction that suddenly leaves her with a Hb of 7g/dL. Assuming no lung disease occurs from the hemolytic reaction, what is most likely to occur with her PaO2, SaO2, and CaO2?

A

PaO2 unchanged, SaO2 unchanged, CaO2 reduced

119
Q 
Which of the following is least likely to change the PAO2 of a patient?
SaO2
PaCO2
Barometric pressure
FiO2
A

SaO2

120
Q

Which of the following situations would be most likely to lower the PaO2 of a patient?

  • Carbon monoxide poisoning
  • Abnormal hemoglobin that holds oxygen with twice the affinity of normal hemoglobin
  • Anemia
  • Lung disease with intrapulmonary shunting
A

Lung disease with intrapulmonary shunting

121
Q

when is CaO2 reduced?

A

anemia
carbon monoxide poisoning
V/Q mismatch
high altitude

122
Q

what converts CO2 to H2CO3?

A

carbonic anhydrase

123
Q

what are the 3 forms of CO2 in the body?

A

PaCO2 (dissolved in plasma)
HCO3- (dissolved in plasma)
HCO3- (attached to Hb)

124
Q

what % of CO2 is dissolved in the plasma?

A

5-10%

125
Q

what % of CO2 is in HCO3- form in the plasma?

A

60-65%

126
Q

what % of CO2 is in HCO3- form attached to Hb?

A

~30%

127
Q

what % of CO2 is in the form of HCO3-?

A

90-95%

128
Q

normal HCO3-: PaCO2 ratio

A

20:1

129
Q

what can venous labs be called?

A

BMP (basic metabolic panel)
venous chem 7
electrolyte panel

130
Q

what is venous CO2 listed as?

A

CO2 or HCO3-

131
Q

what forms of CO2 are included in venous labs?

A 
CO2 form (dissolved)
HCO3- form (dissolved)
132
Q

venous HCO3- normal value

A

24-30mEq/L

133
Q

what is arterial CO2 listed as? why?

A

HCO3-

because it only includes the HCO3- form and omits the PaCO2 form

134
Q

arterial HCO3- normal value

A

22-26mEq/L

135
Q

If HCO3- and PaCO2 double from their normal baseline values, what is most likely to happen to the patient’s pH?

A

stays the same

136
Q

What does the Henderson-Hasselbalch equation predict will happen if a patient’s PaCO2 increases from 40-60mmHg?

  • pH fall
  • bicarb fall
  • bicarb rise
  • cannot determine
A

not enough information provided

137
Q

bohr effect

A

oxygen being displaced from Hb as PaCO2 rises (right shift of curve)

138
Q

Haldane effect

A

CO2 being displaced from Hb as oxygen concentration increases

139
Q

is oxygenated or deoxygenated blood more affinitive for CO2?

A

deoxygenated

140
Q

what % of shunt do normal humans have?

A

3%

141
Q

what does hyper and hypoventilation refer to? respiratory rate or CO2 removal?

A

CO2 removal

142
Q

hypoxia

A

impaired oxygen perfusion

143
Q

hypoxemia

A

decrease in the blood oxygen content (CaO2)

144
Q

can someone be hypoxemic but not hypoxic?

A

yes if they have increased cardiac output to compensate for low blood oxygen content

145
Q

respiratory acidosis

A

increase in PaCO2 concentration

146
Q

what way does respiratory acidosis shift the lechatliers equation?

A

to the right

147
Q

if when you have respiratory acidosis and you shift the equation to the right and you increase H+ and HCO3- then how does the pH go down?

A

1-the number of H+ increases and the definition of pH is the number of H+ ions
2- PaCO2 increases by a greater percentage
(20:1 vs 21:2)

148
Q

diagnosis of resp acidosis

A

low pH

high PaCO2

149
Q

problem with resp acidosis

A

too much H+ ions

150
Q

compensation for resp acidosis

A

kidney reabsorb HCO3-

151
Q

what is the problem with the compensation of resp acidosis?

A

kidneys reabsorbing HCO3- will increase PaCO2 even more

152
Q

why don’t we treat resp acidosis with bicarb?

A

because it will ultimately raise the PaCO2

153
Q

treatment for resp acidosis

A

increase minute ventilation and lower PaCO2

154
Q

resp alkalosis

A

decrease in PaCO2

155
Q

what way does respiratory alkalosis shift the lechatliers equation?

A

to the left

156
Q

if when you have respiratory alkalosis and you shift the equation to the left and you decrease H+ and HCO3- then how does the pH go up?

A

1- decrease in H+ is the definition of pH so it will increase
2- the PaCO2 decreased by a greater percent than bicarb

157
Q

diagnosis of resp alkalosis

A

high pH

low PaCO2

158
Q

problem with resp alkalosis

A

too few H+ ions

159
Q

compensation for resp alkalosis

A

kidneys excrete more bicarb

160
Q

problem with the compensation for resp alkalosis

A

kidneys excreting HCO3- will cause the PaCO2 to decrease more

161
Q

treatment for resp alkalosis

A

lower the minute ventilation and raise PaCO2

162
Q

metabolic acidosis

A

decrease in bicarb concentration

163
Q

what can cause a decrease in bicarb

A

direct physical loss of bicarb

increase in acid that lowers the HCO3- indirectly

164
Q

what are examples of two indirect ways to cause metabolic acidosis

A

lactic acidosis

DKA

165
Q

why pH decreases in metabolic acidosis

A

1- H+ increases

2- HCO3- decreases and decreases the HCO3-/PaCO2 ration and lowers pH

166
Q

diagnosis of metabolic acidosis

A

low pH

low HCO3-

167
Q

the problem with metabolic acidosis

A

too much H+ ion

168
Q

compensation for metabolic acidosis

A

lungs increase ventilation and lower the PaCO2

169
Q

problem with the compensation for metabolic acidosis

A

it will lower PaCO2 but by doing that it will also lower the HCO3-

170
Q

treatment for metabolic acidosis

A

give bicarb

171
Q

sodium bicarb dose

A

(0.3)(kg)(base excess)

172
Q

A 50kg patient has a base excess of -3. What is the dose of bicarb recommended to correct the base excess?

A

45mEq

173
Q

metabolic alkalosis

A

increase in bicarb

174
Q

two possible mechanisms for metabolic alkalosis

A

1-actual physical increase in HCO3-

2- decrease in the H+ causing indirect increase in HCO3-

175
Q

what are ways to cause direct loss of acid?

A

vomiting
diuretics
gastric drainage

176
Q

when would you have buildup of HCO3- in the body

A

massive blood transfusion

citrate preservative is converted to HCO3-

177
Q

T/F massive blood transfusion can cause metabolic alkalosis

A

true

178
Q

why pH increase in metabolic alkalosis

A

1- H+ decreases

2- HCO3- increases the HCO3-/PaCO2 ratio and increases pH

179
Q

diagnosis of metabolic alkalosis

A

high pH

high HCO3-

180
Q

the problem with metabolic alkalosis

A

too few H+ ions

181
Q

compensation for metabolic alkalosis

A

lungs will decrease their minute ventilation (hypovent) and increase the PaCO2 and decrease the pH

182
Q

problem with the compensation for metabolic alkalosis

A

it will also increase the HCO3- and that is what caused the problem in the first place

183
Q

treatment for metabolic alkalosis

A

try to reverse whats causing it

example: zofran if they have had a lot of N/V

184
Q

normal lactate concentration

A

<2mmol/L

185
Q

lactic acidosis serum lactate concentration

A

> 5mmol/L`

186
Q

when does lactic acidosis occur?

A

when cells receive too little oxygen

187
Q

type a lactic acidosis

A

inadequate oxygen delivery to tissues

188
Q

type b lactic acidosis

A

adequate oxygen delivery,

tissues cannot use the oxygen normally

189
Q

causes of lactic acidosis 4

A

1-sepsis
2-shock/ inadequate perfusion
3-hepatic failure
4-exercise

190
Q

treatment of lactic acidosis 2

A

1- restore normal pH

2- improve tissue oxygenation (perfusion) with fluids and pressors

191
Q

cations in our body

A 
Na+
K+
Ca2+
Mg2+
H+
etc
192
Q

anions in our body

A 
HCO3-
Cl-
Lactate
Proteins (albumin)
Phosphates
193
Q

measured cations

A

Na

K

194
Q

measured anions

A

Cl-

HCO3-

195
Q

Na normal values

A

135-145 mEq/L

196
Q

K normal values

A

3.5-4.5 mEq/L

197
Q

Cl- normal values

A

96-106 mEq/L

198
Q

HCO3- normal values venous

A

24-30 mEq/L

199
Q

in theory should a pt have more anions or cations?

A

they should be electrically neutral

equal number of both

200
Q

anion gap definition

A

difference between the number of measured cations and the number of measured anions

201
Q

two ways to calculate the anion gap

A 
AG= measured cations- measured anions
AG= unmeasured anions- unmeasured cations
202
Q

Anion gap equation from our venous lab values

A

anion gap= (Na+K)-(HCO3- + Cl-)

K+ is usually omitted bc it is so small

203
Q

anion gab normal value (without K)

A

12 +/- 4 mEq/L

204
Q

anion gap will increase if=

A

measured cations goes up
measured anions goes down
unmeasured anions goes up
unmeasured cations goes down

205
Q

anion gap will decrease if=

A

measured cations decreases
measured anions increases
unmeasured anions decreases
unmeasured cations increases

206
Q

elevated/WIDE anion gap is most commonly observed when?

A

there has been an increase in the number of unmeasured anions

207
Q

what are unmeasured anions considered?

A

acids bc they dissociate from H+ and increase the H+ ion concentration

208
Q

How does the anion gap increase if I’m increasing both an unmeasured anion (lactate) and an unmeasured cation (H+)? Wouldn’t the anion gap remain unchanged?

A

1- increase in unmeasured anions (lactate)

decrease in the measured anions (HCO3-)

209
Q

normal anion gap is caused by what?

A

direct loss of HCO3-

GI loss or renal dysfunction

210
Q

why doesnt the gap increase when there is direct loss of HCO3-?

A

it is replaced by Cl-

211
Q

hyperchloremic metabolic acidosis

A

acidosis with an increase in Cl- concentration

212
Q

does hyperchloremic metabolic acidosis have a normal or abnormal anion gap?

A

normal

213
Q

common cause of hyperchloremic metabolic acidosis

A

excess 0.9% N/S administration

214
Q

why does excess N/S admin cause hyperchloremic met acidosis?

A

NORMALLY- Na reabsorbs with HCO3-
but in EXCESS-
Na reabsorbs more with Cl- causing loss of HCO3-

215
Q

low anion gap cause

A

hypoalbuminemia (liver failure) bc albumin is neg charged protein

216
Q

why does the anion gap decrease with hypoalbuminemia?

A

bc you are losing unmeasured anions and increases measured anions (Cl- and HCO3-)

217
Q

3 steps to diagnosing acid base status

A

1- acidosis or alkalosis? via pH
2- respiratory (PaCO2) or metabolic (HCO3-)?
3- compensated or uncompensated?

218
Q

what type of diabetes do people that have DKA have?

A

type I-
lack of insulin= starved cells (even with high blood sugar)
starved cells= fat breakdown and ketone bodies made

219
Q

DKA what happens after ketone bodies are made?

A

sugar in blood goes into renal tubules causing osmotic diuresis
leads to hypovolemia and electrolyte abnormalities and acidosis

220
Q

DKA symptoms

A 
hyperglycemia
acidosis
hypovolemia
electrolyte disturbances
hyperosmolarity
221
Q

can DKA cause hyper or hypokalemia?

A 
acute= hyperkalemia (from acidosis)
chronic= hypokalemia (from diuresis)
222
Q

hyperosmolarity symptoms

A 
cell shrinkage
cerebral edema
altered consciousness
increased blood viscosity
thrombosis
223
Q

DKA treatment 4

A

1 insulin (reverse ketone production)
2 fix acidosis (bicarb as needed)
3 treat hypovolemia
4- prevent hypokalemia

224
Q

insulin treatment for DKA protocol

A

once glucose gets to 250-300mg/dL add glucose to insulin infusion to keep at that level until acidosis corrected

225
Q

glucose insulin infusion=

A

5g glucose added to each unit of insulin

1 amp dextrose per 5 units insulin

226
Q

how to treat the hypovolemia

A

large bore IVS
agressive fluid admin
a line

227
Q

how to prevent insulin induced hypokalemia

A

potassium chloride drip as necessary

228
Q

what is in the ABG synringe already?

A

air and anticoagulant

229
Q

PaCO2 in the air

A

0.3 mmHg

230
Q

Will air in the sample falsely higher or lower the PaCO2 reading? why?

A

lower

bc the CO2 will diffuse out of the blood and into the air

231
Q

PaO2 of blood on 100% FiO2

A

500mmHg

232
Q

PaO2 of blood on room air

A

100mmHg

233
Q

PaO2 in the air at sea level

A

160 mmHg

234
Q

will the air in the sample of a pt breathing room air falsely higher or lower the PaO2? why?

A

falsely higher

because O2 will diffuse from the air to the blood

235
Q

will the air in the sample of a pt breathing 100% FiO2 falsely higher or lower the PaO2? why?

A

falsely lower

because O2 will diffuse from the blood to the air

236
Q

What do we tell the lab when sending a ABG?

A

the FiO2

the pts temp

237
Q

if blood is cold what does that do for the solubility of CO2 and O2?

A

increases

238
Q

if the blood is warm what does that do for the solubility of CO2 and O2?

A

decreases

think boiling water

239
Q

what temp are blood samples measured at?

A

37C

240
Q

what happens if the pts blood is not 37C

A

it will be warmed or cooled prior to measurement

241
Q

cold blood sample will be increased or decreased PaCO2 and O2 readings?

A

increased
bc even though the solubility is decreased bc it is warmed….
it also increases the KINETIC ENERGY and that exerts greater pressure

242
Q

warm blood sample will be increased or decreased PaCO2 and O2 readings?

A

decreased
bc even though the solubility will be increased due to cooling….
it decreases the kinetic energy and that exerts less pressure

Fa: Methods 2 (15 decks)

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