Moh.

Supriatna TS

Pediatric Critical Care Chapter

Indonesian Pediatric Society
 Introduction
• Blood gas : O2, CO2, CO, Nitrogen, Helium (<<), Krypto
n (<<)  sometimes need to be measured
• Poul Astrup (1956) : First blood gas analyzer using Van
Slyke method
• Clinical uses of BGA : to monitor ventilation, oxygenati
on and acid base balance
• Homeostasis of pH is tightly controlled  Extracellular
fluid = 7.4 and Blood = 7.35 – 7.45 to keep optimal cell
ular activity
 >> H+ OH- <<

DEATH DEATH
 Normal Values

Arterial Mixed vein Vein

pH 7,4 7,36 7,36

Range pH 7,35 – 7,45 7,31 – 7,41 7,31 – 7,41
pO2 mmHg 80 – 100 35 – 40 30 – 50
pCO2 mmHg 35 – 45 41 – 51 40 – 52
Sat O2 > 95% 60 – 80% 60 – 85%
HCO3- 22 – 26 22 – 26 22 – 28
Base Excess -2 – +2 -2 – +2 -2 – +2
 Ventilation

• PaCO2 :
– Partial pressure of CO2 dissolved within the arteria
l blood
– Assess the effectiveness of ventilation
• PaCO2 = (VCO2 x 0,863) : Va

– VCO2 : minute CO2 production

– Va : minute ventilation = TV x RR
 PaCO2 and Ventilation Status

PaCO2 Blood Ventilation statu

s
> 45 mmHg Hypercapnia Hypoventilation

35 – 45 mmHg Eucapnia Normal

< 35 mmHg Hypocapnia hyperventilation

 Oxygenation

• Indices used to assess oxygenation :

– PaO2 (Partial pressure of oxygen dissolved within th
e arterial blood)
– SaO2 (Arterial blood oxygen saturation)
– P(A-a)O2 (Alveolar to arterial O2 tension difference)
– PaO2/FiO2 (Arterial to fraction of inspired O2 ratio)
 PaO2
• At sea level, the normal PaO2 :
- Newborn : 40-70 mmHg  with increasing age Pa
O2 increases until adult value of 90-120 mmHg
• Hypoxemia :
– PaO2 lower than the acceptable range for age
– For a child  PaO2 < 60 mmHg
 To Evaluate Acid-Base Disorder

Henderson-Hasselbalch Stewart’s Approach

 Steps to analyze acid-base disorder
(Grogono method 2005)

1. Step 1 : Analyze the pH

2. Step 2 : Analyze the PaCO2
3. Step 3 : Analyze SBE
4. Step 4 : analyze severity  PaCO2 and SBE
5. Step 5 : Compensation
 Step 1 :
Analyze the pH

pH

< 7,35 > 7,45

Acidemia/ Alkalemia/
acidosis alkalosis
 Step 2 :
Analyze the PaCO2

pH PaCO2 Interpretation

< 7,35 > 45 mmHg Respiratory acidosis

(acid ) (acid)
>7,45 < 35 mmHg Respiratory alkalosis
(alkali) (alkali)
 Step 3 :
Analyze the SBE

pH SBE Interpretation

< 7,35 ↓ Metabolic acidosis

(acid ) (acid)
>7,45 ↑ Metabolic alkalosis
(alkali) (alkali)
 Step 4 :
Assess Acid-Base Disorder Severity
disorder Interpretation PaCO2 SBE
(mmHg) (mEq/L)
Alkalosis Very severe < 18 > 13
Severe 18 – 25 13 – 9
moderate 25 – 30 9–6
mild 30 – 35 6–2

Normal Normal 35 - 45 2 s/d -2

Acidosis Mild 45 – 50 -2 to -6
moderate 50 – 55 -6 to -9
Severe 55 – 62 -9 to -13
Very severe > 62 < -13
 Step 5 :
Analyze the compensation

Compensation (+) Compensation (-)

Fully Partial
Pure / simple
compensation compensation

Primary disorder with

compensation

Compensation level  3 SBE for 5 PaCO2

or using the formula
Disorders HCO3 (mEq/L) PaC02 (mm Hg) SBE (mEq/L)

Metabolic Acidosis < 22 (1,5 x HC03 )+ 8 -5

40 + SBE
Metabolic Alkalosis >26 (0,7 x HCO3 + 21 > +5

10+(0,6 x SBE)

Acute Respiratory A [(PaCO2 – 40)/10] +24 >45 0

cidosis

Chronic Respiratory [(PaC02 - 40)/3]+24 >45 0

Acidosis

Acute Respiratory A 24 - [(40 – PaCO25] < 35 0

lkalosis

Chronic Respiratory 24 - [(40 – PaCO2/2] < 35 0,4 (PaC02 - 40)

alkalosis
 Acid-Base Disorder Interpretation
pH PaCO2 SBE Interpretation Compensation

Acid Acid Alkali Respiratory acidosis Partial SBE,

with compensation Normal metabolic comp
ensation

Normal Pure respiratory acidosis Normal SBE,

No compensation
Alkali Acid Metabolic acidosis with c Partial PaCO2,
ompensation Normal respiratory com
pensation

Alkali Alkali Acid Respiratory alkalosis with Partial SBE,

compensation Normal metabolic comp
ensation
Normal Pure respiratory alkalosis Normal SBE,
No compensation
Acid Alkali Metabolic alkalosis with c Partial PaCO2,
ompensation Normal respiratory com
pensation
 Acid-Base Disorder Interpretation

pH PaCO2 SBE Interpretation Compensation

Acid Acid Acid Mixed acidosis unmeasurable

Normal Acid Pure metabolic acidosis Normal PaCO2 ,

No respiratory compen
sation
Alkali Alkali Alkali Mixed alkalosis unmeasurable

Normal Alkali Pure metabolic alkalosis Normal PaCO2,

No respiratory compen
sation
 Example
• pH : 7,15
• PaCO2 : 60 mmHg
• SBE: - 6 mEq/L
Interpretation?
• pH ↓ : acidosis
• PaCO2 ↑ : respiratory acidosis
• SBE ↓ : metabolic acidosis
• Compensation : (-) (acidosis and acidosis)
 Severe respiratory acidosis and mild metabolic
acidosis
 Example
• pH : 7,3
• PaCO2 : 60 mmHg
• SBE : 7 mEq/L
Interpretation?
• pH ↓ : acidosis
• PaCO2 ↑ : respiratory acidosis
• SBE ↑ : metabolic alkalosis
• Compensation : (+)  ?
• Expected compensation :
– PaCO2 ↑ : 60 – 40 = 20 mmHg
– SBE = 20 x 3/5 = 12 mEq/L
• Actual value :
– SBE = 7 mEq/L
Partial compensation
 Severe respiratory acidosis with moderate me
tabolic alkalosis as compensation