75 year old lady presented to the emergency department after a fall. In ED she was found to be slightly febrile with blood pressure of 95/55. Part of the investigation performed was LFT and it showed the following:
Bilirubin = 101 umol/L (< 16)
75 year old lady presented to the emergency department after a fall. In ED she was found to be slightly febrile with blood pressure of 95/55. Part of the investigation performed was LFT and it showed the following:
Bilirubin = 101 umol/L (< 16)
Question 1:
PH = 7.599 That is moderate alkalaemia (very close to the severe range – Moderate alkalaemia is PH between 7.5 – 7.6. Severe alkalaemia is PH > 7.6).
PCO2 = 22 mmHg, that is low. So we have respiratory alkalosis.
Next step is compensation.
42 year old alcoholic man, with type 2 DM. Presented with alcohol withdrawal symptoms. His blood gas (VBG) showed the following:
PH = 7.599
PCO2 = 22 mmHg
Answers:
PH = 7.24 that is moderate acidaemia.
HCO3 = 16 mmol/L, so we have metabolic acidosis.
Next, we need to calculate the anion gap and the compensation.
54-year-old asthmatic patient presented with multiple episodes of vomiting. Her pulse-rate was 110 and blood pressure was 96/54. Her blood gases showed the following:
PH = 7.24
pCO2 = 33 mmHg
Question 1:
PH = 7.32 ( less than 7.35) so, we have mild acidaemia.
PCO2 = 48 mmHg ( on arterial blood gas > 40), so we have respiratory acidosis.
Next step, is to calculate the metabolic compensation. Since the condition is acute, we expect the HCO3 to increase by 1 for every 10 PCO2 above 40. Accordingly, expected HCO3 is 24.8. That is very close to 24. So there is no additional metabolic process.
Other findings
Mild lactataemia which can be attributed to dehydration or salbutamol therapy. K = 3.4 (can be also related to salbutamol therapy).
Question 2:
Respiratory acidosis in asthma is a critical situation (severe/ life threatening asthma – even if the acidosis is mild).
This patient should be moved to a resuscitation bay, we should inform the emergency consultant and ICU team. Request the help of anaesthetic team for fast rapid intubation.
Start treatment immediately. (Hit it hard and hit it fast), our aim is to prevent intubating this patient.
Treatment:
Non-invasive ventilation in severe asthma help to:
Ultimately, NIV in asthmatic patient help in the correction of PH and improves ventilation at a lower pressure than that needed for mechanical ventilation and it reduced the need for intubation.
BiPAP setting:
If the above measures fail then we need to proceed to intubate this patient. For intubation, we use Ketamine as the sedating agent and the intubation should be performed by the most experienced doctor available.
32-year-old man presented to ED with an exacerbation of his asthma. On 3L O2, his arterial blood gases showed the following:
PH = 7.32
PO2 = 101 mmHg
Answers:
Question 1 answer:
PH = 7.315, that is mild acidaemia.
pCO2 = 48 mmHg. For venous blood, pCO2 level up to 48 mmHg is considered normal (40 for arterial blood).
65 year old lady with history of progressive supranuclear palsy presented with aspiration pneumonia. Her venous blood gases showed the following:
PH = 7.315
pCO2 = 48 mmHg
pO2 = 48 mmHg
Answer:
Volume = 15 ml. Still significant, Normal amount of synovial fluid in a knee joint is 0.5 to 4 mls. Knee joint can accommodate volume to about 100 ml.