IMPAIRED BLOOD-GAS EXCHANGE. Intraoperative blood gas analysis
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1 IMPAIRED BLOOD-GAS EXCHANGE Intraoperative blood gas analysis
2 When do you perform BGA Intraoperatively? Informe actual NEVER Routine:Thoracic Thoracic, Cardiac,Neurosurgery Emergency situation Drop in SpO2 Ventilatory problems Circulatory problems
3 Basic physiopathological approach for a simple clinical interpretation 1. Arterial BGA Oxygenation: PaO2 Acid-base status: ph, PaCO2,, CO3H H (BE) Anion gap 2. Central Venous BGA Oxygen saturation: SvO2 PvCO2
4 "# # #$% & ' ( PO2 = 40 PCO2 = 45 PO2 = 100 PCO2 = 40 LOWV/Q NORMAL HIGH V/Q
5 + # ) = + * = +
6 Clinical conditions affecting V/Q Conditions producing shunt effect: Any situation reducing lung volume Atelectasis,, abdominal compresion, obesity,, pleural efussion, pneumothorax, lobar-lung lung colapse, pneumonia. Effect: Hypoxemia Measurement: PaO2/FiO FiO2
7 Awake Anesthesia, spontaneous breathing Anesthesia, and paralysis Spontaneous breathing 48 hrs postop ""#$#%&%'( )##*+,##&#- *./ '
8
9 # %&# *,(# % " # $ % &'( & # " ) '& ' ' *
10 Clinical conditions affecting V/Q Conditions producing shunt effect: Any situation reducing lung volume Atelectasis,, abdominal compresion, obesity,, pleural efussion, pneumothorax, lobar-lung lung colapse, pneumonia. Effect: Hypoxemia Conditions producing dead space: Any situation reducing lung perfusion Pulmonary embolism Hipoperfusion: Low CO Effect: Hypercapnia Measurement: PaO2/FiO FiO2 Measurement: PaCO2
11 Why measuring PaCO2 having EtCO2 Clinical estimation of Physiological dead space
12 Why measuring PaCO2 having EtCO2 Clinical estimation of Physiological dead space 56 () Low CO ) * = 4 + 4
13 Basic clinical approach 1. Arterial BGA Oxygenation: PaO2 Acid-base status: ph, PaCO2,, CO3H (BE) 2. Central Venous BGA Oxygen saturation: SvO2 PCO2
14 Not to forget on ph Normal (physiological( physiological) range: : Acid sources in tissues: -Metabolism -Respiration (CO2) Metabolic acid production: buffered by bicarbonate Excreted by the kidneys Excess acids = reduction in bicarbonate Respiratory acid production (CO2): buffered by the blood Eliminated by the ventilation Excess CO2 (reduced VE) = increase in PaCO2 (not affecting bicarbonate) ph (f) CO3H H / PaCO2
15 Intraoperative disorders 1. Acidosis ph < 7.35 Metabolic: : CO3H reduction < 22 meq/l (BE<0) - Increase of metabolic acids Lactic, ketoacids,, uremia - Bicarbonate loss or reduced production (renal failure) Respiratory: PaCO2 increase > 45 mmhg Both - Increase of CO2 production (rebreathing - Reduced elimination by ventilation Dead Space (hypoperfusion) - Hipoventilation (SB) 2. Alkalosis ph > 7.45 rebreathing, hyperthermia)
16 Intraoperative disorders 1. Acidosis ph < Alkalosis ph > 7.45 Metabolic: : CO3H increase > 26 meq/l (BE>0) - Loose of metabolic acids: :? (kidney( not that fast) - Increase bicarbonate (external infusion) Respiratory: PaCO2 reduction < 35 mmhg Both - Decrease in CO2 production (hypothermia) - Hyperventilation (high VE setting: : VT-RF)
17 Examples )-./0 &1/-2/ &12)-3/ )-3/ '-435 )-./0 &1/-95 &12)-/3 )-/3 '-4/ )-.55 &1/-00 &12)-26 )-26 '-735 )-.55 &1/-/8 &12)-/8 )-/8 ' #
18 Arterial BGA intraoperative Metabolic acidosis (acute( acute) 4) 4 1/:&1;& 1/ 4# < 4)(;32=; 4)(1/ >? $ A &12)< # -AAAAAAAA
19 Mind the gap? Hidden anions: -Lactate -Ketoacids (hyperglicemia) are not hidden anymore Forget the gap
20
21 Basic clinical approach 1. Arterial BGA Oxygenation: PaO2 Acid-base status: ph, PaCO2,, CO3H (BE) 2. Central Venous BGA Oxygen saturation: SvO2 PCO2
22 Hypovolemic-hypodynamic early phase Circulatory insufficiency: Low CO Hipovolemia Miocardial depression Vasoregulatory alteration Hypoperfusion Tisular ischemia Macrocirculation O2 Supply O2 Demand Flow maldistribution Tissue hypoxia
23 Reliability of SvO 2 as an indicator of the oxygen extraction ratio (O 2 ER) demonstrated by a large patient data set Keech J, Reed RL. J Trauma : Circulatory failure Low SvO2
24 Normal SvO2: 70-77%
25 60 patients intra-abdominal abdominal surgery >90 m Shoemaker's criteria 2, ASA> 2
26 Abdominal surgery: 36 restrictive fluid-gdt (6 ml/kg) 34 standard fluid-gdt (12 ml/kg) GDT preload optimization for SvO2>71% CO/SV (doppler( doppler): fluid boluses of 250 ml HES Measurement: PvCO2 PaCO2 = Pv-aCO aco2
27 Rationale 7 )) 38#,#&)4 #)# Applied to CO2 Pv-a a CO2 = VCO2/CO Respiratory quotient =VCO2/VO /VO2 VCO2 = RQ x VO2 Pv-a a CO2 = VCO2/CO = RQ x VO2/CO
28
29 When target DO2 is already reached Pv-aCO aco2 may detect further tissue flow defects
30 Summary: Intraoperative BGA Rutine: High risk surgery/emergency Do not wait for problems Arterial BGA: Oxygenation: : P/F: lung volume/colapse/ /colapse/recruitment Acid-base status: ph,, PCO2,, BE Ventilation: High VT, low Tº: Respiratory alkalosis Circulation: Low CO + High VD/VT Respiratory acidosis (+low EtCO2) Metabolic acidosis (+ lactate) Central venous BGA: SvO2: Low PvCO2-PaCO PaCO2: High Low: Hypoperfusion High:HypoperfusionHypoperfusion
31 Muchas gracias por vuestra atención
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