Interpretasi

Analisis Gas Darah (AGD)

Pelatihan Perawat PICU/NICU

Maret 2014

Divisi Pediatri Gawat Darurat

Departemen IKA FK Undip/RSUP Dr Kariadi
Semarang
 Pendahuluan
Blood gas: O2, CO2, CO, Nitrogen, Helium (<<),
Krypton (<<) sometimes need to be measured
Poul Astrup (1956) : First blood gas analyzer using Van
Slyke method
Clinical uses of BGA : to monitor ventilation,
oxygenation and acid base balance
Homeostasis of pH is tightly controlled Extracellular
fluid = 7.4 and Blood = 7.35 7.45 to keep optimal
cellular activity
 >> H+ OH- <<

DEATH DEATH
 AGD apa yang dinilai?

Oksigenasi
pH
PaO2
Asam basa SO2
PaCO2 Ventilasi
HCO3
Nilai normal gas darah
 Oxygenation

Oxygenation process analyzed by :

PaO2
PaO2/FiO2
AaDO2
 Oksigenasi
PaO2
SO2
Pada FiO2 ruangan (21%) PaO2 100
PaO2 FiO2 x 5
Data lain yang Bila pasien dg VM : FiO2 40 pada paru
normal PaO2 200
dibutuhkan:
Dst ..
- FiO2
- Hb
- PIP PaO2/FiO2:
- Normal?
- PEEP
- ALI/ARDS?
 PaO2 = FiO2 x 5
AaDO2
PAO2 = PiO2 1,2 x PaCO2

CaO2 = (1,34 x Hb) + (0,03 x PaO2) mL/dL

 Gangguan oksigenasi

Ada gangguan supply O2

Ada gangguan di paru2 yang menyebabkan
perbedaan tekanan parsial O2 alveoli dengan kadar
O2 arteri meningkat O2 tidak dapat masuk arteri
misalnya pada HMD, ARDS
Ada gangguan kandungan O2 dalam darah (lihat
rumus CaO2), misalnya keadaan Hb
 Ventilasi

PaCO2 :
Partial pressure of CO2 dissolved within the
arterial blood

PaCO2 = VCO2 x 0,863

Va
VCO2 : minute CO2 production
Va : minute ventilation = TV x RR
PaCO2 and Ventilation Status
 Acid-Base balance

BGA determine the type of acid-base disorder

Respiratory Metabolic

Based on Based on

PaCO2 HCO3 BE/SBE SID

 H-H (Traditional approach)

based on :
the centrality of H+ concentration

dependence on the concentration of whole-
body buffers as represented by bicarbonate
and carbonic acid
 HCO
Normal
BASE
[HCO 3]
RENAL
- HCO3
3

pH = 6.1 + log COMPENSATION

Normal
pCO
LUNG
ACID
2
CO
CO22
 Stewarts Approach
Concept dependent and independent variables
in acid-base homeostasis
2 VARIABLES

INDEPENDENT DEPENDENT
VARIABLES VARIABLES

H+ HCO3-
CO2 STRONG ION WEAK ACID
DIFFERENCE OH- CO3- A- AH

pCO2 SID Atot

 Strong Ion Difference
Mg++

Gamblegram
Ca++
K+ 4 HCO3-
24 SID
Weak acid
(Alb-,P-)

Na+
140
Cl-
102

KATION ANION
 STRONG ION GAP
Kellum JA, Kramer DJ, Pinsky MR: Strong ion gap: A methodology for exploring
unexplained anions. J Crit Care 1995,10:51--55.
SIG
Mg++
Ca++

K+ 4
SIDa HCO3-
SIDe
A-
Lactate

= [Na+] + [K+] + [Mg++] + [Ca++] - [Cl-] [Lactate-]

Na+
12.2pCO2/(10-pH Cl-
)+10[alb](0.123pH0.631) +[PO4](0.309pH0.4

SIG = SID a SID e Normal value = zero

If SIG > UA
KATION ANION
The difference between Anion gap and SIG albumin
 Metabolic disorder
in Stewarts Approach
abnormal SID :
Fluid >> (Na + SID ) dilutional acidosis
Fluid << (Na + SID ) contraction alkalosis
Anion imbalance :
hiperchloremia SID
hipochloremia SID
weak acid disorders :
Hiperalbumin &hiperphosphat acidosis
Hipoalbumin & hipophosphat alkalosis
 Dilutional Acidosis

Plasma

1 Liter 140/2 = 70 mEq/L

Na+ = 140 mEq/L H 2O 102/2 = 51 mEq/L
Cl- = 102 mEq/L SID = 19 mEq/L
SID = 38 mEq/L 1 liter 2 liter

SID : 38 19 = Asidosis

George, 2003
19
 CONTRACTION ALKALOSIS
Diuretic
Diabetes Insipidus
Evaporation

Plasma
Plasma

Na+ = 140 mEq/L

Cl- = 102 mEq/L
140/1/2 = 280 mEq/L
SID = 38 mEq/L
102/1/2 = 204 mEq/L
1 liter liter
SID = 76 mEq/L

SID : 38 76 = alkalosis

George, 2003
20
 Abnormal SID dan Weak Acid

K
Mg SID
SID
Ca SID = 34 SID
SID SID
Alb Laktat/keto
PO4 Alb/
Alb Alb
PO4
PO4
PO4
Alb
Na PO4

140

Cl Cl CL Cl Cl Cl
102 115 95 102 102 102

Normal Hyperchlor Hypochlor Keto/lactic Hyopophosphat Hyperphosphat

acidosis alkalosis acidosis /hypoalbumin /hyperalbumin
alkalosis acidosis

George, 2003
Steps to analyze acid-base disorder

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
 Steps to Blood Gas Analysis
1. Step 1 : Analyze the pH
pH

< 7,35 > 7,45

Acidemia/ Alkalemia/
acidosis alkalosis
2. Step 2
Analyze the PaCO2 (Respiratory component)
Match the PaCO2 with the pH
If pH < 7,35 (acid) and PaCO2 > 45
(acid) respiratory acidosis
If pH > 7,45 (alkalosis) and PaCO2 <
35 (alkalosis) respiratory alkalosis
consider mixed disorder (with metabolic)
if there is compensation mechanism
3. Step 3
Analyze the SBE (metabolic component)
Match the SBE with the pH
pH (acid) and SBE (acid) metabolic
acidosis
pH (alkalosis) and SBE (alkalosis)
metabolic alkalosis
consider mixed disorder (with
respiratory) if there is compensation
mechanism
4. Step 4 : Assess Acid-Base Disorder Severity
5. 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
 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 : (+) ?
 Predicted 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
metabolic alkalosis as compensation
Thank You
 Contoh kasus
Anak laki2, 7 bulan , dirawat di PICU dengan
diagnosis DSS, syok refrakter cairan, DIC dan
gagal nafas.
Setelah dilakukan pemasangan ventilator
mekanik dilakukan evaluasi dengan
pemeriksaan AGD dengan hasil sbb:
 Hasil AGD I
Temp : 36,6
Hb : 5,6
FiO2 : 60%
pH : 7,16 Oksigenasi?
pCO2 : 29 mmHg
Ventilasi?
pO2 : 179 mmHg
HCO3- : 10,3 mmol/L
Asam Basa?
BE : - 18,4 mmol/L
SaO2 : 99%
AaDO2 : 214 mmHg
 Hasil AGD II
Temp : 36,2
Hb : 10,6
FiO2 : 60%
pH : 7,4 Oksigenasi?
pCO2 : 38 mmHg
Ventilasi?
pO2 : 178 mmHg
HCO3- : 23,5 mmol/L
Asam Basa?
BE : - 1,3 mmol/L
SaO2 : 100%
AaDO2 : 208 mmHg