ARTERIAL BLOOD GAS ANALYSIS.pptx

ABG exercises and flashcards- Combined Copenhagen and Physicochemical approach

1. ARTERIAL BLOOD GAS ANALYSIS DR UNNIKRISHNAN PRATHAPADAS www.thelaymedicalman.com

2. Questions that an ABG can answer How is oxygenation: is there any hypoxia? Cause? How severe? How is ventilation: any hypercarbia? Any Acid Base abnormalities? Compensation? Mixed?

3. SUMMARY of compensation Facebook page: Anesthesia Info from The Lay Medical Man

4. At the end of the day… Clinical condition Interpret PaO2 with the knowledge of FiO2, A-a Gradient and P/F ratio- PvO2 if needed Interpret PCO2 with the knowledge that, it depends on CO2 production and alveolar ventilation & Dead space ventilation Primary acid-base disturbances: See the pH, PaCO2 and SBE Look for compensation / mixed imbalances Anion gap for metabolic acidosis

5. Case Scenario 1 A 24 year-old woman is found unconcious by some bystanders. The medics are called and, upon arrival, find her with an oxygen saturation of 88% on room air and pinpoint pupils on exam. She is brought into the ER where a room air arterial blood gas is performed and reveals: pH 7.25, PCO2 60 mmHg PO2 65 mmHg HCO3 – 26 mEq /L Base Excess 1.22

6. Case Scenario:1 Acid-base status:• The patient has a low pH ( acidemia )• The PCO2 is high (respiratory acidosis) and the SBE is normal. The low pH and high PCO2 imply that the respiratory acidosis the primary process PaO2/FiO2= 325 , 550-325= 225=10% PAO2=713x0.2-1.25x60=68 pAO2-paO2=3 mm of Hg.. Normal, which tells us that her hypoxemia is entirely due to hypoventilation

7. Sorry.. Foreign ABG There is no compensation happening The respiratory acidosis implies that the patient is hypoventilating . This fact, in combination with the pinpoint pupils suggests the patient is suffering from an acute narcotic overdose. Facebook page: Anesthesia Info from The Lay Medical Man

8. Case Scenario:2 Patient presenting to casualty with tachypnoea, sweating & agitation. He is disoriented and agitated. ABG in RA: pH 7.22, pCO2 24 mmHg pO2 60 mmHg HCO3 8 mEq /L SBE -20, SpO2 96%, CXR: R lower lobe pneumonia and creatinine 2.0.

9. Case Scenario:2 How a good interpretation can help a patient? Patient presenting to casualty with tachypnoea, sweating & agitation. He is disoriented and agitated. ABG in RA: pH 7. 22 , pCO2 24 , pO2 60, HCO3 8, SBE -20, SpO2 96%, CXR: R lower lobe pneumonia and creatinine 2.0. Please use the template to solve this ABG PAO2 = 713 x 0.2 – 1.25 x 24 = 112 A-a gradient = 52 P/F= 300 Metabolic acidosis Pneumonia  V/Q mismatch Gas exchange issues + Metabolic acidosis Hyperventilation-⬆️ WOB Will he tolerate the extra 20% of VO2 demand by respiratory muscles? Facebook page: Anesthesia Info from The Lay Medical Man

10. Case Scenario:3 55 yr old male came to ER with h/o fall. The trainee took ABG sample, value are as follows: pH= 7.36, PaO2 40 mmHg PCO2 = 42 mmHg, SaO2 72%, SpO2 95% SBE = -6 mEq /L  Facebook page: Anesthesia Info from The Lay Medical Man

11. Case Scenario:3 pH= 7.36, SBE = -6 mEq /L , PaO2 40, SaO2 72%, PCO2 = 42 mmHg, SpO2 95%  Metabolic acidosis. Compensation?   PaCO2=SBE marked metabolic acidosis with mild respiratory compensation. Wrong answer Facebook page: Anesthesia Info from The Lay Medical Man

12. Don’t satisfy the criteria for OCD Even stable patients on ventilator can show variability in PaO2 in the range of 2-37 mm of Hg and in PCO2 in the range of 1-12 mm of Hg…should be considered as normal Unnecessary repeating of ABGs will create confusion Facebook page: Anesthesia Info from The Lay Medical Man

13. OXYGENATION

14. Key Step: Oxygenation- any shunt or dead space ventilation? V/Q mismatch is the commonest cause What alters the Ventilation-perfusion match? Dead space is wasted ventilation Shunt is wasted perfusion: No rise in SpO2 with ⬆️ in FiO2, Wide A-a O2 gradient, low PaO2/FiO2 Different diseases have varying proportion of shunt & dead space ventilation: eg ARDS* & emphysema*

15. V/Q MISMATCH : The shunt! Shunt doesn’t affect pCO2 because of the stimulation of respiration by chemoreceptors Shunt fraction Consequence 2-3% Normal 10% Tolerated by a healthy person 25-45% Life threatening: Requires mechanical ventilation, PEEP, recruitment, positioning, FOB and suctioning

16. Key Step: Check the validity of PaO2, look for the gradient & quantify the shunt if present Clinical context Use the Alveolar Gas Equation Know the alveolar PO2 (PAO2) Know the arterial PO2 (PaO2) Find PaO2/FiO2 ratio Quantification of the shunt fraction

17. pAO2 from Alveolar Gas Equation PAO2 =[(P B – PH2O) FiO2 ] – (PaCO2 / RQ) Atmospheric pressure is 760 mm Hg at sea level PH2O is vapor pressure of water at 37°C and is equal to 47 mmHg 713 x FiO2 – 1.25 x PaCO2 The respiratory quotient or respiratory coefficient (RQ) is the ratio of CO2 produced divided by the O2 consumed, and its value is typically 0.8 (RQ = CO2 eliminated / O2 consumed). R is taken as 1 @FiO2> 0.6 P B – PH2O is known as P i O2  713 Simplified as Facebook page: Anesthesia Info from The Lay Medical Man

18. The Alveolar –Arterial Oxygen Gradient PAO2-PaO2 The expected paO2 will be 10-15 mm of Hg lower than that in the alveoli: A-a O2 gradient 10-15 mm in young to middle aged PaO2= 109- 0.43 [age in years] It increases with increase in FiO2 [@FiO2 of 1, 110!) If higher than expected for age, shunt fraction is high Facebook page: Anesthesia Info from The Lay Medical Man

19. The Alveolar –Arterial Oxygen Gradient Hypoxemic respiratory failure with Normal A-a DO2 Hypoventilation** High altitude Fire Inadvertent use of low O2 containing mixtures during anesthesia Hypoxemic respiratory failure with widened A-a DO2 Increased shunt fraction Increased dead space ventilation Diffusion abnormality Low cardiac output and increased O2 uptake Facebook page: Anesthesia Info from The Lay Medical Man

20. PaO2 /FiO2 Normal  500-550 Used to diagnose ARDS (< 200) and ALI (< 300); 300-500 = acceptable Obtained value is subtracted from 550 For every difference of 100, the shunt fraction is  5% Roughly, shunt %: 5005, 30015, 20020 Eg 68/0.4=170 , 550-170=380  20% Facebook page: Anesthesia Info from The Lay Medical Man

21. Case Scenario 4 Patient breathing room air, has PaO2 90 mm of Hg, SpO2 96%, and PaCO2 110 mm of Hg. Check the validity Facebook page: Anesthesia Info from The Lay Medical Man

22. Case Scenario 4 Patient breathing room air, has PaO2 90 mm of Hg, SpO2 96%, and PaCO2 110 mm of Hg. Check the validity (PaO2, PaCO2 values reliable or not?) Apply Alveolar Gas Equation [713x0.2]-[1.2x110]= PAO2 is 18!, but SpO2 is 96. So one among the value is wrong. Facebook page: Anesthesia Info from The Lay Medical Man

23. Case Scenario 4 Patient on mechanical ventilation, has PaO2 150 mm of Hg, FiO2 0.8, and PaCO2 30 mm of Hg. Check the validity and find the gradient. Apply Alveolar Gas Equation [713x0.8]-[1.2x30]= PAO2 is 534. PaO2 is 150. A-a gradient 384 But please remember that the gradient increases with the FiO2 Facebook page: Anesthesia Info from The Lay Medical Man

24. Case Scenario 5 Patient breathing room air. PaO2 125. PC02 50. Please find the gradient? [713x0.2]-[1.2x50]= PAO2 is 86. PaO2 then cannot be 125 Air bubble? MESSAGE: Isolated PaO2 value is meaningless without info about FiO2 and PaCO2- so give enough importance for ’AGE’ Facebook page: Anesthesia Info from The Lay Medical Man

25. Case Scenario 5 Patient breathing room air. PaO2 125. PC02 50. Please find the gradient? Facebook page: Anesthesia Info from The Lay Medical Man

26. CaO2- Oxygen Content Oxygen carried as oxyhemoglobin + dissolved O2 CaO2= [1.39 X Hb (gm/dl) X Saturation ] + 0.003 X PaO2 If Hb=15 g/dl, SaO2 99%, 20.4 ml as oxy Hb + 0.3 ml in plasma 20.7 Anemia : will not affect saturation and evoke physiological adaptations Abnormal Hbs will decrease saturation and decrease O2 content; will not affect solubility and so PaO2 will be normal Facebook page: Anesthesia Info from The Lay Medical Man

27. Case Scenario 6 24 years old male patient rescued from a burning house has dyspnoea- was given O2 6l/min and shows SpO2 of 99%. ABG: PaO2 125 mm of Hg PaCO2 of 35 mm of Hg. Is the blood gas normal? Does he need supplemental O2? Facebook page: Anesthesia Info from The Lay Medical Man

28. Case Scenario 6 24 years old male patient rescued from a burning house has dyspnoea- was given O2 6l/min and shows SpO2 of 99%. ABG: PaO2 125 mm of Hg PaCO2 of 35 mm of Hg. Is the blood gas normal? Does he need supplemental O2? Co-oximetry to find the amount of Carboxy Hb-SpO2 won’t be correct PaO2 will be normal Give O2 Don’t rely on N PaO2 If metabolic acidosis/ disorientation  Mechanical Ventilation Facebook page: Anesthesia Info from The Lay Medical Man

29. Key Step: Check for Mixed Venous ‘Hypoxia’! Decreased Cardiac Output (QT) in the presence of constant O2 consumption (VO2) Increased VO2 (shivering, fever) Decrease mixed venous O2 content: CvO2= (1.39xHbx SvO2)+(0.003xPvO2) Normal: SvO2= 75% SvO2 ~ SaO2-[VO2/Hb x QT] PvO2= 40 mm of Hg In low CO states with continuing O2 extraction, PvO2 will be low Sample from a CVC [if no PAC] can identify low CO states Facebook page: Anesthesia Info from The Lay Medical Man

30. Hypoventilation will cause hypoxia too 1.Hypoventilation  shallow breathing  atelectasis  reduce FRC 2.Hypoventilation  V decrease  overall V/Q of the lung decrease 1+2 = Hypoxia So hypoventilation = Hypercarbia + Hypoxia Facebook page: Anesthesia Info from The Lay Medical Man

31. Also note hypoxia can occur even with normal PaO2 Low Hb- Anemic hypoxia Decreased O2 delivery- Stagnant hypoxia Reduced utilization- Histotoxic hypoxia Facebook page: Anesthesia Info from The Lay Medical Man

32. VENTILATION

33. Key Step: Abnormal production/ alveolar ventilation/ dead space? Abnormality in Production OR Washout

34. Abnormal production? ? Increased production

35. Abnormal alveolar ventilation? ? High or low alveolar ventilation

36. Increased dead space ? Clues to increased dead space ventilation Persisently high PCO2 despite high minute ventilation PCO2-ETCO2 disparity > 5 mmof Hg Increased dead space Pulmonary vascular disease Pulmonary embolism Hypovolemia Low cardiac output COPD ARDS Pulmonary fibrosis

37. ACID BASE IMBALANCE

38. Metabolic and Respiratory acids vs Buffering & Compensation LUNGS 2000mM KIDNEYS 70 mM

39. SBE is a convenient representative of all the buffer systems The concept of Standard Base Excess (SBE) puts all buffers into a single hypothetical system Bring the pCO2 to 40 to negate the effect of respiratory system and assume that the blood is alkaline/acidic now Base Excess/base deficit is the amount of acid/alkali required to return the pH of the blood to 7.4 and hence is the amount of ‘excess base/acid’

40. Further exposing the SBE SBE is the SB of ECF and SBa is that of blood SBE is the perfect parameter as ECF is the vehicle through which AB changes are regulated SBE normal range is +/- 2 mM/L Other measures shown in the ABG like standard pH, standard bicarbonate, buffer base, total CO2 has been given up- no need to learn them

41. So when we arrange it in order, in response to an acid base change First defense : Buffering Second: Respiratory : alteration in arterial pCO2 Third defense : Renal : alteration in HCO3 excretion Facebook page: Anesthesia Info from The Lay Medical Man

42. NORMAL VALUES . Facebook page: Anesthesia Info from The Lay Medical Man

43. ARTERIAL Vs VENOUS BLOOD . Facebook page: Anesthesia Info from The Lay Medical Man

44. INDIVIDUAL ACID BASE ABNORMALITIES AND ‘COMPENSATION’ mm

45. Compensation In respiratory derangements the primary change is in pCO2. Compensation is by kidneys which reabsorb more bicarbonate, which increases the SBE In metabolic derangements, the primary change is in SBE and compensatory changes are provided by the lungs For eg metabolic acidosis make SBE more negative and lungs tries to excrete more CO2 (respiratory acid) to compensate this resulting in a compensatory respiratory alkalosis

46. KEY STEP: ACUTE RESPIRATORY ACID BASE CHANGES Facebook page: Anesthesia Info from The Lay Medical Man

47. KEY STEP: CHRONIC RESPIRATORY ACIDOSIS & ALKALOSIS compensated by renal handling of bicarbonate; hence SBE changes pH return to 2/3 rd of normal Facebook page: Anesthesia Info from The Lay Medical Man

48. Respiratory Acidosis :Causes E.g. if PaCO2 is 60 mm of Hg and cause is chronic respiratory acidosis, then the expected SBE is 0.4 X 20 = 8 mM/L Facebook page: Anesthesia Info from The Lay Medical Man CAUSES Upper airway obstruction Status asthmaticus Pneumonia Pulmonary edema CNS depression Neuro muscular impairment Ventilatory restriction

49. Respiratory Alkalosis Normal in mountain dwellers and pregnant women pH>7.45 PaCO2<35 mm of Hg Generally a poor prognostic sign, when present in critically ill Facebook page: Anesthesia Info from The Lay Medical Man CAUSES Hypoxemia Pulmonary embolism, asthma, pulmonary edema CNS disorders Hepatic failure Sepsis Salicylate toxicity Anxiety- hyperventilation

50. Case Scenario:7 A patient with a long history of COPD presented to the casualty with difficulty in breathing. He was conscious, tachypneic with accessory muscle use. His pH is 7.35; PaO2 is 34 mm of Hg; PaCO2 of 72 mm of Hg, HCO3 37.5 mM/L and SBE is 14 mM/L. He is given 4L O2 by mask and an ABG drawn after 15 mins. Now his pH is 7.30, PaO2 is 70 mm of Hg, PaCO2 of 88 mm of Hg and SBE is 14 mM/L. Analyse these 2 ABGs Facebook page: Anesthesia Info from The Lay Medical Man

51. Case Scenario:7 A patient with a long history of COPD presented to the casualty with difficulty in breathing. He was conscious, tachypneic with accessory muscle use. His pH is 7.35; PaO2 is 34 mm of Hg; PaCO2 of 72 mm of Hg, HCO3 37.5 mM/L and SBE is 14 mM/L. He is given 4L O2 by mask and an ABG drawn after 15 mins. Now his pH is 7.30, PaO2 is 70 mm of Hg, PaCO2 of 88 mm of Hg and SBE is 14 mM/L. Analyse these 2 ABGs RA: A-a gradient-18; P/F-170 He is conscious! Near normal pH. O2 improves PaO2; but PaCO2 increases! Despite a fall in pH, SBE is remaining same! Facebook page: Anesthesia Info from The Lay Medical Man

52. Respiratory Acidosis: effects  CBF and ICP Arrhythmia Hyperventilation Hypoxemia I n patients breathing room air, PCO2 > 90 mm of Hg is not compatible with life If you acutely reduce CO2: accumulated HCO3 will remain Facebook page: Anesthesia Info from The Lay Medical Man

53. KEY STEP: METABOLIC ACIDOSIS Produced by increase in titratable hydrogen ion concentration Diagnosis: pH low and SBE <-5 mM/L, HCO3 <20 mM/L Respiratory compensation is immediate and return pH to one third to half way normal Facebook page: Anesthesia Info from The Lay Medical Man

54. KEY STEP: FINDING THE ANION GAP When all the commonly measured anions are substracted from the cations, the result is a positive value of 12±4 mEq /L Due to unmeasured anions Corrected AG = Calculated AG + 2.5 [4.5-measured albumin in g/dl] Facebook page: Anesthesia Info from The Lay Medical Man

55. WIDE & NORMAL AG GAP ACIDOSIS If AG > 20  suspect ; if > 25 confirmed Some conditions generate anions these are neutralized by bicarbonatebicarbonate falls   AG widens Some conditions lead to loss of bicarbonate this is counterbalanced by gain in chloride gain in chloride exactly matches loss of bicarbonate  AG is normal Facebook page: Anesthesia Info from The Lay Medical Man

56. Metabolic Acidosis : Causes Respiratory Facebook page: Anesthesia Info from The Lay Medical Man

57. Metabolic Acidosis : Causes . Facebook page: Anesthesia Info from The Lay Medical Man

58. Case Scenario:8 A young woman suffering from fever 4 days has been admitted in the ER. She is semi comatose and tachypnoeic. Cool peripheries with BP of 90/30 mm Hg. SpO2- unreliable trace. ABG on RA: pH 7.19, PaO2 100, PaCO2 20, HCO3 8, SBE -17.7. Serum electrolytes Na 140 K 4.5 Cl 100 lactate 10 S creatinine 2.4 Facebook page: Anesthesia Info from The Lay Medical Man

59. Case Scenario:8 A young woman suffering from fever 4 days has been admitted in the ER. She is semi comatose and tachypnoeic. Cool peripheries with BP of 90/30 mm Hg. SpO2- unreliable trace. ABG on RA: pH 7.19, PaO2 100, PaCO2 20, HCO3 8, SBE - 17.7 . Serum electrolytes Na 140 K 4.5 Cl 100 lactate 10 S creatinine 2.4 No oxygenation issue Metabolic acidosis Lungs compensated it by increasing Mv. Pa CO2 20. AG is 37 ( accumulated metabolic acids) Lactate =10 = 10/ 17 is lactate; rest is by accumulation of metabolites from renal failure Facebook page: Anesthesia Info from The Lay Medical Man

60. Metabolic Acidosis : effects Decreased strength of respiratory muscles Hyperventilation Myocardial depression Sympathetic over activity Decreased arrhythmia threshold Resistance to catecholamines Hyperkalemia Increased metabolic demand [N:5% of VO2; in distress 25%] Insulin resistance Facebook page: Anesthesia Info from The Lay Medical Man

61. Metabolic Acidosis and Mechanical ventilation Respiratory effect is hyper ventilation  may not be tolerated by patients with compromised cardiac or respiratory reserve mechanical ventilation may be required in such patients , till underlying metabolic acidosis is addressed When on ventilator, try to mimic the natural compensation; but don’t go < 30 mmof Hg of PaCO2 Facebook page: Anesthesia Info from The Lay Medical Man

62. NaHCO3 Therapy Sodium bicarbonate should probably be administered to intensive care patients with severe metabolic acidemia (pH ≤ 7.20, PaCO2 < 45 mmHg) and moderate to severe acute renal insufficiency The administration of sodium bicarbonate could limit the deleterious cardiovascular, respiratory, and cellular energy effects of loss of bicarbonate . Sodium bicarbonate should be administered carefully as it is associated with a risk of hypokalemia , hypernatremia, hypocalcemia , rebound alkalemia, and water–sodium overload Facebook page: Anesthesia Info from The Lay Medical Man

63. Case Scenario:10 65 years old patient with R MCA stroke, undergoing emergency decompressive hemicraniectomy; known case of RHD on digoxin. Intra operative ABG showing pH 7.5, pCO2 33, pO2 162 (FiO2 0.5), SBE 3.4, HCO3 27.5. Other values: Na 134, K 3.3, Cl 100, HCO3 27. 713 X 0.5 – 1.25 X 33 = 313. 313-162 = 151 is the A-a gradient 162/0.5 = 325 〰️ 15% is the shunt fraction Respiratory alkalosis- uncompensated- as it may most probably be acute..(expected compensation, if it was c/c: 0.4 x 7 = -3) SvO2: should be checked to check if low SvO2 due to low CO is the cause of an increased A-a gradient AG (not needed) = 134+3.4 – 100+27 = 10 = Normal PCO2-ETCO2 disparity was 8  dead space Facebook page: Anesthesia Info from The Lay Medical Man

64. Respiratory Alkalosis : Effects Increased neuromuscular irritability Cerebral vasoconstriction Decreased ICP Increased cerebral excitability Inhibition of respiratory drive Hypokalemia Respiratory alkalosis + abnormal respiratory muscle activity ? High ventilatory demand cautious decision making regarding extubation Facebook page: Anesthesia Info from The Lay Medical Man

65. Case Scenario:9 A 68 year-old man with a history of very severe COPD and chronic carbon dioxide retention presents to the emergency room complaining of worsening dyspnea and an increase in the frequency and purulence of his sputum production over the past 2 days. His oxygen saturation is 78% on room air. Before he is placed on supplemental oxygen, a room air arterial blood gas is drawn and reveals: pH 7.25, PCO2 68, PO2 48, HCO3 31, SBE 6 Pao2/fio2=240, shunt fraction 15%, PAO2-PaO2=13 SBE=0.4 X paCO2= 11.2, Why only 6? Acute on chronic respiratory failure with respiratory acidosis Facebook page: Anesthesia Info from The Lay Medical Man

66. Case Scenario:10 A 65 year-old man is brought into the hospital with complaints of severe nausea and weakness. He has had problems with peptic ulcer disease in the past and has been having similar pain for the past two weeks. Rather than see a physician about this, he opted to deal with the problem on his own and, over the past week, has been drinking significant quantities of milk and consuming large quantities of TUMS (calcium carbonate). On his initial laboratory studies, he is found to have a calcium level of 11.5 mg/ dL,a creatinine of 1.4 and bicarbonate of 35. The resident working in the ER decides to draw a room air arterial blood gas, which reveals: pH 7.45, PCO2 49, PO2 68, HCO 34. SBE=11 On his chemistry panel, the sodium is 139, chloride 95, HCO 34 Facebook page: Anesthesia Info from The Lay Medical Man

67. Case Scenario:10 paO2/FiO2=340—shunt fraction-10% A-a gradient= 14  PaCO2 = 0.6 x SBE=0.6 x 11=47..compensatory Partially compensated Metabolic alkalosis Facebook page: Anesthesia Info from The Lay Medical Man

68. KEY STEP: METABOLIC ALKALOSIS Produced by decrease in titratable hydrogen ion concentration Depress ventilation Facebook page: Anesthesia Info from The Lay Medical Man weaning

69. Metabolic Alkalosis Generally pCO2 wont go > 55; if > 55, indicates severe alkalosis OR combined metabolic alkalosis + respiratory acidosis Usually [HCO3-]   prompt [HCO3-] excretion by kidney; persistence requires additional process to impair [HCO3-] excretion

70. Metabolic Alkalosis: Causes .

71. Effects of Metabolic Alkalosis: Reduced cerebral blood flow Seizures Tetany Reduction in coronary blood flow Predisposistion to refractory arrhythmias Decreased contractility Hypoventilation Hypokalemia , Hypomagnesemia Reduced ionized calcium Promote anaerobic glycolysis  lactate Weaning failure, especially if HCO3 is >35

72. Impaired arterial oxygen content Hypoventilation Micro atelectasis V-P mismatch So assess for the requirement of supplemental oxygen in metabolic alkalosis

73. Additional points- Metabolic alkalosis Depresses respiration  hypoxemia & hypercarbia Effects on PaCO2 are seen only when HCO3> 35 Mm/L Chloride responsive [Urinary Cl- < 15 mEq /L]: Rx is chloride-volume-potassium repletion Chloride resistant [Urinary Cl- >25 mEq /L]: Rx is correction of the cause of mineralocorticoid excess and potassium depletion and Acetazolamide Facebook page: Anesthesia Info from The Lay Medical Man

74. You cant exist alone man; who is behind you? Reduced GFR Chloride depletion Potassium depletion ECF volume depletion Because kidney has a large capacity to excrete bicarbonate and return the plasma level to normal Facebook page: Anesthesia Info from The Lay Medical Man

75. Case Scenario:10 10 years old boy who underwent occipital-C2 fusion for complex Chiari malformation developed stress cardiomyopathy on POD 1. After resuscitating the initial decompensation using milrinone and diuretics, an ABG was taken with FiO2 0.6: PCV- PC:13 , PEEP:8, RR:20 MVe 3.8L/min  PaO2 86 mm of Hg, PCO2 44, pH 7.26, SBE: -7.4. How will you explain the changes? Do you think any change in the ventilatory management would have been more appropriate in this patient? A-a gradient: 373-86=287 P/F: 86/0.6=143; 550-143=407 shunt fraction 20% Acidosis Metabolic Expected compensation: △PaCO2=SBE7.4Expected PCO2-33Present PCO2-44-?

76. .