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Okay. Um, so just going to talk briefly. Bite. Um, our tail. Blood gases. So interpretation off gases untouched. A little bit on arterial lines. I know you talked earlier about hard Teo set up for a tier lines. No, I'm not going to teach you today how to do one, but you might see them done. And recess is under certain circumstances. So just just a brief run. Three of why patients might need arterial lines on a little bit of a technique. And if it is something that anyone specifically wants Teo learn or school, they want to choir that it would be something to speak and maybe two. Neither one of the loss of life. But we'll have a beach at three biggies. My in a way. So, um, so we're gonna talk through hard to interpret neighbor G a step wise approach just to make sure you don't miss anything. And then I'm gonna be forcing you to answer more questions again. So apologies and events. And so my basic approach to a biggies. Um, first of all, the most important thing to know is what's the context of your ABG? So what is your patients presentation. Why are they here? Um, without that information, it's just a pilot. Um, bridge. So understand? What? What? Your patient is something with amounts of this place to start. Um, so just looking through your gas itself. So fresh Will ph. Data. So is this patient acidotic alcoholic or with a normal range? So, um, 7.35 to 7.45 is our normal range. So less than 7.35 there acidotic and more than 7.45 there. Athletic. Um, next thing in your gas is gonna be there. Auction service. So and the normal range on the remainder is somewhere between 10 and 13. Um, but obviously, if a patient is on 10 liters, I a face mask. Although, uh, one option level of 10 to 13 is technically normal. This would not be what would be expected. So a general rule of thumb of trying to understand what expected oxygenation would be for these patients is 10 kill past ALS under the f i 02. So if you're giving a patient he's on and 40% action, you would expect for normal auction a shin there auction should be at least 30 killed. Skills. Um, so that's pitch on auction. Reviewed back, Do you want to know is what their carbon dioxide is up to. So particularly if you're patient you've already find is hypoxemia um so normal range for your carbon dioxide is 4.7 to 6. So if you find the patient who's hypoglycemic depending on what their OT is, you want to understand if they're type one or Type two spirits radio or so parks here with a normal So two that's are type one respiratory failure is That's what we're classically seeing in, um, in our population and then our type two spirits. Bayer's are high pox here with hypercapnia, so you're so you to use more than six. Um, classically. Your type two. You're spiritually years is your bad COPD years. But there is lots of other causes, so if you understand the the physiology behind it, so alveolar hyperventilation. Then you can understand that that could be from COPD. It could be from respiratory depression. So if a patient's taken the produce of opiates and or anything that reduces lung compliance, that could be a viral effusion. Could be rib fractures and you know, it could be mechanical causes a swell. So it's not just the day. And so I'm actually to look at is there bicarb? So that's one of your major side ph buffer. So our normal range is 22 to 26. Um, on it's it's really produced. So a lot of the time you'll see with your patients with, um, chronic renal failure, they'll run probably low bicarbonate. Um, until that since stage for stage five is a compensation. So, um, from that point of these work died, are they acidotic what their primary issue is, if if there's acutely or probably being compensation for it. So I'm just going through the classifications so spiritually acidosis to pass a patient with a low pH on the primary, actually causing the restriction acidosis is a high. See you too. So again, in the context of COPD patients, what your sometimes see is they have a high so two from their attempt to respiratory failure. But actually their pH is normal. When you look at their bicarbonate, they run chronically with the bicarb in the mid 30. So this is because of the chronic nature of their sex type two respects failure. There they're buffer has basically been increased by the kidneys to compensate for the acidosis being caused by the HAE. See you, too. So in terms of compensation for respiratory acidosis, alkalosis because that takes longer to change. Often you will not see that a kid like so that gives you an indication that if there's been compensation, it's a chronic respiratory problem, Um, within the context of metabolic acidosis or alkalosis. So, um, specifically, let's talk about metabolic acidosis. So these patients who have a low bicarbonate, what you'll see quite often, for example, in DKA patients coming in with customer breathing, rapid respiration on what's happening there is that they are trying to blow off Coton the way to normalize the pH. So if they get rid of their CO2 will help to bring back the pH with a normal range. And so the last thing I would look at it is just the other. But some of the ABG so the things we don't want to miss, So don't ever forget to get your glucose. Um, even in patients, you might be coming in with other reasons. It's always relevant. Um, I always look at your lap. Take it and I always have your base access. There was I was out when I see a couple of months ago, we had a patient came in with a little g, see estro, see vomiting. Seizures came in a sense of query head injury because they lived, Um, they look low and they were fine. But the bottom of the stairs with soul, so was the story. It was only the next morning and I see you. We realized that there by that they're Kobach. See him A global was actually 30 which is, um, so really abnormal, but just haven't been addressed because it says right the bottom of our blood gases and isn't always picked up. So that ends up being a welfare check to make sure no one else was in the heist on making sure there was no one else collapse at the bottom of stairs. Eso always consider your carboxyhemoglobin, particularly patients presenting with, um, Luigi CS on The last thing to think about is your ana and Gap. So this is especially helpful for patients. If you've worked out from the rest of the CT or sorry, the ppd. And they're in a matter bolic acidosis if you've worked out. But if you calculate there and I and Gap, it might help me in terms of your differential diagnosis. Um, so simple way to calculate your Ana and Gap is your sodium minus your chloride bicarb. That's a normal range varies a little bit, depending on your creation, but it's usually somewhere between four and 12. Um, okay, back to the quiz questions. So we've got a 64 year old man history CVD, for something with worsening shortness of breath, increased sputum production. So he's got a pH of 7.21, a beauty of 7.2 a p c 025 bicarb of 31. Um, his values otherwise are within normal range. So if we think through our step wise approach, um, what do we What do you think? This mountain has so acidosis around? Hallucis. So he's acidotic absolutely stories with spirit to acidosis and type two years, which will then that's That's exactly right. So, um, so what you're saying there is? Yes, Ph is having to go on to his acidotic his his hypoxia back, and he's hyper Kapidex that's your type. Two years. But it's really know what you can see with this gas is that his bicarb is 31. So that's exactly what we're talking about before that. And that's attempted compensation. But it's been in complete because he still has an abnormal. PH and CSO is diagnosis is type two. Your speech right here on this is important to understand for his management, because it's going to affect how much oxygen you give him and if he need to consider for the therapies like noninvasive ventilation. Um, so here is another one free. So again, always understand the context of your ABG. So this guy is 32 no known past medical history. And then he comes and he's been falling, collapsed by his girlfriend. So going through your step wise approach again. What? What are we looking at here? So is yeah, acidotic around block. And what do we think? Our primary sources for that this guy's got quite a profile and acidosis, um, on the left in through his numbers, his C o. T. Is actually on the low side, so that wouldn't really quaint for it. So if you look in his bicarb by carbs. Very low doses by carbs, only 11. So this looks like a primarily metabolic acidosis. Um, again, attempted respiratory compensation. But it's incomplete. Yeah. So Declan is nailing it here, so, Yeah, there's metabolic acidosis on respiratory compensation. But as I was saying, this would be in complete compensation because he hasn't actually managed to normalize is P. H m. So what is the next step for this man? What's going to help you work out? What's wrong with this with this patient? So next step for this guy is is that I got to you go over to and he killed because you never remember what the equation is and you type in your numbers. I'm not for you here. And so his aunt and Gap is 24. Um, so this, as I said, helps in terms of trying to require it. Warts caused this this patient's metabolic acidosis. So he has a hi, and I'm deaf. Metabolic acidosis. So generally is coming from, um, increase, um, ingestion or production of acid, or inability to clear acid. Um, so in terms of his differential, you're going to start thinking about things like DKA has he got a lactic acidosis from a source. And but particularly in a young, otherwise healthy patient, you're gonna worry about congestion. So is this state poisoning? Is this methanol? Ethanol? Um, if this is ah, on older patient with a lot of former better days, you might think about something more like renal failure and uremia. Um, so that is Ah, just quick wit was it's up to her babies. Thank you for your participation in that touch very briefly. Just on, um, on our minds before you finished, if that's okay. As I said, I'm not here to teach you how to do them, but just helps elliptical. If and if we have a second patient on, does that actually coming down and they've asked for an art line or they're putting one in. It's helpful for us any d to be able to help them else to first understand why they might be doing it. So I think probably the most common reason you'll see them in, in, in in any setting is for patients who are very unwell. You're needing a continuous He would die. Not like monitoring these air. You're, um, septic patients. We haven't responded Teo, Initial treatment to your know I requiring, um, face oppressors, right? Attribute support? Um, more the other case in the D commonly would be patients needing tight BP control on Montel Drink. So these would be your brain injury patients, certain stroke patients or spinal injury patients? One of the other indications have put here, although not really relevant US is anticipated hemodynamic instabilities with someone who's having major abdominal surgery. But that's not usually our problem in the the other reason you might see it, although frankly, with school and we haven't been having to deal with too much of this in the d itself is for cereal sampling for patients with, um, your spirit, you failure here being titrated on mechanical ventilation. So, um, right back of the star of Cupid In terms of our surgeon planning, we did consider the possible and search kind of having a mechanically ventilated cool patients any D and no, that hasn't happened, which is which is great. But that would be another common reason why we would have had heart lines and patients upstairs. Um, so just a quick overview of sort of things also, um, in terms of our line insertion. So what you'll see in terms of technique probably will vary a little bit. But there's two different techniques over the needle is basically an same as venous cannula, uh, venous cannula. And but probably more commonly, you'll see seldinger or over the wire technique. So you have an introducer needle, and once you get your arterial flashback, him a guidewire is. But and then your introduce years removed, and then your arterial line is through out of the top of that. So that's probably the technique you'll see most commonly, um, and again technique. In terms of landmark fresh is ultrasound will depend a little bit on user experience. So, um, so traditional technique would have usually being landmark. But, um, side is being used more commonly, and I, and certainly within a nice see you setting is proven. Teo increase 1st, 1st past success. Um, although that's not as proven a needy, but definitely helpful. So you may see the side team ourselves, using all side for guidance for for the double ones. But And as I said, hopefully I you around three a little bit this morning as a higher dose of it up from the national side of things. Um, and for the doctor's side of things, that would be something that one of the consultants or calisthenics would be deciding, rather than really are spells easily. And any questions about our lines before I finish? We're also about the, um, ABG interpretation is, well, those goods. And I think so. Actually, I think I was. That was server. Just stick with rouge on the best place is not for you. Find that helpful. Um, well, you can go understand. That was Bob.