Data Interpretation: ABGs Video
Summary
This on-demand teaching session is relevant to medical professionals and covers arterial blood gases with case studies and tips on how to read them accurately. It discusses the basics of an acidyme and alkalemia, the importance of oxygen levels, and the components of the blood gas, including the base excess/deficit. It also covers metabolic acidosis and the anion gap, providing two different methods to investigate a metabolic acidosis. Join this session to learn the tips and tricks necessary to accurately interpret arterial blood gases.
Learning objectives
Learning Objectives:
- Identify the components of an arterial blood gas.
- Explain the signs and symptoms of metabolic acidosis.
- Calculate the normalized anion gap and interpret high or normal anion gap metabolic acidosis.
- Explain the difference between alcoholic ketoacidosis and diabetic ketoacidosis.
- Summarize the epidemiology and physiologic effects of pancreatitis and its associated risk for diabetes.
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Thank you. Okay, so hi, guys are able one of the cough under six PM Siris on today we're gonna be covering arterial blood gases. So let's get started on federal. Do you got socials, which will come back through towards the end if you haven't already done so please join our instagram Facebook on Twitter Page is how we can keep everybody up today. And it's how we make sure that we get a smelly people on as we need so we can keep expanding, giving you guys get free content were sponsored by the MG youth. So if you haven't already, uh, please have the look of the cure link on the on work. Know, without the MD, you wouldn't have been able to start a big investments The beginning on sponsored, uh, since the beginning on helped us get on all feet so that we get sort of provide these free content for you and sponsorships so important for us. So again, if you want to have a chance of getting some freebies such a PSA revision cards and a few other things, uh, have, like, a cure link on the right below and joined the MG because you do need some medical legal legal advice when you're an F one F two or is doctor in general. So just to set some ground rules in terms of arterial blood gases and known little bit about them and how to read them. So when we discussed pee hate, I don't want to hear all closest acidosis. The ones I want to be hearing is acidemia alkalemia. So the correct terms are when you're referring to the pH over ph of a bug us you're talking. You mentioned that, uh, the pH is no one of the acidy Make one of the alcohol. The next thing to look at would be the partial pressure of CO2 in regard to sort of ventilation. So is it high? I Are they retaining or is that increased production for whatever reason? Or is it lower day blowing it out forward? A reason Then you'd be looking at the partial pressure oxygen. So that's only on a tear your blood gas. So is that high I other high proxemics or is it low? Are they high proxemics and two Interpret that in contact. You always have to have the oxygen amount that there aren't always on a BG document. How many liters of oxygen narrow or what? The percentage is even better. Come back to that later. Next, looking at the bicarb component, that's the metabolic component, but that's no higher where it's compensating for something. Uh, and another way of looking at the bicarbonate is the base excess will deficit did both doing the same thing. So based Xeloda deficit is the amount of bicarbonate that's work, y it, or the amount that you need to lose to get a neutral pH of 7.4. And it's just another way of looking at the bicarbonate bit more strictly on don't forget the rest of the blood gas. There's lots of electrolytes, there's laxity and a few other things that you could look at on. The help provide you clues and tips as to what's going on with a patient. So but just remember, in terms of pee hate, it's a local redness scale. So, uh, in terms of change in one in Ph is equal to change by a multiple of 10, and then a change in two pH is is a change by ah 100. So it's a logarithmic scale. So the larger changing the pH sort of the larger the change in the hydrogen ion concentration. So by that, what I mean is safe. A patient has, uh, a ph of seven point free. Initially, if that has to a 7.1 or 7.2, it's not that. It's just, you know, changed by a factor of 0.1. The Hytrin I I am concentration, a significant change there, more acidotic than they think you are. Because the pH changes on the log arrhythmic scales. I just want you to remember that again. We talked about this one, referring to blood pH always referred to as a demon. And when you're referring to a process country beating to a pH change, whatever that is, whether that's something that's compensating what that's another process in the background, it should be referred to as a dose is on and, uh, come back to send those towards the end. So without further ado, we're going to get started immediately. So case want a 30 or gentleman presents to a any would five days history of worsening nausea and vomiting, mild non specific abdominal pain. He has a history of alcohol access with previous bouts of alcoholic pancreatitis with complicating episode of pancreatitis. Uh, necrotizing pancreatitis previously has examination is noted below on his blood gas results can be seen below. So what is the most likely cause of his blood gas on the mallet ease and popped up all the So you. But I think it's gonna make you pop the pull up your log been us there. So I think some people are experiencing an issue with the password. I'm gonna trying to troubleshoot that or fix that. Um, I think, Ah, we might be at our 100 issue again today 100 again? Yeah, definitely. Shouldn't be the case. We've got maximum 1000, but we'll have a look at the same time. I'll take the colon. They got any of your friends trying to log in. I'm gonna put the past code in here is Well, uh, it's normally not going to ask for that. You know, we've got a passive about 1000. Oh, look. Yeah, we should be fine. Okay? Yeah, Brook. Okay. So, uh, let's have a little look at what most people answered. So most people have answered. See, alcoholic keto acidosis on that is the correct incorrect answer. So well, come on, toe. Why that is so. The answer is diabetic ketoacidosis, even though I haven't given you to keep him on, will come into why in a second, so the clues hair is so This is a patient who's had a previous history of multiple bouts of pancreatitis, which predisposes a patient to a type of diabetes because of pancreatitis from recurring damage. Now, in regards with history, yes, he's got history, Are cracks, is yes, he's got a history of pancreatitis. But when you can't ignore in hairs, examination finding is that he's got a blood sugar of 30 which is not explained by a colicky to acidosis low the hyperglycemia upon stores. Something else, something else also going on in the background. Eso he's got a low pH of 7.2. He's got a B M of 30. The only thing that I haven't given you is the key toes on. In terms of a diagnosis of DKA, you need free things, so you need either a PhD lessons and treat or a bicarb of last 15. I need blood, Cokie times more than free or you read a urine ketone more than plus two on a blood sugar more than 11. He already needs two of those components on. He's got this unexplained US asa. He's got this unexplained acidosis in that, even though his lack it's a little bit raised, it doesn't explain why that base deficit is so huge and why you so acidotic that likely is no large enough for that. So the answer is diabetic ketoacidosis, alcoholic. Eat ourselves. This is a good four, but it doesn't explain the blood sugar. And also with his history of bouts of pancreatitis, he's at risk of diabetes secondary to expand it slightest. Uh, so let's break down the blood gas so it's a matter Bolic acidosis. So in terms of a summary, it's an acidity. Me, a secondary to a matter. Folic acid doses with failed Risperdal compensation that cannot be completely explained by the raised lactic, and we also note globally low electrolytes. So in terms of hairs, Ph. Again. When you look at it, it's 7.2, which is low. So it's an acidy me up, not an acidosis. In terms of his partial pressure of two. Uh, that is slightly low. Apologize for that. So it's low because of the high risk. Spiritually, right? So there's a respiratory alkalosis school, which is likely a compensate very process for that low pH in terms of the base death s deficit or the low bicarbonate that suggests it's the most deranged component off the blood gas. That's a just a metabolic acidosis. And again, when you look at the lesser electrolytes, is probably nutritional and vomiting related. In terms of the lactate, it's increased. But it alone as 2.5 doesn't explain it, sort of the total based deficit. So as a generic rule on this isn't a hard and fast as a generic cool. If you multiply the black thing by two, and if it's not equal to or more than the base deficit, it can't completely explain the base deficit that's going on for metabolic acidosis. So if you multiply it by two in this case, which is five five on the base air deficit is minus 10. It's about half the base deficit, which means that's roughly about a base deficit of five that we can't explain the lactulose. It is another metabolic component government in this case. It's the ketone is when we when we asked for them to be tested so a little bit about matter. Bolic acidosis. So in clinical practice, the most common causes other metabolic acidosis are a lactate key tones. Hypochloremia, which is known as you know, a cause of the normal on a gap Acidosis, will come back for that later on in a car and CKD related to your area and a mixture of lactic clinical practice. That was the four most common things that you cannot come across in the metabolic acidosis. Now we want to look at things a bit more deeply, such as an I see you or am you to further investigate. The cause is we calculate something called the a non gap, which sometimes you would have come across so that can be used to exist, to assist with diagnosing, of course, specifically for a metabolic acidosis to know. And the way it's calculated is you take the major measured Catholic ones on. I'll show you how to calculate that in a minute. A catatonic, a positive. I own the major measure compounds being sodium and potassium in the blood, and then you take away, the major measured announced. So that's cruel, right on bicarbonate. And that gives you the unmeasured announce a k a. The an hour gap, and that includes albumin because that's a negative charge protein that's not counted. And when the patient has something called a high on our got after loses, I need had, um, uh, That gives you a different set of differentials for the cause of the metabolic acidosis compared to a magma, which is a normal amount of acidosis. So the way you can calculate and I wouldn't focus on too much but stored away in the back your head's. There's two ways you can do it. Method one is either just use sodium chloride and bicarbonate. So you take the amount of sodium the patient has and take away the amount of bicarbonate and crawl right to get them to the negative ions. If the analogy is between 40 12, that's normal. So then they would be a normal and got metabolic acidosis, and that's the and and up is more than 12. Be high on it. Method to is one. We could include potassium. There's no difference between the two and in real practice it's it's It's all a bit more academic from that point on words, to be honest, so just pick one method and stick with it. Uh, if you can use methadone that includes potassium. So when you keep passing, the an arm got range is increased from 8 to 16 on if the if three and and doctors more than 16, it's a higher end up metabolic acidosis. And if it's 8 to 60 it's a normal metabolic acidosis. So in terms of the differentials and you'll come across is as medical students. Well, maybe in exams when you can take that. And, uh, if you've got a raise and and up metabolic acidosis, remember this new morning? It's called mud tunnels if you haven't had a cough, and I did you all the cause that you need to know. Often we had for high honor and up metabolic acidosis. So in terms, the end, it's methadone. Also, you know a type of toxin alcohol use for your email, which is tends to be rate with very severe and stage kidney disease or a K I I diabetic. Easy eso ketoacidosis is starvation. Q. Tips are colicky toasters. Remember that ketone are only in diabetes that happen in starvation and alcoholism as well. Pyroglutamate acid, which is related to Paris, Eat more. It's zoom or more specific thing. Have a look at that in your own time. Per alcohol is a type of old anti seizure at the eclectic drug and still use in young Children. I can do it. Lactics, of course. Effort in glycol. There's another toxic alcohol on Silas cynics. And remember to be able to use this list of differentials, they must have a metabolic acidosis first. And then when you come here, the an arm got they must have a raised on on Gap and that qualifies, Um, is a high on our gap Metabolic acidosis. Fine. So let me have a quick look at any questions just to see if there is any no questions at the minute. That's fine. So we've got a 65 old lady for Case two presents with fever and shortness of breath to a any she has a history of COPD with previous hospital is like hospitalizations. This year, her sputum production is increased and become dark up, and her examination and blood gas results can be seen below. How would you describe the ventilation oxygenation abnormality? The arterial blood gas was taken on there. Let's really which is not okay for the sake of time. Going to move the pool on that. So most of you answered correctly. A chronic type two respectfully end. We're comin toe in a second. So four sort of Risperdal acidosis. Compensation sort of takes place over days. So the kidneys are not excreting hygiene islands through phosphate for from binding it phosphate or ammonia, or they're retaining bicarbonate to try and sort of compensate for it on this gonna pay ideas high based excess or high the normal bicarbonate concentration. And in God's to the Risperdal, she fainted. Criteria for someone to have type one sort of respiratory failure. It's failure of oxygenation. They have to have a peel to of less than six, which, in terms of this patient, uh, they don't currently, as it should be. Opponents that should say less than eight. The the appeal to less than eight, which they currently do you have. The P 02 is roughly about seven. So you do qualify for type one scoop traitor. But there's also type two spiritually which is failure of ventilation when you have appealed to of less than eight and a PCO to of more than six. So when you look at their partial pressure seemed to that part of pressure. See it more than a, which means they're retaining seal to for whatever reason. But they've also got this low oxygen level on their on their A B G of less than eight, which means they qualify for Type two respiratory failure now to qualify for being cross as a chronic type to respect your failure patients because there's lots of reasons why patients could be acutely in in type two respiratory failure. Such a reduced GCS medications or drug overdoses have to have a high bicarbonate, which suggests that they've been compensate for days because for a patient to try and start compensating for respect acidosis, they do food and kidneys, so that bicarbonate increases either by excreting more hydrogen ion is for the kidneys or by retaining more bicarbonate on it also comes as a high base excess, and that takes the period takes place of a period of least three days. We should test you that this chronic process that's going on. So that's why the answer is chronic. Type two respect. You're fairly because one they've got a low peak to of last in eight and two, they've got PCO to of more than three on. They've got bicarbonate that's highly suggested that chronic process that's going on. So in terms of summarizing deaths, ABG the pH is normal. There's respiratory acidosis with a complete compensation by a matter. Bolic Alkalosis, which is done through the kidneys. They're high pox. Scenic would seal to your attention as well as metabolic alkalosis. And that suggests chronic type two smooth. PH. They're they're normal. So I apologize that Norvasc Teaneck You've got a peel, too, which is less than eight. So the high box seen it. That counts as Type one research on got piecing to where that's high, so that suggests respiratory acidosis hypercarbia up with a piece into of more than six. That should say, which is type two spiritually failure on. They've got base access and bicarbonate that's high suggestive of metabolic alkalosis. So a little bit about some of the oxygenation cascade. So whenever you again Ryan and ABG always right, how much oxygen? Because it's very important terms of interpreting there oxygenation and explain why in a second, so when a patient is breathing 21% room oxygen air, atmospheric pressure air, which is 21 killer Paschal's of a pressure of oxygen when you look at that compared to our tour, but that's when you know you breathe it in, it gets a better moisturizer to it. There's a bit of shunting everywhere else. The total amount of partial pressure off or two option becomes 30 when the arteries, that's what it should be in a normal patient, 11 to 13. Now, when you compare the difference of partial pressure between room atmospheric oxygen on three arteries, there's difference of roughly between 8 to 10. So if patients got normal oxygenation I there's no issue with the cast, with Auction Cascade going out from atmospheric or whatever you're breathing in down into the lungs. The difference should be eight of 10. For their not to be an issue of oxygenation of what I'm not to be, sort of be classes hyper quite look scenic now again for him because this type one respiratory failure, failure of oxygenation if they've got PR to of less than eight that counts this failure. Now the important prices say you decide to put whacked them on some oxygen. Say you've got eventually mask. For whatever reason, that's 60% oxygen or whatever is you put the f I 02 down. If they've got, say, 60% 02 and they've got a PA or two of 13, even though the P 02 is within a normal range, that's good for them. And that's going to keep them alive. When you compare that with the difference of what they're actually getting in. So say they've got fo to of 60. That would mean they've got a partial pressure of 60 sort of 60% 60 apartment for for 60 appeal to when you calculate difference being 60 and 13. That is 47 in terms of the difference between yes, there no family speaking high proxemics. But there's no normal oxygenation because they're needing 60% oxygen for them to have a normal P 02 and the difference between the two B 47 instead of 8 to 10. So even though they're no hypoglycemic on the blood that they haven't got normal oxygenation, and I've got a problem with oxygenation on, we can come back towards the Entex. Linger. Uh, if you guys didn't catch what I said that in terms of ventilation, we look at sort of atmospheric seem to use about Lupron, not 4% just stored away on optically porn. But when you look the partial pressure of solitude in the blood, it should roughly be 4 to 6. And whatever you breathe out should roughly be the same or a difference of about one. It shouldn't be much of a difference. If there is a big difference between sort of what their breathing out on what's within that blood, it could be suggestive of a failure of ventilation. I you know they're not. They're not mechanically working properly for everything, which could be a central reason. I something right to the brain, which could be a drug overdose. Reduce the C s or whatever it is, or it could be a mechanical issue with the lunch such as, you know, destruction of the structures such as an emphysema. Or, you know, if they're really kyphotic, they won't be able to expand the lungs and fairly breathe about either, you know or they could have muscular sort of degenerative diseases such as, you know, severe motor neuron diseases and stuff like that. So if they're in tight respect you for you have to have a peel to have less than eight. So I qualify for type one respiratory failure on 80 a seal to of more than six says a Sorry about you out there. So there's someone asking That's actually not bad question. Is there a specific SATs threshold? Where do you prefer B BCG over an ABG? So I think grab. Yeah, anybody. So anybody on a high amount of oxygen are all optional? Put them on. So if there are nasal cannula and they're maintaining their such, you know for their target whatever it is 94 times it's personal 80 to 90% and the no, no retainer. I would get an ABG if you don't know that there are a retainer and then COPD you're not sure about the auction saturations I would also get maybe G and anybody on large months oxygen above a nasal cannula. Always get an ABG cpap anything like that where you're worried about barely a retention. Yeah, eso exactly. Anybody on noninvasive ventilation. Anybody on higher, much walking along the base of ventilation, or you're not sure whether they're a retainer? Just get an ABG. Otherwise, VBG for every other purpose will do everything that region needs to do. Yeah, but to be fair, it's not necessarily a SATs tackled. It's about what their their oxygenation is like or how they're getting it exactly, uh, broke, so we'll move on Sudanese X question. So case free, that's put up a second. You've got 21 year old gentleman who's technique with tinnitus and fever for women overdose, but we don't know what that would be cause the drug is that the minute he has a background of the pressure in schizophrenia. What she takes venlafaxine a spirit on his blood gas result will be seen below what drug has a patient most likely overdosed on based on the history? Add the blood gas pillow, and that's probably the sorry five, the accident and not as chatty, but guys were trying not being a fatty in this series. If you don't like and you feel it gets boring, I can open them out again. But I'm using that time to update my the surgical log book, So ah, feel free to ask any questions as well. Okay, end up all that. So let's shared results. So most if you have gone for risperidone, which is the incorrect answer, and we'll come on two. Why? Why can't you see without question, I'm not sure what you mean by that. People come back to that later. So mostly of on some spirit on what you see incorrect on someone. Come on one second. So the answer exactly. Aspirin. So, uh, made. It's actually a bit deliver. So in terms of the venlafaxine accident overdose, there's lots of similar things or programs between these drugs. There is sort of seizures cut. It can be cardio toxic for typically prolonged Q TC it can cause you have a card and sorts of other red beers is what chemical patient tyrex. It is part of serotonin syndrome, but it isn't associated with tinnitus. That's the clear there in terms of respiratory, only can cause Sinus tacky. Typically in the high overdose of computer course. The cute dystonic reactions because it's an anti dopaminergic drug, as with all antipsychotics, kind of like metoclopramide when they worry about someone having an ocular entire it crisis in exams and stopping that there's other types of acute. This, like reactions on it, can also cause a prolonged QT see. But the SED was normal again, so there wasn't any suggestion that he might have taken these things. But again, it doesn't mean that he hasn't taken those things necessarily with a paracetamol overdose, I technically be expecting right quadrant pain, nausea drawn this. If it was serious, they have course, have a paracetamol level to double. Check these things with patients that generally comment with overdose is, we add, um, a paracetamol Sinus Senate number one alcohol level, always, anyways, just to make sure I haven't taken anything else. But there's nothing to suggest that you've been taking lots of paracetamol, and then the answer is aspirin. So with the aspirin overdoes, it can be associated with tennis. You can also cause pyrexia and also the cleaners the early technique, but it can also cause nausea and vomiting as with any of these doses, so we didn't aspirin overdoes. Typically, Sinus cynic directly stimulates the respiratory center, and it can sort of buy directly stimulate. It can increase their spiritually eight and eventually over time. This initial sort of ongoing appears as a respectful alkalosis when they're huffing and puffing away, which is why he's got high pH and low PCO to. But everything else appears normal, but eventually is convenient. Developed lakes wrong with now, hours after aspirin overdoes, it could develop into a matter bottle acidosis for lots of a multitude of reasons, which I'm not going to explore free for the hair. But just know that condition is start with the aspirin over this condition. Start as storage up close is developing into a matter folic acid does is eventually, is why one of the treatments actually is to help. That excretion is urinary alkalize Asian are criminalization. Just start on the back of your head won't explode it too much. So in summary, this is a patient that's alkalemia again. Looking at the pH, you have to refer to alkalemia or acidy due to a structural closest because of Hypo Carby up due to attack me out. So I got a low PC, too, because he's been having a puffing away because of that because of salads, say over those again, For those reasons mention, is there any additional precautions. If you do, maybe G on the patient states and equipment. No, no, not not, Not necessarily. I think you know, if you need to. Maybe do you do it? Maybe two. You're gonna support of that, you know, bleeding all it's it's it's it just need to have to hold on for longer. And someone wanted to bring the rest and stuff. And, you know, if you're really worried about a fusion or scheme into the rest, if you're really you know, if you're really good, you'll do an island test. I don't know, but I lost some of them that test a Z Well, because really, the only thing you need to worry about skin you're not so much the bleeding because with a bee, gee, you should be putting on pressure anyways to hold onto it. And I've not seen patients you know, catastrophically bleed from an artery blood gas unless you really, you know, really going quite hard. And you postmortem multiple holes on that, in which case of make your little bit of associate associate, you know, be kind to your patients. If you're not getting it, lets some you have to go But that's seen you. This is a more comfortable test. You can give him a little bit of lidocaine injection to make a bit more comfortable if you're really feeling nice, but in an emergency situation, you'll just go and get it. And sometimes we even do farm stands just to go and get it basically for a real problem. Um, all those medications generally what we need to know about overdoses. So, yes, those are general toxic prodrome of those medications. But if you're not sure of what patients taken, and you know the question that you test for those things, although most lose things when they're looking for toxic levels of those they come back days later such as respiratory thing because they have to be sent to, uh, specialist centers actually run those tests, in which case that's going to delay your treatment. So, really, what you're gonna do have to sometimes do is a best guess. Based on the history and based on whatever it's taken, you do a paracetamol Sinus in a level I'll call level always on these patients, and you have to have a look at the history on what medications have available at home on, you know, test for those things and just months with multiple blood gas. If you know what they've taken, you will always go on tac space. Talk spaces, your friends. You don't need to remember what drug you know. Does what? Because lots of medications people overdose on a cross will get the access talk space. It zits a good website that lets you access a little sort of symptom signs of what any drug overdose that you can think of, What we need to monitor for and how it's managed and often important thing about drug overdoses really is is that monitoring period, whether one they've got Walken direction, I you know, other kidney's going off. Are they really low? GCS? In which case did anything introverted? Do anything? Mother Alyssa's Did any other organ support The question You're asking drug overdoses If you don't know what it is, do they need any organ support or one A period of monitoring in I see you. If you can't figure out what it is while you're waiting for to find out what it actually is, if that makes sense, those other questions that you need to ask about medication. Overdose is essentially and you know, typical. You know, I see requirements to keep it simple is days. It passes because of low BP that's unresponsive to fluids or whatever reason, or their particularly fluid overload. Hemodialysis, for multiple reasons because you know annually is no indication for that. It's either, you know, high potassium fluid overload, your symptomatic uremia such, you know, unit pericarditis. If the itching winter and it's so high and it's causing them symptoms or discomfort on your refractory acidosis, which often happen with these drug overdoses, you know they get quite acidotic. Or, if you know, the having arrhythmia sort of reasons with a prolonged QT see, that might be playing a risk of tall sides. In which case do they need to go somewhere more monitored while you're figuring out what they're going one. And do they need organ support? If you can't figure out what you need to treat? I hope that makes sense, you know? Okay, so for the sake of time, we're going to move on. So, uh, in terms of respiratory alkalosis, this is what you need to know. So with your special closest, you've got to sort of chemo receptor center in the CSF, which picks up you know your chemo receptors pick up if you have an increased amount of the or two or a low pH. I eat lots of hydron irons that stimulates the respiratory center in the Madonna Oblongata, which is really in your brain stem, and that would typically cause a higher response. Cherie, so that you can breathe off. Keep it simple. So the proper time I breathe off some of the acid by a breathing off your coat to a So that's how that compensation takes place. And it also increases many advantage a shin because you increased respiratory rate minute maturation is equal to or spiritually, I won't focus too much on that. You can ask a question about towards the end he wanted on eventually. When when you have the height respectfully, you're blowing off your seal to that will eventually hopefully lower your seal to and increase your pH if you're trying to compensate for something else. So in terms of questions for a 32 year old gentleman presents with diarrhea and vomiting, Hey had been at a barbecue earlier today where several his family members have also taken out. Hey, safely had some growth chart. Complete safety Fort a bit pink. I'm still 18. For some reason eso his blood gas is seen below. What is the most likely cause of this gentleman's metabolic are close. And let's start the pool. Yeah, he's being a bit to like who? Apology stood up. Sorry. Oh, that wasn't the answer, was it? No, no. The answer, guys, Not the answer. There you go. Okay. For the sake of time, we're going to move on. So mostly you answered correctly. So the answer is a combination of the above, and we'll talk a little bit about Why so no clue, You know, No, no marks will get guessing. Would he has he's probably got, you know, gap infectious gastroenteritis because he's getting some pink chicken, which could be, you know, compatible with salmonella. Whatever it is something of the sort. Get a stool sample, you know, hydrate him. You managed gastroenteritis conservatively with, you know, fluids and stuff. Only if it's severe enough that they you know, a really sort of hyperbole. Even because the gastrin try, it's not significant. Electrolytes entrance. So when you look at his blood gas. A Zometa Bolic, our closest on I'll talk a little bit about what I mean. So for something to have a medical acid in our closest, that's something that initially causes it. But then it has to be something, a process that maintains that metabolical close to being a little bit of what that means more in the next slide. So in terms of causes of a metabolic alkalosis, very briefly electrolytes and albumin, so a low potassium were low call right can do it for any patient, just as a sort of tipped for any patient with a low potassium or calcium. Make sure to always add on their magnesium, because if it patients got a low potassium and calcium, which this patient does, is very difficult to treat a low potassium or calcium if they've got a low magnesium, because magnesium effects sort of your parathyroid hormone release and production. So it's directly involved in sort of, you know, uh, calcium metabolism. Essentially, on also effectual excretion of potassium from your kidneys, I e. If you've got a low amount of magnesium, you're excreting more potassium for your kidneys, basically, so you got a low potassium or low calcium, or both. Always add on the magnesium to double check that. That's not something that you need to treat for a reason. On hyper of Melena, a low albumin is also associate with a mild metabolic alkalosis. And that's also one of the most common things that you can see really on what patients in hospital is. We'll start on the back. It heads, guys. It's do with the negative charge on argument. I won't talk to much about that, but, uh, moving on. So for the summary of this blood gas with alkalemia secondary to a metabolic alkalosis process, go one because they got a really high base excess and it got really high bicarb. That's the most deranged feature of this but gas, which suggests that it's a metabolic alkalosis going on with attempted Risperdal compensation. PCO to has gone up a little bit, probably to try and compensate for that are closest on, but it's not the most arranged of the two. And also note that there's globally your electrolytes on your blood gas on a slightly raised lactate, which could be with significant type of anemia from the diarrhea and vomiting and maybe if he is a little bit septic, because the gastroenteritis is what but it doesn't happen as often, uh, so P H e l clinic is piecing too high because it's a respiratory acidosis compensation going on. But it's failed because it's not fully compensated. Okay, because it's still our clinic. The high basics and hide bicarb because of the metabolic acidosis alkalosis caused by low electrolytes from vomiting and diarrhea, is when it's acid loss is from stomach on, also through the kidneys, which we put in the little about. Why on a laxative that slight increase because likely because the hyper very make patient with ongoing in practice Castro it's right, but also something else to think about. So what causes a metabolic? Alkalosis should say a top. So typically there is an initiating process of sight and causes them to either have an increased my bicarbonate or to lose acid for whatever reason or two hydrophones. So the weight gain bicarb is, you know, basically it's the academic, so if they're on and assets on the, you know, take lots of that too much that cause the increased by carbon amount, which is associate with a PSA of milk Alkalize syndrome, which I will explore, but we have had a question on previously. We might put one on on the Facebook page for that sodium bicarbonate, which is what we give in practice or really IV to help it in acidosis of whatever reason or something got a tickly bad kidneys. We also want to stop it from getting really started or if they have an acid losing process. What I'm gonna hide reminds being lost, which could be from vomiting mg. You know, whatever that is, or sort of diarrhetics is well could be associated with it. But then, once you have that initiation process, that has to be something, maintaining it for whatever reason. So if you get hypokalemia, that means the kidneys excrete more acid to try and retain potassium, potassium hydrogen pumps within the kidneys, particularly in the distal completion. Chewable but also the collecting ducts that are sort of trying to retain potassium when it's know excrete hydrogen ion in potentially not also, if you're vomiting Nazi, have a look at you not just losing acid for your stomach, you know is an acid for your kidneys because the kidneys are trying to hold onto the potassium in compensation, and you also get shifting of interesting the hydrogen islands as well, cause by conditions just high, broader. Strong is more cortical steroid because of how they affect. Think it knees in terms of those potassium patient I on pumps of the few other bits. But I want hypochloremia is also associated with low chloride because it because it's it's one of the negative ions in the body and to try and sleep electoral sort of neutrality. If you're losing lots of crawl right, your body will try to increase the reabsorption of bicarbonate to make sure that you don't become a battery, essentially, the simple just of it on on. Also, there's sometimes cause of the called contributing contraction alkalosis, which is very low. If you have losses of lots of fluid, it can cause any sort of electrolyte derangements or sort of pee. Hate to change if you have lots of through potentially cause on our closest as well. But you know it can go the other way as well, because of the electrolyte derangements that could be associated with the fentanyl. What elect to use warm so that causes of the metabolic alkalosis. Uh, come back towards that woodsy end, so we'll skip the break, and we're gonna move straight on because we have rapid fired. We only have two more questions left. S. So these quick, rapid fire questions for you to try and test your skills out. So we're going to put the Paul up very quickly, and I want you to answer what the pH is for This blood gas. Okay, Britt moving straight on. Yes. Correct that acidy mix. Remember? They're not acidotic. You have. Ah, a metabolic acidosis contributing to the acidy Me. But that acidy nick, is the time that we're looking for Fantastic find So moving straight on. What's the pc too? Like give you about 15 seconds. So brilliant moving straight on. Most advanced correctly so respectfully s so they've got a respectfully acidosis along with high P CO2. Fantastic. That's contributing to the acid in your moving on, but the pull up again. Fantastic. So we're going to move straight on so they've got a matter Bolic acidosis. That's correct, because they've got a low bicarbonate amount. So you've got a respect your assets on a metabolic acidosis that both contributing to an acid denia. Fantastic. So let's break this down. So this was a patient that I've seen, I want to say about a year back, who was a IV D. He was a IBD who had been injecting heroin into his veins but had a massive abscess and had injected heroin into himself. So he had their special acidosis because he was essentially morphine toxic and both, you know, overdose because his respiratory rate was getting lowered because of because of the more more because the heroin so that he'd been taking. So that's we had a respiratory stuff because reduced GCS on a suppressed respiratory rate of roughly around eight. I want to say, who would have trying to Laaksonen very quickly, But along with that, you accept it because he'd been injecting into his growing. He had a massive growing up so fast because he's been injecting into his growing. So that's we had a metabolic acidosis because he was septic. That's why he's got high lactate. Sort of is enough to explain some of the metabolic acidosis that was done for him. He had low electrolytes because essentially not been eating and drinking because it was homeless essentially on haven't been taking very good care of us off a cell phone in collecting this century. So that's how you would explain that ABG So they've got an acidy me are secondary to a metabolic on Risperdal combined acidosis which was related to his lower spiritually 87 you to a heroin overdose A z Well, as a, uh, sepsis contributing to his high prolactin tenia is how you would summarize that with globally deranged sort of electrical, really sodium and chloride. To be honest, that seems okay. And then the calcium was okay, Let's see, you had some reason. So the next question is the question where very difficult. I'm going to leave this up for about three minutes or so when. No gonna for the explore this question, this question's going to be the most difficult case. So what I want you to do is write down what you think it is. And then we're going to try and get engaged in for his questions. Questions that he posted back up on the Facebook page because one of my favorite questions on the most difficult questions life done in the Siris as previously noted from feedbacks, and we'll put the answer on the Facebook page. But we're going to leave this up for 2 to 3 minutes and I'll give you some clues. Is what What's the what's going on in the middle? So we've got a 35 year old harmless gentleman who was admitted with vomiting palpitations, feeling on while has a history of of intravenous drug use and alcohol axis simple. Similar to the previous story, his venous blood gases. FBC In using these up on the table. What is the most likely cause of these blood gas abnormalities based on the history on the table results one was different. Questions I have put up in the whole Siris, the normal choroid range. I want to say it's about 96 to about 106. For the sake of it. About 96 260 or 90 to 106. Always forget, because different for different trust. Sometimes time but right, that's the right ballpark and opposed to feedback. Drink out in just a second, guys that you hold on on. Uh, what I want you to do is I'm gonna put up Uh put up the, uh, no apparent the pool. You guys go for it. Uh, leave for 2 to 3 minutes on. Then you can tell me what you thought so, but I'm not gonna answer Question leaving on the Facebook page will come on the back on the Facebook page. As a question you guys can engage with what? The answer is there when we post the answer, and I'll put my explanation of that. We'll leave this for about 2 to 3 minutes while I get the feedback linkup. Actually here. Is it continuing to share screen properly? He's our Yeah, So yeah, it is a far as I'm aware. Are you talking about the whole oh, question distance for the Facebook page? We're gonna post this one up on the Facebook page as an engagement answer, but I'm going to leave it here, and I want to see what people think. And then we'll put the full on some information on it was the most difficult when I printed it into the Siris. I think I've ah, let me have a quick read this. You don't remember what the answer is. You know, put up the link for the face from the feedback. Yeah, I don't remember the see. They're actually No, no, that's good. I don't want you to remember. Oh, someone does, remember. But anyway, now that's fine. But the most important part is the process. You have to do the process. Guys. If we get to the answer on, I might have changed it a z Well, which you might not know about this. So I would have a good look at it. Yeah. Is this Is this the last case or question? This's the last case. Okay, that's really good. You wrap that up quite quickly. 40 minutes. Use it through. I left extras at the end, which is not cases, which is just information basically on lactate, which I was always like that. Um but that's going to be in this light. They're all extras, guys, and was based on the question that we post on the emcee cues is Well, the guys I just put a question in there in regards to pre and post assessments were kind of just doing a one question SBA that we send out right now. But I'm thinking of something along the lines of four or five questions before, Like your fourth five questions after Onda. Ah, yeah. I just want to see if everyone be happy and getting involved, Uh, in answering those just to track how you how you answered just for yourself, but also gives us a really good inside as well. It just shows Is this working? Is this not working on? They'll be relatively similar to, um, what we're doing here, so there won't be the exact same question, but relatively summer. So I'm glad to see that everyone likes using metal. Yeah. Catch a continent. Stuff is posted on their guys has been posted. The video also been posted on that. So you guys, you all have access to that. I'm going to head to my No, no. Shit said you go. Yeah, I'll say another five minutes on, then I'll head off. Yet after that, if there's any questions, guys or any anything else that you want to speak about, uh, very happy to be reached. I think at the beginning I left my details. I'll leave it here again. There's a couple of ah research projects that we're working on in the research corroborative, which is called a creature. Uh, we're actually going to be recruiting people to add to the committee again. They'll be interviews. Now we're a bit more advanced. It's not just going to be application. You feel that online? Uh, it's going to be an actual interview. Um, on. We're going to get more senior people involved as well. On the other thing is that, you know, we're always going to be doing survey style stuff. Now, this year, in terms of studying and analyzing what we're doing, I actually got a very interesting email from proximity. I don't know if any of you guys have heard about it, but ah, look it up for you. We're going to much about it, and they're actually interested in doing a study with me and some other people. So if you're interested in anything like that, let me know we can We can figure something out. Um, on if you feel this concepts that are too advanced than just tell me or tell someone that what you're actually able to do, and we'll probably have something that will be able to get you involved in on. Then student ambassadors guys were going to start advertising for that again, If you haven't been involved in the past, If this is the first time that you're getting involved in the six PM Siris, it probably a thing you can look into it will give you an organizational role where this year we're going to have a fit fixed criteria about what you should do as a student of master need to fit all those things. But then, at the end of it, you would have created ah, row for yourself within the organization on you'll be a big part of how we get the word out there in terms of our electricity done on how we can Teo distribute things like cheat sheets. So if you're interested in being stupid bastard for your year or university, get in touch some of the message on uh, yeah, we'll be happy to present state that we're looking to get started. Not much more seriously towards the middle of September, because we know people are still settling into there and new PSA master or settling into getting into university. You're just not supposed to feed back in couple. Guys, just hold on a minute longer. Yeah, thanks for ah love, Freddie uh, I remember you from the previous Siris. I was just going to say that, uh uh, South e A pressures and read a message. I sent you some contact. He tells here you get in touch. Yes, Freddy, keep repairing. We always We always appreciate Ah, people that keep appearing in our very first Siris we had Ah, we had a p who's actually a partner. We finally discovered who that loss on, but she's a final your student And she used to get every single question correct. Every single question on now she's actually doing some of the lectures with us is left one. So, you know, if you keep reappearing on DA, uh, we find out who you are, and you seem to answer all the questions correctly, and then you become a doctor. You probably be doing lectures yourself in some states. All right, let's go be feedback link and get that to you guys. And again, I apologize that I was late. Guys, thank you for covering for me. Share. No, no, that That's absolutely all right. But I expected, but I'm out of practice from waffling, so I learned how to walk for better shouldn't have. You shouldn't have to use your last a waffle side it Fine. But guys just keep always keep that in mind. You know, this isn't are full time job work. We're all trainees. World doctors were obviously doing other things. But this is something that, you know, we want to keep sustained on, keep it sustainable. On they'll be. They'll be They'll be incidents where, you know, it would be difficult for people to be on time, but most of time we run very, very smooth, and we run pretty much on time. Uh, the only real complaint we have is that there's too much talking the beginning where there's too much talking between. We're actually trialling not doing that as much on going to see how it how it goes. Uh, we hope that doesn't make you fall asleep during the lecture, But, uh, way we'll keep electric short, sweet brown. So, uh, for any of you staying opposed to the feedback link up so that you could go when you choose to, uh, I'm just gonna add a little bit about lactate. If anybody I don't know if you guys are, if you put it up in the chat. Does anybody wanna hear about lactate very quickly? Or would you like on the slide since that lucky teacher did anyone to stay for go for okay? Five. That's a very key people. I like it fine. I'll tell you later about like everything that you need to know about lactic acidosis, even within sort of post graduate level or quickly run through it. It's very it's quite simple words. So, like it's the product of anaerobic respirations. When you're elimination is able to keep up with your production at rest. That's normal because you are producing black. They arrest. Yes, it's a social, anaerobic respiration, you know, high level sort of an aerobic activities where, you know, such as, you know, 100 to sprint. Whatever it is you do produce like they arrest. It's just that your body is able to eliminate it at a rate where you don't become. Acidotic is essentially just did the MRI. You stay within a normal P hate training where your enzymes conjunction, so it's when you have an increased production of lactic or decreased or similar elimination. When there's increased deduction, you get lactic acidosis, which could be for multitude of reasons and that for all intensive purposes of selective, more than two never ignore lactate of more than 2.5. Make sure you know why someone got an active off 2.5 or more. Yeah, if you don't already, and you might have to recheck, it s o when you're unable to buffalo or compensate for that lactic acidosis that needs to acidemia your pH and less than 7.35. And its use is a marker. And critical illness is a measure of mortality broken explication, thinking, sepsis, acceptance. But you know, there's lots of other reasons why patients can ever raised lactate that I want to go through very quickly. So what I want to get the just across is a lack. It's not always abnormal. It's normal in some situations. So, for instance, a laxative is normal in during seizures. Or how about after about heavy exercise? So, you know, post seizure, they measure the lactate not because, you know it could be as high as eight or not, because you know that on well, it's because they've been having so much an aerobic muscular activity because I've not been breathing properly and having these say generalized tonic clonic seizures where they're contracting and you know the most, it's like they're doing 100 sprints. Essentially, that's what I like to get raised. And it's used as a diagnostic. I jumped. It's not diagnostic, but it's used as an adjunct suggest this patient has had a seizure. Another case where it's normal, for instance, is, um, impatience where they've had back to back so beautiful nebulizer. So patients that come in with severe asthma attacks will get lots of subject with nebulizers adrenergic increased lack level. So when you measure the lack that's gonna go up and up and up, not because it's necessarily related to, you know, they're having, you know, the asthmatic exacerbation of them being really on. What it's more related to this. The medications we've been giving you there's also expected in those circumstances that makes sense. That's what context of blacked it's very, very important, Um, so very quickly on, like the physiology. So your main producers of the body are your muscles, which makes sense your red blood cells because they don't have a nucleus. You know, aerobic process is your gut, which makes sense is well, because that's when your biggest organs your skin, the largest organ of the body, naturally on your brain as well. Police could be elected, actually. So when you're having respiration, Blue Coast enters sells food group for receptor because insurance allows it to access, a key to the door becomes glucose. Six for statements was for later becomes pyruvate afterwards, and then again you enter. You know the cramps cycles committed to enter the cramps cycle for aerobic respiration or it go down, the anaerobic group on become lacking. Now if it comes lactate your main eliminators of laxity or in your liver, which eliminates 50% of your lactic and your kidneys, which eliminates about 30% of the reason why that's important is again. It gives your context for y. A patient might have a high lactic, not just sucks. It's related. So this is Cohanim words, classification of lactic acidosis. You don't need to memorize it. Essentially, as two types of like the acidosis is, it's like a where there's tissue hypoxia that's causing lactic acidosis, and it's Type B, which is related to a change in the metabolic process is a black things. There's no tissue. And so either the increased production of lactic, for whatever reason, not independent of sort of tissue hypoxia. Or there's decreased elimination, but every, such as the level of the kidneys so tight. A city calls all types of shop severe hypoxia to conceive severe anemia and carbon monoxide poisoning. You can look at the sort of level of carbon monoxide bound to hemoglobin on a blood gas. It comes up on the blood count. So that's one of the things that you could look at when someone's got raised like the acidosis that you don't know where it's coming from. The severely anemic again. Because your oxygen carrying equation, which I won't explore and shock for similar reasons, then this type B without T shirt boxing's gets a little bit more complex, so B one is anything through the underlying disease, which could increase lactic production or decrease elimination. So sepsis is very complex because it can cause, you know, issues of blood passion called shocking, a whole lot of things. But it can also cause, you know, on a micro scale micro, uh, Michael chondral dysfunctions that actually mess with how your mitochondrion work and therefore you know, forced increased likely production that way because they're because of, you know, part of it being forced down the anaerobic right, because of the might conjure, not work, cancers. Because tenses well highlights energy. That's why I don't pat scans Typically, you know, give radioactive things with sugar because they take up mawr energy. So cancers, because they used war energy, they produce more lactate naturally, and also they usually have poor blood supply is that they're solid. Tumors is well, in which case you get. That would increase lactic again is what especially the liquid cancers. The leukemias can increase your lactic wire as well a particle renal dysfunction because your liver eliminates like that and your kidney's number. So if you've got someone with severe alcoholic liver disease, I would expect them to have a raise lactate. It depends on how high it is, but it's someone who I would expect to have a raised lactic independent of sepsis if that sort of makes sense. But how high it goes depends on the clinical contacts and what else is going on. But that's one example. It was really bad kidney failure. It can also have a bit of a raised likely is working because eliminator it can also happen in DKA because of the change of metabolism and pathways, Type B is without again. We've mentioned about two boxes, and there's be two, which is great to medications and toxins. The most common ones that you know is the metformin, which is why metformin doesn't cause in a car. You know, they worry about it and, you know people were any G f are, you know, less than 30 or a creatinine of more than 130 Not because it's causes an A K. Metformin does not cause an a k. I want to stress that metformin. The reason why you stop it because it builds up quite quickly in renal dysfunction and because that can cause a significant lactic acidosis, I can make a patient feeling well. That's where they typically stop it. In patients with sort of black. The Casodex is all bad, achy. I was a teacher far and also before someone goes for a CT scan, with contrast, because contrast can cause contrast and use the proper feed, and if your kidneys taken here, the metformin will naturally stay in assistant for longer and again. They'll become metabolically acidotic and make them more well from that. Because remember, your enzymes function in a certain range. So what I'm going to stress again is metformin doesn't cause an a k I. It stopped in a k i onda low e jafar on before the CT scan, because it can build up in, uh, patient's of renal dysfunction. Adrenergic conduce. It's so spectacular little nebulizers and I see you. It'll be related to raise a process that they give, you know, such as, nor adrenaline matter. I mean, all of everyone's effects sort of, uh and you know anything that you're allergic particular on given in high doses. Toxic alcohol's because it changed in the tablet and powerful effort in glycol methanol. Whatever is protein like all also being a part of the toxic alcohol's. But lots of medications are they looted, are used, are sort of dissolved within program glycols such a zoo IV diazepam. But again, it's more. I see you related, and the last thing is inborn arrows. Metabolism was common thing, which is G six PD deficiency. That's all the differentials, the things that you think about four or because of the increased lack. If you can't quite work on, it's not septic or shock related. Then you can look back at this less that some point and think yourself. What else is there going on? That this patient might have all their kidneys and never Okay. Have they got cancer? Have the other. Any medications that increase have gone in Warner metabolism? That would usually be, you know, known about it wouldn't present with out in late. I don't answer why the common not sample using severe anemia else. Is there hypotheses that we need to treat? And you need to always remember it off. Those guys recheck a lactate. It's after you after you find like they find a cause given intervention that would hopefully improve if appropriate for that case, because, remember, Lactics can be normal and then recheck it. Lost another mention, but lactic acidosis, tres d lactate deal active is a, uh, isomer of a lack lack is what we measure is what human body cells produce. It's what we measure on a blood gas. Delap today is produced by pro carry. It's a bacteria, and that's not measured in the blood gas So sometimes patients can have a lactic acidosis without being raised. Not because of, uh, you know, sort of know, because it's not been measured on the VBG because the weapon, because in my knee, because they have a deal, ask acidosis. And you have to think about the risk factors for patients with small, a sort of less small bottle. And they operated on lots of times in a short bowel syndrome. And that means lots of undigested carbs. Because lots of carbohydrate absorption and digestion takes place within the small gut goes into the code on that means lots of bacteria that aren't used to dealing with the high sugar note can digest it, and these bacteria produce more increased likely. And that can cause an increased the laxity. Me A. You have to ask for a specific blood test. If that's what you suspect, it could happen in short bowel syndrome, severe DKA, but also in May isn't Eric got skinny as well, and it's a rare a cause of acidosis again postgraduate stuff. But slow down the back. You had that, or did you ever need to know about it? And Brennan so hunger. The QR code, but I'll post up the feedback in Kenosha again. Apologies that I was late, Guys, I'll look at some of the questions on the chat and see if you have any. Let's post up the link again. And the video, just as with undersides will be available online. I want you to be back a day afterwards as catch up content. Did you guys managed to get access to yesterday stuff? If you were there now, it should have been available today. Fantastic. Very good. Good, good, good. So it will be the same case for tomorrow. Hasn't been any questions, by the way. I know. I I I know I speak very fast from time to time. And, uh, if it goes just because I had to rush you everything but I hope you managed to come across any questions, guys happy to go for anything again? Yeah, I always real funky. Thank you. Did you mention something about the BG? There's a year, of course. So VG is just a good It's an immediate unless you're trying to answer two questions and that should only be two reasons why you do an ABG. One is whether you're worried about his patients. Oxygenation. I already on oxygen? If so A high amount of oxygen. Really? If so, what's the oxygenation Spaces like? So are they on oxygen? In which case, consider an ABG I don't typically do in patients on a nasal cannula because it's not high enough for me to worry about anything above a nasal cannula that I would I would do an ABG typically, or if patients increases oxygen requirement, say, from 1 to 5 liters in complex than that. I also do an A B so you don't you're trying to answer the first question. What's the oxygenation state is like because the DVD contacted, uh, the second question that you try it on sort of a BG is what is their ventilation like? So that's again when you're looking at the key seal to and appeal to together on, That's a patient, you know. Have they got reduced consciousness? Have they got, you know, already Hawks requirement again? Have they got a low risperidone rate, which means, you know, might be acidotic because of that? Have they got on oxygen target that we suspect it's too high times I r a COPD, but do we know that extreme target? Because remember, COPD does not qualify. Someone is having, you know, had needing 80 to 90%. They have to have a documented evidence of them being a type two retainer on an ABG for them to be crossed as having an 88 to 92% target. So the nurse is telling this patient's COPD a theater to target say no, no, no, no, no, no, no. What is the ABG? Have they got a documents? Evidence that supposed to have it but starting sorts of 80 to 90 to f know we need to do an ABG to confirm that to see if they have got bicarb. That's more than that. So, you know, like a a piece to that's more than six. So in a BG, VBG is just is good. Otherwise, for everything else that you need in terms of acid acid. So in terms of, you know, acid based violence status, the only have you do in a movie star on 22 questions oxygenation and ventilation. For whatever reason that you're interested in, it doesn't make sense. I'm just talking all 100. I'm guessing I'm guessing you're you're Somalia business? Uh, one of the Somali. Okay, obviously. Sovaldi. Sorry. Just bread. That's, um Brennan. Peacefully explain. Based access based deficit. Of course, I can't. So based excessive based deficit is another way of looking at the bicarbonate and have is the metabolic component off a blood gas. So bicarbonate, if it's low or high, will tell you if there's a metabolic acidosis, school or metabolic calculosis and similarly a base excess or deficit told you exact same thing. So the base accessible deficit has a range of plus two to minus two. What it actually means is it tells you how much bicarbonate you need to take away from a patient or how much by carbon eat out to patients to get a perfect pH. 7.4. And the range is minus two plus two for normal patients. So I'll give you an example. Say a patient has come in with a metabolic asado. So for that reason, they've got bicarb of 18 and they've got a base. They have a base deficit. If they're metabolic acidosis, I the bicarbonate be low because acid high a base deficit, say, minus six now to get back to a normal pH. What? This is telling us if I need to give them six more minimally off bicarbonate to get them back to a normal pH of pH of simple. And again, all it tells you is that it tells you if they've got a metabolic acidosis or our closest and how severe it is, I The higher the number is, the more severe than the arrangement is. Basically. And it's just another way of looking at the bicarbonate in more accurate. And it's it's standardized to, you know, a lab in a population. There's an X sense and, uh, well, a surety, I guess. Um Okay, um, any last minute takers for anything else? And is the feedback link working guys that supports improved poise? Well, fantastic. Okay for bringing Okay, um, you know, the only food E o. Would you mind trying again? Deal posted up again? Sometimes. Because lots of people act accessing at the same time, guys, it will work straightaway. Sometimes you have to try multiple times, so just give it a go again. I'll leave a link up for a little while longer. Uh, I'm saying Onda. Yeah, just, you know, a POSTOP. The answer to that question six. If you guys haven't come across it before on the Facebook page to keep it keep looking at it. There on the slides will be posted on metal again as well as the video is Well, um, fine if the only any other questions. Thank you very much. Guys. Join us tomorrow, six. PM again. Teo, go for chest X rays with osb l on gold. See you down. The feedback is the feedback, Like not working. So the feedback because the metal is the link, you know? Try it again. Mmm. Friend. Um, that's have a little look. I think it is still working. I see. I'm opening it. It is definitely working as anybody else having trouble with the feedback, Like was in the chart. And anybody else having trouble? Oh, is it working a minimum? Okay. Pretty flying at D. Can you Can you keep trying? I'm really sorry about this. Give it a go again. I'll stay on for a little bit longer. Okay. Uh, I'm going to end the chat here. Guys again. Oh, see you tomorrow. And thank you very much for joining. Take care of yourselves. sorry about that is only if you've got a metal. Can you still be able to access the content? But I don't know about the certificate will leave the feedback link on on the video at the end or posted up again on the metal page as the feedback link, and we'll see if you can try again from it. They're deeper is going better outcomes. Could still access to stuff, uh, take, uh, buy.