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This on-demand teaching session is relevant to medical professionals and provides tips on how to take an arterial blood gas (ABG) as well as how to interpret results. We will give some tips on how to make the ABG process more comfortable for the patient and go through the reference ranges and steps to interpretation. The session will end with interactive cases to help deepen understanding and knowledge.
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This on-demand teaching session is designed for medical professionals who are looking to increase their foundation year knowledge. Our speakers will help guide you to develop a structured approach to interpret arterial blood gas results. This session will address the different values seen on an ABG, and discuss common physiology and the clinical relevance of this investigation. There will be chances to interact with our case-based discussions and MCQs.

Learning objectives

Learning Objectives: 1. Understand the importance of doing a modified Allen’s test when performing an ABG. 2. Demonstrate how to safely and comfortably administer an ABG to a patient. 3. Recognize the differences between acidemia, alkalemia, respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis. 4. Identify the reference ranges which indicate whether a patient has acidosis, alkalosis, or is in balance. 5. Properly assess the results of an ABG and correctly interpret it in relation to respiratory or metabolic conditions.
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Computer generated transcript

The following transcript was generated automatically from the content and has not been checked or corrected manually.

Hello guys. Um So welcome back to the 6 p.m. series. Um It's the F one series that we're doing. Um Hope it's been useful so far. Um Today we're gonna be talking about A BGS. So to start with, um, I'll go through some tips that I found useful for kind of getting a BGS to begin with because obviously it can be quite difficult. Um And you know, it's just something that you need practice with, but I'll give you some tips that I found useful and then we'll go through how I interpret them. Um And then at the end, we'll go through some cases, the cases will be hopefully interactive. So if you can use the chat form, that would be great as well. So some tips for abgs. I mean, I'm sure you all know what equipment is needed, but just a reminder. So your classic gloves, alcohol, wipe your specific A BG needle. So that's like the primed one with heparin. Um, hopefully have a self fulfilling syringe as well because they're really handy, um, tape and some gauze in some hospitals, they use lidocaine um to help kind of numb the area to begin with. So obviously if you're gonna use lidocaine, you'll need your lidocaine and then a needle and a syringe to draw that up as well. Um, it depends where you are, what hospital you're working, whether they use lidocaine or not. Um, I actually find that it makes it harder because where the sort of where the anesthetic goes in it sort of balloons up the skin and then it's harder to feel the pulse to know exactly where you're going to go. Um But maybe that's just because I haven't had that much practice with lidocaine and ABGS. Um, you know, you can kind of get used to what you practice with. So classic medical thing before you do an A BG, you're meant to do a modified islands test. So the whole point of this is obviously you're taking a sample from the radial artery, which is the main blood supply to the hand. But obviously, you also have your ulnar artery. And the reason why we do the modified Allen's test is to see if the ulnar arteries can still supply the whole of the hand. Um So what you do is basically you get the patient to make a fist and you put pressure over the radial and the all the arteries and then you get the patient to like open the hand up again and then you'll see that it's pretty much all done white because you basically cuts off the blood supply for a bit and then you keep your pressure on the radio artery, but remove it from the ulnar and then the color should return um to the hand. So if you find that it's still taking longer than 15 seconds for the color to go back to normal, then you kind of meant to avoid an A BG in that side because it shows that the all not artery isn't like a good enough collateral to supply the hand. And obviously, with an A BG, what the risk of the hematoma and things like that. So you don't want to damage the radial artery in that case. Um So I've just seen someone's crushing about topical analgesia if the needle phobic um uh potentially, I mean, I've never seen it happen so far in hospital. Most patient's tolerate abgs pretty well. Um But I guess if that's an option in your hospital, then sure, why not? Um Okay. So some tips were actually doing the ABGS no better tip than practice. Basically, the more you do, the more you'll get used to it and the more you kind of get a feel for it. Um So what I found useful and what I found has helped me to get an A BG is you want to make sure the patient's hand is really stabilized. So what that means is like, it's hard to kind of demonstrate. But if I've got the needle in this hand and then the patient's hand is like that. I tend to rest my hand on their hand and it almost sounds bad, but it kind of clamps their hand in place in a way and then it just means that they're less able to sort of move side to side, they're more likely to move down, which won't affect how you're taking the sample if that makes sense, make sure the patient's comfortable. So make sure they're like either sat up with a bed raised if that's what, what's comfortable for them, maybe a pillow under the hand. Um You know, things like that obviously warn them that it's not a very nice test and it will be uncomfortable. Um But obviously you want to say that if it gets too painful that you can always stop, so, you know, you want to give them that option and again, make sure the bed is high enough for you. You want to be breaking your back while you're trying to do an A BG cause that just causes you more stress and stuff like that. So try and raise the bed if you can up to basically what's comfortable for you and then go in like not hunched over because it will help. Um Obviously you wipe where you gonna go, keep feeling the pulse. So once you found it, um, just keep, keep your hand on there, like wipe it, put your hand back on and make sure you've like found ways what you're going to go again when you're putting the needle in, it's best to go slow. I found that when I was first doing them, I was like, going really quickly because the worst part for the patient is actually the needle breaking the skin. Um, so I thought if I did it quicker, the patient wouldn't be in pain as much, but it doesn't really work like that. Actually, if you do it more slowly, um, you're more likely to get it and then the patient is not going to be in pain for longer. Um Some people find the, the bigger the pulse is like the more bounding it is the harder it is. So even if they've got a really great pulse, don't worry if you don't get it the first time. Um What I suggest is, as I said, keep your finger on the pulse and just gently move your needle without taking it out of the skin because that will like not cause as much pain to the patient. You don't want to keep pushing in a needle I/O, you want to try and keep it in. So if you feel like the artery slightly to the left, just withdraw ever so slightly. Um, and then put, turn your needle's slightly to the left and then slowly go down again. If moving to the right angle still doesn't quite work, which can sometimes happen. Don't just give up and pull the needle out really quickly. As something that I used to do as well. What I found that is if I pull out the needle really, really slowly, almost as slowly as I was going in, sometimes you'll find that you'll hit it as you come out because you can actually kind of just go through it by going too quickly in and then as you with tracked, um, or like, withdraw the needle, you can actually find the artery as you're coming back out again. So don't just pull out in frustration of not guessing it just come out slowly and sometimes you'll get it. And that would be amazing. Um Any other questions about tips and things? Obviously, I went through that quite quickly. Um If you do just put them in the chat and I'll pick them up. So interpretation. Um So these are the main sort of reference ranges when you get an A BG result. Once you've imported it into the system, it will tell you the rangers, you won't have to remember them off by heart. Thank God. Um So these are just like generic reference ranges. They're pretty much, you know, the same in every system. Hopefully, my slide kind of makes sense. So if you look at the ph, that's the normal range and then if it's any lower than the PH is acidotic, and so they've got an acidemia because the blood is acidic. If it's higher than that, then they've got an alkalosis iss. So in the blood, there's alkalemia again because there's alkaline in the blood. Um And then Paco two, that's just the amount of carbon dioxide that's in the blood. So obviously, if there's like a lower amount than its hypo, if there's more than expected, there's hyper. Um and then oxygen, hopefully, you should know that hypoxic is less than eight pascal's. Um, so there is a caveat that caveat to that, but I'll come onto that later, um, as well. And then bicarb. So if it's low bicarb or if it's high bicarb and then base excess as well, basic cess is something that is just like, it kind of gives you an idea of how the body is. Kind of, it basically just shows what, how much bases needed to correct the ph that you've got. Um, it's not really, it is useful, but it's not the main thing that I look at. Basically, it's just like another thing that can help if you're a bit stuck. So these are the steps that I use for interpretation, everyone kind of does it slightly differently. Um But this is what I found that just works for me. Um Just within the order, obviously, you know. Um So first thing I look at the ph I see if it's acidotic or Alkyl attic and then from there, I kind of have a picture already. So if it's acidotic, I'm like, is it respiratory or metabolic acidosis? And I kind of forget about the alkalosis for a minute. And then I look at the pot, you want to see if they are hypoxic or not. And then after that, I go to the CO2. So if the CO2 was low, but the PH is like alkalosis iss, then it's a respiratory alkalosis iss or it's compensating for a metabolic acidosis because the lungs are really good at sort of balancing your acid base balance. Whereas the kidneys take a little bit more time. So any metabolic problem, you're going to get a change in the CO2 quite quickly and you'll see that on an A BG sometimes. So, yeah, hopefully that makes sense. But the compensation I'll come onto it a bit later again, just a double check. Um And then again, if the like PCO two is high and they've got an acidosis, it's probably likely to be a respiratory acidosis or if there's a metabolic calculosis going on, then it's trying to compensate, as I said. And then following that, you look at the bicarb and um here you can really tell whether, you know the respiratory issue is there is a respiratory issue or if it's compensating for a metabolic issue. So when you look at the bicarb, if the bicarb is low and you bought an acidosis, then you've got a metabolic acidosis. But if you've got the bicarb is low, um And like they're still alka lot ick that it's compensating for a spiritually alkalosis iss and then on the reverse side, if the bicarb is really high, um it might be that it's a metabolic algal osis or um if the bicarb is really high and actually the PHS acidotic, um it could be compensated, compensating, sorry for respiratory acidosis. This one is more likely in like your chronic cot retainers who are then having an acute episode on top of that because as I said, the kidneys take such a long time to compensate. So it's going to take a while for that to happen. Does that all make sense? Just pop a thing in the chart if you want me to go over it again. Um So hypoxia, as I said, there's a slight caveat. So normally when we look at the PO two, it should be greater than eight. Um But if they're on oxygen, then that kind of rule slightly changes. So when they're on oxygen, say they're on like 30% oxygen, um you to not be hypoxic, then the lowest amount of po two would be 10 minus the inspired oxygen percentage. So as I said, with 30% oxygen on the patient, then on the A BG, their PO two should be 20. Um If it's like nine, if you took the original rule, it looks like it's normal, but because they're on oxygen, they're actually still hypoxic. I hope that makes sense. Okay. So, respiratory failure, um there's two types. Um One is where you only get hypoxia and then the type two respiratory failure is where you got hypoxia and hypercapnia. So your CO2 is like rising and classically, that's your COPD patient's or your severe asthma patient's say causes of type one rest failure. Um It's classically you're sort of heart failure with pulmonary edema or your broncho constriction um from asthma or it's like P as well. Um And that's because it's due to a VQ mismatch. So ventilation profusion um mismatch. So for example, with the pulmonary edema and the asthma, you getting reduced ventilation because your, your Salvio light aren't able to like expand as much as they normally would. Whereas in pe they have the ability to expand, but your perfusion isn't as good because some of your pulmonary arteries will be blocked off. So, ventilation, um Sorry, I was just checking in the chat and so yeah, the profusion of the pulmonary arteries is reduced and then you get a ventilation perfusion mismatch which causes a type one west failure. Ok. Type two. So classically it's your COPD is your pneumonia patient's. Um you can also get it in like MND as well or sort of um opiate OD where you get rest depression. Um and also in severe asthma and that's basically the reason why you get type two rest failure is because of impaired gas exchange. So you're not able to get the oxygen in and you're not able to get the CO2 out. So, um for example, with opiate overdose, then you're not breathing as hardly like as normally as you would, it is more shallow breaths and things. So you're not blowing off the CO2 and you're not bringing in the oxygen. So that's why you get a type two rest failure with that. So cases. So, um 70 year old female presents to a and a with shortness of breath cough and an audible wheeze. That's what you've been referred to by the, and the doctors, can anyone put any more questions that they'd want from the history in the chat? Perfect. So someone's puts beause in production. Um and specifically anything else that you'd want to know about this? I love it. Perfect. When did they start? Yeah, chest pain. Also a good one. Why were you thinking about chest pain? Asthma history? COPD history? Great Glairy P brilliant. Ok. Fab. Um So with these kind of histories, as you said, how long has it been going on for? Is the cough productive of sputum? What color is the sputum? Is there any blood in it? Um with the wheeze. Have they ever been wheezy before? Um, you know, is this new to them or have they known to have boys and their own treatment for it, as you said? Do they have COPD? Do they have asthma? Um, things like that? It's just your normal clacking history. So, presenting complaint, what's all the problems you know, past medical history, allergies, social history. So another big one for this would be smoking, you know. Have you ever smoked? Yeah. Fairfax, someone's just put it in. Um, have you ever smoked? If you have, how long for pack years? Think about that sort of thing. Um, so you've got your basic history and you're going to see the patient and you do a classic 80. So you find that they're pretty alert. Um, they've got their own airway in the dog can do, but it's only a few words at a time. They're kind of having to catch their breath when you go to be. You find that they're sort of bent over and their lips are really pursed. You can hear a wheeze just from the end of the bed. Um, and you look at the news chart and they're like really tacky, um, tachypneic, sorry, with a respirator 30 their SATS are quite low. You listen to the chest and they've got bilateral wheeze and they've got some crackles on the left base as well. Um, so you move on to see, obviously you wouldn't want to move on straight away. What would you want to sort out and be first? Can anyone think of benefit? Okay, perfect. So, at this point, you don't know what they're a BG is going to be and you see the SATS are low. So you're gonna whack on, um, 15 liters non re breathe at that point. Or if you can titrate it down to a nasal cannula or just a face mask, that's great. You just want to try and get the sacks as to what you'd normally put it as cause hypoxia obviously can kill quite quickly. Um, so back on the oxygen and then you go to see and you find that they're warm, they're well perfused. They've got a cap refill of less than two seconds. Their BP is a little on the low side, but it's not, they're not in shock or anything like that. And the pulse is regular, a bit, a bit tacky. And the heart sounds are normal. You go on to D and the abdomen is absolutely fine. The peoples are equal and reactive and their blood clue cases normal and then you look at the calves and they're also absolutely fine. So, because they're requiring oxygen. So you want to go and do an A BG and you've just got it perfectly and you go and run it and then you get the results here. So, first of all, the ph what does anyone think about the ph acidotic? Perfect. And then the purity at this point she um doesn't have oxygen on, you know, she should have very low. Okay. Hypoxic. Perfect. So she's hypoxic and she's got acidosis and as you already jumped onto the CO2 is high. Um And then the bicarb, what do you think about the bicarb? Fine? Yeah. Black lives normal. So putting all of those things together, what do you think is going on spirits yesterday? Six? Perfect. Perfect. So, as well as respiratory acidosis, you've got, you've told me that we've got a hypoxia and we've got a high CO2. Can anyone tell me anything else about the respiratory aspect of this type two? Perfect. So you've got a type two rest failure um with acidosis on top. Now, this I was alluding to as a COPD with an infective exacerbation. Um In this case, you are probably going to need niv, but obviously you'd want to start with antibiotics and go through all the pathway first. Um But yeah, you got the ABG right, which is correct. So causes a respiratory acidosis. So as I said, the main one is COPD. Um you can also get it with respiratory depression. So like I said earlier, um with your opioid overdose and things like that because you're not blowing off the cot, you're not bringing in the ot, you can get um the type to rest failure which can lead eventually to an acidosis because of the build up of SEOT. Um And you can also get it with asthma as well. Okay. So next case, you've got a 17 year old female who comes in with shortness of breath, chest tightness and some palpitations. What else do you want to ask her onset? Yep. Any other questions, duration? Okay. Cough, pain, history of similar events Perfect. Okay. Fine. Anything you want to ask about the chest tightness at all? If I change the wedding to chest pain, what would you character? Perfect radiation? Amazing. A couple more questions. If you can think about your Socrates severity. Yeah. Okay. Yeah. So any other questions could be like, um, whereabouts is the pain? Um, so when you ask her that she says it's just generalized over the chest wall, there's no specific and when you ask her about the pain, it's, it's just feels tight, it doesn't feel like a stabbing pain or a burning pain or anything. It's just a tight, like she feels like she can't open her lungs well enough, um, radiation, as you said, um, any associated symptoms. So obviously comes in with the shortness of breath again, you might want to ask about we's, um, as you said, as well, cough things like that. Um, and then, you know, severity as you've also mentioned and onset and timing, as you also mentioned. And then the palpitations, um, what sort of things would you ask about the palpitations? I'll just give you a couple of minutes. Okay. No. Is, um, so with the palpitations, you'd want to ask sort of what it feels like. Um, when did it start? Does it feel like, um, the heart skipping a beat? Does it, could they tap out the rhythm of the palpitations? Um, things like that as well? You know, if they've ever, as you said someone's put syncope, which is great. Have they ever fainted or felt dizzy or anything like that? Um And then as well, you know, I mean, she's 17, but think about thyroid things as well. So anything like lumps in the neck that she's noted and things like that, that's not specific to this case, but just in general, if you're going to ask about palpitation history kind of things. Um So again, you do the 80 their airways actually fine. They're talking to, um, when you look at the, um, breathing side of things, they're breathing really quick, they're going at 36 per minute, which is a lot, but they're SATS are absolutely fine. Um, and the chest is clear, you can't hear any wheeze or any crackles and then, so you go on to see and heart sounds normal. Um, the warm well perfused their cat refills fine BP is fine. She's a little bit tacky but nothing major. Um, and you get any ZG just in case and it's just sinus tacky. Um And then D and E are absolutely fine as well. Um And then a BG. Um, so if you go onto the ph, can anyone tell me about the ph ankylosis? Perfect. Um And then if we go on to the pot, what do you think about that? Ot is high CO2 is low? Perfect. Do we really care that the OT is very high? Is that a bad thing? Okay. Right. Do you think it's a bad thing? Okay. Perfect. So someone else has put the oxygen is normal. Um, yeah, in this case, the oxygen is normal. Um, if it was another, if it was the previous case and her oxygen was high and she was still had really high CO2, then you're going to think about, you know, hypoxic driving things. Um, and worry about putting too much oxygen in, but in this case, she doesn't have a high CO2. She's got a low CO2. So actually her oxygen is normal. Um and you don't need to worry about like further retention with that kind of thing. Um And then the, the bike up, what do you think about the bike up normal? Perfect. So putting it all together, what do you think is going on with the acid base balance, respiratory alkalosis? Perfect. And then because the bicarb was normal, you've got no compensation yet because as I said, the kidney's take some time um to work. So about this case, she's 17 when he delve further into the history, she sat her exam yesterday for a levels and she's panicking that she might failed it. And so she's got a respiratory alkalosis from a panic attack. Um Obviously, you kind of go down the treatment of that of like trying to calm her. Um reassure her. Sometimes people get like a brown paper bag. I've never seen that happen personally, but apparently that can help because it kind of, you know, tries to increase, you see her to a bit. Um Yeah, everyone's putting hyperventilation, which is about uh just going back quickly. I saw someone put in a quick note about the lump in the neck that I talked about. Basically with that. I was just thinking like palpitations, you know, is there a thyroid problem going on and they got a goiter or something like that? Because if you've got hyperthyroidism, you can just get tachycardia. Um and then the patient can feel that as palpitations, does that make sense? Does that answer your question? Perfect. Okay. So, respiratory alkalosis iss um anxiety. I feel like that's the classic case that you'll get taught medical with the hyperventilation, but the most common cause in hospital is actually from pain. So for example, when you're on like an orthopedic ward and a patient's just had a total hip replacement, but the pizza is worn off or not been re prescribed or something and they're actually in just massive amount of pain, they just breathe more quickly because they're trying to, I mean, I feel like everyone's probably experienced it, but when they get pain, the breathing rate just goes up anyway. And then you can get um we spiritually our closest from that. So obviously, the treatment for that would be, you know, pain medication. Um You can also get it from a P and a pneumothorax as well. Okay. So next case. So you were an 18 year old male who comes in with some tummy pain and, um, you've taken a quick history from him and you find that he seems to be waiting all the time and he can't seem to quench is there's little, um, what further questions are going to ask him? Yeah. So people have said Socrates for the pain. That's great. Um, I mean, yeah, that's probably the main thing, weight gain or loss. Amazing. That's a big one for this case. Um Other things to be thinking about is, you know, when did he start having trouble? Like weighing all the time? How much is he weighing? How much is he drinking a day? Um Someone's foot family history again. Amazing. Um particularly what are you going to ask about the family history? Type two? Okay, to be honest, I would just ask about diabetes in general. I wouldn't be specific because he's only 18. Obviously, that can be quite a late presentation. Um normally tend to get it in kids, but it can still happen in your early like late teens, early twenties. You can still be diagnosed with type one. That's why it's still really important to sort of send off for the antibodies and C peptide and things um for patients who present in the twenties. Um Okay, perfect. And someone's also autoimmune conditions, bob the celiac and thyroid problems, things like that. Um So when you go to assess them again, the airways absolutely fine. The respirator is normal, that's a normal chest is clear. Um, you go on to see and they're warm, they're cat free, feels normal. BP is absolutely fine. Pulse is fine. Heart sounds are fine when you go to d their abdomen soft but it is tender everywhere, but there's no guarding. There's no rebound tenderness and the bowel sounds are present. You quickly look in their eyes and absolutely fine. So you're like, I'm not really sure what's going on. Um I'll do some bloods and we'll do an A BG. So can someone tell me what the PH shows acid? Perfect. And then the PRT, what do you think about that? Normal fab? Um and then Pcot zero to lo fab and then the bicarb? No? Perfect. So, painting that all together, what do you think overall is going on for the IVG? Metabolic acidosis? Perfect. So we've got a metabolic acidosis. Why do we think the CO2 is low? What's the things happening there? The spiritual compensation? Perfect. So, as I said, um your rest system is really good at trying to balance your acid base. Um So when a metabolic acidosis or an alkyl osis kicks in your lungs are really quick to respond. So, um with this patient, they've got a metabolic acidosis and as Ellen's just said, your body just tries to blow off all the extra acid that it can to try and balance out the ph So yeah, that's why your CO2 is low in this case, populace. So, metabolic acidosis. Um Sorry, I just seen your question. So normal po two in the UK is above eight. So yeah, that helps um so metabolic acidosis, it can be sort of split in the high, an eye on gap or low and anion gap. And that basically just helps you kind of decipher slightly better about what's going on. Um realistically, your history should really have with that more than that an iron gap. But if you have no idea, sometimes patient's come in unconscious and they can't give you a history so that online gap can help. So can anyone tell me what is the anion gap? No worries. Okay. So basically, it's kind of just a balance of the positive ions and the negative ions. So in the UK we use the sodium plus the chloride and the bicarb. Um And then that will give you what the anion gap is. So if you've got a high anion gap, it means that you've either got lots and lots of production of like hydrogen irons because um you know, there's a more positive balance or you've got reduced excretion of those hydrogen ions from the kidneys. So again, there's more like acid going on, more positive balance, sorry going on um in the blood. Um and then a normal airline gap is normally do to like loss of bicarb rather than a change in the hydrogen ions. So, um with their um high anion gap, it can be a DKS your sepsis with the lactic acidosis aspirin overdoses. Um renal failure can also cause it and then obviously, a Metformin is due to the lactic acidosis and then normal landline gap is like your diarrhea, your Addison's disease, um and your renal tubular disease as well. Okay. So, coming onto the last case now, so you've got a 25 year old male and he comes into any with a four day history of vomiting. What do you want to ask him? Okay, perfect. So someone put meal history, um someone to put blood in the vomit, someone's but does it come suddenly? Um okay. How long? Perfect. Any other questions that they, how much of effect? Um again, with that question, you could ask how many times as well. Um close contact 20 sick people? Perfect alcohol history, abdominal pain. Amazing. But um color of the vomit. Great. So there you're kind of thinking about, is it bile? Is it food? Is it blood stained? Is it pure blood? Is it blood clots? Is it coffee ground? Um Just things like that. Obviously your abdomen pain, you're just asking about Socrates go through that. Um But good that you're talking about meals. So, you know, have you had any meals that you wouldn't normally have any takeaways any like going to a restaurant or have you reheated rice? As a classic one, things like that. And then, so you've done your basic history. Um, and then you go to examine him, his airways absolutely fine. Um, in terms of be, it's all normal. See, he's slightly got a low BP but he's not in shock or anything. Um, and his pulse is a bit tacky, but it's regular. And again, you get an ECG and it's just sinus tacky and you go to D and it's tender everywhere, but he's not guarding, he's not got any rebound tenderness and the Bell fans are still present. Um And his pupils are fine. Everything else is also fine. So you do an A BG and you get a PH. So what do you think about the Ph Hi? Perfect. And then the oxygen, what does anyone think about the oxygen? Are we worried? No? Perfect. And the cot normal? Okay. And the bicarb not normal ferr fates. Why is it not normal? High? Fabulous. Okay. So it's slightly cheaper with that one. The CO2 is slightly high. Um, because normal is 4.7. But as I said, when you get an A BG, you'll get the reference ranges. So you won't have to remember off the top of your head. Um So taking it all into account, what do you think is going on? Metabolic calculus? Iss perfect. Um And then given that I've said that the CO2 is slightly high. What do you think about that okay. If I said that the cot was five instead and the PH is arc a lot ick. But they're keeping in this year too, anyone compensation? Perfect. So, as I said, the lungs are really quick. So you're used to start breathing more slowly and basically to try and keep in the acid to try and rectify the Ph basically. Okay. So, metabolic alkalosis iss um is normally through gi losses. So vomiting. So if you think about, you know, all the acid that's in your stomach and then, you know, for a lot of people when they vomit, you can really taste the acid and that's all the hydra nines. So it's kind of unsurprising that you're gonna get an Alka Losis because you know, a lot of your hydrogen ions have left through the vomit. Um You can also get it through renal losses. So some diuretics, you can also get it in heart failure and nephrotic syndrome. Um So it's just one to think about as a and that is it for today. Um If anyone has any questions, please feel free to pop it in the chat. Um And then if you could complete the feedback form which was posted at the start of the session, um that just helps us to know like how to improve uh sessions for you and how to tailor it better for you. So that would be really helpful. Thank you.