Medical Laboratory Science Review Harr 5.2 Chemistry - Blood Gases, pH and Electrolytes (1-35)

Which PCO2 value would be seen in maximally compensated metabolic acidosis? A. 15 mm Hg B. 30 mm Hg C. 40 mm Hg D. 60 mm Hg

A. 15 mm Hg A In metabolic acidosis, hyperventilation increases the ratio of bicarbonate to dissolved CO2. The extent of compensation is limited by the rate of both gas diffusion and diaphragm contraction. The lower limit is between 10 and 15 mm Hg PCO2, which is the maximum compensatory effect.

Which of the following best represents the reference (normal) range for arterial pH? A. 7.35-7.45 B. 7.42-7.52 C. 7.38-7.68 D. 6.85-7.56

A. 7.35-7.45 A The reference range for arterial blood pH is 7.35-7.45 and is only 0.03 pH units lower for venous blood owing to the buffering effects of hemoglobin (Hgb) known as the chloride isohydric shift. Most laboratories consider less than 7.20 and greater than 7.60 the critical values for pH.

The following conditions are all causes of alkalosis. Which condition is associated with respiratory (rather than metabolic) alkalosis? A. Anxiety B. Hypovolemia C. Hyperaldosteronism D. Hypoparathyroidism

A. Anxiety A Respiratory alkalosis is caused by hyperventilation, which leads to decreased PCO2. Anxiety and drugs such as epinephrine that stimulate the respiratory center are common causes of respiratory alkalosis. Excess aldosterone increases net acid excretion by the kidneys. Low parathyroid hormone causes increased bicarbonate reabsorption, resulting in alkalosis. Hypovolemia increases the relative concentration of bicarbonate. This is common and is called dehydrational alkalosis, chloride responsive alkalosis, or alkalosis of sodium deficit.

Which of the following mechanisms is responsible for metabolic acidosis? A. Bicarbonate deficiency B. Excessive retention of dissolved CO2 C. Accumulation of volatile acids D. Hyperaldosteronism

A. Bicarbonate deficiency A Metabolic acidosis is caused by bicarbonate deficiency and metabolic alkalosis by bicarbonate excess. Respiratory acidosis is caused by PCO2 retention (defective ventilation), and respiratory alkalosis is caused by PCO2 loss (hyperventilation). Important causes of metabolic acidosis include renal failure, diabetic ketoacidosis, lactate acidosis, and diarrhea

In which circumstance will the reporting of calculated oxygen saturation of hemoglobin based on PO2, PCO2, pH, temperature, and hemoglobin be in error? A. Carbon monoxide poisoning B. Diabetic ketoacidosis C. Patient receiving oxygen therapy D. Assisted ventilation for respiratory failure

A. Carbon monoxide poisoning A CO has about 200 times the affinity as O2 for hemoglobin and will displace O2 from hemoglobin at concentrations that have no significant effect on the PAO2. Consequently, calculated oxygen saturation will be erroneously high. Other cases in which the calculated O2Sat should not be used include any hemoglobinopathy that affects oxygen affinity and methemoglobinemia. The other situations above affect the O2 saturation of hemoglobin in a manner that can be predicted by the effect of pH, PO2, and PCO2 on the oxyhemoglobin dissociation curve

Which of the following conditions is classified as normochloremic acidosis? A. Diabetic ketoacidosis B. Chronic pulmonary obstruction C. Uremic acidosis D. Diarrhea

A. Diabetic ketoacidosis A Bicarbonate deficit will lead to hyperchloremia unless the bicarbonate is replaced by an unmeasured anion. In diabetic ketoacidosis, acetoacetate and other ketoacids replace bicarbonate. The chloride remains normal or low and there is an increased anion gap

In addition to sodium bicarbonate, what other substance contributes most to the amount of base in the blood? A. Hemoglobin concentration B. Dissolved O2 concentration C. Inorganic phosphorus D. Organic phosphate

A. Hemoglobin concentration A The primary blood buffer bases preventing acidosis in order of concentration are bicarbonate, deoxyhemoglobin, albumin, and monohydrogen phosphate. At physiological pH, there is significantly more H2PO4 -1 than HPO4 -2, and phosphate is a more efficient buffer system at preventing alkalosis than acidosis. Since all of the blood buffer systems are in equilibrium, the pH can be calculated accurately from the concentration of bicarbonate and dissolved CO2 using the Henderson-Hasselbalch equation.

Which of the following is the primary mechanism of compensation for metabolic acidosis? A. Hyperventilation B. Release of epinephrine C. Aldosterone release D. Bicarbonate excretion

A. Hyperventilation A In metabolic acidosis, the respiratory center is stimulated by chemoreceptors in the carotid sinus, causing hyperventilation. This results in increased release of CO2. Respiratory compensation begins almost immediately unless blocked by pulmonary disease or respiratory therapy. Hyperventilation can bring the PCO2 down to approximately 10-15 mm Hg.

Which of the following formulas for O2 content is correct? A. O2 content = %O2 saturation/100 × Hgb g/dL × 1.39 mL/g + (0.0031 × PO2) B. O2 content = PO2 × 0.0306 mmol/L/mm C. O2 content = O2 saturation × Hgb g/dL × 0.003 mL/g D. O2 content = O2 capacity × 0.003 mL/g

A. O2 content = %O2 saturation/100 × Hgb g/dL × 1.39 mL/g + (0.0031 × PO2) A Oxygen content is the sum of O2 bound to Hgb and O2 dissolved in the plasma. It is dependent upon the Hgb concentration and the percentage of Hgb bound to O2 (O2 saturation). Each gram of Hgb binds 1.39 mL of O2. The dissolved O2 is determined from the solubility coefficient of O2 (0.0031 mL per dL/mm Hg) and the PO2. O2 content = % Sat/100 × Hgb in g/dL × 1.39 mL/g + (0.0031 × PO2).

Which of the following effects results from exposure of a normal arterial blood sample to room air? A. PO2 increased PCO2 decreased pH increased B. PO2 decreased PCO2 increased pH decreased C. PO2 increased PCO2 decreased pH decreased D. PO2 decreased PCO2 decreased pH decreased

A. PO2 increased PCO2 decreased pH increased A The PO2 of air at sea level (21% O2) is about 150 mm Hg. The PCO2 of air is only about 0.3 mm Hg. Consequently, blood releases CO2 gas and gains O2 when exposed to air. Loss of CO2 shifts the equilibrium of the bicarbonate buffer system to the right, decreasing hydrogen ion concentration and blood becomes more alkaline.

The determination of the oxygen saturation of hemoglobin is best accomplished by: A. Polychromatic absorbance measurements of a whole-blood hemolysate B. Near infrared transcutaneous absorbance measurement C. Treatment of whole blood with alkaline dithionite prior to measuring absorbance D. Calculation using PO2 and total hemoglobin by direct spectrophotometry

A. Polychromatic absorbance measurements of a whole-blood hemolysate A Measurement of oxyhemoglobin, deoxyhemoglobin (reduced hemoglobin), carboxyhemoglobin, methemoglobin, and sulfhemoglobin can be accomplished by direct spectrophotometry at multiple wavelengths and analysis of the absorptivity coefficients of each pigment at various wavelengths. The O2 saturation is determined by dividing the fraction of oxyhemoglobin by the sum of all pigments. This eliminates much of the error that occurs in the other methods when the quantity of an abnormal hemoglobin pigment is increased.

Correction of pH for a patient with a body temperature of 38°C would require: A. Subtraction of 0.015 B. Subtraction of 0.01% C. Addition of 0.020 D. Subtraction of 0.020

A. Subtraction of 0.015 A The pH decreases by 0.015 for each degree Celsius above the 37°C. Because the blood gas analyzer measures pH at 37°C, the in vivo pH would be 0.015 pH units below the measured pH.

Why are three levels used for quality control of pH and blood gases? A. Systematic errors can be detected earlier than with two controls B. Analytical accuracy needs to be greater than for other analytes C. High, normal, and low ranges must always be evaluated D. A different level is needed for pH, PCO2, and PO2

A. Systematic errors can be detected earlier than with two controls A Error detection occurs sooner when more controls are used. Some errors, such as those resulting from temperature error and protein coating of electrodes, are not as pronounced near the calibration point, as in the acidosis and alkalosis range. The minimum requirement for blood gas QC is one sample every 8 hours and three levels (acidosis, normal, alkalosis) every 24 hours. Three levels of control are also used commonly for therapeutic drug monitoring and hormone assays because precision differs significantly in the high and low ranges.

In the Henderson-Hasselbalch expression pH = 6.1 + log HCO3 - /dCO2, the 6.1 represents: A. The combined hydration and dissociation constants for CO2 in blood at 37°C B. The solubility constant for CO2 gas C. The dissociation constant of H2O D. The ionization constant of sodium bicarbonate (NaHCO3)

A. The combined hydration and dissociation constants for CO2 in blood at 37°C A The equilibrium constant, Kh, for the hydration of CO2 (dCO2 + H2O → H2CO3) is only about 2.3 × 10-3M, making dCO2 far more prevalent than carbonic acid. The dissociation constant, Kd, for the reaction H2CO3 →H+ + HCO3 - is about 2 × 10-4 M. The product of these constants is the combined equilibrium constant, K´. The negative logarithm of K´ is the pK´, which is 6.103 in blood at 37°C.

The normal difference between alveolar and arterial PO2 (PAO2-PaO2 difference) is: A. 3 mm Hg B. 10 mm Hg C. 40 mm Hg D. 50 mm Hg

B. 10 mm Hg B The PAO2-PaO2 difference results from the low ratio of ventilation to perfusion in the base of the lungs. The hemoglobin in the blood coming from the base of the lung has a lower O2 saturation. This blood will take up O2 from the plasma of blood leaving well-ventilated areas of the lung, thus lowering the mixed arterial PO2.

A single-point calibration is performed between each blood gas sample in order to: A. Correct the electrode slope B. Correct electrode and instrument drift C. Compensate for temperature variance D. Prevent contamination by the previous sample

B. Correct electrode and instrument drift B Calibration using a single standard corrects the instrument for error at the labeled value of the calibrator but does not correct for analytic errors away from the set point. A two-point calibration adjusts the slope response of the electrode, eliminating proportional error caused by poor electrode performance.

Select the anticoagulant of choice for blood gas studies. A. Sodium citrate 3.2% B. Lithium heparin 100 U/mL blood C. Sodium citrate 3.8% D. Ammonium oxalate 5.0%

B. Lithium heparin 100 U/mL blood B Heparin is the only anticoagulant that does not alter the pH of blood; heparin salts must be used for pH and blood gases. Solutions of heparin are air equilibrated and must be used sparingly to prevent contamination of the sample by gas in the solution.

A patient's blood gas results are: pH = 7.50 PCO2 = 55 mm Hg HCO3 - = 40 mmol/L These results indicate: A. Respiratory acidosis B. Metabolic alkalosis C. Respiratory alkalosis D. Metabolic acidosis

B. Metabolic alkalosis B A pH above 7.45 corresponds with alkalosis. Both bicarbonate and PCO2 are elevated. Bicarbonate is the conjugate base and is under metabolic (renal) control, while PCO2 is an acid and is under respiratory control. Increased bicarbonate (but not increased CO2) results in alkalosis; therefore, the classification is metabolic alkalosis, partially compensated by increased PCO2.

In uncompensated metabolic acidosis, which of the following will be normal? A. Plasma bicarbonate B. PCO2 C. p50 D. Total CO2

B. PCO2 B The normal compensatory mechanism for metabolic acidosis is respiratory hyperventilation. In uncompensated cases, the PCO2 is not reduced, indicating a concomitant problem in respiratory control.

Which set of results is consistent with uncompensated respiratory alkalosis? A. pH 7.70 HCO3 30 mmol/L PCO2 25 mm Hg B. pH 7.66 HCO3 22 mmol/L PCO2 20 mm Hg C. pH 7.46 HCO3 38 mmol/L PCO2 55 mm Hg D. pH 7.36 HCO3 22 mmol/L PCO2 38 mm Hg

B. pH 7.66 HCO3 22 mmol/L PCO2 20 mm Hg B Respiratory alkalosis is caused by hyperventilation, inducing low PCO2. Very often, in the early phase of an acute respiratory disturbance, the kidneys have not had time to compensate, and the bicarbonate is within normal limits. In answer A, the bicarbonate is high and PCO2 low; thus, both are contributing to alkalosis and this would be classified as a combined acid-base disturbance. In answer C, the pH is almost normal, and both bicarbonate and PCO2 are increased. This can occur in the early stage of a metabolic acid base disturbance when full respiratory compensation occurs or in a combined acid-base disorder. In answer D, both bicarbonate and PCO2 are within normal limits (22-26 mmol/L, 35-45 mm Hg, respectively) as is the pH.

Which of the following represents the Henderson Hasselbalch equation as applied to blood pH? A. pH = 6.1 + log HCO3-/PCO2 B. pH = 6.1 + log HCO3-/ (0.03 × PCO2) C. pH = 6.1 + log dCO2/HCO3- D.pH=6.1 + log (0.03×PCO2) / HCO3-

B. pH = 6.1 + log HCO3-/ (0.03 × PCO2) B The Henderson-Hasselbalch equation describes the pH of a buffer comprised of a weak acid and its salt. pH = pKa + log salt/acid, where pKa is the negative logarithm of the dissociation constant of the acid. In this case, the salt is sodium bicarbonate and the acid is the dissolved CO2, which is equal to 0.03 (mmol/L per mm Hg) x PCO2. The pKa includes both the hydration and dissociation constant for dissolved CO2 in blood, 6.1 and is termed pK´.

What is the PO2 of calibration gas containing 20.0% O2, when the barometric pressure is 30 in.? A. 60 mm Hg B. 86 mm Hg C. 143 mm Hg D. 152 mm Hg

C. 143 mm Hg C Convert barometric pressure in inches to mm Hg by multiplying by 25.4 (mm/in.). Next, subtract the vapor pressure of H2O at 37°C, 47 mm Hg, to give dry gas pressure. Multiply dry gas pressure by the %O2: 25.4 mm/in. × 30 in. = 762 mm Hg 762 mm Hg - 47 mm Hg (vapor pressure) = 715 mm Hg (dry gas pressure) 0.20 × 715 mm Hg = 143 mm Hg PO2

What is the normal ratio of bicarbonate to dissolved carbon dioxide (HCO3 - :dCO2) in arterial blood? A. 1:10 B. 10:1 C. 20:1 D. 30:1

C. 20:1 C When the ratio of HCO3 -:dCO2 is 20:1, the log of salt/acid becomes 1.3. Substituting this in the Henderson-Hasselbalch equation and solving for pH gives pH = 6.1 + log 20; pH = 6.1 + 1.3 = 7.4. Acidosis results when this ratio is decreased, and alkalosis when it is increased.

What is the PCO2 if the dCO2 is 1.8 mmol/L? A. 24 mm Hg B. 35 mm Hg C. 60 mm Hg D. 72 mm Hg

C. 60 mm Hg C Dissolved CO2 is calculated from the measured PCO2 × 0.0306, the solubility coefficient for CO2 gas in blood at 37°C. dCO2 = PCO2 × 0.03. Therefore, PCO2 = dCO2 /0.03 PCO2 = 1.8 mmol/L ÷ 0.03 mmol/L per mm Hg = 60 mm Hg

What is the blood pH when the partial pressure of carbon dioxide (PCO2) is 60 mm Hg and the bicarbonate concentration is 18 mmol/L? A. 6.89 B. 7.00 C. 7.10 D. 7.30

C. 7.10 C Solve using the Henderson-Hasselbalch equation. pH = pK´ + log HCO3 -/(0.03 × PCO2), where pK´, the negative logarithm of the combined hydration and dissociation constants for dissolved CO2 and carbonic acid, is 6.1 and 0.03 is the solubility coefficient for CO2 gas. pH = 6.1 + log 18/(0.03 × 60) = 6.1 + log 18/1.8 pH = 6.1 + log 10. Because log 10 = 1, pH = 7.10

Which of the following contributes the most to the serum total CO2? A. PCO2 B. dCO2 C. HCO3- D. Carbonium ion

C. HCO3- C The total CO2 is the sum of the dCO2, H2CO3 (carbonic acid or hydrated CO2), and bicarbonate (as mainly NaHCO3). When serum is used to measure total CO2, the dCO2 is insignificant because all the CO2 gas has escaped into the air. Therefore, serum total CO2 is equivalent to the bicarbonate concentration. Total CO2 is commonly measured by potentiometry. An organic acid is used to release CO2 gas from bicarbonate and pCO2 is measured with a Severinghaus electrode. Alternately, bicarbonate can be measured by an enzymatic reaction using phosphoenol pyruvate carboxylase. The enzyme forms oxaloacetate and phosphate from phosphoenol pyruvate and bicarbonate. The oxaloacetate is reduced to malate by malate dehydrogenase and NADH is oxidized to NAD+. The negative reaction rate is proportional to plasma bicarbonate concentration.

A patient has the following arterial blood gas results: pH = 7.56 PCO2 = 25 mm Hg PO2 = 100 mm Hg HCO3 - = 22 mmol/L These results are most likely the result of which condition? A. Improper specimen collection B. Prolonged storage C. Hyperventilation D. Hypokalemia

C. Hyperventilation C The pH is alkaline (reference range 7.35-7.45) and this can be caused by either low PCO2 or increased bicarbonate. This patient has a normal bicarbonate (reference range 22-26 mmol/L) and a low PCO2 (reference range 35-45 mm Hg). Low PCO2 is always caused by hyperventilation, and therefore, this is a case of uncompensated respiratory alkalosis. The acute stages of respiratory disorders are often uncompensated. Prolonged storage would cause the pH and PO2 to fall, and the PCO2 to rise. Hypokalemia causes alkalosis, but usually is associated with the retention of CO2 as compensation.

Which condition results in metabolic acidosis with severe hypokalemia and chronic alkaline urine? A. Diabetic ketoacidosis B. Phenformin-induced acidosis C. Renal tubular acidosis D. Acidosis caused by starvation

C. Renal tubular acidosis C Metabolic acidosis can be caused by any condition that lowers bicarbonate. In nonrenal causes, the kidneys will attempt to compensate by increased acid excretion. However, in renal tubular acidosis (RTA), an intrinsic defect in the tubules prevents bicarbonate reabsorption. This causes alkaline instead of acidic urine. Excretion of bicarbonate as potassium bicarbonate (KHCO3) results in severe hypokalemia

A patient's blood gas results are as follows: pH = 7.26 dCO2 = 2.0 mmol/L HCO3 - = 29 mmol/L These results would be classified as: A. Metabolic acidosis B. Metabolic alkalosis C. Respiratory acidosis D. Respiratory alkalosis

C. Respiratory acidosis Imbalances are classified as respiratory when the primary disturbance is with PCO2 because PCO2 is regulated by ventilation. PCO2 = dCO2/0.03 or 60 mm Hg (normal 35-45 mm Hg). Increased dCO2 will increase hydrogen ion concentration, causing acidosis. Bicarbonate is moderately increased, but a primary increase in NaHCO3 causes alkalosis. Thus, the cause of this acidosis is CO2 retention (respiratory acidosis), and it is partially compensated by renal retention of bicarbonate.

A decreased PAO2-PaO2 difference is found in: A. A/V (arteriovenous) shunting B. V/Q (ventilation/perfusion) inequality C. Ventilation defects D. All of these options

C. Ventilation defects C Patients with A/V shunts, V/Q inequalities, and cardiac failure will have an increased PAO2-PaO2 difference. However, patients with ventilation problems have low alveolar PO2 owing to retention of CO2 in the airway. This reduces the PAO2-PaO2 difference.

What is the maximum recommended storage time and temperature for an arterial blood gas sample drawn in a plastic syringe? Storage Time / Temperature A. 10 min 2°C-8°C B. 20 min 2°C-8°C C. 30 min 2°C-8°C D. 30 min 22°C

D. 30 min 22°C D Arterial blood gas samples collected in plastic syringes should be stored at room temperature because cooling the sample allows oxygen to enter the syringe. Storage time should be no more than 30 minutes because longer storage results in a significant drop in pH and PO2 and increased PCO2.

Which of the following disorders is associated with lactate acidosis? A. Diarrhea B. Renal tubular acidosis C. Hypoaldosteronism D. Alcoholism

D. Alcoholism D Lactate acidosis often results from hypoxia, which causes a deficit of nicotinamide adenine dinucleotide, the oxidized form (NAD+). This promotes the reduction of pyruvate to lactate, regenerating NAD+ needed for glycolysis. In alcoholic acidosis, oxidation of ethanol to acetaldehyde consumes the NAD+. In diabetes, lactate acidosis can result from depletion of Krebs cycle intermediates. Diarrhea and renal tubular acidosis result in metabolic acidosis via bicarbonate loss. Hypoaldosteronism causes metabolic acidosis via hydrogen and potassium ion retention.

Which of the following will shift the O2 dissociation curve to the left? A. Anemia B. Hyperthermia C. Hypercapnia D. Alkalosis

D. Alkalosis D A left shift in the oxyhemoglobin dissociation curve signifies an increase in the affinity of Hgb for O2. This occurs in alkalosis, hypothermia, and in those hemoglobinopathies such as Hgb Chesapeake that increase the binding of O2 to heme. A right shift in the oxyhemoglobin dissociation curve lowers the affinity of Hgb for O2. This occurs in anemia due to increased 2,3 diphosphoglycerate (2,3-DPG), with increased body temperature, increased hydrogen ion concentration, hypercapnia (increased PCO2), and in some hemoglobinopathies, such as Hgb Kansas

Which of the following conditions is associated with both metabolic and respiratory alkalosis? A. Hyperchloremia B. Hypernatremia C. Hyperphosphatemia D. Hypokalemia

D. Hypokalemia D Hypokalemia is both a cause and result of alkalosis. In alkalosis, hydrogen ions may move from the cells into the extracellular fluid and potassium into the cells. In hypokalemia caused by overproduction of aldosterone, hydrogen ions are secreted by the renal tubules. This increase in net acid excretion results in metabolic alkalosis.

Which would be consistent with partially compensated respiratory acidosis? A. pH PCO2 Bicarbonate increased increased increased B. pH PCO2 Bicarbonate increased decreased decreased C. pH PCO2 Bicarbonate decreased decreased decreased D. pH PCO2 Bicarbonate decreased increased increased

D. pH PCO2 Bicarbonate decreased increased increased D Acidosis = low pH; respiratory = disturbance of PCO2; a low pH is caused by increased PCO2. In partially compensated respiratory acidosis, the metabolic component of the buffer system, bicarbonate, is retained. This helps to compensate for retention of PCO2 by titrating hydrogen ions. The compensatory component always moves in the same direction as the cause of the acid-base disturbance.