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Introduction to acid-base

Joel Topf, M.D. Assistant Clinical Professor of Medicine Wayne State University School of Medicine http://www.pbuids.com

Getting acid-base
Acid base physiology is the regulation of hydrogen ion concentration A normal hydrogen Every change of 0.3 pH units concentration is 40 nmol/L represents a change in H+ by This is .00004 mmol/L a factor of 2 So It is measured on a negative log scale called pH, normal is 7.4

40 nanomol/L = 0.00004 milimol/L

pH = 6.8
Is this patient sick?
Grand mal seizure Methanol toxicity

Its the disease, stupid.


Hydrogen ion concentration can dramatically impact protein structure and enzyme function. The absolute pH is less important than the etiology of the acid-base disturbance.

Since the disease is important


It is imperative to rapidly assess the cause of an acid-base disturbance. Using an arterial blood gas and an electrolyte panel, one can quickly classify a patients primary and compensatory acid-base physiology. Patients may have multiple, simultaneous acid-base disorders. This should be determined.

Determine the primary Acid-Base disorder


Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Determine if the compensation is appropriate


Winters formula the HCO3 1:10 acute 3:10 chronic 2:10 acute 4:10 chronic

Determine the anion gap


Non-Anion gap Anion gap

Determine the urinary anion gap


Positive gap (RTA) Negative gap (GI, IVF)

Determine the osmolar gap


Osmolar gap Non-osmolar gap

Determine the bicarbonate before


Pre-existing met. alkalosis Pre-existing NAGMA No pre-existing acid-base disorders

Step 1: determine the primary disorder

The Henderson-Hasselbalch formula is the mantra of acid-base physiology

There are 4 primary ways that pH can change


Increase in HCO3, increases pH. Metabolic alkalosis

There are 4 primary ways that pH can change


Increase in HCO3, increases pH. Metabolic alkalosis

Decrease in HCO3, decreases pH. Metabolic acidosis

There are 4 primary ways that pH can change


Increase in HCO3, increases pH. Metabolic alkalosis

Decrease in HCO3, decreases pH. Metabolic acidosis

Increase in pCO2, decreases pH. Respiratory acidosis

There are 4 primary ways that pH can change


Increase in HCO3, increases pH. Metabolic alkalosis

Decrease in HCO3, decreases pH. Metabolic acidosis

Increase in pCO2, decreases pH. Respiratory acidosis

Decrease in pCO2, increases pH. Respiratory alkalosis

Patients with primary acid-base disorders compensate to restore normal pH.


In respiratory disorders, the kidney modies the serum bicarbonate to return pH toward normal. In metabolic disorders, breathing is altered to change the pCO2 in order to return pH toward normal.

Compensation minimizes changes in pH

Increased HCO3, increases pH. Increased CO2 compensates to reduce the change in pH.

Compensation minimizes changes in pH

Decreased HCO3, decreases pH. Decreased CO2 compensates to reduce the change in pH.

Compensation minimizes changes in pH

Increased CO2, decreases pH. Increased HCO3 compensates to reduce the change in pH.

Compensation is always in the same direction as the primary disorder.


Primary
Compensation
pCO2
HCO3
HCO3
pCO2

Metabolic acidosis
Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis

HCO3
pCO2
pCO2
HCO3

If all three variables move in the same direction the disorder is metabolic; if they move in discordant directions it is respiratory
Primary
Compensation
pCO2
HCO3
HCO3
pCO2

pH

Metabolic acidosis
Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis

HCO3
pCO2
pCO2
HCO3

Determine the primary disorder

pH / pO2 / pCO2 / HCO3



1.

Acidosis or alkalosis
If the pH is less than 7.4 it is acidosis If the pH is greater than 7.4 it is alkalosis

2.

Determine if it is respiratory or metabolic


If the pH, bicarbonate and pCO2 all move in the same direction (up or down) it is metabolic If the pH, bicarbonate and pCO2 move in discordant directions (up and down) it is respiratory

Determine the primary disorder

7.2 / 78 / 25 / 16

pH / pO2
/
pCO2 / HCO3

1.

Acidosis or alkalosis
If the pH less than 7.4 7.4 it is acidosis If the pH is is less than it is acidosis If the pH is greater than 7.4 it is alkalosis the pH is greater than 7.4 it is alkalosis

2.

Determine if it is respiratory or metabolic

If the pH, bicarbonate pCO2 all move in the same direction If thepH, bicarbonate andand pCO2 all move in the same (up or direction (up or down) it is metabolic down) it is metabolic If the pH, bicarbonate and pCO2 move in discordant directions (up and down) it is it is respiratory and down)respiratory

Metabolic Acidosis

Determine alkalosis Respiratorythe primary disorder

7.5 / 55 / 24 / 36

pH / pO2
/
pCO2 / HCO3

1. 2. 3. 4.

Respiratory acidosis Respiratory acidosis Metabolic acidosis Respiratory alkalosis Respiratory alkalosis alkalosis Metabolic alkalosis Respiratory alkalosis

Now lets do some questions

Determine the primary Acid-Base disorder


Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Determine if the compensation is appropriate


Winters formula the HCO3 1:10 acute 3:10 chronic 2:10 acute 4:10 chronic

Step 2: is there the correct degree of compensation?

The direction of the compensation is always in the same direction as the primary disorder. The magnitude of the compensation is determined solely by the magnitude of the primary disorder.
If, in a case of metabolic acidosis, the bicarbonate falls to 10 then the pCO2 should fall to 232 to compensate. If the pCO2 is not in that range a second primary disorder is present If the pCO2 is less than 21, then the patient also has a respiratory alkalosis If the pCO2 is over 25, the patient has an additional respiratory acidosis

Each primary acid base disorder has its own formula for prediction: Metabolic acidosis: Winters Formula
1.5 HCO3 + 8 2

Metabolic alkalosis:
pCO2 rises 0.7 per mmol rise in HCO3

Respiratory acidosis:
1 or 3 mmol rise in HCO3 for 10 rise in pCO2

Respiratory alkalosis:
2 or 4 mmol fall in HCO3 for 10 fall in pCO2

Predicting pCO2 in metabolic acidosis


In metabolic acidosis the expected pCO2 can be estimated from the HCO3 Expected pCO2 = (1.5 x HCO3) + 8 2 If the pCO2 is higher than predicted then there is an addition respiratory acidosis If the pCO2 is lower than predicted there is an additional respiratory alkalosis

Predicting pCO2 in metabolic acidosis


Example:

7.23 / 78 / 19 / 8

pH / pO2 / pCO2 /

HCO3

Expected pCO2 = (1.5 x HCO3) + 8 2


Expected pCO2 = 18-22
Actual pCO2 is 19, which is within the predicted range, indicating a simple metabolic acidosis

Predicting pCO2 in metabolic acidosis


Example:

7.15 / 112 / 34 / 12

pH / pO2 / pCO2 / HCO3

Expected pCO2 = (1.5 x HCO3) + 8 2


Expected pCO2 = 16-20
Actual pCO2 is 34, which is above the predicted range, indicating an additional respiratory acidosis

Predicting pCO2 in metabolic alkalosis


In metabolic acidosis the expected pCO2 can be estimated from the HCO3 pCO2 should rise 0.7 for every increase in HCO3 of one, 2

Example:

7.46 / 78 / 49 / 34

pH / pO2 / pCO2 / HCO3

HCO3 is 34-24 = 10 above normal, so pCO2 should be 7 over normal, 472


Actual pCO2 is 49, which is within the predicted range, indicating a simple metabolic alkalosis

Respiratory disorders
Metabolic compensation for respiratory acid-base disorders is slow. So the predicted bicarbonate needs to be calculated for pre-compensation, called acute, and after compensation, called chronic. Chronic compensation is complete so the pH will be closer to normal at the expense of increased alteration of serum bicarbonate.

Why is metabolic compensation slow?


The lungs ventilate 12 moles of acid per day as carbon dioxide The kidneys excrete less than 0.1 mole of acid per day as ammonia, phosphate and free hydrogen ions The high excretion capacity of the lungs relative to the kidneys means that metabolic disorders can be rapidly compensated by the lungs while respiratory disorders take a long time to be compensated for by the kidneys.

Respiratory acidosis
For every increase in pCO2 of 10 mmHg the bicarbonate should increase:
1 mEq/L in acute 3 mEq/L in chronic

Example:

7.19 / 78 / 78 / 30

pH / pO2 / pCO2 / HCO3

pCO2 is 38 above normal, so


if the condition is acute the HCO3 should be 282
If the condition is chronic the HCO3 should be 35 2
Actual HCO3 is 30, which is within the predicted range, for acute respiratory acidosis and outside of the range for chronic.

Respiratory alkalosis
For every decrease in pCO2 of 10 mmHg the bicarbonate should decrease:
2 mEq/L in acute 4 mEq/L in chronic

Example:

7.44 / 78 / 25 / 17

pH / pO2 / pCO2 / HCO3

pCO2 is 15 below normal, so


If the condition is acute the HCO3 should be decreased by 3 or 212
If the condition is chronic the HCO3 should be decreased by 6 or 18 2

Summary of metabolic compensation for respiratory acid-base disorders


PCO2 :
Respiratory acidosis
Acute Chronic

HCO3
Respiratory alkalosis

10:1 10:3
For every rise of 10 in the pCO2 the HCO3 will rise by 1 or 3

10:2 10:4
For every fall of 10 in pCO2 the HCO3 will fall by 2 or 4.

Now lets do some questions

Determine the primary Acid-Base disorder


Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Determine if the compensation is appropriate


Winters formula the HCO3 1:10 acute 3:10 chronic 2:10 acute 4:10 chronic

Determine the anion gap


Non-Anion gap Anion gap

Step 3: if you have metabolic acidosis, is there an anion gap?

What is the anion?


Metabolic acidosis is further evaluated by determining the anion associated with the increased H+ cation These can be differentiated by measuring the anion gap. It is either chloride Or it is not chloride

Non-Anion Gap Met Acid

Anion Gap Met Acid

Anion gap

Anion gap

Calculating the anion gap


Anion gap = Na (HCO3 + Cl) Normal at St John is 12
Varies by hospital Average anion gap in healthy controls is 6 3

Improving chloride assays have resulted in increased chloride levels and a decreased normal anion gap.

Other causes of a low anion gap


Increased chloride
Hypertriglyceridemia Bromide Iodide

Sodium

Chloride Bicarb

Decreased Unmeasured anions


Albumin Phosphorous Normal anion gap

Increased Unmeasured cations


Hyperkalemia Hypercalcemia Hypermagnesemia Lithium Increased cationic paraproteins
IgG

Albumin Phos IgA

Potassium Calcium Magnesium IgG

Evaluate the ABG


Acidosis or Alkalosis Acidosis or Alkalosis Metabolic oror Respiratory Metabolic Respiratory Isolated metabolic acidosis?
No. There is concomitant respiratory alkalosis.

7.38 / 212 / 27 / 16

pH / pO2 / pCO2 / HCO3

144 110
3.4 16

Predicted pCO2
(16 x 1.5) + 8 2 = 30-34

Anion gap or Non-Anion Gap Anion gap or Non-Anion Gap

Anion gap
144 (110 + 16) = 18

The anion gap acidosis


Uremia (mild) Ingestions
Methanol Ethylene glycol

L-Lactic acidosis
Salicylate intoxication Ischemia Cyanide intoxication
Nitroprusside

Ketoacidosis
DKA Starvation Alcoholic

Sepsis

Malignancy Metformin Liver failure Thiamine deciency

D-Lactic acidosis Pyroglutamic acidosis

GOLDMARK
The classic mnemonic, MUD PILES, sucks. The new mnemonic is GOLD MARK. Know it. G Glycols O Oxoproline: Pyroglutamic L L-lactic acidosis D D-Lactic acidosis M Methanol A Aspirin R Renal failure K Ketoacidosis
AN Mehta, JB Emmett , M Emmett, Lancet, 372, 9642, p 892, 2008

Now lets do some questions

Determine the primary Acid-Base disorder


Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis

Determine if the compensation is appropriate


Winters formula the HCO3 1:10 acute 3:10 chronic 2:10 acute 4:10 chronic

Determine the anion gap


Non-Anion gap Anion gap

Determine the osmolar gap


Osmolar gap Non-osmolar gap

Step 4: if you have an AGMA, is there an osmolar gap?

Osmolar gap
In the presence of a large anion gap (>20-25) of undetermined etiology you must rule out a toxic alcohol.
Methanol Ethylene Glycol

The low molecular weight of the alcohols means that modest ingestions have a relatively large impact on the serum osmolality
Few grams equals many milimoles

Their presence can be detected by comparing the measured osmolality (which includes the alcohol) to a calculated osmolality (which does not account for the alcohol). If the measured osmolality is signicantly more (>10) than the calculated osmolaility you have an osmolar gap.

BUN Glucose Ethanol Calculated osmolality = (2 Na) + + + 2.8 18 4.6

Question 4: evaluate the ABG


Acidosis or Alkalosis Acidosis or Alkalosis Metabolic oror Respiratory Metabolic Respiratory Isolated metabolic acidosis?
Yes. There is no concomitant respiratory disorder.

7.16 / 212 / 22 / 8

pH / pO2 / pCO2 / HCO3

142 110 46
88
5.4 8 2.2

Serum Osmolality: 312

Predictedgap 2 Osmolar Anion gappCO
(8 x 1.5) + 8 2 = Calc (110 + 8) = 142 Osmolality 18-22 x 142) + 46/2.8 + 88/18 = 24 (2
284 + 16 + 5 = 305

Anion gap or Anion gap or Non-Anion Gap Osmolar gap or Non-Osmolar Gap Non-Osmolar Gap

Osmolality Gap
312 305 = 7

Osmolar gap is not specic


Elevated osmolar gap will be found with:
Ethylene glycol Methanol Isopropyl alcohol Ketoacidosis Lactic acidosis Mannitol infusion Hypertriglyceridemia

Now lets do some questions

Determine the primary Acid-Base disorder


Metabolic Respiratory Respiratory Step 5: if you Metabolic an AGMA, determine have acidosis alkalosis acidosis alkalosis what the bicarbonate was before the anion Determine if the compensation is appropriate gap Winters formula the HCO3 1:10 acute 3:10 chronic

2:10 acute 4:10 chronic

Determine the anion gap


Non-Anion gap Anion gap

Determine the osmolar gap


Osmolar gap Non-osmolar gap

Determine the bicarbonate before


Pre-existing met. alkalosis Pre-existing NAGMA No pre-existing acid-base disorders

The acid-base time machine


If you have an anion gap metabolic acidosis the anion gap should increase by one for every one that the bicarbonate falls.

The acid-base time machine


Assume that the loss of bicarbonate due to addition of an anion is roughly 1:1 So for every increase in the anion gap of one the bicarbonate should drop by one

HCO3 = Anion Gap HCO3 before HCO3 now = AGcurrent AGnormal 12)
HCO3 before = HCO3 now + (AGcurrent AGnormal)

Evaluate:
Acidosis or Alkalosis Acidosis or Alkalosis Metabolic oror Respiratory Metabolic Respiratory Isolated metabolic acidosis?
Yes.

7.14 / 212 / 18 / 6

pH / pO2 / pCO2 / HCO3

134 104
3.4 8

Predicted pCO2
(8 x 1.5) + 8 2 = 18-22

Anion gap or Non-Anion Gap Anion gap or Non-Anion Gap Additional metabolic disorder?
Yes. Non-anion gap metabolic acidosis

Anion gap
134 (104 + 8) = 22

Bicarbonate prior to anion gap


HCO3 + (AG 12) = HCO3 before 8 + (22 12) = 18

Now lets do some questions

Most common error in acid-base


Personal observation

AE
66 yo white male PMHx DM, paraplegia 2 MVA Klebsiella urosepsis induced ARF Blood Cxrs + for Klebsiella

8/16/04
139 5.4 138 4.4 107 20 104 21 31 1.2 38 1.9

8/29/04
139 111 56 3.9 14 2.8 Start bicarbonate gtt

8/26/04

8/30/04
137 104 3.5 22 62 3.0

8/28/04
137 108 53 3.8 16 2.9 Start oral bicarbonate

7.52 / 31 / 46 / 25 Respiratory alkalosis


Predicted HCO3: Acute: 23 Chronic: 21

Fin