Causes Anion Gap Metabolic acidosis (MUDPILES) Non-Gap Metabolic Acidosis Methanol (wood alcohol) blindness Renal tubular

acidosis (RTA)renal bicarb loss Uremia Diarrhea & other bowel loss GI losses Diabetic ketoacidosis Carbonic anhyrdrase inhibitors* Paraldehyde (sedative hypnotic) Infection, INH, iron tablets Lactic acid Ethylene glycol (antifreeze) renal failure Salicylate *Although carbonic anhydrase inhibitors can cause non-gap acidosis, other diuretics (ie-thiazide and loop diuretics) cause metabolic alkalosis

Electrolytes: [Na+] [K+] [HCO3-] [Cl-]

140mEq/L 5.0 mEq/L 16 mEq/L 85 mEq/L

Arterial blood gas: pO2 95 mmHg pH 7.35 (-7.45) pCO2 30 mmHg 4 Steps in Assessment of AB Disorders 1. Examine pH: acidosis or alkalosis 2. What is a min or primary diagnosis: metabolic or respiratory 3. Calculate anion gap 4. Determine if theres compensation Step 1: Determine acid or alkaline. pH = 7.35 acidosis Step 2: Determine type of acidosis. Low [HCO3-] (normal ~26mEq/L) metabolic acidosis Step 3: Determine cause of metabolic acidosis via anion gap Anion gap = [Na+]-([Cl-] + [HCO3-]) or [Na+]- [Cl-] - [HCO3-]= 140-(85 +16) =39 Normal anion gap = 10 2 mEq/L Dx: metabolic acidosis with an anion gap increase

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Describe common metabolic acid base disorders, recognize them

Acidosis induced by either a. Fall in ECF bicarbonate concentration b. in pCO2 Alkalosis induced by either c. Elevation in ECF bicarbonate conc d. in pCO2 Pathologic change in HCO3 Metabolic Acidosis o *H++ and/or *HCO3-] Endogenous or exogenous acid addition, renal leakage of HCO 3 o Causes Impaired renal excretion Renal failure Tubular disorders impairing bicarb reabsorption Increased acid production diarrhea or endogenously lactic acid or ketoacids MUDPILES (CP. 148) addition of H+ Loss of HCO3- from + Gut = diarrhea loss of bicarb w/ attendant/resultant secretion of [H ] into plasma Kidney = renal tubular acidosis o Characterisitics: Chronic metabolic acidosis Normal plasma anion gap Absence of renal failure o Types Distal: H+ secretion impaired Proximal: faulty HCO3- reabsorption Metabolic alkalosis (CP.151) o High pH, high bicarb o [HCO3-] added and/or [H+] loss Vomiting, aldosteronism ( bicarb production), diuretic therapy ( bicarb conc) o Causes Vomiting or GI suction (which liberates HCO3- to plasma) + + ECF decreasesstimulates aldosterone and distal exchange of Na and H ion pH Net result *HCO3-+ and *H++ Diuretics or Contraction alkalosis Proximally-acting or loop diuretics ECF and stimulation of aldosterone + distal tubule H secretion ECF contracts (loses volume) around fixed amount of bicarb AKA contraction alkalosis pH rises Net result *HCO3-+ and *H++

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Respiratory Acidosis (hypoventilation) Low pH, high pCO2 pCO2 (hypoventilation secondary to lung ds, drugs slowing RR) cause fall in pH Causes Sedative overdose, respiration arrest, primary alveolar hypoventilation, brain tumor o Pulmonary COPD, acute obstruction, severe pulmonary edema or pneumonia, restrictive lung ds, o Metabolic myxedema (hypothyroidism) Respiratory Alkalosis (hyperventilation) High pH, low pCO2 pCO2 (hyperventilation due to anxiety, brainstem lesions) causing rise in pH o Metabolic Fever, salicylates, pregnancy (proges stimulates resp drive), gram neg sepsis, hi metab COMPENSATION Immediate buffering Rapid compensation o Respiratory compensation hours o Metabolic compensation days o Compensation can be complete or partial Ultimate correction (ideally) Concept Every acid base disorder has PRIMARY change and COMPENSATORY change Compensatory change is in system (resp or renal) that is OPPOSITE to primary change Primary metabolic problem resp compensation Primary resp problem metabolic compensation Degree of compensation predictable -> bring pH back to normal is goal Renal Compensation for Chronic Respiratory Acidosis (COPD) pCO2 rise = primary insult (normal 40-60) Kidney retains more HCO3 pH normalizes Reflection of this in blood o pH 7.4 o HCO3 = 35 mEq/L elevated (n- 26-28) o pCO2 = 50 mm Renal Compensation for Respiratory Alkalosis -/ pCO2 drop = primary insult /kidney excretes more HCO3 pH normalizes Reflection in blood o pH 7.4 o HCO3 = 15 mEq/L lowered (n- 26-28) o pCO2 = 15 mm