Acid/Base Disorders 2020

©Stephen D. Sisson/Ambulatory Curriculum

Part 1: Metabolic acidosis: differential diagnosis
Elevated Anion Gap Normal Anion Gap Decreased Anion Gap
• Methanol • Diarrhea • Bromide
• Uremia • Ureteral Diversion • Albumin (low)*
• DKA/AKA/Drugs (e.g.metformin) • RTA • Multiple myeloma
• Phosphate/paraldehyde • Hyperalimentation
• Ischemia/INH/Iron • Addison disease/Acetazolamide/Amphotericin *Add 2.5 to anion gap for every 1g/dl that albumin i
• Lactate • Miscellaneous (toluene, chloridorrhea, 4g/dl
• Ethylene Glycol topiramate)
• Starvation/Salicylates
Part 2: Metabolic acidosis: related facts
• Urine anion gap: Urine Na + Urine K – Urine Cl; if >0, suggests Type 1 or Type 4 RTA; if <0, suggests other cause
• Corrected bicarbonate: Calculate change in anion gap and change in serum bicarbonate; if serum bicarbonate decreases significantly more than
anion gap increases, suspect co-existing normal anion gap metabolic acidosis
• Respiratory compensation: pCO2 should be 1.5(HCO3) + 8 +/- 2
Part 3: Osmolar gap
• If measured serum osmolality >10 points higher than estimated, suspect presence of osmotically active substance
• Estimate serum osmolality as 2[Na] + BUN/2.8 + Glu/18
• Most common substances are methanol, ethylene glycol, isopropyl alcohol, toluene
Part 4: Metabolic alkalosis: differential diagnosis
Saline responsive (Urine Cl <10) Saline Resistant (Urine Cl >10)
• Vomiting If hypertensive:
• NG suction • Cushing syndrome; Conn syndrome; Renal artery stenosis; Renal failure + alkali
• Over-diuresis If not hypertensive
• Post hypercapnia • Hypomagnesemia; hypokalemia; Bartter syndrome; Gitelman syndrome; laxative abuse licorice
Part 5: Metabolic alkalosis: related facts: Respiratory compensation: For every 1 unit increase in serum HCO3, pCO2 increases 0.5-1
Part 6: Respiratory acidosis: differential diagnosis
Chest cavity Central causes Lung/airways
• Neurologic/muscular disease • Sedation/narcotics • Pneumonia
• Kyphoscoliosis • Respiratory center hypofunction from • Pulmonary edema
• Pleural effusion ischemia/infection/infarct • Reactive airways
• Pneumothorax • Obstructive sleep apnea • Foreign body
• Flail chest • Tumor
Part 7: Respiratory alkalosis: differential diagnosis
Systemic Central causes Lung/airways
• Sepsis • Respiratory center hyperfunction from • Pulmonary embolus
• Salicylates ischemia/infection/infarct • Restrictive lung dis.
• Liver failure • CNS tumor • Reactive airways
• Hypothyroidism • Progesterone • Pneumonia
• Pregnancy • Pain/Anxiety
• Hypotension • High altitude
• CHF • Fever
• Severe anemia
Part 8: Compensation in respiratory disorders

Disorder Change in pCO2 Compensatory change in HCO3 (per pCO2 change of 10) Change in pH
Acute Respiratory Acidosis Increased +1 -0.08
Chronic Respiratory Acidosis Increased +3-4 -0.03
Acute Respiratory Alkalosis Decreased -2 unpredictable
Chronic Respiratory Alkalosis Decreased -5 unpredictable

Part 9: Converting venous blood gas to arterial blood gas results

Blood sample source Conversion factor to arterial blood gas result
Central venous blood gas: pH Add 0.05
Central venous blood gas: pCO2 Subtract 5mm Hg
Peripheral blood gas: pH Add 0.03*
Peripheral blood gas: pCO2 Subtract 3-8mm Hg*
*less reliable