Acid Base Disorders

Viyeka Sethi PGY 4 Med-Peds

Four Main Acid-Base Disorders

Disorder Primary Alteration
Metabolic Acidosis Metabolic Alkalosis Respirator y Acidosis

Secondary Response

Mechanism of Response

in plasma HCO3

in plasmaHyperventilation pCO2

Hypoventilation in plasma HCO3 increase in pCO2 in plasma pCO2 in plasmaIncrease in acid HCO3excretion; increase in reabsorption of HCO3 in plasmaSuppression of acid excretion;

Respirator y Alkalosis

in

Normal Values
Arterial pH HCO3 pCO2 pO2 7.40 24 40 >70 Venous <7.35 24 >40 <60

Step by Step
1.

Determine the primary disturbance:

Acidemia or Alkalemia: look at the pH < 7.40 = acidemia > 7.40 = alkalemia Respiratory or Metabolic: look at HCO3 and CO2 HCO3 = primary metabolic acidosis pCO2 = primary respiratory acidosis and vice versa for alkalosis

2.

Determine acute or chronic for Respiratory Disturbance:

o o

Compensation attempts to normalize pH but can be present with an abnormal pH Expected change in pCO2 best used for primary metabolic disturbance and expected change in HCO3 for primary respiratory disturbance

Respiratory Disturbance Compensation

pCO2 Acute Resp. Acidosis Chronic Resp. Acidosis pCO2 Acute Resp. Alkalosis Chronic Resp. Alkalosis in pH in HCO3

10 10

0.08 0.03 in pH 0.08 0.03

1 3
in HCO3

10 10

2 5

3.
o

Primary Metabolic Disturbance:

Calculate anion gap : Na (Cl + HCO3) Normal = 12 +/- 2 If gap is >20 then there is primary metabolic acidosis regardless of pH or bicarb. Helps narrow differential with a anion gap or non-anion gap metabolic acidosis

o o

4.

Assess appropriate respiratory compensation for metabolic disorder:

o o

Respiratory compensation is fast Winters formula:

Expected pCO2 = (1.5 * HCO3) + 8 (+/-2)

If measured pCO2 is

< expected then co-existing resp. alkalosis > expected then co-existing

5.

Determine if other metabolic disturbances co-exist with AG metabolic acidosis:

o

Delta gap accounts for increase in anion gap and shows any variation in HCO3 If no other disorder is present then the calculation should be 24

Delta Gap
Corrected HCO3 = measured HCO3 + (AG - 12) o So if corrected HCO3 >24 then metabolic alkalosis co-exists

<24 then non-anion gap metabolic acidosis co-exists

Hints

Simple acid base compensatory response always in direction of primary variable Compensation is more pronounced with chronic disorders Normal pH indicates two or more acid-base disorders If given electrolytes, use them!!!

Pneumonics for pnuemonic lovers

Metabolic Acidosis Anion Gap Metabolic Acute Resp. Metabolic Acidosis Non- Acidosis Alkalosis Gap anything CLEVERPD
causing hypoventilatio n

Respiratory Alkalosis
CHAMPS

MUDPILERS HARDUPS

Methanol

disease on depression Uremia Licorice Hypocapnia DKA/Alcoholic Acetazolamide Airway Endocrine Anxiety obstruction Renal Tubular ketoacidosis (Conn/Cushing Mech. Pulmonary Acidosis /Bartters) Paraldehyde Ventilation edema Diarrhea Vomiting Isoniazid Progesterone Pneumonia Excess alkali Lactic acidosis Uretero-Pelvic Salicylates Hemo/Pneum shunt Refeeding Ethanol Sepsis othorax PostPostRenal Neuromuscul hypercapnia failure/Rhabdo hypocapnia Spironolactone ar Diuretics Salicylates

Hyperalimentati CNS

Contraction

CNS

Case 1

3 yo boy with diarrhea is evaluated in the pCO2 = (1.5 * HCO3) + 8 Expected ER. Initial ABG Alkalemia or acidemia? +/-2 shows: So, Low pH = acidemia Expected pCO2 = (1.5 * 10) + 8 Primary disturbance resp. or ph 7.23 +/-2 metabolic? =(15) + 8 +/-2 Low HCO3 2 metabolic acidosis HCO3 10 =23 +/- = Normal AG so no need for Delta gap pCO2 23 So, we have a metabolic acidosis equation with respiratory compensation BUT Is there adequate respiratory AG - 13
compensation? (Use Winters formula)

Case 2

5 yo boy presents to ED with dyspnea for 3 days. ABG shows Acidemia or alkalemia? the following: Low pH = Acidemia pH 7.35 Primary Resp. or Metabolic paCO2 60 disturbance? Respiratory Check yourself.using rules for paO2 57 Primary Resp disturbance For every 10 increase in pCO2 HCO3 - 31

pH decreases by .08 acutely or .03 chronically HCO3 increases by 1 acutely or 3 chronically

Case 3

15 yo with 4 Acidemia of vomiting and days or alkalemia? High ph = alkalemia fever. Respiratory or Metabolic? High HCO3 = metabolic pH- 7.50 Na- 138 Anion Gap? 138 (80 + 34) = pCO2- 42 Cl- 80 24 Is Resp. compensation appropriate? pO2- 80 HCO3- 34
Checking the Delta gap only useful in a primary metabolic acidosis.

Exp. pCO2 = (1.5 * HCO3) + 8 +/-2 =(51) + 8 +/-2 =59 +/- 2 o, NO the CO2 is lower so we have a Co-existent resp.alkalosis

Case 4