ABGs Steps in Acid/Base evaluation Step 1) obtain ABG and lytes Step 2) check validity How do you determine

if ABG is valid? 1. C02 on lytes should be 2 mEq/L higher than HC03- on ABG 2. Henderson-Hasselbalch equation: [H+] = 78 [H+] = 60 [H+] = 50 [H+] = 40 [H+] = 32 [H+] = 26 [H+] = 20 [H+] = 24 x C02 HC03pH = 7.1 pH = 7.2 pH = 7.3 pH = 7.4 pH = 7.5 pH = 7.6 pH = 7.7

Step 3) determine if respiratory/metabolic and academia/alkylemia Step 4) determine if mixed by applying compensations What are normal compensations? Respiratory Acidosis o Acute: 1 mEq/L HC03- per 10 mmHg C02 o Chronic: 3 mEq/L HC03- per 10 mmHg C02 Respiratory Alkalosis o Acute: 2 mEq/L HC03- per 10 mmHg C02 o Chronic: 5 mEq/L HC03- per 10 mmHg C02 Metabolic Acidosis o Change in PC02 = 1.2 x change in HC03Metabolic Alkylosis o Change in PC02 = 0.6 x change in HC03-

Step 5) determine Anion Gap Anion Gap = Na+ - [HC03- + Cl-] Normal Anion Gap = 12 www.4medstudents.com

If albumin is low, must correct anion gap o Decrease in albumin by 10 = you must increase anion gap by 4

Step 6) determine if Anion Gap is the only process going on: change in Anion Gap = Change in HC03-

Step 7) DDx of increased Anion Gap MUDPILES CAT Methanol Uremia DKA (and other ketoacidoses ie. Starvation & ETOH) Paraldehyde Isoniazide / Iron Lactic Acid o Type A: hypoperfusion (ischemic territory & hypoxia) o Type B: cannot metabolize lactic acid (ie. Liver failure, severe alcoholism and thiamine defficiency o D-lactate: produced by GI infection Ethylene Glycol Salicylates Cyanide ? ?

Step 8) Determine if there is an increased Osmolar Gap (>10) Calculated osmolarity = 2x[Na+] + glucose + urea Osmolar gap = measured osmalirity calculated osmoalirty increased osmolar gap (>10) = increased unmeasured osmoles (ie. Alcohols) DDx of increased Osmolar Gap o MAE-DIE o Methanol o Acetone o Ethanol o Diuretic (mannitol) o Isopropyl Alcohol o Ethylene Glycol

Step 9) Determine if there is a change in the A-a gradient (>10) Calculate the PA02 www.4medstudents.com

o PA02 = Fi02 x (Patm PH20) (1.25 x PaC02) o PA02 = 0.21 x (760 47) (1.25 x PaC02) o PA02 = 150 (1.25 x PaC02) A-a gradient = PA02 Pa02

Step 10) Causes of an increased A-a gradient (>10) V/Q mismatch o Asthma o COPD (chronic bronchitis) o Intraalveolar filling (ie. Pulmonary edema, pneumonia) o Interstitial lung disease o Alveolar disease o Pulmonary vascular disease Shunting (severe V/Q mismatch) o Atelectasis o Intracardiac or intrapulmonary shunt ? decreased diffusion

O2 Sat curve Y axis: O2 sat X axis: pO2 30,60,90 rule o pO2 30 = O2 sat 60% o pO2 60 = O2 sat 90% 55-88 rule (when govt. gives home O2) o pO2 55 = O2 sat 88%

DDx of A/B disorders Metabolic Acidosis: o Normal Anion Gap Direct loss of HCO3 (diarrhea, proximal RTA) Indirect loss of HCO3 (failure of new HCO3 production) CRF not enough nephrons to make HCO3 Hyperkalemia H+ leaves PCT cells so HCO3 not made Acetazolamide use inhibits carbonic anhydrase in PCT o Increased Anion Gap MUDPILES CAT Methanol Uremia DKA (and other ketoacidoses ie. Starvation & ETOH)

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Paraldehyde Isoniazide / Iron Lactic Acid Type A: hypoperfusion (ischemic territory & hypoxia) Type B: cannot metabolize lactic acid (ie. Liver failure, severe alcoholism and thiamine defficiency D-lactate: produced by GI infection Ethylene Glycol Salicylates Cyanide

Metabolic Alkalosis: o ECF Volume Depleted decr GFR so cant excrete extra HCO3 Diuretic use Decreases ECFV with same amount of HCO3 in it Vomiting Lose H+ in vomit so net is high HCO3 o ECF Volume Normal/High Hyperaldosteronism ie adrenal tumor or CAH high K+ excretion, so K+ leaves cells to compensate and H+ goes into PCT cells and activates carbonic anhydrase Renal failure + ingestion of alkaline foods cant excrete excess HCO3 Edematous states with diuretic use Same as diuretic use above, but resulting ECFV is N Chloride-responsive: (treat by giving Cl-) vomiting, contraction alkalosis o Chloride-resistant: diuretics (loop and thiazides), low K+, high aldo, Barters syndrome, Gittlemans syndrome

Respiratory Alkalosis: o Neurological causes: Anxiety, stroke, brainstem disorders o Direct brain stem stimulation Salicylates, Pregnancy, liver disease, sepsis o Pulmonary Diseases Things that stimulate intrapulmonary receptors by inflammatory or other mediators o Hypoxemia due to Lung disease (pneumonia, PE, asthma, pulmonary edema), anemia, high altitude

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Respiratory Acidosis: o Wont breathe (neurological lesions) Sedative drugs (narcotics), severe CNS disease (trauma), Pickwickian syndrome (extreme obesity), hypothyroidism, central sleep apnea o Cant breathe Muscle weakness (muscular dystrophy), kyphoscoliosis, pleural disease, parenchymal lung disease (pneumonia, pulm edema)

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