Acid Base Disorders

David J. Ladin, M.D. Chief Resident PSHMC/GSH Family and Community Medicine Residency Program

Objectives
Identify and evaluate an Acid Base
disorder

Prevent death from Acidosis/Alkalosis

Clinical Scenario 1
70 y/o male with a h/o PUD has been vomiting for 2 weeks. ABG: 7.40/40/pO2/24 BMP: Na 150, K 2.6, Cl 86, CO2 26, BUN 100, Cr 2.5

20 y/o female in DKA

ABGpH: 6.97 pCO2: 27 HCO3: 6

What do you think?

If pure metabolic acidosis then: pCO2 = (1.5)x(6) + 8 = 17 [+/- 2]

So..

Metabolic acidosis w/ Respiratory acidosis Fatigue from compensation

ABG Analysis The Basics!

1. Acidosis or Alkalosis?
pH <7.35 Acidemia pH >7.45 Alkalemia

2. Respiratory or Metabolic process? 3. Is there a mixed process going on?

Can we use CO2 from BMP?

Total of all CO2 present in the blood~ Normally 24 30 mEq/L
Carbonic Acid, Pure dissolved CO2, Bicarbonate, and Carbamino Compounds BMP: CO2=4 HCO3 = 2-3

Chloride
Low chloride = metabolic alkalosis Na to Cl ratio ~ 1.25-1.40
Normal ratio 140, 105 1.33 Hypochloremic 155, 105 1.50

High ratio: Cl relatively low (alkalosis) Low ratio: Cl relatively high (acidosis)

Anion Gap
Normal: 8-15 AG <20 rarely serious acidosis AG >30 rarely benign MUDPILES Normal AG acidosis: HARDUP

Delta Anion Gap + Delta HCO3

In AG Met Acidosis Decrease HC03 = Increase in AG So AG / HCO3 = 1
IF >1 there is superimposed alkalosis IF 0 there is non-anion gap acidosis IF 0-1 there is both AG + non AG acidosis

Severe diarrhea, cachectic, Kussmaul respirations

7.10/18/pO2/7 Na= 155 Cl= 133 CO2= 9 AG = 0 HCO3 = 16

Compensation
Metabolic Acidosis
- pCO2 = 1.5 x HCO3 +8 (+/- 2)

Metabolic Alkalosis
- pCO2 = 0.9 x HCO3 + 15

- General Respiratory Compensation

- 10 mmHg pCO2 = pH 0.08 opposite

Metabolic Compensation - Slow

Chronic Hypercapnia HCO3 increases 3.5 mmol/L for each 10 mmHg increase in PaCO2 > 40
Chronic Hypocapnia HCO3 decreases 5 mmol/L for each 10 mmHg decrease in PaCO2 <40

65 y/o COPD Exacerbation

7.23/85/pO2/35
A. Pure Chronic Resp Acidosis? B. Superimposed Acute Resp. Acidosis? C. Superimposed Acute Resp. Alkalosis?

7.23/85/pO2/35

For every 10 mmHg elevation of chronic pCO2 Bicarb is 3.5 above normal (35-2411 11/3.53. 3x10=30. 40+30=70)
Baseline 7.32/70/pO2/35 Acute Respiratory Acidosis +

Bicarbonate for Acidosis?

What are the dangers?
Increased intracellular acidosis Increases CO2 and ventilation requirements Hypernatremia NS has 154 meq of Na in 1 Liter Bicarb has 1000 meq of Na in 1 Liter
1 amp Bicarb has 50 meq of Na (1/3 NS)

When to give Bicarb?

Low pH - < 6.9
Low HCO3 - </= 5 If pCO2 > 1.5 (HCO3 +8) Ventilate!

Metabolic Alkalosis
Low Chloride: NaCl ratio >1.4 1. Chloride responsive
Vomiting, dehydration, diuretics

2. Chloride unresponsive
Cushing, Corticosteroid, hyperaldosteronism

Clinical Scenario 1
Dual Disorder
Low Chloride = metabolic alkalosis AG: 150 112 = 38 HCO3= 24-24= 0 AG = 38-12 = 26 (mixed disorder) >1 confirms superimposed alkalosis

Questions?
Adrogue, Horacio. Et. Al. Management of Life-

threatening Acid-Base Disorders. NEJM. Jan 1, 1998

Isenhour, Jennifer and Slovis, Corey. Arterial

blood gas analysis: A 3 step approach to acidbase disorders. The Journal of Respiratory Diseases. Vol 29, No 2, Feb 2008.