8 Steps To Solving Acid-Base Problems

1. Is the patient acidemic or alkalemic?

2. What is the minimum diagnosis?
3. Calculate the anion gap
Anion gap = (Na+) ( HCO3-) (Cl-)
4. Calculate the delta gap
gap = anion gap - 12
5. Calculate the "starting bicarbonate"
starting bicarbonate =gap + (HCO3-)
6. Calculate compensation (if necessary)
compensated PaCO2 =1.5(HCO3-) + 8
7.
List all of acid-base disorders identified
8. Clinical correlation
Primary Disorder Expected Compensation
Metabolic Acidosis PaCO2=1.5(HCO3-) + 8
Metabolic Alkalosis PaCO2=0.6(HCO3-)
Respiratory Acidosis
Acute
(HCO3-)=0.10PaCO2
Chronic
(HCO3-)=0.35PaCO2
Respiratory Alkalosis
Acute
(HCO3-)=0.2PaCO2
Chronic
(HCO3-)=0.5PaCO2
Anion Gap Acidosis
M=methanol
U=uremia
D=DKA
P=paraldehyde
I=iron,isoniazid/ibuprofen/inhalents/CN/strychnine/toluene
L=lactate:shock,sepsis,CHF,hypoxia,anemia,CO,CN,metformin,
ischemic bowel/liver fx/seizures/leukemia/inborn errors(G6PD,
fructose 1,6 diphosphatase, pyruvate carboxylase or dehydrogenase,
malignancy,heat stroke,D-lactic acidosis,mitochondrial
myopathies)
E=ethanol/ethylene glycol
S=salicylate, solvents, starvation ketoses
Hyperchloremic Metabolic Acidosis
Loss of bicarbonate from kidney or GI (replaced by HCl)
Gain of HCl (hyperalimentation-cationic acids from H+)
Renal loss (RTA, obstrx) Positive (+20)Urine Anion Gap (UAG)
UAG= (Na+)+(K+)-(Cl-) normal is Negative
GI loss (diarrhea, fistula, ileostomy,cholestyramine)neg UAG (-20)
Ingestion of CaCl2, MgCl2
Diamox, hypoaldosteronism,hyperparathyroidism,
Rapid NS hydration, post-tx DKA (replace HCO3- with Cl-)

Acid-Base Workbook
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Metabolic Alkalosis
UCl-<15=chloride responsive
Vomiting
NG suction
Volume contraction
Diuretics
Cystic Fibrosis
Posthypercapnea
Alkali syndrome
UCl->15=chloride resistant
Hypercortisolism (Cushing or Conns)
Hyperaldosteronism (1o or 2o)
2o:CHF,cirrhosis,ascites,malig HTN
Sodium bicarbonate therapy
Severe renal artery stenosis
Bartter,licorice,renin-tumor,chewing tob
Liddles,severe K dep,cong adrenal hyper
MISC:refeeding alkalosis, non-parathyroidCa
Respiratory Alkalosis
Early shock
Early sepsis
Fear, anxiety
Pulmonary dz (CHF,asthma, pneumonia,PE)
CNS infection or CVA
Pregnancy
Liver disease
Hyperthyroidism
Salicylates (adults)
Respiratory Acidosis
CNS depression
Paralysis of respiratory muscles
Airway obstruction
Respiratory failure
Chronic lung disease
Extreme kyphoscoliosis
Pickwickian syndrome