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Joel Topf, M.D. Assistant Clinical Professor of Medicine Wayne State University School of Medicine http://www.pbuids.com
Getting acid-base
Acid base physiology is the regulation of hydrogen ion concentration
A normal hydrogen Every change of 0.3 pH units concentration is 40 nmol/L
represents a change in H+ by This is .00004 mmol/L
a factor of 2
So
It is measured on a negative log scale called pH, normal is 7.4
pH = 6.8
Is this patient sick?
Grand mal seizure
Methanol toxicity
Increased HCO3, increases pH. Increased CO2 compensates to reduce the change in pH.
Decreased HCO3, decreases pH. Decreased CO2 compensates to reduce the change in pH.
Increased CO2, decreases pH. Increased HCO3 compensates to reduce the change in pH.
Metabolic acidosis
Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis
HCO3
pCO2
pCO2
HCO3
If all three variables move in the same direction the disorder is metabolic; if they move in discordant directions it is respiratory
Primary
Compensation
pCO2
HCO3
HCO3
pCO2
pH
Metabolic acidosis
Respiratory alkalosis
Respiratory acidosis
Metabolic alkalosis
HCO3
pCO2
pCO2
HCO3
Acidosis or alkalosis
If the pH is less than 7.4 it is acidosis
If the pH is greater than 7.4 it is alkalosis
2.
7.2 / 78 / 25 / 16
pH / pO2
/
pCO2 / HCO3
1.
Acidosis or alkalosis
If the pH less than 7.4 7.4 it is acidosis
If the pH is is less than it is acidosis
If the pH is greater than 7.4 it is alkalosis
the pH is greater than 7.4 it is alkalosis
2.
If the pH, bicarbonate pCO2 all move in the same direction If thepH, bicarbonate andand pCO2 all move in the same (up or direction (up or down) it is metabolic down) it is metabolic If the pH, bicarbonate and pCO2 move in discordant directions (up and down) it is it is respiratory and down)respiratory
Metabolic Acidosis
7.5 / 55 / 24 / 36
pH / pO2
/
pCO2 / HCO3
1. 2. 3. 4.
Respiratory acidosis Respiratory acidosis Metabolic acidosis Respiratory alkalosis Respiratory alkalosis alkalosis Metabolic alkalosis Respiratory alkalosis
The direction of the compensation is always in the same direction as the primary disorder.
The magnitude of the compensation is determined solely by the magnitude of the primary disorder.
If, in a case of metabolic acidosis, the bicarbonate falls to 10 then the pCO2 should fall to 232 to compensate.
If the pCO2 is not in that range a second primary disorder is present
If the pCO2 is less than 21, then the patient also has a respiratory alkalosis
If the pCO2 is over 25, the patient has an additional respiratory acidosis
Each primary acid base disorder has its own formula for prediction:
Metabolic acidosis: Winters Formula
1.5 HCO3 + 8 2
Metabolic alkalosis:
pCO2 rises 0.7 per mmol rise in HCO3
Respiratory acidosis:
1 or 3 mmol rise in HCO3 for 10 rise in pCO2
Respiratory alkalosis:
2 or 4 mmol fall in HCO3 for 10 fall in pCO2
7.23 / 78 / 19 / 8
pH / pO2 / pCO2 /
HCO3
7.15 / 112 / 34 / 12
pH / pO2 / pCO2 / HCO3
Example:
7.46 / 78 / 49 / 34
pH / pO2 / pCO2 / HCO3
Respiratory disorders
Metabolic compensation for respiratory acid-base disorders is slow.
So the predicted bicarbonate needs to be calculated for pre-compensation, called acute, and after compensation, called chronic.
Chronic compensation is complete so the pH will be closer to normal at the expense of increased alteration of serum bicarbonate.
Respiratory acidosis
For every increase in pCO2 of 10 mmHg the bicarbonate should increase:
1 mEq/L in acute 3 mEq/L in chronic
Example:
7.19 / 78 / 78 / 30
pH / pO2 / pCO2 / HCO3
Respiratory alkalosis
For every decrease in pCO2 of 10 mmHg the bicarbonate should decrease:
2 mEq/L in acute 4 mEq/L in chronic
Example:
7.44 / 78 / 25 / 17
pH / pO2 / pCO2 / HCO3
HCO3
Respiratory alkalosis
10:1
10:3
For every rise of 10 in the pCO2 the HCO3 will rise by 1 or 3
10:2
10:4
For every fall of 10 in pCO2 the HCO3 will fall by 2 or 4.
Anion gap
Anion gap
Improving chloride assays have resulted in increased chloride levels and a decreased normal anion gap.
Sodium
Chloride Bicarb
7.38 / 212 / 27 / 16
pH / pO2 / pCO2 / HCO3
144 110
3.4 16
Predicted pCO2
(16 x 1.5) + 8 2 =
30-34
Anion gap
144 (110 + 16) =
18
L-Lactic acidosis
Salicylate intoxication
Ischemia
Cyanide intoxication
Nitroprusside
Ketoacidosis
DKA
Starvation
Alcoholic
Sepsis
GOLDMARK
The classic mnemonic, MUD PILES, sucks. The new mnemonic is GOLD MARK. Know it.
G
Glycols
O
Oxoproline: Pyroglutamic
L
L-lactic acidosis
D
D-Lactic acidosis
M
Methanol
A
Aspirin
R
Renal failure
K
Ketoacidosis
AN Mehta, JB Emmett , M Emmett, Lancet, 372, 9642, p 892, 2008
Osmolar gap
In the presence of a large anion gap (>20-25) of undetermined etiology you must rule out a toxic alcohol.
Methanol
Ethylene Glycol
The low molecular weight of the alcohols means that modest ingestions have a relatively large impact on the serum osmolality
Few grams equals many milimoles
Their presence can be detected by comparing the measured osmolality (which includes the alcohol) to a calculated osmolality (which does not account for the alcohol). If the measured osmolality is signicantly more (>10) than the calculated osmolaility you have an osmolar gap.
7.16 / 212 / 22 / 8
pH / pO2 / pCO2 / HCO3
142 110 46
88
5.4 8 2.2
Serum Osmolality: 312
Predictedgap
2
Osmolar
Anion gappCO
(8 x 1.5) + 8 2 =
Calc (110 + 8) = 142 Osmolality
18-22
x 142) + 46/2.8 + 88/18 =
24
(2
284 + 16 + 5 = 305
Anion gap or Anion gap or Non-Anion Gap Osmolar gap or Non-Osmolar Gap Non-Osmolar Gap
Osmolality Gap
312 305 = 7
HCO3 = Anion Gap
HCO3 before HCO3 now = AGcurrent AGnormal
12)
HCO3 before = HCO3 now + (AGcurrent AGnormal)
Evaluate:
Acidosis or Alkalosis
Acidosis or Alkalosis
Metabolic oror Respiratory
Metabolic Respiratory
Isolated metabolic acidosis?
Yes.
7.14 / 212 / 18 / 6
pH / pO2 / pCO2 / HCO3
134 104
3.4 8
Predicted pCO2
(8 x 1.5) + 8 2 =
18-22
Anion gap or Non-Anion Gap
Anion gap or Non-Anion Gap
Additional metabolic disorder?
Yes.
Non-anion gap metabolic acidosis
Anion gap
134 (104 + 8) =
22
AE
66 yo white male
PMHx DM, paraplegia 2 MVA
Klebsiella urosepsis induced ARF
Blood Cxrs + for Klebsiella
8/16/04
139
5.4
138
4.4
107 20 104 21
31
1.2
38
1.9
8/29/04
139
111
56
3.9
14
2.8
Start bicarbonate gtt
8/26/04
8/30/04
137 104 3.5
22
62
3.0
8/28/04
137
108
53
3.8
16
2.9
Start oral bicarbonate
Fin