SlideShare a Scribd company logo
1 of 36
Metabolic Acidosis-Systematic 
Approach 
Dr. T.R. Chandrashekar 
Intensivist, Liver transplantation, 
BMC & RI super-specialty Hospital, 
Bangalore.
Conferenc 
e 
The confusion of one man multiplied 
by the number present. 
Lecture 
The art of transferring information from the 
notes of the lecturer to the notes of the 
students without passing through the minds of 
either.
Metabolic Acidosis- 
Definition 
• Primary reduction in serum 
bicarbonate (HCO-) 
3 
Low HCO3 
- can be due to renal compensation 
• Compensatory decrease in the 
arterial partial pressure of carbon 
dioxide (PaCO2 of ~1mmHg for 
every 1mmol/l fall in serum HCO3 
- 
to chronic respiratory alkalosis 
Look for pH 
HCO3 
- < than 10 mEq/L is diagnostic of 
metabolic acidosis 
concentration). 
• Reduction in blood pH.
CO2 + H2O H2CO3 H+ + HCO3 
- 
CO2 
H+ 
HCO3 
- 
Acid-Base physiology 
Respiratory 
Metabolic 
Bicarbonate is the transport from of COhence both should 
2 move in the same direction 
Ventilation controls PCO2 
Kidney losses H+ and reabsorbs bicarbonate (HCO-) 
3 
PCO2-Respiratory acidosis 
(Hypoventilation) 
PCO2-Respiratory alkalosis 
(Hyperventilation) 
HCO3 
- - Metabolic acidosis 
HCO3 
- - Metabolic Alkalosis
Metabolic acidosis is caused by either a 
gain of acid or a loss of HCO- 
3 
Gain of acid may result from 
• Over production of organic acids such as 
Common causes of Metabolic acidosis we 
encounter are 
Lactic acidosis-Hypoperfusion –sepsis 
Diabetic ketoacidosis 
Acute kidney injury 
Uremia 
Ketoacids or lactic acid 
• Metabolism of ingested toxins such as 
methanol, ethylene glycol, and paraldehyde. 
• Decreased renal excretion of hydrogen ion as in 
uremic acidosis and distal (type I) renal tubular 
acidosis. 
Loss of HCO3 
- may result from 
• Renal loss in proximal renal tubular acidosis. 
• Gastrointestinal loss in diarrhea.
Metabolic acidosis-compensatory 
response 
DISORDER PRIMARY 
RESPONSES 
COMPENSATORY RESPONSE 
Respiratory alkalosis 
Metabolic 
acidosis 
 PH  HCO3 
-  pCO2 
The PaCO2 begins to fall within 1–2hr 
Should reach a steady–state value by 12– 
24hr 
If not patient has hypoventilation- Resp 
Acidosis
Normal Compensatory Response- 
Numbers 
• Winters formula 
• PaCO2 = 1.5 x [HCO3-] + 8 ± 2 
If Serum (HCO3-) = 10mEq/L 
• PaCO2 = 1.5 x [10] + 8 ± 2 = between 21 and 
25mmHg. 
• Respiratory alkalosis (if PCO2 < 21) or 
Respiratory acidosis (if PCO2>25) 
• Last two digits of pH = PaCO2 
• pH being 7.23 = PaCO2should fall to 
23mmHg
Resistance to action of infused 
Catecholamines & Insulin 
Adverse effects 
of Metabolic 
acidosis 
Impaired cellular 
energy production 
Stimulation of 
interleukin 
production 
Decreased cardiac 
contractility 
and cardiac output 
Predisposition to 
ventricular arrhythmias 
Alteration in oxygen binding to 
hemoglobin 
Arterial vasodilation and 
hypotension 
Impaired leukocyte function 
Suppression of lymphocyte function
Diagnosis of metabolic acidosis 
• History 
• 40 year presents with 3 day old peritonitis septic 
BP 80/60mmHg 
• RR 40/min 
• Metabolic acidosis 
• ABG- pH 7.21 / PCO2 = 22 / HCO3- = 9 mEq/l 
• Lactate 6 mmol/L 
• Post operative cardiac arrest 
• Metabolic + respiratory acidosis
Metabolic acidosis-is suspected when 
• HCO- 
3 is low 
• Serum chloride is elevated 
• Increased Anion gap 
??? 
• There is electrochemical balance 
• Sum of all negatively charged electrolytes (anions) = 
Sum of all positively charged electrolytes (cations). 
• More anions are unmeasured than are cations 
• Anion gap is thus an artifact of measurement, and 
not a physiologic reality
More anions are unmeasured than are 
cations 
• Major unmeasured anions 
• albumin 
• phosphates 
• sulfates 
• organic anions- ketones 
and lactate 
Anion gap …
Anion gap is based on only three 
electrolytes: 
sodium, chloride and bicarbonate 
• AG = [Na+] - [Cl- +HCO3 
-] = 
• 140 - 128 = 12mEq/L 
(venous CO2 = HCO- 
3 can be used).
Anion gap issues 
• A 1 gm/dl decrease in serum albumin causes a 2.5 
mEq/L drop in the AG. 
• One problem with the anion gap is deciding what value 
is truly abnormal. 
• In the majority of patients with anion gap between 16 
and 20 mEq/L, no specific anion gap acidosis can be 
diagnosed. 
• Above 20 mEq/L the probability of a true anion gap 
acidosis increases markedly (and is 100% if the AG is 
above 29 mEq/L) 
• As a practical matter, you should consider an AG 20 
mEq/L as reflecting an anion gap metabolic acidosis 
and search for the cause should be instituted
Method to identify mixed 
disorders in 
elevated Anion Gap Metabolic 
acidosis 
The Delta Ratio 
(Δ/Δ)
THE DELTA RATIO (Δ/Δ) 
• Increase in the AG should be equal to the decrease 
in bicarbonate so the ratio between these two 
changes (which we call the delta ratio) should be 
equal to one. 
• anion gap / [HCO3-] 
• = Measured anion gap – Normal anion gap 
• Normal [HCO3-] – Measured [HCO3-] 
• 
(AG – 12) 
(24 - 
[HCO3-]) 
=
The Delta Ratio (Δ/Δ)….. 
• More than 50% of excess acid is buffered 
intracellularly and by bone, not by HCO3-. 
• Most of the excess anions remain in the ECF - 
because anions cannot easily cross the lipid bilayer 
of the cell membrane. 
• As a result, the elevation in the anion gap usually 
exceeds the fall in the plasma [HCO3- ]. 
Delta ratio Assessment Guidelines 
< 0.4 Hyperchloremic normal anion gap acidosis 
< 1 High AG & normal AG acidosis 
1 to 2 Pure Anion Gap Acidosis 
Lactic acidosis: average value 1.6 
DKA more likely to have a ratio closer to 1 due to urine ketone 
loss 
> 2 High AG acidosis and a concurrent metabolic alkalosis 
or a pre-existing compensated respiratory acidosis
Causes of metabolic acidosis 
• Excessive normal saline infusion 
• Chronic kidney disease 
• Adrenal insufficiency (primary or 
secondary) 
• Diarrhea 
• Intestinal, pancreatic, or biliary 
fistulae 
• Proximal RTA // Distal RTA 
• Ureterosigmoidostomy / 
Ureteroileostomy 
Increased anion gap 
• Methanol intoxication 
• Uremic acidosis 
• Diabetic ketoacidosis 
• Paraldehyde intoxication 
• Iron/ INH 
• Lactic acidosis 
• Ethylene glycol 
intoxication 
• Salicylate intoxication 
Normal (hyperchloremic) anion 
gap
• A previously well 55 year old woman is admitted with a 
complaint of severe vomiting for 5 days sec to intestinal 
obstruction. BP 80/60 mmHg RR 28/min 
• ABG: Electrolytes 
• pH 7.23 , Na 140 
• PCO2 22mmHg K 3.4, 
• HCO3- 9 Cl 77 
P 
acidosis 
Creatinine 2.1 
• History : Elevated anion gap acidosis secondary to 
lactic acidosis in the setting of severe persistent 
vomiting which may lead to hypovolemia, and/or 
Metabolic alkalosis in the setting of persistent vomiting 
• Look at the pH. 
The pH is low, (less than 7.35) therefore by 
definition, patient is acidemic. 
• What is the process? Look at the PCO2, HCO3- .
• Distinguish the initial change from the compensatory 
response. 
• A low HCO3- represents acidosis and is consistent with 
the pH, therefore it must be the initial change. 
• The low PCO2 must be the compensatory response. 
• Since the primary change involves HCO3-, this is a 
metabolic process, i.e. Metabolic Acidosis. 
• Calculate the 
The anion gap is Na - (Cl + HCO3-) = 134 -(77 + 9) = 
48 
Is ? Calculate the estimated 
PCO2. 
Using Winter's formula; PCO2 = 1.5 × [HCO3-]) + 8 ± 
2 
• 1.5 × 9 + 8 ± 2 = 19.5 - 23.5. (23) 
• Since the actual PCOfalls within the estimated range,
Since anion gap elevated, calculate the to rule out 
concurrent metabolic alkalosis 
• Delta ratio = Measured anion gap – Normal anion gap 
• Normal [HCO3-] – Measured [HCO3-] 
• 
(AG – 12) 
(24 - 
[HCO3-]) 
= 
• 48-12 36 
= = 2.6 
• 24-9 14 
• Since the delta ratio is greater than 2, we can 
deduce that there is a concurrent metabolic 
alkalosis. This is likely due to vomiting. 
• Mixed elevated anion gap metabolic acidosis 
and metabolic alkalosis likely due to lactic 
acidosis and vomiting.
There is always a underlying cause- treatment 
of which is the most important step in acid 
base problems 
Deodorant 
Flush 
Problem 
.Patient has 
Peritonitis/ Sepsis 
BP 80/60 mmHg 
pH of 7.12, HCO3 
14, Lactate of 6 
Metabolic acidosis 
NAHCO3 
Infusion to 
correct pH 
Fluid 
resuscitation 
Inotropes/ 
vasopressors 
Surviving 
Sepsis bundle 
Sugar control 
Etc..
Treatment of metabolic acidosis 
• Some types of metabolic acidosis will require 
HCO3- therapy and some will not. Therefore, 
determining the cause of the metabolic 
acidosis is central to appropriate 
management. 
• Using base to treat is controversial because 
of a lack of definitive benefit and because of 
potential complications. 
• The failure of sodium bicarbonate 
administration to improve cardiovascular 
function, morbidity and mortality could result, 
in part, to adverse effects of the therapy.
Adverse effects of IV bicarbonate therapy 
• Exacerbation of intracellular acidosis caused by 
generation of the permeable gas CO2 in the process 
of buffering, 
• Hypertonicity of the extracellular fluid when 
bicarbonate is given as a hypertonic solution, volume 
overload, 
• Overshoot metabolic alkalosis, 
• Potentiation of organic acid synthesis, 
• Acceleration of cellular Na+–H+ exchange causing 
deleterious increments in cellular Na+ and Ca2+.
IV bicarbonate therapy 
• pH falls below 7.10 + Respiratory fatigue or developing 
hemodynamic instability emergency HC03- administration, 
regardless of the cause of the acidosis. 
• HCO3- deficit = .5 X Body weight (kg) X ([HCO3-(desired)] 
- [HCO3-(measured)) 
• Give this calculated amount slowly and re-measure pH, 
HCO3-and PCO2 after the HCO3- is given to assess the 
effect of therapy on the acid-base status. 
• In the case of an ongoing acidosis, repeated doses of 
HCO3- may be required until the underlying cause of the 
acidosis can be corrected. 
• 8.4% NaHCO3 solution is used (50ml = 50 mEq) 
(osmolality of 2,000 mOsm/kg.)
IV Bicarbonate therapy 
• In patients with renal impairment or evidence 
of volume overload, consider utilization of 
hemofiltration or dialysis 
• In patients with CO2 retention and adequate 
renal function, consider administration of 
THAM.(tris-hydroxymethyl aminomethane)
Lactic acidosis 
• Lactic acid in not bad – is an alternate energy 
shuttle in stress situations. 
• A lactate of > 2 is significant in sick patients 
• Is a very good prognostic indicator 
• Lactate normalisation time is a better 
prognostic indicator 
• Studies indicate use of lactate levels in goal-directed 
therapy may improve clinical outcome. 
lactate monitoring is a valuable parameter in 
the early resuscitation 
• Can be present in whom systemic 
hypoperfusion is not present
chandrakavi@gmail.c 
om
• Too much normal saline hyperchloremic acidosis 
• Can we explain why increased Cl- causes Acidosis??
NORMAL SALINE INFUSION LEADS 
TO HYPERCHLOREMIC ACIDOSIS 
Explanation of acidosis by HH method Explanation of acidosis by Stewart 
Increase in 
Cl- more than Na+ 
SID falls 
Dilution 
of HCO3 
- 
CO2 
CO2 increases 
HCO3 
- unchanged 
pH falls 
Metabolic 
CO2 
production 
pH falls 
Water H2O 
dissociates 
and adds H+ 
In NS- Na/Cl is 150 mEq/L 
In ECF -Na 145/ Cl 102
TWO APPROACHES USED IN ACID BASE 
EVALUATION 
Traditional approach Stewart approach 
Henderson- 
Hasselbalch 
Metabolic’ component 
of 
acid-base physiology is 
bicarbonate 
HCO3 
- ( KIDNEY) 20 
pH ~ --------- ------------ 
PaCO2 (LUNG) 1 
Water is an important source of H + 
Ionic Strength: weak and strong 
Electrical Neutrality is maintained at 
all times 
Metabolic’ component of acid-base 
physiology is Strong Ion Difference 
(SID) 
SID=(Na+ +K+ +Ca2++Mg2+)-(Cl-+Lactate) 
is 40 to 42 mEq/L
TWO COMMONLY USED APPROACHES 
Henderson-Hasselbalch Stewart approach 
pH rely on three independent Factors 
1. SID- Strong ion difference 
2. (ATOT)- total concentration of weak acids 
(albumin and phosphate) 
3. PCO2 
‘Metabolic’ component of acid-base 
physiology is not 
dependent on bicarbonate but 
instead, predominately on SID 
HCO3 
- ( KIDNEY) 
pH ~ --------- ------ 
PaCO2 (LUNG)
STEWART APPROACH 
• Stewart (physical chemistry principles) suggested 
that the traditional Henderson-Hasselbalch 
explanation of the underlying physiology and 
pathophysiology is wrong. 
• “Traditional” approach merely looks at a mirror image 
of that proposed by Stewart. In fact HH equation is a 
component of Stewart approach 
• The ‘‘modern’’ approach is clinically difficult, more 
CPU based 
• Requires knowledge of protein and phosphate 
concentrations and more electrolytes than may be 
routinely measured
MODIFIED STEWART APPROACH 
= ([Na+] – [Cl-]) – 38 (1) 
{where 38 is normal average difference in strong ions – Na and Cl} 
= 0.25x [4.2–albumin] (2) 
Thus true BE = BE – [1 + 2] 
At bedside- it works well! 
NaCl effect 
Albumin effect 
Story, Belmo, Balasubramanyam 
where 4.2 is normal serum albumin
Diagnosis of metabolic acidosis 
• History 
• 40 year presents with 3 day old peritonitis septic BP 
80/60mmHg 
• RR 40/min 
• ABG- pH 7.21 / PCO2 = 21/ HCO3- = 9 mEq/l 
• Lactate 6 mmol/L 
• Metabolic acidosis with compensation 
• Same patient is drowsy has pneumonia RR 12/mt 
• ABG- pH 7.11 / PCO2 = 41 / HCO3- = 9 mEq/l 
• Metabolic acidosis + Respiratory Acidosis
Equivalent rise of AG and Fall of HCO3…… 
….Pure Anion Gap Metabolic Acidosis 
Discrepancy…….. in rise & fall 
+ Non AG M acidosis, + M Alkalosis
Δ AG =Measured Anion gap-12 
Delta gap = HCO3 + Δ AG 
Delta Gap = 24 …… AG Met Acidosis 
< 24 ….. Non AG Met acidosis 
> 24 ….. Non AG Met acidosis + Meta. Alkalosis

More Related Content

What's hot

Metabolic acidosis and Approach
Metabolic acidosis and ApproachMetabolic acidosis and Approach
Metabolic acidosis and ApproachSamir Jha
 
Abg.2 Arterial blood gas analysis and example interpretation
Abg.2 Arterial blood gas analysis and example interpretationAbg.2 Arterial blood gas analysis and example interpretation
Abg.2 Arterial blood gas analysis and example interpretationsamirelansary
 
ARTERIAL BLOOD GASES INTERPRETATION
ARTERIAL BLOOD GASES INTERPRETATIONARTERIAL BLOOD GASES INTERPRETATION
ARTERIAL BLOOD GASES INTERPRETATIONDr.RMLIMS lucknow
 
Metabolic alkalosis Dr. Mohamed Abdelhafez
Metabolic alkalosis Dr. Mohamed AbdelhafezMetabolic alkalosis Dr. Mohamed Abdelhafez
Metabolic alkalosis Dr. Mohamed Abdelhafeznephro mih
 
Metabolic acidosis ppt (types and pathophysiology)
Metabolic acidosis ppt (types and pathophysiology) Metabolic acidosis ppt (types and pathophysiology)
Metabolic acidosis ppt (types and pathophysiology) Dryogeshcsv
 
Acid base disorders
Acid base disordersAcid base disorders
Acid base disordersqbank org
 
Diagnosis and treatment of acid base disorders(1)
Diagnosis and treatment of acid base disorders(1)Diagnosis and treatment of acid base disorders(1)
Diagnosis and treatment of acid base disorders(1)aparna jayara
 
Metabolic acidosis by Dr. Neha Singh
Metabolic acidosis by Dr. Neha SinghMetabolic acidosis by Dr. Neha Singh
Metabolic acidosis by Dr. Neha SinghNidhi Singh
 
Arterial Blood Gas (ABG) analysis
Arterial Blood Gas (ABG) analysisArterial Blood Gas (ABG) analysis
Arterial Blood Gas (ABG) analysisAbdullah Ansari
 
Seminar (dr. santosh) medicine practical approach to acid base disorders
Seminar (dr. santosh) medicine practical approach to acid base disordersSeminar (dr. santosh) medicine practical approach to acid base disorders
Seminar (dr. santosh) medicine practical approach to acid base disordersSantosh Narayankar
 
Metabolic acidosis
Metabolic acidosisMetabolic acidosis
Metabolic acidosisrazishahid
 
Metabolic alkalosis
Metabolic alkalosisMetabolic alkalosis
Metabolic alkalosisFarragBahbah
 
Respiratory acidosis and alkalosis
Respiratory acidosis and alkalosisRespiratory acidosis and alkalosis
Respiratory acidosis and alkalosisNikhil Agarwal
 
Hyperkalemia and its management
Hyperkalemia and its managementHyperkalemia and its management
Hyperkalemia and its managementMEEQAT HOSPITAL
 
SIMPLE AND SYSTEMATIC APPROACH TO Acid base disorders
SIMPLE AND SYSTEMATIC APPROACH TO Acid base disorders  SIMPLE AND SYSTEMATIC APPROACH TO Acid base disorders
SIMPLE AND SYSTEMATIC APPROACH TO Acid base disorders aishwaryajoshi18
 

What's hot (20)

Metabolic acidosis and Approach
Metabolic acidosis and ApproachMetabolic acidosis and Approach
Metabolic acidosis and Approach
 
Abg.2 Arterial blood gas analysis and example interpretation
Abg.2 Arterial blood gas analysis and example interpretationAbg.2 Arterial blood gas analysis and example interpretation
Abg.2 Arterial blood gas analysis and example interpretation
 
ARTERIAL BLOOD GASES INTERPRETATION
ARTERIAL BLOOD GASES INTERPRETATIONARTERIAL BLOOD GASES INTERPRETATION
ARTERIAL BLOOD GASES INTERPRETATION
 
ABG Analysis
ABG AnalysisABG Analysis
ABG Analysis
 
Metabolic alkalosis Dr. Mohamed Abdelhafez
Metabolic alkalosis Dr. Mohamed AbdelhafezMetabolic alkalosis Dr. Mohamed Abdelhafez
Metabolic alkalosis Dr. Mohamed Abdelhafez
 
ABG Interpretation
ABG InterpretationABG Interpretation
ABG Interpretation
 
Metabolic acidosis ppt (types and pathophysiology)
Metabolic acidosis ppt (types and pathophysiology) Metabolic acidosis ppt (types and pathophysiology)
Metabolic acidosis ppt (types and pathophysiology)
 
Acid base disorders
Acid base disordersAcid base disorders
Acid base disorders
 
Diagnosis and treatment of acid base disorders(1)
Diagnosis and treatment of acid base disorders(1)Diagnosis and treatment of acid base disorders(1)
Diagnosis and treatment of acid base disorders(1)
 
Metabolic acidosis by Dr. Neha Singh
Metabolic acidosis by Dr. Neha SinghMetabolic acidosis by Dr. Neha Singh
Metabolic acidosis by Dr. Neha Singh
 
Metabolic Acidosis
Metabolic AcidosisMetabolic Acidosis
Metabolic Acidosis
 
Arterial Blood Gas (ABG) analysis
Arterial Blood Gas (ABG) analysisArterial Blood Gas (ABG) analysis
Arterial Blood Gas (ABG) analysis
 
Seminar (dr. santosh) medicine practical approach to acid base disorders
Seminar (dr. santosh) medicine practical approach to acid base disordersSeminar (dr. santosh) medicine practical approach to acid base disorders
Seminar (dr. santosh) medicine practical approach to acid base disorders
 
Metabolic acidosis
Metabolic acidosisMetabolic acidosis
Metabolic acidosis
 
Metabolic alkalosis
Metabolic alkalosisMetabolic alkalosis
Metabolic alkalosis
 
Respiratory acidosis and alkalosis
Respiratory acidosis and alkalosisRespiratory acidosis and alkalosis
Respiratory acidosis and alkalosis
 
ABG Interpretation
ABG InterpretationABG Interpretation
ABG Interpretation
 
Hyperkalemia and its management
Hyperkalemia and its managementHyperkalemia and its management
Hyperkalemia and its management
 
SIMPLE AND SYSTEMATIC APPROACH TO Acid base disorders
SIMPLE AND SYSTEMATIC APPROACH TO Acid base disorders  SIMPLE AND SYSTEMATIC APPROACH TO Acid base disorders
SIMPLE AND SYSTEMATIC APPROACH TO Acid base disorders
 
ABG
ABGABG
ABG
 

Viewers also liked

A new perspective on metabolic acidosis
A new perspective on metabolic acidosisA new perspective on metabolic acidosis
A new perspective on metabolic acidosisstevechendoc
 
Metabolic acidosis
Metabolic acidosisMetabolic acidosis
Metabolic acidosissnich
 
Metbolic acidosis and alkalosis
Metbolic acidosis and alkalosisMetbolic acidosis and alkalosis
Metbolic acidosis and alkalosisShrirang Rao
 
Metabolic acidosis
Metabolic acidosisMetabolic acidosis
Metabolic acidosisaxeljm8
 
H1N1 Influenza -DR. K. A. PRAHLAD
H1N1 Influenza -DR. K. A. PRAHLADH1N1 Influenza -DR. K. A. PRAHLAD
H1N1 Influenza -DR. K. A. PRAHLADapollobgslibrary
 
10 Enduring Scientific remarks in Nephrology
10 Enduring  Scientific remarks in Nephrology10 Enduring  Scientific remarks in Nephrology
10 Enduring Scientific remarks in NephrologyKiwon Kim
 
Physical examination of urine
Physical examination of urinePhysical examination of urine
Physical examination of urineMostafa Sabry
 
Renal regulation of metabolic acidosis and alkalosis
Renal regulation of metabolic acidosis and alkalosis Renal regulation of metabolic acidosis and alkalosis
Renal regulation of metabolic acidosis and alkalosis Sana Arbab
 
Urine examination/cosmetic dentistry courses
Urine examination/cosmetic dentistry coursesUrine examination/cosmetic dentistry courses
Urine examination/cosmetic dentistry coursesIndian dental academy
 
Department of nephrology 2012 eng
Department of nephrology 2012 engDepartment of nephrology 2012 eng
Department of nephrology 2012 engnephrology-hsum
 
Diabetic nephropathy
Diabetic nephropathyDiabetic nephropathy
Diabetic nephropathyIrfan Elahi
 
Basic life support
Basic life support Basic life support
Basic life support Dina Ashraf
 
Hypertension - definitions, etiology and mechanisms
Hypertension - definitions, etiology and  mechanismsHypertension - definitions, etiology and  mechanisms
Hypertension - definitions, etiology and mechanismsToufiqur Rahman
 
Islamic method of slaughter is humane and scientific
Islamic method of slaughter is humane and scientificIslamic method of slaughter is humane and scientific
Islamic method of slaughter is humane and scientificShah Abbas
 
Acute Stroke protocol of management .. Dina Ashraf (ZUHP team 2012-2013 )
Acute Stroke protocol of management ..  Dina Ashraf  (ZUHP team 2012-2013 )Acute Stroke protocol of management ..  Dina Ashraf  (ZUHP team 2012-2013 )
Acute Stroke protocol of management .. Dina Ashraf (ZUHP team 2012-2013 )Dina Ashraf
 

Viewers also liked (20)

A new perspective on metabolic acidosis
A new perspective on metabolic acidosisA new perspective on metabolic acidosis
A new perspective on metabolic acidosis
 
Metabolic acidosis
Metabolic acidosisMetabolic acidosis
Metabolic acidosis
 
Metabolic acidosis
Metabolic acidosisMetabolic acidosis
Metabolic acidosis
 
Metbolic acidosis and alkalosis
Metbolic acidosis and alkalosisMetbolic acidosis and alkalosis
Metbolic acidosis and alkalosis
 
Metabolic acidosis
Metabolic acidosisMetabolic acidosis
Metabolic acidosis
 
Metabolic acidosis
Metabolic acidosisMetabolic acidosis
Metabolic acidosis
 
H1N1 Influenza -DR. K. A. PRAHLAD
H1N1 Influenza -DR. K. A. PRAHLADH1N1 Influenza -DR. K. A. PRAHLAD
H1N1 Influenza -DR. K. A. PRAHLAD
 
10 Enduring Scientific remarks in Nephrology
10 Enduring  Scientific remarks in Nephrology10 Enduring  Scientific remarks in Nephrology
10 Enduring Scientific remarks in Nephrology
 
Physical examination of urine
Physical examination of urinePhysical examination of urine
Physical examination of urine
 
Renal regulation of metabolic acidosis and alkalosis
Renal regulation of metabolic acidosis and alkalosis Renal regulation of metabolic acidosis and alkalosis
Renal regulation of metabolic acidosis and alkalosis
 
Urine examination/cosmetic dentistry courses
Urine examination/cosmetic dentistry coursesUrine examination/cosmetic dentistry courses
Urine examination/cosmetic dentistry courses
 
Department of nephrology 2012 eng
Department of nephrology 2012 engDepartment of nephrology 2012 eng
Department of nephrology 2012 eng
 
Diabetic nephropathy
Diabetic nephropathyDiabetic nephropathy
Diabetic nephropathy
 
Diabetic nephropathy
Diabetic nephropathyDiabetic nephropathy
Diabetic nephropathy
 
Urine examination
Urine examinationUrine examination
Urine examination
 
Anemia
AnemiaAnemia
Anemia
 
Basic life support
Basic life support Basic life support
Basic life support
 
Hypertension - definitions, etiology and mechanisms
Hypertension - definitions, etiology and  mechanismsHypertension - definitions, etiology and  mechanisms
Hypertension - definitions, etiology and mechanisms
 
Islamic method of slaughter is humane and scientific
Islamic method of slaughter is humane and scientificIslamic method of slaughter is humane and scientific
Islamic method of slaughter is humane and scientific
 
Acute Stroke protocol of management .. Dina Ashraf (ZUHP team 2012-2013 )
Acute Stroke protocol of management ..  Dina Ashraf  (ZUHP team 2012-2013 )Acute Stroke protocol of management ..  Dina Ashraf  (ZUHP team 2012-2013 )
Acute Stroke protocol of management .. Dina Ashraf (ZUHP team 2012-2013 )
 

Similar to Metabolic acidosis- Systematic analysis

ABG (Emergency Medicine)
ABG (Emergency Medicine)ABG (Emergency Medicine)
ABG (Emergency Medicine)kalyan ram
 
Acid base assessment 6 steps
Acid base assessment 6 stepsAcid base assessment 6 steps
Acid base assessment 6 stepsDr fakhir Raza
 
Acid Base Balance & ABG Interpretation
Acid Base Balance & ABG InterpretationAcid Base Balance & ABG Interpretation
Acid Base Balance & ABG InterpretationAnuradha
 
Understanding ABGs and spirometry
Understanding ABGs and spirometryUnderstanding ABGs and spirometry
Understanding ABGs and spirometryShivashankar S
 
acid-base disorders.pptx
acid-base disorders.pptxacid-base disorders.pptx
acid-base disorders.pptxpriadharshini31
 
Arterial blood gas analysis in clinical practice (2)
Arterial blood gas analysis in clinical practice (2)Arterial blood gas analysis in clinical practice (2)
Arterial blood gas analysis in clinical practice (2)Mohit Aggarwal
 
step by step approach to arterial blood gas analysis
step by step approach to arterial blood gas analysisstep by step approach to arterial blood gas analysis
step by step approach to arterial blood gas analysisikramdr01
 
ACID BASE DISORDERS 2.pptx
ACID BASE DISORDERS 2.pptxACID BASE DISORDERS 2.pptx
ACID BASE DISORDERS 2.pptxmusayansa
 
RENAL TUBULAR ACIDOSIS
RENAL TUBULAR ACIDOSISRENAL TUBULAR ACIDOSIS
RENAL TUBULAR ACIDOSISParth Nathwani
 
Acid-base disorders Abel T..pptx
Acid-base disorders Abel T..pptxAcid-base disorders Abel T..pptx
Acid-base disorders Abel T..pptxAbdirizakJacda
 
Arterial Blood Gases Analysis
Arterial Blood Gases AnalysisArterial Blood Gases Analysis
Arterial Blood Gases AnalysisGamal Agmy
 
American Thoracic Society Interpretation of ABG
American Thoracic Society Interpretation of ABGAmerican Thoracic Society Interpretation of ABG
American Thoracic Society Interpretation of ABGGamal Agmy
 
Acid-Base-balance.pdf
Acid-Base-balance.pdfAcid-Base-balance.pdf
Acid-Base-balance.pdfsiddhimeena3
 

Similar to Metabolic acidosis- Systematic analysis (20)

ABG (Emergency Medicine)
ABG (Emergency Medicine)ABG (Emergency Medicine)
ABG (Emergency Medicine)
 
Abg
AbgAbg
Abg
 
Acid base disorders
Acid base disordersAcid base disorders
Acid base disorders
 
ABGS Interpretation.pptx
ABGS Interpretation.pptxABGS Interpretation.pptx
ABGS Interpretation.pptx
 
Acid base assessment 6 steps
Acid base assessment 6 stepsAcid base assessment 6 steps
Acid base assessment 6 steps
 
Acid Base Balance & ABG Interpretation
Acid Base Balance & ABG InterpretationAcid Base Balance & ABG Interpretation
Acid Base Balance & ABG Interpretation
 
Understanding ABGs and spirometry
Understanding ABGs and spirometryUnderstanding ABGs and spirometry
Understanding ABGs and spirometry
 
Metabolic acidosis
Metabolic  acidosisMetabolic  acidosis
Metabolic acidosis
 
acid-base disorders.pptx
acid-base disorders.pptxacid-base disorders.pptx
acid-base disorders.pptx
 
Arterial blood gas analysis in clinical practice (2)
Arterial blood gas analysis in clinical practice (2)Arterial blood gas analysis in clinical practice (2)
Arterial blood gas analysis in clinical practice (2)
 
Dr hamed aleraky metabolic acidosis
Dr hamed aleraky   metabolic acidosisDr hamed aleraky   metabolic acidosis
Dr hamed aleraky metabolic acidosis
 
step by step approach to arterial blood gas analysis
step by step approach to arterial blood gas analysisstep by step approach to arterial blood gas analysis
step by step approach to arterial blood gas analysis
 
ACID BASE DISORDERS 2.pptx
ACID BASE DISORDERS 2.pptxACID BASE DISORDERS 2.pptx
ACID BASE DISORDERS 2.pptx
 
RENAL TUBULAR ACIDOSIS
RENAL TUBULAR ACIDOSISRENAL TUBULAR ACIDOSIS
RENAL TUBULAR ACIDOSIS
 
Acid-base disorders Abel T..pptx
Acid-base disorders Abel T..pptxAcid-base disorders Abel T..pptx
Acid-base disorders Abel T..pptx
 
Arterial Blood Gases Analysis
Arterial Blood Gases AnalysisArterial Blood Gases Analysis
Arterial Blood Gases Analysis
 
American Thoracic Society Interpretation of ABG
American Thoracic Society Interpretation of ABGAmerican Thoracic Society Interpretation of ABG
American Thoracic Society Interpretation of ABG
 
Acid-Base-balance.pdf
Acid-Base-balance.pdfAcid-Base-balance.pdf
Acid-Base-balance.pdf
 
DNB OSCE ON ABG
DNB OSCE ON ABGDNB OSCE ON ABG
DNB OSCE ON ABG
 
Acid base tut
Acid base tutAcid base tut
Acid base tut
 

More from chandra talur

How do I safely ventilate my patient inOT.pptx
How do I safely ventilate my patient inOT.pptxHow do I safely ventilate my patient inOT.pptx
How do I safely ventilate my patient inOT.pptxchandra talur
 
Advanced modes of Mechanical Ventilation-Do we need them?
Advanced modes of Mechanical Ventilation-Do we need them?Advanced modes of Mechanical Ventilation-Do we need them?
Advanced modes of Mechanical Ventilation-Do we need them?chandra talur
 
Arterial blood gas analysis assesment of oxygenation ventilation and acid base
Arterial blood gas analysis assesment of oxygenation ventilation and acid baseArterial blood gas analysis assesment of oxygenation ventilation and acid base
Arterial blood gas analysis assesment of oxygenation ventilation and acid basechandra talur
 
Physiological triggers for blood transfusion in the icu
Physiological triggers for  blood transfusion in the icuPhysiological triggers for  blood transfusion in the icu
Physiological triggers for blood transfusion in the icuchandra talur
 
New modes of mechanical ventilation TRC
New modes of mechanical ventilation TRCNew modes of mechanical ventilation TRC
New modes of mechanical ventilation TRCchandra talur
 
Mechanical ventilation in COPD Asthma drtrc
Mechanical ventilation in COPD Asthma drtrcMechanical ventilation in COPD Asthma drtrc
Mechanical ventilation in COPD Asthma drtrcchandra talur
 
Snake Bite Icu Management
Snake Bite Icu ManagementSnake Bite Icu Management
Snake Bite Icu Managementchandra talur
 
Hemodynamic Stabilisation In Septic Shock
Hemodynamic Stabilisation In Septic ShockHemodynamic Stabilisation In Septic Shock
Hemodynamic Stabilisation In Septic Shockchandra talur
 
Patho Physiology And Icu Management Of Septic Shock
Patho Physiology And Icu Management Of Septic ShockPatho Physiology And Icu Management Of Septic Shock
Patho Physiology And Icu Management Of Septic Shockchandra talur
 
How Best To Prevent & Manage Acute Renal failure
How Best To Prevent & Manage Acute Renal failureHow Best To Prevent & Manage Acute Renal failure
How Best To Prevent & Manage Acute Renal failurechandra talur
 
Swineflu Update, An Indian Prespective
Swineflu  Update, An Indian PrespectiveSwineflu  Update, An Indian Prespective
Swineflu Update, An Indian Prespectivechandra talur
 

More from chandra talur (11)

How do I safely ventilate my patient inOT.pptx
How do I safely ventilate my patient inOT.pptxHow do I safely ventilate my patient inOT.pptx
How do I safely ventilate my patient inOT.pptx
 
Advanced modes of Mechanical Ventilation-Do we need them?
Advanced modes of Mechanical Ventilation-Do we need them?Advanced modes of Mechanical Ventilation-Do we need them?
Advanced modes of Mechanical Ventilation-Do we need them?
 
Arterial blood gas analysis assesment of oxygenation ventilation and acid base
Arterial blood gas analysis assesment of oxygenation ventilation and acid baseArterial blood gas analysis assesment of oxygenation ventilation and acid base
Arterial blood gas analysis assesment of oxygenation ventilation and acid base
 
Physiological triggers for blood transfusion in the icu
Physiological triggers for  blood transfusion in the icuPhysiological triggers for  blood transfusion in the icu
Physiological triggers for blood transfusion in the icu
 
New modes of mechanical ventilation TRC
New modes of mechanical ventilation TRCNew modes of mechanical ventilation TRC
New modes of mechanical ventilation TRC
 
Mechanical ventilation in COPD Asthma drtrc
Mechanical ventilation in COPD Asthma drtrcMechanical ventilation in COPD Asthma drtrc
Mechanical ventilation in COPD Asthma drtrc
 
Snake Bite Icu Management
Snake Bite Icu ManagementSnake Bite Icu Management
Snake Bite Icu Management
 
Hemodynamic Stabilisation In Septic Shock
Hemodynamic Stabilisation In Septic ShockHemodynamic Stabilisation In Septic Shock
Hemodynamic Stabilisation In Septic Shock
 
Patho Physiology And Icu Management Of Septic Shock
Patho Physiology And Icu Management Of Septic ShockPatho Physiology And Icu Management Of Septic Shock
Patho Physiology And Icu Management Of Septic Shock
 
How Best To Prevent & Manage Acute Renal failure
How Best To Prevent & Manage Acute Renal failureHow Best To Prevent & Manage Acute Renal failure
How Best To Prevent & Manage Acute Renal failure
 
Swineflu Update, An Indian Prespective
Swineflu  Update, An Indian PrespectiveSwineflu  Update, An Indian Prespective
Swineflu Update, An Indian Prespective
 

Recently uploaded

Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...narwatsonia7
 
Call Girls Hsr Layout Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hsr Layout Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Hsr Layout Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hsr Layout Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceCollege Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceNehru place Escorts
 
Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.ANJALI
 
Case Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxCase Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxNiranjan Chavan
 
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi NcrDelhi Call Girls
 
Call Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...rajnisinghkjn
 
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...narwatsonia7
 
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Availablenarwatsonia7
 
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original PhotosBook Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photosnarwatsonia7
 
Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...
Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...
Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...sonalikaur4
 
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi NcrDelhi Call Girls
 
Glomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and  determinants of glomerular filtration .pptxGlomerular Filtration and  determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptxDr.Nusrat Tariq
 
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any TimeCall Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Timevijaych2041
 
Report Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxReport Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxbkling
 
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingCall Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingNehru place Escorts
 
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️saminamagar
 
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking ModelsMumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Modelssonalikaur4
 
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...saminamagar
 

Recently uploaded (20)

Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
Call Girls Kanakapura Road Just Call 7001305949 Top Class Call Girl Service A...
 
Call Girls Hsr Layout Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hsr Layout Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Hsr Layout Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Hsr Layout Just Call 7001305949 Top Class Call Girl Service Available
 
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort ServiceCollege Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
College Call Girls Vyasarpadi Whatsapp 7001305949 Independent Escort Service
 
Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.Statistical modeling in pharmaceutical research and development.
Statistical modeling in pharmaceutical research and development.
 
Case Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptxCase Report Peripartum Cardiomyopathy.pptx
Case Report Peripartum Cardiomyopathy.pptx
 
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In Sarojini Nagar Delhi Ncr
 
Call Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jayanagar Just Call 7001305949 Top Class Call Girl Service Available
 
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
Noida Sector 135 Call Girls ( 9873940964 ) Book Hot And Sexy Girls In A Few C...
 
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
Call Girls Frazer Town Just Call 7001305949 Top Class Call Girl Service Avail...
 
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service AvailableCall Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
Call Girls Jp Nagar Just Call 7001305949 Top Class Call Girl Service Available
 
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original PhotosBook Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
Book Call Girls in Yelahanka - For 7001305949 Cheap & Best with original Photos
 
Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...
Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...
Call Girls Near Airport Ahmedabad 9907093804 All Area Service COD available A...
 
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
9873777170 Full Enjoy @24/7 Call Girls In North Avenue Delhi Ncr
 
Glomerular Filtration and determinants of glomerular filtration .pptx
Glomerular Filtration and  determinants of glomerular filtration .pptxGlomerular Filtration and  determinants of glomerular filtration .pptx
Glomerular Filtration and determinants of glomerular filtration .pptx
 
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any TimeCall Girls Viman Nagar 7001305949 All Area Service COD available Any Time
Call Girls Viman Nagar 7001305949 All Area Service COD available Any Time
 
Report Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptxReport Back from SGO: What’s New in Uterine Cancer?.pptx
Report Back from SGO: What’s New in Uterine Cancer?.pptx
 
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment BookingCall Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
Call Girls Service Nandiambakkam | 7001305949 At Low Cost Cash Payment Booking
 
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
call girls in aerocity DELHI 🔝 >༒9540349809 🔝 genuine Escort Service 🔝✔️✔️
 
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking ModelsMumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
Mumbai Call Girls Service 9910780858 Real Russian Girls Looking Models
 
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...call girls in Connaught Place  DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
call girls in Connaught Place DELHI 🔝 >༒9540349809 🔝 genuine Escort Service ...
 

Metabolic acidosis- Systematic analysis

  • 1. Metabolic Acidosis-Systematic Approach Dr. T.R. Chandrashekar Intensivist, Liver transplantation, BMC & RI super-specialty Hospital, Bangalore.
  • 2. Conferenc e The confusion of one man multiplied by the number present. Lecture The art of transferring information from the notes of the lecturer to the notes of the students without passing through the minds of either.
  • 3. Metabolic Acidosis- Definition • Primary reduction in serum bicarbonate (HCO-) 3 Low HCO3 - can be due to renal compensation • Compensatory decrease in the arterial partial pressure of carbon dioxide (PaCO2 of ~1mmHg for every 1mmol/l fall in serum HCO3 - to chronic respiratory alkalosis Look for pH HCO3 - < than 10 mEq/L is diagnostic of metabolic acidosis concentration). • Reduction in blood pH.
  • 4. CO2 + H2O H2CO3 H+ + HCO3 - CO2 H+ HCO3 - Acid-Base physiology Respiratory Metabolic Bicarbonate is the transport from of COhence both should 2 move in the same direction Ventilation controls PCO2 Kidney losses H+ and reabsorbs bicarbonate (HCO-) 3 PCO2-Respiratory acidosis (Hypoventilation) PCO2-Respiratory alkalosis (Hyperventilation) HCO3 - - Metabolic acidosis HCO3 - - Metabolic Alkalosis
  • 5. Metabolic acidosis is caused by either a gain of acid or a loss of HCO- 3 Gain of acid may result from • Over production of organic acids such as Common causes of Metabolic acidosis we encounter are Lactic acidosis-Hypoperfusion –sepsis Diabetic ketoacidosis Acute kidney injury Uremia Ketoacids or lactic acid • Metabolism of ingested toxins such as methanol, ethylene glycol, and paraldehyde. • Decreased renal excretion of hydrogen ion as in uremic acidosis and distal (type I) renal tubular acidosis. Loss of HCO3 - may result from • Renal loss in proximal renal tubular acidosis. • Gastrointestinal loss in diarrhea.
  • 6. Metabolic acidosis-compensatory response DISORDER PRIMARY RESPONSES COMPENSATORY RESPONSE Respiratory alkalosis Metabolic acidosis  PH  HCO3 -  pCO2 The PaCO2 begins to fall within 1–2hr Should reach a steady–state value by 12– 24hr If not patient has hypoventilation- Resp Acidosis
  • 7. Normal Compensatory Response- Numbers • Winters formula • PaCO2 = 1.5 x [HCO3-] + 8 ± 2 If Serum (HCO3-) = 10mEq/L • PaCO2 = 1.5 x [10] + 8 ± 2 = between 21 and 25mmHg. • Respiratory alkalosis (if PCO2 < 21) or Respiratory acidosis (if PCO2>25) • Last two digits of pH = PaCO2 • pH being 7.23 = PaCO2should fall to 23mmHg
  • 8. Resistance to action of infused Catecholamines & Insulin Adverse effects of Metabolic acidosis Impaired cellular energy production Stimulation of interleukin production Decreased cardiac contractility and cardiac output Predisposition to ventricular arrhythmias Alteration in oxygen binding to hemoglobin Arterial vasodilation and hypotension Impaired leukocyte function Suppression of lymphocyte function
  • 9. Diagnosis of metabolic acidosis • History • 40 year presents with 3 day old peritonitis septic BP 80/60mmHg • RR 40/min • Metabolic acidosis • ABG- pH 7.21 / PCO2 = 22 / HCO3- = 9 mEq/l • Lactate 6 mmol/L • Post operative cardiac arrest • Metabolic + respiratory acidosis
  • 10. Metabolic acidosis-is suspected when • HCO- 3 is low • Serum chloride is elevated • Increased Anion gap ??? • There is electrochemical balance • Sum of all negatively charged electrolytes (anions) = Sum of all positively charged electrolytes (cations). • More anions are unmeasured than are cations • Anion gap is thus an artifact of measurement, and not a physiologic reality
  • 11. More anions are unmeasured than are cations • Major unmeasured anions • albumin • phosphates • sulfates • organic anions- ketones and lactate Anion gap …
  • 12. Anion gap is based on only three electrolytes: sodium, chloride and bicarbonate • AG = [Na+] - [Cl- +HCO3 -] = • 140 - 128 = 12mEq/L (venous CO2 = HCO- 3 can be used).
  • 13. Anion gap issues • A 1 gm/dl decrease in serum albumin causes a 2.5 mEq/L drop in the AG. • One problem with the anion gap is deciding what value is truly abnormal. • In the majority of patients with anion gap between 16 and 20 mEq/L, no specific anion gap acidosis can be diagnosed. • Above 20 mEq/L the probability of a true anion gap acidosis increases markedly (and is 100% if the AG is above 29 mEq/L) • As a practical matter, you should consider an AG 20 mEq/L as reflecting an anion gap metabolic acidosis and search for the cause should be instituted
  • 14. Method to identify mixed disorders in elevated Anion Gap Metabolic acidosis The Delta Ratio (Δ/Δ)
  • 15. THE DELTA RATIO (Δ/Δ) • Increase in the AG should be equal to the decrease in bicarbonate so the ratio between these two changes (which we call the delta ratio) should be equal to one. • anion gap / [HCO3-] • = Measured anion gap – Normal anion gap • Normal [HCO3-] – Measured [HCO3-] • (AG – 12) (24 - [HCO3-]) =
  • 16. The Delta Ratio (Δ/Δ)….. • More than 50% of excess acid is buffered intracellularly and by bone, not by HCO3-. • Most of the excess anions remain in the ECF - because anions cannot easily cross the lipid bilayer of the cell membrane. • As a result, the elevation in the anion gap usually exceeds the fall in the plasma [HCO3- ]. Delta ratio Assessment Guidelines < 0.4 Hyperchloremic normal anion gap acidosis < 1 High AG & normal AG acidosis 1 to 2 Pure Anion Gap Acidosis Lactic acidosis: average value 1.6 DKA more likely to have a ratio closer to 1 due to urine ketone loss > 2 High AG acidosis and a concurrent metabolic alkalosis or a pre-existing compensated respiratory acidosis
  • 17. Causes of metabolic acidosis • Excessive normal saline infusion • Chronic kidney disease • Adrenal insufficiency (primary or secondary) • Diarrhea • Intestinal, pancreatic, or biliary fistulae • Proximal RTA // Distal RTA • Ureterosigmoidostomy / Ureteroileostomy Increased anion gap • Methanol intoxication • Uremic acidosis • Diabetic ketoacidosis • Paraldehyde intoxication • Iron/ INH • Lactic acidosis • Ethylene glycol intoxication • Salicylate intoxication Normal (hyperchloremic) anion gap
  • 18. • A previously well 55 year old woman is admitted with a complaint of severe vomiting for 5 days sec to intestinal obstruction. BP 80/60 mmHg RR 28/min • ABG: Electrolytes • pH 7.23 , Na 140 • PCO2 22mmHg K 3.4, • HCO3- 9 Cl 77 P acidosis Creatinine 2.1 • History : Elevated anion gap acidosis secondary to lactic acidosis in the setting of severe persistent vomiting which may lead to hypovolemia, and/or Metabolic alkalosis in the setting of persistent vomiting • Look at the pH. The pH is low, (less than 7.35) therefore by definition, patient is acidemic. • What is the process? Look at the PCO2, HCO3- .
  • 19. • Distinguish the initial change from the compensatory response. • A low HCO3- represents acidosis and is consistent with the pH, therefore it must be the initial change. • The low PCO2 must be the compensatory response. • Since the primary change involves HCO3-, this is a metabolic process, i.e. Metabolic Acidosis. • Calculate the The anion gap is Na - (Cl + HCO3-) = 134 -(77 + 9) = 48 Is ? Calculate the estimated PCO2. Using Winter's formula; PCO2 = 1.5 × [HCO3-]) + 8 ± 2 • 1.5 × 9 + 8 ± 2 = 19.5 - 23.5. (23) • Since the actual PCOfalls within the estimated range,
  • 20. Since anion gap elevated, calculate the to rule out concurrent metabolic alkalosis • Delta ratio = Measured anion gap – Normal anion gap • Normal [HCO3-] – Measured [HCO3-] • (AG – 12) (24 - [HCO3-]) = • 48-12 36 = = 2.6 • 24-9 14 • Since the delta ratio is greater than 2, we can deduce that there is a concurrent metabolic alkalosis. This is likely due to vomiting. • Mixed elevated anion gap metabolic acidosis and metabolic alkalosis likely due to lactic acidosis and vomiting.
  • 21. There is always a underlying cause- treatment of which is the most important step in acid base problems Deodorant Flush Problem .Patient has Peritonitis/ Sepsis BP 80/60 mmHg pH of 7.12, HCO3 14, Lactate of 6 Metabolic acidosis NAHCO3 Infusion to correct pH Fluid resuscitation Inotropes/ vasopressors Surviving Sepsis bundle Sugar control Etc..
  • 22. Treatment of metabolic acidosis • Some types of metabolic acidosis will require HCO3- therapy and some will not. Therefore, determining the cause of the metabolic acidosis is central to appropriate management. • Using base to treat is controversial because of a lack of definitive benefit and because of potential complications. • The failure of sodium bicarbonate administration to improve cardiovascular function, morbidity and mortality could result, in part, to adverse effects of the therapy.
  • 23. Adverse effects of IV bicarbonate therapy • Exacerbation of intracellular acidosis caused by generation of the permeable gas CO2 in the process of buffering, • Hypertonicity of the extracellular fluid when bicarbonate is given as a hypertonic solution, volume overload, • Overshoot metabolic alkalosis, • Potentiation of organic acid synthesis, • Acceleration of cellular Na+–H+ exchange causing deleterious increments in cellular Na+ and Ca2+.
  • 24. IV bicarbonate therapy • pH falls below 7.10 + Respiratory fatigue or developing hemodynamic instability emergency HC03- administration, regardless of the cause of the acidosis. • HCO3- deficit = .5 X Body weight (kg) X ([HCO3-(desired)] - [HCO3-(measured)) • Give this calculated amount slowly and re-measure pH, HCO3-and PCO2 after the HCO3- is given to assess the effect of therapy on the acid-base status. • In the case of an ongoing acidosis, repeated doses of HCO3- may be required until the underlying cause of the acidosis can be corrected. • 8.4% NaHCO3 solution is used (50ml = 50 mEq) (osmolality of 2,000 mOsm/kg.)
  • 25. IV Bicarbonate therapy • In patients with renal impairment or evidence of volume overload, consider utilization of hemofiltration or dialysis • In patients with CO2 retention and adequate renal function, consider administration of THAM.(tris-hydroxymethyl aminomethane)
  • 26. Lactic acidosis • Lactic acid in not bad – is an alternate energy shuttle in stress situations. • A lactate of > 2 is significant in sick patients • Is a very good prognostic indicator • Lactate normalisation time is a better prognostic indicator • Studies indicate use of lactate levels in goal-directed therapy may improve clinical outcome. lactate monitoring is a valuable parameter in the early resuscitation • Can be present in whom systemic hypoperfusion is not present
  • 28. • Too much normal saline hyperchloremic acidosis • Can we explain why increased Cl- causes Acidosis??
  • 29. NORMAL SALINE INFUSION LEADS TO HYPERCHLOREMIC ACIDOSIS Explanation of acidosis by HH method Explanation of acidosis by Stewart Increase in Cl- more than Na+ SID falls Dilution of HCO3 - CO2 CO2 increases HCO3 - unchanged pH falls Metabolic CO2 production pH falls Water H2O dissociates and adds H+ In NS- Na/Cl is 150 mEq/L In ECF -Na 145/ Cl 102
  • 30. TWO APPROACHES USED IN ACID BASE EVALUATION Traditional approach Stewart approach Henderson- Hasselbalch Metabolic’ component of acid-base physiology is bicarbonate HCO3 - ( KIDNEY) 20 pH ~ --------- ------------ PaCO2 (LUNG) 1 Water is an important source of H + Ionic Strength: weak and strong Electrical Neutrality is maintained at all times Metabolic’ component of acid-base physiology is Strong Ion Difference (SID) SID=(Na+ +K+ +Ca2++Mg2+)-(Cl-+Lactate) is 40 to 42 mEq/L
  • 31. TWO COMMONLY USED APPROACHES Henderson-Hasselbalch Stewart approach pH rely on three independent Factors 1. SID- Strong ion difference 2. (ATOT)- total concentration of weak acids (albumin and phosphate) 3. PCO2 ‘Metabolic’ component of acid-base physiology is not dependent on bicarbonate but instead, predominately on SID HCO3 - ( KIDNEY) pH ~ --------- ------ PaCO2 (LUNG)
  • 32. STEWART APPROACH • Stewart (physical chemistry principles) suggested that the traditional Henderson-Hasselbalch explanation of the underlying physiology and pathophysiology is wrong. • “Traditional” approach merely looks at a mirror image of that proposed by Stewart. In fact HH equation is a component of Stewart approach • The ‘‘modern’’ approach is clinically difficult, more CPU based • Requires knowledge of protein and phosphate concentrations and more electrolytes than may be routinely measured
  • 33. MODIFIED STEWART APPROACH = ([Na+] – [Cl-]) – 38 (1) {where 38 is normal average difference in strong ions – Na and Cl} = 0.25x [4.2–albumin] (2) Thus true BE = BE – [1 + 2] At bedside- it works well! NaCl effect Albumin effect Story, Belmo, Balasubramanyam where 4.2 is normal serum albumin
  • 34. Diagnosis of metabolic acidosis • History • 40 year presents with 3 day old peritonitis septic BP 80/60mmHg • RR 40/min • ABG- pH 7.21 / PCO2 = 21/ HCO3- = 9 mEq/l • Lactate 6 mmol/L • Metabolic acidosis with compensation • Same patient is drowsy has pneumonia RR 12/mt • ABG- pH 7.11 / PCO2 = 41 / HCO3- = 9 mEq/l • Metabolic acidosis + Respiratory Acidosis
  • 35. Equivalent rise of AG and Fall of HCO3…… ….Pure Anion Gap Metabolic Acidosis Discrepancy…….. in rise & fall + Non AG M acidosis, + M Alkalosis
  • 36. Δ AG =Measured Anion gap-12 Delta gap = HCO3 + Δ AG Delta Gap = 24 …… AG Met Acidosis < 24 ….. Non AG Met acidosis > 24 ….. Non AG Met acidosis + Meta. Alkalosis