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- 1. Brad Bemiss, MD Chief Resident. Department of MedicineLoyola University Medical Center 2012.
- 2. Acidemia = pH<7.36 Alkalemia = pH>7.44 Change in pCO2 = Primary respiratory disorder Change in HCO3 = Primary metabolic disorder
- 3. Primary Disorder pH Primary Compensator Change Change y ChangeRespiratory Acidosis pCO2 HCO3Respiratory Alkalosis pCO2 HCO3 Metabolic Acidosis HCO3 pCO2 Metabolic Alkalosis HCO3 pCO2
- 4. Acidosis Alkalosis Metabolic Respiratory Metabolic Respiratory1. Gap or no gap? 1. Acute or chronic? 1. Check for 1. Acute or chronic? respiratory compensation High AG Normal AG Acute Chronic Acute Chronic 2. Measure2a. Winters 2b. Winters 10 ∆pCO2: 10 ∆pCO2: urine 10 ∆pCO2: 10 ∆pCO2: chloride3a. ∆/∆ 3b. Urine - pH ↓ by - pH ↓ by - pH ↑ by - pH ↑ by anion gap 0.08 0.03 0.08 0.034a. Osmol.gap - HCO3 ↑ - HCO3 ↑ - HCO3 ↓ - HCO3 ↓ by 1 by 4 by 2 by 5 2. If expected pH does 2. If expected pH does not equal actual pH, not equal actual pH, superimposed metabolic superimposed metabolic process process
- 5. Acidosis Alkalosis Metabolic Respiratory Metabolic Respiratory1. Gap or no gap? High AG2a.Winters3a. ∆/∆4a. Osmol.gap
- 6. Caused by loss of HCO3 or accumulation of acid (e.g. lactate) in the ECF1. Calculate anion gap2. Check for respiratory compensation3. Check for co-existing non-gap acidosis or metabolic alkalosis4. If gap acidosis and no clear reason for gap, measure osmolar gap
- 7. [anions] = [cations]Cl + HCO3 + unmeas anions = Na + unmeas cationsNa - Cl- HCO3 = unmeas anions – unmeas cations Normal anion gap = 12
- 8. Most of anion gap made up of albumin Low albumin smaller anion gap i.e., albumin 2g/dL “normal gap” = 7 For every 1g/dL below 4g/dL (nl albumin), add 2.5 to the gap or Adj gap = calc gap + 2.5 (4-meas albumin)
- 9. Methanol (formic acid) Uremia (ESRD impaired H+ secretion) DKA Paraldehyde INH, Inborn errors of metabolism Lactic acid Ethylene glycol (oxalic acid) Salicylates (salicylic acid)
- 10. Circulatory shock Sepsis Thiamine deficiency Meds (metformin, nitroprusside, NRTIs, tylenol) Propylene glycol toxicity (used in ativan drips) Hepatic insufficiency Seizures Acute asthma attacks
- 11. Metabolic acid-base disorder almost immediate ventilatory responseWinter’s Formula: Expected pCO2 = 1.5 x [HCO3] + 8 +/- 2 Appropriate compensation measured pCO2 = exp pCO2 Respiratory alkalosis measured pCO2 < exp pCO2 Respiratory acidosis measured pCO2 > exp pCO2
- 12. Assess for non-gap metabolic acidosis or metabolic alkalosis ∆anion gap meas AG - 12 ∆HCO3 24 – meas HCO3 ◦ <1 = non gap acidosis ◦ >1 = metabolic alkalosis Measured HCO3 + ∆gap = 24 ◦ <24 = non gap acidosis ◦ >24 = metabolic alkalosis
- 13. If no clear explanation for high anion gap metabolic acidosis, check osmolar gap Osm gap = measured osm – calc osm Calc osm = 2(Na) + Gluc + BUN 18 28 Normal Osm gap = 10-15 >25 suggests methanol or ethylene glycol poisoning
- 14. Acidosis Alkalosis Metabolic Respiratory Metabolic Respiratory1. Gap or no gap? High AG Normal AG2a. Winters 2b. Winters3a. ∆/∆ 3b. Urine4a. Osmol. anion gapgap
- 15. U reterostomy S mall bowel fistula E ndocrine (adrenal insufficiency) D iarrhea C arbonic anhydrase inhibitors A limentation (TPN) R TA S aline
- 16. Renal (RTA, early renal insufficiency) Acetazolamide, ammonium chloride, hyperal (TPN) Gastrointestinal (diarrhea, fistulas) Endocrine (adrenal insufficiency)S aline
- 17. 2.Check for respiratory compensation with Winter’sformula: Expected pCO2 = 1.5 x [HCO3] + 8 +/- 23.GI loss verses renal loss of HCO3? Urine anion gap
- 18. Urine Na + K – Cl Normal gap is zero or slightly positive Negative urine anion gap (-20 to -50) indicates GI losses (ne-GUT-ive) ◦ Diarrhea ◦ Fistulas
- 19. Acidosis Alkalosis Metabolic Respiratory Metabolic Respiratory1. Gap or no gap? 1. Check for respiratory compensation High AG Normal AG 2. Measure2a. Winters 2b. Winters urine chloride3a. ∆/∆ 3b. Urine anion gap4a. Osmol.gap
- 20. Volume contraction ◦ Vomiting ◦ Diuretics ◦ Dehydration NGT suction Hypokalemia Post-hypercapnia Glucocorticoid excess
- 21. Metabolic acid-base disorder almost immediate ventilatory responseExpected pCO2 = 0.7 x [HCO3] + 21 +/- 2 Appropriate compensation measured pCO2 = exp pCO2 Respiratory alkalosis measured pCO2 < exp pCO2 Respiratory acidosis measured pCO2 > exp pCO2
- 22. Chloride Responsive Chloride Unresponsive Urine Cl<15 Urine Cl >25
- 23. Chloride Responsive Chloride Unresponsive Urine Cl<15 Urine Cl >25• Vomiting• Diuretics• Dehydration• Continuous NG suction• Post-hypercapnia
- 24. Chloride Responsive Chloride Unresponsive Urine Cl<15 Urine Cl >25• Vomiting • Pure hypokalemia• Diuretics • Mineralocorticoid excess• Dehydration• Continuous NG suction• Post-hypercapnia
- 25. Acidosis Alkalosis Metabolic Respiratory Metabolic Respiratory1. Gap or no gap? 1. Acute or chronic? 1. Check for 1. Acute or chronic? respiratory compensation High AG Normal AG Acute Chronic Acute Chronic 2. Measure2a. Winters 2b. Winters 10 10 urine 10 10 ∆pCO2: ∆pCO2: chloride ∆pCO2: ∆pCO2:3a. ∆/∆ 3b. Urine anion gap - pH ↓ by - pH ↓ by - pH ↑ by - pH ↑ by4a. Osmol. 0.08 0.03 0.08 0.03gap - HCO3 ↑ - HCO3 ↑ - HCO3 ↓ - HCO3 ↓ by 1 by 4 by 2 by 5 2. If expected pH 2. If expected pH does not equal actual does not equal actual pH, superimposed pH, superimposed metabolic process metabolic process
- 26. Lung disease ◦ Asthma/COPD ◦ Pulmonary edema/Pneumonia ◦ ARDS Depression of respiratory center ◦ Drug overdose ◦ Obesity Hypoventilation Nerve or muscular disorders ◦ Guillain-Barre ◦ Myasthenia gravis
- 27. Anxiety Drugs ◦ Salicylate overdose ◦ Progesterone Pregnancy Liver disease Head injury
- 28. ∆ pCO2 ∆ pH Acute ↑ 10 ↓ 0.08Respiratory Acidosis Chronic ↑ 10 ↓ 0.03 Acute ↓ 10 ↑ 0.08Respiratory Alkalosis Chronic ↓ 10 ↑ 0.03
- 29. ∆ pCO2 ∆ HCO3 Acute ↑ 10 ↑1Respiratory Acidosis Chronic ↑ 10 ↑4 Acute ↓ 10 ↓2Respiratory Alkalosis Chronic ↓ 10 ↓5
- 30. IfpH is lower than expected pH, metabolic acidosis ◦ Don’t forget to measure the gap! If pH is higher than expected pH, metabolic alkalosis
- 31. Acidosis Alkalosis Metabolic Respiratory Metabolic Respiratory1. Gap or no gap? 1. Acute or chronic? 1. Check for 1. Acute or chronic? respiratory compensation High AG Normal AG Acute Chronic Acute Chronic 2. Measure2a. Winters 2b. Winters 10 ∆pCO2: 10 ∆pCO2: urine 10 ∆pCO2: 10 ∆pCO2: chloride3a. ∆/∆ 3b. Urine - pH ↓ by - pH ↓ by - pH ↑ by - pH ↑ by anion gap 0.08 0.03 0.08 0.034a. Osmol.gap - HCO3 ↑ - HCO3 ↑ - HCO3 ↓ - HCO3 ↓ by 1 by 4 by 2 by 5 2. If expected pH does 2. If expected pH does not equal actual pH, not equal actual pH, superimposed metabolic superimposed metabolic process process
- 32. Metabolic alkalosis 2/27.58/49/80 hypokalemia145 86 81.9 40 0.7Albumin 3.8Urine Chloride = 74
- 33. • Acute respiratory7.52/19/244 alkalosis • Anion gap metabolic140 112 10 acidosis2.8 19 0.7Albumin 1.1Lactate 4.6
- 34. • Anion gap metabolic7.12/19/92 acidosis • Non-gap metabolic140 108 35 acidosis3.8 6 2.1 Urine Na = 55Albumin 3.9 Urine K = 5 Urine Cl = 110
- 35. Chronic respiratory7.35/60/146 acidosis145 102 503.8 33 1.8Albumin 2.3
- 36. • Anion gap metabolic7.14/45/86 acidosis • Respiratory acidosis140 98 503.0 17 2.6 • Metabolic alkalosisAlbumin 3.7
- 37. • Acute respiratory7.59/21/154 alkalosis • Anion gap metabolic127 79 12 acidosis3.7 20 0.5 • Metabolic alkalosisAlbumin 4.1

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