Acid Base Disorders

Viyeka Sethi PGY 4 Med-Peds

Four Main Acid-Base Disorders

Disorder
Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis

Primary Alteration
in plasma HCO3 in plasma HCO3 in plasma pCO2

Secondary Response

Mechanism of Response

in plasma Hyperventilation pCO2 increase in Hypoventilation pCO2 in plasma Increase in acid HCO3 excretion; increase in reabsorption of HCO3 in plasma Suppression of acid HCO3 excretion; decrease in reabsorption of HCO3

Respiratory Alkalosis

in plasma pCO2

Normal Values
Arterial pH HCO3 pCO2 pO2 7.40 24 40 >70 Venous <7.35 24 >40 <60

Step by Step
1.

Determine the primary disturbance:

Acidemia or Alkalemia: look at the pH < 7.40 = acidemia > 7.40 = alkalemia Respiratory or Metabolic: look at HCO3 and CO2 HCO3 = primary metabolic acidosis pCO2 = primary respiratory acidosis and vice versa for alkalosis

2.

Determine acute or chronic for Respiratory Disturbance:

o

Compensation attempts to normalize pH but can be present with an abnormal pH Expected change in pCO2 best used for primary metabolic disturbance and expected change in HCO3 for primary respiratory disturbance

Respiratory Disturbance Compensation

pCO2 Acute Resp. Acidosis Chronic Resp. Acidosis pCO2 Acute Resp. Alkalosis Chronic Resp. Alkalosis in pH in HCO3

10 10

0.08 0.03
in pH

1 3
in HCO3

10 10

0.08 0.03

2 5

3.
o o o

Primary Metabolic Disturbance:

Calculate anion gap : Na (Cl + HCO3) Normal = 12 +/- 2 If gap is >20 then there is primary metabolic acidosis regardless of pH or bicarb. Helps narrow differential with a anion gap or non-anion gap metabolic acidosis

4.
o o

Assess appropriate respiratory compensation for metabolic disorder:

Respiratory compensation is fast Winters formula:
Expected pCO2 = (1.5 * HCO3) + 8 (+/-2)
o

If measured pCO2 is < expected then co-existing resp. alkalosis > expected then co-existing resp. acidosis

5.

Determine if other metabolic disturbances co-exist with AG metabolic acidosis:

o

Delta gap accounts for increase in anion gap and shows any variation in HCO3 If no other disorder is present then the calculation should be 24

Delta Gap
Corrected HCO3 = measured HCO3 + (AG - 12) o So if corrected HCO3 >24 then metabolic alkalosis co-exists <24 then non-anion gap metabolic acidosis coexists

Hints

Simple acid base compensatory response always in direction of primary variable Compensation is more pronounced with chronic disorders Normal pH indicates two or more acid-base disorders If given electrolytes, use them!!!

Pneumonics for pnuemonic lovers

Metabolic Acidosis Anion Gap
MUDPILERS
Methanol Uremia DKA/Alcoholic

Metabolic Acidosis NonGap

HARDUPS
Hyperalimentation Acetazolamide Renal

Acute Resp. Acidosis

anything causing hypoventilation
CNS

Metabolic Alkalosis
CLEVERPD

Respiratory Alkalosis
CHAMPS

ketoacidosis Paraldehyde Isoniazid Lactic acidosis Ethanol Renal failure/Rhabdo Salicylates

Tubular Acidosis Diarrhea Uretero-Pelvic shunt Post-hypocapnia Spironolactone

depression Contraction Airway Licorice obstruction Endocrine Pulmonary (Conn/Cushing edema /Bartters) Pneumonia Vomiting Hemo/Pneumo Excess alkali thorax Refeeding Neuromuscular Posthypercapnia Diuretics

CNS

disease Hypocapnia Anxiety Mech. Ventilation Progesterone Salicylates Sepsis

Case 1

3 yo boy with diarrhea is evaluated in the ER. Initial ABG shows: Expected pCO2 = (1.5 * HCO3) + 8 +/-2 So, Alkalemia or acidemia? Low acidemia ph 7.23 Expected pCO2 = (1.5 * 10) pH + 8= +/-2 =(15) + 8 +/-2 Primary disturbance resp. or metabolic? =23 +/2 HCO3 10 Low HCO3 = metabolic acidosis So, we have a metabolic acidosis with pCO2 23 respiratory compensation Normal AG so no need for Delta gap equation BUT AG - 13
Is there adequate respiratory compensation? (Use Winters formula)

Case 2

5 yo boy presents to ED with dyspnea for 3 days. ABG shows the following: Acidemia or alkalemia? pH 7.35 Low pH = Acidemia paCO2 60 Primary Resp. or Metabolic disturbance? Respiratory paO2 57 Check yourself.using rules for Primary Resp HCO3 - 31 disturbance
For every 10 increase in pCO2 pH decreases by .08 acutely or .03 chronically HCO3 increases by 1 acutely or 3 chronically So, this is a chronic resp. acidosis

Case 3

Acidemia or alkalemia? 15 yo with 4 days of vomiting and fever. High ph = alkalemia Respiratory or Metabolic? pH- 7.50 Na- 138 High HCO3 = metabolic pCO2- 42 Cl- 80 Anion Gap? 138 (80 + 34) = 24 pO2- 80 HCO3- 34 Checking the Delta gap only useful in a primary metabolic acidosis.

Is Resp. compensation appropriate? Exp. pCO2 = (1.5 * HCO3) + 8 +/-2 =(51) + 8 +/-2 =59 +/- 2 So, NO the CO2 is lower so we have a Co-existent resp.alkalosis

Case 4