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11
Metabolic Acidosis:
11 The Overview
WARNING: It has been longer since freshman chemistry than you realize.e strongly
W
advise reading Chapter 10,Introduction toAcid-Basebefore advancing beyond this point.
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The Fluid, Electrolyte and Acid-Base Companion
– –
HCO3 HCO3
pH ∝ pH ∝
CO2 CO2
After compensation for metabolic acidosis, the PCO2 is _____ (low/high). low
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S. Faubel and J. Topf 11 Metabolic Acidosis: The Overview
H+ H+ HCO3 HCO3 H+ C
Loss of bicarbonate
shifts the bicarbonate
buffer equation to-
ward the production
of hydrogen ion.
H+ HCO3 HCO3 H+ C
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The Fluid, Electrolyte and Acid-Base Companion
Na+ Na+
Anions Cl –
Cl –
Addition of an acid is the
addition of an H+ and its ac- HCO3
companying anion. When HCO3
an acid is added, its anion
accumulates in the plas-
– K+ A-
other A-
other K+
ma; the Cl concentration anions anions
does not change. cations = anions anions = cations
The other type of metabolic acidosis is due to the addition of acid. For the
purpose of understanding metabolic acidosis, an acid is defined as a hydro-
gen cation and its accompanying anion. In this type of metabolic acidosis,
the addition of acid directly raises the hydrogen ion concentration (lowers
pH). The increase in hydrogen causes the bicarbonate concentration to de-
crease. Due to the presence of increased anions, the chloride concentration
does not change.
Decreased bicarbonate. Hydrogen and bicarbonate are in equilibrium
with water and carbon dioxide as shown in the bicarbonate buffer equation
above. The addition of acid (hydrogen ion), shifts the reaction toward the
production of water and carbon dioxide. Bicarbonate decreases as it is con-
sumed buffering hydrogen.
Increased anions. As acid is added, the accompanying anions accumu-
late in the plasma. Even though the bicarbonate concentration is low, the
chloride concentration does not change because the accompanying anions
maintain electroneutrality.
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S. Faubel and J. Topf 11 Metabolic Acidosis: The Overview
LOSS OF BICARBONATE NORMAL ANION GAP ADDITION OF ACID INCREASED ANION GAP
– Na+ Na+
Cl
A- H +
Cl–
HCO3
H+ A-
HCO3
HCO3 A-
other
anions
K+ A-
other K+
anions
anions = cations anions = cations
Calculate the anion gap: Na+ = 140 mEq/L, Cl– = 118 mEq/L and anion gap = 7
HCO3– = 15 mEq/L. This is a(n) ________ gap metabolic acidosis. non-anion
Calculate the anion gap: Na+ = 140 mEq/L, Cl– = 101 mEq/L and anion gap = 27
HCO3– = 12 mEq/L. This is a(n) ________ gap metabolic acidosis. anion
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The Fluid, Electrolyte and Acid-Base Companion
Cl
HCO3
A-
other
anions
K+
anions = cations
All of the causes of non-anion gap metabolic acidosis are reviewed in detail in Chapter 12,
MetabolicAcidosis: Non-Anion Gap .
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S. Faubel and J. Topf 11 Metabolic Acidosis: The Overview
O O O O
C C CH3
Oxygen +
Na CH2 CH2 O CH2
Cl– HO C
H
CH3
O
C
CH3
CH3
A-
other
anions
K+
anions = cations
Anion gap metabolic acidosis is due to the addition of acid. The additional
acid is either endogenous (produced by the body) or exogenous (ingested). In
anion gap metabolic acidosis, the anion gap is greater than 12 mEq/L.
There are four fundamental processes that cause anion gap metabolic
acidosis: lactic acidosis, ketoacidosis, renal failure and ingestions. A handy
mnemonic for the differential diagnosis of anion gap metabolic acidosis is
PLUM SEEDS.
Paraldehyde ............................................... Ingestion
Lactic Acidosis ............................................ Lactic acidosis
Uremia ........................................................ Renal Failure
Methanol ..................................................... Ingestion
Salicylate poisoning ................................... Ingestion
Ethanol ....................................................... Ketoacidosis
Ethylene glycol ........................................... Ingestion
DKA ............................................................ Ketoacidosis
Starvation ................................................... Ketoacidosis
All of the causes of anion gap metabolic acidosis are reviewed in detail in Chapter 13,
MetabolicAcidosis:Anion Gap.
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The Fluid, Electrolyte and Acid-Base Companion
32 i
30 ac
28 l ic
26 a bo
24 et
M
22 RESPIRAT ORY
20 ALKALOSIS
18
16
14
6 8 10 12 14 16 18 20 22 24 26
Bicarbonate (mEq/L)
Regardless of the anion gap, compensation for the low bicarbonate found in
both types of metabolic acidosis is a decrease in PCO2. PCO2 decreases through
an increase in ventilation. The expected fall in PCO2 in metabolic acidosis is
predicted by the following equation.
METABOLIC ACIDOSIS
C
C Expected PCO2 = (1.5 × HCO3–) + 8 ± 2
C
If the PCO2 falls within the expected range, appropriate compensation has
occurred.
If the PCO2 is above or below the P CO2 predicted by the formula, a concur-
rent respiratory acid-base disorder is present. If the PCO2 is lower than pre-
dicted, a respiratory alkalosis is also present; if the PCO2 is higher than
expected, a respiratory acidosis is also present.
If the HCO3– is 12 mEq/L, what is the expected PCO2? If the PCO2 24 to 28 mmHg
is 19 mmHg, what other disorder is also present? respiratory alkalosis
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S. Faubel and J. Topf 11 Metabolic Acidosis: The Overview
DELTA - DELTA
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The Fluid, Electrolyte and Acid-Base Companion
The causes of both non-anion gap and anion gap metabolic acidosis are listed
below. The next two chapters will look at the individual disorders in detail.
NON - ANION GAP METABOLIC ACIDOSIS ANION GAP METABOLIC ACIDOSIS
GI loss of bicarbonate Renal tubular acidosis Paraldehyde Starvation
diarrhea proximal Lactic Acidosis Ethanol
fistulas distal Uremia Ethylene glycol
ureterosigmoidostomy hypoaldosteronism Methanol DKA
obstructed ureteroileostomy Salicylate poisoning
cholestyramine
286