Treatment of acid-base disorders

Treatmentof:
Commoncausesof:

MetabolicAcidosis(Non anionGap)
MetabolicAcidosis(AnionGap)
MetabolicAlkalosis
RespiratoryAcidosis
RespiratoryAlkalosis

FOCUSONTHESURGICALPATIENT.
TREATMENTCONSISTSOFTREATINGTHE
UNDERLYINGCAUSE!!

Metabolicacidosis(NonAG)
IfcausedbyPRIMARYLOSSofbicarb,Thelossisbalancedbya
GAINinChloride.
AproportionalincreaseinCl leavestheAGunchanged.
Aniongap=(Na++K+) [Cl +HCO3]
CommoncausesofanormalAGmetabolicacidosis:

Diarrhea(lossofHCO3 inthestool).
Earlyrenalinsufficiency(increasedbicarb lossintheurine)
Infusionofisotonicsaline.
Renaltubularacidosis.

Case1
20YOM
HPI:motocrossracerfellon100ftjump.Bottomedoutsuspension.
PMHx:Nil
VitalsHR120,BP90/50,RR30,Afebrile.
Physical:Talking,collared/boarded,Bruisedrightbuttock/thigh,
tenderanddeformedRightfemur,unstablepelvis.Nootherinjuries.
Xray:FracturedpelvisandRightfemur.

Intraumabaygiven2LwarmedN/S,BP110/55HR120.

Dx ????
Nextstepsinfluidmanagement???

TooMuchNormalsaline
DilutionAcidosis:
Largevolumesoffluidwithoutbicarb orananionthatcanbe
metabolizedtobicarb suchaslactate(Ringers)resultin
metabolicacidosis.

ArticleDec2010Chest:
HMAat24hwashighlyassociatedwithinfusedNS4L.
Hyperchloremic metabolicacidosisfollowingresuscitationof
shock.GheorgheC Chest 01DEC2010;138(6):15212

TX:UseRingersandappropriateuseofcolloid/blood
products!!

Metabolicacidosis(AG)
MUDPILES
M Methanol
U Uremia(impairedsecretionofH+intodistal
tubules)
D Diabeticketoacidosis/starvationketoacidosis
P Paraldehyde
I Isoniazid,iron,ibuprofen
L lactate(ie.Seizures,shock)
E Ethyleneglycol,EtOH
S Salicylates.
TREATUNDERLYINGCAUSE!!!

Starvation/Alcoholic
Ketoacidosis
Ketosis
Insulindeficiency>>Lipolysis>>freefattyaciddeliverytotheliver
Glucagon+freefattyacids>>ketoacids intheliver.

Starvation(3daysstarvationincreaseketones10FOLD)
Decreasedcarbohydrateintake>>>Reduceinsulin+increase
glucagon)
Alcoholic
Malnourished
Alcoholinhibitsgluconeogenesisandstimulateslipolysis
Metabolismofethanolintoaceticacid.
Treatment
Volumeresuscitation(Oftendehydrated).
Dextrose(Stimulatesinsulinandinhibitsglucagon)
InETOHThiaminepriortodextrosetoreduceriskofWernickes.

CASE2
18YOM
PresentstoER.
HPI: POD13ORIFofOpentibiafracture,complainingoffeeling
drowsy/unwellwithvomiting,abdominalpain,beenurinatingalot.
PMHX: KnownT1DMgiveshimselfhisowninjectionsbutsincenot
feelingwelloverlastfewdayandnothungryhasntbeengivingitto
himself.
P/E: HR110,BP101/50,RR20,Febrile38.5C,Drymucousmembranes,
Drainingwoundserosanguinous ?Pus.
Labs:WBC25,Urinalysis+Ketones,Serumketones,ABGconsistentwith
AGmetabolicacidosis,BG=30,Na=135,K=5.4,Cl=97,BUN=12,Cr=150.

DXandInitialtreatmentplan????

Diabeticketoacidosis(DKA)
Intro
OftenresultsofinappropriateInsulindosing(T1DM)
Ruleoutothercauses
20%ofpatientswithDKAarenotknowndiabetics.
MedicalEmergency
ABCsstatus,mentalstatus
Possibleprecipitatingevents(eg,sourceofinfection,myocardial
infarction,usually)
Volumestatus
Workup:
SerumGlucose,Lytes tocalculateAG,BUN/CR,CBC,Urine/Plasma
ketones,Plasmaosmolarity,ABG,ECG.
+/ CXR,cultures,Cardiacworkup.

DKATreatment

LacticAcidosis
Mostcommoncauseofmetabolicacidosisinhospitalized
patients.
Plasmalactateconcentrationabove4meq/L.
CausedbyImpairedtissueoxygenation(Hypoperfusion)>>
increasedanaerobicmetabolism(Lactateendproductof
glycolysis).
MI,heartfailure,hypovolemic/septicshock,VTE,
Cardiopumonary arrest)

Metformintoxicity(Glucose>>lactateinsmallintestine)

BackToCase
60YOM AlcoholicwithUGIB
Vitals:RR30,HR120,BP98/50,Afebrile
BW:HGB62,Lactate20,ABG(consistentwithmetabolic
acidosis),PH=7.1

NextSteps???????

LacticAcidosis(Treatment)
ABCs
Treattheunderlyingproblem(ANEMIA,Hypovelemia,
Stopthebleeding)
BufferingAgents(controversial)
Bicarb (StandardBuffer)
Carbbicarb
Tris[hydroxymethyl]aminomethane (THAM)
Dichloroacetate

IstreatingtheAcidosishelpful?

Istreatingtheacidosis
helpful?
Maybe

(+)Severeacidemia maycontributetotissuehypoperfusion by
decreasingcardiaccontractilityviaareductioninmyocardialcell
pH.
()Bicarb noteffectivebuffer.
PKforcarbonicacidis6.1,whichmeans50%ofacidisdissociatedat
Phof6.1.
Usefulonlyat1PHaroundthePK(5.1<<6.1>>7.1)

()Bicarb maybeharmful.
WorsensacidosisbyincreasingC02(Needslungperfusionand
ventilation)
Postrecovery metabolicalkalosis(astheexcesslactateisconverted
backtobicarbonate.

()Acidosisdecreasesapoptosisofenergydepletecells.

AlternativeBuffers
Carbicarb
Equimolar mixtureofsodiumcarbonate(Na2CO3)and
sodiumbicarbonate.
Carbonatecomponentofcarbicarb willdiminishthetendency
towardvenoushypercapnia.
Notstudiedinhumansyet.

Tris[hydroxymethyl]aminomethane (THAM)
BuffersacidsandCO2byvirtueofitsamine(NH2)moiety.
NoincreaseinC02butalsonochangeinhemodynamicsor
serumbicarb levels.

Dichloroacetate
Increasepyruvatedehydragenase activitytooxidizepyruvate
insteadofconvertingtolactate.
Nochangeinhemodynamicsorbicarb concentrations.

Metabolicalkalosis
Majorcausessurroundingthesurgicalpatient.
Gastricdeleption ofH+(NGtubes,vomiting,villousadenoma).
Contractionalkalosis(Loop/thiazidediuretics).

Treatment(3Generalprinciplesinitialmanagement)
Correctvolumedepletion.
Correctpotassiumdepletion.
Correctchloridedepletion.

TREATTHEUNDERLYINGISSUE!!!!!

RespiratoryAcidosis
Hypoventilation
Acute(abruptdecreaseinventilation)

COPDexacerbation
Asthmaexacerbation
Airwayobstruction
Centraldepressionofrespiratorycenter.
Drugs(Narcotics)

Chronic
COPD
Obesityhypoventilationsyndrome.
Obstructivesleepapnea(positiveairwaypressure).

TREATTHEUNDERLYINGDISORDER!!!

RespiratoryAlkalosis
Hyperventilation
Causes
Asthma
Headtrauma
Hyperthyroidism
Meningitis
MI
Pneumonia
Pneumothorax
Pulmonaryedema
PulmonaryEmbolism
Pulmonaryfibrosis
Sepsis
TREATUNDERLYINGPATHOLOGY!!!