How To Read Acid Base Disorder

Nanda, dr. Preodita, dr. Irzan, dr. Nova, dr.

Stage I: Identify the Primary Acid-Base Disorder

Rule 1: An acid-base abnormality is present if either the PaCO2 or the pH is outside the normal range. (A normal pH or PaCO2 does not exclude the presence of an acid-base abnormality, as explained in Rule 3.)

Rule 2: If the pH and PaCO2 are both abnormal, compare the directional change. If both change in the same direction (both increase or decrease), the primary acid-base disorder is metabolic, and if both change in opposite directions, the primary acid-base disorder is respiratory.

Example: Consider a patient with an arterial pH of 7.23 and a PaCO2 of 23 mm Hg. The pH and PaCO2 are both reduced (indicating a primary metabolic problem) and the pH is low (indicating acidemia), so the problem is a primary metabolic acidosis.

Rule 3: If either the pH or PaCO2 is normal, there is a mixed metabolic and respiratory acid-base disorder (one is an acidosis and the other is an alkalosis). If the pH is normal, the direction of change in PaCO2 identifies the respiratory disorder, and if the PaCO2 is normal, the direction of change in the pH identifies the metabolic disorder.

Example: Consider a patient with an arterial pH of 7.37 and a PaCO2 of 55 mm Hg. The pH is normal, so there is a mixed metabolic and respiratory acidbase disorder. The PaCO2 is elevated, so the respiratory disorder is an acidosis, and thus the metabolic disorder must be an alkalosis. Therefore, this is a combined respiratory acidosis and metabolic alkalosis. There is no primary acid-base disorder in this situation; both disorders are equivalent in severity (which is why the pH is normal).

Stage II: Evaluate Compensatory Responses

Rule 4: If there is a primary metabolic acidosis or alkalosis, use the measured serum bicarbonate concentration in Equation 28.3 or 28.4 to identify the expected PaCO2. If the measured and expected PaCO2 are equivalent, the condition is fully compensated. If the measured PaCO2 is higher than the expected PaCO2, there is a superimposed respiratory acidosis. If the measured PCO2 is less than the expected PCO2, there is a superimposed respiratory alkalosis.

Example: Consider a patient with a PaCO2 of 23 mm Hg, an arterial pH of 7.32, and a serum HCO3 of 15 mEq/L. The pH is acidemic and the pH and PCO2 change in the same direction, so there is a primary metabolic acidosis. Equation 28.3 should be used to calculate the expected PCO2: (1.5 15) + (8 2) = 30.5 2 mm Hg. The measured PaCO2 (23 mm Hg) is lower than the expected PaCO2, so there is an additional respiratory alkalosis. Therefore, this condition can be described as a primary metabolic acidosis with a superimposed respiratory alkalosis

Compensation for Metabolic Acidosis

Compensation for Metabolic Alkalosis

Rule 5: If there is a respiratory acidosis or alkalosis, use the PaCO2 to calculate the expected pH using Equations 28.5 and 28.7 (for respiratory acidosis) or Equations 28.6 and 28.8 (for respiratory alkalosis). Compare the measured pH to the expected pH to determine if the condition is acute, partially compensated, or fully compensated. For respiratory acidosis, if the measured pH is lower than the expected pH for the acute, uncompensated condition, there is a superimposed metabolic acidosis, and if the measured pH is higher than the expected pH for the chronic, compensated condition, there is a superimposed metabolic alkalosis. For respiratory alkalosis, if the measured pH is higher than the expected pH for the acute, uncompensated condition, there is a superimposed metabolic alkalosis, and if the measured

Example: Consider a patient with a PaCO2 of 23 mm Hg and a pH of 7.54. The PaCO2 and pH change in opposite directions so the primary problem is respiratory and, since the pH is alkalemic, this is a primary respiratory alkalosis. The expected pH for an acute respiratory alkalosis is described in Equation 28.6, and is 7.40 + [0.008 (40 - 23)] = 7.54. This is the same as the measured pH, so this is an acute, uncompensated respiratory alkalosis. If the measured pH was higher than 7.55, this would

Respiratory Acidosis

Respiratory Alkalosis

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