Welcome to Scribd, the world's digital library. Read, publish, and share books and documents. See more
Download
Standard view
Full view
of .
Look up keyword
Like this
24Activity
0 of .
Results for:
No results containing your search query
P. 1
Acid-Base Made Easy

Acid-Base Made Easy

Ratings:

4.67

(1)
|Views: 8,597|Likes:
Published by Mayer Rosenberg

More info:

Published by: Mayer Rosenberg on Feb 09, 2009
Copyright:Attribution Non-commercial

Availability:

Read on Scribd mobile: iPhone, iPad and Android.
download as PDF or read online from Scribd
See more
See less

05/10/2014

 
 (+)Scott C. Sherman, MD
Assistant Professor of EmergencyMedicine, Rush Medical College;Assistant Program Director, Cook CountyEmergency Medicine Residency,Chicago, Illinois
Acid-Base Made Easy
The differential diagnoses for acid-base problemscan be reduced to a workable few by using aminimal amount of laboratory data. Following well-established principles and formulas, the presenterwill help you resolve common acid-base problemcases.
 
Identify etiologies of anion gap and non-aniongap acidosis.
 
Explain the principle of osmolar gap.
 
Differentiate the causes of acid-basedisturbance and discuss appropriatemanagement.
 
Identify potential life-threatening disorders byworking through real ED cases.WE-229October 10, 20074:00 PM - 4:50 PMWashington State Convention and Trade Center(+)No significant financial relationships to disclose
 
1
Acid-Base Made Easy
Scott C Sherman, MDAssistant Residency Director Department of Emergency MedicineCook County Hospital (Stroger)Assistant Professor of Emergency MedicineRush Medical CollegeAcid-base analysis strikes fear into the minds of both seasoned clinicians and their junior counterparts. Multiple formulas and rules exist to help guide us through the forest of diagnoses and complex problems. This lecture is set-up to provide a simple, systematicapproach to interpreting arterial blood gas (ABG) samples. All that is needed is a littleclinical information obtained from a history and physical examination, a few readilyavailable laboratory tests, and the knowledge of five simple steps. Getting in the routineof performing these steps on each patient in which an ABG and electrolytes are performed will help decrease the rate of missed complex acid-base disturbances andhopefully improve patient care.
Five Steps of Acid-Base Analysis
1-5
 
Step 1
:
Acidemia (pH <7.38) or alkalemia (pH >7.42)?
Step 2
:
Primary respiratory or metabolic disturbance?(Look at PCO
2
on ABG or HCO
3
on metabolic panel.)
Step 3
:
Is there appropriate compensation for the primary disorder?
 
Metabolic acidosis: PCO
2
= [1.5 x (serum HCO
3
)] + 8 (±2)Metabolic alkalosis:
PCO
2
= 0.6 x
HCO3 (±2)Respiratory acidosis:
PCO
2
10,
 
HCO
3
by 1 (acute) or 4 (chronic)Respiratory alkalosis:
PCO
2
10,
 
HCO
3
by 2 (acute) or 5 (chronic)
Step 4
:
 
Is there an anion gap metabolic acidosis (AGMA)?AG = Na (HCO
3
+ Cl). If > 12, an AGMA is present.
Step 5
:
 
If metabolic acidosis, is there another concomitant metabolic disturbance?If 
AGMA
, then calculate
Gap =
AG – 
HCO
3
= (AG -12) – (24 – HCO3)If the
Gap is > 6, there is a combined AGMA and metabolic alkalosis.If the
Gap is < -6, there is a combined AGMA and NAGMA.If 
NAGMA
, for every 1 mEq/L
Cl, there should be a 1 mEq/L
 
HCO
3
.If HCO
3
decrease is less than predicted, then NAGMA and metabolicalkalosis
 
2
Explanation of the Five Steps
Step 1
. This step is straightforward. Look at the pH. Is the blood acidemic or alkalemic?This is the primary disorder. Any compensation for a metabolic disturbance by the lungsor vice versa will not bring the pH back to “normal”.
Step 2
. Determine whether the primary disorder is respiratory or metabolic. This isaccomplished by looking at the bicarbonate on the chemistry or the pCO
2
on the ABG. Inacidemia, low bicarbonate (< 24) and low pCO
2
(< 40) suggests a metabolic acidosis.Alternatively, a high bicarbonate (> 24) and high pCO
2
(> 40) suggests that the primarydisorder is a respiratory one. The opposite is true for alkalemia. A patient with anelevated bicarbonate (> 24) and pCO
2
(> 40) supports a metabolic alkalosis, while low bicarbonate (< 24) and low pCO
2
(<40) supports a respiratory alkalosis.
Step 3
. The next question you would like to answer is whether or not the other bodysystem (kidneys in a primary respiratory disorder or lungs in a primary metabolicdisorder) are compensating appropriately.
 
Metabolic acidosis: Whether compensation is adequate or not is easiest to answer when the primary disorder is a metabolic acidosis. In this case, Winter’s formulais used. Winter’s formula states that the patient’s pCO
2
should be equal to theserum bicarbonate multiplied by 1.5 plus eight
6
. When this number is within twoof the pCO
2
, the respiratory system is compensating appropriately.
PCO
2
=1.5(HCO
3
) + 8 ± 2
. If the patient’s pCO
2
is higher than expected, a respiratoryacidosis is present in addition to the primary metabolic acidosis. If the patient’s pCO
2
is less than expected, then there is a respiratory alkalosis in addition to the primary metabolic acidosis.
 
Metabolic alkalosis: The respiratory system compensates for a metabolic alkalosis by increasing the pCO
2
level. However, unlike a metabolic acidosis, the normalrespiratory compensation to a metabolic alkalosis is difficult to predict and the pCO
2
level rarely rises above 50 mmHg. However, the increase in the pCO
2
isapproximately equal to the increase in HCO
3
multiplied by 0.6
1
.
 
Respiratory acidosis/alkalosis: Renal compensation for respiratory acid-baseabnormalities improves with time. Acute changes (48-72 hours) in respiratoryfunction occur due to titration of bicarbonate by available buffer systems. Inchronic situations (> 72 hours), the kidney is able to alter production andresorption of bicarbonate and ultimately affect a larger change. In acuterespiratory acidosis, for every pCO
2
increase of 10 mmHg, bicarbonate increases by 1 mEq/L. In chronic respiratory acidosis, a similar change in pCO
2
will resultin a bicarbonate change of 4 mEq/L. In patients with acute respiratory alkalosis, a pCO
2
decrease of 10 mmHg produces a drop in bicarbonate of 2 mEq/L, andwhen chronic, the bicarbonate drops 5 mEq/L. These formulas will give theclinician a rough estimate of whether the respiratory acid-base disorder is beingcompensated for by the kidneys appropriately and whether the patient is sufferingfrom an acute, chronic, or acute on chronic respiratory ailment.

Activity (24)

You've already reviewed this. Edit your review.
1 hundred reads
1 thousand reads
Tae142003 added this note
Can document be downloaded?
drajreed liked this
drrejabora12165 liked this
Sophie Saltzman liked this
Brealai liked this

You're Reading a Free Preview

Download
scribd
/*********** DO NOT ALTER ANYTHING BELOW THIS LINE ! ************/ var s_code=s.t();if(s_code)document.write(s_code)//-->