acid-base worksheet

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Acid-Base Disorders Worksheet

Step 1: Gather the necessary data (electrolytes and an ABG).

pH /pCO2 /HCO3

Step 2. Look at the pH.

Pt has primary:If pH > 7.4, then pt is alkalemic (proceed to Step 3a).

Acidemia / Alkalemia

If pH < 7.4, then pt is acidemic (proceed to Step 3b).

Step 3. Determine the primary etiology.

3a. Alkalemia:Increased HCO3 = Metabolic alkalosis (go to Step 5).Primary process is:Decreased pCO2 = Respiratory alkalosis (go to Step 4a).

Respiratory / Metabolic

3b. AcidemiaDecreased HCO3 = Metabolic acidosis (go to Step 5).Elevated pCO2 = Respiratory acidosis (go to Step 4b)

Step 4. If primary respiratory disorder, determine whether acute or chronic.

4a. Respiratory acidosis:

Acute: pH decrease by 0.08 for every 10 pCO2 is above 40

Respiratory process:

Chronic: pH decrease by 0.03 for every 10 pCO2 is above 40

Acute / Chronic

4b. Respiratory alkalosis:

Acute: pH increased by 0.08 for every 10 pCO2 is below 40

Unknown

Chronic: pH increases by 0.03 for every 10 pCo2 is below 40

A L L

Step 5. Calculate the anion gap.

5a: Na - (HCO3 + Cl) = ___________.Anion gap present

Yes / No

If < 12, skip to Step 6b.5b. Calculate the excess anion gap.

Excess anion gap = _________.

Calculated anion gap - 12 (or 3 X albumin) = __________.

Step 6. Identify concominant disorders.

Metabolic alkalosis present

Yes / No

Non-gap acidosis present

Yes / No

Winter's formula = expected pCO2 = 1.5 (HCO3) + 8 +/- 21.5 (_______) = _________ + 8 +/- 2 = _________.

Respiratory disorder present

*If the actual pCO2 > calculated pCO2, then pt has a concominant Respiratory acidosis.

Yes / No

*If the actual pCO2 < calculated pCO2, then pt has a concominant Respiratory alkalosis.

Identify:________

Step 7. Figure out what's causing the problem(s):

Metabolic AlkalosisRespiratory Alkalosis

"MUD PILERS""HARD UPS""CLEVER PD""CHAMPS"

CNS depressionAirway obstructionPneumoniaPulmonary edemaHemo/pneumothoraxMyopathy

Step 8. Fix it!!!!

Make sure the HCO3 from the electrolyte panel and ABG are within 2 (if not, the results areuninterpretable).

R e s p i r a t o r y D i s o r d e r s

If > 12 (or 3 X albumin), then pt has an anion gap metabolic acidosis(proceed to Step 5b).

M e t a b o l i c A c i d o s i s

6a. Calculate the corrected HCO3. You must understand that this step essentially comparesthe decrease in measured HCO3 to the expected decrease in HCO3 based on the degree of anion gap.Measured HCO3 + excess anion gap = ________.*If the corrected HCO3 is > 30, then the pt has a concominant metabolicalkalosis (more HCO3 than expected for the degree of gap acidosis).*If the corrected HCO3 is < 23, then the pt has a concominant non-gapmetabolic acidosis (less HCO3 than expected for the degree of gapacidosis).6b. Calculate the expected pCO2. Winter's formula shows what the pCO2 should be for thelevel of acidosis present (omit if primary disorder is respiratory).Anion GapMetabolicAcidosisNon-gap MetabolicAcodosisAcute RespiratoryAcidosisanything that causeshypoventilation

M

ethanol

H

yperalimentation

C

ontractionanything that causeshyperventilation

U

remia

A

cetazolamide

L

icorice

D

KA/Alkoholic KA

R

enal tubular acidosis

E

ndo (Conn's, Cushing's,Bartter's)

P

araldohyde

D

iarrhea

C

NS disease

I

soniazid

U

retero-pelvic shunt

V

omiting

H

ypoxia

L

actic acidosis

P

ost-hypercapnea

E

xcess Alkali

A

nxiety

E

tOH/

E

thylene glycol

S

pironolactone

R

efeeding Alkalosis

M

echanical ventilators

R

habdo

P

rogesterone

S

alicylates

P

ost-hyopercapnea

S

alicylates/Sepsis

(

Chronic

respiratory acidosiscaused by COPD andrestrictive lung disease)

D

iuretics

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