ABG pH pO2 measured pCO2 measured HCO3 Lytes Na K Cl Plasma Osmolality Tox Screen Ketones Metabolic Acidosis 1:1 AG (abN

> 12) Note: ignore if AG is N ∆ in AG from N range measured HCO3 expected HCO3 ∆ in HCO3 from baseline measured pCO2 expected pCO2 Plasma Osmolar Gap 7.24 60 70 29

Normal range 7.35-7.45 40 23-31 Normal range 133-146 3.3-4.8 96-110 270-290 Normal range neg

Urine Lytes Na K Cl pH Urine AG Chemistries Glucose BUN Albumin

Normal range <20 >30 <10
good for detecting ↑/↓ HCO3 in urine

0

indirectly estimate NH4+ excretion

Normal range 3.3-11 2.5-8 40 10:3 rule (↓Alb:↓AG)

Other Criteria Pt's age 45

Compensation: Resp Alkalosis -29 -41 29 65 -5 70 45 0

if more HCO3 than expected = metabolic alkalosis also occurring if less HCO3 than expected = non-AG metabolic acidosis also occurring

if pCO2 is more than expected = Resp acidosis also contributing (if measured pCO2 < 40, then partial comp R if pCO2 is less than expected = additional Resp alkalosis also contributing if greater than 10 = alcohol-related AG metabolic acidosis

Metabolic Alkalosis 1:0.7 ∆ in HCO3 from baseline 5 measured pCO2 70 expected pCO2 43.5 Chronic Resp Acidosis 1:0.3 ∆ in pCO2 from baseline 30 measured HCO3 29 expected HCO3 33 Normal Aa gradient 13.8 Nasal prongs O2 (L/min) 0.0 Estimated FiO2 (in %) 21 Aa gradient -10.16 Chronic Resp Alkalosis 1:0.5 ∆ in pCO2 from baseline -30 measured HCO3 29 expected HCO3 39 Normal Aa gradient 13.8 Nasal prongs O2 (L/min) 0.0 Estimated FiO2 21 Aa gradient -10.16

Compensation: Resp Acidosis
if pCO2 is more than expected = addtional Resp acidosis also contributing

if pCO2 is less than expected = Resp alkalosis also contributing (if measured pCO2 > 40, then partial comp R

Compensation: Met Alkalosis
if more HCO3 than expected = additional metabolic alkalosis also occurring if less HCO3 than expected = AG or non-AG metabolic acidosis also occurring or AOC Resp Acidosis N<15 but age-dependent, if > N suggests pathologic lung dz or disorder

elevation in Edmonton is 2192 ft (668m); therefore atmospheric pressure is 701 mmHg

Compensation: Met Acidosis
if more HCO3 than expected = metabolic alkalosis also occurring if less HCO3 than expected = additional AG or non-AG metabolic acidosis also occurring N<15 but age-dependent, if > N suggests pathologic lung dz or disorder

elevation in Edmonton is 2192 ft (668m); therefore atmospheric pressure is 701 mmHg

od for detecting ↑/↓ HCO3 in urine

irectly estimate NH4+ excretion

3 rule (↓Alb:↓AG)

Expected results for: Respiratory Acidosis Metabolic Acidosis Acute Chronic pH ↓ N pH ↓ pCO2 ↑ ↑ pCO2 ↓ HCO3 N ↑ HCO3 ↓ 10:1 10:3 1:1 Respiratory Alkalosis Metabolic Alkalosis pH ↑ N pH ↑ pCO2 ↓ ↓ pCO2 ↑ HCO3 N ↓ HCO3 ↑ 10:1 10:5 1:1

Expected Results for urine lytes: Non-renal volume depletion Vomiting (HCl loss = NaHCO3 gain) Diarrhea (NaCO3 loss = HCl gain) Burns/sweating Renal volume depletion diuretics/Bartters/low Mg hypoadrenalism

urine pH is used to detect HCO3 changes in urine, n H+ excretion, which is found in the NH4+ form Urine AG is used to indirectly estimate H+ excretion

Causes of Hypoxia: Aa = FiO2(Patm-47) - PCO2*1.25 N Aa low FiO2 Expected Aa = (0.3 x age) + 4 OR (age + 10)/4 hypoventilation ↑Aa shunt (AVM, atelectasis) V/Q mismatch diffusion problem ILD: upper lung Silicosis/Sarcoidosis Coal Workers' Pneumoconiosis Hypersensitive Pneumoconiosis Ankylosing Spondylitis Radiation Pneumonitis TB/Talc ILD: lower lung Rheumatoid Arthritis Astbestosis Scleroderma Crytptogenic fibrosis Drugs - amiodarone

sured pCO2 < 40, then partial comp Resp Alk)

ured pCO2 > 40, then partial comp Resp Acid)

urring or AOC Resp Acidosis

is also occurring

not for und in the NH4+ form ectly estimate H+ excretion e) + 4 OR (age + 10)/4 .UNa ↑ ↓ ↓ UK UCl pH ↑ ↓ ↑ ↑ ↑ ↑ ↓ UAG neg ↑ ↑ ↑ ↓ ↑ ↑ t HCO3 changes in urine.

over 30-60 min).45% NS at a slower rate. repeat bolus as necessary to prevent shock. give 10 mEq/hr. can add 5% dextrose to IVF. When glucose < 15. initiate SQ insulin. can switch to 0.g. This is done to replace the free water loss induced by the osmotic diuresis. When anion gap normal. If it does. infection. tox screen. BUN. decrease rate by 1U/hr and recheck in 1 hr. When blood sugar < 15. Potassium replacement: If initial K>6. . Fluids: IVF. 3. BS should not be allowed to fall below 10-15 in the first 4-5 hours of treatment. Insulin infusion: 10-20 unit IV bolus (0. Acids dilutional post-hypocapnia FeHCO3 >15% urine pH var. give 40 mEq/hr GI and Other Diarrhea Fistulas exog. rapid infusion of 1L of 0. If K=5-6. then 5-10 units/hr IV (0. Type II RTA (proximal HCO3 absorption) Fanconi Synd. run @ 125-250 cc/hr. lactate Hyperchloremic / Na Labs: Urine AG DDx: Ketones Methanol Uremia Uremia Salicylates DKA Methanol Paraldehyde All other Alcohols Isoniazid/Iron Lactate/Lactic Acid Lactate ETOH/Ethylene Glycol Salicylates DDx: Ureterostomy Small bowel fistula Extra chloride Diarrhea Carbonic anhydrase inhibitors use Adrenal insufficiency Renal tubular acidosis Pancreatic fistula neg UAG Plasma Osmolar Gap 2Na+glucose+BUN significant if > 10 mmol/L Rx: DKA (triggers .9% NS (e. UTI. 2.Metabolic Acidos Acid Gain / ↑ AG Na-Cl-HCO3 > 12 [Cl] = N Labs: ketones. K=3-4. give 20 mEq/hr. overlap for 1-2hr with insulin infusion. K<3. give 30 mEq/hr.5NSaline. in adults. K=4-5. then withhold replacement.1 unit/kg/hr).stress. MI): 1. When [Na] >145. This stops the lipolysis and gluconeogenesis and allows for the conversion of ketones to bicarbonate.15 u/kg). switch to 5% dextrose/0.

5-8mM KPO4/hr (ie.35 mM @ 2. give 30 mEq/hr. K=3-4. give 40 mEq/hr 4. 5. K<3. Phosphate replacement: Give K-phos if initial P< 0. may need extra K with bicarb Rx.45NS over 30-60 min).30mM PO4/ 44mEq K) .mEq/hr. 10 mL pf KPO4 in 1L NaCl over 6hrs . Bicarb replacement: If pH < 7 and/or cardiac instability present. then give bicarb (50-100mEq NaHCO3 in 1L 0.

FeHCO3 <3% urine pH > 5.3 FeHCO3 < 3% FeHCO3 >15% urine pH var. repeat labs reterostomy mall bowel fistula xtra chloride arbonic anhydrase inhibitors use drenal insufficiency enal tubular acidosis ancreatic fistula DDx: .Ingested halides (F.Lab error pos UAG Renal Causes Hypokalemia Hyperkalemia urine pH < 5.↑ Paraproteins (multiple myeloma) . Type I RTA (Distal H+/NH4+ secretion) Ehlers-Danlos Synd Hereditary elliptocytosis Type IV RTA (hypoaldo or medullary dz w/ less NH3 recycling) . I) .3 Type II RTA (proximal HCO3 absorption) Fanconi Synd. plasma electrophoresis.Metabolic Acidosis Bicarb Loss / Hyperchloremic / Non-AG Na-Cl-HCO3 = 8-12 [Cl] > N Labs: Urine AG ↓ AG Na-Cl-HCO3 < 8 [Cl] > N Labs: Albumin. Cl.↓↓ Albumin (↓10:↓3 rule . Br.alb:AG) .

Hereditary elliptocytosis Sickle cell nephropathy .

.

.

↓ renin) vs. swallowed chewing tabacco) Aldosterone = Na+ reabsorption/K+ and H+ secretion Urine Lytes UNa UCl UK Normal Values <20 <10 >30 Non-renal Vol depletion ↓ ↓ ↑ Vomiting ↑ ↓ ↑ Diarrhea ↓ ↑ ↑ Burns/Sweating ↓ ↓ ↑ Renal Vol depl. (diuretics) ↑ ↑ ↑ Hypoadrenalism ↑ ↑ ↓ . Cushing's. glucocorticoids.Metabolic Alkalosis Saline Responsive Volume Depletion Hypotensive (Exception: post-hypercapnia) Saline Resistant N Volume Status Non-renal Volume Depletion Renal Volume Depletion Hypertensive Hypokalemia DDx: Vomiting/NGT drainage (HCl loss = NaHCO3 gain) Diarrhea secondary to dehydration (NaCO3 loss = HCl gain) Burns/Sweating DDx: Diuretics / ↓ Mg Hypoadrenalism *Check urine lytes if subclinical dehydration Total volume depletion = Salt (NaCl) depletion DDx: Mineralocorticoids (Conn's. (renal artery stenosis. ↑ renin) Mc-like activity (licorice.

respectively) . (renal swallowed DDx: ↓↓ Potassium HCO3 ingested for peptic ulcer Bartter's and Gitelman's Synd (defects in Na-K-2Cl transporter and thiazidesensitive Na-Cl cotransporter.Saline Resistant N Volume Status Normotensive (Conn's. nin) vs.

laryngospam. ALS. obstructive sleep apnea. pulm edema. etc. esophgeal intubation Lower Airway abN: asthma. Neuromuscular D/O: myesthenia gravis. COPD Lung Parenchyma abN: pneumonia. CNS trauma/tumour. Muscular dystrophy. polymyositis.Respiratory Acidosis (underbreathing) DDx: CNS: sedatives. restrictive lung dz. narcotics. pneumothorax. severe hypophosphatemia Upper Airway abN: acute airway obstruction. thoracic cage abN. kyphoscoliosis . flail chest. Guilian-Barre.

cage abN. .

Respiratory Alkalosis (overbreathing) Cardiorespiratory Non-Cardiorespiratory DDx: Hypoxia early restrictive lung Dz Pulm edema PE Pneumonia mild CHF mechanical ventilation DDx: Fever Sepsis Drugs (ASA. progesterone) Anxiety/pain CNS D/O Hyperthyroidism Pregnancy Liver Failure .

alosis Cardiorespiratory (ASA. progesterone) thyroidism .

tegretol. Pneumonia. oxyt . clofibrate. subdural hemorrhage. duodenal pancreatic carcinoma Drugs: Chloropropamide.Hyponatremia (↑ ADH / ↑ free H2O intake) R/O fictitious hyponatremia hyperlipidemia. hyperprotenemia hyperglycemia Hypovolemia Non-renal Volume Depletion Renal Volume Depletion DDx: Vomiting/NGT drainage (HCl loss = NaHCO3 gain) Diarrhea secondary to dehydration (NaCO3 loss = HCl gain) Burns/Sweating DDx: Diuretics / ↓ Mg Hypoadrenalism DDx: SIADH (R/O thyroid disease) hypothyroidism adrenal insufficiency psychogenic polydipsia DDx of SIADH: Pulm: OAT cell. Em CNS: skull#. Guillian Cancer: OAT cell. vincr morphine/narcotics. TB. meningitis. tricyclic antidepressants. lymphoma. lung abcess. subarachnoid cerebral vascularthrombsis. thymoma.

vincritin. propamide. tegretol. lymphoma. hyperglycemia Hypervolemia Euvolemia SIADH (R/O thyroid disease) hypothyroidism adrenal insufficiency psychogenic polydipsia DDx: Cardiac: CHF Renal: nephrotic synd. vinblastin. meningitis. lung abcess. lupus cell. Pneumonia. cotics. Empyema subdural hemorrhage. ularthrombsis. tricyclic antidepressants. thymoma. clofibrate. oxytocin . subarachnoid hemorrhage. renal failure. TB. Guillian-Barre Synd. hyperprotenemia.Hyponatremia (↑ ADH / ↑ free H2O intake) R/O fictitious hyponatremia hyperlipidemia. duodenal carcinoma. Na+ retention Liver: cirrhosis (hypoalbuminemia) GI: protein-losing enteropathy ell.

.

Hypernatremia (↓ ADH / ↓ free H2O intake Hypovolemia Non-renal Volume Depletion Renal Volume Depletion Central Diabetes Insipidus DDx: Vomiting/NGT drainage (HCl loss = NaHCO3 gain) Diarrhea secondary to dehydration (NaCO3 loss = HCl gain) Burns/Sweating DDx: Diuretics / ↓ Mg Hypoadrenalism DDx: trauma neurosurgery mass lesions craniopharyngomas. histiocytosis x vascular aneuryms idiopathic . granuloma. sarcoid.

ischemia via sickle cell.Hypernatremia (↓ ADH / ↓ free H2O intake) Euvolemia Hypervolemia al Diabetes Nephrogenic Diabetes Insipidus Not Common DDx: ↑ Ca (hyperCa2+) .inflitration via amyloid. obstructive uropathy polycystic kidneys idiopathic/congenital . infection via pyelonephritis.malignancy ↓ K (hypokalemia) Lithium Loss of medullary hypertonicity .

Sign up to vote on this title
UsefulNot useful