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Asst Prof Medicine Oakland Beaumont Med School
Acid-Base Physiology! !
Joel M. Topf, MD
At the beginning of every episode of ER, as the impossibly attractive patient is being rolled from the ambulance bay to the resuscitation room, the equally attractive doctor barks orders, “I need a chem-20, CBC, chest x-ray, and blood gas!” The list may have a few other items but those four belong on the diagnostician’s Mount Rushmore of tests. Despite being common, learning to fully interpret any one of those tests means torturing the results to extract the vary last byte of signal from the data. This handbook will guide you through the full extraction of the blood gas.
• • • • Understand how pH is like an earthquake The use and uselessness of the Henderson Hasselbalch formula Identify the 4 primary acid-base disorders Calculate appropriate compensation for all four primary acid-base disturbances • • • • Understand and calculate the anion gap • Trash MUDPILES • Know: GOLDMARK Non-anion gap metabolic acidosis Delta-gap or gap-gap Osmolar gap
................................................................................ MD Table of Contents pH and the hydrogen ion concentration! ....................18 Anion gap metabolic acidosis (AGMA) ! .................................................................................13 Looking for second primary acid base disturbances the old timey way !.................................................................................... Topf.............................................................24 Additional metabolic acid-base conditions!..22 Osmolar Gap!..................................14 Using the prediction equations!......................................................................................................................................................................................................9 Rapid interpretation of ABGs!......5 There are four primary acid-base disturbances!.................................................4 Henderson-Hasselbalch equation ! ..............................................................................................20 Non-Anion Gap Metabolic Acidosis (NAGMA)!...................................................................................12 Multiple primary acid-base disturbances ! .............................................................................................................................................................................................................................Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M......................................................................................................................9 Compensation ! ..............19 Diabetic Ketoacidosis! .................................................28 3 ............26 Answers!.........................................................................15 The anion gap!............
40 nmol/L is 0. MD pH and the hydrogen ion concentration Acid base physiology is the regulation of hydrogen ion concentration Hydrogen ions are similar and different from other physiologically important electrolytes.00004 mmol/L Hydrogen ions exist at such minute concentrations that inorganic chemists decided to measure them on a negative log-rhythmic scale so 0.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. a pH of 6. If the concentration rises too high or falls too low there are physiologic consequences and illness.4 7.4 is 4 nmol/ L.3 pH units changes the hydrogen concentration by a factor of two.7 160 80 40 20 4 .4 is 400 nmol/L and 8. Topf. Like other electrolytes. A normal hydrogen ion concentration is 40 nmol/L and that leads to the principle difference from other ions.4. hydrogen ion concentrations need to be regulated. Every move of one point is a factor of ten. pH H+ concentration (nmol/L) 6.1 7.00004 mmol/L converts to 7. On this scale every change of 0.8 7.
5 . MD Henderson-Hasselbalch equation The primary buffer in the body is bicarbonate which is in equilibrium with carbon dioxide and water. Topf. The relationship between hydrogen ions. This mass action formula can be simpliﬁed to a simple relationship called the Henderson-Hasselbalch formula.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. bicarbonate and carbon dioxide is governed by the law of mass action.
Topf.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. MD The Henderson Hasselbalch formula provides a critical relationship that governs all of acid base physiology. It is the Mantra of Acid Base physiology. 6 .
8 / pCO2 = 50 / HCO3 = 15 You have been told that one question on the boards will require you to use the HendersonHasselbalch equation to determine if the ABG is possible.1+1=7.1). The pCO2 x 0. There will be one acid-base question where the right answer is some variance of: E) There is a lab error. You are taking boards and they give you the following ABG: pH = 6. or B) This ABG is impossible.03 will always be a tenth of the bicarbonate (so the log is 1 and the pH should be 6.1+2=8. One of the keys to the math on these problems is realizing that no one has a calculator and it is rather difﬁcult to do logs in your head so the test writers try to keep the numbers easy to handle.1) or a hundredth of the bicarbonate (so the log is 2 and the pH should be 6.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. Use the Henderson-Hasselbalch equation to determine if this ABG is possible. 7 .1 / pCO2 = 10 / HCO3 = 30 I guarantee you will get one of these questions on the boards. MD Use the Henderson Hasselbalch formula to calculate the normal pH from a normal bicarbonate of 24 and a normal pCO2 of 40 mmHg. ! ! Do the same for this ABG: pH = 8. Topf.
Topf. 8 . increases pH. carbon dioxide. The carbon dioxide is the acid so as its concentration rises the pH falls. If the quantitative approach is not helpful one can understand the relationship from a simple qualitative approach. also increases the pH. CO2 and pH is critical and you must have perfect knowledge of it to understand even the basics of acid-base physiology. A decrease in the denominator. Bicarbonate is alkaline so increases in its concentration occur with increases in pH.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. This relationship of bicarbonate. An increase in the numerator. MD The pH is proportional to the serum bicarbonate over carbon dioxide. bicarbonate.
e. a decrease in bicarbonate 3. an increase in bicarbonate 2. 9 . the other factor changes in the same direction so that the fraction remains nearly constant. For example. This minimizes changes in the ratio that determines the pH. the body responds to a fall in bicarbonate by decreasing carbon dioxide. A decrease in bicarbonate is a metabolic acidosis 3. primary) disturbance to The Mantra: 1. The acid-base disturbances are categorized by Acid-Base disorder Metabolic acidosis the initial (i. A decrease in the carbon dioxide is a respiratory alkalosis Primary disturbance compensation pH = pH = pH = HCO3 CO2 HCO3 CO2 HCO3 CO2 pH = pH = pH = HCO3 CO2 HCO3 CO2 HCO3 CO2 Metabolic alkalosis Respiratory acidosis Respiratory alkalosis pH = HCO3 CO2 pH = HCO3 CO2 Compensation In order to remain in health. Topf. an increase in carbon dioxide 4. a decrease in carbon dioxide Any alteration of acid-base physiology requires at least one of these changes. MD There are four primary acid-base disturbances Looking at The Mantra it becomes apparent there are four disturbances which can occur: 1. An increase in bicarbonate is a metabolic alkalosis 2.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. An increase in carbon dioxide is a respiratory acidosis 4. Faced with a change in one component of The Mantra. the body attempts to minimize changes in pH.
tory changes in carbon dioxide are in the For example: a decrease in bicarbonate same direction as the bicarbonate. or decreased. primary decrease in carbon dioxide with a Conversely. a primary decrease in three Henderson-Hasselbalch variables will bicarbonate (metabolic acidosis) will demove in discordant directions. dioxide minimizes the change in pH but in a respiratory acid-base disturbance the does not erase it. In real The quick method patients. Since bicarbonate is proportional to compenpH. MD The important thing to recognize is that carbon dioxide (respiratory alkalosis) will the primary disturbance without any comincrease the pH. HCO3 and bonate moving in concordant direccurs sipCO2 all move in the same directions tions will be a primary metabolic multanedisease. HCO3 and mary change in pH. Again In respiratory disorders: pH. any ABG with pH and bicarsation ocIn metabolic disorders: pH. since the compensacompensation. since carbon dioxide is incompensatory decrease in bicarbonate. in a respiratory acidThe key to this mystery is the fact that base disturbance the carbon dioxide and pH compensation does not move in discordant completely erase the pridirections. versely related to pH. and the compensasame direction as tory decrease in carbon the primary disorder. Then all you need to do is ously with determine if the pH is elevated. Topf. So. This complicates trying metabolic alkalosis. the primary defect. all three and carbon dioxide could be due to a priHenderson-Hasselbalch variables will move mary decrease in bicarbonate with a comin the same direction in a metabolic acidpensatory decrease in carbon dioxide or a base disturbance. In since compensation pCO2 move in discordant directions metabolic acidosis the pH is always in the falls. crease the pH while a primary decrease in 10 . pensation is a theoretical construct. metabolic to sleuth out what is disease and what is acidosis.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. Additionally.
32 / pCO2 = 36 / HCO3 = 18 8. pH = 7. pH = 7. pH = 7. MD Determine the primary acid-base disturbance: 1. pH = 7. pH = 7. pH = 7.4 2. pH = 7.36 / pCO2 = 80 / HCO3 = 44 7.45 / pCO2 =50 / HCO3 = 33 11 .32 / pCO2 = 28 / HCO3 = 14 5.37 / pCO2 = 50 / HCO3 = 28 6.45 / pCO2 = 48 / HCO3 = 32 4.45 / pCO2 = 18 / HCO3 = 12 12. pH = 7. pH = 7. Topf.57 / pCO2 = 18 / HCO3 = 16 13. pH = 7.43 / pCO2 = 45 / HCO3 = 29 10. pH = 7. pH = 7.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M.27 / pCO2 = 36 / HCO3 = 16 14.47 / pCO2 = 54 / HCO3 = 38 11.36 / pCO2 = 48 / HCO3 = 26 9.34 / pCO2 = 49 / HCO3 = 26 15. pH = 7.34 / pCO2 = 50 / HCO3 = 26 pCO2=40 HCO3=24 3. pH = 7. pH = 7.27 / pCO2 = 34 / HCO3 = 15 normal values pH=7.
If the patient has an AGMA.6 in patients on digoxin and diuretics predisposes to serious arrhythmia. Because of this. From the above examples it should be clear that it is the disease. A pH of 7. look for a pre-existing non-anion gap metabolic acidosis or metabolic alkalosis 12 . Topf. To fully characterize an acid-base disorder there are as many as 5 steps: 1. It also allows the cagey physician to detect and categorize multiple. determine if there is an osmolar gap 5.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. primary acid-base disorders.1 following a grand-mal seizure is routine and without signiﬁcant morbidity. If the patient has an anion gap metabolic acidosis (AGMA). simultaneous. A pH of 7.6 due to anxiety-hyperventilation syndrome is benign. it is imperative to rapidly determine the etiology of an acid-base disturbance. MD Rapid interpretation of ABGs A pH of 7. A pH of 7. not the pH that determines morbidity. Determine if there is a second primary disorder affecting compensation 3. Determine the primary acid-base disorder 2. If the patient has a metabolic acidosis.1 in methanol intoxication is an ominous sign. The ABG and electrolyte panel allow one to easily narrow the differential diagnosis. determine the anion gap 4.
Unfortunately neither computers nor nomograms are available on the boards. Uncovering these complex cases can be done mathematically or graphically. For this reason you need to be able to fully interpret an ABG on your own. Patients are too important and you are too bad at math to do the calculation reliably. On the iPhone and iPod Touch there is a free program called ABG which will do this for you. Topf. MD Multiple primary acid-base disturbances Patients are complex and often have multiple simultaneous primary acid-base disturbances. 13 . especially late at night. Just draw a line connecting the pH and pCO2 or connect the pCO2 and the bicarbonate (the diagonal lines). My suggestion to you is to get a computer. Alternatively one can use an AcidBase nomogram which are accurate and easy to use. Think of the patient with gastroenteritis with diarrhea causing metabolic acidosis and vomiting causing metabolic alkalosis.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M.
compensation occurs in every acid-base disturbance. In metabolic disorders. We use the predictability of compensation to determine if additional primary disorders are present. If the actual HCO3 is less than the predicted HCO3 there is an additional metabolic acidosis. if the actual pCO2 is less than the predicted pCO2 there is an additional respiratory alkalosis. In the absence of a second primary-disorder the degree of compensation can be determined solely by the severity of the primary disturbance (and by the duration in the case of metabolic compensation). If the actual pCO2 is greater than the predicted pCO2 there is an additional respiratory acidosis.5 x HCO3 + 8 ± 2 Winter’s formula CO2 increases 0. If the degree of compensation falls in the predicted range then there is no additional acid-base disturbance. See the table below. Each primary acid-base disturbance has its own equation to calculate the predicted degree of compensation.7 for every 1 mmol increase in HCO3 Acute: HCO3 increases 1 for every 10 mmHg of CO2 Chronic: HCO3 increases 3 for every 10 mmHg of CO2 Respiratory alkalosis decrease in carbon dioxide decrease in bicarbonate Acute: HCO3 decreases 2 for every 10 mmHg of CO2 Chronic: HCO3 decreases 4 for every 10 mmHg of CO2 If the prediction equation explains the compensation then you have a simple acidbase disorder. MD Looking for second primary acid base disturbances the old timey way As discussed earlier. In respiratory disorders.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. If the prediction equation does not explain the compensation then a second primary disorder exists. Topf. if the actual HCO3 is greater than the predicted HCO3 there is an additional metabolic alkalosis. How to predict compensation Disorder Primary disturbance / Compensation decrease in bicarbonate decrease in carbon dioxide increase in bicarbonate increase in carbon dioxide increase in carbon dioxide increase in bicarbonate Metabolic acidosis Metabolic alkalosis Respiratory acidosis CO2 = 1. 14 .
• If the pCO2 was 42. Metabolic alkalosis Suppose a patient has a pH of 7.37. In metabolic alkalosis the pCO2 rises 0. below the predicted pCO2 so this patient has an additional primary respiratory __________. the patient would have an additional respiratory ____________.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. To look for a second primary condition the ﬁrst step is to use Winter’s formula to see if the compensation is appropriate. Topf.7 for every 1 mmol/L increase in HCO3. • An HCO3 of 36 is an increase of 12 from normal. • The actual pCO2 is 48. To look for a second primary condition the ﬁrst step is to determine the expected bicarbonate. The actual HCO3 is 30 so there is an additional _________ _______ if the patient has acute disease and a pure res- 15 . Respiratory acidosis Suppose a patient has a pH of 7. To look for a second primary condition ﬁrst determine what the expected compensation should be. This should be compensated by an increase in pCO2 of _______. Winter’s formula predicts a pCO2 of ______. • If the actual pCO2 was 28 then the patient would have a pCO2 that was higher than predicted or an additional primary respiratory _____________. • If the actual pCO2 was 24. • So the expected bicarbonate is 26 if the respiratory acidosis is acute and 29 if it is chronic. • The pH is ____________ so this is metabolic alkalosis. • All three variables are lower than normal so the patient has a metabolic disturbance. • The actual pCO2 is 18. • The pH is decreased and both the HCO3 and pCO2 are elevated. • The pH is decreased so this is metabolic acidosis. MD Using the prediction equations Metabolic acidosis Suppose a patient has a pH of 7. then the patient would have physiologically compensated metabolic acidosis without a second primary ____________ disorder. • The pH is decreased so this is respiratory ______________. • All three variables are higher than normal so the patient has a __________ disturbance.50. HCO3 of 36 and pCO2 of 48. HCO3 of 30 and a pCO2 of 56.35. so this patient has an isolated metabolic alkalosis with ____________ respiratory compensation. Since the variables move in discordant direction it is a _____________ disturbance. the patient would have an additional primary respiratory ____________. HCO3 of 10 and a pCO2 of 18. • With a bicarbonate of 10. • If the pCO2 was 58. • The pCO2 is 16 above normal which corresponds to an expected increase in HCO3 of 2 in ________ respiratory acidosis and 5 in _______ respiratory acidosis.
The physician must determine that. • The pH is increased and the HCO3 and pCO2 are both ________. 16 . • The pH is increased so this is respiratory alkalosis.56. • So the expected bicarbonate is 20 if the respiratory alkalosis is acute and 16 if it is chronic. Since the variables move in discordant direction it is a __________ disturbance. Respiratory alkalosis Suppose a patient has a pH of 7. Topf. Respiratory acidosis Acute Chronic Respiratory alkalosis 10:1 10:3 For every rise of 10 in the pCO2 the HCO3 will rise by 1 or 3 10:2 10:4 For every fall of 10 in pCO2 the HCO3 will fall by 2 or 4. To look for a second primary condition the ﬁrst step is to determine the expected bicarbonate. • The pCO2 is 18 below normal which corresponds to an expected _________ in HCO3 of 4 in acute respiratory alkalosis and 8 in chronic respiratory alkalosis.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. The actual HCO3 is 23 so this is a respiratory alkalosis with ________ ___________ regardless if it is acute or chronic. HCO3 of 23 and a pCO2 of 22. It is important to understand that the compensation equation can not tell you if the patient has acute or chronic disease. MD piratory acidosis if the condition is _______.
MD Brittany Spears has been out partying and wakes up vomiting. 7.8 John Wayne is admitted to a surgery center for a colonoscopy.32 / 60 / 145 / 31 Aretha Franklin is undergoing chemotherapy for pancreatic cancer.2! 104! 7! 38 1.71 / 33 / 94 with a HCO3 of 40 on the electrolyte panel.8 Hunter Thompson is dragged in to your ofﬁce by his attorney. His caddie says he has been taking nips from a little bottle all day. She develops nausea and vomiting and is admitted for IVF. An ABG and lytes are drawn: 7.2! 91! 35! 36 1.54 / 45 / 104 ! ! ! ! 144! 3. John Daley presents to the ED stuporous. There is no history of diarrhea. In the ER a blood gas and labs are drawn: 7.8! 116! 14! 16 0. After six hours she is still vomiting and calls her personal concierge physician who gets the following ABG: 7. Thompson is incomprehensible but does not appear toxic.3 17 . During the procedure the oxygen saturation monitor malfunctions so the gastroenterologist gets an ABG to conﬁrm good oxygenation. Topf. Mr.22 / 17 / 112 ! ! ! ! 147! 4.28 / 36 / 88 ! ! ! ! 136! 2. His labs reveal the following: 7.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M.
if the anion gap is less than twelve then the increased hydrogen ions are associated with excess chloride and if the anion gap is greater than twelve the excess anion is something else. a low anion gap can also signal disease. Metabolic acidosis is categorized by the In metabolic acidosis bicarbonate (an antype of acid which is consuming the bicarion) is decreased. Causes include: • Increased chloride • Hypertriglyceridemia • Bromide • Iodide Decreased “Unmeasured anions” • Albumin • Phosphorous Increased “Unmeasured cations” • Hyperkalemia • Hypercalcemia • Hypermagnesemia • Lithium • IgG 18 = • • . In metabolic acidosis the acid (anion) can be anything and what it is can have profound implications for your patient. The total number of anions in the blood must equal the total number of cations (otherwise touching blood would give you a shock). This is either chloride anion which can accumulate in the body.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. With metabolic acidosis. which reacts with bicarbonate and an anion must ﬁll the void. ferent metabolic acidosis. The as seen on the left or an other anion as seen identity of the anion is how we name the difon the right. The anion gap is a way to quantify this In all of clinical medicine there are only two types of anions: It’s either chloride or It’s not chloride The anion-gap is a simple calculation which allows you to determine if the excess anion is chloride or not. Abnormally low anion gap Though not related to an acid-base disturbance. relationship: Cl– + HCO3 + Other anions = Na+ + Other cations Then rearrange it to solve for the other ions: Other anions – Other cations = Na+ – (Cl– + HCO3 ) Deﬁne anion gap as the difference between other anions and other cations: Anion gap = Na+ – (Cl– + HCO3 ) On average the anion gap is 6±3 with the upper limit of normal being 12. Topf. MD The anion gap In respiratory acidosis the acid is known. by deﬁnition its carbon dioxide. The acid has two components: a probalance with the unchanged cations another ton. so to keep the anions in bonate.
9642. Aspirin toxicity. malignancy Ketones are produced as an alternative energy supply when glucose is unavailable: • starvation ketosis • alcohol induced hypoglycemia • diabetic ketoacidosis Insulin is a potent suppressor of ketogenesis so treatment requires supplying insulin. D-Lactic acidosis: Bacteria metabolize carbohydrate to the isomer D-lactate.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. metformin. M! A! R! K! Methanol Aspirin. 372. LDH only recognizes L-lactate so Dlactate must be cleared by the kidney. Renal failure Ketoacidosis: DKA. 2008 19 . Lancet. Two types of lactic acidosis: Type A: decreased perfusion causing ischemia resulting in anaerobic metabolism and lactic acidosis. p 892. Type B: anaerobic metabolism due to mitochondrial dysfunction. Topf. M Emmett. NNRTI. MD Anion gap metabolic acidosis (AGMA) Anion gap metabolic acidosis cause the most serious acute metabolic acidosis. The most important causes of AGMA are: • Lactic acidosis • Ketoacidosis • Toxic alcohols • Renal failure Lactic acid is produced during anaerobic metabolism. The new mnemonic is GOLD MARK. The anion is actually lactate in ASA toxicity. The classic mnemonic MUD PILES sucks. The toxic alcohols can cause AGMA and will be discussed more in the section on osmolar gap. The production of lactic acid restores NAD+ needed for glycolysis. G! O! Glycols: ethylene glycol Oxoproline: Pyroglutamic Acid is a rare cause of high anion gap (30s) metabolic acidosis. L-lactic acidosis. JB Emmett . hypotension and infection. Renal failure variably causes AGMA. Shock. In starvation or alcohol ketosis administering glucose allows the secretion of endogenous insulin. hypoglycemia L! D! AN Mehta. The anion gap is usually small and transient because D-lactate is rapidly cleared by the kidneys. Know it. Early in the course of CKD patients develop NAGMA but in late CKD stage 4 and CKD stage 5. starvation. In DKA patients require an insulin drip. It is seen with acetaminophen. sulfur based anions accumulate and cause AGMA.
The gap is often greater than 20 mEq/L. Some 2. hyperglycemia (500-800) and positive serum ketones. Only acetoacetate is detected by the routine serum ketone assay. non-compliance) infarction (myocardial) incision (surgery) infant (pregnancy) Patients who present with DKA are typically quite toxic with hypovolemic shock. Triggers of DKA: a 7 eyed monster initial (new diagnosis) infection illicit drug use insulin (lack of. 20 . • PCO2 is decreased due to compensatory hyperventilation (Kussmaul’s respiration). The osmotic diuresis ± vomiting ( a common symptom of DKA) can result in life-threatening hypovolemic shock.4 per 100 of glucose. • BUN and creatinine are elevated due to pre-renal acute renal failure. To estimate the corrected Na+ add 1. abdominal pain. • Phosphorous is decreased. total body potassium is decreased due to increased renal losses. Duh. vomiting. they have a relative paucity of insulin and go into ketoacidosis. the patient with DM1 forgets or fails to take their insulin. Despite high plasma levels. • pH is decreased. There is no role of serial ketone assays in the management of DKA The lab abnormalities are ubiquitous in DKA: • Sodium is decreased due to pseudohyponatremia. ßhydroxybutyrate or acetone. diabetes. metabolic acidosis. altered mental status.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. The ketones can be acetoacetate.6 mEq/L to the measured Na+ for every 100 mg/dL the glucose is above 100 mg/dL. Lipase is usually normal. DKA occurs when there is an absolute or relative lack of insulin. patients on a stable dose of insulin undergo a crisis that requires additional insulin and if her insulin prescription does not account for this. • White blood cell count is increased due to demargination. The lack of insulin prevents a shift of K+ back into cells. The most profound abnormality is volume depletion. • Glucose is elevated. In the absolute case. just about every lab value that can go wrong has gone wrong. Topf. Duh. • Potassium is usually increased due to solute drag. • Anion gap is increased due to the presence of ketone anions. MD Diabetic Ketoacidosis The most exciting diagnosis in internal medicine In diabetic ketoacidosis. usually above 300 mg/dL. • Amylase is increased because ketones interfere with the laboratory assay. Diagnosis can be made from the combination of an anion gap metabolic acidosis. Acetone can cause a fruity odor on the breath. • Bicarbonate is decreased. in the relative case.
Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. Skin is cool. The insulin drip should be continued until the anion gap has closed (indicating complete reversal of the ketosis) even if that means starting continuing the insulin after the hyperglycemia is resolved. Potassium replacement should be started when the potassium falls below 4 mmol/L. Potassium. She has no edema. Bicarbonate has been tested and should not be used as it can prolong the ketosis and promotes hypophosphatemia without improving patient outcomes. Insulin will lower the glucose but it is used to reverse the ketosis.” She has been waking at night to go to the bathroom 2-3 times a night. Saline is used to reverse the volume loss. When the insulin is started. lungs are clear. Wt 40 kg. MD The three core medicines used to treat DKA are: 1.6 21 . 2.8 A 14 year old actress has been having increasing fatigue for the past few weeks.20 / 16 / 96 / 6 128 6. She is nonresponsive. 3. potassium will shift into the cells and rapidly uncover the hypokalemia. Patients on initial presentation will usually be hyperkalemic despite total body potassium depletion.4 94 44 7 1. Today. abdomen is ﬁrm without rebound. HR 146. accucheck: high ABG 7. Potassium should be frequently assessed during therapy. What are ﬁrst steps in resuscitation? Initial diagnostic procedures? Anion Gap 27 glucose 764 adjusted Na 138.cardic. 0. heart is tachy. Her school performance has slipped and her parents are worried that she may have gotten “into drugs. Topf. Insulin. In her purse the mom found a bag of dried plant-matter and a bottle of unidentiﬁed pills. Blood pressure is 80/P. You made need to start a dextrose infusion to prevent hypoglycemia. RR 32. her mother found her unconscious on the ﬂoor in a puddle of urine.9 Normal Saline.
.80-100 mEq/L Small intestine !.... GI losses The kidney’s role in regard to maintaining a normal bicarbonate can be neatly divided into three tasks: • Reabsorb all of the ﬁltered bicarbonate.............. Hydrochloric acid intoxication or chlorine gas poisoning can also cause NAGMA via excessive chloride.. renal tubular acidosis............ 1 mmol/Kg body weight). In order to synthesize de novo bicarbonate. Almost all of the cases of excessive chloride intake causing NAGMA are due to saline infusions.. Like other valuable small molecules and electrolytes that are freely ﬁltered at the glomerulus.. usually as normal saline 2.. have relatively high bicarbonate concentrations: Bile! .... It also is a massive source of chloride... • Excrete hydrogen as ammonium (NH4+)..... The kidney must also synthesize new bicarbonate to replace bicarbonate consumed in daily metabolism... This causes a NAGMA... the kidney avidly scavenges these particles and reabsorbs them.............30-40 mEq/L Pancreatic secretions!......30-50 mEq/L It should be apparent that diarrhea or a surgical drain could result in rapid and dra- 22 .. often erroneously called dilutional acidosis. • Synthesize new bicarbonate. In GI disturbances the pH follows the food. distal to the highly acidic stomach. Failure of the kidney to excrete the daily hydrogen load.......... with vomiting the food and pH rises.. MD Non-Anion Gap Metabolic Acidosis (NAGMA) Non-anion gap metabolic acidosis occurs in three clinical scenarios: 1..9% normal saline. Failure in the ﬁrst bullet point results in type 2 or proximal RTA....... These hydrogen ions make up the daily acid load (approx. Chloride intake matic losses of bicarbonate.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M... The kidney cannot excrete the daily acid load as free hydrogen and must excrete the hydrogren as either titratable acids or ammonia...5........ Creating new bicarbonate requires excretion of hydrogen ions from the body... How would you compare the relative acidity of saline versus plasma? How much chloride is in all of the plasma? How much chloride is found in a liter of 0. Failure of the second bullet point results in RTA type 1. with diarrhea the food and pH falls Renal tubular acidosis Normal saline has a pH of 5.. the kidney must excrete hydrogen ions in the urine. Excessive chloride intake... Increased lower GI losses.....80-100 mEq/L Large intestine !......... Failure of the third bullet point results in hyperkalemic or type 4 RTA..... Topf... usually as diarrhea 3.. GI secretions..
MD Disorder GI losses Proximal RTA < 6. the urine pH is low enough but the hyperkalemia blocks the release of NH3.0 above Tm. 23 . with urinary acidiﬁcation.0 Hyperkalmia positive The ideal laboratory test to diagnose RTA would be a urinary ammonium assay. Without acidic urine there is nothing to drive the formation of NH4+ from NH3.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. so there is no substrate to produce NH4+. We used the serum anion gap to look for non-speciﬁc anions causing the metabolic acidosis. In type 4 RTA. namely ammonium cations. there is no urinary acidiﬁcation. Unmeasured cations exceed unmeasured anions so there are excess unmeasured cations so the anion gap will be negative. Urine Anion gap = (Na+ + K+) – Cl– Normally. there is increased ammonium in the urine which adds to the unmeasured cations.0 urine pH Plasma K Hypokalemia.0 Electrogenic distal RTA Classic distal RTA Hyperkalemic RTA (type 4) > 5. Topf. > 6. Outside of specialized laboratories this does not exist.5 >5. We will now use the urinary anion gap to look for increased cations.5 Hypokalemia positive < 6. A negative urinary anion gap means good urinary ammonia levels. variable Hypokalemia during treatment Hyperkalmia urine anion gap negative at Tm negative above Tm positive positive at Tm < 6. We can infer the presence of ammonium by looking at the urinary anion gap. In distal RTA.
28 and 46) to convert mg/dL to mmol/dL and then multiplied by ten to get mmol/L 24 . BUN and ethanol levels are divided by their molecular weight (180.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. Laboratory conﬁrmation may take 24 hours. This provides the gap. The osmolar gap allows one to infer the presence of these low molecular weight toxins. a few grams equals many osmoles and will increase the measured osmolality without affecting the calculated osmolality. treatment must be initiated rapidly. The osmolar gap demonstrates an increase in the serum osmolality that can not be explained by the usual suspects: electrolytes. glucose.8 + EtOH/4. One of the keys to building the clinical suspicion is demonstrating an osmolar gap.6 The glucose. urea and ethanol. Usually therapy is begun prior to conﬁrming the diagnosis with a speciﬁc assay for the alcohol. Elevated osmolar gaps are found with: • Ethylene glycol • Methanol • Isopropyl alcohol • Ketoacidosis • Lactic acidosis • Mannitol infusion • Pseudohyponatremia 2 x Na + glucose/18 + BUN/2. Because the molecular weight of methanol and ethylene glycol are low. Topf. consideration should be given to ethylene glycol and methanol toxicity. MD Osmolar Gap In patients with metabolic acidosis and a large anion gap. If a patient has ingested ethylene glycol or methanol. Calculated Osmolality: If the calculated osmolality is more than 10 mosm/Kg H2O less than the measured osmolality you have an abnormal osmolar gap.
! ! ! 10.8! ! 148! 4. and osmolar gap in the following patients 1.! ! ! 4. calculated osmolality.! ! ! 7.2! ! 62! 2.8! ! 146! 4.8! ! 146! 4.8! ! 85! 2.! ! ! 5.! ! ! 9.4! ! 45! 2.0! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Ethanol: 0! Glucose: 40 ! ! Osmolality: 337! ! ! ! ! ! ! ! Ethanol: 0! Glucose: 80 ! ! Osmolality: 311! ! ! ! ! ! ! ! Ethanol: 0! Glucose: 120 ! ! Osmolality: 302! ! ! ! ! ! ! ! Ethanol: 0! Glucose: 335 ! ! Osmolality: 400! ! ! ! ! ! ! ! Ethanol: 0! Glucose: 165 ! ! Osmolality: 338! ! ! ! ! ! ! ! Ethanol: 48! Glucose: 223 ! ! Osmolality: 309! ! ! ! ! ! ! ! Ethanol: 86! Glucose: 40 ! ! Osmolality: 333! ! ! ! ! ! ! ! Ethanol: 112 ! Glucose: 48 ! ! Osmolality: 380! ! ! ! ! ! ! ! Ethanol: 0! Glucose: 90 ! ! Osmolality: 313! ! ! ! ! ! ! ! Ethanol: 0! Glucose: 656 ! ! Osmolality: 344! ! ! ! ! ! ! ! Anion gap: 25 Calculated Osm: 302 Osmolar gap: 35 Anion gap: 23 Calculated Osm: 301 Osmolar gap: 10 Anion gap: 12 Calculated Osm: 293 Osmolar gap: 9 Anion gap: 28 Calculated Osm: 381 Osmolar gap: 19 Anion gap: 38 Calculated Osm: 322 Osmolar gap: 16 Anion gap: 23 Calculated Osm: 309 Osmolar gap: 0 Anion gap: 16 Calculated Osm: 319 Osmolar gap: 14 Anion gap: 18 Calculated Osm: 364 Osmolar gap: 16 Anion gap: 30 Calculated Osm: 268 Osmolar gap: 45 Anion gap: 13 Calculated Osm: 339 Osmolar gap: 5 25 .8! ! 14! 0.8! ! 141! 4. MD Problems: ﬁgure out the anion gap.! ! ! 6.8! ! 130! 4.3! ! 8! 0.6! ! 18! 1.8! ! 135! 4. Topf.8! ! 28! 1.8! ! 138! 4.8! ! 138! 4.! ! ! 8.! ! ! 2.8! ! 111! 12! ! 105! 18! ! 112! 14! ! 106! 12! ! 95! 8! ! 105! 7! ! 112! 10! ! 114! 14! ! 94! 6! ! 120! 15! ! 10! 0.! ! ! 148! 4.8! ! 196! 8.! ! ! 3.8! ! 146! 4.2! ! 127! 6.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M.
reports that he initially developed diarrhea after eating some old chicken salad: 7. Did he have a pre-existing acid-base disorder? What is it and why does he have it? By using the last formula we can actually infer what the bicarbonate was prior to developing the anion gap.6! 106! 8! 16 1. MD Additional metabolic acid-base conditions There is a trick for patients with anion-gap metabolic acidosis that allows physicians to go back in time prior to developing the anion gap and see what the bicarbonate was at that time. Is there a second primary acid-base disturbance. 26 . What is the diagnosis? 5. From that you can deduce if the patient had either a pre-existing metabolic alkalosis or preexisting non-anion gap metabolic acidosis. What is the anion gap? 4. Now we will look at the back with a bad temper preanion gap to determine if the patient has an sents to the ER appearing additional primary acid-base disorder.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M.8 1. Calculate the bicarbonate before 6.28 / 18 / 88 ! glucose: ! 875! ! ! 128! 5. toxic. If the bicarbonate is elevated then the patient had pre-existing metabolic alkalosis. His agent In order to use the anion gap to look for additional acid-base disorders we assume that for every increase in the anion gap over 12 the serum bicarbonate falls by one. Topf. Earlier we looked at compensation to deQuestions termine if a patient has a second primary An over-rated NFL quarteracid-base disorder. What is the primary acid-base disturbance? 2. affecting compensation? What is it? We can establish a formula to represent this: ! HCO3 = ! Anion Gap HCO3before – HCO3now = AGcurrent – AGnormal HCO3 before = HCO3now + (AGcurrent – 12) 3. hypotensive. If this bicarbonate is low we call this a pre-existing non-anion gap metabolic acidosis.
8! 98! 28! 43 2.8! 146! 4.3 8.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M.8! 130! 4.2! 102! 18! 16 1.42 / 32 / 76 ! glucose: ! 56! ! ! 148! 5. Did he have a pre-existing acid-base disorder? What is it and why does he have it? 27 .! ! 1.8! 148! 4. Is there a second primary acid-base disturbance affecting compensation? What is it? 3.8! 135! 4. What is the anion gap? 4.! ! 5.8! 146! 4. Is there a second primary acid-base disturbance affecting compensation? What is it? 3.8! 110! 18! 104! 12! 114! 6! 114! 16! 105! 18! 94! 19! 101! 14! 114! 16! 96! 6! 106! 14! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! ! Anion Gap: 2 Bicarb before: 8 Anion Gap: 18 Bicarb before: 18 Anion Gap: 18 Bicarb before: 12 Anion Gap: 16 Bicarb before: 20 Anion Gap: 18 Bicarb before: 24 Anion Gap: 22 Bicarb before: 29 Anion Gap: 23 Bicarb before: 25 Anion Gap: 16 Bicarb before: 20 Anion Gap: 28 Bicarb before: 22 Anion Gap: 28 Bicarb before: 30 7.! 140! 4. Did he have a pre-existing acid-base disorder? What is it and why does he have it? A person of remarkable genetic luck returns from an African safari with a cyclical fever and nausea and vomiting. What is the primary acid-base disturbance: 2. MD A manic patient with fever and diarrhea presents to the ER.! ! 1.! ! 9. hypotensive with these initial labs: Calculate the bicarb prior to the AGMA: 1.28 / 28 / 88 ! glucose: ! 128! ! ! 142! 3.8 ! 3.8! 138! 4.! ! 4. What is the anion gap? 4. What is the primary acid-base disturbance: 2.! ! 6.! ! 10.! ! 2. Calculate the bicarbonate before 5.! ! 7.8! 138! 4.8! 141! 4.8! 134! 4. Calculate the bicarbonate before 5. He appears toxic: 7. Topf.
Anion Gap: 23 Bicarb before: 25 8. Lactic acidosis of fulminant malaria. 22 4. This patient also has a triple disorder. 2. metabolic alkalosis 2. 6. and osmolar gap in the following patients 1.Anion Gap: 16 Bicarb before: 20 5. Metabolic alkalosis 11. 7. 8. respiratory alkalosis 3. None 3. Metabolic Acidosis Respiratory acidosis Metabolic alkalosis Metabolic Acidosis Respiratory acidosis Respiratory acidosis Metabolic Acidosis Respiratory acidosis Metabolic alkalosis Ms. 3. Respiratory alkalosis Using the prediction equations ! Metabolic Acidosis • 23±2 • alkalosis • respiratory • acidosis ! Metabolic alkalosis • metabolic • increased •8 • appropriate • acidosis • alkalosis ! Respiratory acidosis • respiratory • acidosis • acute • chronic • metabolic alkalosis • chronic ! Respiratory alkalosis • decreased • respiratory • decrease • metabolic alkalosis Multiple Acid-base disturbances.Anion Gap: 18 Bicarb before: 12 4. 5.Anion Gap: 28 Bicarb before: 30 10. 8.Anion Gap: 28 Bicarb before: 22 10.Anion Gap: 12 Bicarb before: 18 2. Calculate the bicarb before: 1. 28 28 . Patient had pre-existing metabolic alkalosis. 9. 10 5. Topf. calculated osmolality. respiratory alkalosis 3. DKA 4. 22 4. Yes. Spears: both a primary metabolic alkalosis and respiratory alkalosis Mr. Wayne: isolated chronic respiratory acidosis or an acute respiratory acidosis and metabolic alkalosis Ms. 9. Case vignettes 10.Acid-Base Physiology! ! ! ! ! ! ! ! ! Joel M. Alkalosis likely due to crack cocain being cut with bicarbonate. The presence of an anion gap in metabolic alkalosis or a primary respiratory acid-base disorder indicates an additional metabolic acidosis. 4. 5. 6. Patient had pre-existing metabolic acidosis. 3. Thompson: metabolic acidosis and respiratory acidosis Mr. respiratory alkalosis and metabolic alkalosis. This patient has a triple disorder: metabolic acidosis. Pre-existing NAGMA due to diarrhea Charlie Sheen.Anion Gap: 22 Bicarb before: 29 7. Anion gap: 25 Calc Osm: 302 gap: 35 Anion gap: 23 Calc Osm: 301 gap: 10 Anion gap: 12 Calc Osm: 293 gap: 9 Anion gap: 28 Calc Osm: 381 gap: 19 Anion gap: 38 Calc Osm: 322 gap: 16 Anion gap: 23 Calc Osm: 309 gap: 0 Anion gap: 16 Calc Osm: 319 gap: 14 Anion gap: 18 Calc Osm: 364 gap: 16 Anion gap: 30 Calc Osm: 268 gap: 45 5.Anion Gap: 18 Bicarb before: 24 6. 4. 18 5. MD Answers Determine the primary acid-base disturbance: 1. metabolic acidosis 2.Anion Gap: 18 Bicarb before: 18 3.Anion Gap: 16 Bicarb before: 20 9. 2. 14 4. Franklin: isolated metabolic alkalosis Problems: ﬁgure out the anion gap. metabolic acidosis 2. Daley: isolated metabolic acidosis Mr. Anion gap: 13 Calc Osm: 339 gap: 5 Gap-Gap case vignettes: Jay Cutler 1. 7. Prince William 1. Winning! 1.