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Acid-Base Balance and

Dr. Paul Morgan
Consultant Intensivist
University Hospital of Wales
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Case 1

A healthy 37 year old man is having an elective

cholecystectomy under a general anaesthetic.
He has no significant past medical history and is
on no routine medication. Preoperative urea and
electrolytes were all within the reference range.
Anaesthetic monitoring shows a very high end-
tidal carbon dioxide level, so an arterial blood
sample is obtained for blood gas analysis
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Here is the blood gas report

pH = 7.10
PCO2 = 9.2 kPa
[HCO3-] = 28 mmol/l
PO2 = 9.9 kPa
How do you explain these findings?
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Case 2

A 75 year old man with a long history of severe

acute chronic obstructive pulmonary disease
(COPD) is admitted to hospital with fever,
confusion and significant respiratory distress. He
lives alone but his neighbour says he has been
unwell for a week and has deteriorated over the
previous 4 days. There is a long history of heavy
smoking. Biochemistry & haematology results
are not yet available.
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An arterial blood specimen has been obtained

Here is the blood gas report
pH = 7.10
PCO2 = 9.2 kPa
[HCO3-] = 28 mmol/l
PO2 = 9.9 kPa
How do you explain these findings?
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The results for the two patients are the same!

How can that be?
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Is the assessment of the results the same even

though the clinical situation is very different?

The pattern (PCO2 elevated, HCO3 borderline
elevated) suggests either a respiratory
acidosis or a metabolic alkalosis but the
severe acidaemia means that it is a
respiratory acidosis that is present. This much
is common ground to these two cases. The
clinical details are necessary to decide if a
simple or a mixed acid-base disorder is
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How can we explain the ABG of

Patient 1?
Respiratory acidosis from hypoventilation
Bicarbonate level appropriate to clinical scenario normal
No metabolic component
Acute change with no time for any metabolic compensation to
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And Patient 2?

Severe COPD, history suggests chronic respiratory acidosis

Measured [HCO3] is lower than expected co-existent
metabolic acidosis
Has he got peripheral circulatory failure?
Is he diabetic?
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The Six Steps to Systematic Acid-Base Evaluation

1. pH : Assess the net deviation of pH from normal

2. Pattern: Check the pattern of bicarbonate & PCO2
3. Clues: Check for additional clues in other investigations
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4. Compensation: Assess the appropriateness of the

compensatory response
5. Formulation: Bring the information together and make
the acid base diagnosis
6. Confirmation: Consider if any additional tests to check
or support the diagnosis are necessary or available &
revise the diagnosis if necessary
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Compensatory Responses

Know the clinical details of the patient

Find the cause of the acid-base disorder
The snapshot problem: Are the results 'current'?
Determine the major primary process
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Fluid Balance and Homeostasis

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A 42 year old man presents with a 3 day history of severe

abdominal pain and profuse watery diarrhoea.
His partner has also been ill with vomiting and diarrhoea. Both
became ill after eating leftover chicken.
On examination his mucous membranes are dry, pulse is
110/min, regular, BP is 105/50.
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Abdominal examination reveals generalised tenderness, but

no peritonism. PR examination is unremarkable save for
some diarrhoea stool.
You suspect an infective enterocolitis. What blood tests would
you request?
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Blood tests

FBC, clotting, U&E, CRP, blood cultures.

His FBC result is
Hb 175, WCC 25.3, Platelets 587
Clotting is normal
Urea 16, Creatinine 223, Na 128, K 5.9
CRP 145
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How do you account for these results?

Hb and platelets elevated due to haemoconcentration as a

result of dehydration
High WCC infection
U&E suggests acute kidney injury from dehydration +/-
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Outline how you would treat this patient

IV fluids
Most cases of infective enterocolitis are viral, but the
possibility of a bacterial infection may merit antibiotic therapy
What bacterial infections may be responsible?
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E. Coli

Clostridium difficile?
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The patient receives 3 litres of 0.9% saline over the next three
hours. Despite this, his urine output remains poor although his
pulse and BP both improve. You decide to re-check his U&E
and an arterial blood gas
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Urea 14, Creatinine 295, Na 128, K 6.4

pH 7.19, pCO2 = 2.5 kPa, pO2 = 12.1 kPa, HCO3 = 14, Base
excess -10.6,
Lactate 1.9 mmol/l
Chloride 114 mmol/l
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What are the explanations for these

abnormal results?
Worsening AKI aggressive fluid resuscitation too late to
save kidneys? Hence rising K, metabolic acidosis
Lactate essentially normal or marginally elevated
Why is his chloride high?
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Abnormal saline!

0.9% saline often referred to as normal saline due to

isotonicity with plasma
Contains a very abnormal mix of electrolytes.
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Electrolyte solutions
Hartmanns 0.9% Saline Dextrose/
Solution Saline
Sodium (mmol/l) 131 150 30

Chloride (mmol/l) 111 150 30

Potassium 5 Nil Nil


Bicarbonate 29 Nil Nil


Calcium (mmol/l) 2 Nil Nil

3L of Dextrose saline is not equivalent to 2L 5% Dextrose and 1L Normal saline

3L Dextrose Saline = 3L water and 90 mmol Na+
2L 5% Dextrose saline + 1L Normal saline = 3L water and 150 mmol Na+
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0.9% Saline v. Hartmanns administration

Blood Sodium Potassium Chloride

volume 5
Normal 140 4.5 100

After 1 litre 142 3.75 108

After 1 litre 138 4.6 102
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Administration of a lot of 0.9% saline raises the plasma

chloride level.
Renal mechanisms for chloride balance cannot cope.
To maintain electrical neutrality, bicarbonate ions are lost
into the urine
Results in a hyperchloraemic metabolic acidosis
Evidence this may be harmful
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Thank you!