chapter ACID-BASE INTERPRETATIONS tna suey conc at univer ching hp, 7D ofa ina eeece eine SIRES Ueda gl ce seit ta cae ANC em Se erat ly dl et sale A a cre ert kad ta ere ae Pe arth acting cge ene ta of eA fore nec ot Raney vel es decor mak sis eed en Hiscmegble peicU whee 1Asic CONCEPTS ‘The hydrogen ion concenttion [HJ neta Mu i deter eG Beales between te prt preaure of carton ‘aed by ts Pecan of carne [ACOs i he a TAS Ciaieip expres a folowes OF TH" Tinag/t = 24 feoy/{HCOD AN Using «normal ater Tey of 40 man He ard a noemal Sen ea een of mg/L he normal (| att Boo BSR Ura te nea/LSH poste Oxon 4°] AND PH [Note that the [1°] n extracel uid is es pres. Ananeutalen one ml ta rl Jen 40 there are miles more sodium, clone and ote on ex seredinmy han ee rhy genes cereus SSiebemope ty oth fortune cprend npua wh SE tne latoabp einen He osama een poet ‘Roormal Hota ponds pitot740 Bees tp ‘banegaive stn Ea pH aeinversely related wehaas icjaderenne Sastcatedwithanineresse ae ‘otethat ss apHidccrane roms ightvae 2h he eae reas, Ts the pH decrenses, ‘eines 5 Sch leemion etetucio ce ores Petites Gs ee an Lo ig (hs thowatow Shy Ge fae trolled) Attheacidotcend ofthe curve, the changein["Tismare than thveefold higher thanat he altalotc end a the carve QOnEq/L versus bnEg/L pet pi unt respectively, Therefore te acd base core: 100. X17 apa" peros pH unt 74 75 70 72 foal 1 ecco "and 361, The ont beven bg ee BETS sere te cee Shag as Sina Sega seers ach had. "iin Dior Py ge Compe spr sts ie, "ico espn) sae tre iiss, fm ies, ike [Mews ae iid i nce of given change In pH cepend on he undeiing cd-bt smaaeguneere the undying ‘COMPENSATORY CHANGES odamrets termed nase ees ‘Sacer p's bat or Oe prin tng Cg ppenaes = _bupetasialrin eee peeernae ites enact oneie a etr BScascopaiicel omeearesran eee eee eee See Peer ei i ead tare enero ay cal expected, after Py ca be ‘own Tale 362 The Soaets incuba [iS vaedin diferent reports Bowevr, te equation shown o Te Seb Watpeoen slate emt up ts HOS vel of © mg/L Metabo Compensation gees OU aEtS Mente HCO etscrpto, wh eros ty FCO cancenmabon, heey rep salou In EOE Gao snc derenes the serum HCO, onenatPRIIIDIVODO 506 sib Onre TABLE 96 BOECTED ANCES IN AGD ASE DISORDERS "iy Or Sen py de lace pny sone [i py able Ieee tutte ast tnmnen ‘Speen seer heer ert Mew dln evagmtenastnea oie sn, pny cea ated ene ‘Sirgen teat kates Stihl Anieacaiienem ates, cas eae a ‘THE RULES OF ACIO-BASE INTERPRETATION ‘The approsch tat olows is based on sve acid-base variables pH, ‘eon, and HCO, The rference ranges foreach of ese rare shown below (3). Any measurement hat Tals usd ofthese anges |stonsdered fo be sbarmal mph sf 7M 10, = 22 to 20 meg, (052) PRIMARY METABOLIC DISORDERS ale priory mutable aids ner pce if she pH ® Sad ep anal Bio, change in the sche deco ‘Thus a primary mean present theater pi below 7.36 an the arterial Poy (Paco) iy decreased, wherest& primary etl ans prever he H sabove 48 ana the Paco em a primey nebo ate dsdeio ened, oo ale 2A superimpom respiratory acid ase duorder i present if any ofthe flowing conan are acd, ‘The measured Peo, normal ‘The ensured Feo; higher than the expected Poo (hin te Sterne sept me ‘The measured Poses han the expert Peo (india 1 uperinposed repay mio) Thus, cae a primary metabolic darder hasbeen identified the appropticequlton in Tble 38 shoul be nado defn the oy i expected wih fl espentory compensation fhe mess ston rpg is shove or below the expected Poy a cmbine (etboi ‘apkaion) sot bee dearth psc PRIMARY RESPRATORY DISORDERS as 9A py tp tre por bse ennai, ie tt ay Spas etary eee steielelioacatg Gheneliemacrmcnn Sopa Cerne arm eer tp igi aa ete REE tnd chang n pl deeming senescent deni se ers ace or chronic and whether s sspermposed teat ine dtonder = present the change pHi 0.08 times the change in Pao therespee fpimentisiraees uber GE STRRS epee eee ea eae ule cSle i or oeropa Saar eon a ete vives eee amet abpe re Rateceetedas hae afeetlosss eau teenies ene gays Riedaet wauereerecerratae INS Seteriavaeatemuietos Sete ee a eae Se greene aes ce ee nome doe Rule 5 A mised (acidosis and allay) acd bate disorder cpr sping Ae Ss the PE chang all ITihe pHi sbroemal and the Paco: unchanged fr noreat ‘Thi rule based on the fc tat compeasiny tes spon 1p sap ace dard dotcom sre ey ota ting’ ai. Tero te Pacts Sl mH and he Seer melbolc Shula in auhienS Seana tory econ RULE ORIENTED ACID-BASEINTERIRETATIONS “This section usa ho he 5 rules ut decribed canbe tothe interpation of ARG. Each of inprctaion Bega ot tear Tithe pit is below 736 check he Peo, and proced follows: A of oral aco nd pinay metab aothe arterial pH is uncanged or normal, the oo, should be checked: 506 seb to0 Dancer Te derece betwee he mesure and pected Paco Theo cnly«upemposed pein Saree ae ‘igh em nda ry eo ale 9 ‘Tichangen pi heme dette wher ede Mira ste orci wheter ssuprtponcl alc SE Ana Ihe pt above 744, tc the eos nd proce lowe Ae righ oc le primary tn x ofthe eared ad expected Po then ed ‘Stlealy on noted open doa le Ato Pane nor alos le 3 Bi Gangetn pi dna Serie wht ede “eris acute or onic or whether superiaposed meabolic ‘Ssonder is prsen (isle) Is high or nde ed enya ‘ale 5 ‘Alove Pessindicries a mined respiratory allalosis metabolic ci dois le 5) ‘A normal pH combined with 2 nermal Pacos snot absolute eve ache opin an net faue dors beaut» tetabolic sido co ‘hn aoc lac Be acrpred by oral Te anon cw rae cestode pe tlt Peat CO onset mere ae sete csp corm cy ances! iets eeant Boy act poet ep Rete Dpto TE weconcr Eptrworteneiin eter shanti sare af ch cop era eee ie aie ara Sere Ris chatiamac ie Paco tn neared ang (UA) rte fallow 3 ony mesure ccc Mee ans Na + UC = (Cl + HCOs) + UA or when hts re rega Ne (CL + HCO) = UA ~ Uc Te manip UA = Utes menses : ate of emesiedsnons andy ced he ao Detemans The ml sedans acne the AC ae 468 The placa proeine ar the major souree ate “va fauna esa vp eben eet chart rect etches a 1. Much ofthis difference i ds Peet sekmeaayacticet «Na asp ate a ere merge Se Sorel sig ents Cn gern : a ae eh ae rar RA meee i Soe METABOUC ACIDOSIS ss meioned previa AC ase ad ASR AC ea aly, Tae een Uansoaed Cos Toes a Gin Sgt opmcssns cay reset "Kewpe omy Moores 38g t Ue mdyit ee ord ae ap = UA = UC Beaty plana pi a rend MS en p=SELES SOUEOLN ° ” ” 2s 0 twcen metab acidows cased by an acuitin of hydrogen ‘nd metabo slows cased by ea af beeen ase om igh Anon Gap ‘When a metabolic acidosis is du tothe accumulation of hydrogen ions in the entracelslr Bud (lc sede) he heen nn embine with biarbonate to for eafboric scl This decreas he ‘iarbonateconcentraton inthe extracellular fig, which trie creases the AG (a prelicted bythe ratonship AG’ Na = CL COs), Therefore, tmetabolcactdosiswithaigh AGo mos ikely organ ci accumulation (i ates or eto) ot larch pated hydrogen inh exert ‘Athoupa high A con Be hel in fe seting of a metabolic scien should not be used ss eence of nebo adoas oles exceed 50 mEq/L G9) fat an leveled AG con bea isms met lcs Tt saa a ce presto by wceasing te srength of he nega charge On ‘bumrin molecules (1011). — Normal Anion Gap ‘When a metabolic acidosis caused bythe loss of bicarbonate fons {som the extracellular Quid (¢g, diarrhea, the bicarbonate loss i {Counterbalanced by agin of chloride oa to matain cecal charge fatality, Because te increase in chloride concentration i propor tonal tothe decrease in bicarbonate concetration, the AG remains Unchanged. Therefor, a metabolic acidosis with 3 normal AG Is taken at a sign ofa bcarbonate-wasting process, such a dares or {feressed bitarbonate losses in the urine in erly renal file saat nena reanpermte seme ome et aca don fies cal dons). Aluough face aid acumulstion amas rap ttn eo Sea aetna penta an ces ot ete ba raMtenn ay academe isco tense cetcoaoniyteree septs ted ipa Maw tae wiser arvar shodintarae ne soem resco wa MIXED METABOLIC DISTURBANCES ned meuboicdsturancs high AG rom tcl pas oe ee rh can deed wang he Teltoatip Parma eras mand he derenp eun HCO> The Sprang oi AG ene) HCO, eit a, wh slatooahip a expressed os he [AG excess/HICOs defict = (AG - 12/24 = HOO) (% MIKED METABOLIC ACIDOSES ine droge occ od te dere ae COs tent encase AG wl the AG ec se tthe i When Vhived seaeeebagh ACS tat a) pu he RE xen, eta dat et ‘oatabaton ofeach type tothe acts rao of ines an Sista combudon ots igh A asd oma Diabet Netaaiens Diabetic Ketonciosisis expect present asa high AC metab aca er lay wi ssa and in Bain BSQLAG scidosis Changes to anormal AG acdots (17) Those {Ste he clo lon nthe ravenous Ie i star, ‘Sum carbonate remain low iutonal fle) but the AG ect ED, denen nn sows say dain he eater Be pe tent dees In srum HCOy ml ree a ae [Ebel are nt beng cared Thr usta the valve of (Saas FICO, Serato fortnemanagement of patient wet lone MUxED ACIOOSIS-ALKALOSS When alkalis added in the presence of 2 high AG acide grease serum bicarbonate ses than the decrease 6 AG and ‘Str dean pater hn wy, Meo ia ‘common nthe ICU becuse rs re se erctre mined meet acess ee aks) ‘more common than suspect ‘VENOUS 81000 Gases mane ol eta tei _ eaters ts emer eeageatnes Asan een ety Sontetice Shee tt iene sum Seashore eomaeepir soe omy ete eee Se ahes iat career athe! iris a Restart Racemneet 13) and 2 the areal Hood f Nt a snatve marr @ ‘Speen igus ember2 590 setae nore 78 0 1 a 4 7 7 erty 7 “0 10 7 “aioial Venous igure 962. Aci-bate arcs in areal and venous dig Taper, Actes nlite weal came the sora ue anand devabon Sy ou oda pte a a Tat Be frm Rea Dine oe se (Free Wel MUL Rashad ean earhoplmonay roc Bagh Mad noais 15-188) ‘Aaa! Venous REFERENCES, SUGGESTED READINGS ret AL Daan RA, dll an ate dire Now Yr cE ccc sen ee iRooUCTION ingen DMC A compli raepeon of ati pH and Ho eM A eed age Cae eazraOa a RSENS Ey repens lod ub com ce Nagas pt cami poncho ase a ye eae ast COMPREHENSIVE Reviews Navi 0, Emmet Me 5 peach ma ara tn AE Gel acon neama 1. Roe} Mao PL Respir er Pap 8 Sunder 18 SELECTED REFERENCES 1p Bh te Cid oe cna. ete 77868 Sr es GO Saran Ue mn pp les EY Dagonicimpencof anne Da Lee may oh en ‘scr pt Co ae See fr macy indo, 1 Hei Radon EC Teva Decne en ‘eared ing cep stn Ng ad