MIDTERM NOTES BY F.L.F.

SANJUAN,RMT,DTA

Classifying an Acid-Base Disorder III.Differentiating the disorders

METABOLIC ACIDOSIS:
I. Determine the primary abnormality • Disorders are categorized by presence
or absence of anion gap and osmolal
gap
ACIDOSIS
• METABOLIC ACIDOSIS: pH and INCREASED Normal Anion Gap
HCO3, decreased from normal anion gap (≥12)
• RESPIRATORY ACIDOSIS: pH and • Methanol • Diarrhea
HCO3, abnormal from opposite • Uremia • Recovery Phase
directions and pCO2 is INCREASED • Ketoacidosis Diabetic Ketoacidosis
ALKALOSIS (Diabetis, Ethanol, • Ureterosigmoidostomy
• METABOLIC ALKALOSIS: pH and Starvation) • Ammonium Chloride
HCO3, INCREASED from normal • Paraldehyde • Carbonic Anhydrase
• RESPIRATORY ALKALOSIS: pH and • Lactic Acidosis inhibitors
HCO3, abnormal from opposite • Ethylene glycol • Total parenteral
directions and pCO2 is • Salicylate nutrition
DECREASED • Renal Tubular Acidosis

II. Determine if the compensation is appropriate Increased Osmolal Gap

With Metabolic Acidosis Without Metabolic
• METABOLIC ACIDOSIS: For each 1.3 Acidosis
mEq decrease in bicarbonate, the • Methanol • Isopropanol
pCO2 decreases by 1.0 mmHg • Propylene glycol • Glycerrol
• METABOLIC ALKALOSIS: For each 0.6 • Ethylene glycol • Sorbitol
mEq increase in bicarbonate, pCO2 • Paraldehyde • Mannitol
increases by 1.0 mmHg • Ethanol (sometimes) • Acetone
• RESPIRATORY ALKALOSIS OR • Ethanol
ACIDOSIS (sometimes)
• Acute: For each 1 mmHg
change in PCO2, the • Calculate the anion gap
bicarbonate changes by 0.1 in • Normal is less than 12
the same direction • In nonanion gap acidosis, the chloride
• Chronic: For each 1 mmHg level is often elevated (hyperchloremic
change in PCO2, the metabolic acidosis)
bicarbonate changes by 0.4 in • Note that low anion gap is uncommon,
the same direction but maybe caused by hypoalbumine-
mia and paraproteinemia, such as in
multiple myeloma
• Calculate the osmolal gap

METABOLIC ALKALOSIS
• Disorders are categorized by chloride
responsiveness or resistance
Chloride Chloride resistant
responsive
• Diuretic therapy • Hyperaldosteronism
• Vomiting • Cushing syndrome
• Nasogastric • Exogenous Steroids
Tube Suction • Licorice
• Villous adenoma (glycyrrhizin)
• Carbenicillin • Bartter Syndrome
• Contraction • Milk-alkali syndrome
alkalosis
• Respiratory acidosis results from any
impairment to ventilation
o Causes include those directly
affecting the lungs (airway
obstruction, alveolar infiltrates,
perfusion defects) and those
affecting the neuromucular support
of breathing
• Respiratory alkalosis most often results
from hypoxemia, in which
compensatory hyperventilation leads
to hypocapnea
• A variety of other stimuli can lead to
hyperventilation, including anxiety,
CNS insults (e.g., trauma, stroke, or
ischemia), pregnancy and a variety of
medications
• Difference in CO2 concentration
between cytoplasm and plasma results
in diffusion from tissues into cells and
the formation of carbonic acid
(H2CO3)
• Most CO2 combines with H20 to form
carbonic acid which quickly dissociates
into H+ and HCO3
• Dissociation in plasma is very slow
(nonenzymatic) but is much faster in
cells because of carbonic anhydrase
• Carbonic anhydrase is present in high
concentrations in red cells and renal
cells
MIDTERM NOTES BY F.L.F.SANJUAN,RMT,DTA
• Dissociation causes increased HCO3
concentration in red cells, resulting in
diffusion into plasma and circulates
bound to Na
In lungs,
• Oxygen diffuses from lungs to blood
forming oxyhemoglobin
• H+ from deoxyhemoglobin in venous
blood is released to recombine with HCO3
to form carbonic acid which dissociates
into CO2 and H20
• CO2 is exhaled and H+ is buffered
resulting in minimal change in pH known
as isohydric shift
• The affinity of hemoglobin for oxygen
depends on temperature, pH, PCO2, &
concentration of 2,3-DPG
In kidneys,
• Kidneys reabsorb HCO3 in the PCT to
restore it
• Aldosterone causes Na reabsorption and
exchanges it with either K or H ions
(whichever is in excess)
• Aldosterone takes bicarbonate along with
Na to maintain electrical neutrality
• Renal cells are rich in carbonic anhydrase,
so the supply of bicarbonate is unlimited
• H ions secreted in exchange with Na may
react with phosphate (filtered through the
glomerulus) to form phosphoric acid
Chloride shift
• When the concentration of bicarbonate in
RBC greater than in plasma during the
buffering process, bicarbonate diffuses out
• Chloride must diffuse into RBC to maintain
electrical neutrality → CHLORIDE SHIFT
• When CO2 is expelled from the lungs,
Chloride again shifts out of te red cells into
plasma
• Plasma proteins and buffers combine with
the free H

ACID-BASE BALANCE
• Acidemia: Arterial pH <7.35
• Alkalemia: Arterial pH >7.45
• Acidosis
o A condition tending to lower pH
(the pH may not actually be
lowered, because of compensation)
• Alkalosis
o A condition tending to raise pH (the
pH may not actually be raised,
because of compensation)
• Respiratory Acidosis
o Insufficient elimination of CO2 by
the lungs (hypoventilation). The
primary change is in CO2.
Compensation involves altered
renal handling of bicarbonate
• Respiratory Alkalosis
o Excessive elimination of CO2 by the
lungs (hyperventilation). The
primary change is in CO2.
Compensation involves altered
renal handling of bicarbonate
• Metabolic acidosis/alkalosis
o Excessive intake of, excessive
production of, or too little renal
elimination of an acid or a base.
The primary change is in
bicarbonate. Compensation
involves alteration in pulmonary
handling of co2
• Simple acid/base disorder: A primary acid-
base disturbance and associated
compensation
• Complex acid/base disorder: there is more
than one primary acid-base disturbance
• PCO2: respiratory component and is
controlled by lungs (rate of respiration)
• HCO3: metabolic component and is
controlled by kidney and erythrocytes
(nonvolatile acids produced in tissues)
• Normal ratio of base to acid 20:1
MIDTERM NOTES BY F.L.F.SANJUAN,RMT,DTA
• Base Excess
o calculated perimeter which
describes excess or deficit of base
or bicarbonate
o Decreased BE: indicator of
metabolic acidosis
o Increased BE: indicator of
metabolic alkalosis
• Compensation
o Uncompensated
o Partial compensation
o Complete compensation
Blood Gas Analysis: Sample requirements
• No tourniquet and no fist clenching
required
• Do not pull plunger, do not use vacutainer
• Only heparin (liquid or dry); other ACs
alter the pH
• Protect from air (anaerobic) to prevent
equilibration with low PCO2 and high PO2
in the air
• Immediately expel any small bubbles
• Keep sample submerged in ice/water
slush to impede WBC metabolism
• pH decreases at 37 degrees Celsius
• PCO2 increases and PO2 decreases from
metabolism
• Volume of blood for most commercial
electrodes is <1mL