ACID BASE IMBALANCE 11.

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DEPARTMENT OF INTERNAL MEDICINE
Dr. Urayenza / Dr. Monis І February 24, 2022 o Normal value = 10 – 12 meq/L
o The significance is to know if the patient has anion gap
Content Outline acidosis or non-anion gap acidosis because normal anion
I. ACID BASE III. ABG PART II gap and high anion gap has different causes.
IMBALANCE A. NORMAL ABG o If the anion gap is between 10 – 12 meq/L, we think of
A. CLINICAL & VALUES MUDPILES and CAT.
LABORATORY B. TERMINOLOGY
PARAMETERS IN C. COMPENSATORY ANION GAP METABOLIC ACIDOSIS
ACID-BASE RESPONSES MUDPILES CAT
DISORDERS D. COMPENSATION Methanol Carbon Monoxide
II. ARTERIAL BLOOD E. MIXED ACID- Uremia Aminoglycosides
GAS BASE DKA Theophylline
A. COMPONENTS OF DISORDERS Paraldehyde
ABG F. STEPS IN ABG
Iron, Isoniazid
B. STEPS IN ACID- INTERPRETATION
Lactic Acidosis
BASE IV. SAMPLE CASES
CLASSIFICATION Ethanol, Ethylene Glycol
C. RESPIRATORY Salicylate, ASA
ACIDOSIS
D. RESPIRATORY NON ANION GAP METABOLIC ACIDOSIS
ALKALOSIS  Think of HAARDUPS
E. METABOLIC  Hyperalimentation
ACIDOSIS  Acetazolamide
F. METABOLIC  Amphotericin
ALKALOSIS  RTA
Red: Audio Black: PPT  Diarrhea
 Ureterosigmoidoscopy
ACID BASE IMBALANCE  Post hypocapneic states
 Acid-base homeostasis in man is accomplished by the  Sulfamyalon
maintenance of systemic arterial pH within a narrow range
despite acid and alkaline loads from the daily intake and ARTERIAL BLOOD GAS (ABG)
degradation of foods.
 Arterial blood gases are an invaluable tool in assessing
 Body pH is protected by: ventilation acid-base balance and oxygenation
o Buffers
 Results should be correlated with good clinical data.
o Pulmonary regulation of PaCO2
 Treat the patient, not the lab results
o Renal reabsorption & excretion of HCO3 & excretion of
 Accurate history and physical examination.
acid
 Two types of acid-base disorders:
COMPONENTS OF ARTERIAL BLOOD GAS
o Metabolic
 pH
 Characterized by primary disturbance in the
o measurement of alkalinity and acidity based on hydrogen
concentration of HCO3 in the plasma
ions present
o Respiratory
o Normal range is 7.35 – 7.45
 Primarily alters PaCO2
ABNORMALITY COMPENSATION  paCO2
o partial pressure of CO2 dissolved in blood
RESPIRATORY
o Normal range is 35 – 45 mmHg
ACIDOSIS CO2 HCO3
 PaO2
ALKALOSIS CO2 HCO3 o partial pressure of O2 dissolved in arterial blood.
METABOLIC o Normal range is 80 – 100 mmHg
ACIDOSIS HCO3 CO2  HCO3
ALKALOSIS HCO3 CO2 o amount of bicarbonate in the bloodstream
 When we say respiratory acidosis, there would be high CO2 o normal range is 22 – 26 meq/L
and to compensate the bicarbonate will also increase.  Base Excess (BE)
 For respiratory alkalosis, there is decrease CO2 and to o Indicates the amount of excess or insufficient levels of
compensate for this, the bicarbonate will also decrease. HCO3 in the system.
 For the metabolic acidosis, the bicarbonate is decrease and o Normal range is -2 to +2 meq/L
to compensate the CO2 will decrease, while in metabolic  SaO2
alkalosis, the bicarbonate is increase and to compensate o arterial oxygen saturation
there is an increase in the CO2. o normal range is 80 – 100%

CLINICAL & LABORATORY PARAMETERS IN ACID-BASE ACCEPTABLE RANGES

DISORDERS pH 7.35-7.45
 Careful history & PE pCO2 35-45
 Electrolytes & arterial blood gas (ABG) HCO3 22-26
 Evaluate the anion gap BE +2 to -2
o To compute for anion gap, we should requests for
sodium, chloride, and ABG
o Anion gap = Na – (Cl + HCO3)
 ACID BASE IMBALANCE
STEPS IN ACID-BASE CLASSIFICATION o pH >7.4: Alkalosis is primary, acidosis is compensatory.
 pH classification o pH <7.4: Acidosis is primary, alkalosis is compensatory
o Normal: 7.35 – 7.45  Classify the degree of compensation (Complete
o Acidemia: <7.35 Compensation, Partial Compensation, and Uncompensated)
o Alkalemia: >7.45 o pH 7.35-7.45: Complete compensation
 paCO2 classification o pH <7.35: Partial Compensation
o Normal: 35 – 45 o pH >7.45: Partial Compensation
o Respiratory acidosis: >45 o When the pH is not normal, the bicarbonate or the PaCO2
o Respiratory alkalosis: <35 did not compensate for the imbalance then that will be
 Metabolic classification your partial compensation.
o Normal: BE: O +/- 2; HCO3: 24 +/- 2
o Metabolic acidosis: BE: <-2; HCO3: <22 RESPIRATORY ACIDOSIS
o Metabolic alkalosis: BE: >+2; HCO3 >26  Defined as pH <7.35 with a paCO2 > 45mmHg
 Acidosis caused by an accumulation of CO2 which combines
with water in the body to produce carbonic acid > lowering the
pH of the blood.
 Any condition that results in hypoventilation can cause
respiratory acidosis. these conditions include:
o Central nervous system depression related to head injury
o Central nervous system depression related to
medications such as narcotics, sedatives, or anesthesia
o Impaired respiratory muscle function related to spinal
cord injury, neuromuscular diseases, or neuromuscular
blocking drugs
o Pulmonary disorders such as atelectasis, pneumonia,
pneumothorax, pulmonary edema or bronchial
obstruction
o Massive pulmonary embolus
o Hypoventilation due to pain, chest wall injury/deformity,
or abdominal distention.

 In this picture, in alkalosis, the pH is high (kicking the pH up).

 For acidosis, the pH is low (sliding the pH down).

pH PaCO2 HCO3
Respiratory   Normal
Acidosis
Respiratory   Normal
Alkalosis
Metabolic  Normal 
Acidosis
Metabolic  Normal 
Alkalosis
 For respiratory acidosis, first look at the pH. Is the pH low?
If low, that is acidosis. Look for the PaCO2 and HCO3, which
of this two is congruent with your acidosis. If your PaCO2 is
more than 45 then that is acidosis, and low pH that is also ACUTE RESPIRATORY ACIDOSIS: CAUSES
acidosis, so that is interpreted as respiratory acidosis.  Excretory problems
 For respiratory alkalosis, look at your pH. Is the pH more o Perfusion
than 7.45 then that would be alkalosis. It would be respiratory  Massive PE
if your paCo2 is congruent with your pH (less than 35) and  Cardiac arrest
that is your respiratory alkalosis. o Ventilation
 For metabolic acidosis, we look at your bicarbonate. If the  Pulmonary edema (severe)
pH is low then that is acidosis and your bicarbonate is also  Pneumonia (severe)
low which is a congruent with acidosis, then that is your  ARDS
metabolic acidosis with normal paCO2.  Airway obstruction
 Metabolic alkalosis when your pH is high and that is more  Lungs/thorax restriction
than 7.45 and we have normal paCo2 but high bicarbonate  Muscular defects
which also indicates alkalosis. So this one is your metabolic  Control problems
alkalosis. o CNS
 Anesthesia
COMPENSATION EVALUATION  Sedatives
 Evaluate for presence of compensation  Trauma/stroke
 Central sleep apnea
 Determine the probable primary problem
o SC & Peripheral nerves

DIOQUINO І FROILAN І LUIS І VARGAS

 ACID BASE IMBALANCE
 Cervical cord injury o Irritation/lesions of airways
 Guillain Barre Syndrome o Stiff lungs
 Neurotoxins o Restrictive lung defects
 N-M blocking agents eg. Curare  Drugs/Hormones
o Failure of mechanical ventilator o Salicylates
o Nicotine
CHRONIC RESPIRATORY ACIDOSIS: CAUSES o Thyroid hormone
 Excretory problems o Progesterone
o COPD o Catecholamines
o Interstitial fibrosis o Xanthines
o Thoracic cage deformity  Others
o CV & vascular problems ex. CTEPH o Liver cirrhosis
 Control problems o Gm (-) sepsis
o CNS o Pregnancy
 Obesity-hypoventilation syndrome o Mechanical ventilation
 Tumors o Recovery from metabolic acidosis
 Brainstem infarcts
 Poliomyelitis METABOLIC ACIDOSIS
 Myxedema  Causes:
o SC & PN o Marked increase in endogenous acid production
 Multiple sclerosis o Loss of HCO3 stores
 Amyotrophic lateral sclerosis (ALS) o Progressive accumulation of endogenous acids
 Diaphragmatic paralysis  Two types of simple metabolic acidosis
o elevated anion gap
RESPIRATORY ALKALOSIS o normal or hyperchloremic acidosis
 Defined as pH> 7.45 with a PaCO2 < 35mmHg.
 Any condition that causes hyperventilation can result in
primary alkalosis. These condition include:
o Psychological responses such as anxiety or fear
o Pain
o Increased metabolic demands such as fever, sepsis,
pregnancy or thyrotoxicosis
o Medications such as respiratory stimulants.
o Central nervous system lesions

EFFECTS OF ACIDOSIS
 Epinephrine release
 Leukocytosis
 Potassium & Calcium alterations
 Emesis
 Hemodynamic effect
o Impair contractility of the heart
o Acid mediated contraction of vena caval blood reservoir
RESPIRATORY ALKALOSIS: CAUSES
 Cortical Influences METABOLIC ACIDOSIS: CLINICAL CAUSES
o Anxiety Increased Anion Gap Normal Anion Gap
o Pain Ketoacidosis Diarrhea
o Tumor Uremia Pancreatic fistula
o Voluntary Salicylate overdose Ureterosigmoidoscopy
o Fever
Methyl alcohol ingestion Ileostomy
o Injury and inflammation
Ethylene glycol ingestion Ingestion of acid
o Decreased blood supply
Paraldehyde ingestion Hyperalimentation
 Hypoxemia
Lactic acidosis Carbonic anhydrase (CA)
o Altitude
inhibitors
o Pulmonary shunts
o V/Q mismatch Renal acidification defects
o Pulmonary diffusion defects
o Hypotension
 Physical stimuli

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 ACID BASE IMBALANCE

LACTIC ACIDOSIS
 Type A
o With tissue hypoperfusion
o Example:
 Cardiogenic shock
 Septic shock
 anemia
 CO poisoning
 Type B
o No tissue hypoperfusion
Eexample:
 Liver disease
 Hypoglycemia
 Malignancy
 Seizures

METABOLIC ACIDOSIS: TREATMENT

 Manage underlying cause
 HCO3 replacement
o HCO3 deficit: (BW (kg) x 0.6) x (24-observed HCO3)
o Example: 60 kg woman, HCO3 = 9 meq/L
ARTERIAL BLOOD GAS (ABG) INTERPRETATION PART 2
HC03 deficit = (60 x 0.6) x (24-9)
NORMAL ABG VALUES
= 36 x 15
 pH = 7.35 – 7.45
= 540 meq/L
 PaCo2 = 35 – 45 mmHg
METABOLIC ALKALOSIS  HCO3 = 22 – 26 meq/L
 Results from  PaO2 = 80 – 120 mmHg (age-dependent)
o Factors that increase HCO3 concentration  Base excess / deficit = + 2.5 to – 2.5 meq/L
o Factors that enhance renal HCO3 retention  Rule of 4
 Effects: o pH – 7.40
o Inc neuromuscular activity o pCO2 – 40
o Prolonged QT interval, U wave o Bicarbonate – 24
o Inc sensitivity to digitalis intoxication o Anything above or below the rule of 4 is with a
o (+) Chvostek, trousseau, twitching &tetany corresponding interpretation provided that during the
o Increase affinity of Hgb to oxygen eyeballing there should be 1 value that is abnormal
o Enhanced glycolysis before you are able to apply this rule.
o Enhanced renal absorption of Ca
o Decrease net renal reabsorption of K TERMINOLOGY
 Alkalowsis – low kalium (potassium) and low calcium pH > 7.40 Alkaline  “alkalosis”
pH < 7.40 Acidic  “acidosis”
PaCO2 > 45 mmHg Respiratory acidosis
PaCO2 < 35 mmHg Respiratory alkalosis
HCO3 > 26 meq/L Metabolic alkalosis
HCO3 < 22 meq/L Metabolic acidosis

 pH is actually governed by your bicarbonate which is primarily

Question:
1. What is the effect of acidosis and alkalosis in the brain in
terms of transmission of impulses?
 Alkalosis excites the neuron resulting to seizures,
irritability, hyperstimulation
 Acidosis inhibits the neurons that’s why there will be
lethargy, changes in sensorium,
a function of the kidneys and the CO2 which is the function of
the lungs.
COMPENSATORY RESPONSES
 Primary Metabolic Disorders
o Induce secondary respiratory responses which may
occur within minutes
o So kunwari metabolic acidosis, the next response there
is, the respiratory. So you check that there is
hyperventilation in this process.
o Take note that a primary metabolic disorder, this occurs
in minutes. Pagkasense ng katawan that you have an
acidotic environment, the lungs will immediately
compensate by increasing the respiration within a minute.

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 ACID BASE IMBALANCE
So, magtatachypnea agad sya, so that’s the first sign of
a respiratory compensation. Unless, you’re not doing
anything that during the process there will be a
respiratory muscle exhaustion from tachypnea, they go
into a normal respiration until they go into respiratory
muscle fatigue. So that’s when they already accumulate
your CO2. So, that’s a late response.
 Primary Respiratory Disorders
o Invoke secondary metabolic responses
o Renal adjustments take at least 8 hours to 24 hours (so
delay ang responses invoke by the kidney).
 If you have a decline in pH brought about by a decline in
bicarbonate, then the compensation is, there should be
hyperventilation to decrease CO2.
 In metabolic alkalosis, you have a high pH because of a high
bicarbonate and the lungs is compensating by retaining the
CO2 to donate the hydronium ions to be able to offset the
metabolic acidosis
 In respiratory acidosis, there is increase in CO2, CO2
retention, that’s why your kidneys now will try to conserve the
bicarbonate.
 For respiratory alkalosis, they have a decline in PCO2, and
naturally, the kidneys now will try to excrete the excess
bicarbonate.
COMPENSATION
 A predictable physiologic consequence of the primary
disturbance
 An attempt by the body to adjust the arterial pH to 7.40
 Does not represent a “secondary” acidosis or alkalosis
 Compensation never over corrects.
DIOQUINO І FROILAN І LUIS І VARGAS
CATEGORIES OF COMPENSATION
 Uncompensated
o Abnormal pH due to deviation of one component
o The other component still within normal limits
 Partly compensated
o Deviation of one component with the other component
changing appropriately to compensate for the acid base
disorder
o pH is still abnormal
 Completely or fully compensated
o Deviation of one component with an appropriate change
of the other component
o pH has been restored to the normal range.
MIXED ACID-BASE DISORDERS
 Exceed the physiologic limits of the compensation.
 Lack of appropriate compensation for a simple disturbance is
evidence for a mixed disturbance
 If changes in both PaCO2 and HCO3 results in either acidosis
or alkalosis mixed or combined abnormality
STEPS IN ABG INTERPRETATION
 Step 1: Determine if the pH is acidic or alkaline
o <7.40  ACIDIC  Acidosis (Respiratory or Metabolic)
o >7.40ALKALINEAlkalosis (Respiratory or Metabolic)
 Step 2: Determine the basic acid-base abnormality
o Which parallels the acidity or alkalinity of the pH: the
PaCO2 or the HCO3
 PaCO2  respiratory
 HCO3  metabolic
 Step 3: Determine compensation
o Is the disorder simple of mixed?
 In respiratory acidosis:
o Primary problem: high PaCO2 more than 45
 ACID BASE IMBALANCE
o Expected change: conserve bicarbonate = [(20.6 x 0.4)] + 24 +/- 2
 In respiratory alkalosis: o Expected HCO3 = 8.24 + 24 +/- 2 = 32.24 +/- 2
o Primary problem: decrease PaCO2 due to o Measured HCO3 (34.9) > Expected HCO3 (32.24 +/- 2)
hyperventilation o There is an underlying metabolic alkalosis
o Expected change: excretion of bicarbonate o pH (7.375) is in the normal range  fully compensated
 Step 4: PaO2 = 61.2  moderate hypoxemia at room air
 ABG interpretation: Respiratory Acidosis with underlying
metabolic alkalosis, fully compensated; moderate
hypoxemia at room air

CASE 1:
 78 M
 Known diabetic and hypertensive
 Admitted due to fever, dyspnea, cough
 Intubated at the E.R because of acute respiratory failure
 CXR = R lower lobe pneumonia
 Problem with pneumonia: initial phase there is
hyperventilation
 Normal response to hypoxemia is tachypnea.
 For metabolic acidosis  ABG results:
o Primary problem: decrease bicarbonate o pH = 7.5 (Alkalosis)
o Expected change: excrete excess CO2 o PaCO2 = 22 mmHg (Alkalosis)
 Metabolic alkalosis o HCO3 = 22 meq/L (Normal; rule of 4 – acidosis)
o Primary problem: retention of bicarbonate o PaO2 = 51 mmHg (severe hypoxemia)
o Expected change: keep PCO2 o Base excess = 3
 Answer
 Step 4: Determine state of oxygenation  Primary disturbance: Respiratory Alkalosis
More than adequate > 120  By eyeballing: uncompensated
oxygenation  Use equation for respiratory alkalosis = 17.5 +/-2 (15.5 to
Adequate oxygenation 80 – 120 19.5)
(Normal)  Answer/Interpretation: UNCOMPENSATED
Mild hypoxemia 70 – 79 RESPIRATORY ALKALOSIS WITH SEVERE
Moderate hypoxemia 60 – 69 HYPOXEMIA at 100% FiO2 if intubated
Severe hypoxemia <60
Very severe hypoxemia <40 CASE 2
 21 F
 Regression of PaO2 with age at sea level  DM type 1
o Supine (Sorbini Formula)  Failed to take her insulin shots for 1 week
 PaO2 = 109 – (0.43 x age) +/-4  Presently dehydrated
o Sitting (Mellemgaard Formula)  (+) acetone breath
 PaO2 = 104.2 – (0.27 x age) +/- 6  (+) kussmaul’s breathing
 Expected acidotic
HYPOXEMIA  ABG
 When hypoxemia is present, O2 saturation should be noted. o pH = 7.1 (Acidosis)
 Oxygen saturation ≥ 90% indicates adequate oxygen o PaCO2 = 23 mmHg (alkalosis)
saturation  presumes that the degree of hypoxemia is not o HCO3 = 6 meq/L (acidosis)
clinically significant o PaCO2 = 130 mmHg (more than adequate)
o Base = -13 (base deficit)
 Answer:
SAMPLE CASES  Primary disturbance: Metabolic Acidosis
 ABGs taken in supine position at room air  Expected response: hyperventilate; eliminate CO2
o pH = 7.375 (normal)  Formula: Winter’s = 15 to 19
o PaCO2 = 60.6 (elevated/acidotic)  Eyeballing: Partial Compensation
o HCO3 = 34.9 (alkalosis)  Interpretation: PARTIALLY COMPENSATED
o BE = 7.4 (alkalosis) METABOLIC ACIDOSIS WITH MORE THAN
o PaO2 = 61.2 (moderate hypoxemia) ADEQUATE OXYGENATION
o Sat = 90.3%  COMPUTE FOR THE ANION GAP
 Step 1: pH < 7.40  acidic o Na = 147meq/L
 Step 2: o Cl = 110meq/L
o PaCO2 = 60.6  respiratory acidosis o AG = 147 – (110+6) = 31
o HCO3 = 34.9  metabolic alkalosis o Norman Anion Gap 10-12
o Primary disorder is respiratory acidosis (retention of  What condition can you give an increased anion gap?
CO2, probably this is COPD in acute exacerbation o Answer: MUDPILES
 Step 3: Compensation for respiratory acidosis
o Expected HCO3 = [(PaCO2- 40) x 0.4] + 24 +/- 2
= [(60.6 – 40) x 0.4] + 24 =/- 2 CASE 3

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 ACID BASE IMBALANCE
 89 M, Known COPD  Speaks in phrases
 Managed as a case of severe pneumonia at the ICU  Chest x-ray revealed hyper-aerated (CO2 retention in an
 Intubated hyper-inflated lung meaning air trapping)
 Drowsy and cyanotic  ABG
 CXR = bilateral PNM, with R sided pleural effusion o pH = 7.35 (normal)
 Presently hypotensive and anuric for 24 hours o PaCo2 = 40 mmHg (normal)
 Respiratory acidosis o HCO3 = 22 meq/L (normal)
 Setting for pneumonia is hypoxemia. o PaO2 = 60 mmHg5 LPM/NC (moderate hypoxemia)
 In hypoxemia, you generate lactic problem because of  Answer
anaerobic metabolism.  Interpretation: Normal Acid-base balance with moderate
 ABG hypoxemia
o pH = 7. 20 (acidosis)
o PaCo2 = 57 mmHg (acidosis)
o HCO3 = 16 meq/L (acidosis)
o PaO2 = 45 mmHg (severe hypoxemia)
o Base deficit = 11
o FiO2 = 100%
 Answer:
 Primary disturbance: Mixed-type of Acidosis
 Interpretation: UNCOMPENSATED METABOLIC AND
RESPIRATORY ACIDOSIS (MIXED TYPE) WITH
SEVERE HYPOXEMIA AT 100% FiO2

CASE 4
 55 F CASE 7
 Cardiomyopathic  35 M
 Dyspneic  CRF on hemodialysis
 CXR = cardiomegaly with signs of congestion  Tachypneic
 ABG  CXR = significant bilateral pleural effusion
o pH = 7.46 (Alkalosis)  ABG
o PaCO2 = 32 mmHg (Alkalosis) o pH = 7.36 (normal; rule of 4: acidosis)
o HCO3 = 16 meq/L (Acidosis) o PaCO2 = 32 mmHg (alkalosis)
o PaO2 = 68 mmHg (moderate hypoxemia) o HCO3 = 18 meq/L (acidosis)
o ABG taken at 2 LPM/NC o PaO2 = 77 mmHg (mild hypoxemia)
 Answer o 3 LPM/NC
 Primary disturbance: Respiratory Alkalosis  Answer
 Use Formula for Respiratory Alkalosis = 18 to 22  Primary disturbance: Metabolic Acidosis
 Interpretation: PARTIALLY COMPENSATED  Eyeballing: Fully compensated
RESPIRATORY ALKALOSIS WITH UNDERLYING  Formula: Winter’s = 33 to 37
METABOLIC ACIDOSIS WITH MODERATE  Interpretation: FULLY COMPENSATED METABOLIC
HYPOXEMIA AT 2 LPM/NC ACIDOSIS WITH UNDERLYING RESPIRATORY
ALKALOSIS WITH MILD HYPOXEMIA AT 3 LPM/NC
CASE 5
 28 F
 Seen at the ER due to moderate exacerbation of asthma CASE 8
 History revealed non-compliance of controller  37 M
 CXR = normal  Seen at the ER
 Initial response of asthmatic: tachypnea due to obstruction  CXR = N
and anxiety leading to respiratory alkalosis  ECG = N
 ABG  ABG
o pH = 7.54 (alkalosis) o pH = 7.41 (normal)
o PaCO2 = 27 mmHg (alkalosis) o PaCO2 = 39 mmHg (normal)
o HCO3 = 19 meq/L (acidosis) o HCO3 = 24 meq/L (normal)
o PaO2 = 75 mmHg (mild hypoxemia) o PaO2 = 110 mmHg (adequate)
o Room Air o ABG taken at room air
 Answer  Answer
 Primary disturbance: Respiratory Alkalosis  Interpretation: Normal acid base balance
 Use Formula for Respiratory Alkalosis = 15.5 to 19.5
 Interpretation: PARTIALLY COMPENSATED CASE 9
RESPIRATORY ALKALOSIS WITH MILD HYPOXEMIA  Jane Doe is a 45-year old, female admitted to the nursing unit
AT ROOM AIR with a severe asthma attack. She has been experiencing
shortness of breath since admission three hours ago. Her
CASE 6: arterial blood gas result is as follows:
 28 F Same case above but  ABG
 Came back at the E.R. this time with severe exacerbation of o pH = 7.22 (acidosis)
asthma o PaCO2 = 55 (acidosis)
 Cyanotic o HCO3 = 25 (alkalosis)

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 ACID BASE IMBALANCE
 Answer
 Primary disturbance: Respiratory acidosis
 Formula for Respiratory Acidosis = 28 to 32
 Interpretation: Uncompensated Respiratory Acidosis
CASE 10
 John Doe a 55-year old admitted to your nursing unit with a
recurring bowel obstruction. He has been experiencing
intractable vomiting for the last several hours despite use of
antiemetics. Here is his arterial blood gas result.
 ABG
o pH = 7.50 (alkalosis)
o PaCO2 = 42 (normal; rule of 4 acidosis)
o HCO3 = 33 (alkalosis)
 Answer
 Primary disturbance: Metabolic Alkalosis
 Formula for Metabolic Alkalosis = 33 to 37
 Interpretation: Uncompensated Metabolic Alkalosis
 One night, pt had tachycardic and tachypneic episode so the
patient was intubated.
 Upon chest x-ray, new infiltrates was noted.
 Post intubation ABG
o pH = 7.407 (normal; rule of 4: alkalosis)
o pCO2 = 32.5 (alkalosis)
o pO2 = 337.1 (more than adequate)
o HCO3 = 20.6 (acidosis)
 Answer
 Primary disturbance: Respiratory Alkalosis
 Formula for Respiratory Alkalosis = 18 to 22
 Interpretation: Fully Compensated Respiratory Alkalosis
with More than Adequate Oxygenation at 100 FiO2

CASE 11
 John Doe is admitted to the hospital. He is a kidney dialysis
patient who has missed his last two appointments at the
dialysis center. His arterial blood gas values are reported as
follows:
 If you missed dialysis, there will be accumulation of fixed acids
(sulfuric acids, phosphoric acids)
 2 types of acids
o Fixed acids
o Volatile acids
 ABG
o pH = 7.32 (acidosis)
o PaCO2 = 32 (alkalosis)
o HCO3 = 18 (acidosis)
 Answer
 Primary disturbance: Metabolic Acidosis
 Formula: Winter’s = 33 to 37
 Interpretation: Partially Compensated metabolic acidosis
with underlying respiratory alkalosis

CASE 12
 47 / M.
 Managed as a case of sepsis secondary to sacral ulcer grade
4, catheter-associated UTI
 Admitted last January under surgery as a case of medullary
mass at the spine. S/P excision. Was discharged, however,
lost to follow up.
 With urinary catheter for almost 2 mos.
 With noted hematuria and pyuria.
 Metabolic acidosis
 ABG
o pH = 7.367 (normal; rule of 4:acidosis)
o pCO3 = 15.8 (alkalosis)
o pO2 = 93.9 (adequate)
o HCO3 = 9.2 (acidosis)
 Answer
 Primary disturbance: Metabolic Acidosis
 Formula: Winter’s = 19.8 to 23.8
 Interpretation: Fully Compensated Metabolic Acidosis
with underlying Respiratory Alkalosis with Adequate
Oxygenation at 10 LPM/FM

CASE 13
 36 / M
 Admitted and managed as tetanus, grade 2, S/P
tracheostomy
 Clinically stable after tracheostomy placement.

DIOQUINO І FROILAN І LUIS І VARGAS