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ABG pH pO2 measured pCO2 measured HCO3 Lytes Na K Cl Plasma Osmolality Tox Screen Ketones Metabolic Acidosis 1:1

AG (abN > 12) Note: ignore if AG is N in AG from N range measured HCO3 expected HCO3 in HCO3 from baseline measured pCO2 expected pCO2 Plasma Osmolar Gap 7.24 60 70 29

Normal range 7.35-7.45 40 23-31 Normal range 133-146 3.3-4.8 96-110 270-290 Normal range neg

Urine Lytes Na K Cl pH Urine AG Chemistries Glucose BUN Albumin

Normal range <20 >30 <10


good for detecting / HCO3 in urine

indirectly estimate NH4+ excretion

Normal range 3.3-11 2.5-8 40 10:3 rule (Alb:AG)

Other Criteria Pt's age 45

Compensation: Resp Alkalosis -29 -41 29 65 -5 70 45 0

if more HCO3 than expected = metabolic alkalosis also occurring if less HCO3 than expected = non-AG metabolic acidosis also occurring

if pCO2 is more than expected = Resp acidosis also contributing (if measured pCO2 < 40, then partial comp R if pCO2 is less than expected = additional Resp alkalosis also contributing if greater than 10 = alcohol-related AG metabolic acidosis

Metabolic Alkalosis 1:0.7 in HCO3 from baseline 5 measured pCO2 70 expected pCO2 43.5 Chronic Resp Acidosis 1:0.3 in pCO2 from baseline 30 measured HCO3 29 expected HCO3 33 Normal Aa gradient 13.8 Nasal prongs O2 (L/min) 0.0 Estimated FiO2 (in %) 21 Aa gradient -10.16 Chronic Resp Alkalosis 1:0.5 in pCO2 from baseline -30 measured HCO3 29 expected HCO3 39 Normal Aa gradient 13.8 Nasal prongs O2 (L/min) 0.0 Estimated FiO2 21 Aa gradient -10.16

Compensation: Resp Acidosis


if pCO2 is more than expected = addtional Resp acidosis also contributing

if pCO2 is less than expected = Resp alkalosis also contributing (if measured pCO2 > 40, then partial comp R

Compensation: Met Alkalosis


if more HCO3 than expected = additional metabolic alkalosis also occurring if less HCO3 than expected = AG or non-AG metabolic acidosis also occurring or AOC Resp Acidosis N<15 but age-dependent, if > N suggests pathologic lung dz or disorder

elevation in Edmonton is 2192 ft (668m); therefore atmospheric pressure is 701 mmHg

Compensation: Met Acidosis


if more HCO3 than expected = metabolic alkalosis also occurring if less HCO3 than expected = additional AG or non-AG metabolic acidosis also occurring N<15 but age-dependent, if > N suggests pathologic lung dz or disorder

elevation in Edmonton is 2192 ft (668m); therefore atmospheric pressure is 701 mmHg

od for detecting / HCO3 in urine

irectly estimate NH4+ excretion

3 rule (Alb:AG)

Expected results for: Respiratory Acidosis Metabolic Acidosis Acute Chronic pH N pH pCO2 pCO2 HCO3 N HCO3 10:1 10:3 1:1 Respiratory Alkalosis Metabolic Alkalosis pH N pH pCO2 pCO2 HCO3 N HCO3 10:1 10:5 1:1

Expected Results for urine lytes: Non-renal volume depletion Vomiting (HCl loss = NaHCO3 gain) Diarrhea (NaCO3 loss = HCl gain) Burns/sweating Renal volume depletion diuretics/Bartters/low Mg hypoadrenalism

urine pH is used to detect HCO3 changes in urine, n H+ excretion, which is found in the NH4+ form Urine AG is used to indirectly estimate H+ excretion

Causes of Hypoxia: Aa = FiO2(Patm-47) - PCO2*1.25 N Aa low FiO2 Expected Aa = (0.3 x age) + 4 OR (age + 10)/4 hypoventilation Aa shunt (AVM, atelectasis) V/Q mismatch diffusion problem ILD: upper lung Silicosis/Sarcoidosis Coal Workers' Pneumoconiosis Hypersensitive Pneumoconiosis Ankylosing Spondylitis Radiation Pneumonitis TB/Talc ILD: lower lung Rheumatoid Arthritis Astbestosis Scleroderma Crytptogenic fibrosis Drugs - amiodarone

sured pCO2 < 40, then partial comp Resp Alk)

ured pCO2 > 40, then partial comp Resp Acid)

urring or AOC Resp Acidosis

is also occurring

UNa

UK UCl pH

UAG neg

t HCO3 changes in urine, not for und in the NH4+ form ectly estimate H+ excretion

e) + 4 OR (age + 10)/4

Metabolic Acidos
Acid Gain / AG Na-Cl-HCO3 > 12 [Cl] = N Labs: ketones, BUN, tox screen, lactate Hyperchloremic / Na

Labs: Urine AG

DDx: Ketones Methanol Uremia Uremia Salicylates DKA Methanol Paraldehyde All other Alcohols Isoniazid/Iron Lactate/Lactic Acid Lactate ETOH/Ethylene Glycol Salicylates

DDx: Ureterostomy Small bowel fistula Extra chloride Diarrhea Carbonic anhydrase inhibitors use Adrenal insufficiency Renal tubular acidosis Pancreatic fistula

neg UAG Plasma Osmolar Gap 2Na+glucose+BUN significant if > 10 mmol/L

Rx: DKA (triggers - stress, UTI, infection, MI): 1. Fluids: IVF, in adults, rapid infusion of 1L of 0.9% NS (e.g. over 30-60 min), repeat bolus as necessary to prevent shock. When [Na] >145, can switch to 0.45% NS at a slower rate. This is done to replace the free water loss induced by the osmotic diuresis. When glucose < 15, switch to 5% dextrose/0.5NSaline, run @ 125-250 cc/hr. 2. Insulin infusion: 10-20 unit IV bolus (0.15 u/kg), then 5-10 units/hr IV (0.1 unit/kg/hr). This stops the lipolysis and gluconeogenesis and allows for the conversion of ketones to bicarbonate. BS should not be allowed to fall below 10-15 in the first 4-5 hours of treatment. If it does, decrease rate by 1U/hr and recheck in 1 hr. When anion gap normal, initiate SQ insulin, overlap for 1-2hr with insulin infusion. When blood sugar < 15, can add 5% dextrose to IVF. 3. Potassium replacement: If initial K>6, then withhold replacement. If K=5-6, give 10 mEq/hr, K=4-5, give 20 mEq/hr, K=3-4, give 30 mEq/hr, K<3, give 40 mEq/hr

GI and Other Diarrhea Fistulas exog. Acids dilutional post-hypocapnia

FeHCO3 >15% urine pH var.

Type II RTA (proximal HCO3 absorption) Fanconi Synd.

mEq/hr, K=3-4, give 30 mEq/hr, K<3, give 40 mEq/hr 4. Bicarb replacement: If pH < 7 and/or cardiac instability present, then give bicarb (50-100mEq NaHCO3 in 1L 0.45NS over 30-60 min); may need extra K with bicarb Rx. 5. Phosphate replacement: Give K-phos if initial P< 0.35 mM @ 2.5-8mM KPO4/hr (ie. 10 mL pf KPO4 in 1L NaCl over 6hrs - 30mM PO4/ 44mEq K)

Metabolic Acidosis
Bicarb Loss / Hyperchloremic / Non-AG Na-Cl-HCO3 = 8-12 [Cl] > N Labs: Urine AG

AG
Na-Cl-HCO3 < 8 [Cl] > N Labs: Albumin, plasma electrophoresis, repeat labs

reterostomy mall bowel fistula xtra chloride arbonic anhydrase inhibitors use drenal insufficiency enal tubular acidosis ancreatic fistula

DDx: - Albumin (10:3 rule - alb:AG) - Ingested halides (F, Cl, Br, I) - Paraproteins (multiple myeloma) - Lab error

pos UAG

Renal Causes

Hypokalemia

Hyperkalemia urine pH < 5.3 FeHCO3 < 3%

FeHCO3 >15% urine pH var.

FeHCO3 <3% urine pH > 5.3

Type II RTA (proximal HCO3 absorption) Fanconi Synd.

Type I RTA (Distal H+/NH4+ secretion) Ehlers-Danlos Synd Hereditary elliptocytosis

Type IV RTA (hypoaldo or medullary dz w/ less NH3 recycling)

Hereditary elliptocytosis Sickle cell nephropathy

Metabolic Alkalosis
Saline Responsive Volume Depletion Hypotensive (Exception: post-hypercapnia) Saline Resistant N Volume Status

Non-renal Volume Depletion

Renal Volume Depletion

Hypertensive Hypokalemia

DDx: Vomiting/NGT drainage (HCl loss = NaHCO3 gain) Diarrhea secondary to dehydration (NaCO3 loss = HCl gain) Burns/Sweating

DDx: Diuretics / Mg Hypoadrenalism *Check urine lytes if subclinical dehydration Total volume depletion = Salt (NaCl) depletion

DDx: Mineralocorticoids (Conn's, Cushing's, renin) vs. (renal artery stenosis, renin) Mc-like activity (licorice, glucocorticoids, swallowed chewing tabacco)

Aldosterone = Na+ reabsorption/K+ and H+ secretion Urine Lytes UNa UCl UK Normal Values <20 <10 >30 Non-renal Vol depletion Vomiting Diarrhea Burns/Sweating Renal Vol depl. (diuretics) Hypoadrenalism

Saline Resistant N Volume Status

Normotensive

(Conn's, nin) vs. (renal

swallowed

DDx: Potassium HCO3 ingested for peptic ulcer Bartter's and Gitelman's Synd (defects in Na-K-2Cl transporter and thiazidesensitive Na-Cl cotransporter, respectively)

Respiratory Acidosis

(underbreathing)

DDx: CNS: sedatives, narcotics, CNS trauma/tumour, etc. Neuromuscular D/O: myesthenia gravis, Guilian-Barre, polymyositis, ALS, Muscular dystrophy, severe hypophosphatemia Upper Airway abN: acute airway obstruction, laryngospam, obstructive sleep apnea, esophgeal intubation Lower Airway abN: asthma, COPD Lung Parenchyma abN: pneumonia, pulm edema, restrictive lung dz, thoracic cage abN, pneumothorax, flail chest, kyphoscoliosis

cage abN,

Respiratory Alkalosis
(overbreathing)

Cardiorespiratory

Non-Cardiorespiratory

DDx: Hypoxia early restrictive lung Dz Pulm edema PE Pneumonia mild CHF mechanical ventilation

DDx: Fever Sepsis Drugs (ASA, progesterone) Anxiety/pain CNS D/O Hyperthyroidism Pregnancy Liver Failure

alosis

Cardiorespiratory

(ASA, progesterone)

thyroidism

Hyponatremia

( ADH / free H2O intake) R/O fictitious hyponatremia hyperlipidemia, hyperprotenemia hyperglycemia Hypovolemia

Non-renal Volume Depletion

Renal Volume Depletion

DDx: Vomiting/NGT drainage (HCl loss = NaHCO3 gain) Diarrhea secondary to dehydration (NaCO3 loss = HCl gain) Burns/Sweating

DDx: Diuretics / Mg Hypoadrenalism

DDx: SIADH (R/O thyroid disease) hypothyroidism adrenal insufficiency psychogenic polydipsia

DDx of SIADH: Pulm: OAT cell, TB, lung abcess, Pneumonia, Em CNS: skull#, subdural hemorrhage, subarachnoid cerebral vascularthrombsis, meningitis, Guillian Cancer: OAT cell, lymphoma, thymoma, duodenal pancreatic carcinoma Drugs: Chloropropamide, tegretol, clofibrate, vincr morphine/narcotics, tricyclic antidepressants, oxyt

Hyponatremia
( ADH / free H2O intake) R/O fictitious hyponatremia hyperlipidemia, hyperprotenemia, hyperglycemia Hypervolemia

Euvolemia

SIADH (R/O thyroid disease) hypothyroidism adrenal insufficiency psychogenic polydipsia

DDx: Cardiac: CHF Renal: nephrotic synd, renal failure, Na+ retention Liver: cirrhosis (hypoalbuminemia) GI: protein-losing enteropathy

ell, TB, lung abcess, Pneumonia, Empyema subdural hemorrhage, subarachnoid hemorrhage, ularthrombsis, meningitis, Guillian-Barre Synd, lupus cell, lymphoma, thymoma, duodenal carcinoma,

propamide, tegretol, clofibrate, vincritin, vinblastin, cotics, tricyclic antidepressants, oxytocin

Hypernatremia

( ADH / free H2O intake

Hypovolemia

Non-renal Volume Depletion

Renal Volume Depletion

Central Diabetes Insipidus

DDx: Vomiting/NGT drainage (HCl loss = NaHCO3 gain) Diarrhea secondary to dehydration (NaCO3 loss = HCl gain) Burns/Sweating

DDx: Diuretics / Mg Hypoadrenalism

DDx: trauma neurosurgery mass lesions craniopharyngomas, granuloma, sarcoid, histiocytosis x vascular aneuryms idiopathic

Hypernatremia
( ADH / free H2O intake)

Euvolemia

Hypervolemia

al Diabetes

Nephrogenic Diabetes Insipidus

Not Common

DDx: Ca (hyperCa2+) - malignancy K (hypokalemia) Lithium Loss of medullary hypertonicity - inflitration via amyloid, infection via pyelonephritis, ischemia via sickle cell, obstructive uropathy polycystic kidneys idiopathic/congenital