Mixed Acid-Base Disorders

Dr. Saurav Dey

PGT
Calcutta National Medical College
 Definition:

Mixed acid-base disturbances are combinations of two or more

primary acid-base disturbances.
Examples-a)Respiratory acidosis and metabolic acidosis
b)Metabolic alkalosis and respiratory acidosis.etc.
 Clinical Approach to Mixed Acid-Base Disorders

Most important step in interpretation of acid-base status is a careful history- taking, including history of vomiting,
diarrhea, trauma, drug ingestion, dyspnea, renal disease, COPD, and asthma.

The second step is a complete physical examination. For example, deep rapid breathing (Kussmaul’s respiration)
suggests a metabolic acidosis, and any sign of dehydration reflects a metabolic alkalosis.

The third step is to perform some laboratory examinations which may support or oppose the acid-base
disturbance. For Example measurement of serum HCO3 , [K+], [Na+], [Cl−] for the calculation of the anion gap (AG);
serum creatinine concentration for determination of renal function, whose failure may be associated with a
metabolic acidosis; blood glucose and serum ketone concentration for the diagnosis of diabetic ketoacidosis; and
so on.
 TRICS
A serum HCO3 of less than 12 mEq/L indicates a metabolic acidosis since metabolic compensation of chronic
respiratory alkalosis rarely reduces the plasma HCO3 less than 12 mEq/L.

A serum HCO3 of more than 45 mEq/L usually implies a metabolic alkalosis since metabolic compensation of
chronic respiratory acidosis seldom elevates the plasma HCO3 to such an extent.

Finally Anion gap (AG); may be helpful in diagnosing and managing the disease.

Even a normal pH does not rule out the presence of a mixed disturbance since the processes may cancel out the
effect of each other on the plasma pH, but they usually change the serum chemistry.

A normal pH with an abnormal HCO3 or pCO2 is highly suggestive of a mixed problem since the compensatory
mechanisms rarely tend to return the blood pH to normal.
 CASE 01

A 47-year-old man, also with chronic emphysema, was pCO2 = 47 mm Hg, HCO3 = 18 mEq/L, pH = 7.205, The
admitted to the hospital with profuse watery diarrhea of serum chemistry reveals: [Na+] = 137 mEq/L,
4 days duration. On admission, his arterial blood gas [K+] = 4.7 mEq/L, [Cl−] = 100 mEq/L What is your
analysis gave the following values: diagnosis?

The coexistence of acidemia and low serum HCO3 reflects a

meta bolic acidosis. Employing Winter’s formula, we have:

measured pCO2 (47 mm Hg) is

significantly higher than 37 mm Hg,
thus, there should also be a
coexistent respiratory acidosis.

Mixed Metabolic and Respiratory Acidosis

 CASE 02

A 25-year-old woman was brought to the emergency room
after a suicide attempt. She had reportedly swallowed a
handful of pills. On arrival, she complains of shortness of
breath and tinnitus, but cannot name the pills she had
ingested. Pertinent laboratory values are given below:
pCO2 = 11 mm Hg, HCO3 = 8 mEq/L, pH = 7.483,
The serum chemistry reveals: [Na+] = 139 mEq/L,
[K+] = 4.7 mEq/L, [Cl−] = 103 mEq/L.

The coexistence of alkalemia and hypocapnia

indicates a respiratory alkalosis. Then, the
expected serum HCO3 may be calculated as:

As the process is acute, the

expected serum HCO3 should be
about 18.2 ± 2 (= 24–5.8 ± 2) mEq/L. Moreover AG value of so much goes in
favour of metabolic acidosis

Mixed Metabolic Acidosis and Respiratory Alkalosis

 CASE 03
A 16-year-old girl, a known case of insulin-dependent diabetes pCO2 = 19 mm Hg, HCO3 = 8 mEq/L,
mellitus, was brought to the emergency room in a coma. pH = 7.246, Serum chemistry:
According to her mother, the patient was well until 3 days before [Na+] = 140 mEq/L, [K+] = 5.1 mEq/L,
when she developed abdominal pain and then diarrhea. The day [Cl−] = 109 mEq/L, Blood sugar = 510 mg/dL
prior to admission she was unresponsive, and finally fell into Urinalysis: 2+ Ketone, 3+ Sugar
coma.
On physical examination, she was mildly dehydrated and feverish.
Vital signs were measured as follows: Temperature: 39.5 °C
(orally), Pulse rate: 96/min (regular), Respiratory rate: 32/ min
(deep), Blood pressure: 100/70 mm Hg (supine position)

very low pH and serum HCO3

indicate a metabolic acidosis. HCO3 is 16 mEq/L (= 24–8) and exceeds ΔAG.
A proportionate change in
pCO2 (Winter’s formula)
support our diagnosis.

Mixed Hyperchloremic (Normal-AG) and High-AG Metabolic Acidosis

 CASE 04
A 40-year-old man with liver cirrhosis and refractory
pCO2 = 53 mm Hg, HCO3 = 34 mEq/L, pH = 7.429
edema was admitted to the hospital for liver
transplantation. Everything went well until a day before
the operation, when he developed a high-grade fever
and a productive cough. Chest roentgenography
revealed bilateral pleural effusion and diffuse interstitial
If the primary disorder is assumed to be a
infiltra tion. Pertinent laboratory exams were as follows.
respiratory acidosis, the serum HCO3 in the
acute and chronic phase of compensation
can be obtained by

A serum HCO3 significantly higher than these predicted values

implies the coexistence of a metabolic alkalosis

Mixed Metabolic Alkalosis and Respiratory Acidosis

 CASE 05
A 32-year-old man, who was injured in a car accident, was Five hours later, his arterial blood gas
admitted to the ICU. On admission, he was in deep coma. An analysis revealed
endotracheal tube was inserted and mechanical ventilatory pCO2 = 27 mm Hg, HCO3 = 26 mEq/L,
assist was started. Also, a urinary catheter and a naso gastric pH = 7.605
tube attached to an intermittent suction were inserted.

The patient has an acute respiratory alkalosis, the serum HCO3

should range from 19.4 to 23.4 (= 24–2.6 ± 2)
mEq/L. Nevertheless, the measured plasma HCO3 significantly
exceeds the expected value, reflecting the presence of a
metabolic alkalosis. Therefore, the diagnosis is mixed acute
respiratory alkalo sis (due to hyperventilation) and metabolic
alkalosis (due to nasogastric suction).

Mixed Metabolic and Respiratory Alkalosis

 SUMMARY
1. Look at the blood pH.

2. Find the primary disturbance based on history, physical examination, arterial pCO2, serum HCO3.

3. Calculate the expected range of compensation.

4. If the level of compensation is within the expected range, your patient has a simple acid-base problem.

5. Otherwise, the patient has a mixed acid-base disturbance.

6. Subsequently find the other acid-base disturbance(s) based on serum chemistry and the AG.
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