ACID BASE

DISORDERS
IT AIN’T ALL THAT SIMPLE
DR ALEX HIEATT
CONSULTANT ED
WHAT IS AN ABG?
The Components
• pH / PaCO2 / PaO2 / HCO3 / O2sat / BE
Desired Ranges
• pH - 7.35 - 7.45
• PaCO2 – 4.5 – 6 kPa
• PaO2 – 10.5 – 13.5 kPa
• HCO3 - 21-27
• O2sat - 95-100%
• Base Excess - +/-2 mEq/L
ACID BASE BALANCE
The body produces acids daily
• 15,000 mmol CO2
• 50-100 mEq Nonvolatile acids

The lungs and kidneys attempt to maintain balance

Buffering also occurs in the liver through ammonia metabolism to
urea / glutamate
ACID BASE BALANCE
Assessment of status via bicarbonate-carbon dioxide buffer system
• Henderson-Hasselbalch
• pH= pK + log ([HCO3-] / [H2CO3 ])

• CO2 + H2O <--> H2CO3 <--> HCO3- + H+

• ph = 6.10 + log ([HCO3] / [0.03 x PCO2])

THE TERMS
ACIDS BASES
• Acidemia • Alkalemia
• Acidosis • Alkalosis
• Respiratory • Respiratory
CO2 CO2
• Metabolic • Metabolic
HCO3 HCO3
RESPIRATORY ACIDOSIS
ph, CO2, Ventilation
Causes
• CNS depression
• Pleural disease
• COPD/ARDS
• Musculoskeletal disorders
• Compensation for metabolic alkalosis
RESPIRATORY ACIDOSIS
Acute vs Chronic
• Acute - little kidney involvement. Buffering via titration via Hb
for example
• pH by 0.1 for 1.25 kPa  in CO2
• Chronic - Renal compensation via synthesis and retention of
HCO3 (Cl to balance charges  hypochloremia)
• pH by approx 0.05 for 1 kPa in CO2
RESPIRATORY
ALKALOSIS
pH, CO2, Ventilation
 CO2   HCO3 (Cl to balance charges 
hyperchloremia)
Causes CHAMPS
• C – CNS Disease e.g. Intracerebral hemorrhage/
Cirrhosis
• H – Hypoxia
• A – Anxiety
• M – Over ventilation
• P – Progesterone
• S – Salicylate/Sepsis
RESPIRATORY
ALKALOSIS
Acute vs. Chronic
• Acute - HCO3 by 1.5 mEq/L for every 1 kPa  in PCO2

• Chronic - Ratio increases to 3 mEq/L of HCO3 for every 1 kPa

 in PCO2

• Decreased renal bicarb reabsorption and decreased

ammonium excretion to normalize pH
METABOLIC ACIDOSIS
pH, HCO3

12-24 hours for complete activation of respiratory

compensation

PCO2 by 0.15 kPa for every 1 mEq/L HCO3

The degree of compensation is assessed via the Winter’s

Formula
 PCO2 = {1.5(HCO3) +8  2 } x 0.133 [converts to kPa]
THE CAUSES
Metabolic Gap Non Gap Metabolic
Acidosis Acidosis
• M - Methanol • H - Hyperalimentation
• U - Uremia
• A - Acetazolamide
• D – DKA - AKA
• R - RTA
• P - Paraldehyde
• I – Isoniazid / Iron • D - Diarrhoea
• L - Lactic Acidosis • U - Uretero-pelvic shunt
• E - Ethylene Glycol • P - Pancreatic Fistula
• R- Rhabdomyolysis • S – Spironolactone
• S - Salicylate
OSMOLAR GAP
OG = Measured osmolality – calculated osmolality
OG = 2 x [ Na mmol/L] + [glucose mmol/L] + [urea mmol/L] +
(1.25 x [Ethanol mmol/L])

Should be <10
Causes:
Methanol Glycine (TRUP)
Ethylene Glycol Propylene Glycol
Sorbitol Polyethylene Glycol
Mannitol Maltose (IV IG)
OG
For raised AG Metabolic Acidocis
Common Causes:
-Ketones
-Lactate
-Renal Failure
NO –
Ingestion possible
YES – Measure OG
Raised – Then likely Ethylene Glycol / Methanol
Normal – Salicylate, Paraldehyde, Iron + Isoniazid
METABOLIC ALKALOSIS
pH, HCO3
PCO2 by 0.1 for every 1mEq/L  in HCO3
Causes – CLEVER PD
• C- Contraction
• L - Liquorice
• E - Endocrine: Conn’s / Cushing’s / Bartter’s
• V - Vomiting / NG Suction
• E - Excess Alkali
• R - Refeeding Alkalosis
• P - Post Hyper-capnoea
• D - Diuretics and Chronic diarrhoea
MIXED ACID-BASE
DISORDERS
Patients may have two or more acid-base disorders at one
time

Corrected Bicarbonate = AG – 12 + Serum HCO3-

If > 30 then there is also underlying metabolic alkalosis
If < 23 then there is an underlying non-AG metabolic acidocis
THE STEPS
Start with the pH – acidaemia or alkalaemia
Note the PCO2
Look for disorders revealed by failure of compensation
Calculate anion gap
Calculate Corrected Bicarbonate
SAMPLE PROBLEM #1
An ill-appearing alcoholic male presents with nausea and vomiting.
• ABG - 7.4 / 5.4 / 11.3 / 22
• Na- 137 / K- 3.8 / Cl- 90 / HCO3- 22
SAMPLE PROBLEM #1
Winter’s Formula = {1.5(22) + 8  2} x 0.133
= {39  2} x 0.133 = 5.3 kPa
 compensated
Anion Gap = 137 - (90 + 22) = 25
 anion gap metabolic acidosis

Corrected Bicarbonate = 25 - 12 = 13
13 + 22 = 35
 metabolic alkalosis
SAMPLE PROBLEM #2
22 year old female presents for attempted overdose. She has
taken an unknown amount of Midol containing aspirin,
cinnamedrine, and caffeine. On exam she is experiencing
respiratory distress.
SAMPLE PROBLEM #2
ABG - 7.47 / 2.5 / 15.7 / 14
Na- 145 / K- 3.6 / Cl- 109 / HCO3- 17
ASA level - 38.2 mg/dL
SAMPLE PROBLEM #2
Winters Formula = {1.5 (17) + 8  2} x 0.133
= 4.65 kPa
 uncompensated
Anion Gap = 145 - (109 + 17) = 19
 anion gap metabolic acidosis

Corrected HCO3- = 19 - 12 = 7
7 + 17 = 24
 no metabolic alkalosis
SAMPLE PROBLEM #3
47 year old male experienced crush injury at building site.
ABG - 7.3 / 4.2 / 12.8 / 15
Na- 135 / K-5 / Cl- 98 / HCO3- 15
SAMPLE PROBLEM #3
Winters Formula = {1.5 (15) + 8  2} x 0.133
= 4 kPa
 compensated
Anion Gap = 135 - (98 + 15) = 22
 anion gap metabolic acidosis

Corrected Bicarb = 22 - 12 = 10
10 + 15 = 25
expected no additional deficit
SAMPLE PROBLEM #4
1 month old male presents with projectile vomiting for x 2
days.
ABG - 7.49 / 5.33 / 13 / 30
Na- 140 / K- 2.9 / Cl- 92 / HCO3- 32
SAMPLE PROBLEM #4
Metabolic Alkalosis, hypochloremic
Winters Formula = {1.5 (30) + 8  2} x 0.133
= 53  2
= 7.3 kPa
 uncompensated
QUESTIONS
Practice makes perfect
MD Calc App has Winters and ABG analysis with SI units.
Josh Steinberg MD App – ABG eval (but US units.)