1

Bedside Round in Acid-Base Disorders

.
.

volatile acid oxidative metabolism 13,000-20,000 mol

CO2 fixed acid protein catabolism 40-60 mol (
1mmol/kg) titratable acid NH4+
respiratory acidosis metabolic acidosis
(endogenous) (exogenous) academia compensatory
response pH 7.37-7.42
Handerson-Hasselbalch [H+] =24 x PCO2 / [HCO3] PCO2
[HCO3] [H+] pH respiratory acidosis
metabolic acidosis compensatory response metabolic acidosis
respiratory alkalosis compensatory response acid-base disorders
respiratory primary metabolic compensated metabolic
primary respiratory compensated compensatory response
pH pH primary cause respiratory
metabolic / compensatory response overcompensation
decompensation overcompensated compensatory response
DKA & pneumonia primary metabolic acidosis (DKA) respiratory alkalosis (
Kussmaul breathing) compensatory respiratory alkalosis (pneumonia)
CO2 pH alkalemia overcompensation
decompensation compensatory response primary cause
cardiopulmonary arrest metabolic acidosis (lactic acidosis hypoxia) respiratory
acidosis (respiratory arrest) ventilate CO2 acidemia
Acute VS Chronic primary cause respiratory metabolic (HCO3)
compensated acute HCO3 buffer system
HCO3 pH acidemia alkalemia
 2

chronic HCO3 compensatory response

pH

Acid-Base disorders Normal compensatory response

pH Normal compensatory response

Respiratory Acidosis

Acute Low HCO3 = 0.1 pCO2

Chronic Slightly low HCO3 = 0.3 pCO2

Respiratory Alkalosis

Acute High HCO3 = 0.2 pCO2

Chronic Slightly high HCO3 = 0.4 pCO2

Met Acidosis Low pCO2 = 1.5 HCO3 + 8

pCO2 = HCO3 +15

Met Alkalosis High pCO2 = (0.4-0.6) HCO3

Acute respiratory acidosis

ventilatory disorder , ,
, chest wall, airway (lung parenchyma)
pulmonary edema pneumonia respiratory alkalosis
intrapulmonary shunting mixed venous blood work of breathing
pCO2 acute respiratory acidosis respiratory support

 3

Standard [HCO3] base excess

buffer system actual [HCO3] 29
mEq/L severe acute respiratory acidosis (PCO2 >80 mmHg
buffer system pH pH acidemia

Chronic respiratory acidosis

acute respiratory acidosis course ( 3 )
compensatory response HCO3 absorption proximal tubule renal
parenchymal disease
standard [HCO3] base excess (base excess > 3 mEq/L) compensatory
response
PCO2 respiratory acidosis metabolic alkalosis
compensatory response hypoventilation PCO2 > 55-60 mmHg respiratory
acidosis primary cause hypoventilation compensatory response
hypoxemia
Overcompensation PCO2 HCO3
artificial ventilation ventilation PCO2
HCO3 pH alkalemia posthypercapnic metabolic
alkalosis neuromuscular symptom
hypokalemia chronic respiratory acidosis hypokalemia
maintain metabolic alkalosis ( potassium H+ K+
Na+ collecting tubule) metabolic alkalosis compensatory response
respiratory acidosis vicious cycle COPD & corpulmonale
diuretics metabolic alkalosis & hypokalemia
PCO2 intracranial pressure papilledema

Acute & Chronic respiratory alkalosis

 4

PCO2 respiratory alkalosis metabolic acidosis

compensatory response kussmaul breathing
respiratory alkaosis tetany neuromuscular symptom
metabolic acidosis kussmaul breathing
()
Respiratory alkalosis acute chronic respiratory alkalosis
pregnancy massive ascites HCO3
12 mEq/L
electrolyte HCO3 hypokalemia respiratory alkalosis
metabolic acidosis (diarrhea renal tubular acidosis) HCO3
hypekalemia metabolic acidosis
acute respiratory alkalosis ( primary hyperventilation )
primary cause / arterial blood gas acute respiratory
acidosis respiratory failure

Metabolic acidosis
metabolic acidosis respiratory response
Kussmaul breathing acidemia pCO2
respiratory compensation pCO2 10-12 mmHg
pCO2 respiratory alkalosis sepsis,
pneumonia ( overcompensation ) pCO2
respiratory acidosis airway disease,
severe lung parenchymal disease decompensation respiratory muscle exhaustion
pCO2 2 pH
pCO2 pH 7.25 HCO3 10 pCO2 24
metabolic acidosis anion gap (Na - [Cl + HCO3]) anion gap
10 mEq/L (wide anion gap) organic acid anion
 5

KUSSMAUL (Ketoacidosis, Uremic acidosis, Stravation ketosis, Salicylate, Methanol, Alcohol,

Lactic acidosis) anion gap lactic acidosis
diabetic ketoacidosis anion gap 10 mEq/L (normal anion gap) diarrhea,
renal tubular acidosis dilitional acidosis saline solution wide anion gap
metabolic acidosis anion gap/ HCO3 (anion gap - 10/ 24 - HCO3)
< 1 = wide anion gap metabolic acidosis & normal anion gap metabolic acidosis
1-2 wide anion gap metabolic acidosis ONLY
> 2 wide anion gap metabolic acidosis & metabolic alkalosis
normal anion gap metabolic acidosis urine anion gap urine net charge
([UNa + UK] - UCl)
< 0 = diarrhea
> 0 = renal tubular acidosis
metabolic acidosis shift potassium non-organic
metabolic acidosis plasma potassium 0.24-1.7 mEq/L 0.1 pH unit
organic metabolic acidosis
hypokalemia metabolic acidosis potassium diarrhea,
diabetic ketoacidosis metabolic acidosis
potassium shift potassium
volume
metabolic acidosis NaHCO3 cardiovascular collapse
respiratory, CNS, GI pH < 7.2
metabolic acidosis metabolic
acidosis organic anion
methanol, salicylate dose NaHCO3 = (desired HCO3 - current HCO3) x
40% body weight metabolic acidosis lactic
 6

acidosis cardiovascular collapse

metabolic acidosis NaHCO3 electrolyte
hypernatremia, hypokalemia, hypocalcemia,
hypophosphatemia, hypomagnesemia

Metabolic alkalosis
HCO3 35 mEq/L primary metabolic alkalosis metabolic
alkalosis compensatory response chronic respiratory acidosis
HCO3 vomiting
metabolic acidosis urine Cl < 20 mEq/L
(chloride responsive metabolic alkalosis) vomiting volume, > 20 mEq/L
(chloride non-responsive metabolic alkalosis) renovascular renal tubular
diesases, endocrine diseases () chloride responsive
metabolic alkalosis volume + potassium
metabolic alkalosis hypokalemia ( posthypercapnic
metabolic alkalosis normo hyperkalemia ) metabolic alkalosis
potassium shift hypokalemia metabolic alkalosis
potassium potassium 2.5 mEq/L potassium
potassium metabolic alkalosis H+
Na+ collecting tubule K+ Na+ urine pH
acid (paradoxical aciduria)
Aminoacid peripheral nutrition metabolic alkalosis
branch chain aminoacid (Aminoleban)

Mixed acid-base disorders

Mixed acid-base disorders primary acid-base disorder 2 3
 7

acute gastroenteritis vomiting (metaboli alkalosis)+

diarrhea (metabolic acidosis), salicylate poisoning CNS (respiratory
alkalosis) + salicylate (metabolic acidosis) COPD (chronic
respiratory acidosis) + diuretics (metabolic alkalosis) decompensatory
response COPD (chronic respiratory acidosis) + pneumonia & respiratory failure (acute
respiratory acidosis + metabolic acidosis)
, , plasma electrolyte, anion gap, blood chemistry
arterial blood gas compensatory responses
arterial blood gas acid-base disorders
arterial blood gas & electrolyte clinic

References
1. Bruce C Kone: Hypokalemia. In Thomas D DuBose, L Lee Hamm. Acid -Base and Electrolyte
Disorders: a companion to Brenner & Rectors The Kidney, Philadelphia, Saunders, 2002,
p381-394
2. Syndrome due to disturbance in acid-base balance. In Jeffrey M Brensilver, Emanuel
Goldberger: A Primer of Water, Electrolyte, and Acid-Base Syndromes 8th ed, Philadelphia,
FA Davis, 1996, p117-338
3. Acid-Base Disorders, Basic Concepts and Clinical Management. In Heinz Valtin, F John
Gennari, Boston/Toronto, 1987
4. Robertson SA: Simple acid-base disorders. Vet Clin North Am Small Anim Pract. 1989
Mar;19(2):289-306
5. Adams LG, Polzin DJ: Mixed acid-base disorders. Vet Clin North Am Small Anim Pract. 1989
Mar;19(2):307-26
8