Normal pH (7.35 - 7.

45)

Acidemia Alkalemia
(pH <7.35) (pH >7.45)
Respiratory Acidosis Metabolic Acidosis Respiratory alkalosis Metabolic alkalosis
(↓ pH + ↑ PCO2 [>40]) ( HCO3 [<20], ↓ PCO2 [<40]) (↓ PCO2 [<40]) (↑ HCO3)
↑ PaCO2, ↓ Serum Cl, ↓ Serum
K
HYPOventilation: ↑ Anion Gap ↓ Gap Normal Anion Gap acidosis HYPERventilation: Hypovolemia:
(anion gap (anion gap Acute Asthma - Vomit
>12) <12) Panic/Anxiety - Pyloric Stenosis
Inadequate ventilation or ↑ ↑ in Diarrhea Pul Embolus - Hyperemesis gravid
increased dead space. concentrations unmeasured Renal tubular acidosis Pul Edema - Diuretics
of anions other serum cations Ketone wasting Pneumonia
Causes include: than K and Cl (seen in Toluene Pregnancy Hyperaldosteronism
- Head or chest trauma myeloma) Progesterone Renin-producing Tumor
- Sedatives, and opiates ↓ serum Cirrhosis Bartter syndrome, Gitelman
- Over-sedation, MUDPILES albumin ↓ Cl CHF Syndrom (genetic Testing)
obtundation, or coma - Methanol, Bromide or ↓K Hypoxemia (High altitude) Antacid use
- Neuromuscular disorders Metformin iodine ↑K ↑ ICP
- Pickwickian syndrome - Uremia poisoning - Renal losses: Toxic salicylates
(obesity-hypoventilation (Pericarditis) (which are Renal tubular acidosis or Sympathomimetics.
syndrome) - Diabetic (or mistaken for acetazolamide
- COPD alcoholic) chloride in - GI losses:
keoacidosis many labs) Diarrhea or malabsorption
Renal compensation occurs - Propylene Laxative abuse
after 48 hrs of steady state. - - Adrenal insufficiency
INH/Iron/Inha - Renal insufficiency
lant (ie, CO) - Posthypocapnia
poisoning HARD-ASS:
- Lactic Hyperalimentation
acidosis Addison disease
(sepsis, shock, Renal tubular acidosis
hypoxia, Diarrhea
seizures, Acetazolamide
cyanide, Spironolactone
metformin, Saline infusion
Rhabdo, Tx:
Ischemia) - Intubation, mechanical
- Ethylene ventilation
glycol - RTA Type 1, & 2 ( ↓ K) :
- Salicylates, Potassium Citrate (Urocit-K) 20-40
Solvents mEq PO qd +/- HCTZ 12.5-50mg
PO qd.
- RTA Type 4 ( ↑ K) : Lasix 20-
80mg po qd OR bumetanide 0.5-
2mg PO qd
- Refractory Acidosis : Na
HCO3 8.4% (1mEq/ml) @ 50
cc/hr.
MOA: Tx: Tx: TX:
- Likely HypOventilating = - May need to be intubated Treatment focuses on Acetazolamide
Retaining CO2 - Treating the underlying cause is the most important action. identifying and addressing the
- Goal = Help pt blow off - Sodium bicarbonate treatment is a controversial and potentially underlying cause of
CO2 dangerous treatment because of the risk of electrolyte disturbances tachypnea.
and paradoxical cerebral acidosis. The cerebral acidosis occurs 2°
Tx: to the inability of HCO3 to quickly cross the blood-brain barrier.
- Ventilatory support Bicarbonate for the treatment of acidosis should only be considered
- O2 may be necessary to for extremely ill patients with severe acidosis.
treat hypoxia, but may - A brief reminder of some special treatments of underlying causes
worsen hypercapnia in of metabolic acidosis includes:
patients with COPD or in - Ethylene glycol and methanol: Fomepizole, Ethanol or 4-
heavily sedated patients. methylpyrazole and dialysis
- Salicylate toxicity: HCO3 to keep serum pH between 7.3 and
7.5 with resultant urine alkalinization; dialysis
- Iron overdose: Deferoxamine
NOTE: - Isoniazid: Pyridoxine (vitamin B6)
Min. Ventilation (VE) = RR
x TV
Acidosis Management: (pH < 7.30)
↑VE = ↓CO2 = ↑pH = ↓ If pH 7.15-7.30:
Cerabral Flow/ICP - Increase RR until pH > 7.30 or PaCO2 < 25 (Maximum set RR
↓VE = ↑CO2 = ↓pH = 35).
If pH < 7.15:
- Increase RR to 35.
- If pH remains < 7.15, VT may be increased in 1 ml/kg steps
until pH > 7.15 (Pplat target of 30 may be exceeded).
- May give NaHCO3 2-5 mEq/kg IV x1
Alkalosis Management: (pH > 7.45)
- Decrease vent rate if possible
↓ Cl

↓K ↑K

- Renal losses: - Adrenal insufficiency

Renal tubular acidosis or acetazolamide - Renal insufficiency
- GI losses: - Posthypocapnia
Diarrhea or malabsorption
Laxative abuse
HARD-ASS:
Hyperalimentation
Addison disease
Renal tubular acidosis
Diarrhea
Acetazolamide
Spironolactone
Saline infusion