12/2/2020 #88: Acid base, boy bands, and grandfather clocks with Joel Topf MD

#88: Acid base, boy bands, and

grandfather clocks with Joel Topf MD
Total points 34/100

Identify the following acid-base disturbances:

1. pH 7.15/ pCO2 34 / pAO2 112 / HCO3 12 with Na 144, K 3.4, Cl 110, 0/33
HCO3 12 *

Non-Anion Gap metabolic acidosis with respiratory acidosis

Non-Anion Gap without compensation

Anion Gap metabolic acidosis without compensation

Anion Gap metabolic acidosis with respiratory acidosis

Correct answer

Anion Gap metabolic acidosis with respiratory acidosis

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Step 1: This is acidosis because the pH is well below 7.4. The HCO3 is less than normal
and the CO2 is also less than normal. This is a primary metabolic acidosis.

Step 2: To determine if the compensation is correct for the severity of the primary disorder
(metabolic acidosis), winter’s formula [Expected pCO2 = (1.5 x HCO3) + 8 ± 2] should be
applied. The expected pCO2 calculated by (1.5 x 12 ) + 8 ± 2 is 24-28. However, the patient
pCo2 is 34. This patient is not breathing off as much Co2 for the severity of his metabolic
acidosis (would be 24-28) and therefore has also has a respiratory acidosis and hence his
Co2 is 34.

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12/2/2020 #88: Acid base, boy bands, and grandfather clocks with Joel Topf MD

Step 3: Given that the patient has a metabolic acidosis, it is also important to discern if
there an anion gap. Anion gap = Na – (HCO3 + Cl) therefore his anion gap is 22, which
above the threshold for normal.

2. pH 7.56 / pCO2 22 / pAO2 91/ HCO3 23 0/33

Respiratory alkalosis without compensation

Respiratory alkalosis with metabolic acidosis

Respiratory alkalosis with metabolic alkalosis

Other:

Correct answer

Respiratory alkalosis with metabolic alkalosis

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Step 1: This is alkalosis because the pH is above 7.4. The HCO3 is near normal but the
pCO2 is well below 40. Since the pH and pCO2 are moving in discordant direction, this is a
primary respiratory disorder.

Step 2: Determine if the compensation is correct for the severity of the primary respiratory
alkalosis: for every 10 mmHg decrease in pCO2, the HCO3 should decrease 2 mEq/L vs. 4
mEq/L in chronic compensation. This patient’s pCo2 of 22 is about 20mmHg below the
normal value of 40, so if this was an acute process, the HCO3 would be 20 mEq/L (4
mEq/L below normal) and if this was a chronic process, the HCO2 would be 16 mEq/L
(8mEq/L below normal). Since this patient HCO3 is 23, which is above the expected HCO3
for both an acute (20) or chronic process (16), there is a concomitant metabolic alkalosis.

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12/2/2020 #88: Acid base, boy bands, and grandfather clocks with Joel Topf MD

3. pH 7.45/ pCo2 17/ pO2 75/ HCO3 12 with Na 139, K 2.5, Cl 114, HCO3 34/34
11, Albumin 2

Anion Gap metabolic acidosis without concomitant disorders

Non Anion gap metabolic acidosis with respiratory alkalosis

Respiratory alkalosis with anion gap metabolic acidosis without concomitant anion-
gap metabolic acidosis

Respiratory alkalosis with anion gap metabolic acidosis with non-anion gap
metabolic acidosis

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Step 1: This is alkalosis because of the pH is above 7.4. The HCO3 is below normal and
pCo2 is also also below normal. Given that the three variables are in discordant directions,
this a respiratory process.

Step 2: Determine if the compensation is correct for the severity of the primary respiratory
alkalosis: For every 10 mmHg decrease in pCO2, the HCO3 should decrease 2 mEq/L in
acute vs. 4 mEq/L in chronic compensation. This patient’s pCo2 of 17 is about 20mmHg
below the normal value of 40, so if this was an acute process, the HCO3 would be 20
mEq/L (4 mEq/L below normal) and if this was a chronic process, the HCO2 would be 16
mEq/L (8mEq/L below normal). However, this patient’s HCO3 is below expected and there
is also a metabolic acidosis.

Step 3: Given that the patient has a metabolic acidosis, it is also important to discern if
there an anion gap. Anion gap = Na – (HCO3 + Cl) is 14. However, the patient albumin is 2.
For every g/dL the albumin is below 4, add 2.5 to the calculated anion gap. Therefore, this
anion gap is 19 when adjusted for the albumin.

Step 4: Would be checking an osmolar gap, but we skip that here.

Step 5: Is there a concomitant non-gap metabolic acidosis? This allows you to nd yet
another acid base disorder “tucked away in the ABG”. If there is an AGMA, then the anion
gap should increase as the bicarbonate falls in a 1:1 fashion (loss bicarbonate = addition
of anion). The following equation can assess for “the bicarbonate before” the anion gap
acidosis was present: HCO3 + (AG – 12) = HCO3 before, which would be 11+ (19- 12) = 18.
Because the HCO3 before is less than 24 then there is a concomitant non-anion gap
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12/2/2020 #88: Acid base, boy bands, and grandfather clocks with Joel Topf MD
Because the HCO3 before is less than 24, then there is a concomitant non anion gap
metabolic acidosis.

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