Acid - Base Balance

Acid – Base Balance
Paolo F. Alianza, MD
Objectives
Discuss a case with acid – base disturbance
Review Mechanisms of Acid – Base Balance
Review steps in ABG Interpretation

Case
J.C.
84/F
Filipino
Roman Catholic
Cc: Generalized Body Weakness

History of Present Illness
1 week PTC
(+)Epigastric pain, burning, aggravated by food intake associated with

vomiting and poor oral intake
No melena, no hematemesis, no fever
No consult done, no medications taken
History of Present Illness
Interval
1 week PTC
History
(+)progression of epigastric pain

(+)poor appetite
(+)vomiting of previously ingested food, ~5x approx 100cc per episode
(+)Generalized Body Weakness
REVIEW OF SYSTEMS
● General: (-) fever
● HEENT: (-) tinnitus, (-) dysphagia, (-) proptosis
● Cardiovascular: (-) easy fatigability, (-) chest pain, (-)palpitations
● Respiratory: (-) dyspnea, (-) cough
● Endocrine: (+) polyphagia, (+) polydipsia, (+) polyuria, (-) purplish
abdominal striae, (-)thinning of hair, (-) heat intolerance
● Genitourinary: (-) dysuria, (-) flank pain, (-) oliguria
● Hematology: (-) easy bruisability
● Musculoskeletal: (-) joint pains (-)edema, (+) pins and needle
sensation on both feet
Past Medical History
● (+)Hypertension – Losartan 50mg/tab 1tab once a day;
Amlodipine 10mg/tab 1tab once a day
● Type 2 DM – (+)Insulin glargine 20u SC OD, Metformin +

Sitagliptin 500mg + 50mg/tab 1tab BID
● (+)CoVax – Modera x 2
Personal and Social
● Nonsmoker
● Denies Alcoholic beverage intake
● Denies Illicit drug use
Family History
● (+)Type 2 DM
● (+)Hypertension
● No thyroid disorder
● No Cancer
● No CV disease
Physical Exam
● GCS 15, Weak looking
● ABW 45kg | IBW 50kg | Ht 150cm | BMI 20
● VS: 90/60 | 84bpm | 18cpm | 36.5C | 98% at Room Air
● Poor skin turgor
● Anicteric Sclera, Pink Palpebral Conjunctivae, Dry Lips and Oral Mucosa, Non
distended neck veins
● Supple Neck, No palpable mass
● Symmetric Chest Expansion, No retractions, Clear breath Sounds
● Adynamic Precordium, Normal Rate and Regular Rhythm, PMI 5th LICS MCL, No
murmur
● Flabby Abdomen, No scars, no caput medusae, tympanitic in all quadrants,
(+)epigastric tenderness
● No edema, full and equal pulses, no asterixis
Salient Features
Positive Negative
84/F No melena, no hematemesis
1 week history of Epigastric pain, vomiting, No pallor, No easy fatigability
poor appetite and generalized body No dysuria, no hematuria, no Flank pain
weakness No changes in sensorium
(+)polyuria, polyphagia, polydipsia No asterixis, no oliguria
(+)pins and needle sensation
(+)HTN and Type 2 DM
Stable VS
(+)poor skin turgor
(+)Dry Lips and Oral Mucosa
Clear breath sounds
(+)Epigastric tenderness
Working Impression
t/c Acid Peptic Disease
T/c Multiple Electrolyte Imbalances from GI Losses
r/o AKI from Dehydration
Type 2 DM probably Uncontrolled
Hypertension St. II, Controlled
Work Ups
CBC Chem ABG CBG – Hi
Hgb 12.1 BUN 29 pH 7.15
UA - Y/ Hazy/ Sugar 3+/ Alb neg/ pH
Hct 0.37 Crea 228 pCO2 17 5.5/ SG 1.010/ Ketones 1+/ wbc 30.0
WBC 12.7 BCR 32 pO2 99 rbc 52.7/ EC 3/ Bacteria 67.5
Seg 86 eGFR 18 HCO3 5.9
Lym 9 Na 130
Mono 5 K 5.5
Plt 265 Cl 109
Admitting Impression
Severe DKA from 1. Uncontrolled Type 2 DM 2. Infection
AKI prob sec to 1. Dehydration 2. Infection on top of probable
CKD St. IV sec to DKD vs HTNNSS
Hypertension St. II, Controlled
DISCUSSION
Acid – Base Balance
1. Intracellular and Extracellular Buffers
2. Renal Regulatory Mechanisms
3. Respiratory Regulatory Mechanisms

Thick Ascending Limb
Distal Nephron
Bicarbonate secretion by cortical collecting duct

β-intercalated cell
Steps in ABG Interpretation
1. Obtain diagnostic clues o the presence of acid-base disorders from
the clinical setting
2. Obtain a Simultaneous ABG and Electrolyte Profile
3. Determine the Primary Acid – Base Disorder
4. Check the Compensatory Response
5.Calculate the Anion Gap
6. Compute for the Delta/Deltas when Applicable
7. Summarize the Acid-Base Disorders and look for the specific cause
Dioquino-Dimacali, C. A Self-Instructional Monograph on Arterial Blood Gas Collection and Interpretation of Acid-Base Disorders
Step 1: Obtain Diagnostic Clues to the Presence of Acid-
Base Disorders from the Clinical Setting
● CASE:
○ Vomiting – Metabolic Alkalosis
○ Dehydration – Metabolic Acidosis
○ Elevated BUN, Crea – Metabolic Acidosis
○ Hyperglycemia, Ketonuria – Metabolic Acidosis
Step 2: Obtain a Simultaneous ABG and
Electrolyte Profile
Step 2: Obtain a Simultaneous ABG and
Electrolyte Profile
CASE: ABG
pH 7.15
pCO2 17
pO2 99
24 ( 17 ) HCO3 5.9
5.9
= 69
Step 3: Determine the Primary Acid – Base
Disorder
pH
ABG Normal Indices
<7.4 >7.4 pH 7.35 – 7.45

Acidosis Alkalosis pCO2 35 – 46 mmHg
HCO3 22 – 26 meq/L
HCO3 <24 pCO2 >40 HCO3 >24 pCO2 >40 pO2 80 – 100mmHg
Metabolic Respiratory Metabolic Respiratory
Disorder
Deviation from the normal ABG indices:
%Deviation paCO2 = [Actual paCO2 – Normal paCO2] x 100

Normal paCO2
%Deviation HCO3 = x 100
Normal pCO2 : 40 mmHg

Normal HCO3 : 24 meq/L
Disorder
CASE: pH
ABG
<7.4 >7.4
Acidosis Alkalosis pH 7.15
pCO2 17
pO2 99
HCO3 <24 pCO2 >40 HCO3 >24 pCO2 >40 HCO3 5

Metabolic Respiratory Metabolic Respiratory
Step 4: Check
the
Compensatory
Response
Step 4: Check the Compensatory Response
CASE:
ABG
pCO2 = (1.5 x HCO3 ) + 8 +/- 2
pH 7.15
= (1.5 x 5) + 8 +/- 2
pCO2 17
= 17 +/- 2
pO2 99
HCO3 5.9
Step 4: Check the Compensatory Response
ABG
Step 4: Check the Compensatory pH 7.15
Response
pCO2 17
pO2 99
HCO3 5.9
CASE:
Step 5: Calculate the Anion Gap
Normal AG: 12 +/- 4 meq/L
CASE:
ABG Chem
pH 7.15 BUN 29 = 145 – (109 + 5.9)
pCO2 17 Crea 228 = 30
pO2 99 BCR 32
HCO3 5.9 eGFR 18
Na 130
Correct 145
ed Na
K 86
Cl 109
CASE: AG = 30
Step 6: Compute for the Delta/Deltas when
Applicable
∆AG = Patient’s AG – normal AG
∆[HCO3-] normal HCO3 – Patient’s HCO3
• Used when High Anion Gap Metabolic Acidosis is

diagnosed
Interpretation:
- Delta AG = Delta HCO3 : Pure HAG Metabolic Acidosis
- Delta AG < Delta HCO3 : HAG Metabolic Acidosis +
NAG Metabolic Acidosis
- Delta AG > Delta HCO3 : HAG Metabolic Acidosis +
Metabolic Alkalosis
Applicable
∆Cl = Patient’s Cl – normal Cl
• Used when Normal Anion Gap Metabolic Acidosis is

diagnosed
Interpretation:
- Delta Cl = Delta HCO3 : Pure HAG Metabolic Acidosis
- Delta Cl < Delta HCO3 : NAG Metabolic Acidosis + HAG
Metabolic Acidosis
- Delta Cl > Delta HCO3 : NAG Metabolic Acidosis +
Metabolic Alkalosis
Applicable
CASE: ∆AG = Patient’s AG – normal AG
∆[HCO3-] normal HCO3 – Patient’s HCO3 ABG
pH 7.15
= 30 – 12 pCO2 17
24 - 6 pO2 99
= 18 HCO3 5.9
18
Applicable
CASE:
∆AG = Patient’s AG – normal AG
= 30 – 12
24 - 6
= 18
18 ABG
Interpretation:
pH 7.15
- Delta AG = Delta HCO3 : Pure HAG Metabolic Acidosis
- Delta AG < Delta HCO3 : HAG Metabolic Acidosis + NAG Metabolic pCO2 17
Acidosis pO2 99
- Delta AG > Delta HCO3 : HAG Metabolic Acidosis + Metabolic Alkalosis
HCO3 5.9
FINAL INTERPRETATION
PRIMARY HIGH ANION GAP METABOLIC ACIDOSIS
DKA
- bicarbonate therapy when pH <7.1 ABG
- fluid resuscitation with isotonic saline pH 7.15
- IV regular Insulin pCO2 17
pO2 99
HCO3 5.9
Thank you!

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Acid – Base Balance

Discuss a case with acid – base disturbance

Review Mechanisms of Acid – Base Balance

Review steps in ABG Interpretation

Cc: Generalized Body Weakness

(+)Epigastric pain, burning, aggravated by food intake associated with

(+)progression of epigastric pain

● Type 2 DM – (+)Insulin glargine 20u SC OD, Metformin +

1. Intracellular and Extracellular Buffers

2. Renal Regulatory Mechanisms

3. Respiratory Regulatory Mechanisms

Bicarbonate secretion by cortical collecting duct

ABG Normal Indices

<7.4 >7.4 pH 7.35 – 7.45

Deviation from the normal ABG indices:

%Deviation paCO2 = [Actual paCO2 – Normal paCO2] x 100

%Deviation HCO3 = x 100

Normal pCO2 : 40 mmHg

HCO3 <24 pCO2 >40 HCO3 >24 pCO2 >40 HCO3 5

Step 4: Check the Compensatory pH 7.15

Normal AG: 12 +/- 4 meq/L

• Used when High Anion Gap Metabolic Acidosis is

• Used when Normal Anion Gap Metabolic Acidosis is

PRIMARY HIGH ANION GAP METABOLIC ACIDOSIS

- bicarbonate therapy when pH <7.1 ABG

- fluid resuscitation with isotonic saline pH 7.15

- IV regular Insulin pCO2 17

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