Acid-Base

Disturbances
Clinical Approach
2006
Pravit Cadnapaphornchai

Simple vs Mixed
Simple
When compensation is appropriate
Mixed
When compensation is inappropriate

Simple Acid-Base Disturbances

When compensation is appropriate

Metabolic acidosis ( HCO3, pCO2)
Metabolic alkalosis ( HCO3, pCO2)
Respiratory acidosis ( pCO2, HCO3)
Respiratory alkalosis ( pCO2, HCO3)

Stepwise Approaches

History & physical examination

Arterial blood gas for pH, pCO2, (HCO3)

Serum Na, K, Cl, CO2 content

Use CO2 content to calculate anion gap

Calculate anion gap

Use the HCO3 from ABG to determine compensation

Anion gap = {Na - (Cl + CO2 content)}

Determine appropriate compensation

Determine the primary cause

Organ dysfunction

CNS respiratory acidosis (suppression) and alkalosis

(stimulation)

Pulmonary respiratory acidosis (COPD) and alkalosis

(hypoxia, pulmonary embolism)

Cardiac respiratory alkalosis, respiratory acidosis,
metabolic acidosis (pulmonary edema)
GI metabolic alkalosis (vomiting) and acidosis (diarrhea)
Liver respiratory alkalosis, metabolic acidosis (liver
failure)
Kidney metabolic acidosis (RTA) and alkalosis (1 st
aldosteone)

Organ Dysfunction

Endocrine

Diabetes mellitus metabolic acidosis

Adrenal insufficiency metabolic acidosis

Cushings metabolic alkalosis
Primary aldosteronism metabolic alkalosis

Drugs/toxins

Toxic alcohols metabolic acidosis

ASA metabolic acidosis and respiratory alkalosis
Theophylline overdose respiratory alkalosis

Stepwise Approaches

History & physical examination

Arterial blood gas for pH, pCO2, (HCO3)

Serum Na, K, Cl, CO2 content

Use CO2 content to calculate anion gap

Calculate anion gap

Use the HCO3 from ABG to determine compensation

Anion gap = {Na - (Cl + CO2 content)}

Determine appropriate compensation

Determine the primary cause

pH
< 7.35

7.4

>7.45

Acidosis

Mixed

Alkalosis

Metabolic
Respiratory

Metabolic
Respiratory

Stepwise Approaches

History & physical examination

Arterial blood gas for pH, pCO2, (HCO3)

Serum Na, K, Cl, CO2 content

Use CO2 content to calculate anion gap

Calculate anion gap

Use the HCO3 from ABG to determine compensation

Anion gap = {Na - (Cl + CO2 content)}

Determine appropriate compensation

Determine the primary cause

CO2 content

Low
Metabolic acidosis
alkalosis
Resp alkalosis

Normal

High

Normal

Metabolic

Mixed

Resp acidosis

A normal CO2 content + high anion gap = metabolic acidosis +

Metabolic alkalosis or metabolic ac + compensatory respiratory ac.

Stepwise Approaches

History & physical examination

Arterial blood gas for pH, pCO2, (HCO3)

Serum Na, K, Cl, CO2 content

Use CO2 content to calculate anion gap

Calculate anion gap

Use the HCO3 from ABG to determine compensation

Anion gap = {Na - (Cl + CO2 content)}

Determine appropriate compensation

Determine the primary cause

Calculation of Anion Gap in

Metabolic Acidosis
Anion gap = Na (Cl + HCO3)
Normal 8 2
Correction for low serum albumin
Add (4-serum albumin g/dL) X 2.5
to the anion gap

Stepwise Approaches

History & physical examination

Arterial blood gas for pH, pCO2, (HCO3)

Serum Na, K, Cl, CO2 content

Use CO2 content to calculate anion gap

Calculate anion gap

Use the HCO3 from ABG to determine compensation

Anion gap = {Na - (Cl + CO2 content)}

Determine appropriate compensation

Determine the primary cause

Compensations for Metabolic

Disturbances

Metabolic acidosis
pCO2 = 1.5 x HCO3 + 8 ( 2)

Metabolic alkalosis
pCO2 increases by 7 for every 10 mEq
increases in HCO3

How does the kidney

compensate for metabolic
acidosis?

How does the kidney compensate for

metabolic acidosis?

By reabsorbing all filtered HCO3

By excreting H+ as NH4+ (and
H2PO4- )
Interpretations
Urine pH
< 5.5
Urine anion gap
Negative

Compensations for Respiratory

Acidosis

Acute respiratory acidosis

HCO3 increases by 1 for every 10 mm
increases in pCO2
Chronic respiratory acidosis
HCO3 increases by 3 for every 10 mm
increases in pCO2

If you dont have kidneys, can you have

chronic respiratory acidosis?

Compensations for Respiratory

Alkalosis
Acute respiratory alkalosis
HCO3 decreases by 2 for every 10 mm
decrease in pCO2
Chronic respiratory alkalosis
HCO3 decreases by 4 for every 10 mm
decrease in pCO2
If you dont have kidneys can you have chronic
respiratory alkalosis?

Mixed Acid-Base Disorders

Mixed respiratory alkalosis & metabolic
acidosis
ASA overdose
Sepsis
Liver failure
Mixed respiratory acidosis & metabolic
alkalosis
COPD with excessive use of diuretics

Mixed Acid-Base Disorders

Mixed respiratory acidosis & metabolic
acidosis
Cardiopulmonary arrest
Severe pulmonary edema
Mixed high gap metabolic acidosis &
metabolic alkalosis
Renal failure with vomiting
DKA with severe vomiting

Stepwise Approaches

History & physical examination

Arterial blood gas for pH, pCO2, (HCO3)

Serum Na, K, Cl, CO2 content

Use CO2 content to calculate anion gap

Calculate anion gap

Use the HCO3 from ABG to determine compensation

Anion gap = {Na - (Cl + CO2 content)}

Determine appropriate compensation

Determine the primary cause

Generation of Metabolic Acidosis

Administration of
HCl, NH4+Cl, CaCl2, lysine HCl
Exogenous acids
ASA
Toxic alcohol

H+

Compensations
Buffers

Endogenous acids
ketoacids
DKA
starvation
alcoholic
Lactic acid
L-lactic
D-lactate
High gap

Loss of HCO3
diarrhea

Lungs
Kidneys

HCO 3

Normal gap

If kidney function is normal, urine anion gap Neg

Loss of H+ from GI
Vomiting, NG suction
Congenital Cl diarrhea
Loss of H+ from kidney
1st & 2nd aldosterone
ACTH
Diuretics
Bartters, Gitelmans, Liddles
Inhibition of OH steroid deh
Gain of HCO3
Administered HCO3,
Acetate, citrate, lactate
Plasma protein products

HCO3

Compensations
Buffer
Respiratory
Forget the kidney

CASE 1
A 24 year old diabetic was admitted for
weakness.
Serum Na 140, K 1.8, Cl 125, CO2 6,
anion gap 9.
pH 6.84 (H+ 144) pCO2 30, HCO3 5

Interpretation of Case 1
Patient has normal gap metabolic
acidosis

Interpretation of Case 1

Next determine the appropriateness of

respiratory compensation
pCO2 = 1.5 x HCO3 + 8 ( 2)
pCO2 = 1.5 x 5 + 8 + 2 = 17.5

The patients pCO2

is 30

The respiratory compensation is

inappropriate

Interpretation of Case 1
This patient has normal anion gap metabolic
acidosis with inappropriate respiratory
compensation
The finding does not fit DKA but is
consistent with HCO3 loss from the GI tract
or kidney

How to differentiate normal

gap acidosis resulting from GI
HCO3 loss (diarrhea) vs dRTA?

Diarrhea vs RTA

Diarrhea
History
Urine pH < 5.5
Negative urine
anion gap

dRTA
History
Urine pH > 5.5
Positive urine
anion gap

Case 2

A 26 year old woman, complains of weakness.

She denies vomiting or taking medications.
P.E. A thin woman with contracted ECF.
Serum Na 133, K 3.1, Cl 90, CO2 content 32,
anion gap11.
pH 7.48 (H+ 32), pCO2 43, HCO3 32.

Interpretation of Case 2

Determine the appropriateness of

respiratory compensation
For every increase of HCO3 by 1, pCO2 should
increase by 0.7
pCO2 = 40 + (32-25) x 0.7 = 44.9

The patients pCO2

= 43

Interpretation of Case 2

This patient has metabolic alkalosis with

appropriate respiratory compensation

Interpretation of Case 2

Urine Na+ 52, UK+ 50, Cl- 0, pH 8

Urine pH =

8 suggests presence of large

amount of HCO3. The increased UNa and UK
are to accompany HCO3 excretion. The
kidney conserves Cl

The findings are consistent with loss of

HCl from the GI tract
Final diagnosis = Self-induced vomiting

Vomiting vs Diuretic

Active vomiting

ECF depletion
Metabolic alkalosis
High UNa, UK, low UCl
Urine pH > 6.5

Remote vomiting

ECF depletion
Metabolic alkalosis
Low UNa, high UK, low
Cl
Urine pH 6

Active diuretic

ECF depletion
Metabolic alkalosis
High UNa, UK and Cl
Urine pH 5-5.5

Remote diuretic

ECF depletion
Metabolic alkalosis
Low UNa, high UK, low
Cl
Urine pH 5-6

Case 3

A 40 year old man developed pleuritic

chest pain and hemoptysis. His BP 80/50.
pH 7.4, pCO2 25, HCO3 15 and pO2 50

Interpretation of Case 3

A normal pH suggests mixed disturbances

Interpretation of Case 3

His pCO2 is 25, his HCO3 15

If this is acute respiratory alkalosis his HCO3
should have been 25-{(40-25) x 2/10}= 22
If this is chronic respiratory alkalosis, his HCO3
should have been 25 {(40-25) x 4/10} = 19
If this is metabolic acidosis, his pCO2 should have
been 1.5 x 15 + 8 = 30-31

Interpretation of Case 3

He has combined respiratory alkalosis and

metabolic acidosis
The likely diagnosis is pulmonary embolism with
hypotension and lactic acidosis or pneumonia
with sepsis and lactic acidosis
Other conditions are ASA overdose, sepsis, liver
failure

Case 4

A patient with COPD developed CHF. Prior to

treatment his pH 7.35, pCO2 was 60 and HCO3
32. During treatment with diuretics he vomited a
few times. His pH after treatment was 7.42, pCO2
80, HCO3 48.

Interpretation of Case 4

Pts data pH 7.35, pCO2 60 and HCO3 32

For acute respiratory acidosis

For every 10 mm elevation of pCO2, HCO3 increases

by 1, his HCO3 should have been 25 + (60-40) x
1/10 = 27

He did not have acute respiratory acidosis

Interpretation of Case 4

Pts data pH 7.35, pCO2 60 and HCO3 32.

For chronic respiratory acidosis
For every 10 mm elevation of pCO2, HCO3 increases
by 3
His HCO3 should have been 25 + (60-40) x 3/10 = 31

His HCO3 is 32

He had well compensated chronic respiratory

acidosis

Interpretation of Case 4

His pH is now 7.42, pCO2 80, HCO3 48

If pCO2 of 80 is due to chronic respiratory
acidosis, HCO3 should only be 32 +(80-60) x
3/10=38 and not 48
He had combined metabolic alkalosis and
respiratory acidosis after treatment of CHF

Case 5

A cirrhotic patient was found to be

confused. Serum Na 133, K 3.3, Cl 115, CO2
content 14, anion gap 4
pH 7.44 (H+ 36), pCO2 20, HCO3 13

Interpretation of Case 5

Determine the respiratory compensation

For chronic respiratory alkalosis, every 10 reduction in pCO 2,
HCO3 should decrease by 4
HCO3 should be 25 - (40-20) x 4/10=17
For acute respiratory alkalosis, HCO 3 = 21
Patients HCO3 is 13 , suggesting a metabolic acidotic
component is present
Anion gap is 4, even corrected for low albumin, is still low
suggesting a normal gap metabolic acidosis
Patient had combined metabolic acidosis and respiratory alkalosis