ACID BASE DISTURBANCES

Liam Mahoney MB BCh BAO

PGY2
Boston Medical Center Department of Emergency Medicine
 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)
• Use the HCO3 from ABG to determine compensation
• Serum Na, K, Cl, CO2 content
• Use CO2 content to calculate anion gap
• Calculate anion gap
• 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 (1st
aldosterone)
 ORGAN DYSFUNCTION

• Endocrine
• Diabetes mellitus – metabolic acidosis
• Adrenal insufficiency – metabolic acidosis
• Cushing’s – 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)
• Use the HCO3 from ABG to determine compensation
• Serum Na, K, Cl, CO2 content
• Use CO2 content to calculate anion gap
• Calculate anion gap
• Anion gap = {Na - (Cl + CO2 content)}
• Determine appropriate compensation
• Determine the primary cause
 pH

< 7.35 7.4 >7.45

Acidosis Mixed Alkalosis

Metabolic Metabolic
Respiratory Respiratory
 STEPWISE APPROACHES

• History & physical examination

• Arterial blood gas for pH, pCO2, (HCO3)
• Use the HCO3 from ABG to determine compensation
• Serum Na, K, Cl, CO2 content
• Use CO2 content to calculate anion gap
• Calculate anion gap
• Anion gap = {Na - (Cl + CO2 content)}
• Determine appropriate compensation
• Determine the primary cause
 CO2 content

Low Normal High

Metabolic acidosis Normal Metabolic alkalosis

Resp alkalosis 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)
• Use the HCO3 from ABG to determine compensation
• Serum Na, K, Cl, CO2 content
• Use CO2 content to calculate anion gap
• Calculate anion gap
• 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)
• Use the HCO3 from ABG to determine compensation
• Serum Na, K, Cl, CO2 content
• Use CO2 content to calculate anion gap
• Calculate anion gap
• 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- )
 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
 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 
 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)
• Use the HCO3 from ABG to determine compensation
• Serum Na, K, Cl, CO2 content
• Use CO2 content to calculate anion gap
• Calculate anion gap
• Anion gap = {Na - (Cl + CO2 content)}
• Determine appropriate compensation
• Determine the primary cause
 GENERATION OF METABOLIC
ACIDOSIS
Administration of Loss of HCO3
HCl, NH4+Cl, CaCl2, lysine HCl diarrhea

Exogenous acids
ASA
Toxic alcohol H+ Compensations

Endogenous acids Buffers

ketoacids
DKA Lungs
starvation
alcoholic Kidneys
Lactic acid HCO -
L-lactic 3
D-lactate

High gap 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 Compensations
ACTH H
Diuretics
Bartter’s, Gitelman’s, Liddle’s Buffer
Inhibition of β – OH steroid deh
Respiratory

Gain of HCO3 Forget the kidney

Administered HCO3, HCO3
Acetate, citrate, lactate
Plasma protein products
 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 patient’s 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
 CASE 2

• 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 2

• A normal pH suggests mixed

disturbances
 INTERPRETATION OF CASE 2

• 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 HCO 3 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 2

• 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 3

• 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 3

• Pt’s 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 3

• Pt’s 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 3

• 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 4

• A cirrhotic patient was found to be

confused. Serum Na 133, K 3.3, Cl 115, CO content 14, anion gap 4
2

• pH 7.44 (H+ 36), pCO2 20, HCO3 13

 INTERPRETATION OF CASE 4

• 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, HCO3 = 21
• Patient’s 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