Acid Base Disorders

Normal values:

 PH 7.35 – 7.45 (7.40)

 PaCO2 35 – 45 (40)

 HCO3 22 – 26 (24)

 AG 10 +/- 4 (12)

 Delta Gap -6 to + 6
 Look at PH and PCO2
 If they move in the same direction primary disorder is
metabolic
 If they move in the opposite direction primary
disorder is respiratory
 Check compensation
 If metabolic acidosis check AG
 Check delta gap if AG met acidosis exits.
 Compensatory Response
 Tend to normalize PH
 pH never returns to normal, except in Chronic
Respiratory Alkalosis

 Requires normal function of kidney/ lung

 Full compensation takes time
 Compensation is predictable
Dr. Friedman’s rule of 7s

 Met Acidosis: 1.5(HCO3) + 8 +/- 2

 Metabolic Alkalosis:

Change of HCO3 by 10 -------------------- Change of PCO2 by 6

 Acute Respiratory Acidosis:

Increase of PCO2 by 10 ----------------- Increase of HCO3 by 1

 Chronic Respiratory Acidosis

Increase of PCO2 by 10 ----------------- Increase of HCO3 by 3.5

 Acute Respiratory Alkalosis:

Decrease of PCO2 by 10----------------- Decrease of HCO3 by 2

 Chronic Respiratory Alkalosis

Decrease of PCO2 by 10 -----------------Decrease of HCO3 by 5

Anion Gap:

 AG = Na – ( Cl + HCO3) = 10 +/- 4
 Unmeasured anions ( Proteins, Phosphates, Sulfates, Organic
Acids) exceed unmeasured cations ( K, Ca, Mg )
 Decreased AG: hypoalbuminemia, paraproteinemia,
Hyponatremia, Lithium toxicity, K, Ca, Mg, halide poisoning
( halide , Iodide)

 AG acidosis may exist with normal AG !

1. Decrease in unmeasured ANIONS: For every decrease of 1g/dl in
albumin a decrease of 2.5 to 3mmol in AG will occur.

2. Increase in unmeasured CATIONS: Pathologic paraproteinemias

lower the AG because IG are largely cationic
∆ Gap: ( AG – 12) – (24 – HCO3 )
 ∆ gap 0= Pure anion gap metabolic acidosis

 ∆ gap <– 6: Normal anion gap metabolic acidosis, or a chronic

respiratory alkalosis exists.
 Remember Negative for Non AG Acidosis !! Because the
decrease in HCO3 is greater than the increase in AG

 ∆ gap >+6: Concomitant Metabolic alkalosis, or a respiratory

acidosis exists
 Case 1
A 22 yr old is evaluated for weakness, weight loss
PH 7.32 Na 135 Cl 101
PaCO2 24 K 4.5 HCO3 12
PaO2 95
Which one of the following is the best interpretation.
A. Metabolic acidosis
B. Metabolic acidosis + metabolic alkalosis
C. Metabolic acidosis + respiratory acidosis
D. Data is inaccurate
 Case 1
PH 7.32 Na 135 Cl 101
PaCo2 24 K 4.5 HCO3 12
PaO2 95
Primary metabolic disorder, PH and PCO2→ same
direction
Respiratory compensation
PaCo2 = 1.5 x 12 +8 ± 2 = 26 ± 2
Anion gap = 135 – (101+12) = 22
Delta Gap: (AG-12)-( 24 - HCO3) = (22-12) - (24-12)= -2
 Case 1
 A 22 yr old is evaluated for weakness, weight
loss

 Answer: (A) Dx Anion gap metabolic acidosis

with appropriate respiratory compensation
Anion gap Metabolic acidosis: MUDPILES

 M= Methanol, Metformin
 U= Uremia
 D= DKA
 P= Paraldehyde
 I= Iron, INH
 L=Lactate
 E= Ethylene Glycol
 S= Salicylates, Shock, sepsis, starvation
 Case 2
72 yr old female admitted from nursing home BP
100/60 supine and 70/40 sitting
PH 7.11 Na 133 Cl 118
PaCO2 16 K 2.8 HCO3 5
PaO2 90
What is the most likely etiology?
A. Hypoperfusion
B. Diarrhea
C. Starvation
D. Methanol ingestion
 PH 7.11 Na 133 Cl 118
PaCO2 16 K 2.8 HCO3 5
PaO2 90

 PH and PaCO2 ↓ 1º Metabolic

 Anion gap (133) – (118) + (5) =10
 Normal anion gap metabolic acidosis
 Respiratory compensation

PaCO2 = 1.5 (5) +8 ± 2 = 15.5 ± 2

 72 yr old female admitted from nursing home
BP 100/60 supine and 70/40 sitting

 Answer: (B) Diarrhea causing Non Anion Gap

Hyperchloremic metabolic acidosis with
appropriate respiratory compensation
 Normal Anion gap
 Common causes of non AG acidosis include
1. GI Loss
2. Early renal Insufficiency
3. Infusion of isotonic Saline ( aka Dilutional acidosis )
4. RTAs
 Check urine anion gap: ( Normal is –10 to + 10)
 ( UNa + UK) – UCl
 Negative urine gap
__ GI loss of HCO3
 Positive urine gap
__ Renal loss of HCO3. Positive for Pee !!!!!!
 Renal Tubular Acidosis

Potassium Urine pH FeHCO3

Type 1 >5.5 <10%

RTA

Type 4 <5.5 <10%

RTA

Type 2 >5.5 or >15%

RTA <5.5
 Case 3
65 yr old on diuretics with difficulty weaning from vent
PH 7.53 Na 146 Cl 92
PaCO2 50 K 3.1 HCO3 40
PaO2 85
Which one of the following is the best interpretation.
A. Metabolic alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis + metabolic acidosis
D. Metabolic alkalosis + respiratory acidosis
 Case 3
PH 7.53 Na 146 Cl 92
PaCO2 50 K 3.1 HCO3 40
PaO2 85
PH and PaCO2 going up 1º Metabolic
∆ PaCO2 = 10meq ∆ in HCO3, PaCO2 ∆ 6 to 7
= ∆ HCO3 = (40-24) = 16
= ∆ PCO2 = (50-40) = 10
 Case 3
65 yr old on diuretics with difficulty weaning from vent
PH 7.53 Na 146 Cl 92
PaCo2 50 K 3.1 HCO3 40
PaO2 85
Which one of the following is the best interpretation.
A. Metabolic alkalosis
B. Respiratory acidosis
C. Metabolic alkalosis + metabolic acidosis
D. Metabolic alkalosis + respiratory acidosis
 Metabolic Alkalosis
Hypovolemic Cl depleted Hypervolemic Cl expanded
(Ucl < 20 mEq/L) (Ucl > 20 mEq/L)
 Renal Loss of H
+
 GI loss of H
+
 Primary Hyperaldosteronism
 Vomiting  Primary Hypercortisolism
 Gastric Suction  Hydrocortisone/
 Villous Adenoma mineralocoticoid excess
 Renin Secreting Tumor
 Renal Loss of H+
 Hypokalemia
 Diuretics  Bicarbonate Overdose
 Post hypercapnia  CoStAl ReHaB
 Case 4
 60 yr old with HTN, PVD acutely C/O leg pain. BP
90/50, HR 120, RR 25, T 102
PH 7.57 Na 135 Cl 101
PaCO2 15 K 3.8 HCO3 5
PaO2 98
Which disorder is most likely ?
 Acute respiratory alkalosis
 Chronic respiratory alkalosis
 Acute respiratory alkalosis + metabolic alkalosis
 Acute respiratory alkalosis + metabolic acidosis
 PH 7.57 Na 135 Cl 101
PaCO2 15 K 3.8 HCO3 5
PaO2 98

 PH and PaCO2 in opposite direction→ 1º Respiratory

 Respiratory alkalosis
 Acute or chronic ( Need to see pt and look at the
chart)
 ∆ PCO2 = 40-15 = 25
 Expected HCO3 = 24-5 = 19. Actual is 5
 AG = 135 – ( 101 + 5 ) = 29
 ∆ Gap = (29-12)- (24-5) = 17 – 19= -2
 Case 4
 60 yr old with HTN, PVD C/O acute leg pain. BP
90/50, HR 120, RR 25, T 102
PH 7.57 Na 135 Cl 101
PaCO2 15 K 3.8 HCO3 13
PaO2 98
Which disorder is most likely ?
 Acute respiratory alkalosis
 Chronic respiratory alkalosis
 Acute respiratory alkalosis + metabolic alkalosis
 Acute respiratory alkalosis + metabolic acidosis
 Respiratory Alkalosis
 Stimulation of the respiratory Hypoxemic Drive:
 Center
Pulmonary Disease with A-a gradient
 Neurologc Disorders
 Pain Cardiac Disease with Right to left shunt
 Psychogenic
 Liver Failure with encephalopathy Cardiac Disease with pulmonary edema
 Sepsis/ infection
High Altitude
 Salicylates
 Pregnancy Acute and Chronic Pulmonary
 Fever
Disease:
 Progesterone
Emphysema

Pulmonary Embolism

 Mechanical Over ventilation Pulmonary Edema

 Case 5
 47 yr old with CRI present with diarrhea, LLQ pain and fever
PH 7.46 Na 130 Cl 106
PaCO2 12 K 5.5 HCO3 8
PaO2 90
Which disorder is most likely ?
 Respiratory alkalosis + anion gap metabolic acidosis
 Respiratory acidosis + anion gap metabolic acidosis
 Respiratory alkalosis, anion gap and non anion gap metabolic
acidosis
 Respiratory alkalosis, anion gap metabolic acidosis and
metabolic alkalosis
 PH 7.48 Na 136 Cl 106
PaCo2 12 K 5.5 HCO3 8
PaO2 90

 PH and PCO2 in opposite direction → respiratory

 Respiratory Alkalosis
 ∆ PCO2 = 40-12 = 28
 Expected HCO3 = 24 - 6 = 18. Actual is 8
 AG = 134 – ( 106 + 4 ) = 24
 ∆ Gap = (24-12)- (24-4) = 12 – 20= - 8
 Case 5
 47 yr old with CRF present with diarrhea, LLQ pain and fever
PH 7.48 Na 136 Cl 106
PaCo2 12 K 5.5 HCO3 8
PaO2 90
Which disorder is most likely ?
 Respiratory alkalosis + anion gap metabolic acidosis
 Respiratory acidosis + anion gap metabolic acidosis
 Respiratory alkalosis, anion gap and non anion gap metabolic
acidosis
 Respiratory alkalosis, anion gap metabolic acidosis and
metabolic alkalosis
 Conclusion:
1. Look at the pH (acidic or alkalemic)
2. Determine if metabolic or respiratory
3. Is there adequate compensation ?
4. Is there an anion gap ?
5. If so what is the delta gap ?
6. How can we correct this problem ?