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Determine the major primary process then select the correct rule
The major primary process is usually suggested by the initial clinical assessment and an initial perusal of the arterial pH,
pCO2 and [HCO3-] results. Once this major primary process is known, then the appropriate rule is chosen to assess the
appropriateness of the patients compensatory response.
The rules assess compensation and are a guide to detecting the presence of a second primary acid-base disorder: For
example in a patient with a metabolic acidosis if the measured pCO2 level was higher than is expected for the severity and
duration of the metabolic disorder, than this points to the coexistence of a respiratory acidosis. With a little practice the
rules are simple to remember and are quick and easy to apply at the bedside. Rules 1 to 4 are best remembered by the
description rather then memorizing the formula. These rules are outlined below
Example: A patient with a metabolic acidosis ([HCO3] 14mmol/l) has an actual pCO2 of 30mmHg. The
expected pCO2 is (1.5 x 14 + 8) which is 29mmHg. This basically matches the actual value of 30 so
compensation is maximal and there is no evidence of a respiratory acid-base disorder (provided that
sufficient time has passed for the compensation to have reached this maximal value). If the actual pCO2
was 45mmHg and the expected was 29mmHg, then this difference (45-29) would indicate the presence of a
respiratory acidosis and indicate its magnitude. See Section 5.5 for more details.
Rule 6 : The Point Seven plus Twenty Rule - for a Metabolic Alkalosis
The expected pCO2(in mmHg) is calculated from the following formula:
The combination of a low [HCO3] and a low pCO2 occurs in metabolic acidosis and in respiratory alkalosis. If only one
disorder is present it is usually a simple matter to sort out which is present. The factors to consider are:
The net pH change indicates the disorder if only a single primary disorder is present (eg acidaemia => acidosis)
An elevated anion gap or elevated chloride define the 2 major groups of causes of metabolic acidosis
Remember that only primary processes are called acidosis or alkalosis. The compensatory processes are just that compensation. Phrases such as secondary respiratory alkalosis should not be used. (see Section 3.1)
> 2 Check for either a co-existing Metabolic Alkalosis (which would elevate [HCO3])
Chronic Respiratory Acidosis (which results in compensatory elevation of [HCO3])
or a co-existing