Case Studies on Acid-Base Disorders

William T. Browne, M.D.

Important concepts
-emia refers to a pH -osis refers to an abnormal condition or process

Normal ranges
pH pCO2 HCO37.36-7.44 38-42 mm Hg 22-28 mEq/L

Fact or Fiction?
A pCO2 < 40 mm Hg always implies a respiratory alkalosis

FICTION!

Fact or Fiction?
A patient cannot have a metabolic acidosis and a metabolic alkalosis simultaneously

FICTION!

Fact or Fiction?
A patient can have a metabolic acidosis with a compensatory respiratory alkalosis

FICTION!

Important concepts
-emia refers to a pH -osis refers to an abnormal condition or process

Six Steps for Acid-Base Analysis

Six Steps for Acid-Base Analysis

Step 1. Is there an acidemia or alkalemia?

Six Steps for Acid-Base Analysis

Step 2. Is the primary process metabolic or respiratory?

Six Steps for Acid-Base Analysis

Step 3: If the primary process is respiratory, is it acute or chronic?

Six Steps for Acid-Base Analysis

Step 4:

Is there an anion gap?

Na+ - Cl- - HCO3- > 12?

Six Steps for Acid-Base Analysis

Step 5: Is the respiratory compensation adequate?

Expected pCO2 range = -)]+8+/- 2 [1.5(measured HCO3

Six Steps for Acid-Base Analysis

Step 6: Are there any other metabolic disturbances?

Corrected HCO3- = -) + (AG-12) (Measured HCO3

Problem #1
60 yo male presents to the ED from a nursing home. You have no history other than he has been breathing rapidly and is less responsive than usual. Na+ 123 pH 7.31 Cl- 99 HCO3- 5 pCO2 10

Six Steps for Acid-Base Analysis

Step 1. Is there an acidemia or alkalemia?

Acidemia

Six Steps for Acid-Base Analysis

Step 2. Is the primary process metabolic or respiratory?

pCO2 = 10 should drive pH HCO3- = 5 should drive pH

Six Steps for Acid-Base Analysis

Step 3: If the primary process is respiratory, is it acute or chronic? Skip this step as primary process is metabolic!

Six Steps for Acid-Base Analysis

Step 4:

Is there an anion gap? + - Cl- - HCO - > 12? Na 3 123 - 99 - 5 = 19

Anion Gap Metabolic Acidosis

Causes of anion gap metabolic acidosis

Methanol Uremia Diabetic ketoacidosis Paraldehyde Isopropyl alcohol Lactic acidosis Ethylene glycol Salicylates Rhabdomyolysis

Six Steps for Acid-Base Analysis

Step 5: Is the respiratory compensation adequate? Expected pCO2 range = [1.5(measured HCO3-)]+8+/- 2
[1.5 (5) +8] +/- 2 = [13.5 17.5] pCO2 = 10, therefore it IS a respiratory alkalosis

Six Steps for Acid-Base Analysis

Step 6: Are there any other metabolic disturbances? Corrected HCO3- = (Measured HCO3-) + (AG-12)
(5) + (19-12) = 12 Since this does not correct bicarbonate back to normal, there is a non anion gap acidosis

Causes of non anion gap acidosis with hypokalemia

Diarrhea Carbonic anydrase inhibitor Ureteral diversion Acetazolamide Renal tubular acidosis
Proximal Distal Mefenamic acid

Mineralcorticoid deficiency

Post hypocapneic state

Causes of non anion gap acidosis with hyperkalemia

Early renal failure Renal disease
SLE interstitial nephritis Amyloidosis Hydronephrosis Sickle cell nephropathy

Acidifying agents
Ammonium chloride Calcium chloride Arginine

Sulfur toxicity

Problem #2
42 yo female has the flu for four days with incessant vomiting. She presents to the ED two days after stopping insulin due to no food intake Na+ 130 pH 7.21 Cl- 80 HCO3- 10 pCO2 25

Six Steps for Acid-Base Analysis

Step 1. Is there an acidemia or alkalemia?

Acidemia

Six Steps for Acid-Base Analysis

Step 2. Is the primary process metabolic or respiratory?

pCO2 = 25 should drive pH HCO3- = 10 should drive pH

Six Steps for Acid-Base Analysis

Step 3: If the primary process is respiratory, is it acute or chronic? Skip this step as primary process is metabolic!

Six Steps for Acid-Base Analysis

Step 4:

Is there an anion gap? + - Cl- - HCO - > 12? Na 3 130 - 80 - 10 = 40!!

Anion Gap Metabolic Acidosis

Six Steps for Acid-Base Analysis

Step 5: Is the respiratory compensation adequate? Expected pCO2 range = [1.5(measured HCO3-)]+8+/- 2
[1.5 (10) +8] +/- 2 = [21 - 25] pCO2 = 25, therefore this is normal respiratory compensation

Six Steps for Acid-Base Analysis

Step 6: Are there any other metabolic disturbances? Corrected HCO3- = (Measured HCO3-) + (AG-12)
(10) + (40-12) = 38 Since this over corrects bicarbonate there is a metabolic ALKALOSIS!!

Problem #3
30 year old female BMT patient with neutropenic fever has been receiving multiple antibiotics including amphotericin B. You are called to the bedside for her fevers, rigors, and dyspnea Na+ 125 pH 7.07 Cl- 100 HCO3- 8 pCO2 28 K+ 2.5

Six Steps for Acid-Base Analysis

Step 1. Is there an acidemia or alkalemia?

Acidemia

Six Steps for Acid-Base Analysis

Step 2. Is the primary process metabolic or respiratory?

pCO2 = 28 should drive pH HCO3- = 8 should drive pH

Six Steps for Acid-Base Analysis

Step 3: If the primary process is respiratory, is it acute or chronic? Skip this step as primary process is metabolic!

Six Steps for Acid-Base Analysis

Step 4:

Is there an anion gap? + - Cl- - HCO - > 12? Na 3 125 - 100 - 8 = 17

Anion Gap Metabolic Acidosis

Six Steps for Acid-Base Analysis

Step 5: Is the respiratory compensation adequate? Expected pCO2 range = [1.5(measured HCO3-)]+8+/- 2
[1.5 (8) +8] +/- 2 = [18-22] pCO2 = 28, therefore this is a respiratory acidosis even though the value is below 40!!

Six Steps for Acid-Base Analysis

Step 6: Are there any other metabolic disturbances? Corrected HCO3- = (Measured HCO3-) + (AG-12)
(8) + (17-12) = 13 Since this is below the normal range after correction, there is a non anion gap acidosis

If data doesnt make sense, check the validity of your data!

24 (pCO2)/(HCO3-) = [H+] 80 [H+] = xx

xx should equal the last two digits of the pH. 7.xx

brow2110@umn.edu