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ACIDOSIS & ALKALOSIS

ABG INTERPRETATION
Tarek Abdel-Gawad MD AbdelHead of PICU Children Hospital Ain Shams University .

 Acidosis

presence of a process which tends to lower pH by virtue of gain of H+ or loss of HCO3 presence of a process which tends to raise pH by virtue of loss of H+ or addition of HCO3HCO3-

 Alkalosis

 Respiratory

processes which lead to acidosis or alkalosis through a primary alteration in ventilation and resultant excessive elimination or retention of CO2

 Metabolic

processes which lead to acidosis or alkalosis through their effects on the kidneys and the consequent disruption of H+ and HCO3HCO3- control

Acid Base Balance


 

pH is maintained within a narrow range to preserve normal cell function Buffers minimize the change in pH resulting from production of acid provides immediate protection from acid The primary buffer system is HCO3HCO3HCO3HCO3- + H+ H2CO3 H2O + CO2

 Simple

acidacid-base disorder a single primary process of acidosis or alkalosis acidacid-base disorder presence of more than one acid base disorder simultaneously

 Mixed

Compensation the normal response of the respiratory system or kidneys to change in pH induced by a primary acid-base disorder acid 

Kidneys slow, lungs fast No overcompensation ( except occasionally primary resp. alkalosis) Lack of compensation (or over) determines a second primary disorder The degree of appropriate compensation is predictable

Role of the kidney  To retain and regenerate HCO3- thereby HCO3regenerating the buffer with the net effect of eliminating the acid  H+ secretion  HCO3- reabsorption HCO3Role of the respiratory system eliminate CO2

Characteristics of the simple acid-base aciddisturbances


Disorder Metabolic acidosis Metabolic alkalosis Respiratory acidosis Respiratory alkalosis Primary pH
q o

Primary
q [HCO3-] [HCO3o [HCO3-] [HCO3o Pco2 q Pco2

Compensated response
q Pco2 o Pco2 o [HCO3-] [HCO3q [HCO3-] [HCO3-

q o

pH

PCO2

HCO3

Interpretation

Alk Acidotic Acid Acid

Respiratory Acidosis Combined respiratory and metabolic Acidosis

Alkalotic

Acid

Metabolic Acidosis

Acidotic

Alk

Metabolic Alkalosis

Alkali Alkalotic

Acid

Respiratory Alkalosis Combined respiratory and metabolic Alkalosis

Alk

STEPWISE APPROACH
   

Determine primary disorder Check the compensatory response Calculate the anion gap Identify specific etiologies for the acid-base aciddisorder Prescribe treatment

DETERMINE THE PRIMARY DISORDER

 pH

= 7.35 7.45 = 35 45 mmHg lungs = 22 26 mmol/L kidneys

 pCO2
(Reference Value = 40)

 HCO3
(Reference value = 24)

DETERMINE PRIMARY DISORDER


 

Check the trend of the pH, HCO3, pCO2 The change that produces the pH is the primary disorder

pH = 7.25 ACIDOSIS

HCO3 = 12 ACIDOSIS

pCO2 = 30 ALKALOSIS

METABOLIC ACIDOSIS

DETERMINE PRIMARY DISORDER


 

Check the trend of the pH, HCO3, pCO2 The change that produces the pH is the primary disorder

pH = 7.25 ACIDOSIS

HCO3 = 28 ALKALOSIS

pCO2 = 60 ACIDOSIS

RESPIRATORY ACIDOSIS

DETERMINE PRIMARY DISORDER


 

Check the trend of the pH, HCO3, pCO2 The change that produces the pH is the primary disorder

pH = 7.55 ALKALOSIS

HCO3 = 19 ACIDOSIS

pCO2 = 20 ALKALOSIS

RESPIRATORY ALKALOSIS

DETERMINE PRIMARY DISORDER




If the trend is the same, check the percent difference The bigger % difference is the 10 disorder (16-24)/24 = 0.33 (60-40)/40 = 0.5 pH = 7.25 HCO3 = 16 ACIDOSIS pCO2 = 60 ACIDOSIS

ACIDOSIS

RESPIRATORY ACIDOSIS

DETERMINE PRIMARY DISORDER




If the trend is the same, check the percent difference The bigger %difference is the 10 disorder (38-24)/24 = 0.58 (30-40)/40 = 0.25 pH = 7.55 HCO3 = 38 ALKALOSIS pCO2 = 30 ALKALOSIS

ALKALOSIS

METABOLIC ALKALOSIS

CHECK THE COMPENSATORY RESPONSE

COMPENSATORY RESPONSE
HENDERSEN-HASSELBACH EQUATION HENDERSEN24 x pCO2 H = ---------------HCO3 Metabolic or Respiratory Acidosis

COMPENSATORY RESPONSE
HENDERSEN-HASSELBACH EQUATION HENDERSEN24 x pCO2 H = ---------------HCO3 Metabolic or Respiratory Alkalosis

PREDICTION OF COMPENSATORY RESPONSES ON SIMPLE ACID BASE DISORDERS


Metabolic Acidosis Metabolic Alkalosis PaCO2 = (1.5 X HCO3) + 8 2 PaCO2 will increase 0.75 mmHg per 1 meq/L increase in HCO3 (0.7 x HCO3) + 20 1.5

Respiratory Acidosis Acute Chronic

HCO3 will increase 1 meq/L per 10 mmHg increase in PaCO2 ( pH by 0.08/10 mm Hg PaCO2) HCO3 will increase 4 meq/L per 10 mmHg increase in PaCO2 ( pH by 0.03/10 mm Hg PaCO2) HCO3 will decrease 2 meq/L per 10 mmHg decrease in PaCO2 HCO3 will decrease 4 meq/L per 10 mmHg decrease in PaCO2

Respiratory Alkalosis Acute Chronic

COMPENSATORY RESPONSE
METABOLIC ACIDOSIS
PaCO2 = (1.5 X HCO3) + 8 2

HCO3 =12 HCO3 =7

PaCO2 =1.5 X 12 + 8 = 26 2 PaCO2 = 1.5 X 7 + 8 = 18.5 2

COMPENSATORY RESPONSE
METABOLIC ALKALOSIS
PaCO2 will increase 0.75 mmHg per 1meq increase in HCO3 meq/L

HCO3 = 35 HCO3 = 40

pCO2 =11 X 0.75 = 8.25 = 8.25 + 40 = 48.25 pCO2 = 16 x 0.75 = 12 = 12 + 40 = 52

COMPENSATORY RESPONSE
ACUTE RESPIRATORY ACIDOSIS HCO3 will increase 1 meq per 10 mmHg meq/L increase in PaCO2 pCO2 = 55 pCO2 =80 HCO3 = 55-40/10= 1.5 1.5 + 24 = 25.5 HCO3 = 80-40/10= 4 4+24 = 28

COMPENSATORY RESPONSE
CHRONIC RESPIRATORY ACIDOSIS
HCO3 will increase 4 meq per 10 mmHg meq/L increase in PaCO2

pCO3 = 55

HCO3 = 55-40/10 x 4 = 1.5 x 4 = 6 6 + 24 = 30

COMPENSATORY RESPONSE
CHRONIC RESPIRATORY ACIDOSIS
HCO3 will increase 4 meq per 10 mmHg meq/L increase in PaCO2

pCO3 = 80

HCO3 = 80-40/10 x 4 = 16 + 24 = 40

COMPENSATORY RESPONSE
RESPIRATORY ALKALOSIS
Acute: HCO3 will decrease 2 meq per 10 mmHg meq/L decrease in PaCO2 Chronic: HCO3 will decrease 4meq meql/L per 10 mmHg decrease in PaCO2

CALCULATE THE ANION GAP

ANION GAP
Na (HCO3 + Cl) = 10-12 mmol/L 10-

Na = 135 Cl = 97

HCO3 = 15 RBS = 100 mg%

Anion Gap = 135 (15 + 97) =135 -112 = 23

ANION GAP
Na (HCO3 + Cl) = 10-12 10Na = 135 Cl = 97 HCO3 = 15 RBS = 500 mg%

Corrected Na = Na + RBS mg% -100 x 1.4 100 Anion Gap = 135 + 5.6 112 = 28.6

CHECK THE DELTA / DELTA

DELTA - DELTA


If with high AG metabolic acidosis 12 AG c HCO3 If normal AG metabolic acidosis 12 Cl cHCO3

A high AG always indicates the presence of a HAG metabolic acidosis

DELTA - DELTA
c/c = 1 c/c > 1 c/c < 1 Pure Anion gap metabolic acidosis AG Metabolic Acidosis + metabolic alkalosis AG Metabolic Acidosis + non-AG metabolic acidosis

CASE 1
6 years F with vomiting and diarrhea 3 days ago despite intake of loperamide. Her last urine output was 12 hours ago. PE showed BP = 80/60, HR = 110, RR = 28. There is poor skin turgor.

CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 42 crea = 2.0 RBS = 100 BUN / crea = 21 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90

PRE-RENAL AZOTEMIA

CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 42 crea = 2.0 RBS = 100 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90

cpH = acidosis, c pCO2 =alk, cHCO3 = acidosis

Metabolic Acidosis

CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 42 crea = 2.0 RBS = 100 Expected pCO2 = (15 x 1.5) + 8 2 = 28.5-32.5 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90

Simple Metabolic Acidosis

CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 42 crea = 2.0 RBS = 100 Anion Gap = Na (HCO3+Cl) 130 (15+105) = 10 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90

NAG Metabolic Acidosis

NORMAL ANION GAP METABOLIC ACIDOSIS Diarrhea Renal Tubular Acidosis Interstitial nephritis External pancreatic or small-bowel drainage smallUrinary tract obstruction

CASE 1
serum Na = 130 K = 2.5 Cl = 105 BUN = 15 crea = 177 RBS = 100 c/c= (105-100)/(24-15) = 0.56 pH = 7.30 pCO2 = 30 HCO3 = 15 pO2 = 90

NAGMA + HAGMA

CASE 1
5 years F with vomiting and diarrhea 3 days ago despite intake of loperamide. Her last urine output was 12 hours ago. PE showed BP = 80/60, HR = 110, RR = 28. There is poor skin turgor. pH 7.30, HCO3=15, pCO2=30, Na=130 K=2.5 How will you correct the acid base disorder?

CASE 1
1) 2) 3) 4) Hydrate Hydrate + IV NaHCO3 Hydrate + oral NaHCO3 Hydrate + correct hypokalemia

How will you correct the acid base disorder?

INDICATIONS FOR HCO3 THERAPY


   

pH < 7.2 and HCO3 < 5 10 mmHg When there is inadequate ventilatory compensation Concurrent severe AG and NAGMA Severe acidosis with renal failure or intoxication

COMPLICATIONS OF HCO3 THERAPY


       

Volume overload Hypernatremia NaHCO3 50 ml = 45 mEq Na Hyperosmolarity NaHCO3 gr X tab = 7 mEq Na Hypokalemia Intracellular acidosis Causes overshoot alkalosis Stimulates organic acid production tissue O2 delivery

Approach to Metabolic Acidosis


High Anion Normal Gap Yes
Diarrhea Ileostomy Enteric fistula

Osmolar Gap Normal Uremia Lactate Ketoacids Salicylate Increased Ethylene glycol Methanol

GI Fluid Loss? No Urine pH > 5.5 < 5.5 Serum K Low High Type 4 RTA

Distal RTA (Type 1)

Proximal RTA (Type 2)

POTASSIUM CORRECTION


K deficit = {(4.0 K) X 350} / 3 + 60 350}

K deficit = {(4.0 2.5) X 350} / 3 + 60 = 235 mEq K to replace in 1 day 1 kalium durule = 10 mEq K 1 medium sized banana = 10 mEq K

CASE 2
12 years M with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2 = 40 K=4 HCO3 = 17 Cl = 98

Metabolic Acidosis

CASE 2
12Y with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2= 40 K=4 HCO3 = 17 Cl = 98 Metabolic & Respiratory Acidosis

Expected pCO2 = (17 X 1.5) + 8 2 = 33.5-37.5

CASE 2
12Y with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2= 40 K=4 HCO3 = 17 Cl = 98

Anion Gap = Na (HCO3+Cl) 140 (17+98) = 25

HAGMA + RAc

HIGH ANION GAP METABOLIC ACIDOSIS


 Ketoacidosis

- diabetic, alcoholic, starvation  Lactic acidosis - hypoxia, shock, sepsis, seizures  Toxic ingestion salicylates, methanol, ethylene glycol, ethanol, isopropyl alcohol, paraldehyde, toluene  Renal failure - uremia

CASE 2
12Y with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2= 40 K=4 HCO3 = 17 Cl = 98

c/c= (25-12)/(24-17) = 1.9

HAGMA + MAlk + RAc

CASE 2
12Y with epilepsy has a grand mal seizure. Labs showed: pH = 7.14 Na = 140 pCO2= 40 K=4 HCO3 = 17 Cl = 98

How will you correct the acid base disorder?

CASE 2
1) IV NaHCO3 using HCO3 deficit 2) oral NaHCO3 at 1 mEq/kg/day 3) intubate 4) no treatment

How will you correct the acid base disorder?

CASE 2
HCO3 DEFICIT = (D A) x 0.5 x kg BW HCO3 deficit = (20 17) x 0.5 x 32 = 48

How as you correct the acid base disorder? Give willbolus and the other as drip in 24 hrs

CASE 2
HCO3 DEFICIT = (D A) x 0.5 x kg BW HCO3 deficit = (18 17) x 0.5 x 30 = 16
As HCO3 < 5-10, the Vd increases; hence use 0.7 to 0.1 dHCO3 = 15 - 18 Maintenance 1 mEq/day

How as you correct the acid base disorder? Give willbolus and the other as drip in 24 hrs

PRINCIPLES OF THERAPY
LACTIC ACIDOSIS
   

HCO3

Primary effort should be improving O2 delivery Use NaHCO3 only when HCO3 < 5 mmol/L In states of CO, raising the CO will have more impact on the pH In cases of low alveolar ventilation, ventilation to lower the tissue pCO2

PRINCIPLES OF THERAPY
KETOACIDOSIS
 

HCO3

Rate of H+ production is slow; NaHCO3 tx may just provoke severe hypokalemia Should be given if 1) severe hyperkalemia despite insulin 2) HCO3 < 5 mmol/L 3) worsening acidemia inspite of insulin

CASE 3
14 years F, is surprised to find her K=2.7 mmol/L because she was normokalemic 6 months ago. She admits to being on a diet of fruit and vegetables but denies vomiting and the use of diuretics or laxatives. She is asymptomatic. BP = 90/55 with subtle signs of volume contraction.

CASE 3
serum Na K Cl HCO3 pH pCO2 Plasma 138 2.7 96 30 7.46 45 Urine 63 34 0 0 5.6

cpH = alk, cpCO2 =acidosis cHCO3 = alkalosis

Metabolic Alkalosis

CASE 3
serum Na K Cl HCO3 pH pCO2 Plasma 138 2.7 96 30 7.46 45 Urine 63 34 0 0 5.6 Compensated Metabolic Alkalosis

PaCO2Expected PCO =mmHg will increase 0.75 2 per 1 mmol/L increase in HCO3 6 x 0.75 = 4.5+40 = 44.5 from 24

CASE 3
serum Na K Cl HCO3 pH pCO2 Plasma 138 2.7 96 30 7.46 45 Urine 63 34 0 0 5.6

Anion Gap = Na (HCO3+Cl) 138 (30+96) = 12

NAG

CASE 3
1) diuretic intake 2) surreptitious vomiting 3) Bartters syndrome 4) Adrenal tumo

What is the cause of the acid base disorder?

CASE 3
serum Na K Cl HCO3 pH pCO2 Plasma 138 2.7 96 30 7.46 45 Urine 63 34 0 0 5.6

What is the cause of the acid base disorder?

CASE 3
1) correct hypokalemia 2) hydrate with NSS 3) administer acidyfing agent 4) give carbonic anhydrase inhibitor

How should her acid-base disorder be managed?

METABOLIC ALKALOSIS Vomiting Remote diuretic use Cystic fibrosis Acute alkali administration

METABOLIC ALKALOSIS Bartters syndrome Severe potassium depletion Current diuretic use Hypercalcemia Hyperaldosteronism Cushings syndrome Gastric aspiration

MANAGEMENT OF METABOLIC ALKALOSIS


     

Chloride repletion Potassium repletion Tx hypermineralocorticoidism Dialysis Carbonic anhydrase inhibitors Acidyfing agents HCl, NH4Cl

INDICATIONS OF HCl


pH > 7.55 and HCO3 > 35 with contraindications for NaCl or KCl use Immediate correction of metabolic alkalosis in the presence of hepatic encephalopathy, cardiac arrhythmias, digitalis intoxication When initial response to NaCl, KCl, or acetalozamide is too slow or too little

USE OF HCl
  

HCL requirement = (A D) x 0.5 x kg BW 0.1 0.2 N HCl solution = 100 200 mEq Do not exceed 0.2 mEq/kg/hour of HCl HCl = 1,380 mEq

HCO3 = 70 wt = 60 kg

CASE 4
15 years M with ILD (pCO2 stable at 52-58 52mmHg), cor pulmonale, and peripheral edema had been taking furosemide for 6 months. Five days ago, he had anorexia, malaise, and productive cough. He continued his medications until he developed nausea. Later he was found disoriented and somnolent

CASE 4
PE: BP 110/70, HR 110, RR 24, T=40 respiratory distress prolonged expiratory phase postural drop in BP drowsy, disoriented scattered rhonchi and rales BLFs distant heart sounds trace pitting edema

CASE 4
admission serum Na 136 K 3.2 Cl 78 HCO3 40 pH 7.33 pCO2 78 pO2 43 cpH = acidosis cpCO2 =acidosis, cHCO3 = alk after 48 hrs 139 3.9 86 38 7.42 61 56 Respiratory Acidosis

Respiratory Acidosis & M. Alkalosis

CASE 4

admission serum Na 136 K 3.2 Cl 78 HCO3 40 pH 7.33 pCO2 78 pO2 43


Expected HCO3 = 78-40/10 = 3.8 + 24 = 27.8

after 48 hrs 139 3.9 86 38 7.42 61 56

CASE 4
admission serum Na 136 K 3.2 Cl 78 HCO3 40 pH 7.33 pCO2 78 pO2 43 after 48 hrs 139 3.9 86 38 7.42 61 56

How should this patient be managed?

CASE 4
1) intubation and mechanical ventilation 2) low flow oxygenation by nasal prong 3) oxygen by face mask 4) sodium bicarbonate infusion with KCl

How should this patient be managed?

RESPIRATORY ACIDOSIS CHRONIC: COPD, intracranial tumors ACUTE: pneumonia, head trauma, general anesthetics, sedatives

MANAGEMENT OF RESPIRATORY ACIDOSIS


 

  

Correct underlying cause for hypoventilation effective alveolar ventilation intubate, mechanically ventilate Antagonize sedative drugs Stimulate respiration (e.g. progesterone) Correct metabolic alkalosis

CASE 5
15 years M, brought to the ER intoxicated. He was found at park in a pool of vomitus. PE showed incoherent patient with a markedly contracted ECF volume. T=390 C with crackles on the chest.

CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 34 crea = 1.4 RBS = 15 mmol/L BUN/Crea = 24 pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38

PRE-RENAL

CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 34 crea = 1.4 RBS = 120 mmol/L pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38

Respiratory Alkalosis

Acute respiratory alkalosis: HCO3 will decrease 2 mmol/L per 10 mmHg decrease in PaCO2

CASE 5

serum Na = 130 K = 2.9 Cl = 80 BUN = 12 crea = 120 RBS = 120 mmol/L HCO3 = 40-25/10 x 2= 3 24 - 3 = 21

pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38 Compensated Respiratory Alkalosis

CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 12 crea = 120 RBS = 15 mmol/L Anion Gap = 130 (80 + 20) = 30 pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38 HAGMA + RAlk

CASE 5
serum Na = 130 K = 2.9 Cl = 80 BUN = 12 crea = 120 RBS = 15 mmol/L pH = 7.53 pCO2 = 25 HCO3 = 20 pO2 = 60 alb = 38

What are the causes of his acid base disturbance?

CASE 5

1) aspiration pneumonia 2) ketoacidosis 3) vomiting

What are the causes of his acid base disturbance?

RESPIRATORY ALKALOSIS Hyperventilation, Liver failure, Methylxanthines

MANAGEMENT OF RESPIRATORY ALKALOSIS


  

Correct underlying cause of hyperventilation Rebreathe carbon dioxide Mechanical control of ventilation increase dead space decrease back up rate decrease tidal volume paralyze respiratory muscles

QUESTIONS?

Thank You