Acid-Base Rules Summary 21/7/10 1. pH acidaemia or alkalaemia - net deviation from normal indicates presence of an acidosis or alkalosis 2.

2. Assess the pattern - each of the simple disorders produce predictable changes in either PCO2 or HCO3 3. Look for associated clues ! certain conditions produce certain changes in biochemistr" . Assess for compensation response HCO3 #ill change for a 10mmHg change in PaCO2 (espirator" $cidosis (espirator" $lkalosis $C%&' 1 + 2 + CH(O)*C , -

.etabolic $cidosis the /10- 1 2 (ule3 + e4pected PaCO2 at ma4 compensation 5 10- 4 HCO3 1 2 .etabolic $lkalosis 7HCO38 1 20 the /Point 6even plus &#ent" (ule3 + e4pected pCO2 5 007

!. "ther #ndices in the Assessment of a $eta%olic Acidosis 9actate $nion :ap ;elta ratio Osmolar :ap %rinar" anion :ap 6te#art e<uation When to calculate what: ($:.$ ! look for lactate= calculate ;elta ratio= 6te#art '<uation )$:.$ ! calculate %rinar" anion gap= 6te#ard '<uation Osmolarit" ! calculate Osmolar gap Lactate C$%6'6 >Cohen ? @oods classificationA Type A - Inadequate Oxygen Delivery >iA anaerobic muscular activit" >sprinting= generalised convulsionsA >iiA tissue h"poperfusion >shock= cardiac arrest= regional h"poperfusion + mesenteric ischaemiaA

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>iiiA reduced tissue o4"gen deliver" >h"po4aemia= anaemiaA or utilisation >CO poisoningA Type B - No Evidence o Inadequate Ti!!ue Oxygen Delivery B1C associated #ith underl"ing diseases 9%D'C leukaemia= l"mphoma &*P6C thiamine deficienc"= infection= pancreatitis= short bo#el s"ndrome E$*9%('6C hepatic= renal= diabetic failures B2C associated #ith drugs ? to4ins phenformin c"anide beta agonists methanol adrenaline salic"lates nitroprusside infusion ethanol into4ication in chronic alcoholics anti retroviral drugs paracetamol salbutamol biguanides fructose sorbitol 4"litol isoniaFid B3C associated #ith inborn errors of metabolism congenital forms of lactic acidosis #ith various enF"me defects >eg p"ruvate deh"drogenase deficienc"A

Anion +ap 5 >)a1 1 D1A ! >Cl 1 HCO3 A normal 12 to 1G the normal anion gap depends on serum phosphate and serum albumin the normal $: 5 002 4 7albumin8 >g/9A 1 10- 4 7phosphate8 >mmol/9A "au!e! o an Anion #ap $eta%olic Acido!i! & accu'ulation o organic acid! or i'paired () excretion >9&D(A 9actate &o4ins ! methanol= metformin= penformin= paraldeh"de= prop"lene gl"col= p"roglutamic acidosis= acid= Ee= isoniaFid= ethanol= eth"lene gl"col= salic"lates= solvent Detones (enal Eailure

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Expanded "au!e! *$+D,I-E./ .ethanol %raemia ;D$ Phenformin= Paracetamol= P"roglutamic metabolic acidosis= Paraldeh"de *ron= isoniaFid 9actate 'th"lene gl"col= ethanol 6alic"lates= solves "au!e! o a Non-anion #ap $eta%olic Acido!i! & lo!! o ("O0- ro' E"1 >C$:'A Chloride $cetaFolamide/$ddisons :* loss >diarrhoea= vomiting= enterostomies= fistulae= ileostomiesA '4traC (&$ t"pe 1 Expanded "au!e! *(A2D+,/ H"perchloraemia $cetaFolamide= $ddison3s disease (enal tubular acidosis ;iarrhoea= vomiting= ileostomies= fistulae %reteroenterostomies Pancreatoenterostomies "au!e! o a -ow Anion #ap ;ecrease in unmeasured anions >albumin= dilutionA *ncrease in unmeasured cations >multi m"eloma= h"percalcaemia= h"permagnesaemia= lithium O;= bromide O;= pol"mi4in BA )on random anal"tical errors >increased )a1= increased viscosit"= iodide ingestion= increased lipidsA ,elta Ratio 5 the increase in $nion :ap/the decrease in HCO3 indicates #hat has happen to the denominator >HCO3 A used in ($:.$ to see #hether change in HCO3 is appropriate >ie0 #hether there is a ($:.$ component to disorderA normal value 5 1 to 10if normal there is onl" one patholog" >uncomplicated ($:.$A Interpretation - ). h"perchloraemic normal anion gap acidosis ). - ).. consider combined high $: ? normal $: acidosis B%& note that the ratio is often H 1 in acidosis associated #ith renal failure 1 2 usual for uncomplicated high $: acidosis >lactic acidosisC average value 10G= ;D$C around 1A

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/ 2 a high delta ratio + an elevated bicarbonate at onset of the metabolic acidosis + pre e4isting metabolic alkalosis or compensated respirator" acidosis0 "smolar +ap the osmolalit" is measured in lab calculated osmolarit" 5 >2 4 7)a18A 1 7glucose8 1 7urea8 the osmolar gap 5 Osmolalit" Osmolarit" an osmolar gap + 10 mOsm/l is often stated to be abnormal0 .igni icance indirect evidence for the presence of an abnormal solute #hich is present in significant amounts0 ethanol= methanol ? eth"lene gl"col + #ill cause an elevated osmolar gap0 7)BC &o convert ethanol levels in mg/dl to mmol/l divide b" ,0G0 Eor e4ample= an ethanol level of 000-I is -0mg/dl0 ;ivide b" ,0G gives 100Jmmols/l8 "au!e! o 2ai!ed O!'olar #ap *$E,$E-3/ .ethanol/mannitol 'thanol P ! isoprop"l alcohol .eth"lene gl"col 'th"lene gl"col 9actate Detones "au!e! o a Nor'al O!'olar #ap $eta%olic Acido!i! P"roglutamic acid 6alic"clates

0rinary Anion +ap the cations normall" present in urine are )a1= D1= )H,1= Ca11 and .g110 the anions normall" present are Cl = HCO3 = sulphate= phosphate and some organic anions0 onl" )a1= D1 and Cl are commonl" measured in urine so the other charged species are the unmeasured anions >%$A and cations >%CA0 %rinar" $nion :ap 5 7)a181 7D18 7Cl 8 "linical +!e the urinar" anion gap can help to differentiate bet#een :*& and renal causes of a h"perchloraemic metabolic acidosis0 h"perchloraemic acidosis can be caused b"C >iA loss of base via the kidne" >eg renal tubular acidosisA >iiA loss of base via the bo#el >eg diarrhoeaA= or >iiiA gain of mineral acid >eg HCl infusionA0

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if the acidosis is due to loss of base via the bo#el then the kidne"s can respond appropriatel" b" increasing ammonium e4cretion to cause a net loss of H1 from the bod" + the %$: #ould tend to be decreased + increased )H,1 >#ith presumabl" increased Cl A + increased %C + decreased %$:0 if the acidosis is due to loss of base via the kidne" + it is not able to increase ammonium e4cretion and the %$: #ill not increase0 Ste1art 23uation pH is dependent on other ions in solution not Kust H1 and HCO3 there are dependent and independent variables Dependent: H1 OH HCO3 CO32 H$ >#eak acidsA $ >#eak basesA Independent: PaCO2 $&O& >total of #eak non volatile acidsA 6*; .trong Ion Di erence a strong ion 5 an ion that totall" dissociates at a given pH 6*; 5 strong cations ! strong anions 6*; 5 >)a1 1 D1 1 Ca21 1.g21A ! >Cl other anionsA

.odified 6*; 5 >)a1 D1A ! Cl 6*; + 0 5 alkalosis 6*; H 0 5 acidosis normal 6*; of plasma 5 ,0m'</9 >slightl" alkalaemicA an" movement from this is roughl" e<ual to the standard base e4cess .i'ple .ID calculator '4pected B' 5 >)a1 Cl A ! 32

if e4pected B' H observed B' + there is a mi4ed ($:.$ 1 )$:.$

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