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METABOLICACIDOSIS
III-D2 Rodriguez, Jan Gayl – Sahagun, Marie Janice
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SALIENT FEATURES
OBJECTIVE SUBJECTIVE
• 45 Y/O FEMALE
• HIGH GRADE FEVER (39oC)• CHILLS
• MYALGIA
• DIARRHEA
• BP : 84/52• PR : 118 BEATS PER MINUTE
• RR : 42 CYCLES PER MINUTE, LABORED
• DIABETES MELLITUS
• NO MEDICATIONS/ ALCOHOL
• DRY MUCOUS MEMBRANES
• FLAT NECK VEINS
• NO EDEMA
• FIRM, MILDLY TENDER, DISTENDED ABDOMEN
• HYPERACTIVE BOWEL SOUNDS
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SALIENT FEATURES
OBJECTIVE(LAB DATA)
ACTUAL NORMAL
Hemoglobin 15.5 g/dL 12-16 g/dL
Hematocrit 48 % 37-48%
WBC count 22.8x103 4.5-11 x103
Segmenters 66 % 50-70% Bands 23 % 0-5%
Serum Na 138 meq/L
135-145 mEq/L
Serum K 4.2 meq/L
3.5-5.0 mEq/L
Serum Cl 108 meq/L
95-108 meq/L
ACTUAL NORMAL
SerumCreatinine
2.4 mg/dl 0.35-0.9 mg/dl
Lactate 3.0 meq/L 0.5-1.3 mEq/L
pH 7.39 7.34-7.44
pCO2
17.0 mmHg
35-45 mmHg
Glucose 342.0 mg/dL
65-110 mg/dL
Ketones None None
BUN 28.0 mg/dL
7-21 mg/dL
HCO3
10.0 meq/L
22-26 mEq/L
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WHAT IS THE ACID BASE DISTURBANCE PRESENT IN THIS
CASE?
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Respiratory acidosis
Respiratory alkalosis
Metabolic alkalosis
Metabolic acidosis
Patient Normal values
pH 7.38 – 7.44
H+ 40 meq/L
pCO2 35 – 45 mmHg
HCO3 21 – 30 meq/L
METABOLIC ACIDOSIS
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METABOLIC ACIDOSIS
• Infection Increased plasma lactate: 3.0 meq/L
• Severe diarrhea Decreased serum bicarbonate: 10 meq/L
• Increased serum chloride: 108 meq/L• Kussmaul respiration• Decreased PCO2 : 17 mmHg (compensated)• Normal blood pH: 7.39 (compensated)
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ALGORITHM FOR THE DIAGNOSIS OF THE ACID BASE
DISORDER
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1. Establish database
2. Identify the main disorder:
3. Evaluate compensation (using the formulas)
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4. Determine the anion gap (AG, normal = 12).
* If the AG is >20 = metabolic acidosis
* If there is an AG,
Calculate the gap-gap (delta-gap) = patient’s anion gap – 12 (normal anion gap).
Calculate the delta HCO3 = normal HCO3 (use 25) – the patient's HCO3.
delta-gap ÷ delta HCO3 should normally be between 1-2
If < 1 = combined non-gap and gap acidosis
If > 2 suggests = metabolic alkalosis.
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RULE OF THUMB IN BEDSIDE INTERPRETATION OF ACID BASE
DISORDER
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Metabolic acidosis
• PaCO2 should fall by 1.0 to 1.5 X the fall in
plasma HCO3- concentration
• pCO2 should rarely be < 20 mmHg.
• Bicarbonate deficit (mEq/L) = [0.5 x BW(kg)] x (24 - HCO3)
Metabolic alkalosis • PsCO2 should rise by 0.25 to 1.0 X the rise in
plasma HCO3- concentration
RULE OF THUMB
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Acute respiratory acidosis • Plasma HCO3
- concentration should rise by about
1 mmole per liter for each 10 mm Hg increment in PaCO2 ( 3 mmoles per liter).
• Acute change pH/pCO2 = 0.008
Chronic respiratory acidosis • Plasma HCO3
- concentration should rise by about 4
mmoles per liter for each 10 mm Hg increment in PaCO2 ( 4 mmoles per liter).
• Chronic change pH/pCO2 = 0.003
RULE OF THUMB
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Acute respiratory alkalosis • Plasma HCO3
- concentration should fall by about
1 to 3 mmoles per liter for each 10 mm Hg decrement in the PaCO2, usually not to less than
18 mmoles per liter
• Acute change pH/pCO2 = 0.008
Chronic respiratory alkalosis • Plasma HCO3
- concentration should fall by about 2
to 5 mmoles per liter per 10 mm Hg decrement in PaCO2 but usually not to less than 14 mmoles per
liter.
• Chronic change pH/pCO2 = 0.003
RULE OF THUMB
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HOW DO YOU COMPUTE FOR THE
ANION GAP?
WHAT IS ITS SIGNIFICANCE?
COMPUTE FOR THE ANION GAP OF
THIS PATIENT
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ANION GAP COMPUTATION
• Anion Gap
represents the difference between the concentration of the major plasma cation (Na+) and the major plasma anions (Cl- and HCO3
-)
• Formula
AG = [Na+] – ([Cl-] + [HCO3-])
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SIGNIFICANCE OF AG• Nonvolatile acid added to body fluids ↑ [H+], ↓ pH, ↓
[HCO3-] ↑ Anion Concentration
• Change in Anion- provides convenient way to analyze and help
determine the cause of metabolic acidosis• NV 10-12 mmol/L• Normal AG
- Anion of nonvolatile acid Cl-
• High AG- Anion of nonvolatile acid Lactate, β-
hydroxybutyrate
Calculation of AG is a useful way to identify thecause of a metabolic acidosis
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AG COMPUTATION (Case)
AG = [Na+] – ([Cl-] + [HCO3-])
= [138] – ([108) + [10])
= 20 meq/L (High AG)
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ANION GAP
Normal Anion Gap
• Loss of bicarbonate
• Addition of HCl
• Renal Tubular Dysfunction
High Anion Gap
• Overproduction of organic acids
• Failure of the kidneys to maintain bicarbonate levels
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Normal Anion Gap
• Diarrhea
• Renal Tubular Acidosis
• Carbonic Anhydrase Inhibition
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High Anion Gap
• Lactic Acidosis
• Ketoacidosis
• Drug and Toxin Induced
• Advanced Renal Failure
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Prediction of Compensatory Responses on Simple Acid Base Disturbances
• Acid-Base Nomogram– Shaded areas show 95% confidence limits for
normal compensation – Finding acid-base values within the shaded
areas does not rule out a mixed disturbance– Not a substitute for computation
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Prediction of Compensatory Responses on Simple Acid Base Disturbances
• Acid-Base Nomogram– pH 7.39
– HCO3 10 mEq/L
– PCO2 17 mmHg
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TREATMENT
• Antibiotic
• IVF/Vasopressors
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