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==Metabolic Acidosis== | ==Metabolic Acidosis== | ||
{| class="wikitable" | {| class="wikitable" | ||
! rowspan=" | ! rowspan="4" |Category | ||
! colspan="2" rowspan=" | ! colspan="2" rowspan="4" |Disease | ||
! colspan="3" |Mechanism | ! colspan="3" rowspan="3" |Mechanism | ||
! | ! colspan="6" |Clinical | ||
! | ! colspan="9" |Paraclinical | ||
! | ! rowspan="4" |Gold standard diagnosis | ||
! | ! rowspan="4" |Other findings | ||
! | |- | ||
! | ! colspan="3" rowspan="2" |Symptoms | ||
! | ! colspan="3" rowspan="2" |Signs | ||
! | ! colspan="7" |Lab data | ||
! | ! colspan="2" rowspan="2" |Imaging | ||
! | |- | ||
! colspan="2" |ABG | |||
!U/A | |||
! colspan="3" |Electrolytes | |||
! rowspan="2" |Renin | |||
|- | |- | ||
!↑ acid <br>production | !↑ acid <br>production | ||
!Loss of <br>bicarbonate | !Loss of <br>bicarbonate | ||
!↓ renal acid <br>excretion | !↓ renal acid <br>excretion | ||
!Fever | |||
!Dyspnea | |||
!Edema | |||
!Toxic/ill | |||
!BP | |||
!Dehydration | |||
!pH | !pH | ||
!Serum AG | !Serum AG | ||
!Urine AG | !Urine AG | ||
! | !Cl<sup>-</sup> | ||
! | !K<sup>+</sup> | ||
!Na<sup>+</sup> | |||
!US | |||
! | !CT scan | ||
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! rowspan="11" |Toxin/Medication | ! rowspan="11" |Toxin/Medication | ||
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|Paraldehyde | |Paraldehyde | ||
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|Nl or ↑ | |Nl or ↑ | ||
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|Salicylates | |Salicylates | ||
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|Metformin | |Metformin | ||
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|↑ | |↑ | ||
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|Isoniazid | |Isoniazid | ||
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|↓ | |↓ | ||
|Nl | |Nl | ||
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|Ammonium chloride | |Ammonium chloride | ||
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|Nl | |Nl | ||
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|Amphotericin B | |Amphotericin B | ||
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|↓ | |↓ | ||
|Nl | |Nl | ||
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|Cholestyramine | |Cholestyramine | ||
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| rowspan="2" |Systemic | | rowspan="2" |Systemic | ||
|Infection | |Infection | ||
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|Ischemia | |Ischemia | ||
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|↑ | |↑ | ||
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| rowspan="6" |Renal | | rowspan="6" |Renal | ||
|Uremia | |Uremia | ||
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|Hyperalimentation | |Hyperalimentation | ||
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|Endocrine | |Endocrine | ||
|Addison's disease | |Addison's disease | ||
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|Post hypocapnea | |Post hypocapnea | ||
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!Category | !Category | ||
!Disease | !Disease | ||
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!Serum AG | !Serum AG | ||
!Urine AG | !Urine AG | ||
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!Volume depletion | !Volume depletion | ||
!HTN | !HTN | ||
! | ! | ||
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Revision as of 14:46, 10 May 2018
Acid Base Disorders
Blood Gas Analysis
Blood gas analysis | Vessel | Range | Interpretation |
---|---|---|---|
Oxygen Partial Pressure (pO2) | Arterial | 80 to 100 mmHg | Normal |
<80 mmHg | Hypoxia | ||
Venous | 35 to 40 mmHg | Normal | |
Oxygen Saturation (SO2) | Arterial | >95% | Normal |
<95% | Hypoxia | ||
Venous | 70 to 75% | Normal | |
pH | Arterial | <7.35 | Acidemia |
7.35 to 7.45 | Normal | ||
>7.45 | Alkalemia | ||
Venous | 7.26 to 7.46 | Normal | |
Carbon Dioxide Partial Pressure (pCO2) | Arterial | <35 mmHg | Low |
35 to 45 mmHg | Normal | ||
>45 mmHg | High | ||
Venous | 40 to 45 mmHg | Normal | |
Bicarbonate (HCO3−) | Arterial | <22 mmol/L | Low |
22 to 26 mmol/L | Normal | ||
>26 mmol/L | High | ||
Venous | 19 to 28 mmol/L | Normal | |
Base Excess (BE) | Arterial | <−3.4 | Acidemia |
−3.4 to +2.3 mmol/L | Normal | ||
>2.3 | Alkalemia | ||
Venous | −2 to −5 mmol/L | Normal | |
Osmolar gap
(Osmolality – Osmolarity) |
>10 | Abnormal | |
Anion gap
[Na+] – {[Cl−]+[HCO3−]} |
<8 | Low | |
8 to 16 | Normal | ||
>16 | High |
Compensation
Primary disorder | pH | PaCO2 | [HCO3-] | Compensation | Compensation formula |
---|---|---|---|---|---|
Metabolic acidosis | ↓ | ↓ | ↓ | Respiratory |
|
Metabolic alkalosis | ↑ | ↑ | ↑ | Respiratory |
|
Respiratory acidosis | ↓ | ↑ | ↑ | Renal | |
Respiratory alkalosis | ↑ | ↓ | ↓ | Renal |
Approach to acid–base disorders
Check pH on ABG | |||||||||||||||||||||||||||||||||||||||||
pH < 7.35= Acidosis | pH > 7.45= Alkalosis | ||||||||||||||||||||||||||||||||||||||||
Check PaCO2 | |||||||||||||||||||||||||||||||||||||||||
PaCO2 > 45mm Hg = Respiratory acidosis | PaCO2 Normal or < 35mm Hg = Metabolic acidosis | Check PaCO2 | |||||||||||||||||||||||||||||||||||||||
PaCO2 > 45mm Hg = Metabolic alkalosis | PaCO2 < 35mm Hg = Respiratory alkalosis | ||||||||||||||||||||||||||||||||||||||||
[HCO3-] > 29 | Check [HCO3-] | ||||||||||||||||||||||||||||||||||||||||
Normal or slight decrease = Acute respiratory alkalosis | Decreased < 24 = Chronic respiratory alkalosis | ||||||||||||||||||||||||||||||||||||||||
Management of Acidosis
pH < 7.35 | |||||||||||||||||||||||||||||||||||||||||||||||||||
Acidosis | |||||||||||||||||||||||||||||||||||||||||||||||||||
Determine the primary disorder Metabolic or respiratory? | |||||||||||||||||||||||||||||||||||||||||||||||||||
Check [HCO3-] and PaCO2 | |||||||||||||||||||||||||||||||||||||||||||||||||||
Low [HCO3-] and Low to normal PaCO2 | High PaCO2 and High to normal [HCO3-] | ||||||||||||||||||||||||||||||||||||||||||||||||||
Metabolic acidosis | Respiratory acidosis | ||||||||||||||||||||||||||||||||||||||||||||||||||
Check for respiratory compensation Calculate expected PCO2 | Check for renal compensation Calculate expected [HCO3-] | ||||||||||||||||||||||||||||||||||||||||||||||||||
Decrease in PaCO2=1.25 x (24- measured HCO3-)? | Acute acidosis? Increase [HCO3-]=0.1 x (measure PaCO2-40)? | Chronic acidosis? Increase [HCO3-]=0.1 x (measure PaCO2-40)? | |||||||||||||||||||||||||||||||||||||||||||||||||
PaCO2 too low? Mixed metabolic acidosis with respiratory alkalosis | PaCO2 too high? Mixed metabolic acidosis with respiratory acidosis | [HCO3-] too low? Mixed respiratory acidosis with metabolic acidosis | [HCO3-] too high? Mixed respiratory acidosis with metabolic alkalosis | [HCO3-] too low? Mixed respiratory acidosis with metabolic acidosis | E04=[HCO3-] too high? Mixed respiratory acidosis with metabolic alkalosis | ||||||||||||||||||||||||||||||||||||||||||||||
Measured PaCO2 is equal to expected value? Compensated metabolic acidosis | Measured [HCO3-] is equal to expected value? Compensated respiratory acidosis | Measured [HCO3-] is equal to expected value? Compensated respiratory acidosis | |||||||||||||||||||||||||||||||||||||||||||||||||
Click here for the management of metabolic acidosis | Click here for the management of respiratory acidosis | ||||||||||||||||||||||||||||||||||||||||||||||||||
Metabolic Acidosis
Category | Disease | Mechanism | Clinical | Paraclinical | Gold standard diagnosis | Other findings | ||||||||||||||||
---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|---|
Symptoms | Signs | Lab data | Imaging | |||||||||||||||||||
ABG | U/A | Electrolytes | Renin | |||||||||||||||||||
↑ acid production |
Loss of bicarbonate |
↓ renal acid excretion |
Fever | Dyspnea | Edema | Toxic/ill | BP | Dehydration | pH | Serum AG | Urine AG | Cl- | K+ | Na+ | US | CT scan | ||||||
Toxin/Medication | Alcohol
|
+ | ↓ | ↑ | ||||||||||||||||||
Paraldehyde | ↓ | ↑ | ||||||||||||||||||||
Toluene | + | ↓ | Nl or ↑ | |||||||||||||||||||
Pyroglutamic acid
(5-oxoproline) |
+ | ↓ | ↑ | |||||||||||||||||||
Salicylates | ↓↑ | ↑ | ||||||||||||||||||||
Metformin | ↓ | ↑ | ||||||||||||||||||||
Isoniazid | ↓ | ↑ | ||||||||||||||||||||
Acetazolamide | + | ↓ | Nl | |||||||||||||||||||
Ammonium chloride | ↓ | Nl | ||||||||||||||||||||
Amphotericin B | ↓ | Nl | ||||||||||||||||||||
Cholestyramine | ↓ | Nl | ||||||||||||||||||||
Lactic acidosis | + | ↓ | ↑ | |||||||||||||||||||
Ketoacidosis | Diabetic | + | ↓ | ↑ | ||||||||||||||||||
Starvation | + | ↓ | ↑ | |||||||||||||||||||
Alcoholic | + | ↓ | ↑ | |||||||||||||||||||
Systemic | Infection | ↓ | ↑ | |||||||||||||||||||
Ischemia | ↓ | ↑ | ||||||||||||||||||||
Renal | Uremia | ↓ | ↑ | |||||||||||||||||||
Ureteral diversion | + | ↓ | Nl | |||||||||||||||||||
Renal failure | + | ↓ | ↑ | |||||||||||||||||||
Renal tubular acidosis | Type I | + | ↓ | Nl | ↑ | |||||||||||||||||
Type II | + | ↓ | Nl | ↓ | ||||||||||||||||||
Type IV | + | ↓ | Nl | ↑ | ||||||||||||||||||
GI | Diarrhea | + | ↓ | Nl | ||||||||||||||||||
Hyperalimentation | ↓ | Nl | ||||||||||||||||||||
Endocrine | Addison's disease | ↓ | Nl | |||||||||||||||||||
Post hypocapnea | ↓ | Nl | ||||||||||||||||||||
Category | Disease | pH | Serum AG | Urine AG | Volume depletion | HTN |
Metabolic Alkalosis
Category | Disease | pH | Renin | Urine chloride | Volume depletion | HTN | ||||
---|---|---|---|---|---|---|---|---|---|---|
Exogenous HCO3− loads | Acute alkali administration | ↑ | ||||||||
Milk-alkali syndrome | ↑ | |||||||||
Gastrointestinal origin | Vomiting | ↑ | ↓ | + | ||||||
Nasogastric tube suction | ↑ | ↓ | + | |||||||
Gastric aspiration | ||||||||||
Congenital chloridorrhea | ||||||||||
Villous adenoma | ||||||||||
Renal origin | Diuretics | ↑ | ↓ | + | ||||||
Posthypercapnic state | ||||||||||
Hypercalcemia/hypoparathyroidism | ||||||||||
Recovery from lactic acidosis or ketoacidosis | ||||||||||
Nonreabsorbable anions including penicillin, carbenicillin | ||||||||||
Hypomagnesemia | ↑ | Nl | - | |||||||
Hypokalemia | ↑ | Nl | - | |||||||
Bartter's syndrome | ↑ | Nl | - | |||||||
Gitelman’s syndrome | ||||||||||
Renal artery stenosis | ↑ | ↑ | Nl | + | ||||||
Cushing's syndrome | ↑ | ↓ | Nl | + | ||||||
Hyperaldosteronism | ↑ | ↓ | Nl | + | ||||||
Licorice ingestion | ↑ | ↓ | Nl | - | ||||||
Category | Disease | pH | Renin | Urine chloride | Volume depletion | HTN |
Mixed Acid-Base Disorders
Disorder | Key features | Examples |
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Metabolic acidosis & respiratory alkalosis |
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Metabolic acidosis & respiratory acidosis |
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Metabolic alkalosis & respiratory alkalosis |
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Metabolic alkalosis & respiratory acidosis |
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Metabolic acidosis & metabolic alkalosis |
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Metabolic acidosis & metabolic acidosis |
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