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| align="left" style="background:#F5F5F5;" + |Hypoxia
| align="left" style="background:#F5F5F5;" + |Hypoxia
|-
|-
|align="center" style="background:#DCDCDC;" + |Venous
| align="center" style="background:#DCDCDC;" + |Venous
| align="left" style="background:#F5F5F5;" + |70 to 75%
| align="left" style="background:#F5F5F5;" + |70 to 75%
| align="left" style="background:#F5F5F5;" + |Normal
| align="left" style="background:#F5F5F5;" + |Normal
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{| class="wikitable"
{| class="wikitable"
!Disease
!Disease
!PH
!
!pH
!Poisoning
!Poisoning
!AG
!Serum AG
!Urine AG
!Loss of consciousness
!Loss of consciousness
!Fever
!Fever
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|-
|-
|Methanol
|Methanol
|
|Low
|Low
|Yes
|Yes
|High
|High
|
|
|
|
|
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|-
|-
|Metformin
|Metformin
|
|Low
|Low
|
|
|High
|High
|
|
|
|
|
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|-
|-
|Uremia
|Uremia
|
|Low
|Low
|
|
|High
|High
|
|
|
|
|
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|-
|-
|Diabetic ketoacidosis
|Diabetic ketoacidosis
|
|Low
|Low
|
|
|High
|High
|
|
|
|
|
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|-
|-
|Paraldehyde
|Paraldehyde
|
|Low
|Low
|Yes
|Yes
|High
|High
|
|
|
|
|
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|-
|-
|Propylene glycol
|Propylene glycol
|
|Low
|Low
|Yes
|Yes
|High
|High
|
|
|
|
|
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|-
|-
|Infection
|Infection
|
|Low
|Low
|
|
|High
|High
|
|
|
|
|
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|-
|-
|Ischemia
|Ischemia
|
|Low
|Low
|
|
|High
|High
|
|
|
|
|
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|-
|-
|Isoniazid
|Isoniazid
|
|Low
|Low
|
|
|High
|High
|
|
|
|
|
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|-
|-
|Ethylene glycol
|Ethylene glycol
|
|Low
|Low
|Yes
|Yes
|High
|High
|
|
|
|
|
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|-
|-
|Ethanol
|Ethanol
|
|Low
|Low
|Yes
|Yes
|High
|High
|
|
|
|
|
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|-
|-
|Salicylates
|Salicylates
|
|Low/high
|Low/high
|Yes
|Yes
|High
|High
|
|
|
|
|
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|-
|-
|Starvation
|Starvation
|
|Low
|Low
|
|
|High
|High
|
|
|
|
|
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|-
|-
|Diarrhea
|Diarrhea
|
|Low
|Low
|
|
|Nl
|Nl
|
|
|
|
|
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|-
|-
|Ureteral diversion
|Ureteral diversion
|
|Low
|
|Nl
|
|
|
|
|
|
|
|-
|Renal failure
|
|Low
|
|Nl
|
|
|
|
|
|
|
|-
| rowspan="3" |Renal tubular acidosis
|Type I
|Low
|
|Nl
| +
|
|
|
|
|
|
|-
|Type II
|Low
|Low
|
|
|Nl
|Nl
| -
|
|
|
|
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|
|
|-
|-
|Renal tubular acidosis
|Type IV
|Low
|Low
|
|
|Nl
|Nl
| +
|
|
|
|
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|-
|-
|Hyperalimentation
|Hyperalimentation
|
|Low
|Low
|
|
|Nl
|Nl
|
|
|
|
|
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|-
|-
|Addison's disease
|Addison's disease
|
|Low
|Low
|
|
|Nl
|Nl
|
|
|
|
|
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|-
|-
|Acetazolamide
|Acetazolamide
|
|Low
|Low
|
|
|Nl
|Nl
|
|
|
|
|
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|-
|-
|Ammonium chloride
|Ammonium chloride
|
|Low
|Low
|
|
|Nl
|Nl
|
|
|
|
|
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|-
|-
|Congenital chloride diarrhea
|Congenital chloride diarrhea
|
|Low
|Low
|
|
|Nl
|Nl
|
|
|
|
|
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|-
|-
|Amphotericin B
|Amphotericin B
|
|Low
|Low
|
|
|Nl
|Nl
|
|
|
|
|
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|-
|-
|Toluene
|Toluene
|
|Low
|Low
|
|
|Nl
|Nl
|
|
|
|
|
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|-
|-
|Cholestyramine
|Cholestyramine
|
|Low
|Low
|
|
|Nl
|Nl
|
|
|
|
|
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|-
|-
|post hypocapnea
|post hypocapnea
|
|Low
|Low
|
|
|Nl
|Nl
|
|
|
|
|
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|-
|-
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Revision as of 14:20, 7 May 2018

Acid Base Disorders

Approach

Normal range

Blood gas analysis Vessel Range Interpretation
Oxygen Partial Pressure (pO2) Arterial 80 to 100 mmHg (10.6 to 13.3 kPa) 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 ([H+] 35 to 45 nmol/L) Normal
>7.45 Alkalemia
Venous 7.26 to 7.46 Normal
Carbon Dioxide Partial Pressure (pCO2) Arterial <35 mmHg Low
35 to 45 mmHg (4.7 to 6.0 kPa) Normal
>45 mmHg High
Venous 40 to 45 mmHg Normal
[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 formula

Primary disorder pH PaCO2 [HCO3-] Compensation
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
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 

Approach to Metabolic Acidosis

 
 
 
 
 
 
 
 
 
 
pH<7.35
And
[HCO3-]<24 meq/L
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Metabolic acidosis
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Calculate the anion gap (AG)

Na+ - Cl- - HCO3-
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Low AG
AG<8
 
 
 
 
 
Normal AG
8<AG<16
 
 
 
 
 
 
High AG
AG>16
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check albumin

Correct the AG if albumin is low
For every decrease of 1 g/dl of albumin, AG is decreased by 2.5 meg/L
 
Check Ca2+, Mg2+, K+, immunoglobulins

High levels of these unmeasured cations decrease the AG
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Check urine AG
Na+ + K+ - Cl-
 
 
 
 
 
 
Check ΔAG/ΔHCO3-
 
 
R/O low Ca2+, Mg2+, K+
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
Negative urine AG

GI causes
RTA type II
 
 
 
Positive urine AG

Renal failure
RTA type I
RTA type IV
 
ΔAG/ΔHCO3-<1

High AG metabolic acidosis combined with normal AG metabolic acidosis
 
1<ΔAG/ΔHCO3-<2

Pure high AG metabolic acidosis
 
ΔAG/ΔHCO3->2

High AG metabolic acidosis combined with metabolic alkalosis

Metabolic Acidosis

Disease pH Poisoning Serum AG Urine AG Loss of consciousness Fever
Methanol Low Yes High
Metformin Low High
Uremia Low High
Diabetic ketoacidosis Low High
Paraldehyde Low Yes High
Propylene glycol Low Yes High
Infection Low High
Ischemia Low High
Isoniazid Low High
Ethylene glycol Low Yes High
Ethanol Low Yes High
Salicylates Low/high Yes High
Starvation Low High
Diarrhea Low Nl
Ureteral diversion Low Nl
Renal failure Low Nl
Renal tubular acidosis Type I Low Nl +
Type II Low Nl -
Type IV Low Nl +
Hyperalimentation Low Nl
Addison's disease Low Nl
Acetazolamide Low Nl
Ammonium chloride Low Nl
Congenital chloride diarrhea Low Nl
Amphotericin B Low Nl
Toluene Low Nl
Cholestyramine Low Nl
post hypocapnea Low Nl

Metabolic Alkalosis

Respiratory Acidosis

Respiratory Alkalosis

Related Chapters

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