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ACID-BASE 101

The Basic ABG


1. Determine the pH status
q <7.35: acidaemia. Raised serum H+ ion conc
q >7.45: alkalaemia. Decreased serum H+ ion conc

2. Determine if it is respiratory or metabolic


component: pCO2, HCO3, BE
q Normal pCO2: 35-45 mmHg
q Normal bicarb: 22-26 mmol/L
q Normal BE: -2 to 2 For calculations
Assume PaCO2 = 40 (35- 45)
3. Determine if component is acute or chronic Assume HCO3 = 24 (21 - 28)
Assume AG = 12 (8 -12)
BE = +/-2
4. Adequacy of oxygenation: paO2
q Normally 80-100mmHg, on RA
3 Methods in describing Acid-base

1. HCO3 and PaCO2


2. Standard BE
3. Strong Ion Difference (SID)
HCO3 and PaCO2

Henderson-Hasselbalch equation Problems with the HH equation:


1. Does not discern the severity (quantity) of
the metabolic derangement.
¨ We can only estimate from the change in
HCO3.
¨ HCO3 is not a good indicator because it is
affected by either respiratory and
Loosely translated to: metabolic components.

pH = pK + log [ HCO3____ ] 2. Equation 1 does not tell us about any


acids other than carbonic acid.
0.03 (pCO2)
¨ The relationship between CO2 and HCO3
allows us to work out the etiology -
respiratory of metabolic. It does not
explain how the pH and HCO3
concentration are altered independent of
pCO2.
Base Excess, Standard BE
To quantify the severity of metabolic Problems with SBE:
derangement
q HCO3 is not a good indicator because it is 1. Accurate in vitro but inaccurate in vivo
affected by either respiratory and 2. SBE involves only strong acids and bases.
metabolic components.
Base Excess is used as an indicator of the ¨ HCO3 is not a strong base and its addition
degree of metabolic derangements, or removal from plasma cannot translate
unlike HCO3. to changes in SBE.
¨ "Buffering" of the strong acids/base by
plasma proteins, Hb and HCO3 is what
Definition of SBE: determines changes in HCO3 and PH.
¨ Quantity of metabolic acidosis or alkalosis, These buffers are weak.
defined as amount of acid or base that
must be added to a sample of ECF in vitro
in order to restore the PH to 7.40 (at PCO2
of 40mm Hg and at 37 deg Celsius).
¨ Uses Hb = 5, based on the principle that
this closely represents the behaviour of
the whole body, as Hb effectively buffers
the plasma as well as the ECF
Strong Ion Difference (Stewart
Method)
Basic Principle: SID = Sum of all strong cations - sum of all
strong anions
1. Electroneutrality = (Na+ + K+ + Ca2+ + Mg2+) – (Cl- – other
¨ In aqueous solutions, the sum of all strong anions, like lactate or SO42-)
positively charged ions must equal the
sum of all negatively charged ions. ¨ Number of +ve and –ve ions in a
solution must be equal (SID = 0)
¨ Strong ions = completely dissociated in l Increased SID (>0) = alkalosis
water. Eg. Na+, K+, Ca2+, Mg2+, and l Decreased SID (<0) = acidosis
Cl– l Normal SID = 40mEq/L à ALKALINE
¨ Weak ions = H+, albumin, phosphate,
HCO3 l Problem:
H2O = H+ + OH- We cannot measure all the strong
ions in practice
¨ Weak = Can exist both as charged
(dissociated) and uncharged forms
Hyperchloremic NAGMA
2 ways:

1. First, Cl– ions can be added to the circulation, either via an exogenous source (eg
HCl or saline) or via internal shifts (eg from the red cell).

1. Second, Cl– ions can be retained or reabsorbed, whereas water and other ions (ie
Na+) are excreted so that the relative concentration of Cl– increases.

¨ A decrease in HCO3– or increase in H+ concentration is necessary to maintain


electroneutrality. Hence, an increase in Cl- is the cause of acidosis.
SID, Chloride, and your Guts
¨ If gastric secretions are removed by suctioning or vomiting, Cl- will be progressively lost
without the loss of a strong cation.
¤ Hence, SID will increase = H+ decreases and PH increases

¨ The pancreas secretes fluid into the small intestine that has a SID much higher than plasma
(more alkaline) and is very low in Cl.
¤ If large amount of pancreatic fluid is lost eg. from surgical drainage, fistulas; there will be
decreased plasma SID causing acidosis.

¨ Fluid in the large intestine has a high SID because most of the Cl has been removed in the
small intestines, leaving mostly Na+ and K+.
¤ Hence, in severe diarrhoea, large amounts of cations are lost, causing plasma SID to
decrease resulting in acidosis.
The Basic ABG
1. Determine the pH status
q <7.35: acidaemia. Raised serum H+ ion conc
q >7.45: alkalaemia. Decreased serum H+ ion
conc

2. Determine if it is respiratory or metabolic


component: pCO2, HCO3, BE
q Normal pCO2: 35-45 mmHg
q Normal bicarb: 22-26 mmol/L For calculations
q Normal BE: -2 to 2 Assume PaCO2 = 40 (35- 45)
Assume HCO3 = 24 (21 - 28)
3. Determine if component is acute or chronic Assume AG = 12 (8 -12)
BE = +/-2

4. Adequacy of oxygenation: paO2


To calculate expected values for compensation

Every Unit PaCO2 changes by HCO3 (take 24) changes


decrease in HCO3 factor of by factor of

Increased HCO3 0.7 Every ACUTE CHRONIC


(alkalosis) 10mmHg
change in
PaCO2
from
Decreased HCO3 1.2 40mmHg
(acidosis)
Increased 1 3.5
PaCO2
(acidosis)

Decreased 2 4
Unlike other things in life, we CANNOT PaCO2
OVERCOMPENSATE. (alkalosis)
What kills?

l Decompensated type 2
MUDPILES for HARDUP for NAGMA
respiratory failure
HAGMA
l pH less than 7.35
Methanol Hyperchloraemia
Uremia Acetazolamide, Addison’s
l Severe metabolic acidosis Diabetic, alcoholic, disease
starvation ketoacidosis Renal tubular acidosis
l HAGMA vs NAGMA
Paracetamol; Propylene Diarrhoea, ileostomies,
l MUDPILES vs HARDUP glycol fistulae
IEM Ureteroenterostomies
Lactic acid Pancreato-enterostomies
l (Severe respiratory/metabolic Ethylene glycol
alkalosis) Salicylates (aspirin)
Metabolic Acidosis
Ø Calculate Anion Gap
¨ to look for presence of unmeasured anions
¨ Anion Gap = cations - anions
= (Na+) + (K+) – (Cl- + HCO3-)
--> assumes serum alb = 40

¨ Albumin is a major unmeasured anion. Every 10 drop in serum albumin


from 40, AG decreases by 2.5

q Corrected measured AG (for low albumin) =


Calculated AG + [(40-albumin)/10 x 2.5] =
Calculated AG + [(40-albumin) x 0.25]
Delta Ratio for HAGMA

l Delta ratio = (Increase in Anion Gap / Decrease in bicarbonate)


= (AG – 12)
(24 – HCO3)

l Corrected AG = Calculated AG + [(40-Alb) x 0.25]


Additional factors: Osmolar Gap

l Osmolar Gap = Measured osmolality - Calculated osmolarity


l Measured osmolality = lab value
l Calculated osmolarity = (2xNa+) + Glucose + Urea

l Osmol gap > 10mOsm/l is abnormal


l Causes: (MIME ELK)
1. Methanol/mannitol
2. Isopropyl alcohol
3. Methylene glycol
4. Ethylene glycol
5. Ethanol
6. Lactate
7. Ketones
Why do we bother?

1. Severe metabolic acidosis


l Compensate by hyperventilating > tachypnoeic
l NOT an indication for NIV. In fact, contraindicated.
l Fix the underlying cause if HAGMA. If NAGMA, can try bicarbonate

2. Decompensated respiratory acidosis


l NIV in select group of patients (COPD, Bronchiectasis, Fluid overload)

3. Contraction alkalosis
• Loss of relatively large volumes of fluid that has a high sodium chloride concentration but
a low bicarbonate concentration (lower than the extracellular fluid bicarbonate
concentration)
• Loop diuretics
• Loss of gastric Cl = Pyloric stenosis, Zollinger-Ellison Syndrome
• Sweat losses in cystic fibrosis, congenital chloride diarrhea, and, possibly, the loss of gastric
secretions in patients with achlorhydria
l Hydrate hydrate
Case 1

l 56M

l Appendicectomy 1/52 ago

l R LL swollen

l Hypotensive, unrecordable
sats

For calculations
Assume PaCO2 = 40 (35- 45)
Assume HCO3 = 24 (21 - 28)
Assume AG = 12 (8 -12)
BE = +/-2
Case 1
l Decompensated metabolic
acidosis
l Anion gap = 35, delta ratio 1.6
l HAGMA
l Lactic acidosis
l Renal acids
l Fulminant septic shock from
necrotising fasciitis
l Immediate intubation,
stabilisation, and source
control
l Bicarbonate is not a cure
Bicarbonate infusion
Detriments of IV NaHCO3 infusion:
1. Stimulate production of lactate in animal models

n Lactate itself is a strong acid which may have independent negative effects
on cardiac contractility
2. Effects on intracellular PH are unclear
n HCO3 reacts with H+ to form H2O and CO2.
n CO2 diffuses readily across cell membranes -> may cause paradoxical
decrease in intracellular PH.
n Animal models on intracellular PH changes with NaHCO3 infusion has been
variable - can increase, decrease or stay unchanged.
3. 8.4% NaHCO3 is hypertonic --> will increase osmolality and Na
Bicarbonate Infusion
¨ Use with CAUTION
¤ Whole animal studies have failed to demonstrate any hemodynamic benefit.
¤ 2 human RCTs on NaHCO3 therapy in patients with lactic acidosis found no benefits over
sodium chloride in improving global hemodynamics or cardiovascular response to infused
catecholamines.
¤ 1 RCT (Lancet 2018): Bicarb in ICU+AKI: pH≤7.20, PaCO2 ≤45 mmHg, serum bicarb ≤20 mmHg.
¤ Protocol: 4.2% sodium bicarb infusion to maintain pH above 7.30 (each infusion within range
of 125-250ml in 30min, max 1L in 24hr), vs no bicarb
¤ Primary outcome: composite of death from any cause by day 28 and the presence of at least 1
organ failure at day 7
¤ Results: Patients with severe metab acidaemia, sodium bicarbonate had no effect on primary
outcome. However, sodium bicarb decreased the primary composite outcome and day 28
mortality in the a-priori defined stratum of patients with AKI.

¨ Recommendations?
¤ If decision is made to administer, then slow infusion is preferable.
¤ In hyperchloremic NAGMA (bicarbonate losing acidosis) from diarrhoea or RTA, administration
is reasonable.
However, benefit of therapy is difficult to predict.
Case 2

l Engraftment syndrome of lungs


l ARDS
l Ventilated on volume-controlled
mode
l Day 10
l Acute kidney injury

For calculations
Assume PaCO2 = 40 (35- 45)
Assume HCO3 = 24 (21 - 28)
Assume AG = 12 (8 -12)
BE = +/-2
Case 2

l Decompensated T2RF, with severe


T1RF component

l Component of met acidosis

l Inadequate metabolic
compensation: expected bicarb =
42

l Support by increasing minute


ventilation: Rate, (tidal volume),
recruitment, FiO2, PEEP, (correct
anaemia)

l Support AKI
Case 3

l 70F
l Diarrhoea, vomitting

l What is the anion


gap?
l What is the delta
ratio?
l Does it matter?

For calculations
Assume PaCO2 = 40 (35- 45)
Assume HCO3 = 24 (21 - 28)
Assume AG = 12 (8 -12)
BE = +/-2
Case 3

l Anion gap = 20
l Delta gap = (20 – 12)
(24 – 12)
= 0.67
• mixed HAGMA and NAGMA

Hyperchloraemia from Diarrhoea


(loss of alkaline fluids (HCO3 loss)
from large intestines)

l Cautious fluid and bicarb


replacement (can use isotonic
bicarb)
Case 4

l 47F
l Lymphoma
l Chemotherapy induced pancreatitis

l Was placed on NIV overnight


because of hypoxaemia
l Diuresed as well

For calculations
Assume PaCO2 = 40 (35- 45)
Assume HCO3 = 24 (21 - 28)
Assume AG = 12 (8 -12)
BE = +/-2
Case 4

l Marked mixed respiratory and metabolic


alkalosis
l Expected bicarb = 20
l Hyperventilating + over-diuresis
Case 5 – D1

• 62F
• Diabetic, asthmatic
• PC: Fall, shortness of breath

• BSL 25
• Wheezy

For calculations
Assume PaCO2 = 40 (35- 45)
Assume HCO3 = 24 (21 - 28)
Assume AG = 12 (8 -12)
BE = +/-2
Case 5 – D1

• Expected HCO3 if acute respiratory


acidosis = 22-23
• AG 17.5

• Lactate 2
• BOHB 2.0

• Mixed respiratory and metabolic


acidosis
– T2RF: asthma/bronchospasm, tiring
out
– Met acidosis: DKA, AKI, sepsis
• Intubate, treat DKA and sepsis, hydrate
Case 5 – D2

• Oh no. ABG has so many red


numbers despite excellent ICU care.
• What is the main abnormality here
now?
Case 5 – D2

• It is now a NAGMA
• She was given lots of 0.9% NaCl.

• Remember SID?
• Can consider bicarb, or if her
kidneys are normal with excellent
urine output, no need to worry, just
decrease Cl- load.
Case 6

¨ 26F
¨ No PMH
¨ Presents with shortness of breath
and difficulty swallowing 1-2/52
¨ Travelled to Thailand recently
¨ Oral thrush present
¨ ABG done on 2L INO2

For calculations
Assume PaCO2 = 40 (35- 45)
Assume HCO3 = 24 (21 - 28)
Assume AG = 12 (8 -12)
BE = +/-2
Case 6
¨ Central hyperventilation
¨ Partial metabolic compensation
¨ Brainstem glioma
¨ Treatment = treat glioma
Case 7
• 44M
• APS, EF 40%, multiple RWMA
– Intubated for hypoxaemic resp
failure with cardiorespiratory
arrest
– +10L overall prior to plans for
extubation

• RT tells you cannot extubate


because he has apnoeic episodes
despite good diuresis with IV lasix

• What is/are the abnormalit(ies)


here?

For calculations

Assume PaCO2 = 40 (35- 45)


Assume HCO3 = 24 (21 - 28)
Assume AG = 12 (8 -12)
BE = +/-2
Case 7
• Metabolic alkalosis with partial
respiratory compensation
• Diuresed a little too aggressively

• He stops breathing to try to undo


what we have done

• Stop diuresis
• Consider fluids containing Cl-,
acetazolamide
Case 8

Background Labs

¨ 70M ¨ Na 127, K 5.2, Cl 79, Urea 50.5, Creat


¨ CCF 180

¨ Vomiting past 5 days ¨ Glucose 9.5

¨ Hyperventilating ¨ Anion gap 33


¨ pH 7.58
¨ pCO2 21
¨ pO2 154
¨ HCO2 19

For calculations
Assume PaCO2 = 40 (35- 45)
Assume HCO3 = 24 (21 - 28)
Assume AG = 12 (8 -12)
BE = +/-2
Case 8
¨ The history suggests the following
possibilities:

¨ Respiratory alkalosis in response to the


dyspnoea associated with the congestive
heart failure
¨ A lactic acidosis is possible if cardiac
output is low and tissue perfusion is
poor
¨ Vomiting suggests metabolic alkalosis
¨ The renal failure could be associated
with a high anion gap acidosis
Case 8
¨ The history suggests the following ¨ Diagnosis: Triple acid base disorder.
possibilities: Resp alkalosis, HAGMA, metabolic
alkalosis
¨ Respiratory alkalosis in response to the
¨ pH: pH is greater than 7.44 so an
dyspnoea associated with the congestive alkalaemia is present. The cause is an
heart failure alkalosis: mixed in this case.
¨ A lactic acidosis is possible if cardiac
¨ Pattern: pCO2 & bicarbonate are both
output is low and tissue perfusion is low suggesting either a metabolic
poor acidosis or a respiratory alkalosis. As we
already know an alkalosis is present then
¨ Vomiting suggests metabolic alkalosis the primary disorder is a respiratory
¨ The renal failure could be associated alkalosis.
with a high anion gap acidosis ¨ Clues: The anion gap is noted to be very
high so there must be a high-anion gap
metabolic acidosis present as well.
(Think through the causes of HAGMA:
MUDPILES – check if unsure!)
Summary
l Interpretation of ABG should be completed by looking at
l (Corrected) Anion gap
l Delta ratio
l Osmolar gap

l Strong ion difference is an important concept to know, but in real life, we don’t calculate it

l A single ABG can yield enough answers to help determine next course of immediate action

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