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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.
¨ 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
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
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 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
For calculations
Assume PaCO2 = 40 (35- 45)
Assume HCO3 = 24 (21 - 28)
Assume AG = 12 (8 -12)
BE = +/-2
Case 2
l Inadequate metabolic
compensation: expected bicarb =
42
l Support AKI
Case 3
l 70F
l Diarrhoea, vomitting
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
l 47F
l Lymphoma
l Chemotherapy induced pancreatitis
For calculations
Assume PaCO2 = 40 (35- 45)
Assume HCO3 = 24 (21 - 28)
Assume AG = 12 (8 -12)
BE = +/-2
Case 4
• 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
• Lactate 2
• BOHB 2.0
• 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
For calculations
• Stop diuresis
• Consider fluids containing Cl-,
acetazolamide
Case 8
Background Labs
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:
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