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Case
• A 50-Year old woman underwentintestinal bypass for morbid obesity .She has 10-15 watery stool motion perday , she was treated by tincture ofopium . Next day she was foundsomnolent and hypotensive. The plasmavalue were:
• A 50-Year old woman underwentintestinal bypass for morbid obesity .She has 10-15 watery stool motion perday , she was treated by tincture ofopium . Next day she was foundsomnolent and hypotensive. The plasmavalue were:
2
Laboratory data
PH 7.02
PaCO2 30
HCO3(mEq/L)
10 What isyour
Diagnosis ?
HCO3(mEq/L)
Na(mEq/L)
130
K(mEq/L)
3.2
CL(mEq/L)
1023
What isyour
Diagnosis ?
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
• Step 1.History taking and physical examination
Comprehensive history taking and physicalexamination can often give clues as to theunderlying acid-base disorder
• Step 1.History taking and physical examination
Comprehensive history taking and physicalexamination can often give clues as to theunderlying acid-base disorder
Respiratory alkalosisPulmonary embolus
Respiratory acidosisCOPD
Metabolic acidosisDehydration or shock
Hyperkalaemia
Metabolic alkalosisVomiting , Hypokalaemia Metabolic alkalosisVomiting , Hypokalaemia
Metabolic acidosisSevere diarrhea
salisylates or alcohol intoxication
Metabolic acidosisRenal failure
metabolic acidosisHyperglycaemia (DKA? if ketonespresent
Respiratory alkalosisCirrhosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
• Principle – The body does not fullycompensate for primary acid-base disorders.
i.e.PH < 7.4 ……. acidosis
PH > 7.4 ……. alkalosis
• Principle – The body does not fullycompensate for primary acid-base disorders.
i.e.PH < 7.4 ……. acidosis
PH > 7.4 ……. alkalosis
- If PCO2 is the initial chemical change, thenprocess is respiratory.
- if HCO3- is the initial chemical change, thenprocess is metabolic.
- If PCO2 is the initial chemical change, thenprocess is respiratory.
- if HCO3- is the initial chemical change, thenprocess is metabolic.
PCO2HCO3PH
AcidosisAcidosis
AlkalosisAlkalosis
MetabolicMetabolic
MetabolicMetabolic
AcidosisAcidosis
AlkalosisAlkalosis
AlkalosisAlkalosis MetabolicMetabolic
RespiratoryRespiratory
RespiratoryRespiratory
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
Metabolic acidosisExpected pCO2 = 1.5 x [HCO3] + 8 (range: +/- 2)
Metabolic alkalosisExpected pCO2 = 0.7 [HCO3] + 20 (range: +/- 5)
“If the actual pCO2 or [HCO3-]
is different from the predicted values,You must suspect a 2nd acid-base disorder”
Metabolic acidosisExpected pCO2 = 1.5 x [HCO3] + 8 (range: +/- 2)
Metabolic alkalosisExpected pCO2 = 0.7 [HCO3] + 20 (range: +/- 5)
“If the actual pCO2 or [HCO3-]
is different from the predicted values,You must suspect a 2nd acid-base disorder”
• Acute Respiratory :The [HCO3] will increase by 1 mmol/l for every 10
mmHg elevation in pCO2 above 40 mmHg.Expected [HCO3] = 24 + { (Actual pCO2 - 40) / 10 }
• Chronic Respiratory :The [HCO3] will increase by 4 mmol/l for every 10
mmHg elevation in pCO2 above 40mmHg.Expected [HCO3] = 24 + 4 { (Actual pCO2 - 40) / 10}
• Acute Respiratory :The [HCO3] will increase by 1 mmol/l for every 10
mmHg elevation in pCO2 above 40 mmHg.Expected [HCO3] = 24 + { (Actual pCO2 - 40) / 10 }
• Chronic Respiratory :The [HCO3] will increase by 4 mmol/l for every 10
mmHg elevation in pCO2 above 40mmHg.Expected [HCO3] = 24 + 4 { (Actual pCO2 - 40) / 10}
• Acute RespiratoryThe [HCO3] will decrease by 2 mmol/l for every 10
mmHg decrease in pCO2 below 40 mmHg.Expected [HCO3] = 24 - 2 { ( 40 - Actual pCO2) / 10 }
• Chronic RespiratoryThe [HCO3] will decrease by 5 mmol/l for every 10
mmHg decrease in pCO2 below 40 mmHg.Expected [HCO3] = 24 - 5 { ( 40 - Actual pCO2 ) / 10 }(range: +/- 2)
• It takes 2 to 3 days to reach maximal renal compensation
• Acute RespiratoryThe [HCO3] will decrease by 2 mmol/l for every 10
mmHg decrease in pCO2 below 40 mmHg.Expected [HCO3] = 24 - 2 { ( 40 - Actual pCO2) / 10 }
• Chronic RespiratoryThe [HCO3] will decrease by 5 mmol/l for every 10
mmHg decrease in pCO2 below 40 mmHg.Expected [HCO3] = 24 - 5 { ( 40 - Actual pCO2 ) / 10 }(range: +/- 2)
• It takes 2 to 3 days to reach maximal renal compensation
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
• The anion gap is defined as the quantity ofanions not balanced by cations.
• (Na + K) + Unmeasured cations =(Cl + HCO3) + Unmeasured anions
• Anion Gap=measured cation- measured anion.
• Anion gap = [Na + K] – (Cl + HCO3)• Value: 12 ± 4 meq/L
• The anion gap is defined as the quantity ofanions not balanced by cations.
• (Na + K) + Unmeasured cations =(Cl + HCO3) + Unmeasured anions
• Anion Gap=measured cation- measured anion.
• Anion gap = [Na + K] – (Cl + HCO3)• Value: 12 ± 4 meq/L
Anions and Cations in Serum(Values in mEq/L)
CATIONSANIONS
Calcium 5Organic acids 5
Magnesium 1.5Sulfates 1
Potassium 4.5Phosphates 2
Actually there is no gap
Potassium 4.5Phosphates 2
Sodium 140Proteins 15
Bicarbonates 24
Chlorides 104
Total 151Total 151
High Anion Gap Normal anion gap
• 1. Ketoacidosis- Diabetic- Alcoholic- Starvation
• 2. Lactic acidosis• 3. Toxicosis
- Ethylene glycol- Methanol- Salicylates
• 4. Advanced renal failure
• 1. GIT HCO3- loss
- Diarrhea- External fistulas
• 2. Renal HCO3- loss
- Proximal RTA- Distal RTA- Hyperkalemic RTA
metabolic acidosis
(MUD PILES)(MUD PILES)MethanolUremiaDiabetic ketoacidosisPropylene glycolIsoniazid intoxicationLactic acidosisEthanol ethylene glycolSalicylates
• 1. Ketoacidosis- Diabetic- Alcoholic- Starvation
• 2. Lactic acidosis• 3. Toxicosis
- Ethylene glycol- Methanol- Salicylates
• 4. Advanced renal failure
• 1. GIT HCO3- loss
- Diarrhea- External fistulas
• 2. Renal HCO3- loss
- Proximal RTA- Distal RTA- Hyperkalemic RTA
(MUD PILES)(MUD PILES)MethanolUremiaDiabetic ketoacidosisPropylene glycolIsoniazid intoxicationLactic acidosisEthanol ethylene glycolSalicylates
Osmolal gap
Step 1:Calculate Osm = 2[Na+] + glucose/18 + BUN/2.8
Step 2: Measure Osm
Step 3: Osmolal gap (measured - calc) should be ≤ 10
.ىرخأ ةرم اھجاردإ مث ةروصلا فذح ىلإ رطضت دق ،رھظت ءارمحلاxةمالع تلظ اذإ .ىرخأ ةرم فلملا حتفا مث ،رتویبمكلا لیغشت ةداعإب مق .ةفلات ةروصلا نوكت دق وأ ةروصلا حتفل رتویبمكلا ىلع ةركاذلل ةیفاك ةحاسم كانھ نوكت ال دق .ةروصلا ضرع نكمي ال
Low Anion Gap
- Hypoalbuminemia
- Plasma cell dyscrasia
- Monoclonal protein
- Bromide intoxication
- Normal variant
Corrected AG=Anion Gap + 2.5 x
(4- Albumin)
- Hypoalbuminemia
- Plasma cell dyscrasia
- Monoclonal protein
- Bromide intoxication
- Normal variant
Corrected AG=Anion Gap + 2.5 x
(4- Albumin)
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
• If a metabolic acidosis is diagnosed, then theDelta Ratio should be checked
Delta ratio= ∆ Anion gap/∆ [HCO3-]∆ Anion gap = (12-AG)∆ [HCO3-] = (24 - [HCO3-])
Delta ratio Assessment Guidelines
< 0.4 Hyperchloremic normal anion gap acidosis< 1 High AG & normal AG acidosis
1 to 2 Pure Anion Gap AcidosisLactic acidosis: average value 1.6DKA more likely to have a ratio closer to 1due to urine ketone loss
Pure Anion Gap AcidosisLactic acidosis: average value 1.6DKA more likely to have a ratio closer to 1due to urine ketone loss
> 2 High AG acidosis and a concurrent metabolicalkalosisor a pre-existing compensated respiratoryacidosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
Urine anion gab= (N a +K) -Cl
POSITIVEurinary anion gab
NEGATIVEurinary anion gab
(normal NH(normal NH33 excreationexcreation))
POSITIVEurinary anion gab
NEGATIVEurinary anion gab
(normal NH(normal NH33 excreationexcreation))
GUT causesNEGATIVEn bowel
causes
Urinary causes
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
1. History taking and physical examination2. Assess accuracy of data (validity).3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis2. HCO3
- & pCO2 analysis---primary disorder.4. Compensatory responses5. Calculate AG6. Assess delta ratio7. Urine anion gab8. Formulate acid-base diagnosis
Case
• A 50-Year old woman underwentintestinal bypass for morbid obesity .She has 10-15 watery stool motion perday , she was treated by tincture ofopium . Next day she was foundsomnolent and hypotensive. The plasmavalue were:
• A 50-Year old woman underwentintestinal bypass for morbid obesity .She has 10-15 watery stool motion perday , she was treated by tincture ofopium . Next day she was foundsomnolent and hypotensive. The plasmavalue were:
45
Laboratory data
PH 7.02
PaCO2 30
HCO3(mEq/L)
10
H = (PCO2/ HCO3) ×24 =PH-7.8 ×100H= (30/10)X24=7.02-7.8X100
Validity
PH= acidosis------Hco3= Met acidosisPrimarydefect
Expected pCO2 = 1.5 x [HCO3] + 8(range: +/- 2)=1.5X10+8= 22pco2 30 added respiratory acidosis.
CompensationHCO3(mEq/L)
10
Na(mEq/L)
130
K(mEq/L)
3.2
CL(mEq/L)
10246
Expected pCO2 = 1.5 x [HCO3] + 8(range: +/- 2)=1.5X10+8= 22pco2 30 added respiratory acidosis.
Compensation
= [Na+] – [HCO3-] – [Cl-]
=130-(10+ 102)= 18High AG
AG
Anion gap/∆ [HCO3-]=18-12/24-10= <1 (0.42).High AG & normal AG acidosis
Delta ratio
Final diagnosis:
• Normal Anion gap and high Anion gapmetabolic acidosis+ combined respiratoryacidosis.– Lactic acidosis (hypotension)– Metabolic acidosis due to HCO3 loss (diarrhea).– Respiratory acidosis due to respiratory
depression by opiate.
• Normal Anion gap and high Anion gapmetabolic acidosis+ combined respiratoryacidosis.– Lactic acidosis (hypotension)– Metabolic acidosis due to HCO3 loss (diarrhea).– Respiratory acidosis due to respiratory
depression by opiate.
Case
• A 23y old women with rheumatoid artheritisincreased her dose of salicylate because offlare up. She developed epigastric pain andvomiting that persist for 2 days. She went tolocal hospital where the following blood resultobtained:
• PH =7.61 Pco2 25mmHg, Hco3 =33mmol/l.• What is your acid base diagnosis?
• A 23y old women with rheumatoid artheritisincreased her dose of salicylate because offlare up. She developed epigastric pain andvomiting that persist for 2 days. She went tolocal hospital where the following blood resultobtained:
• PH =7.61 Pco2 25mmHg, Hco3 =33mmol/l.• What is your acid base diagnosis?
Laboratory data
PH 7.61
PaCO2 25mmHg.What is
yourDiagnosis ?
PaCO2 25mmHg.
HCO3(mEq/L)
33mmol/l.
49
What isyour
Diagnosis ?
Laboratory data
PH 7.61PaCO2 25mmHg.
HCO3(mEq/L)
33mmol/l.
H = (PCO2/ HCO3) ×24 =PH-7.8×100
H= (25/33)X24=7.61-7.8X100Validity
PH= alkalosis------increased Hco3=Metabolic alkalosis
Primarydefect
Metabolic alkalosisExpected pCO2 = 0.7x [HCO3] + 20(range: +/- 2)=0.7X33+ 20=43So compansation is not adaqauterespiratory alkalosis.
CompensationHCO3(mEq/L)
33mmol/l.
50
Metabolic alkalosisExpected pCO2 = 0.7x [HCO3] + 20(range: +/- 2)=0.7X33+ 20=43So compansation is not adaqauterespiratory alkalosis.
Compensation
Final diagnosis
Combined Metabolic alkalosis (GIT loss Vomiting )and respiratory alkalosis with salicylate.
PH 7.26 PaCO2 52 HCO3 34
AlkalineNormalAcidic
PH HCO3
Pa CO2
Respiratory acidosis withcompensation (Partial)
PH 7.48 PaCO2 51 HCO3 29
AlkalineNormalAcidic
PH
Pa CO2 HCO3
Metabolic alkalosis withcompensation (Partial)
PH 7.36 PaCO2 50 HCO3 34
AlkalineNormalAcidic
PHPa CO2 HCO3
Respiratory acidosis withcompensation (complete)
PH 7.43 PaCO2 49 HCO3 30
AlkalineNormalAcidic
PHPa CO2 HCO3
Metabolic alkalosis withcompensation (complete)