Acid Base Balance & Disorders - Part II

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Acid-Base Balance & Disorders . Part II . Respiratory & Mixed Acid Base Disorders ABG Interpretation:

Acid-Base Balance & Disorders . Part II . Respiratory & Mixed Acid Base Disorders ABG Interpretation Presented By Mohammed Abdel Gawad

Acid Base Balance & Disorders:

Acid Base Balance & Disorders Normal Acid Base Balance Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis Mixed Acid Base Disorders ABG Interpretation 2 Part I Part II

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3 CO 2 Red Blood Cell Systemic Circulation H 2 O H + HCO 3 - carbonic anhydrase Plasma CO 2 CO 2 CO 2 CO 2 CO 2 CO 2 CO 2 Click for Carbon Dioxide diffusion + + Tissues H + Cl - Hb H + is buffered by Hemoglobin Tissue side

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4 Red Blood Cell Pulmonary Circulation CO 2 H 2 O H + + + HCO 3 - Cl - Alveolus Plasma CO 2 H 2 O Hb Lung side

Respiratory regulation of acid-base balance :

Respiratory regulation of acid-base balance 5

Classification of Acid-basic Disorders:

Classification of Acid-basic Disorders pH PCO2 HCO3 Metabolic Acidosis ↓ ↓ (compensation) ↓ (1ry disorder) Metabolic Alkalosis ↑ ↑ (compensation) ↑ (1ry disorder) Respiratory Acidosis ↓ ↑ (1ry disorder) ↑ (compensation) Respiratory Alkalosis ↑ ↓ (1ry disorder) ↓ (compensation) 6

Acute or Chronic?:

Acute or Chronic? 7 NO YES

I- Approved respiratory acidosis: :

I- Approved respiratory acidosis: pH < 7.35 PCO2 > 45 mmHg HCO3 > 26 mEq /L (compensation) 1. Acute respiratory acidosis: HCO3 rises 1 mEq /L for each 10 mm Hg rise in PCO2 (in minutes). 2. Chronic respiratory acidosis: HCO3 rises 3.5 mEq /L for each 10 mm Hg rise in PCO2 (over days). In absence of full compensation, this is called: A- partial compensation or better called: B- mixed metabolic & respiratory acidosis 8 II- Expected compensation:

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9

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10

Acid Base Balance & Disorders:

Acid Base Balance & Disorders Normal Acid Base Balance Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis Mixed Acid Base Disorders ABG Interpretation 11 Part I Part II

I- Approved respiratory alkalosis: :

I- Approved respiratory alkalosis: pH > 7.45 PCO2 < 35 mmHg HCO3 < 22 mEq /L (compensation) 1. Acute respiratory alkalosis: HCO3 falls 2 mEq /L for each 10 mm Hg fall in PCO2 (in minutes). 2. Chronic respiratory alkalosis: HCO3 falls 5 mEq /L for each 10 mm Hg fall in PCO2 (over days). In absence of full compensation, this is called: A- partial compensation or better called: B- mixed metabolic & respiratory alkalosis 12 II- Expected compensation:

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13

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14

Acid Base Balance & Disorders:

Acid Base Balance & Disorders Normal Acid Base Balance Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis Mixed Acid Base Disorders ABG Interpretation 15 Part I Part II

PowerPoint Presentation:

All acid base disorders can be combined in a double or triple disorders BUT NEVER COMBINE respiratory acidosis with respiratory alkalosis 16

Acid Base Balance & Disorders:

Acid Base Balance & Disorders Normal Acid Base Balance Metabolic Acidosis Metabolic Alkalosis Respiratory Acidosis Respiratory Alkalosis Mixed Acid Base Disorders ABG Interpretation 17 Part I Part II

Step 1 - pH:

Step 1 - pH If it falls into the normal range: < 7.4 = normal/acidic, > 7.4 = normal/ alkalotic . 18

PowerPoint Presentation:

Parameter Normal value PCO2 35 – 45 mmHg HCO3 22- 26 mEq /L Step 2 – PCO2 & HCO3 analysis pH PCO2 HCO3 Metabolic Acidosis ↓ ↓ ↓ Respiratory Alkalosis ↑ ↓ ↓ Metabolic Alkalosis ↑ ↑ ↑ Respiratory Acidosis ↓ ↑ ↑ Mixed Acidosis ↓ ↑ ↓ Mixed Alkalosis ↑ ↓ ↑

If Metabolic Acidosis:

If Metabolic Acidosis 20

I- Approved metabolic acidosis: :

I- Approved metabolic acidosis: pH < 7.35 HCO3 < 22 mEq /L PCO2 < 35 mmHg (compensation) for each 1 ↓ HCO3 → 1.2 ↓ CO2 or Δ ↓ P co 2 = 1.2 x ΔHCO3 In absence of full compensation, this is called: A- partial compensation or better called: B- mixed metabolic & respiratory acidosis: as the lung not washing enough CO2 as needed, which mean that it is actually accumulating CO2 even if the PCO2 is lower than normal. 21 II- Expected compensation:

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22 Normocholeremic Hypercholeremic III- Calculate Anion Gap

III- Calculate Anion Gap:

III- Calculate Anion Gap Equations: AG = (Na + K) – ( Cl + HCO3) = 12 ± 4 mmol /l or AG = (Na) – ( Cl + HCO3) = 12 ± 2 mmol /l Corrected Anion Gap: anion gap is decreased by 4 mmol /l for each 1 g/dl decrease in the serum albumin concentration below normal. The result: Wide (high) anion gap metabolic acidosis or Non (normal) anion gap metabolic acidosis 23

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High AG acidosis • • • • • • • • K U S S M A L E Ketoacidosis (starvation, DM, alcohol) Uremia Sepsis Salicylate & other drugs e.g.paraldhyde Methanol Alcohol (Ethanol) Lactic acidosis Ethylene glycol 24 Wide Anion Gap Causes Normocholeremic

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25 4- uretrosigmoid-ostomy Non Anion Gap Causes Hypercholeremic

To remember:

To remember I- Approved Metabolic Acidosis II- Calculate Compensation III- Calculate Anion Gap IV- a- if high anion gap → calculate delta gap b- if normal anion gap → calculate urinary AG 26

IV- a- if high anion gap → calculate delta gap :

IV- a- if high anion gap → calculate delta gap ∆ Gap = ∆AG / ∆HCO3 > 1 = high AG metabolic acidosis mixed with metabolic alkalosis < 1 = high AG metabolic acidosis mixed with non AG metabolic acidosis = 1 = simple high AG metabolic acidosis 27 Ketoacidosis Uremia Sepsis Salicylate & other drugs Methanol Alcohol (Ethanol) Lactic acidosis Ethylene glycol AG HCO3 Cl 12 24 105

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28 NH4Cl IV- b- if normal anion gap → calculate urinary AG 4- uretrosigmoid-ostomy urine AG = u[Na + K] – u[ Cl ] If – ve : so the loss is non renal If zero or + ve : so the loss is renal N.B. Normally it is + ve ranging from +30 to +50 mmol /L

To remember:

To remember I- Approved Metabolic Acidosis II- Calculate Compensation III- Calculate Anion Gap IV- a- if high anion gap → calculate delta gap b- if normal anion gap → calculate urinary AG 29

Bicarbonate Deficit – Equation 1:

Bicarbonate Deficit – Equation 1 30

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31 Bicarbonate Deficit – Equation 2

If Metabolic Alkalosis:

If Metabolic Alkalosis 32

I- Approved metabolic alkalosis: :

I- Approved metabolic alkalosis: pH > 7.45 HCO3 > 26 mEq /L PCO2 > 45 mmHg (compensation) for each 1 ↑ HCO3 → 0.7 ↑ CO2 or Δ ↑ P co 2 = 0.7 x ΔHCO3 In absence of full compensation, this is called: A- partial compensation or better called: B- mixed metabolic & respiratory alkalosis: as the lung can not retain enough CO2 as needed, which mean that it is actually washing CO2 even if the PCO2 is higher than normal. 33 II- Expected compensation:

III- Causes :

III- Causes A- Chloride Depletion (urine Cl < 10 mEq /L) B- Corticosteroid & Apparent Corticosteroid Induced (chloride resistant) (urine Cl > 10 mEq /L) C- Alkali Administration or Ingestion 34

A- Chloride Depletion (urine Cl < 10 mEq/L):

A- Chloride Depletion (urine Cl < 10 mEq /L) 35

B- Corticosteroid & Apparent Corticosteroid Induced (chloride resistant) (urine Cl > 10 mEq/L):

B- Corticosteroid & Apparent Corticosteroid Induced (chloride resistant) (urine Cl > 10 mEq /L) 36

C- Alkali Administration or Ingestion:

C- Alkali Administration or Ingestion 37

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38

If Respiratory Disorder:

If Respiratory Disorder 39

Acute or Chronic?:

Acute or Chronic? 40 NO YES

If Respiratory Acidosis:

If Respiratory Acidosis 41

I- Approved respiratory acidosis: :

I- Approved respiratory acidosis: pH < 7.35 PCO2 > 45 mmHg HCO3 > 26 mEq /L (compensation) 1. Acute respiratory acidosis: HCO3 rises 1 mEq /L for each 10 mm Hg rise in PCO2 (in minutes). 2. Chronic respiratory acidosis: HCO3 rises 3.5 mEq /L for each 10 mm Hg rise in PCO2 (over days). In absence of full compensation, this is called: A- partial compensation or better called: B- mixed metabolic & respiratory acidosis 42 II- Expected compensation:

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43

If Respiratory Alkalosis:

If Respiratory Alkalosis 44

I- Approved respiratory alkalosis: :

I- Approved respiratory alkalosis: pH > 7.45 PCO2 < 35 mmHg HCO3 < 22 mEq /L (compensation) 1. Acute respiratory alkalosis: HCO3 falls 2 mEq /L for each 10 mm Hg fall in PCO2 (in minutes). 2. Chronic respiratory alkalosis: HCO3 falls 5 mEq /L for each 10 mm Hg fall in PCO2 (over days). In absence of full compensation, this is called: A- partial compensation or better called: B- mixed metabolic & respiratory alkalosis 45 II- Expected compensation:

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THANK YOU:

THANK YOU 49 Mohammed Abdel Gawad 02-02-2012

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