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Acid-Base Disorders Acid-Base Disorders Benson S. Hsu, MD, MBA,* Saquib A. Lakhani, MD,† Michael Wilhelm, MD‡ *Pediatric Critical Care, University of South Dakota, Sanford School of Medicine, Sioux Falls, SD. †Pediatric Critical Care, Yale School of Medicine, New Haven, CT. ‡Pediatric Critical Care, University of Wisconsin School of Medicine and Public Health, Madison, WI. Education Gap To treat critically ill children, a physician must have a clear understanding of acid-base balance. Objectives After completing this article, readers should be able to: 1. Describe the mechanisms regulating acid-base physiology and identify blood gas abnormalities associated with an acid-base imbalance. 2. Recognize the differential diagnosis and clinical and laboratory features associated with metabolic acidosis and metabolic alkalosis as well as how to manage each appropriately. 3. Calculate an anion gap and formulate a differential diagnosis associated with various anion gap values. 4. Identify factors contributing to compensatory changes associated with primary metabolic and respiratory acidoses and alkaloses. INTRODUCTION The body’s ability to maintain acid-base homeostasis is based on a complex set of interactions between the respiratory and metabolic systems. This article reviews normal acid-base physiology and examines disorders of acid-base imbalances, first within a primary metabolic cause and then within a primary respiratory cause. Covering the complex nuances of acid-base control within a limited-scope review article is impossible. Thus, this article focuses on the traditional model based on the Henderson-Hasselbalch equation rather than the strong ion (or Stewart) model, which explores the difference between all the dissociated cations and anions. Using the traditional model, the authors explore the various meta- bolic and respiratory disturbances while addressing the implications of the anion gap on metabolic acidoses. AUTHOR DISCLOSURE Drs Hsu and Lakhani have disclosed no financial relationships relevant to this article. Dr Wilhelm has REGULATION OF ACID-BASE disclosed that he holds stock in Inovio Pharmaceuticals. This commentary does not The Henderson-Hasselbalch Equation contain discussion of an unapproved/ investigative use of a commercial product or Homeostatic control of acid-base balance is critical for all metabolic and phys- device. iologic functions of the human body. The Henderson-Hasselbalch equation Vol. 37 No. 9 SEPTEMBER 2016 361 Downloaded from http://pedsinreview.aappublications.org/ by guest on November 14, 2018 describes the relationship between pH and the bicarbonate ranges and not independently examine any of the variables. fl buffering system (the predominant buffering system in For example, a blood gas with a high PCO2 may re ect a normal plasma) to establish this homeostasis: pH and should be interpreted as nonacidotic (Table 1). þ 4 4 þ þ À The Anion Gap CO2 H2O H2CO3 H HCO3 Use of only the Henderson-Hasselbalch equation is insuf- ¼ þ À= ficient to describe a patient’s metabolic acid-base state com- pH pK log HCO3 H2CO3 pletely. The anion gap further describes the interactions of fi the measured positive charges (cations) and negative charges When accounting for H2CO3, the modi ed equation (anions) to the unmeasured charged particles. The anion gap becomes: equation is based on the understanding that the cations in the ¼ þ À=½ : ∗ pH pK log HCO3 0 03 Pco2 plasma balance the anions in the plasma at equilibrium. The “measureable” positive and negative charges in the Examination of the modified equation reveals the impor- serum refer to those measured with a standard electrolyte À panel. To calculate the anion gap, positive charges include tance of bicarbonate ion (HCO3 ) and dissolved carbon þ þ dioxide (PCO2) in the determination of pH. The pK is the sodium (Na ) and potassium (K ) while negative charges À À include bicarbonate (HCO ) and chloride (ClÀ). In normal pH at which the bicarbonate ion (HCO3 )andcarbon 3 dioxide (CO2) are equal. This value is approximately conditions, the measured cations exceed the measured 6.35. The 0.03 constant is used to describe the PCO2 anions (the normal anion gap), which is predominantly solubility. When changes occur in the pH due to PCO2 accounted for by the serum proteins. This normal value changes, the predominant system involved is the respira- for the anion gap ranges from 12 to 20 mEq/L (12–20 þ tory system. When changes in pH occur due to changes in mmol/L) when the K concentration is included and 8 to À 16 mEq/L (8-16 mmol/L) when it is not included. HCO3 , the predominant system involved is the metabolic À system. However, the system favors the HCO at physiologic þ þ À À 3 Anion Gap ¼ Na þ K À HCO þ Cl pH, therefore, the buffering ability of the metabolic system 3 ’ is dependent on the body s ability to eliminate CO2 through In the setting of low serum protein, such as hypoalbumi- the respiratory system. Thus, it is evident that two comple- nemia, the normal unmeasured anions are decreased and mentary systems, respiratory and metabolic, are used to the anion gap narrows. Thus, with critical illness when describe changes to the body’s pH. protein concentrations are oftenlow,anelevatedconcen- Clinically, the acid-base state is normally determined by tration of unmeasured anions can frequently be masked a blood gas sample. Although the gold standard remains by an apparently normal (falsely low) anion gap. Conse- arterial blood gas measurement, use of the venous or quently, the combination of the modified Henderson- capillary blood gas sample is prevalent within the pediatric Hasselbalch equation and the anion gap calculation begins population due to the relative ease in obtaining these sam- to illustrate an individual patient’sacid-basebalance. ples. Although minor differences exist within pH and PCO2 among the different blood gas sample types, these differ- ences can be accounted for during interpretation by assum- ing expected slight increases in PCO2 and decreases in pH TABLE 1. General Reference Ranges for Arterial for venous samples. As expected due to the location of the and Venous Blood Gases blood draw, venous blood gas samples are unreliable for PO2 measurements. Because capillary blood gradually transitions ARTERIAL VENOUS between arterial and venous states, the PCO2 and pH norma- pH 7.38 – 7.42 7.36 – 7.38 tive values often are between the arterial and venous norma- – – tive values. Of note, a blood gas machine measures the pH PO2 (mm Hg) 80 100 30 50 À – – and the partial pressure of the gases, but the HCO3 ion PCO2 (mm Hg) 38 42 43 48 concentration is a calculated value. À – – HCO3 (mmol/L) 22 24 25 26 In examining blood gases, acidosis occurs when the pH À¼ ¼ ¼ value is lower than normal. In contrast, alkalosis occurs HCO3 bicarbonate, PCO2 partial pressure of carbon dioxide, PO2 partial pressure of oxygen. Reference normal values are laboratory-dependent when the pH value is higher than normal. It is important to and may vary due to differing techniques. À characterize pH in context of PCO2 and HCO3 reference 362 Pediatrics in Review Downloaded from http://pedsinreview.aappublications.org/ by guest on November 14, 2018 The human body has a natural inclination toward a desired Extending from this initial assessment, additional clues from equilibrium, which accounts for the common finding of results of blood gas analysis and a basic metabolic panel reflect- compensatory changes in the opposite direction. Within set- ing the anion gap can help discern a primary metabolic versus tings of respiratory derangement leading to changes in the respiratory cause. Determining the acute or chronic nature of the pH, the compensatory mechanism occurs within the meta- compensation adds additional diagnostic information. bolic system. For respiratory acidosis (commonly arising due to an increase of PCO2), the body compensates by creating À METABOLIC ACIDOSIS metabolic alkalosis (from a retention of HCO3 ). In contrast, for respiratory alkalosis (commonly arising from a decrease A combination of the anion gap calculation and knowledge of of PCO2), the body compensates by creating metabolic acidosis the pH state within the body is required to describe metabolic À (from a loss of HCO3 ) (Table 2). Metabolic compensation to acidosis. The regulation of the acid-base state, as noted by the respiratory derangements often takes hours to days to estab- Henderson-Hasselbalch equation, is based on the buffering À lish. In comparison, compensatory mechanisms within the effect of HCO3 . However, from an electroneutrality view- respiratory system for primary metabolic derangements gen- point, use of the anion gap calculation can further differentiate erally occur more rapidly, often over minutes to hours. causes for the metabolic acidosis. Because reference values in the calculation of unmeasured anions or anion gap vary among laboratories, clinicians must be aware of normal values ASSESSMENT AND DETERMINATION OF for the laboratories they use. As noted previously, due to the ACID-BASE STATE importance of homeostasis, normal gap versus increased gap The first step in the assessment of an acid-base imbalance acidosis indicate vastly different clinical pictures. for a patient is to determine a primary respiratory versus primary metabolic etiology. A detailed history and compre- Hyperchloremic (Non-anion Gap) Metabolic Acidosis À À hensive physical examination can offer clues to the present- Chloride (Cl ) has an important relationship to HCO3 ing cause. Such evaluation may reveal a neurologic
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