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Clinical Approach to the Patient with Potential Acid- Base Disturbances

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Clinical Approach to the Patient with Potential Acid- Base Disturbances Iran J Ped Education Article June 2007, Vol 17 (No 2), Pp:171-178 Clinical Approach to the Patient with Potential Acid- Base Disturbances Farahnak Assadi*1, MD 1. Pediatric Nephrologist, Rush University Medical Center, Chicago, IL, USA Received: 3/1/07; Accepted:7/4/07 Introduction • Renal failure = metabolic acidosis • Hepatic failure = respiratory alkalosis Patient can present with normal acid-base • Vomiting = metabolic alkalosis balance, a single disorder, or multiple • Diarrhea = metabolic acidosis combinations of two or three disorders. The pH • Thiazide and loop diuretics = metabolic can be estimated in a patient with a single alkalosis disturbance using the formulas which describe • Acetazolamide = metabolic acidosis predicted compensation. Situations which are often associated with Blood gas studies are required for diagnosis mixed disturbances include: and pH estimation when more than one • Pulmonary edema or asthma: Respiratory disturbance may be present or when the alkalosis followed by respiratory acidosis information is insufficient to allow diagnosis (as the condition worsens) and metabolic of a single disturbance with confidence (e.g., acidosis (lactic acidosis due to hypoxia). the patient is unable to give an adequate • Sepsis: Respiratory alkalosis and metabolic history). acidosis (lactic acidosis) The diagnostic approach to acid-base • Hepatorenal syndrome: Respiratory disorders utilizes information from the history alkalosis (liver failure) and metabolic and physical examination, venous blood acidosis (renal failure) laboratory studies, and arterial blood gas • Cardiopulmonary arrest: Respiratory studies in a stepwise fashion. acidosis (lack of pulmonary function) and metabolic acidosis (lactic acidosis due to Step 1. Identify potential processes in the tissue hypoperfusion) history, and recognizeArchive the situations that often of• Salicylate SID poisoning: Respiratory alkalosis are associated with mixed disturbances. (due to stimulation of respiratory system by Potential processes which can be identified in salicylate) and metabolic acidosis (due to the history include: salicylic acid) • Congestive hear failure = respiratory • Use of diuretics to treat right sided failure in alkalosis chronic lung disease: Metabolic alkalosis • Pneumonia = respiratory alkalosis (diuretics) and chronic respiratory acidosis (tachypnea) (chronic lung disease) • Obstructive airway disease = chronic respiratory acidosis * Correspondence author. Address: Rush University Medical Center, 1725 West Harrison St, 718 Professional Bldg, Chicago, IL. USA E-mail: [email protected] www.SID.ir 172 Approach to the potential acid-base disturbance, F Assadi • Vomiting in a patient with renal failure: If high, there is either metabolic alkalosis or Metabolic alkalosis plus metabolic acidosis chronic respiratory acidosis. Determine which fits better with the history and physical examination. Step 2. Review the physical examination for • Delta (Anion gap): Is the AG increased clues to diagnoses. This is usually much less above normal (ie, >12-13 mEq/L)? productive than a good history. Clues include: • Tachypnea = respiratory alkalosis If no, a process which produces H+ in • Tetany (Chvostek or Trousseau sign) = low association with anions (lactate, Keto- ionized Ca concentration. Alkalosis lowers acidosis, etc) is not present. the ionized Ca concentration by increasing Ca binding to protein If yes, by definition there is present a • Hypotension = hypoperfusion with process that is producing acid (ie, H+ in metabolic acidosis from lactic acid association with an anion). production. • Edema can indicate congestive heart failure If this AG is increased above normal, there which is often associated with respiratory should be concordance between the fall in alkalosis the HCO3 concentration and the increase in • Jaundice, ascites and tremor can indicate AG. If there is not concordance, several impending liver failure which is associated processes are present. with respiratory alkalosis As an example, a patient presents with diabetic ketoacidosis and the following set of electrolytes is obtained: Na 140, Cl 102, K 5.1, Step 3. Review the laboratory data. Laboratory HCO3 10. The AG is 28 and it has increased by data provide information on organ function as 15-16 from a normal value of 12-13. The well as the electrolytes which provide specific HCO3 has fallen by 15 from a normal value of information relative to acid-base. 25. The concordance in the change in the First check the studies that indicate organ HCO3 and the AG is consistent with a simple function and provide potential diagnoses. disturbance of metabolic acidosis. • The BUN and creatinine indicate renal However, if the values were Na 140, Cl failure 108, K 5.1, HCO3 10, there is not concordance. • Liver enzyme tests indicate hepatic function The AG is 22, an increase of 10-11 above the • Positive blood cultures would confirm the normal while the HCO3 fell by 15. Therefore, presence of sepsis some process in addition to increased Next evaluate the electrolytes as follows: metabolic acid production is contributing to the fall in HCO3 without affecting the AG. This • HCO3 Concentration: Is the total CO2 (the could be respiratory alkalosis or it could be bicarbonate concentration) normal, non-AG metabolic acidosis (eg, from diarrhea) decreased orArchive increased?) ofboth conditions SID which lower the HCO3 If normal, either the patient has no acid- concentration but do not increase the AG. base disturbances or he has more than one (ie, a mixed or complex disturbance) each of which influences the HCO3 in a different Step 4. Assemble a tentative acid-base diag- direction. nosis using the information obtained with the history, physical examination and laboratory If low, there is either metabolic acidosis or data. respiratory alkalosis. Determine which fits • Simple disturbance: If all the data sources better with the history and physical are consistence with the presence of a single examination. disturbance, estimate the pH from the www.SID.ir Iran J Pediatr, Vol 17 (No 2), June 2007 173 bicarbonate concentration using the modified Normal Compensation Henderson Hasselbach equation as follows: The following equations are used to evaluate H+= 24 pCO : HCO . To convert H into pH 2 3 the appropriateness of compensation for a use the equation listed below: single acid-base disorder. + Δ10 nEq/L increment in H =Δ0.10 fall in Acute respiratory acidosis: ΔHCO3=0.1 ΔpCO2 pH The plasma HCO3 concentration rises by (every 0.1 fall in pH is equivalent to a 10 1mEq/L for every 10 mmHg elevation in the + nEq/L rise in plasma H concentration): pCO2 pH H+ (nEq/L) • Acute respiratory Alkalosis: ΔHCO = 0.2 7.40 = 40 3 ΔpCO : The plasma HCO concentration 7.30 = 50 2 3 falls by 2 mEq/L for every 10 mmHg 7.20 = 60 decline in the pCO . 7.10 = 70 2 Blood gases are not necessary unless there is • Chronic respiratory acidosis: Δ HCO3= likely to be a marked change in pH. 0.3 ΔpCO2: The plasma HCO3 concent- ration rises by 3 mEq/L for every 10 mmHg • Complex disturbance: If the data suggest elevation in the pCO2. that there is more than one disturbance • Chronic respiratory alkalosis: Δ HCO3= present, the pH can not be estimated. It is 0.4 ΔpCO2: The plasma HCO3 concen- necessary to measure the pH to corroborate tration falls by 4 mEq/L for every 10 mmHg the diagnoses present and to determine decline in the pCO2. treatment for the abnormal pH. • Metabolic acidosis: Δ pCO2= 1.2Δ HCO3: Mistakes can be made in the laboratory. The respiratory compensation results in a Always ensure the blood gas data are correct 1.2 mmHg fall in the pCO2 for every 1 (ie, fit the Henderson Hasselbach equation mEq/L reduction in serum HCO3 before using the information). If the data are concentration. correct, are they consistent with normal • Metabolic alkalosis: Δ pCO2= 0.6 Δ compensation of a simple disturbance? If yes, HCO3: The respiratory compensation the process is complete. If no, why? When you results in an increase in pCO2 of 0.6 mmHg are happy with the validity of the pH and the for every 1 mEq/L elevation in serum HCO3 diagnosis, complete a treatment plan. concentration. ACID-BASE DISTURBANCES CLINICAL QUIZ 1. A 12-year Archiveold female is brought to the ofWhat do SIDyou estimate her arterial pH to be? Emergency Room because of increasing A. 7.20-7.24 weakness. She had been having low grade B. 7.25-7.29 fever and severe diarrhea for four days. C. 7.30-7.34 Laboratory studies reveal sodium 140 mEq/L, D. 7.40-7.44 potassium 2.4 mEq/L, chloride 115 mEq/L, E. 7.45-7.49 bicarbonate 15 mEq/L, BUN 21 mg/dL, The correct answer is C. The acid-base creatinine 1.5 mg/dL, glucose 88 mg/dL, diagnosis is uncomplicated hyperchloremic calcium 10.0 mg/dL, phosphate 3.5 mg/dL, acidosis due to severe diarrhea. This would magnesium 1.8 mg/dL, and plasma osmolality allow you to estimate her pCO from Winter’s 284 mosmol/kg. 2 formula which applies only when simple www.SID.ir 174 Approach to the potential acid-base disturbance, F Assadi (uncomplicated) metabolic acidosis is present: Would you like to draw a blood gas? ΔpCO2 =1.2 x ΔHCO3 or 12 mmHg. Thus, the A. Yes, I believe one is indicated predicted pCO2 compensation would be 28 B. No, I do not believe it is necessary mmHg, the difference between normal pCO2 The correct answer is A. A blood gas is and the expected fall in pCO2 [normal pCO2 indicated in this case. This is because you (40)] – [ΔpCO2 (12)]. The pH can then be cannot be sure that there is only one acid-base calculated with the modiefied Henderson- disturbance present when there is no history + Hasselbach equation: H = 24 x pCO2 : HCO3. available and thus you cannot predict the pH. The value obtained is 45 nEq/L, which is equivalent to a pH of 35.0 (every 0.1 fall in pH 3.
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