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1、A Practical Approach to Acid-Base Disorders,Bin DU,MDMedical Intensive Care UnitPeking Union Medical College Hospital,Primary Acid-Base Disorders,Rules of Thumb for Recognizing Primary Acid-Base Disorders Without Using a Nomogram,Simple Acid-Base Disorders,Acute Respiratory Alkalosis,Acute Respirato
2、ry Acidosis,Chronic Respiratory Acidosis With Metabolic Compensation,The Importance of Differentiating Acute From Chronic Respiratory Acidosis,Acute respiratory acidosisMedical emergency requiring emergent intubation and mechanical ventilationChronic respiratory acidosisOften a clinically stable con
3、dition,Metabolic Acidosis With Respiratory Compensation,Importance of Urinary Chloride Level in Metabolic Alkalosis,Low urinary chloride levelDecreased ECFOr posthypercapnic state,Normal or high urinary chloride levelNormal or increased ECFOr recent diuretic use,Urinary chloride level=preferred meth
4、od for assessing the renal response to circulating volume in patients with metabolic alkalosisUrinary sodium level=less reliable as a guide,Metabolic Acidosis With Respiratory Compensation,Mixed Acid-Base Disorders,ABG Interpretation,ABGpH 7.49,PCO2 47 mmHg,HCO3 35 mmol/L,Na 139 mmol/L,K 3 mmol/L,Cl
5、 89 mmol/LInterpretationSimple metabolic alkalosis with compensatory respiratory acidosis?orMixed metabolic alkalosis and respiratory acidosis?,Summary of Expected Compensation for Simple Acid-Base Disorders,Summary of Expected Compensation for Simple Acid-Base Disorders,ABG Interpretation,ABGpH 7.4
6、0,PCO2 40 mmHg,HCO3 24 mmol/L,Na 139 mmol/L,K 4 mmol/L,Cl 105 mmol/LCalculationAG=139 105 24=10Interpretationnormal,ABG Interpretation,ABGpH 7.49,PCO2 47 mmHg,HCO3 35 mmol/L,Na 139 mmol/L,K 3 mmol/L,Cl 89 mmol/LCalculationAG=139 89 35=15PCO2=0.6(HCO3)=0.6 x 11=6.6 mmHgInterpretationSimple metabolic
7、alkalosis,ABG Interpretation,ABGpH 7.45,PCO2 25 mmHg,HCO3 17 mmol/L,Na 139 mmol/L,K 3.5 mmol/L,Cl 107 mmol/LCalculationAG=139 107 17=15HCO3=2(PCO2/10)=2 x 15/10=3 mmHgInterpretationSimple respiratory alkalosis?,ABG Interpretation,ABGpH 7.65,PCO2 30 mmHg,HCO3 32 mmol/L,Na 139 mmol/L,K 2.8 mmol/L,Cl 9
8、2 mmol/LCalculationAG=139 92 32=15HCO3=2(PCO2/10)=2 x 10/10=2 mmHgInterpretationMixed metabolic and respiratory alkalosis,ABG Interpretation,ABGpH 7.67,PCO2 30 mmHg,HCO3 34 mmol/L,Na 140 mmol/L,K 3 mmol/L,Cl 94 mmol/LCalculationAG=140 94 34=12HCO3=2(PCO2/10)=2 x 10/10=2 mmHgInterpretationMixed metab
9、olic and respiratory alkalosis,ABG Interpretation,ABGpH 7.61,PCO2 30 mmHg,HCO3 29 mmol/L,Na 140 mmol/L,K 3 mmol/L,Cl 94 mmol/LCalculationAG=140 94 29=17HCO3=2(PCO2/10)=2 x 10/10=2 mmHgInterpretationMixed metabolic and respiratory alkalosis and lactic acidosis,ABG Interpretation,ABGpH 7.33,PCO2 70 mm
10、Hg,HCO3 36 mmol/L,Na 140 mmol/L,K 4.0 mmol/L,Cl 94 mmol/LCalculationAG=140 94 36=10HCO3=3.5(PCO2/10)=3.5 x 30/10=10.5 mmHgInterpretationSimple chronic respiratory acidosis,ABG Interpretation,ABGpH 7.40,PCO2 67 mmHg,HCO3 40 mmol/L,Na 140 mmol/L,K 3.5 mmol/L,Cl 90 mmol/LCalculationAG=140 90 40=10HCO3=
11、3.5(PCO2/10)=3.5 x 27/10=9.5 mmHgInterpretationMixed respiratory acidosis and metabolic alkalosis,ABG Interpretation,ABGpH 7.11,PCO2 16 mmHg,HCO3 5 mmol/L,Na 140 mmol/L,K 4.5 mmol/L,Cl 125 mmol/LCalculationAG=140 125 5=10PCO2=11 mmHgInterpretationSimple hyperchloremic metabolic acidosis,ABG Interpre
12、tation,ABGpH 7.11,PCO2 16 mmHg,HCO3 5 mmol/L,Na 140 mmol/L,K 4.0 mmol/L,Cl 105 mmol/LCalculationAG=140 105 5=30PCO2=11 mmHgInterpretationSimple high AG metabolic acidosis,ABG Interpretation,ABGpH 7.11,PCO2 16 mmHg,HCO3 5 mmol/L,Na 140 mmol/L,K 4.0 mmol/L,Cl 115 mmol/LCalculationAG=140 115 5=20PCO2=1
13、1 mmHgInterpretationMixed hyperchloremic and high AG metabolic acidosis,Is There A Simple Way?,Mixed Acid-Base Disorders,ABGpH 7.32,PCO2 28 mmHg,HCO3 14 mmol/L,BUN 100 mmol/LInterpretationAcidemic with low PCO2 and low bicarbonate concentrationLow bicarbonate as a primary disorder metabolic acidosis
14、(secondary to renal failure)PaCO2 30 in the presence of low HCO3 primary respiratory alkalosis,PaCO2 30 in the presence of low HCO3 primary respiratory alkalosis,Mixed Acid-Base Disorders?,ABGpH 7.12,PCO2 88 mmHg,HCO3 28 mmol/LInterpretationAcidemic with high PCO2 and high bicarbonate concentrationH
15、igh PCO2 as a primary disorder respiratory acidosis(secondary to cor pulmonale)HCO3 30 in the presence of acutely elevated PCO2 primary metabolic alkalosisHCO3 45 in the presence of chronically elevated PCO2 primary metabolic alkalosis,HCO3 30 in the presence of acutely elevated PCO2orHCO3 45 in the
16、 presence of chronically elevated PCO2 primary metabolic alkalosis,Mixed Acid-Base Disorders?,ABGpH 7.50,PCO2 38 mmHg,HCO3 31 mmol/L,K 3.5 mmol/LInterpretationAlkalemic with low PCO2 and high bicarbonate concentrationHigh HCO3 as a primary disorder metabolic alkalosis PCO2 55 in the presence of elev
17、ated HCO3 primary respiratory alkalosis,PCO2 55 in the presence of elevated HCO3 primary respiratory acidosis,Mixed Acid-Base Disorders?,ABGpH 7.48,PCO2 29 mmHg,HCO3 23 mmol/LInterpretationAlkalemic with low PCO2 and normal bicarbonate concentrationLow PCO2 as a primary disorder respiratory alkalosi
18、s(secondary to asthma)HCO3 20 in the presence of acutely decreased PCO2 primary metabolic acidosisHCO3 15 in the presence of chronically decreased PCO2 primary metabolic acidosis,HCO3 20 in the presence of acutely decreased PCO2orHCO3 15 in the presence of chronically decreased PCO2 primary metaboli
19、c acidosis,Is There Another Solution?,Rules of Thumb for Recognizing Primary Acid-Base Disorders Without Using a Nomogram,The Relation Between Level of Anion Gap and Biochemical Diagnoses in 51 Patients Without Renal Failure*,The Effect of Unmeasured Acid on the Bicarbonate Concentration,Anion Gap,a
20、nd Excess Anion Gap,mmol/L,Na+,Cl-,Cl-,HCO3-,HCO3-,Normal Anion Gap,Normal Anion Gap,ExcessAnion Gap,Metabolic Acidosis(anion gap),Normal,Respiratory Alkalosis And Metabolic Acidosis,ABGpH 7.50,PCO2 20 mmHg,HCO3 15 mmol/L,Na 140 mmol/L,Cl 103 mmol/LInterpretationAlkalemic with low PCO2 and low bicar
21、bonate concentrationLow PCO2 as a primary disorder respiratory alkalosisAG=140(103+15)=22 20 anion gap metabolic acidosisExcess AG=22 12=10 mmol/LExcess AG+HCO3=25 mmol/L no further primary abnormalities,Respiratory Alkalosis And Metabolic Acidosis,DiagnosisRespiratory Alkalosis And Metabolic Acidos
22、isReasonIngestion of a large quantity of aspirinCentrally mediated respiratory alkalosisAnion gap metabolic acidosis associated with salicylate overdose,Metabolic Alkalosis And Metabolic Acidosis,ABGpH 7.40,PCO2 40 mmHg,HCO3 24 mmol/L,Na 145 mmol/L,Cl 100 mmol/LInterpretationNormal ABGAG=145(100+24)
23、=21 20 anion gap metabolic acidosisExcess AG=21 12=9 mmol/LExcess AG+HCO3=33 mmol/L metabolic alkalosis,Metabolic Alkalosis And Metabolic Acidosis,DiagnosisMetabolic Alkalosis And Metabolic AcidosisReasonChronic renal failure(metabolic acidosis)Vomiting(metabolic alkalosis),Respiratory Alkalosis,Met
24、abolic Acidosis and Metabolic Alkalosis,ABGpH 7.50,PCO2 20 mmHg,HCO3 15 mmol/L,Na 145 mmol/L,Cl 100 mmol/LInterpretationAlkalemic with low PCO2 and low bicarbonate concentrationLow PCO2 as a primary disorder respiratory alkalosisAG=145(100+15)=30 20 anion gap metabolic acidosisExcess AG=30 12=18 mmo
25、l/LExcess AG+HCO3=33 mmol/L metabolic alkalosis,Respiratory Alkalosis,Metabolic Acidosis and Metabolic Alkalosis,DiagnosisRespiratory Alkalosis,Metabolic Acidosis and Metabolic AlkalosisReasonHistory of vomiting(metabolic alkalosis)Evidence of alcoholic ketoacidosis(metabolic acidosis)Bacterial pneu
26、monia(respiratory alkalosis),Respiratory Acidosis,Metabolic Acidosis and Metabolic Alkalosis,ABGpH 7.10,PCO2 50 mmHg,HCO3 15 mmol/L,Na 145 mmol/L,Cl 100 mmol/LInterpretationAcidemic with elevated PCO2 and low bicarbonate concentrationIncreased PCO2 and decreased bicarbonate both as primary disorders
27、 respiratory acidosis and metabolic acidosisAG=145(100+15)=30 20 anion gap metabolic acidosisExcess AG=30 12=18 mmol/LExcess AG+HCO3=33 mmol/L metabolic alkalosis,Respiratory Acidosis,Metabolic Acidosis and Metabolic Alkalosis,DiagnosisRespiratory Acidosis,Metabolic Acidosis and Metabolic AlkalosisR
28、easonObtunded state(respiratory acidosis)History of vomiting(metabolic alkalosis)Diabetic ketoacidosis(metabolic acidosis),Anion Gap and Nonanion Gap Metabolic Acidosis,ABGpH 7.15,PCO2 15 mmHg,HCO3 5 mmol/L,Na 140 mmol/L,Cl 110 mmol/LInterpretationAcidemic with low PCO2 and low bicarbonate concentra
29、tionLow bicarbonate as a primary disorder metabolic acidosis with respiratory compensation?AG=140(110+5)=25 20 anion gap metabolic acidosisExcess AG=25 12=13 mmol/LExcess AG+HCO3=18 mmol/L nonanion gap metabolic acidosis,Anion Gap and Nonanion Gap Metabolic Acidosis,DiagnosisAnion Gap and Nonanion Gap Metabolic AcidosisReasonDiabetic ketoacidosis(anion gap acidosis)Failure to regenerate bicarbonate from ketoacids lost in the urine during recovery phase of diabetic ketoacidosis(nonanion gap metabolic acidosis),
