Approach to Acid-Base

Disorders
Dr. Zeeshan Maqbool
Dr. M. Akram Asi

“Saving One Life Is As If Saving Whole Of Humanity…”

Quran 5:32
 CLINICAL CASE
Patient XYZ, 40 years old female, admitted due AKI
secondary to PPH, 5 times hemodialysis performed from
20 days.
Now she presented with persistent vomiting from 7 days,
gradual onset of SOB and leg swelling from 7 days
GPE: Pallor+, JVP+
CVS: S1+S2 and Gallope.
Resp: Bibasal fine crepitations.
CNS: Intact

Promptly hemodialysis performed and ABG’s done:

PH: 7.04
PC02: 37.6
PO2: 62
HC03: 10
Na: 128
K: 2.51
CL: 70.7

Single Acid Base Disorder…?

Double Acid Base Disorder..?
Tripple Acid Base Disorder..?
 Objectives
1. History and Physical Examination.
2. Acid Base Physiology.
3. Types of Acid-Base Disorders.
4. Compensation.
5. Anion Gap.
6. Delta AG
Delta HCO3
7. Practical Approach
 1. History & Physical Examination
 Presenting complain.
 HOPI.
 Past History.
 Drug History.

GPE: Vitals; BP, RR, Pulse, Temp.

Pallor, Pedal Edema, JVP, Cyanosis.
 Resp:
 CVS:
 Abdomen:
 CNS:
 2. Acid Production

Carbohydrates CO2+H2O+ATP
Fat CO2+PO4+H2O+ATP
Protein CO2+S04+H2O+ATP

CO2  Volatile Acid

PO4, SO4No Volatile Acids
 3. Acid-Base Disorders
Boston Method
PH: 7.35-7.45
pCO2: 35-45 mmHg
HCO3: 22-28 mmol/L

pH= 6.1 = log HCO3

0.03 x pCO2

--pH is directly proportional to HCO3

--pH is inversely proportional to pCO2
 Acid-Base Disorders
Carbon dioxide: Acidic
Bicarbonate ion: Basic

 If Carbon dioxide = PH = Acidosis

 If Carbon dioxide = PH = Alkalosis
 If Bicarbonate = PH = Alkalosis
 If Bicarbonate = PH = Acidosis
Simple (Single) Acid-Base Disorder

Metabolic Acidosis: PH , HCO3 , pCO2

Metabolic Alkalosis: PH , HCO3 , pCO2

Respiratory Acidosis: PH , pCO2 , HCO3

(Acute and Chronic)

Respiratory Alkalosis: PH , pCO2 , HCO3

(Acute and Chronic)
Back
 4. Expected Compensatory Responses and
Mixed Acid-Base Disorders
Metabolic Acidosis
pH Initial Chemical Compensatory Expected
Change Change Compensation
HCO3 PC02 PCO2=(1.5xHCO3)+8 +/-2.
PCO2=HCO3 + 15

If PC02 is equal to expected compensatory resp= Simple Metabolic Acidosis

If PC02 is lower than expected compensatory resp= Resp. Alkalosis also exists
If PC02 is More than expected compensatory resp= Resp. Acidosis also exists

Back
 Metabolic Alkalosis

pH Initial Chemical Compensatory Expected

Change Change Compensation
HCO3 PC02 PCO2=(0.9xHCO3)+9
PCO2=(0.7xHCO3)+20

If PC02 is equal to expected compensatory resp= Simple Metabolic Alkalosis

If PC02 is lower than expected compensatory resp= Resp. Alkalosis also exists
If PC02 is more than expected compensatory resp= Resp. Acidosis also exists
 Respiratory Acidosis
pH Initial Chemical Compensatory Expected
Change Change Compensation
PC02 HCO3 If Acute:
HCO3 1mEq for every 10mmHg
increase in PCO2

If Chronic:
HCO3 4mEq for every 10mmHg
increase in PCO2

If measured HCO3 = to expected compensatory resp= Simple Res. Acidosis

If measured HCO3 is > expected compensatory resp= Met. Alkalosis also exists
If measured HCO3 is < expected compensatory resp= Met. Acidosis also exists
 Respiratory Alkalosis
pH Initial Chemical Compensatory Expected
Change Change Compensation
PC02 HCO3 If Acute:
HCO3 2mEq for every 10mmHg
decrease in PCO2

If Chronic:
HCO3 5mEq for every 10mmHg
decrease in PCO2

If measured HCO3 = to expected compensatory resp= Simple Res. Acidosis

If measured HCO3 is > expected compensatory resp= Met. Alkalosis also exists
If measured HCO3 is < expected compensatory resp= Met. Acidosis also exists
 5. Anion GAP
Based on law of Electroneutrality(Emmet and Naris)

Cation charge Conc.=Anion Charge Conc.

Na+K=HCO3+CL+ (UMA)

AG = (Na+K) (HCO3+CL)
= (145+5) (28+110)
AG= 8-12 mEq/L
UMA= Unmeasured Anions (SO4,Pi,urate)
A-= Weak Acids; Albumin and Pi
 Corrected Anion Gap
(Figge and colleagues)
• If UMA increase, then the AG also increases.
• If UMA decrease, then the AG also decreases.

If Hypoalbuminemia, AG reduces 2.5mEq/L for each

1g/dl reduction of albumin.

AGc = AG+2.5(4-S/Albumin)

In Hypoalbuminemia, AG my be normal in DKA

 Interpretation of Anion Gap
Normal AG High AG Low AG
H.Hyperalimentation M. Methanol B. Bromide Intoxication
A. Acetazolamide U. Uremia P. Plasma cell dyscrasia
R. RTA D. DKA H. Hypoalbuminemia
D. Diarrhea P. Propylene Glycol M. Monoclonal Protein.
U. Uretosigmoid I. INH N. Normal Variant
fistula L. Lactic Acidosis
P. Pancreatic fistula E. Ethanol
E. Ehylene Intox.
S. Salicylates
 Delta AG
6. Delta HCO3
• Delta AG = Patient AG-Normal AG(12).
• Delta HCO3 = Patient HCO3- Normal HCO3(24)

 Increase in AG should be quantitatively similar to the

magnitude of reduction in HCO3.

 If 10mEq delta AG, then 10mEq delta HCO3 should

be decreased . And the net ratio should be 1
 Delta AG
Delta HCO3
• Delta AG
If Ratio is = 1; No other AB disorder
Delta HCO3

• Delta AG
Delta HCO3 If Ratio is >1; Met.Alkalosis

• Delta AG
Delta HCO3 If Ratio is <1; NAG Met.Acidosis

Back
 7. Practical Approach
Step 1: Dx of Primary disorder
Step 2: Compensation
Step 3: Calculate Anion Gap
Step 4: Delta AG
Delta HCO
 1. CLINICAL CASE
Patient XYZ, 40 years old female, admitted due AKI
secondary to PPH, 5 times hemodialysis performed from
20 days.
Now she presented with persistent vomiting from 7 days,
gradual onset of SOB and leg swelling from 7 days
GPE: Pallor+, JVP+
CVS: S1+S2 and Gallope.
Resp: Bibasal fine crepitations.
CNS: Intact

Promptly hemodialysis performed and ABG’s done:

PH: 7.04
PC02: 37.6
PO2: 62
HC03: 10
Na: 128
K: 2.51
CL: 70.7
Single Acid Base Disorder…?
Double Acid Base Disorder..?
Tripple Acid Base Disorder..?
 Step 1: Dx of Primary disorder
PH: 7.04 Metabolic Acidosis
PC02: 37.6 Step 2: Compensation
PCO2=(1.5xHCO3)+8 +/-2
PO2: 62
=(1.5x10)+8 +/-2
HC03: 10 = 23 +/-2
Na: 128 37.6 > 23
Respiratory Acidosis also exists
K: 2.51
Step 3: Calculate Anion Gap
CL: 70.7 AG= (Na+K)-(HCO3+Cl)
= (128+2.5)-(10+70)= 50
Step 4: Delta AG (50-12) =38
Delta HCO3(10-24) =14
Ratio is 2.71 (>1)
Metabolic Alkalosis also exists
 DX: Tripple Acid Base Disorder
• High AG Metabolic Acidosis : May be due to Uremia
• Respiratory Acidosis : May be due to Pulmonary Edema
• Metabolic Alkalosis: May be due to persistent vomiting
 2. CLINICAL CASE
• Patient XYZ, 26 years old female, admitted due
Salicylate poisoning, presenting severe epigastric
pain, vomiting and severe SOB
BP: 110/70
• GPE: Pulse: 110
• CVS: S1+S2 RR: 32
Temp: 99.8F
• Resp: 32 breaths/minute. SP02: 86%
• CNS: Intact

Ix: ABGs
PH: 7.32 Step 1: Dx of Primary disorder
PC02: 30 Metabolic Acidosis
HC03: 15 Step 2: Compensation
PCO2=(1.5xHCO3)+8 +/-2
Na: 140
= 30 +/-2
K: 5
30 = 30 +/-2
CL: 105 Appropriate compensaton exists
Step 3: Anion Gap
AG= (Na+K)-(HCO3+Cl)= 20

High AG Metabolic Acidosis with

appropriate Compensation
PH: 7.32 PH: 7.50
PC02: 30 PC02: 20
HC03: 15 HC03: 15
Na: 140 Na: 140
K: 5 K: 5
CL: 105 CL: 105

High AG Met.Acidosis High AG Met.Acidosis

with appropriate with Severe
Compensation Respiratory Alkalosis

1 2
 3. CLINICAL CASE
• Patient XYZ, 60 years old, 20 pack year smoker,
known case of COPD from 1 year also using loop
diuretics,Presented with c/o SOB, productive cough
• GPE: Tachycardia, tremors. BP: 110/70
• CVS: S1+S2 Pulse: 110
RR: 32
• Resp: Bilateral ronchi. Temp: 99.8F
• CNS: Intact SP02: 79%

Ix: ABGs
PH: 7.41 Step 1: Dx of Primary disorder
PC02: 60 Respiratory Acidosis
HC03: 37 Step 2: Compensation
--HCO3 4mEq for every 10mmHg
Na: 140 increase in PCO2.
K: 3.5 Caclulated HCO3 = 32
Actual HCO3 = 37
CL: 90
Metabolic Alkalosis also exists
 Validity of ABG’s
Hydrogen ions = 24 x PC02
HCO3
.