ABG (Kane) Multiple Choice Flashcards
Which of the following best describes the normal pH range of human blood?
a) 7.0 - 7.2
b) 7.35 - 7.45
c) 7.5 - 8.0
d) 6.5 - 7.0
Answer: b) 7.35 - 7.45
7.4 is what we will be using in class
Why is the pH of blood tightly regulated within a narrow range?
a) To maintain hormone levels
b) To ensure optimal function of enzymatic reactions.
c) To ensure optimal function of non-enzymatic reactions
d) To control the level of electroyltes coming in and out of our body
Answer: b) To ensure optimal function of enzymatic reactions.
An increase in H+ ions will lower the pH (making it more acidic), while an increase in OH- ions will raise the pH (making it more basic).
What effect does a change in the relative concentration of ions in water have on pH?
a) It only affects temperature, not pH.
b) It disassociates water into glucose molecules.
c) It alters the auto-ionization of water
d) It dissasociates water into only protons H+
Answer: c) It alters the auto-ionization of water into H+ or OH- ions, thus changing the pH.
Change in relative concentrations of F/E (Fluid and electrolytes) changes waters ability to auto-ionize (dissasociate into H+ or OH- ions and alter pH)
In the context of acid-base balance, what significant observation did O’Shaughnessy make in 1831 regarding cholera patients?
a) They had elevated levels of calcium in their blood.
b) They had a loss of carbonate of soda.
c) They had a decrease in enzymatic activity.
d) They showed septic signs d/t increased carbonate soda levels
b) They experienced a loss of carbonate of soda.
Which of the following best describes the relationship between alkalemia and hydrogen ions (H+)?
a) Excess production of OH- ions in relation to H+ ions.
b) Excess production of H+ ions in relation to OH- ions
c) Balance between H+ and OH- ions.
d) None of the above
Answer: a) Excess production of OH- ions in relation to H+ ions.
Increased OH- ions and decreased H+ therefore increased pH
In which condition would you expect a higher concentration of H+ ions relative to OH- ions?
a) Alkalemia
b) Neutral pH
c) Acidemia
d) Alkalosis
Answer: c) Acidemia
What does the pH scale measure?
a) The concentration of hydroxyl ions (OH-) and hydrogen ions (H+).
b) The concentration of hydroxyl ions (OH-) in a solution.
c) The concentration of hydrogen ions (H+) in a solution.
d) The enzymatic level of electrolytes.
c) The concentration of hydrogen ions (H+) in a solution.
Why is pH often referred to as “the power of hydrogen”?
a) It measures the energy produced by hydrogen.
b) It represents the concentration of hydrogen ions in terms of logarithmic power.
c) It indicates the weight of hydrogen atoms in a solution in terms of logarithmic power.
d) It calculates the force exerted by hydrogen in a solution.
b) It represents the concentration of hydrogen ions in terms of logarithmic power.
How does the body manage the removal of CO2 to help stabilize pH levels?
a) It enters through lungs and leaves through the digestive system.
b) It enters and leaves through the lungs during respiration.
c) It enters the lungs and is stored in muscle tissues.
d) It enters through the lungs and leaves through the sweat glands.
b) Enters/leaves the lungs during respiration.
Which organ is primarily responsible for managing bicarbonate (HCO3-) levels in the body to maintain pH balance?
a) Liver
b) Pancreas
c) Kidneys
d) Intestines
C) Kidneys
In which part of the kidney is hydrogen ion (H+) reabsorption primarily regulated to help maintain pH stability? Select 2
a) Collecting Ducts
b) Proximal tubule
c) Loop of Henle
d) Distal tubule
e) Glomerulus
a) Collecting Ducts
d) Distal tubule
The Henderson-Hasselbalch equation is used to calculate pH. Which of the following correctly represents this equation?
a) pH = 6.1 + log (HCO3-/0.03 x SvCO2)
b) pH = 7.4 + log (H2O/CO2)
c) pH = 6.1 + log (HCO3-/0.03 x PaCO2)
d) pH = 5.5 + log (HCO3-/0.03 x PaCO2))
c) pH = 6.1 + log (HCO3-/0.03 x PaCO2)
Henderson-Hasselbalch coined “acid-base” balance
Which property allows water to act as both an acid and a base?
a) Alcalescent nature
b) Amphoteric nature
c) Alkalescent nature
d) Amphiprotic nature
b) Amphoteric nature
How does HCL hydrochloric acid interact with water?
a) Water acts as an acid and donates a proton to HCl.
b) Water acts as a base and accepts a proton from HCl.
c) Water remains neutral and does not react with HCl.
d) Water acts as a base and donates a proton from HCL.
b) Water acts as a base and accepts a proton from HCl.
How does potassium hydroxide (KOH) interact with water?
a) Water acts as an acid and donates a proton to KOH.
b) Water acts as a base and accepts a proton from KOH.
c) Water remains neutral and does not react with KOH.
d) Water acts as a base and donates a proton from KOH.
a) Water acts as an acid and donates a proton to KOH.
Why is lactic acid (pKa 3.4) considered a strong acid in the context of its dissociation in water?
a) Because it has a high pKa value.
b) Because it completely dissociates in water.
c) Because it is less soluble in water.
d) Because it is a neutral molecule in water.
b) Because it completely dissociates in water
LA (pKa 3.4) completely dissociates in water.. therefore strong acid
Which of the following best describes carbonic acid (H2CO3) in water based on its pKa (6.4) value?
a) It is a strong acid because it completely dissociates in water.
b) It is a strong acid because it incompletely dissociates in water.
c) It is a weak acid because it completely dissociates in water.
d) It is a weak acid because it incompletely dissociates in water.
d) It is a weak acid because it incompletely dissociates.
Which principle ensures that the total positive charge in a solution must equal the total negative charge?
a) Mass Conservation
b) Dissociation Equilibria
c) Electrical Neutrality
d) Chemical Equilibrium
c) Electrical Neutrality
*The sum of all positive charges in a system must equal the sum of all negative charges.
For example: NaCl –> The number of Na+ ions is equal to the number of Cl- ions to maintain pH balance in biological systems
Which of the following describes the concept of dissociation equilibria?
a) The rate at which a large compound evaporates in a solution.
b) A larger complex to separates into its smaller parts
c) The rate at which a compound turns from a liquid into a solid.
d) When a large compound goes through a chemical reaction and does not change
b) b) A larger complex to separates into its smaller parts
Kane describe this as things breaking into pieces or chunks, not staying solid. The sum of cations are equal to anions
Example - Acids produce hydrogen ions due to dissociation. Consider the ionization of hydrochloric acid,
HCl → H+(aq) + Cl-(aq).
What does the principle of mass conservation state about chemical reactions?
a) The total mass of reactants must be greater than the total mass of products.
b) The total mass of reactants is equal to the total mass of products.
c) Mass can be created during the reaction process.
d) The total mass changes based on reaction conditions.
b) The total mass of reactants is equal to the total mass of products.
Kane says the AMOUNT matters not the size. You cannot lose substance or create a new substance
Science says: The total mass of substances before a chemical reaction is equal to the total mass of substances after the reaction, reflecting the law of conservation of mass.
What is a defining characteristic of strong ions in a solution?
a) They only partially dissociate in solution.
b) They completely dissociate in solution
c) They do not dissociate at all in solution.
d) They change their dissociation based on the temperature of the solution.
b) They completely dissociate into their constituent ions in solution.
Which of the following are considered the most abundant strong ions in the extracellular fluid (ECF)?
a) Potassium (K+) and Magnesium (Mg2+)
b) Sodium (Na+) and Chloride (Cl-)
c) Sulfate (SO42-) and Calcium (Ca2+)
d) Potassium (K+) and Calcium (Ca2+)
b) Sodium (Na+) and Chloride (Cl-)
Which statement is true about the Strong Ion Difference (SID) in the extracellular fluid (ECF)?
a) SID is always negative in the ECF.
b) SID is always positive in the ECF.
c) SID equals zero in the ECF.
d) SID fluctuates between positive and negative values in the ECF.
b) SID is always positive in the ECF.
Strong cations-strong anions
This keep pH balance
Which of the following ions contribute to the Strong Ion Difference (SID) in the ECF? Select 6
a) HCO3-
b) Ca2+
c) Na+
d) K+
e) NH4+
f) Cl-
g) Mg2+
i) PO43-
j) SO42-
b) Ca2+
c) Na+
d) K+
f) Cl-
g) Mg2+
j) SO42- (sulfate)
Chemistry ptsd anyone?
If a patient’s blood pH is measured to be 7.25, how is this classified?
a) Normal
b) Acidic (Acidosis)
c) Alkaline (Alkalosis)
d) Hypertonic
Answer: b) Acidic (Acidosis)
pH has decreased
Which of the following blood pH values indicates alkalosis?
a) 7.20
b) 7.35
c) 7.40
d) 7.50
d) 7.50
pH has increased
In a scenario where both PaCO2 and HCO3- levels are increased from their normal values, what can be inferred?
a) There is a mixed acid/base disorder.
b) There is a primary disorder with tertiary compensation.
c) There is a primary disorder with secondary compensation.
d) There is no significant disturbance.
c) There is a primary disorder with secondary compensation.
Which condition is suggested if PaCO2 is decreased and HCO3- is increased from normal?
a) Primary respiratory acidosis with metabolic compensation
b) Primary metabolic alkalosis with respiratory compensation
c) Mixed acid/base disorder
d) Primary respiratory alkalosis with metabolic compensation
c) Mixed acid/base disorder
Given the values: pH 7.33, PCO2 48, HCO3- 26
What type of acid-base disturbance is present?
a) Metabolic acidosis with respiratory compensation
b) Respiratory acidosis with metabolic compensation
c) Metabolic alkalosis with respiratory compensation
d) Respiratory alkalosis with metabolic compensation
Normal: pH 7.35-7.45, PCO2 35-45, HCO3 22-26
b) Respiratory acidosis with metabolic compensation
The high normal HCO3- (26 mEq/L) indicates metabolic compensation, as the kidneys retain bicarbonate to buffer the excess CO2.
ROME - Respiratory Opposite, Metabolic Equal
Given the values: pH 7.58, PCO2 35, HCO3- 29
What type of acid-base disturbance is present?
a) Metabolic acidosis with respiratory compensation
b) Respiratory acidosis with metabolic compensation
c) Metabolic alkalosis with respiratory compensation
d) Respiratory alkalosis with metabolic compensation
Normal: pH 7.35-7.45, PCO2 35-45, HCO3 22-26
c) Metabolic alkalosis with respiratory compensation
The **low normal **PCO2 (35 mm Hg) shows respiratory compensation, where the lungs are expelling CO2 to counteract the high bicarbonate levels.
Given values: pH 7.28, PCO2 46, HCO3- 18
What type of acid-base disturbance is present?
a) Mixed Respiratory/Metabolic Acidosis
b) Respiratory acidosis with metabolic compensation
c) Metabolic alkalosis with respiratory compensation
d) Respiratory alkalosis with metabolic compensation
Normal: pH 7.35-7.45, PCO2 35-45, HCO3 22-26
a) Mixed Respiratory/Metabolic Acidosis
The increased PCO2 (46 mm Hg) indicates that respiratory compensation has not fully occurred, but the body is retaining CO2 due to possible decreased respiratory function.
Given values: pH 7.48, PCO2 32, HCO3- 22
What type of acid-base disturbance is present?
a) Metabolic acidosis with respiratory compensation
b) Respiratory acidosis with metabolic compensation
c) Metabolic alkalosis with respiratory compensation
d) Respiratory alkalosis with metabolic compensation
Normal: pH 7.35-7.45, PCO2 35-45, HCO3 22-26
d) Respiratory alkalosis with metabolic compensation
The **low normal **HCO3- (22 mEq/L) indicates that metabolic compensation is in effect, where the kidneys are excreting bicarbonate to counteract the loss of CO2 from hyperventilation.
Acidosis can significantly impact the heart’s function. How does a pH of 7.2 specifically affect the heart?
A) Increased contractility due to acidosis
B) No effect on contractility
C) Impaired contractility due acidosis
D) Impaired contractility due to increased calcium availability
C) - Acidosis impairs the heart’s contractility
How does acidosis affect arterial blood pressure?
A) It increases arterial blood pressure
B) It decreases arterial blood pressure
C) It stabilizes arterial blood pressure
D) It has no direct effect on arterial blood pressure.
B - Acidosis decreases arterial blood pressure primarily through vasodilation and reduced myocardial contractility, leading to lower cardiac output.
Acidosis makes the cardiovascular system more sensitive to re-entry dysrhythmias. Which factor contributes most to this increased sensitivity?
A) Enhanced conduction velocity in myocardial tissue
B) Decreased repolarization period of myocardial cells
C) Increased repolarization period of myocardial cells
D) Uniform repolarization of cardiac cells
B - Acidosis alters ion channel function. It delays or decreases repolarization and conduction in the myocardium, increasing sensitivity to re-entry dysrhythmias.
Kane - more sensitive to cyclic arrythmias, never have that repolarization, no break/rest, continuosly depolarize, more susceptible to Vtach
Acidosis affects the threshold for ventricular fibrillation (v-fib). Which statement best describes this effect?
A) Increases the threshold for v-fib
B) Decreases the threshold for v-fib
C) Does not alter the threshold for v-fib
D) Only affects atrial fibrillation threshold, not v-fib
B - Acidosis decreases the threshold for ventricular fibrillation, making it easier for the heart to enter this life-threatening rhythm.
Regarding the impact of acidosis on the responsiveness to catecholamines, which statement is accurate for a pH of 7.1?
A) Increased responsiveness to catecholamines
B) No change in responsiveness to catecholamines
C) Decreased responsiveness to catecholamines
D) Enhanced catecholamine release but decreased receptor sensitivity
C) - Acidosis decreases the responsiveness to catecholamines, which are critical for stimulating heart rate and contractility.
Kane - If the pt is in vtach or vfib and we are trying to give vaso/epi, these drugs are a whole lot less responsive
Acidosis can lead to various levels of altered consciousness. Which of the following best describes obtundation?
A) Complete unresponsiveness with no arousal to stimuli
B) Slight confusion with full alertness
C) Decreased alertness with diminished response to stimuli
D) Full alertness but with significant motor impairment
C - Obtundation is characterized by decreased alertness and a diminished response to stimuli, which can occur with acidosis
How does severe acidosis affect consciousness?
A) Enhances mental clarity and alertness
B) Causes mild confusion and disorientation
C) Can lead to coma
D) Leads to hyperactivity and increased motor function
C - Severe acidosis can lead to coma, a state of profound unresponsiveness due to significant depression of central nervous system activity.
Kane -First obtundation and then coma, its a continuation per Kane
How does the body initially respond to acidosis to compensate and maintain normal pH levels?
A) Decreased respiratory rate to retain CO2 levels in the blood
B) Hyperventilation to increase minute ventilation and decrease CO2 levels
C) Hypoventilation to increase minute ventilation and decrease CO2 levels
D) No change in respiratory rate as the body uses renal compensation
B - The body responds to acidosis by hyperventilating to increase minute ventilation and blow off CO2, thereby reducing the acid load and increasing pH.
Acidosis often leads to a sensation of difficulty breathing. What term best describes this symptom?
A) Eupnea
B) Dyspnea
C) Apnea
D) Bradypnea
B) Dyspnea is the term that describes the sensation of difficulty or labored breathing commonly experienced during acidosis.
In acidosis, why might respiratory muscle fatigue become a significant clinical concern?
A) Because the muscles adapt and become less efficient at sustaining increased ventilation
B) Because long-term hyperventilation leads to overexertion and muscle weakness
C) Because the kidneys can no longer compensate for the acid-base imbalance
D) Because CO2 levels become too low to maintain normal respiratory function
B - In acidosis, respiratory muscle fatigue becomes a significant concern because long-term hyperventilation can lead to overexertion and subsequent muscle weakness.
Which of the following is a consequence of acidosis related to metabolism?
a) Hypokalemia
b) Hypocalcemia
c) Hypercalcemia
d) Hyperkalemia
d) Hyperkalemia
Acidosis can lead to __________ resistance, affecting glucose metabolism.
a) Leptin
b) Glucagon
c) Insulin
d) Somatostatin
c) Insulin
Acidosis results in the inhibition of __________ glycolysis.
a) Aerobic
b) Anaerobic
c) Both aerobic and anaerobic
d) Neither aerobic nor anaerobic
b) Anaerobic
How is Respiratory Acidosis defined? “An acute decrease in alveolar ventilation results in __________.”
a) Increased PaCO2
b) Decreased PaCO2
c) Decreased HCO3-
d) Increased HCO3-
a) Increased PaCO2
Aka “resp failure”
Respiratory acidosis is characterized by a pH level of __________.
a) > 7.45
b) < 7.35
c) 7.35-7.45
d) Exactly 7.40
b) < 7.35
Which of the following is NOT a cause of respiratory acidosis?
a) Drug-induced ventilatory depression
b) Upper airway obstruction
c) Status asthmaticus
d) Hyperventilation
d) Hyperventilation
Which acid-base imbalance is seen the most or is caused by providers the most?
A) Respiratory Alkalosis
B) Metabolic Alkalosis
C) Respiratory Acidosis
D) Respiratory Alkalosis
C) Respiratory Acidosis
Which cause of respiratory acidosis is seen more often and considered Central ventilation control?
A) Status asthmaticus
B) Malignant hyperthermia
C) Disorder of neuromuscular function
D) Drug-induced ventilatory depression
D) Drug-induced ventilatory depression
Kane - we give prop/fent/versed, depresses the system and causes slow/shallow breathing
Treatment might be reversals like narcan, romazicon, time
What is a cause of respiratory acidosis that Kane emphasized that was categorized as “our fault”. Select 5
A) Opioid excess
B) Pneumonia
C) Restriction of ventilation (rib fracture,flail chest)
D) Inadequate NMBD reversal
E) Permissive hypercapnia
F) CO2 insufflation
E) Upper airway obstruction
H) Drug-induced ventilatory depression
*A) Opioid excess
*D) Inadequate NMBD reversal - didn’t give enough neostigmine and robinal, or atropine and neostigmine
E) Permissive hypercapnia (we didn’t set our ventilator right and we allowed them to get elevated PaCO2)
*F) CO2 insufflation (Abdomen is insufflated with CO2 and absorbs in the blood)
H) Drug-induced ventilatory depression (we gave too much drugs)
*starred ones she emphasized at the bottom of the slide
What is an example of Peripheral Ventilatory Control in regards to causing respiratory acidosis?
A) Neuromuscular Disorders
B) Myasthenia Gravis
C) Multiple Sclerosis
D) V/Q mismatch
E) Pneumothorax
F) High Spinal/epidural
G) Flail chest/ Rib fx
H) Hemothorax
I) All of the above
ALL OF THEM
Kane- specifically said MG, MS, “those immune like functions” and Neuromuscular Disorders
What is considered a V/Q mismatch that causes Respiratory Acidosis?
A) Pneumonia
B) Pleural Effusion
C) Retained secretions
E) Pulmonary Edema
F) Atelectasis
G) Abdominal Splinting
H) All of the above
ALL OF THEM
What does Peripheral Problems cause that can create Respiratory Acidosis?
A) Slow shallow breathing
B) Rapid shallow breathing
C) Airway problem
D) Rapid quick breathing
B) Rapid shallow breathing
What is NOT an example of an Obstructed breathing/airway problem that causes Respiratory Acidosis?
A) Supraglottic
B) Subglottic
C) Glottic
D) Infraglottic
E) Bronchospasm
D) Infraglottic
KANE LOVES THIS CHART <3
In acute hypercarbia, a rise in PaCO2 of 10 mmHg results in an increase in plasma HCO3- by __________.
a) 1 mmol/L or meq/L
b) 2 mmol/L or meq/L
c) 3 mmol/L or meq/L
d) 4 mmol/L or meq/L
a) 1 mmol/L or meq/L
10:1
In chronic hypercarbia, a rise in PaCO2 of 10 mmHg results in an increase in plasma HCO3- by __________.
a) 1 mmol/L
b) 2 mmol/L
c) 3 mmol/L
d) 4 mmol/L
c) 3 mmol/L
Kane - the body has had more time to retain the bicarb
10:3
The main difference between acute and chronic hypercarbia in terms of bicarbonate response is:
a) Acute hypercarbia results in a faster increase in plasma HCO3-.
b) Chronic hypercarbia results in a faster increase in plasma HCO3-.
c) Acute hypercarbia results in a slower increase in plasma HCO3-.
d) Chronic hypercarbia does not affect plasma HCO3- levels.
c) Acute hypercarbia results in a slower increase in plasma HCO3-.
Kane - caused by not reversing, opioids. Not compensated by the kidneys yet
Which statement correctly describes the bicarbonate response in hypercarbia?
a) Both acute and chronic hypercarbia result in the same increase in plasma HCO3-.
b) Acute hypercarbia results in a greater increase in plasma HCO3- compared to chronic hypercarbia.
c) Chronic hypercarbia results in a greater increase in plasma HCO3- compared to acute hypercarbia.
d) Neither acute nor chronic hypercarbia affect plasma HCO3- levels.
c) Chronic hypercarbia results in a greater increase in plasma HCO3- compared to acute hypercarbia.
Caused by COPD
On arrival to the ICU following a bowel resection, our patients PaCO2 is 80mm Hg. What is the expected HCO3-?
Is this an acute or chronic hypercapnia?
80 mm Hg is 40 mm higher than normal PaCO2
40 mm is 4 - 10’s…so increase in HCO3- is 4meq/L from normal
24+4=28 meq/L
This is compensating
Not much else to do but give it more time..
You could reverse drugs, recheck NMB, recheck vent settings (Vt, RR). If it was less than expected 28, then it is not compensated and be more aggressive with treatment
Why must caution be exercised when reversing chronic hypercarbia with bicarbonate? Select 3
a) It can cause hypokalemia.
b) It can lead to excessive bicarbonate
c) It can cause CNS irritability
d) It can induce metabolic alkalosis.
e) It can result in hyperglycemia.
f) It can cause seizures.
b) It can lead to excessive bicarbonate
c) It can cause CNS irritability
f) It can cause seizures.
These are the COPD patients
If hypercarbia is marked and CO2 narcosis present
If the patient is ventilated and has respiratory acidosis, what can you do with your vent to improve their status?
A) Increase minute ventilation
B) Decrease Respiration Rate
C) Give bicarbonate
D) Increase Oxygen Levels
A) Increase Minute ventilation
Kane - this could be increasing their Tidal Volume or Respiration rate to blow off CO2
Normal Tidal volume 6-8ml/kg. Bicarb is NOT the first choice for respiratory acidosis
What acid/base imbalance do you give Bicarbonate?
A) Metabolic Alkalosis
B) Metabolic Acidosis
C) Respiratory Acidosis
D) Respiratory Alkalosis
B) Metabolic Acidosis
Kane - You need data, you need to PROVE that there is a low bicarb level on the blood gasses.
Metabolic acidosis is defined as a lowered blood pH that signifies an underlying condition where:
a) Respiratory compensation fully counteracts the excessive acid production.
b) Respiratory compensation does not fully counteract the excessive acid production.
c) Respiratory compensation is not required.
d) There is an increase in blood pH but is fully compensated
b) Respiratory compensation does not fully counteract the excessive acid production.
Kane - this is nothing you accidently did, not due to ventilation or opioids, it an underlying condition or process of the body that has to be fixed
Which of the following is NOT a cause of metabolic acidosis?
a) Increased production of acid
b) Decreased excretion of acid
c) Acid ingestion
d) Increased excretion of bicarbonate
e) Renal/GI bicarbonate losses
Answer: d) Increased excretion of bicarbonate
Acid ingestion - poison. Renal/GI bicarbonate losses - alter the ratio fo cations and ions
Metabolic acidosis is associated with:
a) Decreased ionized calcium
b) Leftward shift of the oxyhemoglobin dissociation curve
c) Increased ionized calcium
d) Decreased production of acid
c) Increased ionized calcium
Assoc with
-alterations in transcellular ion pumps -Na/K pumps
-↑ ionized calcium
-Rightward shift of oxyhgb dissociation curve
For every 1 mEq/L decrease in Base Excess (BE), PaCO2 should fall by __________ mm Hg.
a) 0.8
b) 1.0
c) 1.2
d) 1.5
Answer: c) 1.2
If not falling then compensation is inadequate and to give bicarb
What is the formula to calculate the expected compensation PaCO2 in Acute metabolic acidosis?
A) 1.5 x HCO3- + 8
B) 1.5 x HCO3- + 3
C) 1.5 x HCO3- + 2
D) 1.2 x HCO3- + 8
A) 1.5 x HCO3- + 8
If HCO3- is 12 mml/L then expected PaCO2 is 26 mm Hg
1.5 x 12 +8 = 26
If PaCO2 is higher than 26, compensation is inadequate (lungs are not functioning properly and can only blow off so much); concomitant problem. Might have to give bicarb.
In acute metabolic acidosis.. If HCO3- is 10 mmol/L, what would be the expected PaCO2?
a) 18 mm Hg
b) 23 mm Hg
c) 24 mm Hg
d) 30 mm Hg
b) 23 mm Hg
1.5 x HCO3- + 8
In normal anion gap, bicarbonate loss caused by metabolic acidosis is countered by a net gain of __________ ions.
a) Sodium
b) Potassium
c) Chloride
d) Calcium
c) Chloride
Normal anion gap metabolic acidosis is often called __________.
a) Hypokalemic metabolic acidosis
b) Hyperchloremic metabolic acidosis
c) Hypochloremic metabolic acidosis
d) Hyperkalemic metabolic acidosis
b) Hyperchloremic metabolic acidosis
Electrical ____________ in normal anion gap metabolic acidosis is maintained by balancing sodium with the sum of bicarbonate and __________.
a) Equlibria/Potassium
b) Conservation/Calcium
c) Dissociation/Magnesium
d) Neutrality/Chloride
d) Neutrality/Chloride
How do sodium chloride infusions contribute to normal anion gap metabolic acidosis?
a) By increasing bicarbonate levels
b) By decreasing chloride levels
c) By increasing chloride levels
d) By increasing potassium levels
c) By increasing chloride levels
Kane - Liters of saline in a fluid resusitation, GSW, ruptured abcess, bleeding, volume depletion. Normal saline is not the crystalloid to choose in fluid repleation for someone with metabolic acidosis
Early renal failure can lead to normal anion gap metabolic acidosis because of:
a) Increased acid excretion
b) Decreased bicarbonate reabsorption
c) Increased chloride reabsorption
d) Increased bicarbonate production
b) Decreased bicarbonate reabsorption
The simple anion gap is calculated as Na+ minus the sum of Cl- and HCO3-. The normal range is:
a) 8-10 mEq/L
b) 10-12 mEq/L
c) 12-14 mEq/L
d) 14-16 mEq/L
c) 12-14 mEq/L
Kane - the cation that is the most ubiquitious or has the highest amount is first then subtract the anions
140 - (105+24) = 11mEq/L (pretty close)
Na+ - (Cl- + HCO3-) = 12-14 mEq/L
The conventional anion gap includes Na+, K+, Cl-, and HCO3-. The normal range is:
a) 10-14 mEq/L
b) 12-16 mEq/L
c) 14-18 mEq/L
d) 16-20 mEq/L
c) 14-18 mEq/L
Conventional anion gap is more accurate
(140+4.5)-(105+24) = 15.5
(Na+ + K+) - (Cl- + HCO3-) = 14-18 mEq/L
How does hypophosphatemia and hypoalbuminemia complicate the calculation for the anion gap?
a) It increases the anion gap
b) It decreases the anion gap
c) Underestimating the disturbance
d) Overestimates the disturbance
c) It complicates the calculation, often underestimating the disturbance
Kane- The calculation has the most abundant big ions. Hypoalbuminemia/phosphatemia are not as abundant or miniscule and don’t contribute much to the anion gap calculations
In high anion gap metabolic acidosis, acid dissociates, and the H+ ion combines with bicarbonate to form __________.
a) Hydrochloric acid
b) Sulfuric acid
c) Carbonic acid
d) Nitric acid
c) Carbonic acid
This decreases the available bicarb
H+ + HCO3- –> H2CO3 –> CO2 + H2O.
Which of the following is NOT a cause of high anion gap metabolic acidosis?
a) Lactic acidosis
b) Ketoacidosis
c) Renal failure
d) Hyperventilation
e) Poisoning
d) Hyperventilation
More severe than normal anion gap
In the context of extracellular fluid (ECF), an anion gap greater than __________ is considered high.
a) 10
b) 14
c) 18
d) 20
d) 20
Causes for Anion Gap Acidosis Mnemonic
CAT
C: _____ and _____
A: ________
T: ______
C: Cyanide and CO
A: Arsenic
T: Toluene
I thought it was Arsenic but I was exposed to Cyanide and deveolped Carbon monoxide poisoning d/t smoke inhalation . Dr. Toulene was there to help me in the ER.
Anion Gap Acidosis Mnemonic
MUD
M: _________, __________
U: ________
D: _______
M: Methanol, Metformin
U: Uremia
D: DKA
I thought it was Arsenic but I was exposed to Cyanide and deveolped Carbon monoxide poisioning d/t smoke inhalation. Dr. Toulene was there to help me in the ER. He gave me some sweet menthol peppermint to calm me, but it made my blood sugar spike. I took my Metformin but it was too late and I went into DKA. He also said my kidney function was not looking great either (Uremia).
Anion Gap Acidosis Mnemonic
PILES
P: _______________
I: __________
L: ___________
E: ____________
S: ___________
P: Paraldehyde
I: Iron
L: Lactate
E: Ethylene glycol
S: Salicylates
I thought it was Arsenic but I was exposed to Cyanide and deveolped Carbon monoxide poisioning d/t smoke inhalation. Dr. Toulene was there to help me in the ER. He gave me some sweet menthol peppermint to calm me, but it made my blood sugar spike. I took my Metformin but it was too late and I went into DKA. He also said my kidney function was not looking great either (Uremia).I was so nervous but he gave me Paraldehyde to calm me down. After checking my labs he told me my Iron was low and my Lactate was high. After taking Iron pills the nurses tried to give me polyethylene glycol, but I refused. I asked for some Aspirin (Salicylate) though to help with my headache.
Lactic acidosis is a marker of critical illness and results from:
a) Overproduction of lactate
b) Inadequate clearance of lactate
c) Both overproduction and inadequate clearance of lactate
d) Overexcretion of lactate
c) Both overproduction and inadequate clearance of lactate
Kane - you are either making too much or can’t get rid of it leading to ongoing illness or Persistant acidosis
Lactate is a degradation product of:
a) Protein metabolism
b) Glucose metabolism
c) Fat metabolism
d) Nucleic acid metabolism
b) Glucose metabolism
Lactic acidosis comes from degradation products of glucose
Due to lactic acidois, catecholamines degrade glucose to lactate, which is then converted to __________.
a) Acetyl-CoA
b) Glycogen
c) Pyruvate
d) Gluconeogenesis
c) Pyruvate
*Which then causes gluconeogenesis or creating more sugar for energy.
Why are there catecholamines? You could have given them to the pt because they are very sick/dying , epi gtt. “One foot on the banana peel, the other in the grave” -Kane*
From catecholamines, to lactate, to pyruvate, to gluconeogenesis
Lactic acidosis is often associated with __________ metabolism.
a) Anaerobic
b) Aerobic
c) Both anaerobic and aerobic
d) Neither anaerobic nor aerobic
a) Anaerobic
*Does not rely on oxygen
Aerobic - relies on oxygen*
What would cause an increase in Lactic Acidosis in a healthy person?
A) Running 26 miles
B) 1 hour of Hatha Yoga
C) 9 holes of golf
D) One game of Pickleball
A) Running 26 miles
Run like a demon is chasing you. This will clear and won’t become persistant acidosis
Lactate can act as a buffer in __________ solutions.
a) Hypertonic
b) Hypotonic
c) Isotonic
d) None of the above
c) Isotonic
Here’s a long explanation… When lactate is introduced into the body, it undergoes metabolism in the liver. This process converts lactate into bicarbonate. The bicarbonate buffering system helps maintain the pH balance of the blood by neutralizing excess hydrogen ions (H+), which can cause acidosis. When lactate is used in isotonic solutions, it helps maintain osmotic balance, ensuring that cells neither swell nor shrink due to osmotic pressure differences.The end
Yay more charts - Decision Tree for Lactic Acidosis
According to the decision tree, what’s the initial criteria that should prompt the evaluation for lactic acidosis?
a) Lactate > 3 mEq/L and pH < 7.35
b) Lactate < 3 mEq/L and pH > 7.35
c) Lactate > 5 mEq/L and pH < 7.45
d) Lactate < 2 mEq/L and pH > 7.45
a) Lactate > 3 mEq/L and pH < 7.35*
Kane circled these… maybe for a reason..
In the decision tree, what parameters are checked to classify the type of lactic acidosis?
a) HR, CVP, CO
b) SvO2, CVP, and SV
c) SaO2, CVP, and SV
d) HCO3-, chloride, and anion gap
b) SvO2(mixed venous), CVP, and SV
How is the CO and the heart doing once you have checked the Lactic acid and pH?
If SvO2 < 70%, CVP < 5, and SV < 0.7 mL/kg, which type of lactic acidosis is considered?
a) Type A
b) Type B
c) Type C
d) Type D
a) Type A
Kane said to remember the oxyhemoglobin dissociation curve with high anion gap. Decreased SvO2 –> Increased CO2 –> right shift into acidosis
If SvO2 > 70%, CVP > 5, and SV > 0.7 mL/kg, which type of lactic acidosis is considered?
a) Type A
b) Type B
c) Type C
d) Type D
b) Type B
In Type A lactic acidosis, what is the next step if hemoglobin is low?
a) Check CRP/WCC
b) Look for bleeding source
c) Consider poisoning
d) Perform echocardiography
b) Look for bleeding source
hemorrhagic shock - consider GI/ retro-peritoneum, intra-abdomina
If Hgb and CRP/WCC is normal, and the echocardiography shows low ejection fraction or tamponade in Type A lactic acidosis, what is the likely condition?
a) Hypovolemic shock
b) Cardiogenic shock
c) Septic shock
d) Anaphylactic shock
b) Cardiogenic shock
*Consider IABP, inotropes, and drain pericardium. *
In Type A lactic acidosis, if hemoglobin is normal and CRP/WCC is high, what is the likely diagnosis?
a) Hemorrhagic shock
b) Cardiogenic shock
c) Septic shock
d) Metabolic shock
c) Septic shock
Consider chest, UTI, intra-abdominal or IV site
In Type B lactic acidosis, what should be considered if there is a possibility of poisoning? Select 4
a) Infection
b) Dehydration
c) Sodium nitroprusside
d) Electrolyte imbalance
e) Carbon monoxide
f) Cyanide
g) Metformin
c) Sodium nitroprusside
e) Carbon monoxide
f) Cyanide
g) Metformin
If lactic acidosis is NOT caused by poisioning, consider Endogenous or Exogenous epinephrine and check for liver failure of mitochondrial failure (late stage sepsis)
In Type B lactic acidosis, if not caused by poisioning, regional hypoperfusion is suspected and all pulses are NOT intact in peripheral perfusion, what should be considered next?
a) Poisoning
b) Liver failure
c) Renal failure
d) Arterial thrombosis
d) Arterial thrombosis
Consider Angiography and revascularization
In Type B if not caused by poisoning, regional hypoperfusion is suspected, pulses are intact, and bowel or splanchnic ischemia is considered, what is the next step? Select 3
a) Start broad-spectrum antibiotics
b) Image abdomen
c) Initiate dialysis
d) Laparotomy
e) Administer high-dose steroids
f) Bowel resection
b) Image abdomen
d) laparotomy
f) bowel resection
Are you tired of this chart yet?
What is the primary approach to treating metabolic acidosis?
a) Administering sodium bicarbonate
b) Treating the underlying cause
c) Providing supplemental oxygen
d) Reducing fluid intake
b) Treating the underlying cause
Its a complicated process with multiple factors and maybe more than one cause
Metabolic Acidosis
What are the primary treatments for ketoacidosis?
a) Insulin and fluids
b) Sodium bicarbonate and fluids
c) Diuretics and insulin
d) Oxygen therapy and dialysis
a) Insulin and fluids
How is lactic acidosis typically managed? Select 3
a) Improving tissue perfusion
b) Fluid resuscitation
c) Administering insulin
d) Discontinuing metformin
e) Providing diuretics and reducing fluid intake
f) Add oxygen and switch from aerobic to anaerobic process
a) Improving tissue perfusion
b) Fluid resuscitation
d) Discontinuing metformin
Kane - add that oxygen and switch the anerobic process to aerobic process
What is the recommended treatment for metabolic acidosis related to renal failure?
a) Insulin administration
b) Fluid resuscitation
c) Dialysis
d) Sodium bicarbonate infusion
c) Dialysis
In the management of lactic acidosis, why is it important to discontinue metformin?
a) It increases blood glucose levels.
b) Contributes to further acid production.
c) Causes dehydration.
d) It leads to hypokalemia.
b) It can contribute to further acid production.
Sodium bicarbonate is usually not the first choice for treating metabolic acidosis because:
a) It can lead to metabolic alkalosis
b) It to mixed metabolic acidosis/alkalosis
c) It has no side effects
d) It is very expensive
a) It can lead to metabolic alkalosis if not stopped soon enough
It is controversial
Sodium bicarbonate may be considered for treatment when pH is less than __________ or bicarbonate is less than 10 meq/L.
a) 7.3
b) 7.2
c) 7.1
d) 7.4
c) 7.1
This is the Data or information in order to confirm metabolic acidosis and give bicarb
In Metabolic Acidosis, sodium bicarbonate reacts with H+ ions to generate __________, which diffuses ______________ and decreases pH.
a) Oxygen/Intracellularly
b) Nitrogen/ Extracellularly
c) CO2/Intracellularly
d) Chloride/ Extracellularly
c) CO2/Intracellularly
More CO2, increased H+ and decreased pH - acidic…right shift
H+ + HCO3- –> H2CO3 –> CO2 + H2O.
In chronic metabolic acidosis, acute pH changes from sodium bicarbonate administration can negate the right shift of the curve (Bohr effect) and cause __________.
a) Hyperventilation
b) Tissue hypoxia
c) Hyperkalemia
d) Metabolic alkalosis
b) Tissue hypoxia
*Doesn’t allow it to shift to the right and can’t get oxygen to the tissues by binding to hemoglobin.
The full correction dose of sodium bicarbonate (mmol) can be calculated using the formula:
a) 0.3 x base deficit (mmol/L) x body weight (kg)
b) 0.4 x base deficit (mmol/L) x body weight (kg)
c) 0.5 x base deficit (mmol/L) x body weight (kg)
d) 0.6 x base deficit (mmol/L) x body weight (kg)
a) 0.3 x base deficit (mmol/L) x body weight (kg)
When administering sodium bicarbonate, it is recommended to give __________ of the calculated full dose and then reassess the patient.
a) 1/4
b) 1/2
c) 3/4
d) The full dose
b) 1/2
After reassessing the patient if they are doing ok, you can give the rest of the dose
What is the recommended management for a patient with metabolic acidosis scheduled for elective surgery?
a) Proceed with surgery as planned
b) Postpone the surgery
c) Administer sodium bicarbonate and proceed
d) Perform surgery with additional monitoring
b) Postpone the surgery
For elective surgeries, you can fix the metabolic acidosis and reschedule the sx
For urgent or emergent surgeries in patients with metabolic acidosis, what type of monitoring is recommended?
a) Standard monitoring
b) Hemodynamic monitoring
c) No additional monitoring
d) Only pulse oximetry and ECG monitor
b) Hemodynamic monitoring
Get all the information you can get that is invasive that let you make choices. SVV monitoring can including arterial line and Swan-Ganz catheter
Hemodynamic monitoring in patients with metabolic acidosis undergoing surgery is used to:
a) Guide fluid administration
b) Monitor cardiac function
c) Perform frequent lab tests
d) All of the above
d) All of the above
Performing frequent bedside labs like ABG, Hgb, Calcium q30min. Watch everything you can watch. DONT SEND TO LAB…they are slow and suck
Respiratory alkalosis is defined as:
a) An acute decrease in alveolar ventilation
b) An acute increase in alveolar ventilation
c) A chronic decrease in alveolar ventilation
d) A chronic increase in alveolar ventilation
b) An acute increase in alveolar ventilation
Hyperventilation results in __________ PaCO2.
a) Increased
b) Decreased
c) Unchanged
d) Fluctuating
b) Decreased
In respiratory alkalosis, the pH level is:
a) < 7.35
b) 7.35-7.45
c) > 7.45
d) Unchanged
c) > 7.45
Kane - classic anxious, panic patient, person breathing in a paper bag on tv
Which of the following is NOT a cause of respiratory alkalosis?
a) Pregnancy
b) High altitude
c) Iatrogenic hyperventilation
d) Opioid overdose
d) opioid overdose
This causes respiratory acidosis
Iatrogenic hyperventilation during the perioperative period can lead to respiratory alkalosis. What does “iatrogenic” mean in this context?
a) Caused by a medical condition
b) Caused by medical treatment
c) Caused by environmental factors
d) Caused by genetic factors
b) Caused by medical treatment or intervention
Hyperventilation of patient with ventilator
True or False
Salicylate acid overdose can cause respiratory alkalosis
True - salicylate acid = aspirin
Injesting acid, body tries to get rid of it by hyperventilating, driving down PaCO2 and H+ causing pH to increase - alkalosis
Which of the following symptoms is due to vasoconstriction in respiratory alkalosis?
a) Nausea
b) Lightheadedness
c) Palpitations
d) Sweating
b) Lightheadedness which can lead to dizziness
Respiratory alkalosis can cause __________ due to vasoconstriction.
a) Diarrhea
b) Visual disturbance
c) Chest pain
d) Skin rash
b) Visual disturbance
..did you see that pink elephant?
Greater binding of calcium to albumin in respiratory alkalosis leads to __________.
a) Hypercalcemia
b) Hypocalcemia
c) Hyperkalemia
d) Hypokalemia
b) Hypocalcemia
There is no free calcium because its all bound. Available calcium levels in plasma drop
Which of the following are symptoms of hypocalcemia? Select 6
a) Paresthesia
b) Muscle spasm
c) Hypertension
d) Circumoral numbness
e) Seizures
f) Flacidity of muscles
g) Tetany
e) Vomiting
g) Cramps
a) Paresthesia
b) Muscle spasm
d) Circumoral numbness
e) Seizures
g) Tetany
g) Cramps
Gotta get use to these select all that apply
Trousseau’s sign, indicative of hypocalcemia, involves carpopedal spasm when __________.
a) The patient hyperventilates
b) The blood pressure cuff is inflated
c) The patient exercises excessively
d) The patient is at rest
b) A blood pressure cuff is inflated
Carpopedal spasm is in the hand and wrist
Chvostek’s sign, seen in hypocalcemia, is characterized by __________.
a) Carpal spasm
b) Muscle cramps
c) Facial twitching
d) Seizures
c) Facial twitching
Tapping on the facial nerve illicits irritability and twitching in mouth, nose and cheek
In the context of anesthesia management for respiratory alkalosis, addressing pain and anxiety can involve: Select all that apply
a) Increasing ventilation
b) Administering pain medication
c) Administering anxiolytics
d) Increasing oxygen concentration
e) Giving versed
f) Building patient/provider rapport
g) Withholding all information
b) Administering pain medication
c) Administering anxiolytics
e) Giving versed
f) Building patient/provider rapport
Kane - Rebreathing CO2 in a bag does help, just you being there helps, versed, comforting measures, reassurance you will be there for the patient, giving more information, building that patient relationship.
What could be another consequence of Respiratory Alkalosis besides pain and anxiety? Select 2
A) Catatonic state
B) Agitation
C) Having a Foley
D) Full bladder
B) Agitation
C) Full bladder
A poor mechanical ventilation strategy that may contribute to respiratory alkalosis involves:
a) Inadequate ventilation
b) Hyperventilation
c) Hypoventilation
d) Controlled ventilation
b) Hyperventilation - the settings on your vent are not correct
Decreased PaCO2, decreased H+ and increased pH
**Therapeutic hyperventilation **is rebreathing CO2 in a bag to help increase PaCO2 in the body..
Which of the following best defines Metabolic Alkalosis?
a) Marked decrease in plasma bicarb usually compensated for by a decrease in carbon dioxide.
b) Marked increase in plasma bicarb usually compensated for by an increase in carbon dioxide.
c) Increase in plasma potassium usually compensated for by an increase in sodium.
d) Decrease in plasma sodium usually compensated for by a decrease in chloride.
b) Marked increase in plasma bicarb usually compensated for by an increase in carbon dioxide.
This is in response to increased PaCO2, it is a SLOW process - days
True or False
Metabolic Alkalosis is usually caused by non-iatrogenic reasons.
False - If caused in the hospital, then it is usually related to us giving things to them.
In Metabolic Alkalosis, Renal or extrarenal causes are usually caused by:
a) Net loss of H+
b) Net loss of H+ or net gain of bicarb
c) Net gain of bicarb
d) Net gain of H+
b) Net loss of H+ or net gain of bicarb
Maybe we gave too much bicarb trying to reverse metabolic acidosis
Which of the following Renal or extrarenal causes can contribute to Metabolic Alkalosis?
a) Excess citrate
b) Excess calcium
c) Excess magnesium
d) Excess potassium
a) Excess citrate
Metabolic Alkalosis can also be referred to as:
a) Volume overload or depletion alkalosis
b) Respiratory alkalosis
c) Only volume overload
d) Volume alkalosis
a) Volume overload or volume depletion alkalosis
Which of the following is a common cause of Metabolic Alkalosis?
a) Hypovolemia
b) Hyperkalemia
c) Hypoglycemia
d) Hypercalcemia
a) Hypovolemia
Which medical intervention is most likely to cause Metabolic Alkalosis?
a) Insulin therapy
b) NG suction
c) Antibiotic therapy
d) Chemotherapy
b) NG suction (Nasogastric suction)
Loss of acid or H+ increasing pH. This is why we don’t leave our NG suction on continuous. Also think of vomiting, loss of acid as well
Diuretic therapy can lead to Metabolic Alkalosis by:
a) Increasing potassium levels
b) Increasing bicarbonate levels
c) Decreasing sodium levels
d) Decreasing bicarbonate levels
b) Increasing bicarbonate levels
Remember too much bicarb can decrease free calcium and cause hypocalcemia and the s/s with that.
Hyperaldosteronism contributes to Metabolic Alkalosis by:
a) Decreasing renal excretion of potassium
b) Increasing renal retention of hydrogen ions
c) Increasing renal excretion of hydrogen ions
d) Decreasing renal retention of sodium
c) Increasing renal excretion of hydrogen ions
Mnemonic for Causes of Metabolic Alkalosis
DANG Big Happy Vacation
Diuretic therapy
Aldosteronism (Hyperaldosteronism)
NG suction (Nasogastric suction)
GI loss (Vomiting)
Bicarbonate administration
Hypovolemia
Vomiting
DANG Big Happy Vacation
The treatment for Metabolic Alkalosis due to volume depletion is:
a) PPI (Proton Pump Inhibitors)
b) Saline fluid resuscitation
c) Lactated ringers resuscitation
d) Magnesium infusion
b) Saline fluid resuscitation
Careful - it can can cause hyperchloremic acidosis
When treating Metabolic Alkalosis induced by loop diuretics, it is advisable to:
a) Give Lactated ringers
b) Increase loop diuretics
c) Administer PPI
d) Add potassium sparing
d) Add potassium-sparing diuretics
You can decrease loop diuretic and add potassium sparing diuretics like spironalactone, helps with cation balance better
For Metabolic Alkalosis caused by gastric loss, the recommended treatment is:
a) Saline fluid resuscitation
b) Loop diuretics
c) PPI
d) TUMS
c) PPI (Proton Pump Inhibitors)
Treat stomach issue, anti-emetics so they don’t vomit
