Kirila Acid Base

Question 1

normal electrolytes: Na, K, Cl, CO2

Answer 1

Na = 135-145 (140)
K = 3.5-5 (4)
Cl = 98-106 (103)
CO2 = 21-28 (24)

Question 2

Anion Gap: calculation and normal values, and what it means

Answer 2

ANION GAP:

Na- (CL + HCO3) = AG

Normal: 12 +/- 2

Anion gap – reflects concentration of anions that aren’t routinely measured. (Sulfates, phosphates, acetoacetic acid, beta hydroxybutric acid)

Question 3

Normal ABGs (pH, PaCO2, PaO2, HCO3, O2)

Answer 3

pH  7.35 – 7.45 (7.4)
PaCO2  35 – 45 (40)
PaO2  80 – 100 (90)
HCO3  22 – 26 (24)
O2 Sat  92-100%

Question 4

what do you request to completely evaluate acid base states: shock, low perfusion state, lactic acid level?

Answer 4

Basic metabolic panel

Question 5

Normal O2 calculations

Answer 5

104 - (.27 x age) or 100 - (1/3 x age)

o2 naturally declines with age

Question 6

causes of hypoxia

Answer 6

Hypoventilation

V/Q (Ventilation/Perfusion)
mismatch as seen in

Pulmonary Embolus (PE)

Shunting e.g. cardiac anomalies

Low inspired fraction of O2 (FiO2)

High altitude

Diffusion abnormalities e.g.
Alveolar Hemorrhage, Connective Tissue disorder

Question 7

values defining Acidosis, alkalosis, hypoxia, hypercapnia, hypocapnia

Answer 7

Acidosis pH < 7.35
Alkalosis pH > 7.45

Hypoxia pO2 < 60

Hypercapnia pCO2 > 45
Hypocapnia pCO2 < 35

Question 8

3 step approach to determining alkalosis or acidosis

Answer 8

1) is pH high or low?
2) is it respiratory or metabolic?
3) if its respiratory in nature, is it a pure respiratory process or is there a metabolic component?

Question 9

pH and pCO2 are both elevated

Answer 9

metabolic process

Question 10

pH and pCO2 are in opposite directions

Answer 10

respiratory process

Question 11

in a PURE respiratory process…..

Answer 11

for each 10 mmHg change in PaCO2, the pH should move in the opposite direction by .08 (+/- .02) ((so .06-.1 ))

Question 12

PURE Respiratory:

If PaCO2 is 30, the pH should be

Answer 12

If PaCO2 is 30 ( a decrease of 10 mmHg from 40) the pH should be 7.48 (7.4 + .08)

Question 13

PURE Respiratory:

If PaCO2 is 60, the pH should be….

Answer 13

If PaCO2 is 60 (an increase of 20 mmHg) the pH should be 7.24 (7.4 – 2 x .08 or .16) a decrease of .16 or .08 for each 10 mmHg rise in pCO2

Question 14

If the rule for a pure respiratory process is (meaning the pH and PaCO2 go in opposite directions but not in their respective proportions) is not consistent with the measured findings

Answer 14

“a second metabolic process is present”

referred to as a mixed process

Question 15

metabolic acidosis with high anion gap: diagnosis

Answer 15

Acute heart failure
Atrial Fibrillation with Rapid Ventricular Response
Hyponatremia
Azotemia
Metabolic acidosis
Mitral regurgitation

Question 16

Metabolic acidosis: defined and causes

Answer 16

Metabolic acidosis – decrease in extracellular pH caused by a decrease in HCO3

1. Loss of HCO3 – GIT (Gastrointestinal Tract), renal
2. Increase Hydrogen load – DKA or lactic
3. Decrease hydrogen excretion by kidney – uremic acidosis or RTA

Question 17

types of metabolic acidosis

Answer 17

1. elevated anion gap

2. normal anion gap with hyperchloremia

Question 18

lactic acidosis: type A

Answer 18

shock, severe anemia, heart failure, CO poisoning

Question 19

lactic acidosis type B1

Answer 19

associated with systemic disorders, DM, liver failure, spesis, seizures

Question 20

lactic acidsosis type b2

Answer 20

associated with drugs/toxins, ethanol, methanol, ethylene glycol, ASAw

Question 21

tests when metabolic acidosis is suspected

Answer 21

Echocardiogram
Lactic acid level
Cardiac Enzymes (Troponin I, CK MB)

Question 22

Treatment of the acidotic patient

Answer 22

Oxygen 2-4 liters/min N/C

IV – loop diuretic

Fluid restriction 1-1.5 L/day

Na HCO3 – cautiously (why?)

ACEI – cautiously (why?)

Question 23

Normal anion gap

Answer 23

12 +/- 2 (10-14)

Question 24

Normal anion gap met acid – what it means

Answer 24

HCO3 falls and CL rises (hyperchloremic met acid)

Question 25

HARDUPS

Answer 25

H - Hyperalimentation A - Acid infusion, acetazolamide R – RTA – renal loss of HCO3/or decreased H sec D – Diarrhea – losing HCO3, K U – Ureteral sigmoid or ileal diversion – losing HCO3 / increased CL and H resorption P – Pancreatic fistula – losing HCO3, K S – Spironolactone

Question 26

RTA types 1-3

Answer 26

1) Distal – decreased secretion of H+, so not getting rid of acid, ie “failure to acidify urine” – aka Type I Possible causes: SLE (Lupus), Sjögren's, toluene 2) Proximal – decreased absorption of HCO3 , so not absorbing buffer – aka Type II Possible causes: multiple myeloma, heavy metal poisoning, Wilson’s Disease, amyloidosis 3) Hyperkalemic RTA – Hyporenin and hypoaldosterone – decreased NH4 excretion and decreased HCO3 production – aka Type IV Possible causes: analgesic nephropathy, sickle cell disease and SLE

Question 27

analgesic nephropathy, sickle cell disease and SLE

Answer 27

type IV normal anion gap metabolic acidosis

Question 28

multiple myeloma, heavy metal poisoning, Wilson’s Disease, amyloidosis

Answer 28

type II normal anion gap metabolic acidosis

Question 29

SLE (Lupus), Sjögren's, toluene

Answer 29

type 1 normal anion gap metabolic acidosis

Question 30

tx for mixed high anion gap metabolic acidosis and respiratory acidosis

Answer 30

Dialysis – hemodialysis Na HCO3 Synthyroid Aerosol treatments with nebulizers

Question 31

tx for normal anion gap metabolic acidosis

Answer 31

IV fluids for volume restoration (careful not to give too much NaCL or N/S) Could give fluids of ½ strength N/S with Na HCO3 and K Rx underlying cause Rx of CV compromise; pH <7.2, HCO3 <10 HCO3 deficit = desired HCO3 – measured HCO3 x (.5 x wt kg) RX NaHCO3 1 amp 8.5%, 50 mEq/50cc Tablets – 650 mg

Question 32

metabolic alkalosis

Answer 32

pH increase, HCO3 doubly increases, paCO2 increases Compensatory paCO2 .7 increase for every 1 increase in HCO3 paCO2 = (.9 x HCO3) +9 (+/- 2) Causes "CLEVER PD" CL loss or HCO3 excess Volume contraction CL loss – vomiting, N/G suction, villous adenoma, diuretics ``` HCO3 excess – enhanced HCO3 resorption (hyperaldo, licorice excess) ```

Question 33

METABOLIC ALKALOSIS CAUSES “CLEVER PD”

Answer 33

``` C – Contraction of volume L – Licorice E – Endocrine (Conns, Cushing's, Bartters) V – Vomiting E – Excess Alkali R – Refeeding alkalosis ``` P – Post Hypercapnia D – Diuretics

Question 34

METABOLIC ALKALOSIS | TWO TYPES

Answer 34

chlorine reponsive and chlorine unresponsive

Question 35

cl responsive

Answer 35

one type of metabolic alkalosis ``` CL (Chloride) Responsive -Urine CL < 10-20 mEq/l -Improves with NaCl and Volume -a decrease in Serum CL and Volume Contraction Vomiting, NG suction, diuretics ```

Question 36

cl unresponsive

Answer 36

one type of metabolic alkalosis CL (Chloride) Unresponsive Urine CL > 10-20 mEq/l Unresponsive to saline Endocrine causes: Bartters, severe K depletion, hyperaldo, Cushing's

Question 37

paCO2 =

Answer 37

paCO2 = (.9 x HCO3) +9 (+/- 2)

Question 38

Compensatory paCO2

Answer 38

Compensatory paCO2: .7 increase for every 1 increase in HCO3

Question 39

ꜜ pH. ꜜ PaCO2, ꜜꜜ HCO3

Answer 39

metabolic acidosis

Question 40

metabolic acidosis compensation

Answer 40

ꜜ paCO2 = 1.2 for ea 1 ꜜ HCO3 paCO2 = 1.5 x HCO3 + 8 paCO2 = last 2 digits of pH paCO2 = HCO3 + 15

Question 41

↑ pH, ↑ PaCO2, ↑↑ HCO3

Answer 41

metabolic alkalosis

Question 42

metabolic alkalosis compensation

Answer 42

↑ paCO2 = .7 for each 1↑ HCO3 ↑ paCO2 by 6 for each 10 ↑ in HCO3  

Question 43

↓ pH, ↑ ↑ PaCO2, ↑ HCO3

Answer 43

respiratory acidosis

Question 44

respiratory acidosis compensation

Answer 44

↑ HCO3 = 1 for ea 10 ↑ paCO2 pH ↓ by .08 for ea 10 ↑ paCO2

Question 45

conn's syndrome

Answer 45

Primary Hyperaldosteronism Mineralocorticoid excess Saline resistant (UCL >20) Increased HCO3 excretion in urine

Question 46

drugs, CVA, Neuromuscular Airway obstruction, pneumonia, Pulmonary edema, pneumothorax, pleural disease, COPD, restrictive disease (disorders of the chest wall, resp. muscles)

Answer 46

cause hypoventilation--> resp acidosis

Question 47

hyperventilation causes and mnemonic

Answer 47

``` Septic – pyelonephritis, renal abscess Hyperthyroid Anxiety – biochemistry test Pain/fever Respiratory hyperventilation may also be due to infection (sepsis) ``` ``` C – CNS disease H – Hypoxia A – Anxiety M – Mechanical Ventilation P – Progesterone S – Salicylates/Sepsis/Stress ```