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SMUPASPG19-MED 1 > RENAL- ACID/BASE > Flashcards

RENAL- ACID/BASE Flashcards

1
Q

Which ACID is powerful quick, harmful?

A

CO2

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2
Q

Which ion is slow, complex, creative for ACIDs?

A

Bicarbonate
HCO3
TCO2 (on chem panel) ABG (essentially HCO3 is a byproduct of CO2>

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3
Q

How do LUNGS compensate using CO2?

A

Exhale-fast flexible
INC RR- BLOW OFF CO2 (raises pH)
DEC RR
RESPIRTORY

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4
Q

How do KIDNEYs compensate using HCO3?

A

save HCO3-inc pH
discard HCO3-dec pH
METABOLIC- RENAL
but OTHER system occure

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5
Q

How dose our body use HCO3 and CO2?

A

Provides automatic and predictable outcomes

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6
Q

What is the ratio to bicarb and acid?

A

20 parts bicarb to one part acid (carbonic acid).

pH (pH = potential of Hydrogen).

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7
Q

What is the pH of our extracellular fluid?

A

7.35 – 7.45pH
Remember 7.40
Means fully compensated
Tells us the CONDITION of the Pt.

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8
Q

What condition results in the accumulation of H+ ions? What is the result and pH?

A

ACIDOSIS
ACEDEMIA
LOWERED ARTERIAL pH.
too much acid or too little HCO3***

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9
Q

What condition results in the excess of bicarbonate ions? What is the result and pH?

A

ALKALOSIS
ALKALEMIA,
ELEVATED ARTERIAL pH.
too much HCO3*** or too little acid

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10
Q

What is significant about pH in regards to its value?

A 
ANY small change outside of NORMAL 
is SIGNIFCANT
7.2 VERY SICK, UNCONSCIOUS
<7.0 LIFE THREATENING
<6.8 RARE SURVIVAL

PH>8.0 LIFE threatening

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11
Q

How is Acidosis or Alkalosis actually harmful?

A

-Acidosis
-Shifts the oxyhemoglobin dissociation curve to the right (Bohr effect), most marks INC CO2, temp, H+, (low O2)
-Depression of CNS, hypercarbia
-Disorders of respiration
-Decreased cardiac contractility
-Decreased vascular response to catecholemines and
decreased vascular tone (low blood pressure)
-Interference with pharmacologic agents

  • Alkalosis (lowered CO2 or too much HCO3)
  • Shifts the oxyhemoglobin dissociation curve to the left- most marks DEC CO2, temp, H+, (high O2)
  • Decreased cerebral blood flow, alterations of consciousness
  • Over-excitation of CNS resulting in muscle spasm and tetany (severe)
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12
Q

What Indicates need for ABG?

A
  • significant hypoxemia, hypercapnia or Chem panel abnormalities
  • Toxicology or the Mystery Patient
  • Monitoring effects of therapy (intubated pt’s; DKA, COPD management, etc)
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13
Q

How do we obtain an arterial blood gas?

A

-Venous (VBG) ok if pH is all you need now becoming common

  • Radial artery, Femoral now (big target), Brachial is last
  • **Allen’s test every time to verify patency of ulnar artery
  • Arterial blood is bright red and fills the tube on it’s own
  • LABEL Put specimen on ice
  • 5 min. firm pressure at site - you’ve punctured an artery
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14
Q

WHat are THE FOURS?

A

pH-7.40
CO2-40
HCO3-24

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15
Q

What is “simple” “pure” primary entails?

A

Primary event results

Compensatory even that leads to min. effect

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16
Q

Which compesatory event takes hours vs sec.

A

Metabolic take HRS-Kidney deciding

Respiratory takse sec- easy hypervenilation

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17
Q

What are the common Primary Disorders?

A

RESPIRATORY ACIDOSIS
RESPIRATORY ALKALOSIS
METABOLIC ACIDOSIS (2 types)- w/ ANION GAP OR W/O ANION GAP
METABOLIC ALKALOSIS

18
Q

What are the FIVE QUESTIONS?

A

1- pH - acidosis or alkalosis or normal?

  1. Respiratory or Metabolic?
  2. Who should be compensating (CO2 or HCO3-)?
    - Look at the patient
  3. Is there an anion gap? (automatic metabolic acidosis if AG >20). ALWAYS CALULATE

5 If a metabolic acidosis exists, is it a “pure” or “mixed” disorder?
-Respiratory process other than compensation?
-Rule of 15? Are the CO2 and last 2 digits of pH same?
NO-Winter’s formula?

-If an anion gap >20 exists, is there an additional Metabolic process? Winter’s formula? Calculate the Delta gap or Delta Ratio

19
Q
  1. Is this a Primary Respiratory or Metabolic disorder?
A

Normal CO2 = 35 - 45 or 40
Normal HCO3- = 22 -26 or 24

Which one is abnormal?
HIGH OR LOW
For each, does indicate acidosis or alkalosis?
Which one caused the pH change?

ROME
For simple, single acute acid-base disorders:
LOW pH, HIGH CO2 (lots of acids) = RESPIRATORY ACIDOSIS
HIGH pH, LOW CO2 = RESPIRATORY ALKALOSIS

HIGH pH, HIGH HCO3- = METABOLIC ALKALOSIS
LOW pH, LOW HCO3- = METABOLIC ACIDOSIS

20
Q

If the CO2 drives the pH in the opposite direction,

A

primary respiratory disorder exists

21
Q

If the CO2 and pH move in the same direction (up or down)

A

primary metabolic disorder exists

22
Q

What begins immediately which may throw values into confusion?

A

-Are BOTH the CO2 and HCO3- abnormal?
Compensation begins immediately. CO2, HCO3- values are off a bit, reflecting the attempt.

pH abnormal = acute illness or partial compensation.
-Has there been time for compensation?

-If the compensation doesn’t make sense, there is “mixed disorder” – very common condition

Rare CO2 >55, a respiratory process also present

“Primary respiratory acidosis with adequate metabolic compensation”
“ pH adequate will see how treatment helps

23
Q

RESPIRATORY ACIDOSIS

A

pH - low (<7.35), CO2 - high, HCO3- normal or elevated compensation: acute or chronic
Inadequate ventilation - results in retention of CO2

CO2 retention: 
d/t lung disease or obstruction;
muscles  or chest wall aren’t working;
alveolar ventilation dfx, arterial CO2 goes up; 
you are unconscious 
you have stopped breathing (CPR).
  • Pulmonary – COPD/emphysema, asthma, pneumonia, aspiration, pulmonary edema, pleural effusion, pneumothorax, smoke inhalation
  • Cardiac – cardiac arrest, CHF
  • Mechanical – Airway obstruction – infection, foreign body, bronchospasm
  • Central/CNS – Neuromuscular Dz (Guilain-Barre, polio, myasthenia gravis, MS, etc), stroke, tumors, CNS infection, anesthetic/paralyzing drugs
24
Q

RESPIRATORY ALKALOSIS- Most common acid-base disorder.

A

pH - high (>7.45), CO2 - low, HCO3- normal or low compensation: acute or chronic
Inc RR- excessive removal of CO2.

hyperventilation.
Hypoxia also stimulates respiration - tachypnea.

Disorders

  • airway obstruction/bronchospasm, CHF, infection, PE, altitude
  • Drugs – stimulants, salicylates (OD), catecholamines
  • Central/CNS – tumors, infection, trauma, stoke, fever, sepsis, pain
  • Miscellaneous – pregnancy, hyperthyroid, liver failure, ventilator settings
  • Anxiety, psychiatric
25
Q

METABOLIC ALKALOSIS

A

-pH - high, HCO3- is high, CO2 is usually elevated, compensating (quick)

-Excess of serum HCO3- ions through H+ ion loss
-retention of HCO3-, or
- addition of alkali rich substances.
Kidneys are overwhelmed or sick.

No ABG needed
Chloride Responsive (correction) Causes
-Volume depletion (dehydrated), severe vomiting, diuretics, NG tube
-Fix: IV hydration; replacing sodium/chloride balances the anion/cation pool
-Be aware of hypokalemia. precursor and result

Chloride Unresponsive Causes
-mineralcorticoid excess and severe hypokalemia.

26
Q

METABOLIC ACIDOSIS

A

-pH - low, HCO3- low, CO2 is usually low depending on severity of acidosis and compensation.

  • Direct Depletion of bicarbonate
  • excessive use of Bicarb stores,
  • relative acid gain
  • decreased renal excretion of H+ ion.
27
Q

What should you considered in all HIGH anion GAPS during Metbolic acidosis?

A

M – Metformin, methanol (Sterno) ingestion
U - uremia (think aminoglycosides, NSAID’s)-ARF
D - diabetic ketoacidosis, alcoholic ketoacidosis
P - paraldehyde (liquid sedative - rare anymore), phenphormin (diet pill RX)
I - INH or iron overdose
L - lactic acidosis (post-seizure, sepsis, carbon monoxide, cyanide, etc)
E - ethylene glycol ingestion (antifreeze, wiper fluid)
R – Renal failure, rhabdomyolysis
S - salicylate overdose (aspirin), starvation

28
Q

What should you considered in an anion gap (>20)? How do you calculate it

A

a metabolic acidosis automatically, regardless of value of pH, CO2 or HCO3
Calculate all the time in head

29
Q

WHat is the RULE of 15

A

Add 15 to HCO3
if pH and CO2 #s are close
if add 15, the sum should match the last #in pH and CO2
-CO2 and last two digits of the pH should be roughly the same (HCO3 10 or >)

fifth question uncovers concurrent processes that may be missed-Determines if something other than just respiratory compensation exists.

30
Q

Is the anion GAP open or Closed?

A

calculation of unmeasured anions in the serum.

  • Anions negative charge acids.
  • In the face of depletion, the body will produce acids compensate. Thus acid disorders only
    • drug overdoses

-Anion gap of >18 is significant
Normal AG = 8 to 12 (or 15)
Na- (Cl+HCO3)

31
Q

Non-Anion Gap (Normal Gap) Metabolic Acidosis.

A

Direct HCO3- loss (diarrhea most common), or kidney fails to excrete H+ ions.
Another pneumonic – H.A.R.D.U.P.
H – hypoaldosteronism/Addison’s, hyperalimentation
A – acetazolamide (Diamox), spironolactone
R – renal tubular acidosis, renal failure, nephritis
D - diarrhea
U – ureterosigmoidostomy/ileostomy
P – pancreatic fistula
low Delta Gap/Delta Ratio

32
Q

So how do you know if a mixed disorder exists?? Is there a chronic disorder?

A

if the CO2 and HCO3- are abnormal in the same direction, a mixed disorder is UNLIKELY but not ruled out, particularly with metabolic conditions and chronic conditions.

33
Q

Mixed Disorders - Rule Number One:

A

EXISTS if the pH is NORMAL and the CO2 is ABNORMAL (if no chronic condition exists)

34
Q

Mixed Disorders - Rule Number Two:

A

In a “pure” respiratory process:
A change in the CO2 by 10 will change the pH by .08 in the OPPOSITE direction (CO2 changes by 20, pH changes by 1.6, etc)
-If pH is higher than it should be, then a metabolic ALKalosis also exists
-If pH is lower than it should be, then a metabolic acidosis also exists

35
Q

Mixed Disorders - Rule Number Three:

A

A change in HCO3- by 10 will change the pH by .15 in the SAME direction (HCO3- changes by 20, pH changes by .30, etc)
-If the pH is higher or lower than it should be, then a respiratory or another metabolic process also exists

36
Q

CHRONIC ACID-BASE IMBALANCES

A
  • baseline chronic acid base imbalance, but fine and walking a fine line.
  • Identify patients at risk for decompensation in the event of acute illness.
  • Follow rules for interpreting blood gases, tell us if the compensation attempted by the body is adequate, or acute or chronic.
37
Q

CHRONIC RESPIRATORY ACIDOSIS

A

COPD’ers, asthmatics, lung cancer/mass, neuromuscular dz
pH - 7.36 almost normal – due to chronic compensation
CO2->50-60’s
HCO3- around 55

Rule-increase in CO2 by 10 will decrease pH by .03 and increase HCO3- by 3.5
If doesn’t roughly match the patient’s blood gas, there is another problem addition to the chronic problem.

38
Q

CHRONIC RESPIRATORY ALKALOSIS

A

hypoxia, CHF, CNS tumors, hyperthyroidism, pregnancy
pH - almost normal
CO2 - low
HCO3- low as well
Rule-decrease in CO2 by 10 will increase pH by .03 and decrease HCO3- by 5
If doesn’t roughly work out, something else

39
Q

Is this a “pure” metabolic acidosis or a mixed disorder?

A

-Determines if something OTHER than just respiratory compensation exists
ASK ONLY if ANION GAP metabolic acidosis >20
-“Rule of 15”:
1. HCO3- plus 15 should equal CO2 and last 2 digits of pH, (HCO3 10 or >)
2. CO2 too low? = Primary Respiratory Alkalosis also exists
3. CO2 too high? = Primary Respiratory Acidosis also exists

IF the RULE 15 not roughly the same, calculate if the respiratory compensation to this metabolic acidosis adequate:
Winter’s formula: CO2 = 1.5 x HCO3 + 8 (±2) (use after 12-24hrs)
CO2 too low? = Primary Respiratory Alkalosis also exists
CO2 too high? = Primary Respiratory Acidosis also exists

40
Q

What Uncovers a hidden/chronic metabolic or respiratory process?

A

Use only if gap >20
All values are from the Chem panel:
Delta Gap = HCO3 + change in the anion gap (Anion gap-12) (normal 24 +/- 1)
>30 = metabolic alkalosis also exists
<18= non-gap metabolic acidosis also exists
18-30=no addn chronic dz
Example: Na 136, Cl 99, HCO3 10; AG = 136 – (99 + 10) = 27
Delta Gap = 10 + (27 – 12)
10 + 15 = 25

SMUPASPG19-MED 1 (27 decks)

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