2. Acid-base disorders  Acid-base disorders are divided into two broad categories:  Those that affect respiration and cause changes in CO 2 concentration are called respiratory acidosis (low pH) and respiratory alkalosis (high pH).  Respiratory acid-base disorders are commonly due to Lung diseases or conditions that affect normal breathing.

3. Acid-base disorders  Disorders that affect HCO 3 - concentration are called metabolic acidosis (low pH) and metabolic alkalosis (high pH).  Metabolic acid-base disorders may be due to, kidney diseases electrolyte disturbances, severe vomiting or diarrhea, ingestion of certain drugs and toxins, and diseases that affect normal metabolism.

4. Acid-base disorders Acute acidosis  Increased rate and depth of breathing, confusion, and headaches, and it can lead to seizures, coma, and in some cases death. Alkalosis  Symptoms of alkalosis are often due to associated potassium (K + ) loss and may include irritability, weakness, and cramping.

5. Acidosis  Due to increased acid production within the body  Consumption of substances that are metabolized to acids  Decreased acid excretion, or increased excretion of base. Alkalosis  Due to electrolyte disturbances caused by, for example prolonged vomiting or severe dehydration  Administration or consumption of base, and hyperventilation

7. Respiratory acidosis  Reduced CO 2 elimination  Decreased breathing rate (respiratory drive) due to drugs or central nervous system disorders  Respiratory muscle/nerve disease (myasthenia gravis.  Airway obstruction (food or foreign object)

8. Respiratory alkalosis  Increased CO 2 elimination  Hyperventilation due to anxiety, pain, shock  Drugs (aspirin)  Pneumonia, pulmonary (lung) congestion, or embolism  Exercise, fever  Central nervous system tumor, trauma, infection  Liver failure

9. Metabolic acidosis  Decreased HCO 3 -, due to loss or to increased acid  Alcoholic ketoacidosis  Diabetic ketoacidosis  Kidney failure  Lactic acidosis  Toxins – overdose of salicylates (aspirin), methanol, ethylene glycol  Gastrointestinal bicarbonate loss, such as from prolonged diarrhea

10. Metabolic alkalosis  Increased HCO 3 -, due to loss of acid or gain of bicarbonate  Diuretics  Prolonged vomiting  Severe dehydration  Administration of bicarbonate, ingestion of alkali

11. Acid-Base Disorder pHHCO 3 - PCO 2 Body Compensation Metabolic acidosis Less than 7.4Low Increased breathing rate (hyperventilation ) to increase CO 2 elimination Metabolic alkalosis Greater than 7.4High Slowed breathing (hypoventilation) to decrease CO 2 elimination Respiratory acidosis Less than 7.4High Kidney increases retention of HCO 3 - and excretion of acid Respiratory alkalosis Greater than 7.4Low Kidney decreases retention of HCO 3 - and excretion of acid

13. Metabolic Compensation Acute Hypercapnia: HCO3 increases 1 mmol/L for each 10 mmHg increase in PaCO 2 >40 Chronic Hypercapnia: HCO3 incr. 3.5 mmol/L for each 10 mmHg increase in PaCO 2 >40 Acute Hypocapnia: HCO3 decreases 2 mmol/L for every 10 mmHg decrease in PaCO 2 <40 Chronic Hypocapnia: HCO3 decreases 5 mmol/L for every 10 mmHg decrease in PaCO 2 <40 CO2 + H2O H2CO3 H + HCO3

14. Respiratory Compensation for Metabolic Acidosis:  Occurs rapidly  Hyperventilation  “Kussmaul Respirations”  Deep > rapid (high tidal volume)  Is not Respiratory Alkalosis Metabolic Alkalosis:  Calculation not as accurate  Hypoventilation  Not Respiratory Acidosis  Restricted by hypoxemia  PCO 2 seldom > 50-55 pCO 2 =1.5 x HCO 3 + 8 +/- 2 Winter’s formula pCO 2 =0.9 x HCO 3 + 15

16. Case 1 A 26 year old man with unknown past medical history is brought in to the ER by ambulance, after friends found him unresponsive in his apartment. He had last been seen at a party four hours prior. ABG: pH 7.25Chem 7:Na + 137 P CO 2 60K + 4.5 P CO 2 60K + 4.5 HCO 3 - 26Cl - 100 HCO 3 - 26Cl - 100 P O 2 55 HCO 3 - 25 P O 2 55 HCO 3 - 25

17. Case 3 A 68 year old woman with metastatic colon cancer presents to the ER with 1 hour of chest pain and shortness of breath. She has no known previous cardiac or pulmonary problems. ABG: pH 7.49Chem 7:Na + 133 P CO 2 28K + 3.9 P CO 2 28K + 3.9 HCO 3 - 21Cl - 102 HCO 3 - 21Cl - 102 P O 2 52HCO 3 - 22 P O 2 52HCO 3 - 22

18. Case 4 A 6 year old girl with severe gastroenteritis is admitted to the hospital for fluid rehydration, and is noted to have a high [HCO 3 - ] on hospital day #2. An ABG is ordered: ABG: pH 7.47Chem 7:Na + 130 P CO 2 46K + 3.2 P CO 2 46K + 3.2 HCO 3 - 32Cl - 86 HCO 3 - 32Cl - 86 P O 2 96 HCO 3 - 33 P O 2 96 HCO 3 - 33 Urine pH:5.8

19. Case 5 A 75 year old man with morbid obesity is sent to the ER by his skilled nursing facility after he developed a fever of 103° and rigors 2 hours ago. In the ER he is lucid and states that he feels “terrible”, but offers no localizing symptoms. His ER vitals include a heart rate of 115, and a blood pressure of 84/46. ABG: pH 7.12Chem 7:Na + 138 P CO 2 50K + 4.2 P CO 2 50K + 4.2 HCO 3 - 13Cl - 99 HCO 3 - 13Cl - 99 P O 2 52HCO 3 - 15 P O 2 52HCO 3 - 15 Urine pH:5.0

20. Case 6 A 25 year old man with type I diabetes presents to the ER with 24 hours of severe nausea, vomiting, and abdominal pain. ABG: pH 7.15Chem 7:Na + 138 P CO 2 30K + 5.6 P CO 2 30K + 5.6 HCO 3 - 10Cl - 88 HCO 3 - 10Cl - 88 P O 2 88HCO 3 - 11 P O 2 88HCO 3 - 11 Cr 1.1 Urine pH:5.0

21. Case 7 A 62 year old woman with severe COPD comes to the ER complaining of increased cough and shortness of breath for the past 12 hours. There are no baseline ABGs to compare to, however, her HCO 3 - measured during a routine clinic visit 3 months ago was 34 mEq/L. ABG: pH 7.21Chem 7:Na + 135 P CO 2 85K + 4.0 P CO 2 85K + 4.0 HCO 3 - 33Cl - 90 HCO 3 - 33Cl - 90 P O 2 47 HCO 3 - 34 P O 2 47 HCO 3 - 34 Urine pH5.5

22. Case 8 A 36 year old man with a history of alcoholism is brought to the ER after being found on the floor of his apartment unresponsive, soiled with vomit, and with an empty pill bottle nearby. ABG: pH 7.03Chem 7:Na + 134 P CO 2 75K + 5.2 P CO 2 75K + 5.2 HCO 3 - 19Cl - 90 HCO 3 - 19Cl - 90 P O 2 48 HCO 3 - 20 P O 2 48 HCO 3 - 20 Urine pH5.0