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HOSAM M ATEF;MD
SUEZ CANAL UNIVERSITY
Rule 2 : The 4 for 10 Rule for Chronic Respiratory Acidosis The [HCO3] will increase by 4 mmol/l for every 10 mmHg elevation in pCO2 above 40mmHg.
Rule 3 :The 2 for 10 Rule for Acute Respiratory Alkalosis The [HCO3] will decrease by 2 mmol/l for every 10 mmHg decrease in pCO2 below 40 mmHg.
Rule 4 : The 5 for 10 Rule for a Chronic Respiratory Alkalosis The [HCO3] will decrease by 5 mmol/l for every 10 mmHg decrease in pCO2 below 40 mmHg.
Rule 6 : The Point Seven plus Twenty Rule - for a Metabolic Alkalosis The expected pCO2(in mmHg) is calculated from the following formula:
Metabolic acidosis is conveniently divided into elevated and normal anion gap (AG) acidosis. AG is calculated as
AG = Na+ - (Cl- + CO2)
Note: CO2 in this equation is the “total CO2”consists mostly of bicarbonate.
A- = anion gap
Normal anion gap
Early renal failure
Ketoacidosis Uremia Lactic acidosis Toxins: Ethylene glycol
pH < 7.1 ( HCO3 < 15)
1/3 wt × base deficit
50 % - recheck
When to use
How to use
Molar solution= 23 +1+12+48
= 84 g/l ( 8.4 % solution)
Molar solution = 84 g/l ( 8.4 % )
= 84 g/1000 ml
= 1 mol/1000 ml
= 1000 mmol/1000 ml
= 1 mmol/ml
( loss of chloride )
( loss of H+ )
Urine chloride ( mmol/L)
= 30% × Bwt × ( 100 - Clm)
= 50% × Bw × BE
HCO3 gap = Na-Cl-36
< - 6
ΔOsmgap = Osmmeasured − Osmcalculated(mOsm/kg).
The measured osmolality 285 and 295 mOsm/kg
The normal osmolal gap is <10 to 12 mOsm/kg H2O.
SSIDa = Na + K+ Ca+ Mg- (Cl+lactate)
IDa= Na + K+ Ca+ Mg- (Cl+lactate)
SIDe = HCO3 + 0.28 * Albumin (g/L) + 1.8 * Pi (mmol/L)
SIG= SIDa- SIDe
the “normal” SIG as 8 ± 2 mEq/L (Fencl et al., 2000)
METABOLIC ACIDOSISIncreased anion gap
Central nervous system depression (e.g., drug overdose)
Chest bellows dysfunction (e.g., Guillain-Barré syndrome, myasthenia gravis) Disease of lungs and/or upper airway (e.g., chronic obstructive lung disease, severe asthma attack, severe pulmonary edema)
Hypoxemia (includes altitude)
Any acute pulmonary insult, e.g., pneumonia, mild asthma attack, early pulmonary edema, pulmonary embolism
Chloride responsive (responds to NaCl or KCl therapy): contraction alkalosis, diuretics; corticosteroids; gastric suctioning; vomiting
TIP 1. Don’t interpret any blood gas data for acid-base diagnosis without closely examining the serum electrolytes: Na+, K+, Cl- and CO2.
TIP 2. a truly normal pH with distinctly abnormal HCO3- and PaCO2 invariably suggests two or more primary disorders.
TIP 3. Simplified rules predict the pH and HCO3- for a given change in PaCO2. If the pH or HCO3- is higher or lower than expected for the change in PaCO2, the patient probably has a metabolic acid-base disorder as well.
a) A normal or slightly low HCO3- in the presence of hypercapnia suggests a concomitant metabolic acidosis, e.g., pH 7.27, PaCO2 50 mm Hg, HCO3- 22 mEq/L. Based on the rule for increase in HCO3- with hypercapnia, it should be at least 25 mEq/L in this example; that it is only 22 mEq/L suggests a concomitant metabolic acidosis.
b) A normal or slightly elevated HCO3- in the presence of hypocapnia suggests a concomitant metabolic alkalosis, e.g., pH 7.56, PaCO2 30 mm Hg, HCO3- 26 mEq/L. Based on the rule for decrease in HCO3 with hypocapnia, it should be at least 23 mEq/L in this example; that it is 26 mEq/L suggests a concomitant metabolic alkalosis
TIP 4. In maximally-compensated metabolic acidosis, the numerical value of PaCO2 should be the same (or close to) the last two digits of arterial pH. This observation reflects the formula for expected respiratory compensation in metabolic acidosis:
Expected PaCO2 = [1.5 x serum CO2] + (8 ± 2)
1. A patient’s arterial blood gas shows pH of 7.14, PaCO2 of 70 mm Hg, and HCO3- of 23 mEq/L. How would you describe the likely acid-base disorder(s)?
2. A 45-year-old man comes to hospital complaining of dyspnea for three days. Arterial blood gas reveals pH 7.35, PaCO2 60 mm Hg, PaO2 57 mm Hg, HCO3- 31 mEq/L. How would you characterize his acid-base status?
1. an acute respiratory acidosis. For every 10 mm Hg rise in PaCO2 (before any renal compensation), pH falls about 0.07 units. Because this patient\'s pH is down 0.26 more than expected for a 30 mm Hg increase in PaCO2, there must be an additional, metabolic problem. Also, note that with acute CO2 retention of this degree, the HCO3- should be elevated 3 mEq/L. Thus a low-normal HCO3- with increased PaCO2 is another way to uncover an additional, metabolic disorder. Decreased perfusion leading to mild lactic acidosis would explain the metabolic component.
3. State whether each of the following statements is true or false.
a) Metabolic acidosis is always present when the measured serum CO2 changes acutely from 24 to 21 mEq/L.F
b) In acute respiratory acidosis, bicarbonate initially rises because of the reaction of CO2 with water and the resultant formation of H2CO3.T
c) If pH and PaCO2 are both above normal, the calculated bicarbonate must also be above normal.T
d) An abnormal serum CO2 value always indicates an acid-base disorder of some type.T
e) The compensation for chronic elevation of PaCO2 is renal excretion of bicarbonate.F
f) A normal pH with abnormal HCO3- or PaCO2 suggests the presence of two or more acid-base disorders.T
g) A normal serum CO2 value indicates there is no acid-base disorder.F
Case 1 - Discussion.
OXYGENATION: The PaO2 and SaO2 are both reduced on room air. Since P(A-a)O2 is elevated (approximately 43 mm Hg), the low PaO2 can be attributed to V-Q imbalance, i.e., a pulmonary problem. SaO2 is reduced, in part from the low PaO2 but mainly from elevated carboxyhemoglobin, which in turn can be attributed to cigarettes. The arterial oxygen content is adequate.
VENTILATION: Adequate for the patient\'s level of CO2 production; the patient is neither hyper- nor hypo- ventilating.
ACID-BASE: Elevated pH and HCO3- suggest a state of metabolic alkalosis, most likely related to the patient\'s diuretic; his serum K+ should be checked for hypokalemia.
Case 2 - Discussion.
OXYGENATION: The PaO2 is lower than expected for someone hyperventilating to this degree and receiving supplemental oxygen, and points to significant V-Q imbalance. The oxygen content is adequate.
VENTILATION: PaCO2 is half normal and indicates marked hyperventilation.
ACID-BASE: Normal pH with very low bicarbonate and PaCO2 indicates combined respiratory alkalosis and metabolic acidosis. If these changes are of sudden onset the diagnosis of sepsis should be strongly considered, especially in someone with a documented infection.