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TYPES OF ACID BASE DISORDERS
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There are two types of acid base disorders: respiratory and metabolic Primary respiratory disorders affect blood acidity by causing changes in PCO2, and primary metabolic disorders are caused by disturbances in the HCO3 concentration The primary disturbances are usually accompanied by compensatory changes; however, even though these changes attenuate a pH shift from the normal value (740), they do not fully compensate for the primary acid base disorders even if the disorders are chronic Therefore, if the pH is less than 740, the primary
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Treatment is directed toward alleviating progression of CKD Calcium acts as an antagonist to Mg2+ and may be given intravenously as calcium chloride, 500 mg or more at
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Table 21 13 Primary acid-base disorders and expected compensation
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Disorder Respiratory acidosis Acute Chronic Respiratory alkalosis Acute Chronic Metabolic acidosis Metabolic alkalosis Pco2 Pco2 HCO3 HCO3 HCO3 HCO3 Pco2 Pco2 HCO3 2 mEq/L per 10 mm Hg Pco2 HCO3 5 mEq/L per 10 mm Hg Pco2 Pco2 13 mm Hg per 1 mEq/L HCO3 Pco2 07 mm Hg per 1 mEq/L HCO3 PCO2 Pco2 HCO3 HCO3 HCO3 1 mEq/L per 10 mm Hg Pco2 HCO3 35 mEq/L per 10 mm Hg Pco2 Primary Defect Compensatory Response Magnitude of Compensation
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process is acidosis (either respiratory or metabolic) If the pH is higher than 740, the primary process is either respiratory or metabolic alkalosis The presence of one disorder with its appropriate compensatory change is a simple disorder
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STEP-BY-STEP ANALYSIS OF ACID-BASE STATUS
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Step 1: Determine the primary (or main) disorder whether it is metabolic or respiratory from blood, pH, HCO3 , and PCO2 values Step 2: Determine the presence of mixed acid-base disorders by calculating the range of compensatory responses (Table 21 13) Step 3: Calculate the anion gap (Table 21 14) Step 4: Calculate the corrected HCO3 concentration if the anion gap is increased (see above) Step 5: Examine the patient to determine whether the clinical signs are compatible with the acid-base analysis thus obtained
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MIXED ACID BASE DISORDERS
The presence of more than one simple disorder (not compensatory) is a mixed disorder Double or triple disorders can coexist but not quadruple ones, because simultaneous respiratory acidosis and alkalosis are not possible Clinicians frequently find it difficult to decide if a mixed disorder is present One useful scheme is to determine if the degree of compensation for the primary disorder is appropriate (Table 21 13) In respiratory disorders, if the magnitude of compensation in HCO3 level differs from what is predicted, the patient has a mixed disorder Therefore, superimposed metabolic acidosis will decrease HCO3 to lower than the predicted level, and a metabolic alkalosis will increase HCO3 over the predicted value For example, a patient with chronic respiratory acidosis and PCO2 of 60 mm Hg should have a HCO3 of 31 mEq/L (assuming that normal HCO3 is 24 mEq/L) If the HCO3 is 25 mEq/L, a superimposed metabolic acidosis exists, and if the HCO3 is 45 mEq/L, there is a superimposed metabolic alkalosis Using data from Table 21 13, similar calculations can be made for primary metabolic disorders Furthermore, corrected bicarbonate (cHCO3 ), calculated from measured HCO3 plus the increase in anion gap (see box), is useful to assess the superimposed metabolic alkalosis or normal anion gap metabolic acidosis In increased anion gap acidosis, there must be a mole for mole decrease in HCO3 as anion gap increases Therefore, an HCO3 value higher or lower than normal (24 mEq/L) indicates the concomitant presence of metabolic alkalosis or normal anion gap acidosis, respectively
Herd AM An approach to complex acid-base problems: keeping it simple Can Fam Physician 2005 Feb;51:226 32 [PMID: 15751566] Kellum JA Determinants of plasma acid-base balance Crit Care Clin 2005 Apr;21(2):329 46 [PMID: 15781166] Whittier WL et al Primer on clinical acid-base problem solving Dis Mon 2004 Mar;50(3):122 62 [PMID: 15069420]
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