Emergency Medicine

(Nancy Kaufman) #1
Acid–Base, Electrolyte and Renal Emergencies 127

ACID–BASE DISTURBANCES

3 Causes of a high anion gap metabolic acidosis (anion gap >16) include:
(i) Increased acid production:
(a) ketoacidosis, e.g. diabetic, alcoholic, starvation
(b) lactic acidosis (serum lactate >2.5 mmol/L):


  • type A: impaired tissue perfusion in cardiac arrest, shock,
    hypoxia, sepsis

  • type B: impaired carbohydrate metabolism in hepatic or
    renal failure, lymphoma, pancreatitis and drugs such as
    metformin.
    (ii) Decreased acid excretion, as in renal failure.
    (iii) Exogenous acid ingestion:
    (a) methanol, ethylene glycol, iron, cyanide and salicylates.
    4 Causes of a normal anion gap metabolic acidosis (anion gap 8–16) include:
    (i) Renal:
    (a) renal tubular acidosis
    (b) carbonic anhydrase inhibitors.
    (ii) Gastrointestinal:
    (a) severe diarrhoea
    (b) small bowel fistula
    (c) drainage of pancreatic or biliary secretions.
    (iii) Other:
    (a) administration of synthetic amino acid solutions, ammonium
    chloride
    (b) recovery from ketoacidosis.
    5 The body compensates to reduce the acid load by hyperventilation.
    The expected compensatory reduction in PaCO 2 may be calculated (see
    Table 3.2):


Table 3.2 Predicting the expected compensatory changes in PaCO 2 and HCO 3
Metabolic acidosis Metabolic alkalosis
Predicted
PaCO 2
(kPa)

0.2  [HCO 3 ] + 1 kPa (+/– 0.25) [HCO 3 ]
+ 2.5 kPa (+/– 0.7)
10

Predicted
PaCO 2
(mmHg)

1.5  [HCO 3 ] + 8 mmHg (+/– 2) 0.7  [HCO 3 ] + 20 mmHg (+/– 5)

Respiratory acidosis Respiratory alkalosis
Predicted
HCO 3
(kPa)

Acute
24 + (PaCO 2 –
5.33)  0.75

Chronic
24 + (PaCO 2 –
5.33)  3

Acute
24 – (5.33 –
PaCO 2 )  1.5

Chronic
24 – (5.33 –
PaCO 2 )  3.75
Predicted
HCO 3
(mmHg)

24 + PaCO 2 – 40
10 24 +(

PaCO 2 – 40
10 )^ ^4 24 – (

40 – PaCO 2
10 )^ ^2 24 – (

40 – PaCO 2
10 )^ ^5

Table 3.2.indd 1 15/03/2011 15:02

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