Introduction to acid-base

Joel Topf, M.D.

Assistant Clinical Professor of Medicine
Wayne State University School of Medicine
http://www.pbfluids.com
Getting acid-base
• Acid base physiology is the
regulation of hydrogen ion
concentration
• A normal hydrogen
Every change of 0.3 pH units
concentration is 40 nmol/L+
represents a change in H by 40 nanomol/L = 0.00004 milimol/L
• This is .00004 mmol/L
a factor of 2
So
• It is measured on a negative log
scale called pH, normal is 7.4
 pH = 6.8
Is this patient sick?

Grand mal seizure

Methanol toxicity
It’s the disease, stupid.

• Hydrogen ion concentration can dramatically impact

protein structure and enzyme function.

• The absolute pH is less important than the etiology of the

acid-base disturbance.
Since the disease is important

• It is imperative to rapidly assess the cause of an acid-base

disturbance.

• Using an arterial blood gas and an electrolyte panel, one

can quickly classify a patient’s primary and compensatory
acid-base physiology.

• Patients may have multiple, simultaneous acid-base

disorders. This should be determined.
 Determine the primary Acid-Base disorder
Metabolic Metabolic Respiratory Respiratory
acidosis alkalosis acidosis alkalosis

Determine if the compensation is appropriate

Winter’s ⅓ the Δ HCO3 1:10 acute 2:10 acute
formula 3:10 chronic 4:10 chronic

Determine the anion gap

Non-Anion gap Anion gap

Determine the urinary anion gap Determine the osmolar gap

Positive gap Negative gap
Osmolar gap Non-osmolar gap
(RTA) (GI, IVF)

Determine the bicarbonate before

Pre-existing met. alkalosis Pre-existing NAGMA No pre-existing acid-base disorders
Step 1: determine the primary disorder
The Henderson-Hasselbalch formula is the
mantra of acid-base physiology
 There are 4 primary ways that pH
can change
Increase in HCO3, increases pH.
Metabolic alkalosis
 There are 4 primary ways that pH
can change
Increase in HCO3, increases pH. Metabolic
alkalosis

Decrease in HCO3, decreases pH.

Metabolic acidosis
 There are 4 primary ways that pH
can change
Increase in HCO3, increases pH. Metabolic
alkalosis

Decrease in HCO3, decreases pH.

Metabolic acidosis

Increase in pCO2, decreases pH.

Respiratory acidosis
 There are 4 primary ways that pH
can change
Increase in HCO3, increases pH. Metabolic
alkalosis

Decrease in HCO3, decreases pH.

Metabolic acidosis

Increase in pCO2, decreases pH.

Respiratory acidosis

Decrease in pCO2, increases pH.

Respiratory alkalosis
Patients with primary acid-base disorders
compensate to restore normal pH.
• In respiratory disorders, the • In metabolic disorders,
kidney modifies the serum breathing is altered to change
bicarbonate to return pH the pCO2 in order to return pH
toward normal. toward normal.
 Compensation minimizes changes in
pH

Increased HCO3, increases pH.

Increased CO2 compensates to
reduce the change in pH.
 Compensation minimizes changes in
pH

Decreased HCO3, decreases pH.

Decreased CO2 compensates to
reduce the change in pH.
 Compensation minimizes changes in
pH

Increased CO2, decreases pH.

Increased HCO3 compensates to
reduce the change in pH.
 Compensation is always in the same
direction as the primary disorder.

Primary
Compensation

Metabolic acidosis
HCO3
pCO2

Respiratory alkalosis
pCO2
HCO3

Respiratory acidosis
pCO2
HCO3

Metabolic alkalosis
HCO3
pCO2

 If all three variables move in the same
direction the disorder is metabolic;
if they move in discordant directions it is
respiratory
Primary
Compensation
pH

Metabolic acidosis
HCO3
pCO2

Respiratory alkalosis
pCO2
HCO3

Respiratory acidosis
pCO2
HCO3

Metabolic alkalosis
HCO3
pCO2

Determine the primary disorder

pH / pO2 / pCO2 / HCO3

1. Acidosis or alkalosis
– If the pH is less than 7.4 it is acidosis
– If the pH is greater than 7.4 it is alkalosis

2. Determine if it is respiratory or metabolic

– If the pH, bicarbonate and pCO2 all move in the same direction (up or
down) it is metabolic
– If the pH, bicarbonate and pCO2 move in discordant directions (up
and down) it is respiratory
Determine the primary disorder

7.2 / 78 / 25 / 16

pH / pO2
/
pCO2 / HCO3

1. Acidosis or alkalosis
– If the
If thepH
pHis islessless
than 7.4 it7.4
than is acidosis
it is acidosis
– If the
the pH
pH isis greater
greater than
than 7.4
7.4 itit isis alkalosis
alkalosis

2.
– If
Metabolic Acidosis

Determine if it is respiratory or metabolic
the pH,
pH,bicarbonate andand
pCOpCO
If the bicarbonate 2 all 2
move in the in
all move same
thedirection
same (up or
down) it is metabolic
direction (up or down) it is metabolic
– If the pH, bicarbonate and pCO2 move in discordant directions (up and
and down)
down) it is respiratory
it is respiratory
Respiratorythe
Determine alkalosis
primary disorder

7.5 / 55 / 24 / 36

pH / pO2
/
pCO2 / HCO3

1.
1. Respiratory acidosis
Respiratory acidosis
2. Metabolic acidosis
3.
3. Respiratory alkalosis
Respiratory alkalosis
alkalosis
4. Respiratoryalkalosis
Metabolic alkalosis
Now let’s do some questions
 Determine the primary Acid-Base disorder
Metabolic Metabolic Respiratory Respiratory
acidosis alkalosis acidosis alkalosis

Determine if the compensation is appropriate

Winter’s ⅓ the Δ HCO3 1:10 acute 2:10 acute
formula 3:10 chronic 4:10 chronic

Step 2: is there the correct degree of

compensation?
• The direction of the compensation is always in the same
direction as the primary disorder.

• The magnitude of the compensation is determined solely

by the magnitude of the primary disorder.

– If, in a case of metabolic acidosis, the bicarbonate falls to 10 then

the pCO2 should fall to 23±2 to compensate.

– If the pCO2 is not in that range a second primary disorder is

present

• If the pCO2 is less than 21, then the patient also has a
respiratory alkalosis

• If the pCO2 is over 25, the patient has an additional

respiratory acidosis
• Each primary acid base disorder has its own formula for
prediction:

– Metabolic acidosis: Winter’s Formula

• 1.5 × HCO3 + 8 ± 2

– Metabolic alkalosis:
• pCO2 rises 0.7 per mmol rise in HCO3

– Respiratory acidosis:
• 1 or 3 mmol rise in HCO3 for 10 rise in pCO2

– Respiratory alkalosis:
• 2 or 4 mmol fall in HCO3 for 10 fall in pCO2
Predicting pCO2 in metabolic acidosis

• In metabolic acidosis the expected pCO2 can be estimated

from the HCO3

Expected pCO2 = (1.5 x HCO3) + 8 ± 2

• If the pCO2 is higher than predicted then there is an

addition respiratory acidosis

• If the pCO2 is lower than predicted there is an additional

respiratory alkalosis
Predicting pCO2 in metabolic acidosis

• Example:

7.23 / 78 / 19 / 8

pH / pO2 / pCO2 / HCO3

– Expected pCO2 = (1.5 x HCO3) + 8 ±2

– Expected pCO2 = 18-22

– Actual pCO2 is 19, which is within the predicted range,
indicating a simple metabolic acidosis
Predicting pCO2 in metabolic acidosis

• Example:

7.15 / 112 / 34 / 12

pH / pO2 / pCO2 / HCO3

– Expected pCO2 = (1.5 x HCO3) + 8 ±2

– Expected pCO2 = 24-28

– Actual pCO2 is 34, which is above the predicted range,
indicating an additional respiratory acidosis
Predicting pCO2 in metabolic alkalosis

• In metabolic acidosis the expected pCO2 can be estimated from the

HCO3
pCO2 should rise 0.7 for every increase in HCO3 of one, ±2

Example:

7.46 / 78 / 49 / 34

pH / pO2 / pCO2 / HCO3

– HCO3 is 34-24 = 10 above normal, so pCO2 should be 7

over normal, 47±2

– Actual pCO2 is 49, which is within the predicted range,
indicating a simple metabolic alkalosis

Respiratory disorders

• Metabolic compensation for respiratory acid-base disorders

is slow.

• So the predicted bicarbonate needs to be calculated for

pre-compensation, called acute, and after compensation,
called chronic.

– Chronic compensation is complete so the pH will be

closer to normal at the expense of increased alteration
of serum bicarbonate.
Why is metabolic compensation slow?

• The lungs ventilate 12 moles of acid per day as carbon

dioxide

• The kidneys excrete less than 0.1 mole of acid per day as
ammonia, phosphate and free hydrogen ions

• The high excretion capacity of the lungs relative to the

kidneys means that metabolic disorders are rapidly
compensated by the lungs while respiratory disorders take
hours to days for compensation by the kidneys.
Respiratory acidosis
For every increase in pCO2 of 10 mmHg the bicarbonate
should increase:
• 1 mEq/L in acute • 3 mEq/L in chronic

• Example:
7.19 / 78 / 78 / 30

pH / pO2 / pCO2 / HCO3

• pCO2 is 38 above normal, so

– if the condition is acute the HCO3 should be 28±2

– If the condition is chronic the HCO3 should be 35 ±2

– Actual HCO3 is 30, which is within the predicted range,
for acute respiratory acidosis and outside of the range
for chronic.

Respiratory alkalosis
For every decrease in pCO2 of 10 mmHg the bicarbonate
should decrease:
• 2 mEq/L in acute • 4 mEq/L in chronic

• Example:
7.44 / 78 / 25 / 17

pH / pO2 / pCO2 / HCO3

• pCO2 is 15 below normal, so

– If the condition is acute the HCO3 should be decreased
by 3 or 21±2

– If the condition is chronic the HCO3 should be
decreased by 6 or 18 ±2

Summary of metabolic compensation for
respiratory acid-base disorders

PCO2 : HCO3
Respiratory Respiratory
acidosis alkalosis

Acute 10:1 10:2

Chronic
10:3 10:4
For every rise of 10 For every fall of 10
in the pCO2 the in pCO2 the HCO3
HCO3 will rise by 1 will fall by 2 or 4.
or 3
Now let’s do some questions
 Determine the primary Acid-Base disorder
Metabolic Metabolic Respiratory Respiratory
acidosis alkalosis acidosis alkalosis

Determine if the compensation is appropriate

Winter’s ⅓ the Δ HCO3 1:10 acute 2:10 acute
formula 3:10 chronic 4:10 chronic

Determine the anion gap

Non-Anion gap Anion gap

Step 3: if you have metabolic acidosis, is

there an anion gap?
What is the anion?
• Metabolic acidosis is further evaluated by determining the
anion associated with the increased H+ cation
• These can be differentiated by measuring the anion gap.

It is either chloride Or it is not chloride

Non-Anion Gap Met Acid Anion Gap Met Acid

Anion gap

=
Anion gap

=
Calculating the anion gap

• Anion gap = Na – (HCO3 + Cl)

• Normal is 12

– Varies by hospital

– Average anion gap in healthy controls is 6 ±3

• Improving chloride assays have resulted in increased

chloride levels and a decreased normal anion gap.
Other causes of a low anion gap
Sodium Chloride
• Increased chloride
– Hypertriglyceridemia Bicarb
– Bromide
– Iodide
• Decreased “Unmeasured anions”
– Albumin Albumin
– Phosphorous Normal Phos
• Increased “Unmeasured cations” anion IgA
– Hyperkalemia gap
– Hypercalcemia
– Hypermagnesemia
– Lithium Potassium
– Increased cationic paraproteins Calcium
• IgG
Magnesium
IgG
Evaluate the ABG
• Acidosis
Acidosis ororAlkalosis
Alkalosis 7.38 / 212 / 27 / 16

• Metabolic
Metabolic ororRespiratory
Respiratory pH / pO2 / pCO2 / HCO3

• Isolated metabolic acidosis? 144 110

 No. There is concomitant
respiratory alkalosis. 3.4 16

• Anion
Anion gap
gapororNon-Anion
Non-AnionGap
Gap
• Predicted pCO2
 (16 x 1.5) + 8 ±2 =
 30-34

• Anion gap
 144 – (110 + 16) =
 18
The anion gap acidosis
• Uremia (mild) • L-Lactic acidosis
• Ingestions – Salicylate intoxication
– Methanol – Ischemia
– Ethylene glycol – Cyanide intoxication
• Ketoacidosis • Nitroprusside

– DKA – Malignancy
– Starvation – Metformin
– Alcoholic – Liver failure
– Thiamine deficiency
• Sepsis
• D-Lactic acidosis
• Pyroglutamic acidosis
GOLDMARK
• The classic mnemonic, MUD PILES, sucks.
The new mnemonic is GOLD MARK. Know it.
• G Glycols
• O Oxoproline: Pyroglutamic
• L L-lactic acidosis
• D D-Lactic acidosis
• M Methanol
• A Aspirin
• R Renal failure
• K Ketoacidosis
AN Mehta, JB Emmett , M Emmett, Lancet, 372, 9642, p 892, 2008

Now let’s do some questions
 Determine the primary Acid-Base disorder
Metabolic Metabolic Respiratory Respiratory
acidosis alkalosis acidosis alkalosis

Determine if the compensation is appropriate

Winter’s ⅓ the Δ HCO3 1:10 acute 2:10 acute
formula 3:10 chronic 4:10 chronic

Determine the anion gap

Non-Anion gap Anion gap

Determine the osmolar gap

Osmolar gap Non-osmolar gap

Step 4: if you have an AGMA, is there an

osmolar gap?
Osmolar gap
• In the presence of a large anion gap (>20-25) of undetermined etiology
you must rule out a toxic alcohol.
– Methanol
– Ethylene Glycol
• The low molecular weight of the alcohols means that modest ingestions
have a relatively large impact on the serum osmolality
– Few grams equals many milimoles
• Their presence can be detected by comparing the measured osmolality
(which includes the alcohol) to a calculated osmolality (which does not
account for the alcohol).
• If the measured osmolality is significantly more (>10) than the
calculated osmolaility you have an osmolar gap.

BUN Glucose Ethanol

Calculated osmolality = (2 × Na) + + +
2.8 18 4.6
Question 4: evaluate the ABG
• Acidosis
Acidosis ororAlkalosis
Alkalosis 7.16 / 212 / 22 / 8

• Metabolic
Metabolic ororRespiratory
Respiratory pH / pO2 / pCO2 / HCO3

• Isolated metabolic acidosis? 142 110 46

 Yes. There is no concomitant 88

respiratory disorder. 5.4 8 2.2

• Anion
Aniongap
gaporor
Non-Anion Gap
Serum Osmolality: 312

• Osmolar
Predicted
Anion gapgap
pCO2
• Osmolar gap or
 142
Calc
(8 x 1.5)
–Osmolality
(110
+ 8+±28) =
=
Non-Osmolar Gap
Non-Osmolar Gap
 24  (2 x 142) + 46/2.8 + 88/18 =
18-22
 284 + 16 + 5 = 305
 Osmolality Gap
 312 – 305 = 7
Osmolar gap is not specific
• Elevated osmolar gap will be found with:
– Ethylene glycol
– Methanol
– Isopropyl alcohol
– Ketoacidosis
– Lactic acidosis
– Mannitol infusion
– Hypertriglyceridemia
Now let’s do some questions
 Determine the primary Acid-Base disorder

Step 5:
Metabolic
acidosis
if you have
Metabolic
alkalosis
an AGMA,
Respiratory determine
acidosis
Respiratory
alkalosis
what the bicarbonate was before the anion
Determine if the compensation is appropriate
gap
Winter’s ⅓ the Δ HCO3 1:10 acute 2:10 acute
formula 3:10 chronic 4:10 chronic

Determine the anion gap

Non-Anion gap Anion gap

Determine the osmolar gap

Osmolar gap Non-osmolar gap

Determine the bicarbonate before

Pre-existing met. alkalosis Pre-existing NAGMA No pre-existing acid-base disorders
The acid-base time machine
• If you have an anion gap metabolic acidosis the anion gap should
increase by one for every one that the bicarbonate falls.

=
The acid-base time machine
• Assume that the loss of bicarbonate due to addition of an anion
is roughly 1:1
• So for every increase in the anion gap of one the bicarbonate
should drop by one

∆ HCO3 = ∆ Anion Gap

HCO3 before – HCO3 now = AGcurrent – AGnormal

12)
normal)
HCO3 before = HCO3 now + (AGcurrent – AG
Evaluate: 7.14 / 212 / 18 / 6

pH / pO2 / pCO2 / HCO3

• Acidosis
Acidosis ororAlkalosis
Alkalosis 134 104

• Metabolic
Metabolic ororRespiratory
Respiratory 3.4 8

• Isolated metabolic acidosis? • Predicted pCO2
 Yes.  (8 x 1.5) + 8 ±2 =
• Anion
Anion gap
gapororNon-Anion
Non-AnionGap
Gap  18-22

• Anion gap
 134 – (104 + 8) =
• Additional metabolic disorder?
 22
 Yes. • Bicarbonate prior to anion gap
 Non-anion gap metabolic  HCO3 + (AG – 12) = HCO3 before
acidosis  8 + (22 – 12) =
 18
Now let’s do some questions
Most common error in acid-base

Personal observation
AE
• 66 yo white male
• PMHx DM, paraplegia 2° MVA
• Klebsiella urosepsis induced ARF
• Blood Cxrs + for Klebsiella
• 8/16/04 • 8/29/04
139 107 31 139 111 56
5.4 20 1.2 3.9 14 2.8
• 8/26/04 – Start bicarbonate gtt
138 104 38 • 8/30/04
4.4 21 1.9 137 104 62
• 8/28/04 3.5 22 3.0
137 108 53 • 7.52 / 31 / 46 / 25
3.8 16 2.9
Respiratory alkalosis
– Start oral bicarbonate
Predicted HCO3:
Acute: 23
Chronic: 21
Fin