Metabolic Alkalosis

• Metabolic changes that result in the accumulation of base
• Accumulation of base occurs as a result of
  • Increased acid loss
  • Excess alkali intake

Causes

• G          GIT excess acid loss
  • Vomit (and pyloric stenosis)
  • NGT drainage
  • Diarrhoea
  • Ileostomy
  • Dehydration
• R          Renal excess acid loss
  • Bartter’s
  • Gitelman’s
  • Diuretics (Loss of H+, K+, Cl-)
• O          Overdose of base
  • Antacid OD, Laxative, Milk-alkali syndrome
  • Massive Hartmann’s transfusion
  • Iatrogenic use of HCO3
• E           Endocrine
  • Cushing
  • Steroid excess
  • Hyperaldosteronism

Clinical

• Shift O2 dissociation curve to left (increased affinity for Hb-O2)
  • Right shift with increase TEMP, 2-3 DPG, H+
• Hypokalemia, hypocalcaemia, hypochloraemia
• Symptoms related to HYPOcalcaemia and HYPOkalaemia
  • Dizzy, light-headed
  • Chest tightness
  • Anxiety, dysphasia…..laryngospasm

Correction

• Correct underlying problem
• Improve renal bicarbonate excretion (Cl, K and volume)
• Correct electrolyte imbalance
• Oxygen
• Avoid hyperventilation
• Rarely, acetazolamide or HCl infusion

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Metabolic Acidosis

Normal Anion Gap Metabolic Acidosis

• U            Ureteric diversion
• S             Small bowel fistula
• E             Extra chloride (ED resuscitation) or HCl ingestion
• D            DKA (resolving)
• C             Carbonic anhydrase inhibitors
• A             Addisons (Type 4 RTA)
• R             Renal tubular acidosis types 1, 2, and 4
• P             Pancreatic fistula

Increased Anion Gap Metabolic Acidosis

• M            Methanol (formic acid), metformin
• U            Uraemia (including aminoglycosides)
• R            Renal failure (Uric acid)
• K            Ketoacidosis (alcohol, diabetes (acute), starvation)
• L            Lactic acidosis
• E            Ethanol
• S            Salicylates
• E            Ethylene glycol (glycolic acid)
• P            Paraldehyde, propylene glycol
• T            Toluene
• I             Iron, isoniazid
• C            Cyanide and carbon monoxide

Low Anion Gap

• Increase in unmeasured cations (Increased Li, K, Ca, Mg, and IgG)
  • Lithium toxicity
  • Hypercalcaemia
  • Hypermagnesaemia
  • Hyperkalaemia
  • IgG (Multiple Myeloma)
• Decreased unmeasured anions (Decreased PO4, albumin)
  • HYPOalbuminaemia, HYPOphosphatemia
• Chloride over-estimation (anion)
  • Bromide toxicity (Read as increased chloride)
  • Iodide toxicity
  • Hypercholesterolemia

Clinical

• Respiratory
  • Hyperventilation
  • Shift of Oxy-Hb curve to right
• Cardiovascular
  • Myocardial depression
  • Tissue catecholamine resistance
  • Pulmonary vasoconstriction
  • Hyperkalaemia

Correction

• Treat underlying cause
• Supportive therapy
• IV bicarbonate controversial – usually not helpful

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Acid Base Disorders

Arterial blood gas analysis is used to determine the adequacy of oxygenation and ventilation, assess respiratory function and determine the acid–base balance. These data provide information regarding potential primary and compensatory processes that affect the body’s acid–base buffering system.

• Metabolic Acidosis
• Metabolic Alkalosis
• Respiratory Acidosis
• Respiratory Alkalosis

Interpret the ABGs in a stepwise manner:

1. Determine the adequacy of oxygenation (PaO2)
   • Normal range: 80–100 mmHg (10.6–13.3 kPa)
2. Determine pH status
   • Normal pH range: 7.35–7.45 (H+ 35–45 nmol/L)
   • pH <7.35: Acidosis is an abnormal process that increases the serum hydrogen ion concentration, lowers the pH and results in acidaemia.
   • pH >7.45: Alkalosis is an abnormal process that decreases the hydrogen ion concentration and results in alkalaemia.
3. Determine the respiratory component (PaCO2)
4. Primary respiratory acidosis (hypoventilation) if pH <7.35 and HCO3– normal.
   • Normal range: PaCO2 35–45 mmHg (4.7–6.0 kPa)
   • PaCO2 >45 mmHg (> 6.0 kPa): Respiratory compensation for metabolic alkalosis if pH >7.45 and HCO3– (increased).
   • PaCO2 <35 mmHg (4.7 kPa): Primary respiratory alkalosis (hyperventilation) if pH >7.45 and HCO3– normal. Respiratory compensation for metabolic acidosis if pH <7.35 and HCO3– (decreased).
5. Determine the metabolic component (HCO3–)
   • Normal HCO3– range 22–26 mmol/L
   • HCO3 <22 mmol/L: Primary metabolic acidosis if pH <7.35. Renal compensation for respiratory alkalosis if pH >7.45.
   • HCO3 >26 mmol/L: Primary metabolic alkalosis if pH >7.45. Renal compensation for respiratory acidosis if pH <7.35.

Additional Definitions

• Osmolar Gap
  • Use: Screening test for detecting abnormal low MW solutes (e.g. ethanol, methanol & ethylene glycol [Reference])
  • An elevated osmolar gap (>10) provides indirect evidence for the presence of an abnormal solute which is present in significant amounts [Reference]
  • Osmolar gap = Osmolality – Osmolarity
  • Osmolality (measured)
    • Units: mOsm/kg
    • Measured in laboratory and returned as the plasma osmolality
  • Osmolarity (calculated)
    • Units: mOsm/l
    • Osmolarity = (1.86 x [Na⁺]) + [glucose] + [urea] + 9  (using values measured in mmol/l)
    • Osmolarity = (1.86 x [Na⁺]) + glucose/18 + BUN/2.8 + 9 (using US units of mg/dl)
  • NOTE: even though the units of measured (mOsm/kg) and calculated (mOsm/l) are different [Reference], strictly they cannot be subtracted from one another… However, the value of the difference is clinically useful so the problem is usually overlooked!

Arterial Blood Gas (ABG) Interpretation Chart

Simple table to calculate Respiratory compensation in Acidosis and Alkalosis

Simple calculation to predict changes in HCO3– from PaCO2
	HCO3 (Baseline 24 mmol/L)
Every 10 mmHg D PaCO2 from baseline 40 mmHg	ACUTE	CHRONIC
↑PaCO2	1	4
↓PaCO2	2	5

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