1

2
3
4
3
6
7
8


1he meLabollc componenL of acld-base sLaLus ls deLermlned by Slu and A
1C1
ln Lhe
physlcochemlcal meLhod. Albumln may conLrlbuLe Lo anlons and weak aclds.
A
1C1
=concenLrauon of nonvolaule weak aclds, Slu=sLrong lon dlerence


9
10
uecreased Slu--uecreased na and lncreased Cl (dlarrhea)
lncreased Slu--lncreased na or decreased Cl
11
1hese formulas uslng Lhe Lradluonal meLhod approach wlll be used Lo solve
subsequenL acld-base problems.
Assume Lhe normal anlon gap = 12 and Lhe normal [PCC
3
] = 24.
12
13
14
13
16
17
1ype 8 lacuc acldosls assoclaLed wlLh adequaLe C
2
dellvery: alLered cell meLabollsm,
lncreased aeroblc meLabollsm or glucose producuon wlLh enhanced pyruvaLe
producuon, elevaLed nAuP/nAu rauos, or lnhlbluon of cyLochrome oxldase.
18
Lacuc acldosls ln Lhe crlucally lll may be a comblnauon of Lype A and Lype 8. urugs
wlLh beLa-agonlsL acuvlLy cause an lncreased producuon of lacLaLe (Lype 8) LhaL ls noL
assoclaLed wlLh ussue lschemla. Severe hepauc dysfuncuon may also resulL ln
decreased clearance of lacLaLe.
19
20
u-lacuc acldosls ls assoclauon wlLh anaLomlc or funcuonal shorL bowel resulLs
ln overgrowLh of u-lacLaLe produclng gram posluve organlsms: loctoboclllos
oclJopbllos, 5tteptococcos bovls, 8ldobacLerlum, LubacLerlum.
A carbohydraLe load can preclplLaLe an lncrease ln u-lacLaLe producuon.
21
22
23
24
ln alkalemla, albumln becomes more negauvely charged whlch lncreases anlons.
23
26
1he delLa gap ls used Lo ldenufy a second meLabollc dlsorder ln meLabollc acldoses.

27
28
29
1hls acld-base pauern ls assoclaLed wlLh profuse dlarrhea whlch ls conslsLenL wlLh
Lhe pauenLs orLhosLauc hypoLenslon and low poLasslum level. Pypoperfuslon would
llkely cause an anlon gap meLabollc acldosls and sLarvauon would cause keLoacldosls
wlLh an lncreased anlon gap. oLasslum levels would be low ln hypoaldosLeronlsm.
30
31
32
Calculauon of Lhe urlne anlon gap can deLermlne lf Lhe PCC
3
loss ls renal or Cl lf lL ls
noL evldenL cllnlcally.
33



34
33
36
37
38
39
1he expecLed aCC
2
would be 40 + 10-11 or 30-31. 1he pauenL has hypovenulauon ln
response Lo a meLabollc alkalosls from dluresls.
1he mlnlmally elevaLed anlon gap ls due Lo Lhe alkalemla.
40
41
Hypophosphatemia can never cause a large enough change in A
TOT
to result in
metabolic alkalosis.
42
ln meLabollc alkalosls, urlne Cl more accuraLely reecLs lnLravascular volume Lhan
urlne na because na musL be excreLed wlLh PCC
3
.
43
44
43
46
47
A small lncrease ln blcarbonaLe ls due Lo uLrauon of lnLracellular buers.
48
1he lncrease ln blcarbonaLe ls greaLer ln a chronlc process due Lo renal adapLauons.
49
30
31
32
1he resplraLory alkalosls does noL L Lhe expecLed changes of acuLe or chronlc
resplraLory alkalosls. ln addluon Lhe decrease ln blcarbonaLe ls greaLer Lhan
predlcLed. Calculauon of Lhe anlon gap demonsLraLes Lhe coexlsLence of an anlon gap
meLabollc acldosls.

1hls pauern of acld-base dlsorders should ralse Lhe concern of sepsls.
33
34
33
36
37
1he pP ls hlgher Lhan anuclpaLed for a pure acuLe resplraLory process and Lhe change
ln aCC
2
ls opposlLe of whaL ls predlcLed by Lhe PCC
3
value. 1hese 2 ndlngs suggesL
a comblned meLabollc and resplraLory alkalosls.
38
39
60
61
lomng Lhe values on an acld-base dlagram would suggesL a mlld acuLe resplraLory
alkalosls. More lnformauon ls requlred Lo accuraLely assess Lhe acld-base sLaLus ln
Lhls pauenL.
62
63
lor purposes of analysls, Lhe pP should be consldered Lo be alkalemlc. A near normal
pP ln a severely lll pauenL should ralse Lhe conslderauon of complex processes.
AlLhough Lhe pP and PCC
3
are close Lo expecLed values, calculauon of Lhe anlon gap
reveals a slgnlcanL anlon gap acldosls. 1he delLa gap calculauon conrms Lhe
presence of a concomlLanL meLabollc alkalosls.
1hls acld-base pauern ls noL uncommon ln pauenLs wlLh dlabeuc keLoacldosls.
64
63
1he AC acldosls may be secondary Lo renal fallure and Lhe normal AC acldosls may be
secondary Lo renal Lubular dysfuncuon from chronlc dlsease or lmmunosuppressanLs.
66
67
1he meLabollc alkalosls ln Lhls pauenL ls llkely secondary Lo Lhe nausea and vomlung
wlLh volume depleuon. 1he meLabollc acldosls ls llkely secondary Lo hypoLenslon and
hypoperfuslon.
68
69
Clven Lhe hlsLory of CCu, Lhe formula for chronlc resplraLory acldosls would be
applled. 1he anlon gap denes Lhe coexlsLence of an anlon gap meLabollc acldosls
and Lhe posluve delLa gap suggesLs a meLabollc alkalosls. 1he acldosls may resulL
from Lhe hypoLenslon and Lhe meLabollc alkalosls would be conslsLenL wlLh dlureuc
use.
70
71
1he anlon gap acldosls ls evldenL buL Lhe delLa gap calculauon reveals Lhe
concomlLanL meLabollc alkalosls. 1he acldosls may be secondary Lo renal aclds or
lacLaLe whlle Lhe meLabollc alkalosls ls secondary Lo dehydrauon.
72
73
1hls pauenL's pP falls beLween Lhe calculaLed pP for an acuLe or chronlc resplraLory
acldosls. ln Lhe absence of a meLabollc acldosls, Lhls ndlng suggesLs an acuLe
resplraLory acldosls componenL on Lop of a chronlc resplraLory acldosls. 1hls ls a
Lyplcal ndlng ln acuLe exacerbauons of CCu.
74
73