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HOW TO ... Approach For Metabolic acidosis
Transcript of HOW TO ... Approach For Metabolic acidosis
simple metabolic acidosis
is an acid-base disorder characterized by an
arterial pH of less
. It is created by 1 of 3 mechanisms:
from the body.
(2) Impaired ability to
by the kidney.
to the body.
Causes of metabolic acidosis
HOW to find the cause ?!
The Result ...
What dose our body response ??!!
it has to compensate the problem
excrete an increased
after the compensatory hyperventilation begins and continues for
, the kidneys attempt to
- to compensate for the acidosis.
compensate for a metabolic acidosis through
increases in alveolar ventilation.
tachypnea and hyperpnea to
reduces the PaCO2 process happens
and is complete within
appropriate respiratory compensation for a metabolic acidosis
normalizes the patient's pH.
Anion gap !
No. of -
charged ions (
the No. of +
charged ions (
) to give
net charge .
Cl and Hco3
, and the
unmeasured anions include phosphates, So4, and proteins (eg, albumin).
The measured serum
but other cations are noted,
such as Ca, K, and Mg.
Anion Gap = (Sodium) – (Chloride + Bicarbonate)
Metabolic Acidosis is divided into processes that are associated with
Normal anion gap (8-12 mEq/L)
seizures, a depressed sensorium, or both in a neonate - This warrants consideration of an inborn error of metabolism, or neonatal sepsis .
depressed mental status, lethargy, and poor feeding in a neonate - Left-sided, obstructive cardiac lesions should be considered (eg, aortic coarctation or hypoplastic left heart syndrome)
*Hyperventilation or Kussmaul breathing.
*impaired cardiac contractility ,arrhythmia , hypotension.
*Signs of dehydration may include tachycardia, dry mucous membranes, and delayed capillary refill.
*Patients with diabetic ketacidosis may present with fruity odor to their breath
*Hepatomegaly and metabolic acidosis may occur in children with sepsis, congenital or acquired heart disease, hepatic failure, or inborn errors of metabolism.
*neurologic signs that may indicate meningitis or
inborn error of metabolism
Failure to thrive suggestive of chronic metabolic acidosis in RTA,
New onset of polyuria, polydipsia, and weight loss -DM DKA
ingestion of a toxin or medications .
trauma, or fever
states associated with a lactic acidosis secondary to shock from hypovolemia, sepsis, cardiac failure, anaphylaxis, or spinal shock
normoglycemia, and glycosuria occur in children when type II RTA is part of Fanconi syndrome;
anion gap occurs when there is an
most common cause ....
low >>> Hco3 ,Na ,H2O,K
increase >>>> lactic acid , aldosterone,
ketonemia or ketonurea
high anion gap
In distal RTA
Patients with distal RTA cannot acidify their urine and, thus, have a urine
despite a metabolic acidosis.
Failure to thrive due to chronic metabolic acidosis is the most common presenting complaint.
, and excessive
urinary losses of phosphate and uric acid
Note : bicarbonate therapy increases bicarbonate losses in the urine, and the urine pH increases.
Rickets and/or failure to thrive may be the presenting complaint
due to either an
absence of aldosteron
e or an inability of the kidney to
respond to aldosterone
and metabolic acidosis are accompanied by
This is done by :
Dr.Tawaa Nasser Al-Salman
NORMAL VALUES OF ARTERIAL BLOOD GASES
[HCO3−] 20-28 mEq/L
Pco2 35-45 mm Hg
the Henderson-Hasselbalch equation, emphasizes the
concentration, and the
the hydrogen ion concentration; the pH
the hydrogen ion concentration; the pH
pH below normal (<7.35)
is a pathologic process that causes an
increase in the hydrogen ion concentration.
Whereas acidemia is always acidosis
a patient can have an acidosis and a low, normal, or high pH.
EX , a patient may have a mild metabolic acidosis but a simultaneous, severe respiratory alkalosis; the net result may be alkalemia.
Acidemia and alkalemia indicate the pH abnormality; acidosis and alkalosis indicate the pathologic process that is taking place
Metabolic Acidosis either :
GI bicarb loss
Impaired renal acid excretion
classic distal RTA (type I)
hyperkalemic distal RTA (type IV)
Renal bicarbonate loss
proximal RTA (type II)
carbonic anhydrase inhibitors
elevated anion gap (>12 mEq/L).
Intestinal bacterial overgrowth
Inborn errors of metabolism
Tissue hypoxia: Shock Hypoxemia Severe anemia
Nucleoside reverse transcriptase inhibitors
measurements of electrolytes, BUN, creatinine, and serum glucose levels.
urine analysis .
Calculate the anion gap from the electrolyte levels. This guides the initial diagnostic approach (ie, for a normal or elevated anion gap).
Patients have elevated BUN and CR suggesting rena lBUN-to-creatinine ratio greater than 20:1 supports the diagnosis of prerenal azotemia and hypovolemia.
Hypoglycemia associated with a metabolic acidosis can be caused by adrenal insufficiency or liver failure.
Hyperglycemia, glycosuria, ketonuria, and a metabolic acidosis support the diagnosis of diabetic ketoacidosis.
The combination of metabolic acidosis, hyperkalemia, and hyponatremia occurs in patients with severe aldosterone deficiency (adrenogenital syndrome) or aldosterone resistance.
he serum potassium level is often abnormal
metabolic acidosis causes K to move from the intracellular space to the extracellular space,
low serum K leve
l owing to excessive body losses of K.
diarrhea, in type I or type II RTA,
, urinary losses of K are high, but the shift of potassium out of cells due to lack of insulin and metabolic acidosis is significant.
total body K is almost always decreased.
K level is increased
with acidosis due to
renal insufficiency; urinary potassium excretion is impaired.
Hyperchloremic metabolic acidosis
Inborn error of metabolism
A mixed acid-base disorder is present when there is
more than 1 primary
may have severe acidemia due to a combined metabolic acidosis caused by lactic acid and respiratory acidosis caused by ventilatory failure.
A patient has a primary metabolic acidosis with a serum bicarbonate concentration of 10m Eq/L. The expected respiratory compensation is a carbon dioxide concentration is ???
(1.5 x 10 + 8 +\- 2 =
Calculate the excess anion gap (total anion gap minus 12) and add this value to the measured bicarbonate concentration; if the sum is greater than 30 mmol/L there is an underlying metabolic alkalosis; if the sum is less than 23 mmol/L there is an underlying non-anion gap metabolic acidosis.
Blood gas: 7.40 / 40 / 24
Na= 145, Cl= 100
AG = 21 (primary metabolic acidosis)
Metabolic Acidosis and Metabolic Alkalosis
This patient had chronic renal failure (met. acidosis) and began vomiting (met. alkalosis) as his uremia worsened. The acute alkalosis of vomiting offset the chronic acidosis of renal failure = normal pH