Loading presentation...

Present Remotely

Send the link below via email or IM

Copy

Present to your audience

Start remote presentation

  • Invited audience members will follow you as you navigate and present
  • People invited to a presentation do not need a Prezi account
  • This link expires 10 minutes after you close the presentation
  • A maximum of 30 users can follow your presentation
  • Learn more about this feature in our knowledge base article

Do you really want to delete this prezi?

Neither you, nor the coeditors you shared it with will be able to recover it again.

DeleteCancel

Make your likes visible on Facebook?

Connect your Facebook account to Prezi and let your likes appear on your timeline.
You can change this under Settings & Account at any time.

No, thanks

Acid Base Disorders Algorithm

Acid and Base Disorders Algorithm Step-by-Step Instruction Guide
by

Clinton Pong

on 3 February 2013

Comments (0)

Please log in to add your comment.

Report abuse

Transcript of Acid Base Disorders Algorithm

Acid Base Disorders Evaluate Patient &
Generate Hypotheses Acidemia <7.4 >7.4 Alkalemia Check pH Henderson-Hasselbach Eq: pH = pK + log([HCO3]/[0.03 x pCO2])
Modified H-H eq: [H+] = 24 x (pCO2/[HCO3]) --> 40nEq/L Check PaCO2
and HCO3 High PaCO2 Low HCO3 Respiratory
Acidosis Metabolic
Acidosis Step 1: Evaluate the Patient and Generate Hypotheses


Step 2: Check pH and determine if Primary Process is Acidemia/Alkalemia


Step 3: Check PaCO2 and HCO3 to determine if Respiratory or Metabolic


Step 4: Check for Compensation


Step 5: Check Anion Gap


Step 6: Reach final diagnosis Low PaCO2 High HCO3 Respiratory alkalosis Metabolic
Alkalosis Respiratory Acidosis Any process that participates in normal ventilation
(brain - brainstem - spinal cord - nerve - NMJ - muscle - chest wall - lung Metabolic Acidosis
Anion gap or Non-Anion Gap? Respiratory Alkalosis Hyperventilation, blowing off the CO2 Metabolic Alkalosis Increased mineralocorticoid activity
Primary hyperaldosteronism
Renal Artery Stenosis
JGA Tumor
Cushing's Hypercortisolism
Excessive licorice ingestion
Bartter's
Recent Diuretic use Mnemonics GOLDMARK
Glycols (Ethylene & Propylene)
Oxyproline
L-lactic acid
D-lactic acid
Methanol
Aspirin
Renal Failure
Ketoacidosis (DM, EtOH) KILU
Ketones
Ingestion
Lactic acid
Uremia MUDPILES
Methanol
Uremia
DKA
Propylene glycol
Iron/INH
Lactic acid
Ethylene glycol
Salicylates The metabolic acidoses are generally separated into two categories on the basis of an anion gap calculation (Na+[Cl−HCO3−]): the high-anion-gap metabolic acidoses, and the normal-anion-gap, or hyperchloraemic, metabolic acidoses. Two popular mnemonics are often used to remember the major causes of the high-gap metabolic acidoses.
The first is KUSMALE (a useful misspelling of Adolph Kussmaul's name), which represents Ketoacidosis, Uraemia, Salicylate poisoning, Methanol, Aldehyde (paraldehyde), Lactate, and Ethylene glycol.
The second is MUD PILES, representing Methanol, Uraemia, Diabetes, Paraldehyde, Iron (and Isoniazid), Lactate, Ethylene glycol, and Salicylate.
Metabolic acidosis due to excessive paraldehyde use has become exceedingly rare. Iron and isoniazid are just two of many drugs and toxins that cause hypotension and lactic acidosis (isoniazid can also generate a component of ketoacidosis). Three “new” organic anion-gap-generating acids and acid precursors have been recognised in recent years. They are D-lactic acid, which can occur in some patients with short bowel syndromes; 5-oxoproline (or pyroglutamic acid) associated with chronic paracetamol use, often by malnourished women; and the anion-gap acidosis generated by high-dose propylene glycol infusions. Propylene glycol, the solvent used for several parenteral medications including lorazepam, phenobarbital, and others is metabolised to D-lactate and L-lactate.

Therefore we propose a new anion gap mnemonic for the 21st century: GOLD MARK. This acronym represents Glycols (ethylene and propylene), Oxoproline, L-lactate, D-lactate, Methanol, Aspirin, Renal failure, and Ketoacidosis. Mnemonic aids are only helpful if they are easily remembered and we believe GOLD MARK fits that requirement.

Mehta A.N., Emmett J.B., Emmett M. (2008). "GOLD MARK: an anion gap mnemonic for the 21st century." The Lancet, Volume 372, Issue 9642, Page 892, 13 September 2008 NAG AG Occurs when an acid is produced and the unmeasured negatively charged Anion accumulates (ketones, lactate, sulfate, phosphate, organic anions) Metabolic acidosis
HCO3 drop 1 = PaCO2 drop 1.2
[Winter's Formula]
[1.5(HCO3)+8 +/-2 = PaCO2] Metabolic alkalosis
HCO3 up 1 = PaCO2 up 0.7
pCO2 ~ HCO3 +15
0.9(HCO3)+16 or ΔpCO2 = 0.75(ΔHCO3) Respiratory Acidosis
PaCO2 up by 10 per Acute Chronic HCO3 up by 1 HCO3 up by 3.5 Respiratory Alkalosis
PaCO2 down by 10 per Acute Chronic HCO3 down by 2 HCO3 down by 4 Na - Cl - HCO3 = AG. Normal AG = 12 +/- 4
Expected drop in Anion gap is 2.5 mEq/L for every 1 g/dL drop in the serum albumin (below 4.4 g/dL)
Occurs when HCO3 is lost in the urine or stool Anion gap is due to the presence of normal negatively charged proteins (albumin), phosphates, and sulfates
Normal is typically 12 +/- 4 Ketoacidosis
Diabetic ketoacidosis
Starvation ketoacidosis
Alcoholic ketoacidosis
Ingestions/Toxins
Salicylate
Methanol
Ethylene glycol
Rhabdomyolysis
D-lactic acidosis
Lactic acidosis
Shock, hypoxia, hypotension
Uremia (assoc w/ more phosphate & sulfate) Diarrhea
Renal Tubular Acidosis
Type IV (most common)
Type I
Type II
Carbonic anhydrase inhibitor
Dilutional (large NS volume (hyperchloremia)
Early renal failure Check PaCO2
and HCO3 Brain
Stroke
Drugs and intoxicants
Hemorrhage
Trauma
Sleep apnea Brainstem
Herniation Spinal cord
Trauma
ALS
Polio Nerve
Guillain-Barre NMJ
Myasthenia gravis CW/muscle
Flail chest
Muscular dystrophy Pleural disease
Effusion
PTX Most commonly:
COPD
Asthma
Pulmonary edema
PNA Hypoxemia
Pulmonary disorders
PNA
Asthma
PE
Pulmonary edema
Interstitial lung disease
Mechanical ventilation via both hypoxic and vagal mechanisms Extra Pulmonary Disorders
Anxiety
Pain
Fever
Pregnancy
CNS insult
Drugs
Salicylates
Nicotine
Catecholamines
Cirrhosis Check for
combined disorders Check for a combined disorder with "Delta-Delta" or "Delta Gap"

1. Δ/Δ: ΔAG/ΔHCO3 = (AG-10)/(24-HCO3)
<1 : AG-met-acid + non-AG-met-acid; or AG-metacid + chronic resp alk
1-2: Pure AG-met-acid
>2: AG-met-acid + metalk; or AG-met-acid + chronic resp acid
2. Δgap: (AG-10)+HCO3+6
normal (24-30): no add'l underlying d/o
<24: concomitant non-AG-met-acid
>30: concomitant-metalk Are there any hidden organic anions? Check the OSMOLE GAP
Sosm - Calc osm
[calc osm = 2Na+BUN/2.8+Glu/18] elevated OsmGap >10
EtOH, MeOH, Glycols OsmGap <10
Normal Check urine AG: Na+K-Cl I: hypercalciruria, stone, hyperglobulin, AI, nephrocalcinosis

II: fanconi, dysproteinemia, heavy metal Positive:
HCO3 loss by urine
Renal Tubular Acidosis Negative:
(HCO3 loss via GI)
GI losses IV: DM, obstructive, tubulointerstitial dz, SCD, Transplant rejection, cyclosporine I: Uk dec, UpH>5.5
II: Uk dec, UpH<5.5
IV: Uk inc, UpH<5.5 Check urine Cl UCl<20
(Cl responsive) UCl >20 Vomiting
NGT use
Remote diuretic use
tx w/ NS (saline responsive) ABG: pH / pCO2 / pO2 / HCO3 / BE / O2sat (on vent settings or FiO2 "X") Na Cl BUN
Glu
K HCO3 Cr
Full transcript