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CME EDUCATIONAL OBJECTIVE: Readers will apply a systematic approach to diagnosing acid-base disturbances ON A
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CLINICAL
SHYLAJA MANI, MD GREGORY W. RUTECKI, MD
Department of Internal Medicine, Department of Internal Medicine, CASE
Cleveland Clinic Cleveland Clinic
low and the Pco2 can be high. In mixed meta- Our patient’s bicarbonate level is 16
bolic and respiratory alkalosis, the bicarbon- mmol/L, which is 9 mmol/L lower than nor-
ate level can be high and the Pco2 can be low mal (for acid-base calculations, we use 25
(Table 2). mmol/L as the nominal normal level). If she is
Our patient’s serum bicarbonate level is compensating appropriately, her Pco2 should
low at 16.0 mmol/L, indicating that the pro- decline from 40 mm Hg (the nominal normal
cess is metabolic. Her Pco2 is also low (28 mm level) by about 11.7 mm Hg (9 × 1.3), to ap-
Hg), which reflects an appropriate response to proximately 28.3 mm Hg. Her Pco2 is, indeed,
compensate for the acidosis. 28 mm Hg, indicating that she is compensat-
3. What is her anion gap? ing adequately for her metabolic acidosis.
Always calculate the anion gap, ie, the serum If we use Winter’s formula instead (Pco2 =
sodium concentration minus the serum chlo- [1.5 × the bicarbonate level] + 8 ± 2),3 the
ride and serum bicarbonate concentrations. If lowest calculated Pco2 would be 30 mm Hg,
the patient’s serum albumin level is low, for which is within 2 mm Hg of the Rules of 5
every 1 gram it is below normal, an additional calculation. Other formulas for calculating
2.5 mmol/L should be added to the calculated compensation are available.3
anion gap. We consider an anion gap of 10 This information rules out the first two an-
mmol/L or less as normal. swers to question 1, ie, metabolic acidosis with
Caveats. The blood sample used to calcu- respiratory alkalosis or acidosis.
late the anion gap should be drawn close in
time to the arterial blood gas sample. 5. Is there a delta gap?
Although the anion gap is an effective Although we know the patient has metabolic
tool in assessing acid-base disorders, further acidosis with an elevated anion gap, we have
investigation is warranted if clinical judg- not ruled out the possibility that she may have
ment suggests that an anion gap calculation a triple disturbance. For this reason we need to
is inconsistent with the patient’s circum- check her delta gap.
stances.2 In metabolic acidosis with an elevated an-
Our patient’s anion gap is elevated (21 ion gap, as the bicarbonate level decreases, The patient
mmol/L). Her serum albumin level is in the the anion gap should increase by the same lives alone,
normal range, so her anion gap does not need amount. If the bicarbonate level decreases and her family
to be adjusted. more than the anion gap increases, the ad-
ditional decline is the result of a second pro- suspects she
4. Is the degree of compensation appropriate
for the primary acid-base disturbance?
cess—an additional normal-anion-gap acido- abuses alcohol
sis. If the bicarbonate level does not decrease
The kidneys compensate for the lungs, and and pain
as much as the anion gap increases, there is an
vice versa. That is, in respiratory acidosis or medications
additional metabolic alkalosis.
alkalosis, the kidneys adjust the bicarbonate
levels, and in metabolic acidosis, the lungs ad- Our patient’s bicarbonate level decreased
just the Pco2 (although in metabolic alkalosis, 9 mmol/L (from the nominal normal level of
it is hard for patients to breathe less, especially 25 to 16), and therefore her anion gap should
if they are already hypoxic). have increased approximately the same
In metabolic acidosis, people compensate amount—and it did. (A normal anion gap for
by breathing harder to get rid of more carbon problem-solving is 10, and this patient’s anion
dioxide. For every 1-mmol/L decrease in the gap has increased to 21. A difference of ± 2 is
bicarbonate level, the Pco2 should decrease by insignificant.) This conclusion verifies that a
1.3 mm Hg. triple acid-base disturbance is not present, so
Compensation does not return pH to nor- the last answer is incorrect.
mal; rather, it mitigates the impact of an acid So, the correct answer to the question
or alkali excess or deficit. If the pH is normal- posed above is metabolic acidosis with an
ized with an underlying acid-base disturbance, elevated anion gap (that is, metabolic aci-
there may be mixed acid-base processes rather dosis with appropriate respiratory compen-
than compensation. sation).
CL EVEL AN D CL I NI C J O URNAL O F M E DI CI NE V O L UM E 84 • NUM BE R 1 J ANUARY 2017 29
ACID-BASE DISTURBANCE
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34 CLEV ELA N D C LI N I C JO URNAL OF MEDICINE VOL UME 84 • NUM BE R 1 J ANUARY 2017