The body needs to keep blood pH in a very tight range, 7.35 - 7.45.

• Outside of this range you have abnormalities in electrolyte concentrations (esp K and Ca), membrane potentials, protein folding and cellular function

• May seem narrow - its because small changes in pH mean larger changes in H+ concentration (logarithmic scale)

We are constantly exposed to substances/metabolic changes that would result in large changes in pH. Our body works against this by:

1. Bicarbonate buffer equation: LeChatlier’s principle

2. The lungs: hypo or hyperventilation

3. The kidneys: secrete or retain acid, secrete or retain bicarb, produce de novo bicarb

4. Honorable mention: Hgb acts as potent buffer by binding CO2 to form carbaminohemoglobin

Hx of ABG Interpretation

Donald Van Slyke was a dutch American chemist who popularized the Bronsted Lowry definition of acids/bases and the Hendersen Hassalbach equation back in the 1950s

• Acids donate protons to solution, bases accepts protons in solution

• Henderson Hassalbach - related pH, pcO2, bicarb

We still use this definition today. There is a different, more quantitative approach to acid base that takes a lot more into account - the effects of chloride, lactate and the strong ion difference.

• This is called the Stewart approach and was popularized by Peter Stewart back in the 1980s; its complicated, and a useful clinical skill, but beyond scope of this episode. Read more:

  • Emcrit Acid-Base Series

• -emia: in the blood vs -osis: the condition of having

• pH<7.40-> acidemia

• pH>7.40 ->alkalemia

• Can use rule of 4’s to remember normals: 7.40 (pH)/40 (pCO2)/ 24(bicarb)

What makes sense?

• Respiratory -> pCO2

  • Replace “pCO2” with the word “acid”

    • If your pCO2 (acid) is ↑, what will happen to your pH?

      • ↓ More acidotic - respiratory acidosis

    • If your pCO2 (acid) is ↓, what will happen to your pH?

      • ↑ More alkalotic - respiratory alkalosis

• Metabolic -> bicarbonate

  • Replace “bicarbonate” with the word “base”

    • If your bicarb (base) is ↑, what will happen to your pH?

      • ↑ More alkalotic - metabolic alkalosis

    • If your bicarb (base) is ↓, what will happen to your pH?

      • ↓ More acidotic - metabolic acidosis

A) Respiratory compensation for metabolic acidosis

• Winters formula:

  • 1.5 x bicarbonate + 8 + 2 = New normal pCO2

• If the pCO2 on the gas is equal to the new normal pCO2 per winter’s formula, you are COMPENSATED (not necessarily if pH is normal)

B) Chronic respiratory diseases (i.e. COPD) will have higher than normal bicarbonate levels and will much better tolerate high pCO2 levels (little change in pH with pCO2 changes)

• 10 mmHg change in pCO2 ->

  • pH change by 0.08 for acute process

  • pH change by 0.03 or less for chronic process

[Na+] - ([Cl−] + [HCO3])

• All your plus’ should equal all of your minuses. If it doesn’t (there’s extra minuses in there), you have an anion gap

• Causes of HAGMA: Dissociates into acid into the blood (acid producing process)

• Causes of NAGMA: bicarb loss

• Bicarb in NAGMA? Yes!

  • Bicarb loss —> replacing bicarb makes sense

• Bicarb in HAGMA? Quite a debate

  • Bicarb can ruin intracellular pH, cause more dissociation of whatever is elevating your anion gap (bicarb pushes are hypertonic - incr plasma tonicity)

    • Will temp fix pH but pH can worsen very quickly later

  • Whether or not you push bicarb, will you have an affect on mortality? Probably not

  • Good to push bicarb if: pH severely low OR you have an out (i.e. you are getting ready to start CRRT, go to OR for source control)

Answers the question: does patient have NAGMA on top of HAGMA, should I give a little bicarb?

• Delta gap is often used interchangeably with delta ratio and corrected bicarbonate

• You only calculate this if anion gap is high

• Corrected bicarb (surrogate for delta gap) -

  • Anion gap - 12 + bicarbonate

  • Two results:

    • Corrected Bicarb <22 - you also have a NAGMA

    • Corrected Bicarb 22-26: Just HAGMA

    • Correct Bicarb >26 - you also have metabolic alkalosis

Attributions

"The Last Question", “Squinting at the Sun” by Lee Rosevere is licensed under CC BY-NC 4.0 / Song has been cropped in length from original form

"get out", “our rules” by Jahzzar is licensed under CC BY-SA 3.0 / Song has been cropped in length from original form

"Trickle Down” by Podington Bear is licensed under CC BY-NC 3.0 / Songs have been cropped in length from original form

"Hoh Harph (ID 924)" by Lobo Loco is licensed under CC BY-NC-ND 4.0 / Song has been cropped in length from original form

"Cue 2a - Spacey-Scary-Dark-no drums (No Light Without Shadow)" by Soularflair is licensed under CC BY-NC-ND 4.0 / Song has been cropped in length from original form

“Game Sound Correct.wav” by Bertrof is licensed under CC BY 3.0 / Song was not edited or cropped in any form

“Laugh Track 5.mp3” by LittleRainySeasons is licensed under CC BY 3.0 / Song was not edited or cropped in any form

“Bell, Candle Damper, A (H4n).wav” by InspectorJ is licensed under CC BY 3.0 / Song was not edited or cropped in any form

“Record scratch.wav” by luffy is licensed under CC BY 3.0 / Song was not edited or cropped in any form