Acidosis resident survival guide: Difference between revisions
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{{CMG}}; '''Associate Editor-In-Chief:''' [[User:Rim Halaby|Rim Halaby]] | {{CMG}}; '''Associate Editor-In-Chief:''' [[User:Rim Halaby|Rim Halaby]] | ||
== | ==Overview== | ||
[[Acidosis]] occurs when the [[pH]] is less or equal to 7.35 due to excess of [[hydrogen]] ions. | [[Acidosis]] occurs when the [[pH]] is less or equal to 7.35 due to excess of [[hydrogen]] ions. | ||
==Causes== | ==Causes== | ||
2 main causes of primary acidosis in the body can be differentiated from each other based on ABG. Metabolic acidosis is caused by decreased amount of serum bicarbonate while respiratory acidosis is caused by increased CO2 retention in the body. | |||
=== | Metabolic acidosis itself is divided into 2 subcategories based on the calculated amount of [[anion gap]]. | ||
*[[Diabetic ketoacidosis]] | |||
===High Anion Gap Metabolic Acidosis=== | |||
Mnemonics are helpful to summarize them, last recent mnemonic involving almost all causes go elevated anion gap metabolic acidosis is" | |||
'''''<u>CAT MUDPILES</u>''''' | |||
* [[Carbon monoxide poisoning]] - [[Cyanide|Cyanide toxicity]] - [[Caffeine]] | |||
* [[Aminoglycosides|Amino-glycosides]] - [[Acetaminophen]] - [[Aspirin]] | |||
* [[Theophylline]] - [[Toluene]] | |||
* [[Methanol]] - [[Metformin]] | |||
* [[Uremia]] | |||
* [[DKA]] (and other causes of [[Ketoacidosis]]) | |||
* [[Phenytoin]] - [[Propylene glycol]] | |||
* [[Isoniazide]] - [[Iron]] - [[Ibuprofen]] | |||
* [[Lactic acidosis]] | |||
* [[Ethanol]] - [[Ethylene glycol]] | |||
* [[Salicylates]] | |||
[[Diabetic ketoacidosis]] | |||
*[[Ethylene glycol poisoning]] | *[[Ethylene glycol poisoning]] | ||
* [[Hypoventilation]] | * [[Hypoventilation]] | ||
| Line 14: | Line 44: | ||
*[[Methanol]] | *[[Methanol]] | ||
=== | ===Normal Anion Gap Metabolic Acidosis=== | ||
* [[Diabetic ketoacidosis]] | * [[Diabetic ketoacidosis]] | ||
* [[Diarrhea]] | * [[Diarrhea]] | ||
| Line 26: | Line 56: | ||
==Management== | ==Management== | ||
{{familytree/start}} | {{familytree/start}} | ||
{{familytree | | | | | | | | | A01 | | | | | |A01='''pH < 7.35'''}} | {{familytree | | | | | | | | | A01 | | | | | |A01='''[[pH]] < 7.35'''}} | ||
{{familytree | | | | | | | | | |!| | | | | | | | }} | {{familytree | | | | | | | | | |!| | | | | | | | }} | ||
{{familytree | | | | | | | | | B01 | | | | | |B01='''Acidosis'''<br>(High [H<sup>+</sup>])}} | {{familytree | | | | | | | | | B01 | | | | | |B01='''[[Acidosis]]'''<br>(High [H<sup>+</sup>])}} | ||
{{familytree | | | | | | | | | |!| | | | | | | | }} | {{familytree | | | | | | | | | |!| | | | | | | | }} | ||
{{familytree | | | | | | | | | B02 | | | | | |B02='''Determine the primary disorder'''<br> Metabolic or respiratory?}} | {{familytree | | | | | | | | | B02 | | | | | |B02='''Determine the primary disorder'''<br> Metabolic or respiratory?}} | ||
{{familytree | | | | | | | | | |!| | | | | | | | }} | {{familytree | | | | | | | | | |!| | | | | | | | }} | ||
{{familytree | | | | | | | | | B03 | | | | | |B03=Check [HCO3<sup> | {{familytree | | | | | | | | | B03 | | | | | |B03=Check [HCO3<sup>-</sup>] and PaCO<sub>2</sub>}} | ||
{{familytree | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| }} | {{familytree | | | |,|-|-|-|-|-|^|-|-|-|-|-|-|-|.| }} | ||
{{familytree | | | C01 | | | | | | | | | | | |C02|C01=Low [HCO3<sup> | {{familytree | | | C01 | | | | | | | | | | | |C02|C01=Low [HCO3<sup>-</sup>] <br>and<br> Low to normal PaCO<sub>2</sub>|C02= High PaCO<sub>2</sub> <br>and<br> High to normal [HCO3<sup>-</sup>] }} | ||
{{familytree | | | |!| | | | | | | | | | | | | |!| }} | {{familytree | | | |!| | | | | | | | | | | | | |!| }} | ||
{{familytree | | | C03 | | | | | | | | | | | | C04 |C03='''Metabolic acidosis'''|C04='''Respiratory acidosis'''}} | {{familytree | | | C03 | | | | | | | | | | | | C04 |C03='''[[Metabolic acidosis]]'''|C04='''[[Respiratory acidosis]]'''}} | ||
{{familytree | | | |!| | | | | | | | | | | | | |!| }} | {{familytree | | | |!| | | | | | | | | | | | | |!| }} | ||
{{familytree | | | C05 | | | | | | | | | | | | C06 |C05='''Check for respiratory compensation'''<br><br>Calculate expected PCO<sub>2</sub>|C06='''Check for renal compensation'''<br><br> Calculate expected [HCO3<sup> | {{familytree | | | C05 | | | | | | | | | | | | C06 |C05='''Check for respiratory compensation'''<br><br>Calculate expected PCO<sub>2</sub>|C06='''Check for renal compensation'''<br><br> Calculate expected [HCO3<sup>-</sup>] }} | ||
{{familytree | | | |!| | | | | | | | | | | | | |!| }} | {{familytree | | | |!| | | | | | | | | | | | | |!| }} | ||
{{familytree | | | |!| | | | | | | | | |,|-|-|-|^|-|-|-|-|.|}} | {{familytree | | | |!| | | | | | | | | |,|-|-|-|^|-|-|-|-|.|}} | ||
{{familytree | | | D01 | | | | | | | | D02 | | | | | | D03 |D01=Decrease in PaCO<sub>2</sub>=1.25 x (24- measured HCO3<sup> | {{familytree | | | D01 | | | | | | | | D02 | | | | | | D03 |D01=Decrease in PaCO<sub>2</sub>=1.25 x (24- measured HCO3<sup>-</sup>)?|D02='''Acute acidosis?'''<br><br>Increase [HCO3<sup>-</sup>]=0.1 x (measure PaCO<sub>2</sub>-40)?|D03='''Chronic acidosis?'''<br><br>Increase [HCO3<sup>-</sup>]=0.1 x (measure PaCO<sub>2</sub>-40)?}} | ||
{{familytree | |,|-|+|-|.| | | | | |,|-|+|-|.| | | |,|-|+|-|.| | }} | {{familytree | |,|-|+|-|.| | | | | |,|-|+|-|.| | | |,|-|+|-|.| | }} | ||
{{familytree | E01 |!| E02 | | | | E03 |!| E04 | | E05 |!| E06 |E01=PaCO<sub>2</sub> too low?<br><br> '''Mixed metabolic acidosis with respiratory alkalosis'''|E02=PaCO<sub>2</sub> too high?<br><br> '''Mixed metabolic acidosis with respiratory acidosis'''|E03=[HCO3<sup> | {{familytree | E01 |!| E02 | | | | E03 |!| E04 | | E05 |!| E06 |E01=PaCO<sub>2</sub> too low?<br><br> '''Mixed metabolic acidosis with respiratory alkalosis'''|E02=PaCO<sub>2</sub> too high?<br><br> '''Mixed metabolic acidosis with respiratory acidosis'''|E03=[HCO3<sup>-</sup>] too low? <br><br> '''Mixed respiratory acidosis with metabolic acidosis'''|E04=[HCO3<sup>-</sup>] too high? <br><br> '''Mixed respiratory acidosis with metabolic alkalosis'''|E05=[HCO3<sup>-</sup>] too low? <br><br> '''Mixed respiratory acidosis with metabolic acidosis'''|E06=E04=[HCO3<sup>-</sup>] too high? <br><br> '''Mixed respiratory acidosis with metabolic alkalosis''' }} | ||
{{familytree | |:| E07 |:| | | | | |:| E08 |:| | | |:| E09 |:|E07=Measured PaCO<sub>2</sub> is equal to expected value?<br><br> '''Compensated metabolic acidosis'''|E08=Measured [HCO3<sup> | {{familytree | |:| E07 |:| | | | | |:| E08 |:| | | |:| E09 |:|E07=Measured PaCO<sub>2</sub> is equal to expected value?<br><br> '''Compensated metabolic acidosis'''|E08=Measured [HCO3<sup>-</sup>] is equal to expected value? <br><br> '''Compensated respiratory acidosis'''|E09=Measured [HCO3<sup>-</sup>] is equal to expected value? <br><br> '''Compensated respiratory acidosis''' }} | ||
{{familytree | |:| |:| |:| | | | | |:| |:| |:| | | |:| |:| |:| | }} | {{familytree | |:| |:| |:| | | | | |:| |:| |:| | | |:| |:| |:| | }} | ||
{{familytree | |L| F01 |J| | | | | |L|~|A|~|A| F02 |A|~|A|~|J| | F01=[[Metabolic acidosis resident survival guide|'''Click here for the management of metabolic acidosis''']]|F02=[[Respiratory acidosis resident survival guide|'''Click here for the management of respiratory acidosis''']] }} | {{familytree | |L| F01 |J| | | | | |L|~|A|~|A| F02 |A|~|A|~|J| | F01=[[Metabolic acidosis resident survival guide|'''Click here for the management of metabolic acidosis''']]|F02=[[Respiratory acidosis resident survival guide|'''Click here for the management of respiratory acidosis''']] }} | ||
Latest revision as of 21:12, 7 October 2023
Editor-In-Chief: C. Michael Gibson, M.S., M.D. [1]; Associate Editor-In-Chief: Rim Halaby
Overview
Acidosis occurs when the pH is less or equal to 7.35 due to excess of hydrogen ions.
Causes
2 main causes of primary acidosis in the body can be differentiated from each other based on ABG. Metabolic acidosis is caused by decreased amount of serum bicarbonate while respiratory acidosis is caused by increased CO2 retention in the body.
Metabolic acidosis itself is divided into 2 subcategories based on the calculated amount of anion gap.
High Anion Gap Metabolic Acidosis
Mnemonics are helpful to summarize them, last recent mnemonic involving almost all causes go elevated anion gap metabolic acidosis is"
CAT MUDPILES
- DKA (and other causes of Ketoacidosis)
- Isoniazide - Iron - Ibuprofen
Normal Anion Gap Metabolic Acidosis
- Diabetic ketoacidosis
- Diarrhea
- Ethylene glycol
- Lactic acidosis
- Methanol
- Renal tubular acidosis
- Salicylates
- Uremia
Management
| pH < 7.35 | |||||||||||||||||||||||||||||||||||||||||||||||||||
| Acidosis (High [H+]) | |||||||||||||||||||||||||||||||||||||||||||||||||||
| Determine the primary disorder Metabolic or respiratory? | |||||||||||||||||||||||||||||||||||||||||||||||||||
| Check [HCO3-] and PaCO2 | |||||||||||||||||||||||||||||||||||||||||||||||||||
| Low [HCO3-] and Low to normal PaCO2 | High PaCO2 and High to normal [HCO3-] | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Metabolic acidosis | Respiratory acidosis | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Check for respiratory compensation Calculate expected PCO2 | Check for renal compensation Calculate expected [HCO3-] | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Decrease in PaCO2=1.25 x (24- measured HCO3-)? | Acute acidosis? Increase [HCO3-]=0.1 x (measure PaCO2-40)? | Chronic acidosis? Increase [HCO3-]=0.1 x (measure PaCO2-40)? | |||||||||||||||||||||||||||||||||||||||||||||||||
| PaCO2 too low? Mixed metabolic acidosis with respiratory alkalosis | PaCO2 too high? Mixed metabolic acidosis with respiratory acidosis | [HCO3-] too low? Mixed respiratory acidosis with metabolic acidosis | [HCO3-] too high? Mixed respiratory acidosis with metabolic alkalosis | [HCO3-] too low? Mixed respiratory acidosis with metabolic acidosis | E04=[HCO3-] too high? Mixed respiratory acidosis with metabolic alkalosis | ||||||||||||||||||||||||||||||||||||||||||||||
| Measured PaCO2 is equal to expected value? Compensated metabolic acidosis | Measured [HCO3-] is equal to expected value? Compensated respiratory acidosis | Measured [HCO3-] is equal to expected value? Compensated respiratory acidosis | |||||||||||||||||||||||||||||||||||||||||||||||||
| Click here for the management of metabolic acidosis | Click here for the management of respiratory acidosis | ||||||||||||||||||||||||||||||||||||||||||||||||||