Metabolic Acidosis

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1. anion gap increases 2. osmolar gap decreases

What happens to anion gap and osmolar gap when methanol is converted to formic acid overtime?

isopropyl (rubbing) alcohol

toxic alcohol that does NOT produce an anion gap but DOES cause an osmolar gap

pH < 7.35

definition of acedemia

AG = Na+ - (Cl- + HCO3-)

equation for anion gap

corrected AG = 2.5 (4 - alb) + AG

equation for corrected anion gap

1. alteration of O2 binding to hemoglobin 2. reduced cardiac contractility and output 3. vasodilation --> HTN 4. altered mental status 5. predisposition to arrhythmias

five major consequences of acidosis

respiratory acidosis (hypoventilation)

if measured pCO2 > 1.5(HCO3-) + 8 +/- 2

less than 10 - 15

normal range of osmolar gap

non anion-gapped metabolic acidosis

AKA hyperchloremic metabolic acidosis - loss of bicarbonate or lack of excretion of acid

oxalic acid

What does ethylene glycol convert to?

formic acid

What does methanol convert to?

pyruvic acid, acetic acid, lactic acid, propionaldehyde

What does propylene glycol convert to?

pCO2 = 1.5(HCO3-) + 8 +/- 2

Winter's formula equation

greater release

a decrese in pH causes a __________ release of oxygen from hemoglobin

1. Glycols - ethylene, propylene 2. 5-Oxyprolene (metabolite of acetaminophen intoxication) 3. L-lactic acidosis 4. D-lactic acidosis (short gut syndrome) 5. Methanol 6. Aspirin 7. Renal failure (uremia) 8. Ketosis - diabetic, alcoholic, starvation

anion-gapped metabolic acidosis - mnemonic "GOLDMARK"

1. Methanol 2. Uremia (renal failure w/ symptoms) 3. Diabetic ketoacidosis (DKA) 4. Paraldahyde (not used in US) 5. Iron, INH 6. Lactic acidosis 7. Ethylene glycol (in antifreeze, suicide attempts) 8. Salicylate toxicity (aspirin)

anion-gapped metabolic acidosis - mnemonic "MUDPILES"

calculated osmolality = 2Na+ + Glc/18 + BUN/2.8 + ethanol/4.8

calculated osmolality equation

osmolar gap

created by an unmeasured osmole in the bloodstream = measured osmolality - calculated osmolality - should be less than 10 - 15 - > 10 may be indicative of an alcohol intoxication

(patient's AG - 10) / (24 - patient's HCO3-)

delta delta equation

delta delta

equation in which change in bicarbonate should be equal to change in anion gap - 1/1 ratio - if result is > 1, metabolic alkalosis - if result is < 1, non-gapped acidosis

Winter's formula

equation that determines if appropriate respiratory compensation or if a respiratory process also present - if greater than range --> respiratory acidosis (hypoventilation) - if less than range --> respiratory alkalosis (hyperventilation)

1. serum HCO3- is low (< 22 - 26 depending on lab) 2. check ABG for pH to confirm acidosis present (< 7.35) 3. calculate anion gap 4. use Winter's formula to assess respiratory compensation 5. use delta/delta to look for additional disturbance

five major steps to interpreting acid base disorders

urine anion gap

helps to decipher b/w renal causes (RTA) and non-renal causes of non anion-gapped metabolic acidosis UAG = (urine Na+ + urine K+) - urine Cl- - positive value indicates renal cause - negative value non-renal cause

non-gapped acidosis

if delta delta < 1

metabolic alkalosis

if delta delta > 1

respiratory alkalosis (hyperventilation)

if measured pCO2 < 1.5(HCO3-) + 8 +/- 2

1. Hyperalimentation, Hyperchloremia 2. Acetazolamide, Addision's Ammonium chloride 3. Renal tubular acidosis - Types I, II, IV 4. Diarrhea 5. Ureterosigmoid fistula 6. Pancreatic fistula

non anion-gapped metabolic acidosis mnemonic "HARDUP"

metabolic acidosis

pathologic disturbance characterized by low arterial pH w/ dec plasma HCO3- conc

salicylates (aspirin)

substance that causes BOTH anion gapped metabolic acidosis AND respiratory alkalosis

acidosis

the process that caused acidemia - metabolic or respiratory

1. inc acid generation 2. dec acid excretion 3. loss of bicarbonate

three major causes of metabolic acidosis

1. blindness 2. anion gap 3. osmolar gap

three major results when methanol converts to formic acid

1. ethylene glycol 2. methanol 3. propylene glycol

three major toxic alcohols that produce an anion gap and an osmolar gap

1. anion-gapped 2. non anion-gapped

two types of metabolic acidosis

UAG = (urine Na+ + urine K+) - urine Cl-

urine anion gap equation

6 ~ 12

what is the normal range of anion gap?


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