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Acidosis
The main source of acid (H+ ions) in the body is tissue respiration. Carbon dioxide produced
by cellular respiration is converted to carbonic acid, which dissociates to generate H+ (acid)
and HCO3- ions (buffering base). The retention of CO2, increase in H+ or reduction in HCO3may result in an acidosis.
CO2 + H2O <--> H2CO3 <--> H+ + HCO3Three types of acidosis are recognized:
Respiratory acidosis.
Metabolic acidosis with a high anion gap.
Metabolic acidosis with a normal anion gap.
Reproduced from A Rapid Review of Clinical Medicine by Sanjay Sharma, with kind
permission from Manson publishing.
Alkalosis
Alkalosis may be respiratory or metabolic in origin. In respiratory alkalosis, there is a high pH
due to hyperventilation, causing a low pCO2. Metabolic alkalosis is usually due to increased
loss of H+ from the kidney or gastrointestinal tract, or to increased ingestion of alkaline
agents. It is characterised by a high bicarbonate and a high pH. Respiratory alkalosis is rare
and is usually acute. Chronic cases, usually due to chronic hyperventilation, are
compensated by increasing bicarbonate excretion by the kidneys. Metabolic alkalosis - which
is much more common than respiratory alkalosis - is compensated by respiratory
hypoventilation, which results in an increase in pCO2 and hence an increase in H+.
Reproduced from A Rapid Review of Clinical Medicine by Sanjay Sharma, with kind
permission from Manson publishing.
SELF-ASSESEMENT
Question 1*
A 75 year old man was seen by his general practitioner with a five day history of wheeze and
ankle swelling. He was prescribed some medication but continued to deteriorate and was
admitted to hospital. Investigations were as follows:
Arterial blood gases pH 7.33
pO2 7kPa
pCO2 6.5kpa
Bicarbonate 20mmmol/l
Biochemistry
Sodium 133mmol/l
Potassium 5mmol/l
Urea 28mmol/l
Creatinine 200mmol/l
What is the most likely cause of her presentation?
1. What is the acid base disturbance?
2. Suggest two possible causes for this metabolic picture.
Reproduced from A Rapid Review of Clinical Medicine by Sanjay Sharma, with kind
permission from Manson publishing.
Question 2*
A 13 year old girl is admitted under the surgeons with acute abdominal pain. The blood
pressure was 100/60 mm. Hg.
Investigations are as follows:
Biochemistry
Sodium
Potassium
Urea
Creatinine
Bicarbonate
Chloride
Abdominal X-ray
Normal
Urinalysis
Glucose +++
131 mmol/l
7.2 mmol/l1
3 mmol/l
121mmol/l
8 mmol/l
96 mmol/l
Reproduced from A Rapid Review of Clinical Medicine by Sanjay Sharma, with kind
permission from Manson publishing.
Answer to Question 1
1. Combined respiratory and metabolic acidosis.
2. Acute cardiac failure. Severe exacerbation of obstructive airways disease and pre renal
failure from diuretics.
The patient has a respiratory acidosis, which is characterised by a pCO2 of 6.5kPa or more
and a pH below 7.35 and is hypoxic. In the acute situation respiratory acidosis is not
compensated by the kidney but after 3-5 days the kidneys retain HCO3 ions to compensate
which results in normalisation of the pH at the expense of a relative metabolic alkalosis. In
this patient the HCO3 is slightly low suggesting a metabolic acidosis. This may be due to
coexistent renal disease which prevents adequate compensation or due to another
factorcausing metabolic acidosis. The serum urea and creatinine are elevated but there is a
relatively larger increase in the serum urea suggesting dehydration in this case. It is possible
that he was prescribed a diuretic for symptoms of chronic obstructive airways disease which
have precipitated renal failure by causing dehydration.
An alternative suggestion is that he has developed severe cardiac failure leading to
pulmonary oedema causing hypoxia and respiratory acidosis and hypo-perfusion of the
kidneys causing metabolic acidosis from renal failure.
Other causes of combined respiratory and metabolic acidosis include:
Aspirin poisoning.
Severe pneumonia with renal failure due to septicaemia or interstitial nephritis
(Legionnaire's disease).
Septicaemia from any cause complicated by ARDS.
Malaria complicated by pneumonia.
Acute renal failure and fluid overload.
Renal pulmonary syndromes: Anti GBM disease, Wegener;s granulomatosis,
microscopic polyarteritis nodosa.
Acute massive pulmonary embolism.
Cardiac arrest (before ventilation).
Answer to Question 2
1. Metabolic acidosis with a high anion gap.
2. Diabetic ketoacidosis.
3. a) Intravenous calcium gluconate to prevent hyperkalaemic cardiac arrest
b) Intravenous insulin infusion to halt further ketoacidosis
c) Intravenous saline to rehydrate patient and correct acidosis.
Reproduced from A Rapid Review of Clinical Medicine by Sanjay Sharma, with kind
permission from Manson publishing.