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etabolic derangements and respi- the difference can be greater in severely
ratory distress are common pre- hypoperfused patients.5
senting problems in emergency Arterial samples are particularly use-
medicine.1 A focused physical examina- ful in assessing the patients oxygenation
tion and emergency intervention should and ventilation status. For example, the
of BEecf was developed.17 The BEecf takes table 1The Four Primary AcidBase Disorders and
into account all of the bodys buffer systems,
including HCO3 , to predict the quantity of
Their Compensatory Changesa
acid or alkali required to return the extracellu- Conditions Primary Disorder Compensation
lar fluid compartment to neutrality (pH = 7.4) pH and HCO3 (BEecf) Metabolic acidosis Pco2
while the Paco2 is held constant at 40 mm Hg.10
By standardizing for the effects of the respira- pH and HCO3 (BEecf) Metabolic alkalosis Pco2
tory component, the BEecf is representative of
all the metabolic acidbase disturbances in a pH and Pco2 Respiratory acidosis HCO3 (BEecf)
patient.17 Normally, the BEecf is 0 4 mEq/L.12
Lower values (BEecf <4) indicate metabolic pH and Pco2 Respiratory alkalosis HCO3 (BEecf)
acidosis, whereas higher values (BEecf >+4) a Rose BD, Post TW. Introduction to simple and mixed acidbase disorders. In: Clinical Physiology of AcidBase and Electrolyte
Disorders. 5th ed. New York: McGraw-Hill Book Co; 2001:541.
indicate metabolic alkalosis.
Metabolic acidosis can be caused by increases
in the generation of hydrogen ions (H+) from
endogenous (e.g., lactate, ketones) or exogenous table 2Sample Arterial Blood Gas Report From a
acids (e.g., ethylene glycol, salicylates) and by the
inability of the kidneys to excrete H+ from dietary Patient With Acute Respiratory Failure
protein (renal failure). These increases in H+ in the Analyte Value Reference Range
body are buffered by decreases in HCO3, produc-
pH 7.22 7.357.45
ing a lowered HCO3:Pco2 ratio and, subsequently,
a lowered pH. In addition, metabolic acidosis can Paco2 65 mm Hg 3640 mm Hg
be caused by a direct loss of bicarbonate (HCO3)
through the gastrointestinal tract (diarrhea) or kid- Pao2 45 mm Hg 90100 mm Hg
neys (renal tubular acidosis) or, less commonly, by
the aggressive use of intravenous fluids that con- HCO3 26 mEq/L 2024 mEq/L
tain no bicarbonate or bicarbonate precursors (e.g.,
saline).12 Metabolic alkalosis can occur from a loss BEecf +4 mEq/L 4 to +4 mEq/L
of H+ (vomiting of stomach contents) or from a
gain of HCO3 (e.g., sodium bicarbonate adminis-
tration, hypochloremic alkalosis caused by the use
of loop diuretics).20
Summary of Compensatory Responses in Dogs
table 3
Step 4: Evaluate the Compensatory With Metabolic and Respiratory AcidBase Disorders21
Response Primary Disorder Expected Compensation
Simple acidbase disorders are caused by the
four primary acidbase disturbances, metabolic Metabolic acidosis: Pco2 of 0.7 mm Hg per 1.0 mEq/L decrease in
or respiratory in origin, with an anticipated HCO3 (BEecf) [HCO3] (3)
compensatory change9 (Table 1). The primary
Metabolic alkalosis: Pco2 of 0.7 mm Hg per 1.0 mEq/L increase in
disorder leads to a change in pH, while com- HCO3 (BEecf) [HCO3] (3)
pensatory changes attempt to normalize the
HCO3 :Pco2 ratio and bring the pH back to neu- Acute respiratory acidosis: [HCO3] of 0.15 mEq/L per 1.0 mm Hg increase in
tral. Compensatory changes in Pco2 and HCO3 Pco2 Pco2 (2)
parallel each other, as shown by the direction
of the arrows in each row in Table 1. Chronic respiratory acidosis: [HCO3] of 0.35 mEq/L per 1.0 mm Hg increase in
Typically, pH changes arising from one com- Pco2 Pco2 (2)
ponent (e.g., metabolic) are opposed by changes
in the other component (e.g., respiratory) to main- Acute respiratory alkalosis: [HCO3] of 0.25 mEq/L per 1.0 mm Hg decrease in
Pco2 Pco2 (2)
tain the proper ratio of metabolic to respiratory
contribution to the overall pH.10,21 For example,
Chronic respiratory alkalosis: [HCO3] of 0.55 mEq/L per 1.0 mm Hg decrease in
with metabolic acidosis, the HCO3 concentration Pco2 Pco2 (2)
decreases, thereby lowering the HCO3:Pco2 ratio
[HCO3] = bicarbonate concentration
and resulting in acidemia (pH <7.35).12 In most
3 CE
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Medicine. Subscribers may take individual CE tests online and get real-time scores at CompendiumVet.com. Those who wish to apply this
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1. A pH of 7.40 means the a. correlates with a faster respiratory rate d. a negative value always indicates a meta-
a. HCO3 concentration is within normal and an increased respiratory effort. bolic acidosis, not metabolic compensa-
limits. b. causes an increase in the aa gradient. tion for a respiratory alkalosis.
b. Pco2 is within normal limits. c. by itself causes the pH and the Pao2 to
c. patient does not have an acidbase decrease. 5. Simple acidbase disturbances are
disorder. d. is unresponsive to oxygen typically characterized by which of the
d. HCO3:Pco2 ratio is normal. supplementation. following?
a. an abnormal pH with Pco2and HCO3 con-
2. A simple metabolic acidosis is character- 4. The BEecf is the most effective parameter
centration values changing in opposite
ized by a low pH and a to measure the metabolic component of
directions (e.g., HCO3 and Pco2)
a. decreased BEecf, HCO3 concentration, acidbase disorders because
a. it is the only useful parameter when b. an acidbase disorder (metabolic or
and Pco2.
calculating the amount of sodium bicar- respiratory in origin) and no apparent
b. normal BEecf and HCO3 concentration change in the opposing system
and increased Pco2. bonate to administer to severely acidemic
c. decreased Tco2. patients. c. a neutral pH (7.4) with abnormal Pco2or
b. it is a direct measurement, not a HCO3 concentration values
d. normal BEecf and HCO3 concentration
and decreased Pco2. calculation. d. an acidbase disorder (metabolic or
c. it standardizes for the respiratory contri- respiratory in origin) and a quantifiable
3. Hypoventilation (Pco2) is potentially dan- bution (Pco2 of 40 mm Hg) to the acid parallel compensation in the opposing
gerous because it base balance. system (e.g., HCO3 and Pco2)
6. Jack, an adult Labrador retriever, pre- Bonbons metabolic alkalosis could be 9. Please explain Lucys oxygenation status
sented with a 2-day history of weakness, explained by from her arterial blood gas results. The
excessive thirst, and urination. On exami- a. an upper GI obstruction with loss of gas- sample was collected before oxygen
nation, he was found to be 8% to 10% tric juices in the vomitus. supplementation was instituted.
dehydrated. Please explain Jacks acid b. pain-associated hypoventilation.
base status from his initial venous blood c. compensation for the primary respiratory Arterial blood gas results (Fio2= 21%):
gas results: acidosis. Reference
d. lactic acidosis from shock. Results Interpretation Value*
Venous blood gas results: Pco2 mm Hg 62.1 Hypoxemia 95
Reference 8. Please explain the acidbase status Pco2 mm Hg 67.6 Respiratory acidosis 38
Results Interpretation Value* of Lucy, a geriatric dog with a 3-day *midpoint of range
pH 7.012 Acidemia 7.4 history of progressive increased respi-
The aa gradient calculation is:
Pco2 mm Hg 24.2 Respiratory alkalosis 38 ratory effort. On presentation, Lucys
Pao2 = 150 1.2 (Paco2)
HCO3 mEq/L 5.4 Metabolic acidosis 22 temperature was 103.6F (39.8C), her
Pao2 = 150 1.2 (67.6)
respiratory rate was 42 breaths/min, and
BEecf mEq/L -26.2 Metabolic acidosis 0 Pao2 = 68.9
her heart rate was 140 bpm. Her physical
*midpoint of range
examination revealed inspiratory stridor aa = Pao2 Pao2
The expected respiratory compensation for on auscultation. aa = 68.9 62.1 = 6.8
this metabolic acidosis (within a margin of
variance of 3 mm Hg) can be calculated as Arterial blood gas results Lucys respiratory evaluation reveals
follows: (Fio2= 21%, at sea level): a. hypoxemia secondary to ventilationper-
Expected Pco2 decrease from midpoint ref- Reference
fusion abnormalities and hypoventilation.
erence value = HCO3 (decrease in HCO3 Results Interpretation Value* b. hypoxemia secondary to hypoventilation
concentration from a midpoint reference pH 7.2 Acidemia 7.4
only.
value associated with the metabolic acidosis) c. hypoxemia secondary to ventilation
Pco2 mm Hg 62.1 Hypoxemia 95
0.7 (expected mm Hg decrease in Pco2 for perfusion abnormalities only.
Pco2 mm Hg 67.6 Respiratory acidosis 38 d. hypoxemia secondary to pulmonary
each 1.0 mEq/L decrement in HCO3)
HCO3 mEq/L 30.4 Metabolic alkalosis 22 disease.
In this case: (22 5.4) 0.7 BEecf mEq/L +12.4 Metabolic alkalosis 0
16.6 0.7 = 11.6 mm Hg *midpoint of range 10. Bob is a young adult mixed-breed dog
that presented after being hit by a car.
Expected Pco2 = Pco2 midpoint reference The expected metabolic compensation for Physical examination revealed extensive
range Expected change in Pco2 this chronic respiratory acidosis (within a abrasions on his thorax. His temperature
margin of variance of 2 mEq/L) can be cal- was 102.8F (39.4C), his respiratory rate
In this case:
culated as follows: was 62 breaths/min, and his heart rate
38 mm Hg 11.6 = 26.4 mm Hg
was 140 bpm. Please explain Bobs oxy-
Therefore, Jacks expected Pco2 is 26.4 mm Expected HCO 3 increase from midpoint genation status from the arterial gas data
Hg, and his measured Pco2 is 24.2 mm Hg. reference value = Pco2 (increase in Pco2 collected on presentation:
from midpoint reference range associ-
After reviewing Jacks measured and ated with the respiratory acidosis) 0.35 Arterial blood gas results (Fio2= 21%):
expected Pco2 values, we can conclude (expected mEq/L increase in HCO3 for
Reference
that Jacks respiratory compensation for each 1.0 mm Hg increment in Pco2): Results Interpretation Value*
his metabolic acidosis is In this case: (67.6 38) 0.35 pH 7.48 Alkalemia 7.4
a. adequate (within the 3 margin of 29.6 0.35 = 10.4 mEq/L Pco2 mm Hg 63 Hypoxemia 95
variance).
Pco2 mm Hg 25.9 Respiratory alkalosis 38
b. inadequate (outside the 3 margin of Expected HCO3 = HCO3 midpoint reference
variance). range + Expected increase in HCO3 HCO3 mEq/L 18.8 Metabolic acidosis 22
c. acute. BEecf mEq/L -4.8 Metabolic acidosis 0
d. chronic. In this case: *midpoint of range
22 + 10.4 = 32.4 mEq/L The aa gradient is:
7. Bonbon, a shih tzu puppy, presented with a Pao2 = 150 1.2 (Paco2)
2-day history of vomiting and anorexia. On Therefore, Lucys expected HCO3 is 32.4
mEq/L, and her measured HCO3is 30.4 Pao2 = 150 1.2 (25.9)
physical examination, a foreign body was Pao2 = 119
palpated in the cranial abdomen. Please mEq/L.
explain Bonbons acidbase status from aa = Pao2 Pao2
her initial venous blood gas results: Lucys acidbase status can be described aa = 119 63 = 56
as
Venous blood gas results: a. a mixed acidbase disorder. Bobs respiratory evaluation reveals
b. respiratory acidosis with adequate meta- a. hypoxemia secondary to ventilationper-
Reference
Results Interpretation Value*
bolic compensation (within the fusion abnormalities and hypoventilation.
2 margin of variance). b. hypoxemia secondary to hypoventilation
pH 7.5 Alkalemia 7.4
c. metabolic alkalosis with respiratory only.
Pco2 mm Hg 52.1 Respiratory alkalosis 38 compensation. c. hypoxemia secondary to ventilation
HCO3 mEq/L 37.3 Metabolic alkalosis 22 d. respiratory acidosis with no com- perfusion abnormalities only.
BEecf mEq/L +12.0 Metabolic alkalosis 0 pensation (outside the 2 margin of d. hypoxemia secondary to decreased
*midpoint of range variance). inspired oxygen.