1. A 50-year-old woman with a history of intestinal bypass surgery for obesity presented with 10-15 watery stool motions per day and was found to be somnolent and hypotensive the next day. 2. Laboratory analysis of her blood revealed a low pH of 7.02, low bicarbonate of 10 mEq/L, and low pCO2 of 30, consistent with a metabolic acidosis. 3. Further evaluation of the patient's history, physical exam findings, and acid-base panel results is needed to make a diagnosis of the specific cause of her metabolic acidosis.

2. Case
• A 50-Year old woman underwent
intestinal bypass for morbid obesity .
She has 10-15 watery stool motion per
day , she was treated by tincture of
opium . Next day she was found
somnolent and hypotensive. The plasma
value were:
• A 50-Year old woman underwent
intestinal bypass for morbid obesity .
She has 10-15 watery stool motion per
day , she was treated by tincture of
opium . Next day she was found
somnolent and hypotensive. The plasma
value were:
2

3. Laboratory data
PH 7.02
PaCO2 30
HCO3
(mEq/L)
10 What is
your
Diagnosis ?
HCO3
(mEq/L)
Na
(mEq/L)
130
K
(mEq/L)
3.2
CL
(mEq/L)
102
3
What is
your
Diagnosis ?

6. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

7. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

8. • Step 1.
History taking and physical examination
Comprehensive history taking and physical
examination can often give clues as to the
underlying acid-base disorder
• Step 1.
History taking and physical examination
Comprehensive history taking and physical
examination can often give clues as to the
underlying acid-base disorder

9. Respiratory alkalosisPulmonary embolus
Respiratory acidosisCOPD
Metabolic acidosis
Dehydration or shock
Hyperkalaemia
Metabolic alkalosisVomiting , Hypokalaemia Metabolic alkalosisVomiting , Hypokalaemia
Metabolic acidosis
Severe diarrhea
salisylates or alcohol intoxication
Metabolic acidosisRenal failure
metabolic acidosis
Hyperglycaemia (DKA? if ketones
present
Respiratory alkalosisCirrhosis

10. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

11. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

13. ValidityValidity

14. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

15. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

16. 1.Arterial pH
2.Look at PCO2, HCO3

17. • Principle – The body does not fully
compensate for primary acid-base disorders.
i.e.
PH < 7.4 ……. acidosis
PH > 7.4 ……. alkalosis
• Principle – The body does not fully
compensate for primary acid-base disorders.
i.e.
PH < 7.4 ……. acidosis
PH > 7.4 ……. alkalosis

18. Acidosis AlkalosisAcidosis

19. - If PCO2 is the initial chemical change, then
process is respiratory.
- if HCO3- is the initial chemical change, then
process is metabolic.
- If PCO2 is the initial chemical change, then
process is respiratory.
- if HCO3- is the initial chemical change, then
process is metabolic.

20. PCO2HCO3PH
  

AcidosisAcidosis
AlkalosisAlkalosis
MetabolicMetabolic
MetabolicMetabolic

 




AcidosisAcidosis
AlkalosisAlkalosis
AlkalosisAlkalosis MetabolicMetabolic
RespiratoryRespiratory
RespiratoryRespiratory

21. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

22. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

23. Metabolic acidosis
Expected pCO2 = 1.5 x [HCO3] + 8 (range: +/- 2)
Metabolic alkalosis
Expected pCO2 = 0.7 [HCO3] + 20 (range: +/- 5)
“If the actual pCO2 or [HCO3
-]
is different from the predicted values,
You must suspect a 2nd acid-base disorder”
Metabolic acidosis
Expected pCO2 = 1.5 x [HCO3] + 8 (range: +/- 2)
Metabolic alkalosis
Expected pCO2 = 0.7 [HCO3] + 20 (range: +/- 5)
“If the actual pCO2 or [HCO3
-]
is different from the predicted values,
You must suspect a 2nd acid-base disorder”

24. • Acute Respiratory :
The [HCO3] will increase by 1 mmol/l for every 10
mmHg elevation in pCO2 above 40 mmHg.
Expected [HCO3] = 24 + { (Actual pCO2 - 40) / 10 }
• Chronic Respiratory :
The [HCO3] will increase by 4 mmol/l for every 10
mmHg elevation in pCO2 above 40mmHg.
Expected [HCO3] = 24 + 4 { (Actual pCO2 - 40) / 10}
• Acute Respiratory :
The [HCO3] will increase by 1 mmol/l for every 10
mmHg elevation in pCO2 above 40 mmHg.
Expected [HCO3] = 24 + { (Actual pCO2 - 40) / 10 }
• Chronic Respiratory :
The [HCO3] will increase by 4 mmol/l for every 10
mmHg elevation in pCO2 above 40mmHg.
Expected [HCO3] = 24 + 4 { (Actual pCO2 - 40) / 10}

25. • Acute Respiratory
The [HCO3] will decrease by 2 mmol/l for every 10
mmHg decrease in pCO2 below 40 mmHg.
Expected [HCO3] = 24 - 2 { ( 40 - Actual pCO2) / 10 }
• Chronic Respiratory
The [HCO3] will decrease by 5 mmol/l for every 10
mmHg decrease in pCO2 below 40 mmHg.
Expected [HCO3] = 24 - 5 { ( 40 - Actual pCO2 ) / 10 }
(range: +/- 2)
• It takes 2 to 3 days to reach maximal renal compensation
• Acute Respiratory
The [HCO3] will decrease by 2 mmol/l for every 10
mmHg decrease in pCO2 below 40 mmHg.
Expected [HCO3] = 24 - 2 { ( 40 - Actual pCO2) / 10 }
• Chronic Respiratory
The [HCO3] will decrease by 5 mmol/l for every 10
mmHg decrease in pCO2 below 40 mmHg.
Expected [HCO3] = 24 - 5 { ( 40 - Actual pCO2 ) / 10 }
(range: +/- 2)
• It takes 2 to 3 days to reach maximal renal compensation

26. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

27. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

28. • The anion gap is defined as the quantity of
anions not balanced by cations.
• (Na + K) + Unmeasured cations =
(Cl + HCO3) + Unmeasured anions
• Anion Gap=
measured cation- measured anion.
• Anion gap = [Na + K] – (Cl + HCO3)
• Value: 12 ± 4 meq/L
• The anion gap is defined as the quantity of
anions not balanced by cations.
• (Na + K) + Unmeasured cations =
(Cl + HCO3) + Unmeasured anions
• Anion Gap=
measured cation- measured anion.
• Anion gap = [Na + K] – (Cl + HCO3)
• Value: 12 ± 4 meq/L

29. Anions and Cations in Serum
(Values in mEq/L)
CATIONSANIONS
Calcium 5Organic acids 5
Magnesium 1.5Sulfates 1
Potassium 4.5Phosphates 2
Actually there is no gap
Potassium 4.5Phosphates 2
Sodium 140Proteins 15
Bicarbonates 24
Chlorides 104
Total 151Total 151

31. High Anion Gap Normal anion gap
• 1. Ketoacidosis
- Diabetic
- Alcoholic
- Starvation
• 2. Lactic acidosis
• 3. Toxicosis
- Ethylene glycol
- Methanol
- Salicylates
• 4. Advanced renal failure
• 1. GIT HCO3
- loss
- Diarrhea
- External fistulas
• 2. Renal HCO3
- loss
- Proximal RTA
- Distal RTA
- Hyperkalemic RTA
metabolic acidosis
(MUD PILES)(MUD PILES)
Methanol
Uremia
Diabetic ketoacidosis
Propylene glycol
Isoniazid intoxication
Lactic acidosis
Ethanol ethylene glycol
Salicylates
• 1. Ketoacidosis
- Diabetic
- Alcoholic
- Starvation
• 2. Lactic acidosis
• 3. Toxicosis
- Ethylene glycol
- Methanol
- Salicylates
• 4. Advanced renal failure
• 1. GIT HCO3
- loss
- Diarrhea
- External fistulas
• 2. Renal HCO3
- loss
- Proximal RTA
- Distal RTA
- Hyperkalemic RTA
(MUD PILES)(MUD PILES)
Methanol
Uremia
Diabetic ketoacidosis
Propylene glycol
Isoniazid intoxication
Lactic acidosis
Ethanol ethylene glycol
Salicylates

32. Osmolal gap
Step 1:
Calculate Osm = 2[Na+] + glucose/18 + BUN/2.8
Step 2: Measure Osm
Step 3: Osmolal gap (measured - calc) should be ≤ 10

33. ‫ﻻ‬‫ﻳ‬‫ﻤ‬‫ﻜ‬‫ﻦ‬‫ﻋ‬‫ﺮ‬‫ض‬‫ا‬‫ﻟ‬‫ﺼ‬‫ﻮ‬‫ر‬‫ة‬.‫ﻗ‬‫ﺪ‬‫ﻻ‬‫ﺗ‬‫ﻜ‬‫ﻮ‬‫ن‬‫ھ‬‫ﻨ‬‫ﺎ‬‫ك‬‫ﻣ‬‫ﺴ‬‫ﺎ‬‫ﺣ‬‫ﺔ‬‫ﻛ‬‫ﺎ‬‫ﻓ‬‫ﯿ‬‫ﺔ‬‫ﻟ‬‫ﻠ‬‫ﺬ‬‫ا‬‫ﻛ‬‫ﺮ‬‫ة‬‫ﻋ‬‫ﻠ‬‫ﻰ‬‫ا‬‫ﻟ‬‫ﻜ‬‫ﻤ‬‫ﺒ‬‫ﯿ‬‫ﻮ‬‫ﺗ‬‫ﺮ‬‫ﻟ‬‫ﻔ‬‫ﺘ‬‫ﺢ‬‫ا‬‫ﻟ‬‫ﺼ‬‫ﻮ‬‫ر‬‫ة‬‫أ‬‫و‬‫ﻗ‬‫ﺪ‬‫ﺗ‬‫ﻜ‬‫ﻮ‬‫ن‬‫ا‬‫ﻟ‬‫ﺼ‬‫ﻮ‬‫ر‬‫ة‬‫ﺗ‬‫ﺎ‬‫ﻟ‬‫ﻔ‬‫ﺔ‬.‫ﻗ‬‫ﻢ‬‫ﺑ‬‫ﺈ‬‫ﻋ‬‫ﺎ‬‫د‬‫ة‬‫ﺗ‬‫ﺸ‬‫ﻐ‬‫ﯿ‬‫ﻞ‬‫ا‬‫ﻟ‬‫ﻜ‬‫ﻤ‬‫ﺒ‬‫ﯿ‬‫ﻮ‬‫ﺗ‬‫ﺮ‬،‫ﺛ‬‫ﻢ‬‫ا‬‫ﻓ‬‫ﺘ‬‫ﺢ‬‫ا‬‫ﻟ‬‫ﻤ‬‫ﻠ‬‫ﻒ‬‫ﻣ‬‫ﺮ‬‫ة‬‫أ‬‫ﺧ‬‫ﺮ‬‫ى‬.‫إ‬‫ذ‬‫ا‬‫ﻇ‬‫ﻠ‬‫ﺖ‬‫ﻋ‬‫ﻼ‬‫ﻣ‬‫ﺔ‬x‫ا‬‫ﻟ‬‫ﺤ‬‫ﻤ‬‫ﺮ‬‫ا‬‫ء‬‫ﺗ‬‫ﻈ‬‫ﮫ‬‫ﺮ‬،‫ﻗ‬‫ﺪ‬‫ﺗ‬‫ﻀ‬‫ﻄ‬‫ﺮ‬‫إ‬‫ﻟ‬‫ﻰ‬‫ﺣ‬‫ﺬ‬‫ف‬‫ا‬‫ﻟ‬‫ﺼ‬‫ﻮ‬‫ر‬‫ة‬‫ﺛ‬‫ﻢ‬‫إ‬‫د‬‫ر‬‫ا‬‫ﺟ‬‫ﮫ‬‫ﺎ‬‫ﻣ‬‫ﺮ‬‫ة‬‫أ‬‫ﺧ‬‫ﺮ‬‫ى‬.

34. Low Anion Gap
- Hypoalbuminemia
- Plasma cell dyscrasia
- Monoclonal protein
- Bromide intoxication
- Normal variant
Corrected AG=
Anion Gap + 2.5 x
(4- Albumin)
- Hypoalbuminemia
- Plasma cell dyscrasia
- Monoclonal protein
- Bromide intoxication
- Normal variant
Corrected AG=
Anion Gap + 2.5 x
(4- Albumin)

35. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

36. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

37. • If a metabolic acidosis is diagnosed, then the
Delta Ratio should be checked
Delta ratio= ∆ Anion gap/∆ [HCO3-]
∆ Anion gap = (12-AG)
∆ [HCO3-] = (24 - [HCO3-])

38. Delta ratio Assessment Guidelines
< 0.4 Hyperchloremic normal anion gap acidosis
< 1 High AG & normal AG acidosis
1 to 2 Pure Anion Gap Acidosis
Lactic acidosis: average value 1.6
DKA more likely to have a ratio closer to 1
due to urine ketone loss
Pure Anion Gap Acidosis
Lactic acidosis: average value 1.6
DKA more likely to have a ratio closer to 1
due to urine ketone loss
> 2 High AG acidosis and a concurrent metabolic
alkalosis
or a pre-existing compensated respiratory
acidosis

39. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

40. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

41. Urine anion gab= (N a +K) -Cl
POSITIVE
urinary anion gab
NEGATIVE
urinary anion gab
(normal NH(normal NH33 excreationexcreation))
POSITIVE
urinary anion gab
NEGATIVE
urinary anion gab
(normal NH(normal NH33 excreationexcreation))
GUT causes
NEGATIVEn bowel
causes
Urinary causes

42. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

43. 1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis
1. History taking and physical examination
2. Assess accuracy of data (validity).
3. Identify the primary disturbance
1. Check arterial pH-------- acidosis or alkalosis
2. HCO3
- & pCO2 analysis---primary disorder.
4. Compensatory responses
5. Calculate AG
6. Assess delta ratio
7. Urine anion gab
8. Formulate acid-base diagnosis

44. Final DiagnosisFinal DiagnosisFinal DiagnosisFinal Diagnosis

45. Case
• A 50-Year old woman underwent
intestinal bypass for morbid obesity .
She has 10-15 watery stool motion per
day , she was treated by tincture of
opium . Next day she was found
somnolent and hypotensive. The plasma
value were:
• A 50-Year old woman underwent
intestinal bypass for morbid obesity .
She has 10-15 watery stool motion per
day , she was treated by tincture of
opium . Next day she was found
somnolent and hypotensive. The plasma
value were:
45

46. Laboratory data
PH 7.02
PaCO2 30
HCO3
(mEq/L)
10
H = (PCO2/ HCO3) ×24 =PH-7.8 ×100
H= (30/10)X24=7.02-7.8X100
Validity
PH= acidosis------Hco3= Met acidosis
Primary
defect
Expected pCO2 = 1.5 x [HCO3] + 8
(range: +/- 2)
=1.5X10+8= 22
pco2 30 added respiratory acidosis.
CompensationHCO3
(mEq/L)
10
Na
(mEq/L)
130
K
(mEq/L)
3.2
CL
(mEq/L)
102
46
Expected pCO2 = 1.5 x [HCO3] + 8
(range: +/- 2)
=1.5X10+8= 22
pco2 30 added respiratory acidosis.
Compensation
= [Na+] – [HCO3
-] – [Cl-]
=130-(10+ 102)= 18
High AG
AG
Anion gap/∆ [HCO3-]
=18-12/24-10= <1 (0.42).
High AG & normal AG acidosis
Delta ratio

47. Final diagnosis:
• Normal Anion gap and high Anion gap
metabolic acidosis+ combined respiratory
acidosis.
– Lactic acidosis (hypotension)
– Metabolic acidosis due to HCO3 loss (diarrhea).
– Respiratory acidosis due to respiratory
depression by opiate.
• Normal Anion gap and high Anion gap
metabolic acidosis+ combined respiratory
acidosis.
– Lactic acidosis (hypotension)
– Metabolic acidosis due to HCO3 loss (diarrhea).
– Respiratory acidosis due to respiratory
depression by opiate.

48. Case
• A 23y old women with rheumatoid artheritis
increased her dose of salicylate because of
flare up. She developed epigastric pain and
vomiting that persist for 2 days. She went to
local hospital where the following blood result
obtained:
• PH =7.61 Pco2 25mmHg, Hco3 =33mmol/l.
• What is your acid base diagnosis?
• A 23y old women with rheumatoid artheritis
increased her dose of salicylate because of
flare up. She developed epigastric pain and
vomiting that persist for 2 days. She went to
local hospital where the following blood result
obtained:
• PH =7.61 Pco2 25mmHg, Hco3 =33mmol/l.
• What is your acid base diagnosis?

49. Laboratory data
PH 7.61
PaCO2 25mmHg.
What is
your
Diagnosis ?
PaCO2 25mmHg.
HCO3
(mEq/L)
33mmol/l.
49
What is
your
Diagnosis ?

50. Laboratory data
PH 7.61
PaCO2 25mmHg.
HCO3
(mEq/L)
33mmol/l.
H = (PCO2/ HCO3) ×24 =PH-7.8
×100
H= (25/33)X24=7.61-7.8X100Validity
PH= alkalosis------increased Hco3=
Metabolic alkalosis
Primary
defect
Metabolic alkalosis
Expected pCO2 = 0.7x [HCO3] + 20
(range: +/- 2)
=0.7X33+ 20=43
So compansation is not adaqaute
respiratory alkalosis.
CompensationHCO3
(mEq/L)
33mmol/l.
50
Metabolic alkalosis
Expected pCO2 = 0.7x [HCO3] + 20
(range: +/- 2)
=0.7X33+ 20=43
So compansation is not adaqaute
respiratory alkalosis.
Compensation
Final diagnosis
Combined Metabolic alkalosis (GIT loss Vomiting )
and respiratory alkalosis with salicylate.

51. Let’s play tic-tac-toe

52. PH 7.26 PaCO2 42 HCO3 17
AlkalineNormalAcidic
PH Pa CO2
HCO3
Metabolic acidosis

53. PH 7.49 PaCO2 30 HCO3 23
AlkalineNormalAcidic
PHHCO3
Pa CO2
Respiratory alkalosis

54. PH 7.26 PaCO2 52 HCO3 34
AlkalineNormalAcidic
PH HCO3
Pa CO2
Respiratory acidosis with
compensation (Partial)

55. PH 7.48 PaCO2 51 HCO3 29
AlkalineNormalAcidic
PH
Pa CO2 HCO3
Metabolic alkalosis with
compensation (Partial)

56. PH 7.36 PaCO2 50 HCO3 34
AlkalineNormalAcidic
PHPa CO2 HCO3
Respiratory acidosis with
compensation (complete)

57. PH 7.43 PaCO2 49 HCO3 30
AlkalineNormalAcidic
PHPa CO2 HCO3
Metabolic alkalosis with
compensation (complete)