Acid-Base and Electrolytes
Gary L. Horowitz, MD
Beth Israel Deaconess Medical Center
Boston, MA
Objectives
• Identify the 4 major acid-base disturbances,
giving typical values for PCO2, pH, and HCO3
• List the most common causes for each of the
major acid-base disturbances
• Describe the significance of the “anion gap”
• Differentiate pseudohyponatremia from genuine
hyponatremia
Important Fact #1
• Venous Blood Gas (VBG) samples can be used
for Acid-Base analysis
– Arterial Blood Gas (ABG) samples are
required only for PO2 and for PaO2
– VBG samples are acceptable because
• pH and PCO2 are comparable to ABG samples
• exception: patients in severe circulatory failure (shock)
• VBG samples can also be used to measure
carboxyhemoglobin and methemoglobin
Important Fact #2
(from high school chemistry)
Implications
• [H+] is inversely proportional to HCO3
• decreases as HCO3 increases (obvious)
• [H+] is directly proportional to PCO2
• increases (more acid) as PCO2 increases
• If PCO2/HCO3- does not change
[H+] does not change!
• pH is –log10[H+]
if H+ does not change, pH does not change
Important Fact #3
• Know 3 “normal” values
• PCO2 = 40
• HCO3- = 24
• H+ = 40 (pH=7.40)
• you can derive K =24
• Also:
• 40 nmol/L [H+] = 7.40
• 30 nmol/L [H+] = 7.50 +10 nmol ~ -0.10 pH
• 50 nmol/L [H+] = 7.30 -10 nmol ~ +0.10 pH
A Normal H+ (pH) Does Not Exclude
an Acid-Base Disturbance
• In each of the following cases,
the H+ (and pH) are the same:
• But only the first case (40/24) is normal;
the others (10/6 and 80/48)
represent severe disturbances!
pH & Henderson-Hasselbalch
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Important Fact #4
• The body does not try to maintain H+,
but it helps to think it does
• In most acid-base disturbances, there is
– a 1o disturbance, followed by
– a 2o compensation
which may take time to develop
which partially, but never fully,
corrects the 1o disturbance
This Method for Acid-Base Analysis
• Exploits these four important facts
• Enables you to correctly
– diagnose ~95% of acid-based disturbances
– recognize the other ~5% as exceptions
Respiratory Alkalosis
compensation
“normal values” in parentheses
Acute Respiratory Alkalosis
(no renal compensation)
no
compensation
compensation
Respiratory Acidosis
Metabolic Alkalosis
Metabolic Acidosis
Summary: Acid-Base Disturbances
(with compensation)
PCO2 and HCO3 always move in same direction!
– if only one changes acute disturbance
– if different direction >1 disturbance!
measured (but Anion Gap unmeasured
ignored) cations anions
Mg++ = 1 Acids = 9
Ca++ = 3
K+ = 5 Proteins=16
HCO3-= 24
Na+=140 Cl- = 100
“anion gap”
Metabolic Acidosis
HCO3- Decreases from 24 to 12
HCO3 = 12 ? ? = 12
Cl = 112 HCO3 = 12
Cl = 100
Normal anion gap Increased anion gap
Chloride has increased, Chloride has not changed
replacing lost HCO3 A new anion has replaced
lost HCO3
On to Electrolytes
• HCO3-: covered already with acid-base
• Cl-: covered already with anion gap
• that leaves Na and K
• specifically --
– pseudohyponatremia
– pre-analytic issues affecting hyperkalemia
Some General Comments
• measurement of Na, K, Cl:
– ISE (ion selective electrodes)
• measurement of HCO3:
– usually, spectrophotometry
– ABG analyzers: calculated from PCO2 and pH
• focus in this talk will be measurement issues
• medical disorders will not be covered here
– Hypo- and hyper-natremia are usually disorders of
water (SIADH, lack of free access to water)
Pseudohyponatremia
• hyponatremia is a fairly common abnormality
• pseudohyponatremia is relatively rare,
but one needs to be rule it out often,
so that only the patients with real
hyponatremia receive treatment
ISE Measurement
• Distinguish between
– Activity (in aqueous phase)
– Concentration (in total volume)
• Serum is normally 93% water and 7% solids
– the latter is comprised of proteins and triglycerides
• ISE:
– electrode is permeable to all but ion of interest
– difference in concentration of ion across electrode yields voltage
difference (Nernst equation)
• Samples typically undergo large dilution for ISE:
– separate phases disappear
– one needs to correct result back to original sample
1.0 mL sample, [Na] = 135 mmol/L
actually 93% aqueous, contains 126 umol Na
measured Na = 126 mmol/L
corrected for 93% aqueous 135 mmol/L
1 mL sample, [Na] = 135 mmol/L
actually 85% aqueous, contains 115 umol Na
measured Na = 115 mmol/L
corrected for 93% aqueous 124 mmol/L
7% 15%
sample 1:100 dilution sample 1:100 dilution
1.0 mL sample, [Na] = 135 mmol/L
Direct ISE measures 135 mmol/L
1.0 mL sample, [Na] = 135 mmol/L
Direct ISE measures 135 mmol/L
7% 15%
135
sample 1:100 dilution sample 1:100 dilution
Final Notes on Pseudohyponatremia
• If you suspect it, you can determine the true [Na] by
– using a non-dilutional ISE (e.g., ABG analyzer)
– measuring osmolality (more on this later)
• You can also suspect it when you come across samples with
– very high total protein (e.g., multiple myeloma)
– very high triglycerides (e.g., lipemic samples)
• You might consider confirming all very low [Na]
• Whenever a clinician inquires about falsely low [Na],
you should confirm your results
Hyperkalemia: Is It Real?
Things to Watch Out For (1)
• “Hemolysis”: in vitro vs in vivo
– in vitro (real but not present in patient)
• poor phlebotomy, prolonged storage without centrifugation
• rejecting such samples may not be the best solution
– A normal or low K on a hemolyzed sample may be helpful
– Hgb indices can be used to calculate degree of hemolysis
– in vivo (real and present in the patient)
• in vivo hemolysis can be life-threatening
– e.g., acute transfusion reaction, babesiosis
• importance of hemoglobinuria to distinguish from in vitro
Hyperkalemia: Is It Real?
Things to Watch Out For (2)
• High platelet counts
– serum K is ~0.5 mmol/L higher than plasma K
– difference is proportional to platelet count
– during clotting, platelets release K
– with platelet counts >500K, effect may become
clinically significant
– to prove this is the case,
analyze a plasma sample (e.g., heparin)
• Also reported with high WBC counts (and/or
fragile WBCs)
Self-Assessment Question 1
Which of the following represents the typical findings
in a respiratory alkalosis?
A) increased PCO2, decreased HCO3
B) increased PCO2, increased HCO3
C) decreased PCO2, decreased HCO3
D) decreases PCO2, increased HCO3
Self-Assessment Question 2
Which of the following is a cause for a normal anion
gap metabolic acidosis?
A) diarrhea
B) diabetic ketoacidosis
C) vomiting
D) lactic acidosis
Self-Assessment Question 3
Pseudohyponatremia can be caused by which of the
following:
A) high glucose concentrations
B) low platelet counts
C) high concentrations of serum proteins (e.g.,
multiple myeloma)
D) high concentrations of ADH
