Rationale
Abnormally high or low hydrogen ion concentration—acidemia and alkalemia, respectively—is encountered relatively frequently, particularly in hospital-based practice. Acidemia may be caused by an underlying life-threatening condition. Several acid-base abnormalities can coexist in a single patient.
Causal Conditions
(list not exhaustive)
- Metabolic acidosis
- High anion gap
- Increased acid production
- Exogenous (e.g., methanol)
- Endogenous (e.g., ketoacidosis)
- Decreased renal acid excretion (e.g., kidney injury)
- Increased acid production
- Normal anion gap
- Gastrointestinal bicarbonate loss (e.g., diarrhea)
- Renal bicarbonate loss (e.g., renal tubular acidosis, interstitial nephritis)
- High anion gap
- Metabolic alkalosis
- Expanded effective arterial blood volume (e.g., mineralocorticoid excess)
- Contracted effective arterial blood volume
- Gastrointestinal loss (e.g., vomiting)
- Renal loss (e.g., diuretics)
- Exogenous ingestion
- Respiratory acidosis
- Neuromuscular causes (e.g., medications, illicit drugs, neuromuscular disease)
- Pulmonary causes of decreased alveolar ventilation (e.g., severe asthma exacerbation with impending respiratory failure)
- Kyphoscoliosis
- Hypoventilation (e.g., due to obesity)
- Respiratory alkalosis
- Hypoxemia with tachypnea
- Metabolic (e.g., hepatic failure)
- Cardiopulmonary disorders (e.g., pneumonia, embolism)
- Central nervous system disorders (e.g., subarachnoid hemorrhage)
- Drugs (e.g., salicylate)
- Miscellaneous (e.g., fever, pain, pregnancy)
Key Objectives
Given a patient with an acid-base abnormality, the candidate will diagnose the cause, severity, and complications and will initiate an appropriate management plan, particularly when dealing with a high anion gap metabolic acidosis.
Enabling Objectives
Given a patient with an acid-base abnormality, the candidate will
- through efficient and focused data gathering, diagnose the cause of acidemia or alkalemia expeditiously;
- list and interpret critical clinical and laboratory findings that are key in the processes of exclusion, differentiation, and diagnosis, including those derived from
- an accurate arterial blood gas (ABG) analysis; and
- complementary investigations for acidemia or alkalemia aimed at identifying the primary abnormality and the adequacy of the associated secondary compensation; and
- construct an effective initial management plan for acidemia or alkalemia, including
- describing general supportive measures;
- describing management for specific acid-base disorders; and
- determining whether the patient needs to be referred for consultation.