This is the second part of a 4 part series on acid base.
You should listen to Acid-Base Part I first. In Part III, we solve the problem below and reunify everything. Part IV discusses the acid-base of administered solutions.
For this podcast to be optimally effective, you need to print out my acid base sheet:
EMCrit Acid Base Sheet
Here is the problem to work on for the next podcast:
I gave some shout-outs during the talk, here are the links:
- The Air Medical Memorial honors those flight medics, docs, pilots, and nurses who have fallen in the line of duty.
- Josh Mularella developed the free app call ERRES, search for it on itunes.
- Casey Parker created a site for outback EM and Crit Care called Broome Docs.
- Ivor Kovic donated three free codes to his cpr app, CPRPRO. Sign up for the mailing list if you want to enter to win one.
Need an Audio Only Version?
Acid Base Part II MP3 [Play] (Right Click and Choose Save as)
>
Podcast: Play in new window | Download (83.9MB) | Embed
Hi, my name is Scott Weingart. 
Chris Watford was kind enough to translate the problem for those not familiar with the old-school labs layout:
Na: 122
Cl: 88
BUN: 50 mg/dl
K: 5.3
Bicarb: 5
Creatinine: 2.1 mg/dl
Glu: 640 mg/dl
pH: 7.05
PaCO2: 14 mm Hg
PaO2: 96 mm Hg
FiO2: 100%
Man, this is it! Finally someone put this into a very compact and solid, digestable packet!
Well friggin’ done!
Bravo,
JP
I’m getting a SIG of 15, seemingly explained by DKA?
Don´t know if we were supposed to discuss that here, but since Brandon started …
I would say metabolic acidosis with a SIG of 11 (mmol/l ?), DKA being on top of the differentials. However: Why is the pCO2 so low? Compensation rules predict a pCO2 of 40-18=22 mmHg. I´ve learned that overcompensation does not exist. So associated respiratory alkalosis? Btw, do the compensation formulas apply the same way no matter what the FiO2 is? Suppose they should since pCO2 is not affected by FiO2 (=oxygenati0n) but only by ventilation …
looking forward to part III ; )
Feel free to discuss here and I will answer all comments in podcast part 3. Reason you two are getting different SIGs is I had to switch up the sodium from 126 to 122 to be able to make an important point later down the road. Folks that came up with a SIG of 15 got to the problem within the first few hours. There is nothing tricky about the problem; it just provides fodder for discussion.
For those who might not know about it but might be interested in it, there is a free online version of Stewart’s original textbook. You can also order the new edition of the book through the site.
http://www.acidbase.org
Love your work Scott !
Step 1: Get Labs! (See above post w/ lab values)
Step 2: pH; 7.05 -> acidosis.
Step 3: CO2; 14 mmHg -> respiratory alkalosis (consider compensatory).
Step 4: SID; 34 (Low-normal -> SID metabolic?)
Step 5: Lactate 0.5 (WNL)
Step 6: SIG: 18 + (34 – 38) + 2.5 (4.2 – 5.2) – 0.5 = 12 (SIG metabolic)
At this step I am considering DKA as the cause due to SIG metabolic acidosis and a BGL of 640 mg/dL (annnd the Hx that screams a diabetes problem).
I enjoy this process, very logical.
Do you have the audio only version for part 2? Only part 1 is posted.
Love the site, love the podcasts- I listen to them in my car and I have already learned a ton.
link in the post for audio-only is is now fixed. thanx for finding this.
Hi Scott. Thanks for these posts. The topic spurred my interest, and I’ve subsequently read 26 journal articles on the topic, as well as bought and read “Stewart’s Textbook of Acid-Base,” and numerous websites including http://www.acidbase.org.
I have two questions.
1. I’m interested in any references to the PCO2 or HCO3- compensations using Base Excess. I have multiple articles outlining the Winter’s formula as well as others, but none have references to Base excess.
2. I’m wondering where you found references to use Base Excess in calculating theSIG?
Clearly SIG is the difference between apparent and effective SID, but there doesn’t seem to be uniform agreement on how to calculate affective SID (various values for the valences of Mg and Ca) nor for effective SID… one that I found being: (HCO3- + (Alb/10)((pH x 0.1204) – 0.625) + (PO4-/0.323)((pH x 0.309)-0.469). Clearly too complicated for bedside use!
Thanks and know that your work to make these podcasts is appreciated!
Mike,
I will answer these excellent questions in part III.
Scott,
I absolutely love EMCrit. <3
Albumin in Canada is measured in g/L. so
(Base Deficit) + (SID – 38) +0.25[42-albumin{g/L}] – Lactate
should work.
Shannon
thanks Shannon
A deep dive into Acid/Base chemistry, physics, physiology, and medicine from our anesthesia friends can be found at: http://www.anaesthesiamcq.com/
Maybe a silly question, but I assume you calculate the Sid with the measured sodium not the sodium adjusted for hyperglycaemia?