Cite this post as:
Scott Weingart, MD FCCM. EMCrit Podcast 44 – Acid Base: Part I. EMCrit Blog. Published on April 11, 2011. Accessed on March 24th 2023. Available at [https://emcrit.org/emcrit/acid-base-i/ ].
Financial Disclosures:
Dr. Scott Weingart, Course Director, reports no relevant financial relationships with ineligible companies.
This episode’s speaker(s), (listed above), report no relevant financial relationships with ineligible companies.
CME Review
Original Release: April 11, 2011
Date of Most Recent Review: Jan 1, 2022
Termination Date: Jan 1, 2025
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Hey Scott,
From what I can tell, the first day your new Podcast comes out, it is not yet on the i-Tunes list. So the only way to listen to it is as a quicktime file on my PC. Is there another way? I usually just have to wait painfully to see that i-tunes has your latest but this is sometimes a day or two. Thanks for your hard work!
Matt
Refresh button on the bottom right of your itunes podcast screen will cause instant updates.
(Na + K+ Mg + Ca) – (Cl + lactate) = Answer to the Ultimate Question of Life, the Universe, and Everything
(when SID is normal)
C
I thought 42 was the ultimate answer to everything; remember your towel.
Exactly (if you fudge the numbers a little)
😉
C
Scott,
No mp3 version????
Mike
Added inside the post, just for you Mike.
Thanks Scott,
I am I-literate! But I have a towel
Mike
Great first part of the acid-base lecture. In fact, great website overall.
I start 3rd year of med school in July, and these lectures will no doubt improve my understanding of medicine and what goes on in the hospital.
Thanks!
Zach, thanks for the feedback. Get back to us and let us know how this version of acid-base fits in to what you learned years 1-2.
scott
Here they teach us H-H pretty religiously. What’s CO2 doing? What’s bicarb doing? What’s the pH? A little bit on anion gap. It all stays pretty superficial, and every discussion leaves you wanting more.
So, it’s nice to get a fresh perspective on the topic. Thanks again.
Hey Scott:
I light of this paper, do you guys still use NS at Hurst, or are you prefering LR. Just curious.
This lecture is very helpful for my understanding of Acid/base coming from a 1st year. I really enjoy coming to the website to clarify and solidify many of the concepts we are covering in class.
thanks for the feedback, Christopher.
Hey Scott, a quick question (but afraid its a long answer)
When the SID is decreased by giving NS, where does the H+ come from? Why does the decreased SID really cause an acidosis? It can’t be from the H2CO3 dissociating to H+ as that would also increase your HCO3-, right? I have been reading everything on Stewart’s approach that we have access to (Kaplan, Morgan, etc) but no one really explains it (and we can’t get a copy of the Stewart paper).
Thanks
Austin
Short answer–
Go right to the source:
http://www.acidbase.org/index.php?show=sb&action=explode&id=22&sid=24
Stewarts book for free. Short answer is H+lives attached to water molecules just waiting to emerge.
My name is Olivier, MD at the university hospital of frankfurt.
So when you give diuretics (Furosemid, Torasemid) you will get low serum sodium leading to a small SID and thus acidosis but on the other hand there will be more sodium in the Collecting duct system in the kidney that will be taken into the principal cells causing a Transepithelial potential difference that will lead to H+ excretion by the H+-ATPase.
So will diuretics rather cause azidosis or alcalosis?
Hi Olivier,
it might not be a sound explanation but if you consider that the loop diuretics inhibit the NKCC which has a stoichometry of 1:1:2, you might loose more chloride than sodium and end up with a hypochloremic alkalosis.
I took this argument from this article in the NEJM: N Engl J Med. 2015 Jan 22;372(4):391-2
Is there any way of estimating how much a mild element of renal failure would account for a certain strong ion gap?
Could you use the urea / BUN value to calculate this?
nope
and mild shouldn’t do it. that usually causes SID effects. To cause SIG, there is significant renal damage
Hi Scott.
In addition to this, is it possible to add a ketone concentration to our ‘unmeasured anions’ (to ensure there are no other unmeasured anions other than ketones)?
I can’t find a way to do this. From what I’ve read, serum ketone testing only measures acetoacetate and the ratios of hydroxybutyrate:acetoacetate:acetone vary, so ketone measurement is only semi-quantitative. Is this correct?
Thanks,
Stacy
Dear Scott, I just discovered your great blog a few month ago and I’m trying to work my way through it now. Reading your Acid-Base-sheet I came up with a question with a question of no practical implications but i would be happy if someone could come up with a good explanation: You wrote that if the urine anion gap is negative one can rule out RTA. I found a paper (N Engl J Med. 2015 Jan 8;372(2):195 ) that put proximal RTA with a negative UAG. On the other hand Medline goes with you, on uptodate i could not… Read more »
Sir I have came across a case in which there was severe hyperlactatemia with normal ph in a patient with HCC for hepatectomy
Ph 7.392
Pco2 35.5
PO2 78
Hco3 23
Lactate 8
Albumin 4.37
Na 139
Cl 102
Phosphate not measured
How can we explain this
Expecting reply
Thanks
Hi Dr. Weingart, I am struggling to apply this to a recent patient with the following:
I am struggling to understand the discrepency.
by those numbers, there definitely needs to be some Unknown Cation. Metabolic Alkalosis from contraction, the Cl would have dropped in tandem with the increase in bicarb.