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PAEP Renal > Metabolic Acidosis > Flashcards

Metabolic Acidosis Flashcards

1
Q

what is metabolic acidosis?

A

pH of blood < 7.35 due to an increase in H+, lactate, and organic acids OR a loss of HCO3-

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2
Q

what are 4 broad categories of metabolic acidosis?

A
  1. Increased H+ production
  2. Acid ingestion
  3. Bicarb losses via GI/renal
  4. Decreased H+ excretion
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3
Q

how do you calculate the serum anion gap?

A

AG = [Na] - ( Cl- + HCO3-)

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4
Q

what is the equation for urine anion gap?

A

urine Na + urine K - urine Cl

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5
Q

what unmeasured anions are typically major contributors to metabolic acidosis?

A

lactate and acetoacetate

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6
Q

what does HAGMA stand for?

A

High Anion Gap Metabolic Acidosis (HAGMA)

there is a gain of extra acidic anions

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7
Q

what does NAGMA stand for?

A

Normal Anion Gap Metabolic Acidosis (NAGMA)

there is a loss of bicarb or a failure of kidneys to excrete acid

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8
Q

what does HARDASS stand for re: NAGMA?

A

H - Hypercholeremia/Hyperalimentation
A - Addison’s Disease
R - Renal tubular acidosis
D - Diarrhea

A - Acetazolamide
S - Spironolactone
S - Saline infusion

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9
Q

Hypercholeremia and hyperalimentation cause NAGMA by increasing ___ which decreases ___ making the pH _____

A

increasing Cl-
decreasing HCO3-
decreases pH

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10
Q

Addison’s disease (adrenal insufficiency) causes NAGMA by not producing ________ (hormone) which impacts _____ (ion) resulting in _____ not being excreted

A

aldosterone
impacts Na+ ➔ more Na+ is being excreted than supposed to (salt wasting)
H+ not being moved into the tubule fluid and being excreted

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11
Q

Renal tubular acidosis causes NAGMA by the kidneys _____________ the acid

A

not being able to remove acid from the blood into urine for excretion

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12
Q

how does diarrhea cause NAGMA?

A

increased GI losses of bicarb = more acid in the blood = acidosis

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13
Q

How do carbonic anhydrase inhibitors cause NAGMA? what is one type/the name of one?

A

Causes an accumulation of carbonic acid ➔ acidifies the blood

A - Acetazolamide

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14
Q

How does spironolactone cause NAGMA?

A

spironolactone = aldosterone blocker → leaves Na+ in urine (not reabsorbed) → H+ cannot be excreted in urine

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15
Q

saline can cause NAGMA because _______

A

external infusion of more Cl- which leads to a decrease in HCO3-

and just more fluids = dilutional acidosis as there is no additional administration of HCO3-

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16
Q

how do you distinguish if a NAGMA is from a GI (diarrhea) or renal loss (renal tubular acidosis) of bicarb?

A

use the urine anion gap

if gap is positive/normal = renal tubular acidosis ➔ doesn’t change because the kidneys are not able to compensate for the bicarb loss

if gap is negative/low = diarrhea ➔ bc the kidneys are still able to try to compensate for the loss of bicarb, so its increasing ammonium excretion

17
Q

what does GOLDMARK stand for re: HAGMA?

A

G - Glycols
O - Oxoproline - chronic acetaminophen use
L - L-lactate
D - D-lactate → very rare, usually have hx of short bowel syndrome
M - Methanol - organic alcohol
A - Aspirin/ASA
R - Renal Failure (Uremia)
K - Ketoacidosis

18
Q

how do glycols cause HAGMA?

A

they are metabolized into acid, which acidifies the blood ➔ lowers the pH

19
Q

real-life examples of glycols (ethylene glycol and propylene glycol) are?

A

antifreeze, brake fluid, paints

20
Q

what medication is associated with Oxoproline (pyroglutamic acid)?

A

acetaminophen

21
Q

how does oxoproline cause HAGMA?

A

it’s also known as pyroglutamic acid, and is an organic acid that can accumulate and acidify the blood

22
Q

how does L-lactate and D-lactate cause HAGMA?

A

D-lactacte, can be broken down into other organic acids by bacteria in the colon ➔ more seen in pts with short gut syndrome

L-lactate is a byproduct of normal metabolic ➔ lactic acid

both cases accumulation = additional organic acids = pH lowers

23
Q

what is methanol? how does it cause HAGMA?

A

organic alcohol

converted into formic acid ➔ accumulate acid ➔ pH lowers

24
Q

how does ASA cause HAGMA?

A

stops the electron transport chain in mitochondria ➔ build-up of lactic acid ➔ pH lowers

25
Q

how does renal failure/uremia cause HAGMA?

A

injury to kidney ➔ not able to excrete acid anions ➔ accumulation ➔ pH lowers

26
Q

why does renal tubular acidosis cause NAGMA and renal failure/uremia cause HAGMA?

A

renal tubular acidosis ➔ only problem with tubules, so only a defect with ability to acidify the urine and excrete acid ➔ there is balance because some level of hyperchloremia as well (negative Cl and positive H)

renal failure/uremia ➔ problem with both glomeruli and tubules ➔ so low excretion of acid and also low reabsorption of HCO3 ➔ HAGMA, larger anion gap bc additional acids not getting excreted

27
Q

how do ketones cause metabolic acidosis?

A

ketones are broken down into excess hydrogen ions ➔ binds up bicarb ➔ decreased bicarb ➔ decreased pH

28
Q

what states can cause ketoacidosis for metabolic acidosis?

A

diabetic, alcoholic, and starvation

29
Q

alcohol causes ketoacidosis because it inhibits the body’s ability to _____ forcing the body to make ketones

A

produce glucose

30
Q

starvation causes ketoacidosis because ____ in the body so it’s forced to make ketones

A

no glucose

31
Q

what s/s might you see for acidosis?

A
  • hyperventilation to remove CO2 ➔ respiratory compensation to increase the pH (Kussmaul)
  • altered mental status ➔ confusion
  • tachycardia
  • electrolyte imbalances
  • N/V, abdo pain
32
Q

what is the major risk of having hyperkalemia with metabolic acidosis?

A

cardiac arrhythmias

33
Q

how would you treat a metabolic acidosis?

A
  1. correct the underlying cause ➔ consider antidotes for toxicities, dialysis, abx, insulin/glucose, thiamine (alcohol/starvation) and bicarbonate solutions
  2. fluid resuscitation
  3. correct electrolyte abnormalities
34
Q

what are some ways you can correct hyperkalemia?

A
  • IV insulin and IV glucose
  • inhaled albuterol (Ventolin)
  • Dialysis ➔ AEIOU

bicarb or resins are not recommended for routine use if other options haven’t been explored yet

35
Q

what is the AEIOU for dialysis?

A

A - acidosis
E - electrolyte imbalances
I - intoxications
O - overload fluid
U - uremia

36
Q

what are the main AEs we’re concerned about when there is acute metabolic acidosis (2)?

A

heart: decreased cardiac output and arterial dilation w/ hypotension and poor oxygen delivery ➔ arrhythmias
immune: impaired immune response

37
Q

what are the main AEs are we concerned about for chronic metabolic acidosis? (2)

A

muscle degradation
abnormal bone metabolism

PAEP Renal (11 decks)

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