Acid−base disorders are common in the critically ill. Arterial blood gas (ABG) analysis is frequently used to identify and manage acid−base disturbances. Using a systematic problem-solving approach to acid−base disturbances will facilitate the identification and assess the progression and severity of the metabolic and respiratory abnormality. The intent of this review is to examine acid−base physiology and regulation, provide a method to evaluate a patient’s acid−base disorder, and provide therapeutic interventions.
HendersonLJ. The regulation of neutrality in the animal body. Science. 1913;37(950):389–395.
5.
CoreyHE. Stewart and beyond: new models of acid-base balance. Kidney Int. 2003;64(3):777–787.
6.
StewartPA.
How to understand acid-base: a quantitative acid-base primer for biology and medicine. New York, NY: Elsevier; 1981.
7.
WootenEW. Science review: quantitative acid-base physiology using the Stewart model. Crit Care. 2004;8(6):448–452.
8.
MartinL.
All you really need to know to interpret arterial blood gases. 2nd ed.Philadelphia, PA: Lippincott Williams & Wilkins; 1999.
9.
MortensenJD. Clinical sequelae from arterial needle puncture, cannulation, and incision. Circulation. 1967;35(6):1118–1123.
10.
GokelYPaydasSKoseogluZ. Comparison of blood gas and acid-base measurements in arterial and venous blood samples in patients with uremic acidosis and diabetic ketoacidosis in the emergency room. Am J Nephrol. 2000;20(4):319–323.
11.
BrandenburgMADireDJ. Comparison of arterial and venous blood gas values in the initial emergency department evaluation of patients with diabetic ketoacidosis. Ann Emerg Med. 1998;31(4):459–465.
12.
AkAOgunCOBayirA. Prediction of arterial blood gas values from venous blood gas values in patients with acute exacerbation of chronic obstructive pulmonary disease. Tohoku J Exp Med. 2006;210(4):285–290.
13.
KellyAMKerrDMiddletonP. Validation of venous pCO2 to screen for arterial hypercarbia in patients with chronic obstructive airways disease. J Emerg Med. 2005;28(4):377–379.
14.
KellyAMKyleEMcAlpineR. Venous pCO(2) and pH can be used to screen for significant hypercarbia in emergency patients with acute respiratory disease. J Emerg Med. 2002;22(1):15–19.
15.
WalkeyAJFarberHWO’DonnellC. The accuracy of the central venous blood gas for acid-base monitoring. J Intensive Care Med. 2010;25(2):104–110.
16.
WeilMHRackowECTrevinoR. Difference in acid-base state between venous and arterial blood during cardiopulmonary resuscitation. N Engl J Med. 1986;315(3):153–156.
17.
AARC clinical practice guideline. Sampling for arterial blood gas analysis. American Association for Respiratory Care. Respir Care. 1992;37(8):913–917.
18.
HarstenABergBInerotS. Importance of correct handling of samples for the results of blood gas analysis. Acta Anaesthesiol Scand. 1988;32(5):365–368.
19.
BoidinMPJornaP. Influence of different heparin solutions upon blood gas analysis and biochemical values measured in plasma. Intensive Care Med. 1984;10(5):255–260.
20.
AshwoodERKostGKennyM. Temperature correction of blood-gas and pH measurements. Clin Chem. 1983;29(11):1877–1885.
21.
CakarNTuorulMDemirarslanA. Time required for partial pressure of arterial oxygen equilibration during mechanical ventilation after a step change in fractional inspired oxygen concentration. Intensive Care Med. 2001;27(4):655–659.
22.
SherterCBJabbourSMKovnatDM. Prolonged rate of decay of arterial PO2 following oxygen breathing in chronic airways obstruction. Chest. 1975;67(3):259–261.
23.
HaberRJ. A practical approach to acid-base disorders. West J Med. 1991;155(2):146–151.
24.
NarinsRGEmmettM. Simple and mixed acid-base disorders: a practical approach. Medicine (Baltimore). 1980;59(3):161–187.
25.
MoeOWFusterD. Clinical acid-base pathophysiology: disorders of plasma anion gap. Best Pract Res Clin Endocrinol Metab. 2003;17(4):559–574.
26.
FiggeJJaborAKazdaA. Anion gap and hypoalbuminemia. Crit Care Med. 1998;26(11):1807–1810.
27.
StoryDAPoustieSBellomoR. Estimating unmeasured anions in critically ill patients: anion-gap, base-deficit, and strong-ion-gap. Anaesthesia. 2002;57(11):1109–1114.
28.
WinterSDPearsonJRGabowPA. The fall of the serum anion gap. Arch. Intern Med. 1990;150(2):311–313.
29.
CasalettoJJ. Differential diagnosis of metabolic acidosis. Emerg Med Clin North Am. 2005;23(3):771–787, ix.
30.
BrentJ. Fomepizole for ethylene glycol and methanol poisoning. N Engl J Med. 2009;360(21):2216–2223.
31.
BrentJMcMartinKPhillipsS. Fomepizole for the treatment of methanol poisoning. N Engl J Med. 2001;344(6):424–429.
32.
DuBoseTJJr. Acidosis and alkalosis. In: FauciASBraunwaldEIsselbacherKJWilsonGDMartinJBKasperDLHauserSLLongoDL, eds. Harrison's Principles of Internal Medicine. 14th ed. New York, NY: McGraw-Hill; 1998:277–286
33.
KitabchiAEUmpierrezGEMurphyMB. Hyperglycemic crises in patients with diabetes mellitus. Diabetes Care. 2003;26(suppl 1):S109–S117.
HenryGHaynesS.Isoniazid and other antituberculosis drugs. In: FordMDDelaneyKALingLJEricksonT, eds. Clinical Toxicology. Philadelphia, PA: WB Saunders; 2001:439–441
36.
PahlMVVaziriNDNessR. Association of beta hydroxybutyric acidosis with isoniazid intoxication. J Toxicol Clin Toxicol. 1984;22(2):167–176.
37.
BrownAMallettMFiserD. Acute isoniazid intoxication: reversal of CNS symptoms with large doses of pyridoxine. Pediatr Pharmacol (New York). 1984;4(3):199–202.
38.
MillsKCCurrySC. Acute iron poisoning. Emerg Med Clin North Am. 1994;12(2):397–413.
39.
RobothamJLLietmanPS. Acute iron poisoning. A review. Am J Dis Child. 1980;134(9):875–879.
40.
TenenbeinMKopelowMLdeSaDJ. Myocardial failure and shock in iron poisoning. Hum Toxicol. 1988;7(3):281–284.
41.
ForsytheSMSchmidtGA. Sodium bicarbonate for the treatment of lactic acidosis. Chest. 2000;117(1):260–267.
42.
NahasGGSutinKMFermonC. Guidelines for the treatment of acidaemia with THAM. Drugs. 1998;55(2):191–224.
GallaJH. Metabolic alkalosis. J Am Soc Nephrol. 2000;11(2):369–375.
50.
SabatiniS. The cellular basis of metabolic alkalosis. Kidney Int. 1996;49(3):906–917.
51.
JohnsonLRBarrettKEPhysiology of the Gastrointestinal Tract. 4th ed.Boston, MA: Elsevier Academic Press; 2006.
52.
EllisonDH. The physiologic basis of diuretic synergism: its role in treating diuretic resistance. Ann Intern Med. 1991;114(10):886–894.
53.
HropotMFowlerNKarlmarkB. Tubular action of diuretics: distal effects on electrolyte transport and acidification. Kidney Int. 1985;28(3):477–489.
54.
ChanYLBiagiBGiebischG. Control mechanisms of bicarbonate transport across the rat proximal convoluted tubule. Am J Physiol. 1982;242(5):F532–F543.
55.
GallaJHGiffordJDLukeRG. Adaptations to chloride-depletion alkalosis. Am J Physiol. 1991;261(4 pt 2):R771–R781.
56.
JacobsonHRSeldinDW. On the generation, maintenance, and correction of metabolic alkalosis. Am J Physiol. 1983;245(4):F425–F432.
57.
KurtzmanNA. Disorders of distal acidification. Kidney Int. 1990;38(4):720–727.
58.
SabatiniSKurtzmanNA. The maintenance of metabolic alkalosis: factors which decrease bicarbonate excretion. Kidney Int. 1984;25(2):357–361.
59.
LevitinHBranscomeWEpsteinFH. The pathogenesis of hypochloremia in respiratory acidosis. J Clin Invest. 1958;37(12):1667–1675.
60.
VerlanderJWMadsenKMTisherCC. Effect of acute respiratory acidosis on two populations of intercalated cells in rat cortical collecting duct. Am J Physiol. 1987;253(6 pt 2):F1142–F1156.
61.
PedroliGLiechti-GallatiSMauriS. Chronic metabolic alkalosis: not uncommon in young children with severe cystic fibrosis. Am J Nephrol. 1995;15(3):245–250.
62.
JonesJWSebastianAHulterHN. Systemic and renal acid-base effects of chronic dietary potassium depletion in humans. Kidney Int. 1982;21(2):402–410.
63.
KassirerJPLondonAMGoldmanDM. On the pathogenesis of metabolic alkalosis in hyperaldosteronism. Am J Med. 1970;49(3):306–315.
64.
LukeRGLevitinH. Impaired renal conservation of chloride and the acid-base changes associated with potassium depletion in the rat. Clin Sci. 1967;32(3):511–526.
65.
HeneRJKoomansHADorhout MeesEJ. Correction of hypokalemia in Bartter’s syndrome by enalapril. Am J Kidney Dis. 1987;9(3):200–205.
66.
ShaerAJ. Inherited primary renal tubular hypokalemic alkalosis: a review of Gitelman and Bartter syndromes. Am J Med Sci. 2001;322(6):316–332.
67.
SolomonSMKirbyDF. The refeeding syndrome: a review. JPEN J Parenter Enteral Nutr. 1990;14(1):90–97.
68.
Ventilation with lower tidal volumes as compared with traditional tidal volumes for acute lung injury and the acute respiratory distress syndrome.. The Acute Respiratory Distress Syndrome Network. N Engl J Med. 2000;342(18):1301–1308.
69.
FulmerJDSniderGL. American College of Chest Physicians (ACCP)—National Heart, Lung, and Blood Institute (NHLBI) Conference on oxygen therapy. Arch Intern Med. 1984;144(8):1645–1655.
70.
RotheramEBJrSafarPRobinE. CNS disorder during mechanical ventilation in chronic pulmonary disease. JAMA. 1964;189(13):993–996.
