chapter 48. quiz 3. Respiratory Acidosis and Alkalosis in Perioperative Medicine
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What is a common cause of acute respiratory acidosis in perioperative medicine?

  • Excessive mechanical ventilation
  • Rapid deep breathing
  • Normal respiratory drive
  • Increased dead space ventilation (correct)

    • How is acute respiratory acidosis manifested in patients in the recovery room?

  • Elevated PaCO2 (correct)
  • Decreased HCO3−
  • Sudden increase in pH
  • Fast and deep breathing

    • What does slow shallow breathing in a patient signify according to the text?

  • Chest wall or lung pathology
  • Normal respiratory function
  • Airway obstruction
  • Impaired respiratory drive (correct)

    • In perioperative medicine, what can lead to respiratory alkalosis?

    <p>excessive mechanical ventilation</p> Signup and view all the answers

    What should be the expected value of Base Excess (BE) in the context of acute respiratory acidosis?

    <p>Zero</p> Signup and view all the answers

    During laparoscopy, CO2 insufflation might lead to ?

    <p>respiratory acidosis</p> Signup and view all the answers

    What is the expected baseline PaCO2 for a patient with a total CO2 of 30 mEq/L?

    <p>60 mm Hg</p> Signup and view all the answers

    In a patient with a postoperative PaCO2 of 90 mm Hg and total CO2 of 35 mEq/L, what condition is indicated?

    <p>acute or chronic respiratory acidosis</p> Signup and view all the answers

    What might be a cause of acute respiratory alkalosis?

    <p>Hyperventilation due to anxiety</p> Signup and view all the answers

    How much does the [HCO3−] fall for every 10 mm Hg fall in PaCO2 in acute respiratory alkalosis?

    <p>2 mEq/L</p> Signup and view all the answers

    What may result in respiratory acidosis in a patient with abdominal hypertension?

    <p>Failure to ventilate due to high intraabdominal pressures</p> Signup and view all the answers

    In a patient with lactic acidosis and a lactate level of 10 mEq/L, what should the BE be?

    <p>-10</p> Signup and view all the answers

    What does the reduction in PCO2 from baseline equate to in acute metabolic acidosis?

    <p>Magnitude of the base deficit</p> Signup and view all the answers

    What happens to PaCO2 in a multi-trauma patient with massive blood loss and lactic acidosis?

    <p>Increases</p> Signup and view all the answers

    What is the expected baseline total CO2 for a patient with chronic respiratory failure and PaCO2 of 50 mm Hg?

    <p>27 mEq/L (mmol/L)</p> Signup and view all the answers

    patient arrive to PACU from OR with respiratory distress, what is the first thing to do for management?

    <p>examination of the patient’s breathing pattern</p> Signup and view all the answers

    rapid shallow breathing suggests

    <p>chest wall or lung pathology</p> Signup and view all the answers

    For patient with chronic respiratory failure, for intraoperative management, the etCO2 should be maintained

    <p>between 3 and 5 mm Hg of baseline</p> Signup and view all the answers

    respiratory acidosis due to patient “won’t breathe” can be due to

    <p>neurologic injury</p> Signup and view all the answers

    patients with acute metabolic acidosis characterized by?

    <p>pH &lt; 7.35 with fall in PaCO2 and (HCO3−)</p> Signup and view all the answers

    Which condition results in a negative base excess (BE) in the context of metabolic acidosis?

    <p>Diabetic ketoacidosis</p> Signup and view all the answers

    What is the primary purpose of using the Anion Gap (AG) in evaluating metabolic acidosis?

    <p>To differentiate hyperchloremic acidosis from other causes</p> Signup and view all the answers

    What change in PaCO2 is typically observed in patients without COPD or chronic CO2 retention in acute metabolic acidosis?

    <p>PaCO2 &lt; 40 mm Hg</p> Signup and view all the answers

    What characterizes a metabolic acidosis that is metabolic in origin according to the text?

    <p>[HCO3−] below 24 mEq/L</p> Signup and view all the answers

    What is the recommended action if plasma lactate does not fall after fluid resuscitation?

    <p>Discontinue fluid resuscitation</p> Signup and view all the answers

    In lactic acidosis, why is the presence of good overall oxygen delivery and normal consumption not reassuring?

    <p>It may mask underlying conditions like bowel ischemia</p> Signup and view all the answers

    when should D-lactate levels be measured ?

    <p>in post major abdominal surgery</p> Signup and view all the answers

    What is a significant risk factor for metformin-associated lactic acidosis?

    <p>Renal impairment</p> Signup and view all the answers

    What is the mechanism through which metformin may induce lactic acidosis?

    <p>impair oxidative metabolism in hepatocyte mitochondria</p> Signup and view all the answers

    What is the recommended treatment for patients with metformin-associated lactic acidosis?

    <p>Withdraw the drug and provide gentle rehydration</p> Signup and view all the answers

    What is the primary cause of lactic acidosis?

    <p>Overproduction of lactate</p> Signup and view all the answers

    Which isoform of lactate can only be produced by fermentation by bacteria?

    <p>D-lactate</p> Signup and view all the answers

    What is the main function of lactate in isotonic fluids like lactated Ringer’s solution?

    <p>To act as a buffer</p> Signup and view all the answers

    Under what conditions does lactate metabolism lead to gluconeogenesis?

    <p>In aerobic conditions</p> Signup and view all the answers

    Plasma lactate and arterial pH should be measured early in any critically ill patient—it is now a diagnostic component of

    <p>Septic shock</p> Signup and view all the answers

    In which type of lactic acidosis does global inadequate oxygen delivery play a significant role?

    <p>Type 1 (type A)</p> Signup and view all the answers

    What is a characteristic feature of type 2 (type B) lactic acidosis?

    <p>Associated with cyanide poisoning</p> Signup and view all the answers

    What is a common association with type 2 lactic acidosis?

    <p><em>Excess circulating catecholamines</em></p> Signup and view all the answers

    Under normal conditions, the ratio of lactate to pyruvate is

    <p>less than 20:1</p> Signup and view all the answers

    Persistence of lactic acidosis strongly predicts

    <p>poor outcomes in acute illness</p> Signup and view all the answers

    What are the three types of ketone bodies?

    <p>Acetone, acetoacetate, β-hydroxybutyrate</p> Signup and view all the answers

    What type of acid-base disorder can be associated with increased acetone levels in the body?

    <p>Metabolic acidosis</p> Signup and view all the answers

    What is a potential consequence of untreated ketoacidosis in a patient?

    <p>Hypokalemia</p> Signup and view all the answers

    What role do ketone bodies play in the body during fasting or starvation?

    <p>Primary source of energy for the brain and heart</p> Signup and view all the answers

    what is the most abundant Ketone bodies

    <p>3-β-hydroxybutyrate (βOHB</p> Signup and view all the answers

    During ketogenesis, acetoacetate is generated from

    <p>acetyl co-enzyme</p> Signup and view all the answers

    in which amount the ketones are found normally in blood and urine ?

    <p>undetectable</p> Signup and view all the answers

    in starvation or low-carbohydrate diets, what is the primary ketones found in blood

    <p>3-β-hydroxybutyrate (βOHB)</p> Signup and view all the answers

    in starvation or low-carbohydrate diets, what is the primary ketones found in urine

    <p>acetoacetate</p> Signup and view all the answers

    dramatic increase in circulating ketones occurs. most commonly occur in

    <p>insulin deficiency (DM)</p> Signup and view all the answers

    The diagnosis of DKA.is confirmed by?

    <p>ABG analysis.</p> Signup and view all the answers

    What may lead physicians to miss ketoacidosis in patients presenting for emergency surgery?

    <p>Elevated lactate levels resulting in search satisficing</p> Signup and view all the answers

    What inappropriate therapies may be administered to a patient with unresolved acidosis in ketoacidosis?

    <p>Renal replacement therapy and sodium bicarbonate</p> Signup and view all the answers

    What is a key treatment requirement for all forms of ketoacidosis, including non-diabetic cases?

    <p>insulin administration</p> Signup and view all the answers

    In what time frame can ketoacidosis of non-diabetic origin take to resolve?

    <p>Hours, and occasionally days</p> Signup and view all the answers

    What scenario may cause urinary ketones to increase while whole-body ketone load is falling during the resolution of ketosis?

    <p>Acetoacetate metabolism</p> Signup and view all the answers

    What is the primary purpose of administering IV dextrose in the management of DKA?

    <p>To assist ketone metabolism</p> Signup and view all the answers

    In the management of DKA, what is a significant benefit of using Plasmalyte-148 compared to normal saline (NS)?

    <p>Improved blood pressure profile</p> Signup and view all the answers

    Why is it important to measure blood ketones rather than relying solely on urinary ketone sticks for diagnosing ketoacidosis?

    <p>Urinary ketone sticks only detect acetoacetate, not all ketones</p> Signup and view all the answers

    What is the effect of insulin on ketone production in the context of DKA?

    <p>Suppresses ketone production</p> Signup and view all the answers

    How does the majority of ketones exist in the body during a state of ketoacidosis?

    <p>As βOHB only</p> Signup and view all the answers

    What is a major error often made in DKA management due to misinterpretation?

    <p>Mistaking hyperchloremic acidosis for persistent ketoacidosis</p> Signup and view all the answers

    What is the primary source of acidosis early in acute kidney injury (AKI)?

    <p>Chloride</p> Signup and view all the answers

    Which electrolyte accounts for up to 30% of the acidosis associated with AKI?

    <p>Phosphate</p> Signup and view all the answers

    What percentage of patients with AKI in critical illness have a normal Anion Gap (AG)?

    <p>50%</p> Signup and view all the answers

    In perioperative medicine, AKI may accompany all of the following EXCEPT:

    <p>Liver failure</p> Signup and view all the answers

    Which of the following is NOT a symptom associated with metabolic acidosis in AKI?

    <p>Hypokalemia</p> Signup and view all the answers

    What is key to the diagnosis, severity, and therapeutic strategy in AKI?

    <p>Identification of metabolic acidosis</p> Signup and view all the answers

    How is renal acidosis usually diagnosed?

    <p>By excluding ketones and lactate</p> Signup and view all the answers

    What is a key decision step regarding RRT ?

    <p>hyperkalemia</p> Signup and view all the answers

    How is hyperchloremia typically related to renal acidosis?

    <p>It accompanies renal acidosis</p> Signup and view all the answers

    What can be a temporary control method for renal acidosis?

    <p>Sodium bicarbonate administration</p> Signup and view all the answers

    What is the risk associated with delaying Renal Replacement Therapy (RRT) in critical illness?

    <p>4.7% increase in mortality at 90 days</p> Signup and view all the answers

    Which solution was demonstrated to lead to more acidosis and hyperkalemia in anephric patients undergoing renal transplantation?

    <p>normal saline solution</p> Signup and view all the answers

    What is one of the major excretory roles of the kidney?

    <p>Excreting more chloride than sodium</p> Signup and view all the answers

    What is the consequence of renal failure in relation to chloride levels?

    <p>Chloride accumulates</p> Signup and view all the answers

    What is the approximate amount of chloride excretion per day to maintain electrical neutrality?

    <p>15 to 20 mmol</p> Signup and view all the answers

    What is the primary component of isotonic saline solution (normal saline, NS)?

    <p>Chloride</p> Signup and view all the answers

    What is the metabolic load increase for the kidney when administering 1 liter of NaCl 0.9% to a patient?

    <p>8 to 10-fold increase</p> Signup and view all the answers

    Why is high circulating chloride nephrotoxic according to the text?

    <p>reduced renal blood flow</p> Signup and view all the answers

    What is the effect of hyperchloremia on mortality in critically ill patients with acid-base disorders, according to the text?

    <p>Mortality rates are lowest for hyperchloremic acidosis compared to lactic acidosis and SIG acidosis.</p> Signup and view all the answers

    What is a potential outcome difference between intravenous saline and balanced salt solutions (BSS) in surgical patients?

    <p>Intravenous saline increases the risk of blood transfusions compared to BSS.</p> Signup and view all the answers

    What is a potential consequence of a hyperchloremic state in relation to renal function?

    <p>Renal vasoconstriction and hypoperfusion.</p> Signup and view all the answers

    What was the outcome of a before-and-after cohort study comparing chloride-rich fluids to balanced salt solutions (BSS) in an Australian ICU?

    <p>Chloride-rich fluids were associated with a 3.7% absolute increase in the risk for RRT relative to BSS.</p> Signup and view all the answers

    What is a common cause of metabolic alkalosis in perioperative patients?

    <p>Loss of chloride-rich fluids from the GI tract</p> Signup and view all the answers

    Why are isotonic fluids usually administered in perioperative fluid therapy?

    <p>To prevent cerebral edema</p> Signup and view all the answers

    What is a challenge associated with acquired hypernatremia in perioperative patients?

    <p>Difficult to treat and linked to adverse outcomes</p> Signup and view all the answers

    Why are balanced salt solutions (BSSs) considered safer than normal saline (NS) for resuscitation?

    <p>They are less likely to cause hypernatremia</p> Signup and view all the answers

    What is the primary cause of metabolic alkalosis in patients with over ventilation-induced acute metabolic alkalosis?

    <p>Increased SID due to sodium gain</p> Signup and view all the answers

    How is chloride-sensitive alkalosis, induced by sodium gain, best treated?

    <p>Administration of potassium chloride</p> Signup and view all the answers

    Which ion is responsible for 'chloride-sensitive' alkalosis ?

    <p>Sodium</p> Signup and view all the answers

    How does the administration of large volumes of BSSs contribute to metabolic alkalosis?

    <p>ATOT dilution</p> Signup and view all the answers

    Which condition may result from ineffective treatment of chloride-sensitive alkalosis?

    <p>Respiratory acidosis</p> Signup and view all the answers

    What is the primary adverse effect of not correcting chloride-sensitive alkalosis in patients during perioperative care?

    <p>'CO2 narcosis'</p> Signup and view all the answers

    What is the most common single disturbance in acid-base in critically ill patients?

    <p>Hypoalbuminemia</p> Signup and view all the answers

    Which acid-base disturbance may be masked by hypoalbuminemia in critically ill patients?

    <p>Lactic acidosis</p> Signup and view all the answers

    What additional metabolic alkalosis may be induced by prolonged respiratory failure in critically ill patients?

    <p>Alkalosis due to chloride loss in urine</p> Signup and view all the answers

    What might be a significant consequence of late polyuric renal failure in critically ill patients?

    <p>Contraction alkalosis</p> Signup and view all the answers

    In critically ill patients, what is vulnerable to significant changes and may indicate fluid shifts?

    <p>Strong Ion Difference (SID)</p> Signup and view all the answers

    What may be associated with hypercarbia-induced metabolic alkalosis in the context of respiratory failure?

    <p>Chloride loss</p> Signup and view all the answers

    What electrolyte imbalance may be provoked by loop diuretics like furosemide in critically ill patients?

    <p>contraction alkalosis</p> Signup and view all the answers

    Which therapy may lead to a metabolic acidosis similar to that caused by ethylene glycol ingestion due to its dilution in propylene glycol?

    <p>Lorazepam</p> Signup and view all the answers

    What effect might continuous renal replacement therapy (CRRT) have on a metabolic alkalosis in the presence of hypoalbuminemia?

    <p>unmask a metabolic alkalosis</p> Signup and view all the answers

    What electrolyte disturbance is commonly associated with the administration of isotonic saline solution (normal saline, NS) in neurosurgical patients?

    <p>Hyperchloremic acidosis</p> Signup and view all the answers

    Which electrolyte abnormality may be treated with carbonic anhydrase inhibitors like acetazolamide?

    <p>Hypochloremia</p> Signup and view all the answers

    How does surgery with drains placed in tissue beds contribute to electrolyte disturbances?

    <p>By increasing sodium levels through drainage fluid</p> Signup and view all the answers

    What is the primary treatment for diabetic ketoacidosis according to the text?

    <p>Insulin, IV fluid, and glucose</p> Signup and view all the answers

    How is hyperchloremic acidosis commonly managed based on the text?

    <p>Sodium bicarbonate (NaHCO3-) administration</p> Signup and view all the answers

    What is the main treatment approach for acute kidney injury (AKI) according to the text?

    <p>Dialysis and ultrafiltration</p> Signup and view all the answers

    How does sodium bicarbonate (NaHCO3-) impact respiratory acidosis based on the text?

    <p>Exacerbates respiratory acidosis despite increased strong ion difference (SID)</p> Signup and view all the answers

    Which of the following scenarios can lead to increased intracellular acidosis according to the text?

    <p>Usage of sodium bicarbonate (NaHCO3-)</p> Signup and view all the answers

    Why is NaHCO3- commonly used to treat hyperchloremic acidosis according to the text?

    <p>To widen the strong ion difference (SID)</p> Signup and view all the answers

    What is a potential benefit of NaHCO3− therapy as discussed in the text?

    <p>Improved kidney blood flow</p> Signup and view all the answers

    How is contraction alkalosis typically treated according to the text?

    <p>Correcting free water deficit</p> Signup and view all the answers

    What is a possible speculation for the reduction in need for renal replacement therapy with NaHCO3− therapy?

    <p>Delayed decision to start RRT</p> Signup and view all the answers

    How is respiratory alkalosis typically managed in the perioperative period?

    <p>Treating the underlying cause</p> Signup and view all the answers

    What is a common cause of metabolic alkalosis in critically ill patients according to the text?

    <p>Hypoalbuminemia</p> Signup and view all the answers

    How is hypercarbic acidosis typically reversed according to the text?

    <p>Increasing tidal volume</p> Signup and view all the answers

    What is a potential consequence of a hyperchloremic state on renal function as discussed in the text?

    <p>Decreased glomerular filtration rate</p> Signup and view all the answers

    What is a recommended treatment for hypochloremic alkalosis as per the text?

    <p>Correcting chloride deficit using IV solutions</p> Signup and view all the answers

    What is an appropriate approach to managing hypercarbic acidosis associated with ARDS according to the text?

    <p>Tolerating hypercarbia ('permissive hypercarbia')</p> Signup and view all the answers

    Study Notes

    Respiratory Acidosis and Alkalosis

    • Acute respiratory acidosis results from hypoventilation or increased dead space ventilation.
    • Causes of respiratory acidosis: • Excessive sedation (particularly opioids) • Partial neuromuscular blockade • Intraoperative hypoventilation • Pneumothorax • CO2 insufflation during laparoscopy
    • Blood gas analysis of acute respiratory acidosis: • pH falls dramatically • PaCO2 elevates • HCO3- rises by 1 mEq/L (mmol/L) for every 10 mm Hg (1.3 kPa) rise in PaCO2 • BE is zero

    Patients with Chronic Respiratory Failure

    • Calculate baseline PaCO2 from total CO2 on blood chemistry panel
    • Total CO2 (HCO3-) rises by 3 mEq/L (mmol/L) for every 10 mm Hg (1.3 kPa) rise in PaCO2
    • For intraoperative management, maintain etCO2 between 3 and 5 mm Hg (0.5 –1 kPa) of baseline

    Acute Respiratory Alkalosis

    • Caused by hyperventilation, either due to: • Anxiety or pain • Central respiratory stimulation (e.g., early in salicylate poisoning) • Excessive artificial ventilation
    • Blood gas analysis of acute respiratory alkalosis: • pH is above 7.45 • PaCO2 is below 40 mm Hg (5.3 kPa) • HCO3- falls by 2 mEq/L (mmol/L) for every 10 mm Hg (1.3 kPa) fall in PaCO2 • No change in BE

    Metabolic Acidosis and Alkalosis

    Metabolic Acidosis

    • Acute metabolic acidosis caused by: • Alteration in SID or ATOT • Alteration in the relative quantity of strong anions to strong cations
    • Characteristics of acute metabolic acidosis: • pH < 7.35 • Fall in both PaCO2 and HCO3- below the patient's baseline • Negative BE (base deficit) whose magnitude represents the net strong anion gain
    • Tools to investigate metabolic acidosis: • Anion gap (AG) • Osmolar gap • Serum creatinine • Direct measurement of anions (e.g., lactate, ketones, phosphate, albumin)

    Lactic Acidosis

    • Lactic acidosis is a marker of acute critical illness
    • Lactic acidosis occurs when the production of lactate is greater than the liver's capacity to clear it
    • Causes of lactic acidosis: • Type 1 (type A): hypovolemic/hemorrhagic shock • Type 2 (type B): despite normal global oxygen delivery and tissue perfusion
    • Lactic acidosis may develop in situations with significant regional hypoperfusion
    • Lactic acidosis is a sensitive marker of disease severity
    • Persistence of lactic acidosis strongly predicts poor outcomes in acute illness

    Ketoacidosis

    • Ketoacidosis is caused by: • Inadequate insulin • Increased glucagon • Increased cortisol • Increased catecholamines
    • Management of DKA: • Insulin administration • Resuscitation with isotonic crystalloid • Administration of IV dextrose when blood glucose falls within a "controlled" range
    • Two major mistakes in the management of DKA: • Administration of 0.9% NaCl results in hyperchloremic acidosis • Measuring urinary ketones instead of blood ketones

    Renal Acidosis

    • Renal acidosis is caused by: • AKI • Hyperchloremia • Hyperphosphatemia • UMA
    • Characteristics of renal acidosis: • Widened AG • Base deficit gap • SIG • Exclusion of ketones and lactate
    • Key decision step regarding RRT: • Uncontrolled hyperkalemia
    • Renal acidosis can be temporarily controlled by: • Administration of sodium bicarbonate • Increasing the SID### Hyperchloremic Acidosis
    • The extracellular space contains approximately 58 g of Na+ and 65 g of Cl- for a 70 kg male.
    • The body needs to excrete 30% more Cl- than Na+ to maintain the normal ratio of Na+ to Cl- (1.4:1), which is one of the major excretory roles of the kidney.
    • In renal failure, Cl- accumulates, leading to early metabolic acidosis associated with AKI.

    Metabolic Alkalosis

    • Perioperative fluid therapy is highly controversial, and the administration of isotonic fluids can result in large amounts of solute, including sodium and chloride, accumulating in the extravascular space.
    • Acquired hypernatremia is associated with adverse clinical outcomes and is difficult to treat.
    • Metabolic alkalosis is often of iatrogenic origin, particularly in perioperative patients, and can be caused by over-ventilation, sodium gain, and loss of Cl- rich fluids from the GI tract.

    Acid-Base Disturbances in Critical Illness

    • Critically ill patients may have multiple confounding acid-base disturbances that are not evident when only a single quantitative measure, such as base deficit, is employed.
    • The most common single disturbance in acid-base in critically ill patients is hypoalbuminemia, which causes a metabolic alkalosis of unpredictable magnitude.
    • Kidney injury is associated with accumulation of metabolic byproducts, leading to metabolic acidosis.

    Treating Acid-Base Disturbances

    • Acid-base disturbances are clinical indicators of disease processes that are more harmful than hydrogen ion abnormalities themselves.
    • Correcting the pH is usually unlikely to resolve the problem, except in certain circumstances, such as hyperkalemia in AKI, where acidosis is the major cause of the problem.
    • Treatment of acid-base abnormalities is determined by whether the acids are organic or mineral acids.
    • Sodium bicarbonate (NaHCO3-) has been used to “correct” acidosis, but its benefits are unclear, and it may have drawbacks such as sodium and volume overload, metabolic alkalosis, hypertension, and hypocalcemia.

    Specific Treatment Strategies

    • Hyperchloremic acidosis can be treated with IV sodium bicarbonate, which corrects the base deficit, but the benefit is unclear.
    • Metabolic alkalosis can be treated by correcting the chloride deficit using NS or LR, or by correcting the free water deficit using a specific formula.
    • Respiratory alkalosis can be treated by reducing minute ventilation, and hypochloremic alkalosis can be treated by correcting the chloride deficit using NS or LR.
    • Hypercarbic acidosis can be treated by increasing minute ventilation, but in ARDS, permissive hypercarbia may be necessary to avoid ventilator-induced lung injury.

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    Explore the concepts of respiratory acid-base abnormalities in the context of perioperative medicine, focusing on complications related to prolonged spontaneous breathing under anesthesia and inadequate or excessive mechanical ventilation. Learn about acute respiratory acidosis from hypoventilation and increased dead space ventilation.

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