so welcome to part 6 of acid-base

disorders and this is where it all sort of comes together at this point where

we’re looking at the questions and we’re going to go through a specific order and

hopefully we stick to that order we’ll be able to figure out any acid-base

question they’ll throw at us remember the form that we’re going to follow is

for the ABG okay we’re going to have the pH first okay then the pco2 second

followed by the po2 and then the bicarb I’ll last there and for the chem seven

remember we’re always going to have this sort of a pattern we’ll see that over

and over again with the sodium potassium chloride and the hco3 – we’re not really

going to be talking about the blood urea nitrogen the Kratt Neen or the glucose

so we’ll just focus on these areas right there okay so let’s throw the screen and

let’s go ahead with our first question so first hand the someone gives you a

blood gas and the pH is 7 point 4 7 / 29 / 94 okay

and the bicarb in this case is 22 we can also pick that on the chem 7 let’s go

ahead and give you the chem 7 and the chem 7 is 1:40 and the potassium is 4.0 the

chloride is 106 and against a winch and the bicarb is 22 so what’s the very

first step that you need to do very first step that you need to do is number

one calculate the anion gap this is always going to be the first step the

reason why this is the first step is because remember if you have an anion

gap then you always have an anti gap metabolic acidosis so that will tell you

first off so what is the anion gap it’s going to be 140 minus the addition of

these two so 106 plus 22 is 128 so 140 minus 128 is equal to 12 now we’re going

to assume here for all of these answers that everyone has a normal albumin

remember that you could calculate what someone’s out anion gap should be based

on their albumin simply by multiplying their albumin times three

normal albumin is 4 so 3 times 4 is 12 and so we’ll always assume that the

normal ni gap should be equal to 12 so the patient has an anti gap of 12

therefore the Delta gap which is the second thing that we calculate or the

next thing the Delta gap is simply the anion gap which is 12 minus 12 always

okay so we always take 12 away from the NI gap and our Delta gap is zero that

means that there is no anion gap metabolic acidosis is occurring none

that’s very important okay all right so next next step is number two okay with

number two we look to second rule which is look at the pH and the pco2

and if they’re going in the same direction it’s a metabolic process and

if they’re going in different directions it’s a respiratory process here the pH

is going up from seven point four zero and here the pco2 is going down from a

PCO to of 40 they’re going in different directions

therefore we know this must be a respiratory problem and is it a

respiratory alkalosis or respiratory acidosis well it must be a respiratory

alkalosis because the pH is greater than seven point four five

it’s higher than seven point four zero so it’s a respiratory alkalosis now

there’s two types of respiratory alkalosis there’s a chronic and there is

an acute okay chronic and acute so the question is

which one of these two are we dealing with for that we need to use winters

formula remember if you look back at our previous lectures in a chronic

respiratory alkalosis in a chronic respiratory alkalosis the bicarbonate

will drop hco3 one unit for every two units that the pco2 drops okay in an

acute respiratory alkalosis remember that for every drop that the

pco2 does or specifically for every five units that the pco2 drops the bicarb is

only going to drop by one point and why is that because this is an acute

respiratory alkalosis so it’s going to drop more before the bicarb kicks in

because it’s acute the kidney doesn’t have a chance to kick in whereas in a

chronic state the pco2 is going to drop by less before the pco2 goes down so

let’s look and see in terms of bicarb and pco2 where we are you’ll see here

that the pco2 went from 40 down to 29 now that is a drop of about 11 so the

pco2 actually dropped by 11 points how much did the bicarb drop by normal is 24

so it dropped by about two points so which one of these ratios does this fit

better does it fit better under the chronic or does it fit better under the

acute you can see that it fits better under the acute because it follows that

ratio more carefully a two over eleven is very similar to one over five

therefore the answer is that this is an acute respiratory alkalosis okay let’s go on to the next question

suppose we have a pH of seven point four to twenty nine 94 and bicarb of nineteen

and we have a chem-7 here which is 140 over four point zero one ten over

nineteen let’s go ahead and do it our first step which is to calculate the

anion gap okay so remember we’re going to add up these two numbers here which

is the chloride and the bicarbonate which in this case is 129 and subtract

it from 140 so we get an anion gap of 11 which is about 12 which is normal so our

Delta gap is actually negative one in this case which is close to zero so

there’s no anion gap metabolic acidosis number two we look at the pH and the

pco2 and remember if they’re going in the same direction its metabolic if

they’re going in different directions its respiratory here the pH is going up

from seven point four zero the pco2 is going down to going in opposite

directions it must be respiratory and in this case it must be a respiratory

alkalosis since the pH is alkyl emic slightly so it’s a respiratory alkalosis

again is it an acute or is it chronic respiratory alkalosis and for that we

need to look at winters formulas once again remember in in the alcohol in the

respiratory alkalosis acute for every drop

in the pco2 of five there was a drop in the bicarb of one and then for chronic

the ratio was for every two that dropped in the pco2 the bicarb dropped one okay

so let’s take a look here and see how much did our bicarb draw our bicarb

dropped by about five points I went from normal of twenty four down

to nineteen so a ratio is a five on the top that it dropped how much that our

pco2 drop well it dropped by about eleven points because it went from about

a forty which is normal down to a twenty-nine so that’s our ratio now

which one does that most look like does it look like the acute or does it look

like the chronic you can see here that that looks more like the chronic and so

this is a chronic respiratory alkalosis let’s go into the next question

pH of seven point two six sixty fifty-five and a bicarb of twenty six

again let’s do our little chem seven sodium here one forty potassium 4.0

chloride is 110 I’m sorry let’s do let’s make it 104 and the bicarb is again

twenty-six what’s our first step that we need to do you’ve got it got to

calculate the anion gap and I gap here 104 plus 126 is 130 and 131 40 is 10 so

the anion gap is equal to 10 which again is

essentially normal there’s no increase ni gap Delta gap if you want to

calculate it would be around negative two anyway for the most part there is no

anion gap metabolic acidosis so we go on to number two

and that’s when we look at the pH and the pco2

here the pH is definitely going down and here the PA or the pco2 is definitely

going up again we’ve got opposite problems opposite directions and so what

we have here is a respiratory acidosis no question about that but you’ll

remember there’s two types of respiratory acidosis there’s an acute

respiratory acidosis and a chronic respiratory acidosis and you’re

recalling the acute respiratory acidosis for every increase in the pco2 by 10 the

bicarb goes up by 1 and in the chronic respiratory acidosis for every increase

in the pco2 that goes up by 3 the bicarb goes up by 1 why is that again because

in the acute remember the kidney doesn’t have a chance to compensate so you’re

going to have a much higher rise in co2 before the kidney kicks in then you will

in the chronic so let’s put that to the test here with our specific question how

much of the bicarb go up by well we see here

normal is 24 it went up by 2 points so we’ll put a 2 there and how much that RP

co2 go up well it went up by about 20 because normal is 40 so the question is

what ratio does this most look like and you can see 2 over 20 is most like 1

over 10 therefore this must be an acute respiratory acidosis okay let’s go

through it again let’s do another question here we have a pH as equal to

27.3 460 55 and a bicarb of 30 got a chem-7 going on here and the sodium is

140 the bike sorry the potassium is 4.0 the chloride is a hundred and as we

mentioned the bicarb is thirty okay so what’s our first step again calculate

the anion gap of course here we have 100 plus 30 which is 130 minus one from 140

is 10 so the Delta gap is negative 2 essentially we have no anion gap

metabolic acidosis go into number two the pH and the pco2

here pH definitely going down pco2 definitely going up okay

so again it must be a respiratory component and it must be an acidosis but

again the question is is it an acute or is it a chronic and let’s review those

again remember for acute and for chronic for acute respiratory acidosis the ratio

is 1 over 10 and for a chronic respiratory acidosis is 1 over 3 and

we’re simply talking about the increase in hco3 – over the increase in p co2

increase in hco3 – over the increase in pco2 so let’s do our ratio here again

how much did the bicarb go up by bicarb is 30 from 24 that would be an increase

of 6 and how much did our pco2 go up by it went up by 20 because 40 is normal

and it’s 60 so that would be 20 so which one does

this look most like does this ratio here look more like this or like this and you

can see it looks more like the 1 over 3 therefore this is a chronic respiratory

acidosis good well join me for part 7 for more questions

Clear and informative…thank you

Very helpful practice problems..thanks

these videos are really helpful thank you so so much. please consider making more teaching videos.

You guys should team up with KhanAcademy… love his site but it sorely lacks in the more technical/professional medical subjects. It would give you more exposure and probably more resources. Either way, keep doing what you're doing.

Sure, we just got started so more's on the way.

So where does base excess come into the equation? Is it just the same as calculating the delta gap?

Thanks for the great videos! Could you please tell why the Cl values are different in eache case, bearing in mind you put normal values for the other parametes in the C7. thanks in advance

sorry, just realised you randomly make them up..

I found in Tortora that normal Na is 142, normal Cl is 100, and normal HCO3 is 24. Together these give an anion gap of 18 rather than 12. Can you solve this for me? Thanks. I enjoyed the lecture. Very helpful. But I kept thinking of the other gap.

Na range is 135-145, Cl also has a range too. so numbers move around.

Na = 140. Cl = 104 HCO3 = 24 are averages.

base excess is another way of saying metabolic alkalosis.

Thank you very much.Easy to understand.

Brilliant! Thank you very much! Please, keep on doing this. You have a rare talent to transmit the knowledge. Highly appreciated!

Thank you very much

awesome!!!!Talented Teacher. Thank you so much. You teach very clearly.

Dr. Seheult, Thank you sooo….. much for making these videos. No body ever explained acid-base this clearly. The book that we follow did not help to understand. Your lecture helped me to understand acid-base. We are using the acid-base graph to plot the values but did not have a clear understanding of what it meant. After you explained the graph, I can understand better about what it is. You started from the basics and explained step-by-step. Now, I am able to work out the example problems that you have used in this video. Thank you.

This is amazing. Thank you so much. You made 3 and a half weeks of incomprehensible lectures seem like something that I'm ready to tutor in a matter of an hour. That is incredible.

Overall great videos, which have raised my knowledge by far. But, I have a question regarding the pCO2 reference which you display as 4.0 or 40. pH (7,35-7,45), pCO2 (4,5-6,0), HCO3- (22-26). Why is the pCO2 reference value not "52"?

i do not think i will need to memorize the winters formula & i do not think i will need it .. i can differentiate between acute & chronic respiratory alkalosis or acidosis by seeing if there is compensation happened or not i.e in the hco3 .

Your videos are amazing. Please upload more.

On the first question, you used 26 as the normal HCO3- while applying Winters' Formula, but used 24 in the second problem…..does it matter which you use? Should we just use 25, since there's no even number in the middle of the normal HCO3- range?

Thank you sir, but am bit confuse , the time you introduced cam 7 you used cl as 104, in expl 1 you used 106, and now in expl 2 you used 110, i just become confuse, please help

OMG!!! I LOVE YOU!!!!!!! FINALLY I KNOW WHY THE WINTER'S FORMULA IS THAT IMPORTANT, NOW I GOTTA GO BACK AND TAKE NOTES ALL THOSE FORMULAS THAT I SKIPPED xD

What do you do if for example you have a patient with a primary resp acidosis but instead of bicarb going up it actually went down? pts anion gap was normal, AG was 8 with albumin of 3. Would you say that this is a resp acidosis with concurrent non gap acidosis? abg is 7.05/61/116/17

Thank you so much. You're helping us to become great doctors. I really appreciate that❤️

Thank you for this brilliant series

Thank you so much… really great illustration thanks again

thank you!! this was really, REALLY helpful!

Thanks a lot. May God almighty bless you with all peace and prosperity.

I completely disagree with you. Acute and chronic respiratory alkalosis is explained in vice versa fashion. It is the opposite of what you said.

Thank you very much sir, you cleared my concepts regarding ABGs

Thanku..very helpful

I understand why the second example at around 10:50 is chronic respiratory alkalosis, but couldn't there also potentially be a non-AG metabolic acidosis occurring concurrently, as the pH is within the normal range and when you add the delta AG to the bicarbonate level, it is less than the normal bicarbonate level which would indicate normal AG metabolic acidosis?

thankkkk you so muchhh ???

Winthers formula ratios for chronic respiratory acidosis is stated both 1/2 (at first) but then in the following example as 1/3.

I hit the liked button before I watch it. I always struggle with acid base, and you made it so easy to understand! Thank you so much!!!!

Very good step wise explanation …