What are then the definitions? We’ll go briefly over them. But we have here acidosis and alkalosis and it can either be caused by the lungs - in which case it is called respiratory - or it can be caused by something else besides the lungs, in which it is called metabolic. Forget about all this. We’ll get back to that later. There’s just really four choices. Now, that’s not exactly true because on top of those four choices you have two more. Do you have a combined something-or-other? And number two, do you have a compensation? So when we are trying to solve these problems, after you’ve got them solved, you always have to remember to ask those two questions. Do we have more than one, and/or is there some compensation going on here? It’s reasonably easy if you ask the questions in order.
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Here’s what the Europeans are doing. This is the concentration of hydrogen ion and this is the pH and as you can see, as the hydrogen ion goes up the pH goes down. It’s easy to remember that because you know that’s what is happening but in reporting these things out, as soon as you get the normal ranges in your mind - and you really don’t have to do that anymore because the computers print out the normal ranges. If they don’t they are not doing their job - then it becomes fairly easy to say, “Hey, 25 is low and 80 is high” and it is going right in the direction that you want. But my guess is that we are stuck with pH, probably to your grandchildren. That’s progress. Unless maybe Bill Gates decides that Microsoft wants to get into the pH business, then we are okay.
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Now the last thing that I think you need to deal with is that specimens differ in where they came from. We can do all these things on arterial, venous, capillary or alveolar gas. I guess rather than remembering this, you always have to remember to look on the report and ask yourself, “Where did this come from?” where does it come from, because the normal values will be different. Again, if the computer is doing it’s job right it will tell you pH, it will tell you where it came from, and it will give you the normal range for those sources. Frankly I deal with them every day and I’m not sure, except in some of the major ones, that I could tell you what all the normal ranges are. So there’s not a real problem not knowing them. But there is a problem if you don’t ask yourself the question; “where did the stuff come from?”
One last concept that we will talk a little bit about is the concept of base excess. Now, bicarbonate is called a base and you can talk to your chemist as to why it’s called a base. Anyway it’s called a base. It’s not a pejorative name. It’s just base. So base excess or base deficit really means that you have too much or too little bicarbonate and you can say, “Okay, but we are going to measure serum bicarbonate, why isn’t serum bicarbonate alone? Why isn’t that okay?” and the answer is, mostly it is okay. But since the body is multiple compartments and since you’ve got two compartment that’s the blood, you have one compartment that’s the plasma and one compartment that is in the cells. There is not free motion between those three compartments that you can get some disparate results in chronic conditions. So we put the anion or base excess or deficit in there to give you a kind of a qualitative estimation as to how bad it is. You come down and you say, “This patient is acidotic, this patient is metabolic acidosis, this patient is diabetic.” So you’ve got that. Then this deficit then gives you a sort of a semi-quantitative estimate as to how bad it is. I’ll show you in a minute. It’s a little bit better than just using the plasma bicarb alone. Now this is a graph, it’s in your thing, you’ll probably never use it. I just wanted you to know that it exists because if your computers ever break, here is the PCO2, here’s the pH and here’s the CO2 content and right here is the base excess, and you can draw a line across here. For example, this is 40 mmHg which would be normal, this is 7.40 which would be normal, and this is 25 mmol/L of bicarb. That would be normal. If you had a normal patient and drew a line across there, this is the base excess grid and you hit zero. So it’s no excess, no deficit. So if ever someone gives you some numbers and they want to ask you “What’s the base excess or what’s the base deficit?” you just put the three points here, here and here and it’s on the grid. As I say, the only time anybody would ever use that is if the computerized method for calculating it would go bad.
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