CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3– |
‘In metabolic acidosis, there is either additional acid (H+) production on the right side of the equation, or direct loss of bicarbonate which drives the equation to the right, increasing H+ and lowering pH.’
The consequent reduction in pH stimulates the respiratory centre to increase ventilation and lower pCO2. This in turn drives the reaction to the left, lowering both bicarbonate and H+ to achieve compensation. There is also increased H+ secretion in the kidneys (linked to increased HCO3– reabsorption), further lowering H+.
Further classification of a metabolic acidosis depends on the anion gap – the difference between the major plasma cations (Na+ and K+) and anions (Cl– and HCO3–):
Anion gap = (Na+ + K+) – (Cl– + HCO3–) |
A normal anion gap is in the range 9-14 mmol/l.
A raised anion gap can be due to excess acid production or ingestion contributing extra H+:
Remember: MUDPILERS
For example, in a patient with diabetic ketoacidosis, without any compensation:
The pH is low, the pCO2 is normal and the bicarbonate is low indicating a metabolic acidosis. The anion gap is raised at 23.6 due to the ketoacidosis.
In a normal anion gap acidosis, bicarbonate is lost from the gut or the kidneys and there is a raised chloride, which compensates for the extra cations, thus keeping the gap normal. This occurs as a result of reabsorption of sodium chloride via the kidneys:
Irrespective of its cause, a metabolic acidosis has a detrimental effect on the cardiovascular system: there is impaired cardiac contractility and a reduced response to catecholamines. There is also increased pulmonary vascular resistance and decreased hepatic and renal perfusion. The threshold for ventricular fibrillation is lowered.
Remember: HARDUPS
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