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  <head>
    <title>019-02 Quantitative compensation, hidden mixtures, and acid-base treatment traps</title>
    <ownerName>Integrated Medical Foundations</ownerName>
  </head>
  <body>
    <outline text="Quantitative compensation and hidden mixtures">
      <outline text="Process before equations">
        <outline text="Carbon dioxide changes within minutes"/>
        <outline text="Renal handling shifts over hours to days"/>
        <outline text="Timing is part of the diagnosis"/>
        <outline text="Low bicarbonate: acidosis or compensation"/>
        <outline text="High bicarbonate: alkalosis or compensation"/>
        <outline text="Rules give ranges, not exact targets"/>
        <outline text="A value outside the range means another process"/>
      </outline>
      <outline text="Respiratory compensation in metabolic disease">
        <outline text="Expected value: one and a half times bicarbonate">
          <outline text="Then add eight, with a small range"/>
          <outline text="A higher measured value means ventilatory failure"/>
          <outline text="A lower measured value means respiratory alkalosis"/>
        </outline>
        <outline text="High minute ventilation must be sustained">
          <outline text="Sedation, fatigue and weakness remove it"/>
          <outline text="Intubation must match compensatory demand"/>
        </outline>
        <outline text="Alkalosis compensation limited by oxygenation"/>
      </outline>
      <outline text="Acute and chronic respiratory change">
        <outline text="Acute retention raises bicarbonate a little"/>
        <outline text="Chronic retention raises it through the kidney"/>
        <outline text="Less bicarbonate than expected: added acidosis"/>
        <outline text="More bicarbonate: alkalosis or higher baseline"/>
        <outline text="Pregnancy is chronic mild respiratory alkalosis"/>
        <outline text="Post-hypercapnic alkalosis after rapid correction">
          <outline text="Volume, chloride, potassium and diuretics maintain it"/>
        </outline>
      </outline>
      <outline text="Correcting and dissecting the gap">
        <outline text="Low albumin lowers the expected gap">
          <outline text="Correction reveals hidden organic acids"/>
        </outline>
        <outline text="Delta: gap rise against bicarbonate fall">
          <outline text="Much larger fall adds normal-gap acidosis"/>
          <outline text="Smaller fall suggests coexisting alkalosis"/>
        </outline>
        <outline text="Chloride-rich fluid replaces the organic gap">
          <outline text="Hyperchloraemic acidosis as lactate clears"/>
          <outline text="Serial values prevent a false failure"/>
        </outline>
      </outline>
      <outline text="Normal-gap acidosis and urine">
        <outline text="Bicarbonate loss or impaired acid excretion"/>
        <outline text="Diarrhoea loses gastrointestinal bicarbonate"/>
        <outline text="Proximal disease loses filtered bicarbonate"/>
        <outline text="Distal disease cannot acidify the urine"/>
        <outline text="Urine gap: sodium plus potassium minus chloride">
          <outline text="Negative value: appropriate ammonium excretion"/>
          <outline text="Positive value: reduced ammonium production"/>
        </outline>
        <outline text="Urine pH alone is insufficient"/>
      </outline>
      <outline text="Alkalosis: generation and maintenance">
        <outline text="Vomiting removes hydrogen and chloride"/>
        <outline text="Volume depletion drives sodium reclamation"/>
        <outline text="Chloride unavailable for bicarbonate exchange"/>
        <outline text="Mineralocorticoid signalling secretes hydrogen distally"/>
        <outline text="Low urine chloride after remote losses"/>
        <outline text="High urine chloride with ongoing diuretics"/>
        <outline text="Potassium depletion sustains the alkalosis">
          <outline text="Magnesium depletion blocks potassium replacement"/>
        </outline>
      </outline>
      <outline text="Lactate, ketones and toxins">
        <outline text="Lactate is a shared endpoint">
          <outline text="Hypoxia, ischaemia, seizures, thiamine deficiency"/>
          <outline text="Normalisation need not precede improvement"/>
        </outline>
        <outline text="Ketoacidosis carries several changes at once">
          <outline text="Osmotic diuresis loses volume and electrolytes"/>
          <outline text="Potassium high while stores are depleted"/>
        </outline>
        <outline text="Toxic alcohols move osmolar gap to anion gap">
          <outline text="A late normal osmolar gap excludes nothing"/>
        </outline>
        <outline text="Salicylate: ventilation plus organic acids"/>
      </outline>
      <outline text="Physicochemical interpretation">
        <outline text="pH from gas, strong ions and weak acids"/>
        <outline text="Albumin and phosphate are the weak acids"/>
        <outline text="Chloride narrows the strong-ion difference">
          <outline text="Narrowing promotes acidosis"/>
        </outline>
        <outline text="Chloride loss or added sodium widens it">
          <outline text="Widening promotes alkalosis"/>
        </outline>
        <outline text="Low albumin has an alkalinising effect"/>
        <outline text="Complements bicarbonate-centred analysis"/>
      </outline>
      <outline text="Treatment follows the cause">
        <outline text="Bicarbonate for selected severe states">
          <outline text="It adds sodium and carbon dioxide"/>
          <outline text="It lowers ionised calcium and shifts potassium"/>
          <outline text="Central acidity worsens if ventilation fails"/>
        </outline>
        <outline text="Restore ventilation without erasing adaptation"/>
        <outline text="Chloride-responsive alkalosis needs volume and chloride"/>
        <outline text="Dialysis removes selected acids and toxins"/>
        <outline text="State every process and its danger"/>
        <outline text="A normal pH must not end the analysis"/>
        <outline text="Serial measurements confirm recovery"/>
      </outline>
    </outline>
  </body>
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