Approach to Elevated Bicarbonate (HCO3) Risk Factors for Hypercapnea? (Hx of COPD, OSA, sedative use, CNS/muscular disorders?) (+) Evaluate for Respiratory Acidosis (Check Blood Gas) (-) Likely Metabolic Alkalosis Urine CI < 20 (Saline Responsive) • GI Hydrogen loss (Vomiting/NG) • Laxatives/Villous Adenoma • Remote Diuretics - Loop or Thiazides • Volume Contraction Urine Cl > 20 (Saline Unresponsive): • Excess Mineralocorticoid • Primary Hyperaldosteronism • Recent Diuretics - Loop or Thiazides • Licorice • Liddle's. Barter, or Gitelman Syndrome Unremarkable Labs @UnremarkableLab #Bicarbonate #Elevated #metabolic #alkalosis #algorithm #diagnosis