A 45-year-old woman presents with Kussmaul respirations, vomiting, abdominal pain, and warm flushed skin. Which acid-base disturbance is most likely?

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Kussmaul respiration is the body's deliberate deep, rapid breathing to blow off CO2 when there is an acid load, so this pattern points to a metabolic acidosis with respiratory compensation. Here, the deep, labored breaths signal that the primary problem is a fall in bicarbonate and acidemia, rather than a primary respiratory disorder. Vomiting and abdominal pain can accompany metabolic disturbances such as diabetic ketoacidosis or lactic acidosis, which provide the extra acid load; warm flushed skin can occur due to peripheral vasodilation seen with acidosis.

If it were a respiratory issue, you'd expect the opposite pattern—either hypoventilation with CO2 retention in respiratory acidosis, or hyperventilation without acidemia in respiratory alkalosis. Metabolic alkalosis would present with elevated bicarbonate and often hypoventilation, not the pronounced acidosis and ventilatory drive seen here. Respiratory alkalosis would involve low CO2 and high pH, not the acidemia suggested by the breathing and symptoms.

Thus the combination of acidemia with a compensatory, hyperventilatory response best fits metabolic acidosis.