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10
10 Introduction to Acid-Base Physiology
249
The Fluid, Electrolyte and Acid-Base Companion
H+ H+
Acidemia Alkalemia
Acidemia is an increase in plasma hy- Alkalemia is a decrease in plasma hy-
drogen concentration above normal. drogen concentration below normal.
It is recognized by a hydrogen con- It is recognized by a hydrogen con-
centration above 45 nanomol/L or a centration below 35 nanomol/L or a
pH below 7.35. pH above 7.45.
Acidosis Alkalosis
Acidosis is a process which increas- Alkalosis is a process which decreas-
es plasma hydrogen concentration. es plasma hydrogen concentration.
250
S. Faubel and J. Topf 10 Introduction to Acid-Base Physiology
16 40 160
nanomol/L nanomol/L nanomol/L
0 50 100 150
0.00004 mEq/L
ALKALEMIA ACIDEMIA
251
The Fluid, Electrolyte and Acid-Base Companion
180 180
160 160
120 120
100 100
80 80
60 60
40 40
20 20
0 0
6.8 6.9 7.0 7.1 7.2 7.3 7.4 7.5 7.6 7.7 7.8
pH
252
S. Faubel and J. Topf 10 Introduction to Acid-Base Physiology
16 40 160
nanomol/L nanomol/L nanomol/L
0 50 100 150
ALKALEMIA ACIDEMIA
253
The Fluid, Electrolyte and Acid-Base Companion
H+ A- H+ HCO3 H+
254
S. Faubel and J. Topf 10 Introduction to Acid-Base Physiology
total Ca ++
albumin Ca++
protein Ca++
calcium HCO3 Ca++
ionized (free) bound calcium
calcium
With all ions, only the free form is active. Usually, only the free form
of an ion is measured, but one notable exception is calcium. The cal-
cium concentration reported on routine chemistry panels is the total
calcium content, bound and free. The ionized (free) calcium must be
specially ordered. (The blood sample for ionized calcium needs to be
drawn in an ABG syringe and placed on ice.)
Normal total calcium concentration is between 8.5 and 10 mg/dL.
Since about 50% of total calcium is bound to protein, measurements of
total calcium can vary depending on the protein concentration. The cor-
rection for total calcium in the presence of a low plasma albumin con-
centration is as follows: for every 1 gram/dL the albumin concentration
is below normal, 0.8 mg/dL is added to the total calcium. The formula is:
corrected calcium = [ 0.8 × (4.0 - measured albumin)] + measured calcium
255
The Fluid, Electrolyte and Acid-Base Companion
High pH
When hydrogen concentra-
tion is low (pH high), hydro- A- H+ H+ A-
gen sponges release hydro-
gen and increase the free
sponge with free hydrogen ion sponge
hydrogen concentration. hydrogen
Low pH
When hydrogen concentra-
tion is high (pH low), hydro-
gen sponges absorb hydro-
H+ A- A- H+
gen and decrease the free
hydrogen concentration. free hydrogen ion sponge sponge with
hydrogen
256
S. Faubel and J. Topf 10 Introduction to Acid-Base Physiology
[ H+] [A ] -
Ka
[A ]- H+
[ H+ ] [ A- ] [ ][ ]
H+ A-
Ka Ka
[ ]
A- H+ [ A- H ] +
A poorly absorbent sponge has a high Ka: A highly absorbent sponge has a low Ka:
the majority of hydrogen is free. the majority of hydrogen is bound.
257
The Fluid, Electrolyte and Acid-Base Companion
[ H+ ] [A ] -
Ka
[A ]
- H+
[ H+ ] [A ] -
– log × Ka × – log
[A ]
- H+
[A ] - H+
pKa log
[ ] [A ]H+ -
The Ka of hydrogen ion sponges ranges from tiny to huge. The Ka for HCl
is over 1,000,000 (10 6) and the Ka for bicarbonate is less than 0.000001
(10 ). A large Ka, as with HCl, means that at equilibrium the vast majority
–6
of the hydrogen ions are free. A small Ka, as with bicarbonate, means that
the majority of hydrogen ions are bound.
To keep track of such a wide range of values, chemists again applied the
magic of the negative log to create the pKa.
pKa = – log Ka
A high pKa means that at equilibrium hydrogen is mostly bound to the
buffer, while a low pKa indicates that at equilibrium most of the hydrogen
is free.
258
S. Faubel and J. Topf 10 Introduction to Acid-Base Physiology
BH+)
Low pH (B hydrogen + bicarbonate H2CO3 water + carbon dioxide
When the pH is low, bicarbon-
ate binds (absorbs) excess hy-
drogen forming H2CO 3 which H+ + HCO3 HCO3 H+ + C
breaks down into water and car-
bon dioxide.
?H+)
High pH (? hydrogen + bicarbonate H2CO3 water + carbon dioxide
When pH is high, water and car-
bon dioxide combine to form H+ + HCO3 HCO3 H+ + C
H2CO3 which breaks down into
bicarbonate and hydrogen. This
increases the hydrogen concen-
tration. From these equations, it is clear that a fall in pH results in the con-
sumption of bicarbonate and an accumulation of CO2, while an in-
crease in pH results in the consumption of CO2 and an accumula-
tion of bicarbonate.
259
The Fluid, Electrolyte and Acid-Base Companion
H2O + CO2 C H2CO3 C H+ + HCO3– H2CO3– is rapidly broken down by carbonic anhy-
drase (the fastest enzyme in the body). Since it is
H2O + CO2 C H+ + HCO3– so transient, it is dropped from the equation.
[H+ ] [HCO3– ] Unlike H+, HCO3– and CO2, the concentration of wa-
[H2O] × Ka = × [H2O] ter in the body does not change (i.e., it is a con-
[H2O] [CO2]
stant). By multiplying both sides of the equation by
this constant, H2O drops out of the right-hand side
of the equation.
260
S. Faubel and J. Topf 10 Introduction to Acid-Base Physiology
[CO2] [H+ ] [HCO3– ] [CO2] The initial equation can be solved for H+
Ka' =
[HCO3– ] [CO2] [HCO3– ] by multiplying both sides of the equation
by: CO2 / HCO3–.
[CO2]
Ka' = [H+ ]
[HCO3– ]
[CO2]
[H+ ] = Ka' The equation is rearranged so that H+ is
[HCO3– ] on the left side.
[HCO3– ]
pH = pKa' + log [CO ] The Henderson-Hasselbalch equation.
2
pH = 7.4
Although there are other types of buf fers besides bicarbonate (e.g., phosphate, hemoglo-
bin), all of the buf
fer systems work in parallel.
Therefore, examination of one buf
fer system,
such as bicarbonate, is sufficient to describe the fect
ef of all buffers on pH.
261
The Fluid, Electrolyte and Acid-Base Companion
The Mantra
[HCO3– ]
pH = pKa + log
[CO2]
[HCO3– ]
pH |
[CO2]
Acidity = Bicarbonate
Carbon Dioxide
A = B⁄C D
These equations show that pH is simply the ratio of bicarbonate to CO2.
Changes in pH and acid-base disorders only occur when there is a change in
bicarbonate and/or PCO2.
Since pH is the ratio of bicarbonate to PCO2, keeping the pH constant
depends on keeping the ratio constant. If one component changes, then the
other must change in the same direction in order to maintain a constant
ratio (and hence a constant pH).
262
S. Faubel and J. Topf 10 Introduction to Acid-Base Physiology
HCO3– HCO3–
pH | pH |
CO2 CO2
HCO3– HCO3–
pH | pH |
CO2 CO2
For the purposes of acid-base interpretation, changes in pH above and below 7.4 are used,
as opposed to alterations from the normal range of 7.35 to 7.45. For the remainder of this
book, acidemia and alkalemia are defined by pH less than and greater than 7.4, respectively
.
263
The Fluid, Electrolyte and Acid-Base Companion
264
S. Faubel and J. Topf 10 Introduction to Acid-Base Physiology
265
The Fluid, Electrolyte and Acid-Base Companion
HCO3– C HCO3–
pH | C pH |
CO2 C CO2
metabolic acidosis
increased ventilation
decreases PCO2
C
C
HCO3– C HCO3–
pH | C pH |
CO2 CO2
C
metabolic alkalosis
C
C decreased ventilation
C increases PCO2
266
S. Faubel and J. Topf 10 Introduction to Acid-Base Physiology
lo sis 50
lka
48
Normal a
o lic 46
tab
44
Me 42
PCO2 (mmHg)
40 40
38
36
34 s is
32
i do
ac
30
28
26 l ic
24
a bo
22 et
20 M
18
16
14
6 8 10 12 14 16 18 20 22 24
Bicarbonate (mEq/L)
The expected range of PCO2 for HCO3 levels in metabolic disorders can
–
also be depicted graphically, as above. The PCO2 values within the dark grey
bands are the appropriate respiratory compensation for metabolic acid-base
disorders.
The lowest the PCO2 can fall in metabolic acidosis is about 10 mmHg,
while the highest it can reach in metabolic alkalosis is about 60 mmHg.
Please note that there are many dif
ferent formulas and rules available to assess compensa-
tion in both metabolic and respiratory acid-base disorders.
The formulas and rules used to
assess compensation should be thought of as estimates, and some variability does exist.
267
The Fluid, Electrolyte and Acid-Base Companion
HC
O3
–
HCO3– HCO3–
pH | pH |
CO2 CO2
respiratory acidosis
HCO3–
HCO3– HCO3–
pH | pH |
CO2 CO2
268
S. Faubel and J. Topf 10 Introduction to Acid-Base Physiology
32
30
28
s
26 atory acidosi
Acute respir
24 Normal
22 l k a l o sis
a
atory
20 c u t e respir
A
18
16
14
15 20 25 30 35 40 45 50 55 60 65 70 75
PCO2 (mmHg)
269
The Fluid, Electrolyte and Acid-Base Companion
38
36 is
34 ci dos
to ry a
Bicarbonate (mEq/L)
32 pira
es
30 on ic r
28 Chr
s
26 atory acidosi
Acute respir
24 Normal
22 l k a l o sis
tory a is
20 cute respira los
a lka
A r y
18 rato
r e spi
16 ic
ron
14 Ch
15 20 25 30 35 40 45 50 55 60 65 70 75
PCO2 (mmHg)
270
S. Faubel and J. Topf 10 Introduction to Acid-Base Physiology
HCO3– HCO3–
metabolic alkalosis HCO3– pH | pH |
CO2 CO2
HCO3– HCO3–
respiratory acidosis CO2 pH | pH |
CO2 CO2
HCO3– HCO3–
respiratory alkalosis CO2 pH | pH |
CO2 CO2
271
The Fluid, Electrolyte and Acid-Base Companion
BUN
Na+ Cl– glucose
K+ CO2
Cr
– –
pH / PCO2 / PO2 / HCO3 / O2 sat CO2 | HCO3
saturation. HCO3 is calculated from the pH and the PCO2 using the
–
272
S. Faubel and J. Topf 10 Introduction to Acid-Base Physiology
Step one
Look at the pH to determine if
an alkalosis or an acidosis is
present. If the pH is above 7.40,
the primary acid-base disturbance
pH / PCO2 / PO2 / HCO3– / O2 sat
is an alkalosis. If the pH is below
7.40, the primary acid-base distur-
bance is an acidosis.
BUN
chem-7 and determine if the pri-
Na+ Cl– glucose
mary acid-base disorder is respi-
K+ HCO
ratory or metabolic. If the bicar-
bonate and pH have changed in the
Cr
3
same direction, the primary distur-
bance is metabolic. If the bicarbon-
ate and pH have changed in oppo-
site directions, the primary disor-
der is respiratory.
Step three
Evaluate compensation by us-
ing the acid-base graph or formu-
las. If the compensation is as ex-
Metabolic acidosis
Metabolic alkalosis
expected PCO2 = (0.7 × HCO3–) + 20 ± 2
Respiratory alkalosis
acute 2:10
?HCO3–: ?PCO2
chronic 4:10
273
The Fluid, Electrolyte and Acid-Base Companion
–
respiratory acidosis HCO3 too low ........................ metabolic acidosis
–
HCO3 too high ....................... metabolic alkalosis
274
S. Faubel and J. Topf 10 Introduction to Acid-Base Physiology
Low pH
(B
Bhydrogen) H+ + HCO3 HCO3 H+ + C
High pH
(?
?hydrogen) H+ + HCO3 HCO3 H+ + C
a consistent ratio between HCO3 and PCO2. Decreased renal excretion and
–
–
HCO 3
HC
O3
276