Introduction To Acid-Base

Balance
INTRODUCTION
Normal pH : 7.35-7.45
Normal HCO3: 24-28 mEq/L
Normal pCO2: 35-45 mmHg
Normal serum Na: 135-145 mEq/L
Normal serum K: 3.8-4.8 mEq/L
Normal Serum CL: 79-110 mEq/L
INTRODUCTION
The Body Keeps normal pH by 3 systems:
1. Respiratory System.
2. Kidneys.
3. Buffers.
INTRODUCTION
Respiratory System
In Metabolic Acidosis Hyperventilation
and wash out of CO2 Compensatory
Respiratory alkalosis.
In Metabolic Alkalosis Hypoventilation
and retention of CO2 Compensatory
respiratory acidosis.
THE KIDNEYS
INTRODUCTION
The Buffers:
Calcium
Hemoglobin
Plasma Proteins
The bones
BICRBONATE
INTRODUCTION
PRIMARY DISORDER HCO3 PCO2
Metabolic Acidosis Decrease Decrease
Metabolic Alkalosis Increase Increase
Respiratory Acidosis Increase Increase
Respiratory Alkalosis Decrease Decrease

METABOLIC ACIDOSIS
Definition:
A PRIMARY decrease in serum bicarbonate
leading to decrease in pH.
Differentiate it from Compensatory metabolic
acidosis. How ??
METABOLIC ACIDOSIS
Causes:
Group 1 : Accumulation of Acids:
1. Ketoacids- Diabetic Ketoacidosis, Alcoholic intoxication.
2. Organic Acids - CRF.
3. Lactic Acid, Shock, Sepsis, Crush injuries, Hypoxemia,
Alcoholic Intoxication
4. Formaldehyde & Formic Acid Methanol, Paraldehyde,
Ethylene glycol.
5. Salicylate Toxicity: Lactic Acid.

METABOLIC ACIDOSIS
Group 2Loss of Alkali:
Renal:
1. RTA. Proximal & Distal.
2. Fanconi Syndrome.
GIT loss:
1. Severe diarrhea
2. GIT fistulas
3. Entero-ureteric fistulas.
METABOLIC ACIDOSIS
How to differentiate between Group 1 & 2 ?:
Group 1 is associated with high Anion Gap.
Group 2 is associated with normal Anion Gap
AG = Serum Na CL + CO2
Normal AG = 12 + 2 mEq/L
METABOLIC ACIDOSIS
Plasma Osmolal Gap:
POG = The measured calculated plasma osmolality.
Calculated PO = 2 X Na + Glucose + BUN
18 2.8
High POG reflects the presence of unmeasured non-
ionized compound:
1. Usually alcohol as methanol, ethanol, or ethylene glyc.
2. IV mannitol or glycine

METABOLIC ACIDOSIS
Diagnosis:
Diagnosis of the cause
Look at pH - >7.35
Look at serum HCO3 - <24 mEq/L
Look at pCO2 - <35 (compensatory)
Calculate AG to DD between Group 1 & 2.
METABOLIC ACIDOSIS
Treatment:
Treat The cause.
Hydrate the patient if volume depleted.
IV HCO3 given Only if severe metabolic
acidosis, ie pH<7.1 or HCO3 <10 mEq/L.
HCO3 deficit= 0.6 X body wt X Desired
HCO3- Actual HCO3.
Give only half the dose as an IV bolus, the rest
by continuous IV infusion over 12-24 h. Why?
METABOLIC ACIDOSIS
Side Effects of Rapid injection of HCO3:
1. Volume overload.
2. Hypokalemia. Why ?
3. Hypocalcaemia. Why ?
4. CSF Obtundation.
METABOLIC ALKALOSIS
Definition:
A Primary increase in serum HCO3, which leads
to increase in pH >7.45.
METABOLIC ALKALOSIS
Causes:
1. Loss of Acid: HCL loss by severe vomiting, or
nasogastric suction.
2. Chloride loss: Vomiting, villous adenoma,
severe diarrhea & diuretics.
3. Loss of Potassium: Diuretics, excess of
corticosteroids & hyperaldosteronism.

METABOLIC ALKALOSIS
Causes:
4. Volume contraction: contraction alkalosis.
5. Exogenous HCO3 or citrate administration.
6. Bartters syndrome.
METABOLIC ALKALOSIS
The Value of urine electrolytes:
In severe vomiting urine CL <10 mEq/L.
In diuretics Urine K >20 & CL>20mEq/L.
Corticosteroids & hyperaldosteronism
Urine K >40 mEq/L.
Contraction alkalosis Urine Na<10 mEq/L.

METABOLIC ALKALOSIS
ABG Example:
pH: 7.5.
pCO2: 50 mmHg.
paO2: 75 mmHg.
HCO3: 35 mEq/L.
METABOLIC ALKALOSIS
Treatment:
Treat the underlying cause.
Replace the Fluid deficit.
Replace K deficit.
Hyperaldosteronism K sparing diuretics as
spironolactone or amiloride.
Acetazolamide promotes bicarbonaturia.
METABOLIC ALKALOSIS
Treatment:
Metabolic alkalosis + RF can be corrected with
hemodialysis against a bath with low [HCO3].
Severe metabolic alkalosis (pH>7.70) with ECF
volume excess or renal failure or both, can be
treated with isotonic (150 mmol/L) HCL,
administered via a central line.
RESPIRATORY ACIDOSIS
RESPIRATORY ACIDOSIS
Definition:

A Primary increase in arterial PaCO2 leading
to decrease in arterial pH

Respiratory Center


Motor Roots


Neuromuscular Junction


Respiratory Muscles

Pleural Cavity


Lung Parenchyma and Airways


Alveolo-capillary membrane disease



RESPIRATORY ACIDOSIS - CAUSES
RESPIRATORY ACIDOSIS
The Value of A-a Gradient:
Calculation:
1. paCo2 X 1.2 = X
2. 150 X = A
3. A (alveolar O2) a (arterial O2) = A-a gradient.
Normal A-a Gradient = Up to 15 mmHg.
High A-a Gradient Vent Perfusion mismatching.
Normal A-a Gradient Alveolar Hypoventilation.
Alveolar Hypoventilation
Alveolar Hypoventilation
Alveolar Hypoventilation
Pulmonary perfusion scan shows multiple segmental
perfusion defects in both lung fields LPO: left posterior
oblique. POST: posterior. RPO: right posterior oblique
Ventilation Perfusion Mismatching
Ventilation Perfusion Mismatching
RESPIRATORY ACIDOSIS
Acute or Chronic Respiratory Acidosis:
Acute: pH: 7.2
pCO2: 50 mmHg
HCO3: 27 mEq/L
Chronic: pH: 7.34
pCO2: 55 mmHg
HCO3: 37 mEq/L
RESPIRATORY ACIDOSIS
Alveolar Hypoventilation or V/P Mismatching:
Case 1: A 45 Years male heavy smoker, chronic dyspnea &
cough. Symptoms got worse, admitted. ,ABG:
PH : 7.25 paCO2: 62 mmHg
paO2: 64 mmHg HCO3: 36 mEq/L.

Case 2: A 45 Years male heavy smoker, chronic dyspnea &
cough. Symptoms got worse, fever, admitted, ABG:
PH : 7.25 paCO2: 52 mmHg
paO2 : 50 mmHg HCO3 : 30 mmHg
RESPIRATORY ACIDOSIS
Treatment:
Treat the cause.
Bronchial asthma, severe
or not ?
Oxygen in COPD ?
Treatment of V/P
mismatching ?
RESPIRATORY ALKALOSIS
Definition:

A Primary drop of paCO2 leading to increase
in arterial pH>
RESPIRATORY ALKALOSIS
Causes:
1. Hypoxia: pulm disease, anemia, heart failure,
high altitude.
2. Respiratory center stimulation: CNS disorders,
liver failure, sepsis, drugs, salicylates, etc.
3. Pulmonary disease: pneumonia, edema, emboli
4. Mechanical hyperventilation.
5. Hysterical.

RESPIRATORY ALKALOSIS-ACUTE OR CHRONIC
Acute Respiratory Alkalosis:
1. A decrease in PaCO2 by 10 mmHg Increases pH by
0.08.
2. A decrease in PaCO2 by 10 mmHg Decreases HCO3 by
2 mEq/L.
Chronic Respiratory Alkalosis:
1. A decrease in PaCO2 by 10 mmHg Increases pH by
0.03.
2. A decrease of PaCO2 by 10 mmHg Decreases HCO3 by
4 mEq/L.
RESPIRATORY ALKALOSIS
Example:
CASE 1:
pH: 7.61 paCO2: 20 mmHg
paO2: 105 mmHg HCO3: 20 mEq/L
CASE 2:
pH: 7.50 paCO2: 20 mmHg
paO2: 100 mmHg HCO3: 16 mEq/L
RESPIRATORY ALKALOSIS
Treatment:
1. Treat the cause.
2. Hysterical: sedation,
reassurance, closed
breathing system.
3. Treat hypocalcaemia if
it occurs.
Approach To
Acid-Base Balance
PH

Low -Acidosis) High -Alkalosis)

Low HCO3 High paCO2 High HCO3 Low paCO2

Metab. Acidosis Resp. Acidosis Metab. Alkalosis Resp. Alkalosis

Calculate AG. Calculate A-a G Check Urine Acute vs Chr.
Electrolytes

High AG Low AG Normal High Urine Cl <10 Vomiting
Urine K >20 - Diuretics
Urine Na <10- Contraction alkalosis
Acid Excess Alkali Loss Alv Hypo V/P M Urine K >40 Steroids & aldosteron
APPROACH TO ACID BASE BALANCE
END
FIN