ACID-BASE BALANCE

By:
Husnil Kadri

Biochemistry Departement
Medical Faculty Of Andalas University
Padang


2
CARA TRADISIONAL :
Hendersen-Hasselbalch
(1909)
3
pH = 6.1 + log
[HCO
3
-
]
pCO
2
GINJAL
PARU
BASA
ASAM CO
2
HCO
3
HCO
3
CO
2
Kompensasi
Normal
Normal
4
Carbonic acid/bicarbonate buffer system

The pK
a
of carbonic acid is 6.1
Carbonic acid is the major buffer in ECF
The pH of blood can be determined using
the Henderson-Hasselbalch equation
H
2
CO
3
H
+
+ HCO
3
-
Carbonic acid Bicarbonate ion
pKa = 6.1
ECF:
5
pH = pK
a
+ log [HCO
3
-
]/[H
2
CO
3
]

pH = pK
a
+ log [HCO
3
-
]/0.03 x PCO
2

7.4 = 6.1 + log 20 / 1

7.4 = 6.1 + 1.3

Plasma pH equals 7.4 when buffer ratio is 20/1
The solubility constant of CO
2
is 0.03

Henderson-Hasselbalch equation
DISORDER pH PRIMER RESPON
KOMPENSASI
ASIDOSIS
METABOLIK
HCO
3
- pCO
2

ALKALOSIS
METABOLIK
HCO
3
- pCO
2

ASIDOSIS
RESPIRATORI
pCO
2
HCO
3
-
ALKALOSIS
RESPIRATORI
pCO
2
HCO
3
-
GANGGUAN KESEIMBANGAN ASAM-BASA
TRADISIONAL
Normal Compensatory Response
Any primary disturbance in acid-base
homeostasis invokes a normal
compensatory response.
A primary metabolic disorder leads to
respiratory compensation, and a primary
respiratory disorder leads to an acute
metabolic response due to the buffering
capacity of body fluids.
A more chronic compensation (1-2 days) due
to alterations in renal function.

Mixed Acid - Base Disorder
Most acid-base disorders result from a single primary
disturbance with the normal physiologic compensatory
response and are called simple acid-base disorders.

In certain cases, however, particularly in seriously ill
patients, two or more different primary disorders may
occur simultaneously, resulting in a mixed acid-base
disorder.

The net effect of mixed disorders may be additive (eg,
metabolic acidosis and respiratory acidosis) and result
in extreme alteration of pH;

or they may be opposite (eg, metabolic acidosis and
respiratory alkalosis) and nullify each others effects on
the pH.

DUA VARIABEL
pH atau [H
+
] DALAM PLASMA
DITENTUKAN OLEH
VARIABEL
INDEPENDEN
Stewart PA. Can J Physiol Pharmacol 61:1444-1461, 1983.
VARIABEL
DEPENDEN
Cara Stewart ;
Strong Ions
Difference
pCO
2
Protein
Concentration
pH

INDEPENDENT VARIABLES DEPENDENT VARIABLES
VARIABEL INDEPENDEN
CO
2
STRONG ION DIFFERENCE WEAK ACID
pCO
2
SID A
tot
DEPENDENT VARIABLES
H
+

OH
-

CO3
-
A
-

AH
HCO3-
CO
2
Didalam plasma berada
dalam 4 bentuk
sCO
2
(terlarut)
H
2
CO
3
asam karbonat
HCO
3
-
ion bikarbonat
CO
3
2-
ion karbonat
Rx dominan dari CO
2
adalah rx
absorpsi OH
-
hasil disosiasi air
dengan melepas H
+
.
Semakin tinggi pCO
2
semakin
banyak H
+
yang terbentuk.
Ini yg menjadi dasar dari
terminologi respiratory acidosis,
yaitu pelepasan ion hidrogen akibat
pCO
2
CO
2

STRONG ION DIFFERENCE
Definisi:
Strong ion difference adalah ketidakseimbangan muatan
dari ion-ion kuat. Lebih rinci lagi, SID adalah jumlah
konsentrasi basa kation kuat dikurangi jumlah dari
konsentrasi asam anion kuat. Untuk definisi ini semua
konsentrasi ion-ion diekspresikan dalam ekuivalensi
(mEq/L).
Semua ion kuat akan terdisosiasi sempurna jika berada didalam
larutan, misalnya ion natrium (Na
+
), atau klorida (Cl
-
). Karena
selalu berdisosiasi ini maka ion-ion kuat tersebut tidak
berpartisipasi dalam reaksi-reaksi kimia. Perannya dalam kimia
asam basa hanya pada hubungan elektronetraliti.

Gamblegram
Na
+
140
K
+
4
Ca
++
Mg
++
Cl
-
102
KATION ANION
SID
STRONG ION DIFFERENCE
[Na
+
] + [K
+
] + [kation divalen] - [Cl
-
] - [asam organik kuat
-
]
[Na+] + [K+] - [Cl-] = [SID]
140 mEq/L + 4 mEq/L - 102 mEq/L = 34 mEq/L
SKETSA HUBUNGAN ANTARA SID,H
+
DAN OH
-
SID
()
(+)
[H
+
] [OH
-
]
Dalam cairan biologis (plasma) dgn suhu 37
0
C, SID hampir
selalu positif, biasanya berkisar 30-40 mEq/Liter
Asidosis Alkalosis
Konsentrasi [H+]
Kombinasi protein dan posfat disebut asam
lemah total (total weak acid) [Atot].
Reaksi disosiasinya adalah:
[A
tot
] (KA) = [A
-
].[H
+
]
[Protein H]
[Protein-] + [H+]
WEAK ACID
disosiasi
Gamblegram
Na
+
140
K
+
4
Ca
++
Mg
++
Cl
-
102
HCO
3
-
24
KATION ANION
SID
Weak acid
(Alb-,P-)
Na
140



K

Mg

Ca



Cl
102


P


Alb


HCO
3
= 24




Cl
115


P


Alb


HCO
3
-


Asidosis
hiperkloremi
SID n
SID



Cl
102

Laktat/keto=UA
Keto/laktat
asidosis
CL
95
P
Alb
SID
Alkalosis
hipokloremi
KATION ANION
APLIKASI
H
3
O
+
= H
+
= 40 mEq/L
HCO
3
-


HCO
3
-

KLASIFIKASI GANGGUAN
KESEIMBANGAN ASAM BASA
BERDASARKAN PRINSIP STEWART
Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic acid-base disturbances in
critically ill patients. Am J Respir Crit Care Med 2000 Dec;162(6):2246-51
KLASIFIKASI




ASIDOSIS



ALKALOSIS

I. Respiratori

PCO
2


PCO
2


II. Nonrespiratori (metabolik)






1. Gangguan pd SID






a. Kelebihan / kekurangan air

[Na
+
], SID

[Na
+
], SID


b. Ketidakseimbangan anion
kuat:






i. Kelebihan / kekurangan Cl
-

[Cl
-
], SID [Cl
-
], SID

ii. Ada anion tak terukur


[UA
-
], SID




2. Gangguan pd asam lemah





i. Kadar albumin


[Alb]


[Alb]

ii. Kadar posphate


[Pi]


[Pi]

Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic acid-base disturbances in
critically ill patients. Am J Respir Crit Care Med 2000 Dec;162(6):2246-51
RESPIRASI M E T A B O L I K
Abnormal
pCO2
Abnormal
SID
Abnormal
Weak acid
Alb PO4-
Alkalosis
Asidosis
Turun
Meningkat
Turun
kelebihan
kekurangan
Positif meningkat
Fencl V, Am J Respir Crit Care Med 2000 Dec;162(6):2246-51
AIR Anion kuat
Cl- UA-
Hipo
Hiper
Na
+
= 140 mEq/L
Cl
-
= 102 mEq/L
SID = 38 mEq/L
140/
1/2
= 280 mEq/L
102/
1/2
= 204 mEq/L
SID = 76 mEq/L
1 liter liter
KEKURANGAN AIR - WATER DEFICIT
Diuretic
Diabetes Insipidus
Evaporasi
SID : 38 76 = alkalosis
ALKALOSIS KONTRAKSI
Plasma Plasma
Na
+
= 140 mEq/L
Cl
-
= 102 mEq/L
SID = 38 mEq/L
140/2 = 70 mEq/L
102/2 = 51 mEq/L
SID = 19 mEq/L
1 liter 2 liter
KELEBIHAN AIR - WATER EXCESS
1 Liter
H
2
O
SID : 38 19 = Acidosis
ASIDOSIS DILUSI
Plasma
Na
+
= 140 mEq/L
Cl
-
= 95 mEq/L
SID = 45 mEq/L
2 liter
ALKALOSIS HIPOKLOREMIK
SID ALKALOSIS
GANGGUAN PD SID:
Pengurangan Cl
-
Plasma
Na
+
= 140 mEq/L
Cl
-
= 120 mEq/L
SID = 20 mEq/L 2 liter
ASIDOSIS HIPERKLOREMIK
SID ASIDOSIS
GANGGUAN PD SID:
Penambahan/akumulasi Cl
-
Plasma
Na
+
= 140 mEq/L
Cl
-
= 102 mEq/L
SID = 38 mEq/L
Na
+
= 154 mEq/L
Cl
-
= 154 mEq/L
SID = 0 mEq/L
1 liter 1 liter
PLASMA + NaCl 0.9%
SID : 38
Plasma NaCl 0.9%
2 liter
ASIDOSIS HIPERKLOREMIK AKIBAT
PEMBERIAN LARUTAN Na Cl 0.9%
=
SID : 19 Asidosis
Na
+
= (140+154)/2 mEq/L= 147 mEq/L
Cl
-
= (102+ 154)/2 mEq/L= 128 mEq/L
SID = 19 mEq/L
Plasma
Na
+
= 140 mEq/L
Cl
-
= 102 mEq/L
SID= 38 mEq/L

Cation
+
= 137 mEq/L
Cl
-
= 109 mEq/L
Laktat
-
= 28 mEq/L
SID = 0 mEq/L

1 liter
1 liter
PLASMA + Larutan RINGER LACTATE
SID : 38
Plasma Ringer laktat
Laktat cepat
dimetabolisme


2 liter
=
Normal pH setelah pemberian
RINGER LACTATE
SID : 34 lebih alkalosis dibanding jika diberikan
NaCl 0.9%
Na
+
= (140+137)/2 mEq/L= 139 mEq/L
Cl
-
= (102+ 109)/2 mEq/L = 105 mEq/L
Laktat
-
(termetabolisme) = 0 mEq/L
SID = 34 mEq/L
Plasma
Na
+
= 140 mEq/L
Cl
-
= 130 mEq/L
SID =10 mEq/L
Na
+
= 165 mEq/L
Cl
-
= 130 mEq/L
SID = 35 mEq/L
1 liter
1.025
liter
25 mEq
NaHCO3
SID : 10 35 : Alkalosis, pH kembali normal namun mekanismenya bukan
karena pemberian HCO
3
-
melainkan karena pemberian Na
+
tanpa anion kuat yg
tidak dimetabolisme seperti Cl
-
sehingga SID alkalosis
Plasma;
asidosis
hiperkloremik
MEKANISME PEMBERIAN NA-
BIKARBONAT PADA ASIDOSIS
Plasma + NaHCO
3

HCO
3
cepat
dimetabolisme
Na
+
Na
+
K
HCO
3
-
Cl
-
Cl
-
HCO
3
-
SID
Normal Ketosis
UA = Unmeasured Anion:
Laktat, acetoacetate, salisilat, metanol dll.

A-
A-
Keto
-
SID
K
Lactic/Keto asidosis
Na
Na Na
K K
K
HCO
3
Cl Cl Cl
HCO
3
HCO
3
SID
Normal Acidosis Alkalosis
GANGGUAN PD ASAM LEMAH:
Hipo/Hiperalbumin
-
atau P
-
Alb/P
Alb
-
/P
-
Alb
-
/P
-
SID
SID
Alkalosis
hipoalbumin
/hipoposfate
mi
Asidosis
hiperprotein/
hiperposfatemi
Anion Gap
Described by Gamble in 1939
Electroneutrality
Na+, Cl-, and HCO
3
are measured ions

Na + UC = Cl + HCO
3
+ UA

UC = Sum of unmeasured cations
UA = Sum of unmeasured anions
Anion Gap
Unmeasured Cations:
total 11 mEq/L
Potassium 4
Calcium 5
Magnesium 2
Unmeasured Anions:
total 23 mEq/L
Sulfates 1
Phosphates 2
Albumin 16
Lactic acid 1
Org. acids 3
Anion Gap
Na + UC = Cl + HCO
3
+ UA
140 + 11 = 104 + 24 + 23
151 = 151
UA UC = Na - (Cl + HCO3);
Anion Gap = Na - (Cl + HCO3)
If the anion gap is elevated
Then compare the changes from normal between
the anion gap and [HCO3 -].
If the change in the anion gap is greater than the
change in the [HCO3 -] from normal, then a
metabolic alkalosis is present in addition to a gap
metabolic acidosis.
If the change in the anion gap is less than the
change in the [HCO3 -] from normal, then a non
gap metabolic acidosis is present in addition to a
gap metabolic acidosis.

Anion Gap Acidosis:
Anion gap >12 mEq/L; caused by a
decrease in [HCO3 -]
balanced by an increase in an
unmeasured acid ion from either
endogenous production or exogenous
ingestion (normochloremic acidosis).

Non anion Gap Acidosis:
Anion gap = 8-12 mmol/L; caused by a
decrease in [HCO3 -] balanced by an
increase in chloride (hyperchloremic
acidosis). Renal tubular acidosis is a type
of non gap acidosis


Increased Anion Gap
Normal = 8-15
May differ institutionally
Accumulation of organic acids (ketones,
lactate)
Toxic Ingestions
methanol, ethylene glycol, salicylates
Reduced inorganic acid excretion
phosphates, sulfates
Decrease in unmeasured cations
(unusual)
Increased AG Metabolic Acidosis:
Methanol
Uremia/Renal
Failure
INH, Iron--lactate
Paraldehyde
Lactic Acidosis
Has many etiologies
Cyanide, CO, Toluene,
HS
Poor perfusion
Ethylene glycol
Salicylates
Methyl salicylate
(Oil of wintergreen)
Mg salicylate
Levraut J et al. Int Care
Med 23:417, 1997
Increased Anion Gap
Normal = 8-15
May differ institutionally
ion specific electrodes
Accumulation of organic acids (ketones, lactate)
Toxic Ingestions
methanol, ethylene glycol, salicylates
Reduced inorganic acid excretion
phosphates, sulfates
Decrease in unmeasured cations (unusual)
44
Decreased or Negative Anion Gap
Clin J Am Soc Nephrol 2: 162-174, 2007
Low protein most important
Albumin has many unmeasured negative
charges
Normal anion gap (12) in cachectic person
Indicates anion gap metabolic acidosis
Other etiologies of low AG:
Low K, Mg, Ca, increased globulins (Mult.
Myeloma), I intoxication
Negative AG
more unmeasured cations than unmeasured
anions
Bromide, Iodide, Multiple Myeloma
Change in Anion Gap vs HCO
3
In simple AG Metabolic Acidosis
decrease in plasma bicarbonate = increase in
AG

Anion Gap = 1
HCO
3

Helpful in identifying mixed disorders
Respiratory Compensation
for
Metabolic Acidosis:
Occurs rapidly
Hyperventilation
Kussmaul Respirations
Deep > rapid (high tidal
volume)
Is not Respiratory Alkalosis
Metabolic Alkalosis:
Calculation not as
accurate
Hypoventilation
Not Respiratory
Acidosis
Restricted by
hypoxemia
PCO
2
seldom > 50-55
47
Reference
1. Achmadi, A., George, YWH., Mustafa, I. Pendekatan Stewart
Dalam Fisiologi Keseimbangan Asam Basa. 2007
2. Beaudoin, D. Electrolytes and ion sensitive electrodes. PPT.
2003.
3. Ivkovic, A ., Dave, R. Renal review. PPT
4. Kersten. Fluid and electrolytes. PPT.
5. Marieb, EN. Fluid, electrolyte, and acid-base balance. PPT.
Pearson Education, Inc. 2004
6. Rashid, FA. Respiratory mechanism in acid-base homeostasis.
PPT. 2005.
7. Silverthorn, DU. Integrative Physiology II: Fluid and Electrolyte
Balance. Chapter 20, part B. Pearson Education, Inc. 2004
8. Smith, SW. Acid-Base Disorders. www.acid-base.com