Focus On Acid-Base Balance

Focus on
Acid-Base Balance
Copyright 2007, 2004, 2000, Mosby, Inc., an affiliate of Elsevier Inc. All Rights Reserved.
Purpose
Maintain a steady balance between acids
and bases to achieve homeostasis
Health problems lead to imbalance
Diabetes mellitus
Vomiting and diarrhea
Respiratory conditions
Shock
Acid
Substance that contains H+ ions
that can be released
H2CO3-Carbonic acid releases H+
Base
Substance that can accept H+ ions
HCO3-Bicarbonate accepts H+
pH
Measure of H+ ion concentration
H+ = 40 nmol/l
pH = NEGATIVE LOGARITHM OF H+
Normal Acid-Base Balance
Normal pH 7.35-7.45
Narrow normal range
___/______/___/______/___
6.8 7.35 7.45 7.8
Acid Alkaline
pH
Blood is slightly alkaline pH 7.35 to 7.45

Below 7.35 is acidemia
Above 7.45 is alkalemia
Regulators of Acid/Base
Metabolic processes produce acids that
must be neutralized and excreted
Regulatory mechanisms
Buffers
Respiratory system
Renal system
Buffer Systems
Combination of a weak acid with the respective
salt
Acts as a base or an acid depending of the
environement H+
H+
Prevent major changes in pH H+
Act as sponges
3 main systems
Bicarbonate-carbonic acid buffer
Phosphate buffer
Protein buffer
Henderson equation
Key concept
H+ = Ka x (HA/A-)
H+ = 24 x (PCO2/HCO3) = 40 nmol/l
CO2 +H2O H2CO3 H+ + HCO3

Carbon Carbonic Bicarbonate
Dioxide Acid
(ACID) (BASE)
Henderson-Hasselback equation
pH = pKa x log (A-/HA)
pH = pK x log(HCO3/paCO2) x 0.03 = 7.4
7.4 = 6.1 + log 20/1
Buffers: act chemically to neutralize acids
or change strong acids to weak acids
Primary regulators
React immediately
Cannot maintain pH without adequate
respiratory and renal function
Respiratory system: eliminates CO2
Respiratory center controls breathing
Responds within minutes/hours to changes in
acid/base
Increased respirations lead to increased CO2
elimination and decreased CO2 in blood
Renal system: eliminate H+ and reabsorb
HCO3-
Regeneration of HCO3-
Reabsorption and secretion of electrolytes
(e.g., Na+, Cl-)
Responds within hours to days
Kidneys usually secrete acidic urine (pH 6)
Kidneys can increase or decrease pH as a
compensatory mechanism
Blood Gas Values
Arterial blood gas (ABG) values provide
information about
Acid-base status
Underlying cause of imbalance
Bodys ability to regulate pH
Overall oxygen status
Interpretation of ABGs
7.4 = 6.1 + log 20/1
HCO3-/H2CO3 = 20/l
Acid-Base Imbalances
Acidemia
pH falls below 7.35
Increase in blood carbonic acid
or
Decrease in bicarbonate
Alkalemia
pH greater than 7.45
Increase in bicarbonate
or
Decrease in carbonic acid
Primary cause or origin:
Metabolic
Changes brought about by systemic
alterations (cellular level)
Respiratory
Changes brought about by
respiratory alterations
Acid-Base Imbalances (cont'd)
Alterations in acid-base balance
Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis
Mixed acid-base disorders
Modificri primare ale EAB i mecanismul compensator corespunztor
Parametru Mecanism
Modificare primar modificat compensator
Acidoza metabolic HCO3- pCO2
Alcaloza metabolic HCO3- pCO2
Acidoza respiratorie pCO2 HCO3-
Alcaloza respiratorie pCO2 HCO3-
Diagnosis in six steps
Evaluate pH
Analyze PaCO2
Analyze HCO3-
Determine if CO2 or HCO3- matches the
alteration
Decide if the body is attempting to
compensate
Interpreting ABGs
Determine level of compensation
Has the body tried to readjust the pH?
Uncompensated
Partly compensated
Compensated
Interpreting ABGs
Uncompensated
pH abnormal (high or low)
One component abnormal (high or
low CO2 or HCO3)
The other component is normal
(The component not causing the acid-base
imbalance is still normal)
Example: pH 7.2; pCO2 65; HCO3 24
Partly compensated
pH not normal (but moving toward
normal)
Both CO2 and HCO3 are outside normal
range
The component that was normal is
changing in order to compensate
Interpreting ABGs
Compensated
pH almost normal
Other values abnormal in
opposite directions
One is acidotic the other alkaline
Modificari in tulburarile acido-bazice primare
Modificari primare Variatie asteptata

Acidoza metabolica PCO2 = 1,5 x HCO3 + (8 2)
Alcaloza metabolica PCO2 = 0,7 x HCO3 + (21 2)
Acidoza respiratorie acuta pH = 0,008 x (PCO2 40)
Acidoza respiratorie cronica pH = 0,003 x (PCO2 40)
Alcaloza respiratorie acuta pH = 0,008 x (40 PCO2)
Alcaloza respiratorie cronica pH = 0,017 x (40 PCO2)
Practice Problem
80 year old female with severe

pneumonia, fever
pH = 7.25
PaCO2 = 55 mm Hg
HCO3 = 24 mEq/L
PaO2 = 65 mm Hg
O2 sat = 80%
Practice Problems
What is the problem?
Acidosis or alkalosis?
Respiratory or metabolic?
Compensated or not?
Level of hypoxemia?
Diagnoses?
Interventions?
pH 7.18
PaCO2 38 mm Hg
PaO2 70 mm Hg
HCO3- 15 mEq/L
What is this?
pH 7.50
PaCO2 30 mm Hg
PaO2 60 mm Hg
HCO3- 22 mEq/L
What is this?
pH 7.36
PaCO2 67 mm Hg
PaO2 47 mm Hg
HCO3 37 mEq/L
What is this?
pH 7.28
PaCO2 28 mm Hg
PaO2 70 mm Hg
HCO3- 18 mEq/L
What is this ?
pH 7,47
paCO2 45 mmHg
HCO3 32 mEq/l
Cl 97 mEq/l
Na 140 mEq/l
K 2,8 mEq/l
Management - Respiratory Acidosis
Maintain patent airway

Oxygen support, ventilation
Positioning/turning q 2 hrs
Pulmonary hygiene (postural drainage, chest
clapping)
Noninasive ventilation
Mechanical ventilation
Management - Respiratory Alkalosis
Teach how to relieve/ prevent anxiety
Calm environment
Positioning for comfort
Management - Metabolic Alkalosis
Monitor serum electrolytes, ABGs
Antiemetics to relieve vomiting
Administer K and Cl replacement as ordered
Monitoring of diuretic therapy
Management - Metabolic Acidosis
Frequent assessment of vital signs esp
respiratory rate and rhythm (compensatory
mechanisms)
Treat diabetes, shock.
Sodium bicarbonate IV ?
In considering acute bicarbonate replacement four
questions should be considered
1. What are the deleterious effects of

acidemia and when are they
manifest?
2. When is acidemia severe enough to

warrant therapy?
3. How much bicarbonate should be given
and how is that amount calculated?
4. What are the deleterious effects of

bicarbonate therapy?
Deleterious effects of acidemia
Decreased myocardial contractility

Fall in cardiac output
Fall in BP
Pulmonary venoconstriction
Sensitizes the myocardium to arrhythmias
Deleterious effects of acidemia
Decreased binding of norepinephrine to its

receptors
Acidemia may adversely affect cell

functions such as enzymatic reactions,
ATP generation, fatty acid biosynthesis,
and bone formation/resorption
Extracellular pH is a surrogate for intracellular
pH
Optimal extracelluar pH 7.4
Optimal intracellular pH 7.1
Deviations from normal pH will obviously

decrease the efficiency of all reactions
Acidemia protects the central nervous
system against seizures
When is acidemia severe enough to warrant therapy?
Give bicarbonate to a patient with an

arterial pH < 7.1
Not a hard and fast rule
How much bicarbonate should be given and
how is that amount calculated?
The volume of distribution of
bicarbonate is approximately that of
total body water
How much bicarbonate should be given and how is
that amount calculated?
Any calculated amount is approximate
0,6 x G x (15 - HCO3 actual):2
Reevaluate in two hours
Make new plan based on the new data
Correct the underlying cause(s)
What are the deleterious effects of bicarbonate
therapy?
Bicarbonate therapy is associated with an
increase in mortality
Fall in blood pressure and cardiac output
Sensitizes the heart to abnormal electrical

activity and subsequent arrhythmias
therapy?
Paradoxical intracellular acidosis CO2
shifts into cells
Both volume expansion and

hypernatremia can occur
Fulminate congestive heart failure with

flash pulmonary edema may result
therapy?
Rebound alkalemia especially with low
arterial pCO2
This potential bicarbonate will be

converted back to actual bicarbonate
unless it lost in the urine
Anionic gap
AG = (Na+ + K+) - (Cl- + HCO3-)
Acidoza metabolica cu AG crescut
acumulare H+ -> +HCO3 -> H2CO3 =>
scadere bicarbonat
acidoza lactica
ketoacidoza
insuficienta renala
Acidoza metabolica cu AG normal
pierdere de bicarbonat din SEC =>
acumulare de clor pentru mentinerea
electroneutralitatii
diaree
IR precoce
Metabolic acidosis
Anion-Gap:
Non-anion gap:
Acids associated with an
unmeasured anion are Bicarbonate, chloride
produced or exogenously Hyperchloremic acidosis
gained Renal vs. GI loss of HCO3-
Treatment: Treatment:
Correct underlying Bicarbonate therapy
cause
(Bicarbonate: severe
acidemia)
Indicaiile terapiei cu soluii alcaline
Indicaii ferme Indicatii posibile Indicatii abandonate
Acidoz Acidoza Stopul cardio-

metabolic metabolic sever respirator
hipercloremic cu AG crescut (n faza iniial a
(pH 7,20) resuscitrii cardio-
pulmonare
Pierderi de Agravarea rapid Acidoza metabolic
HCO3- a acidozei moderat cu AG
metabolice cu normal
AG crescut pH 7,20
Exemplu Exemplu
Acidoza hipercloremica Acidoza lactica
in diaree severa pH 7,29
pH 7,29 paCo2 29 mmHg
paCo2 29 mmHg HCO3 14 mEq/l
HCO3 14 mEq/l Na 136 mEq/l
Na 138 mEq/l Cl 105 mEq/l
Cl 116 mEq/l AG 21 mEq/l
AG 11 mEq/l lactat 10 mEq/l
lactat 1.5 mEq/l K 4.0 mEk/l
K 3,0 mEq/l

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Focus on

Blood is slightly alkaline pH 7.35 to 7.45

CO2 +H2O H2CO3 H+ + HCO3

7.4 = 6.1 + log 20/1

7.4 = 6.1 + log 20/1

Modificari primare Variatie asteptata

80 year old female with severe

Maintain patent airway

1. What are the deleterious effects of

2. When is acidemia severe enough to

4. What are the deleterious effects of

Decreased myocardial contractility

Decreased binding of norepinephrine to its

Acidemia may adversely affect cell

Optimal extracelluar pH 7.4

Optimal intracellular pH 7.1

Deviations from normal pH will obviously

Give bicarbonate to a patient with an

Not a hard and fast rule

Any calculated amount is approximate

0,6 x G x (15 - HCO3 actual):2

Make new plan based on the new data

Correct the underlying cause(s)

Fall in blood pressure and cardiac output

Sensitizes the heart to abnormal electrical

Both volume expansion and

Fulminate congestive heart failure with

This potential bicarbonate will be

Indicaii ferme Indicatii posibile Indicatii abandonate

Acidoz Acidoza Stopul cardio-

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