Presented by

Dr Achyut Bhakta Acharya

Resident,IM
NAMS

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 TERMINOLOGIES
 ACID:- A chemical species that can act as a proton (H+)
donor
 BASE:- A chemical species that can act as a proton (H+)
acceptor

 STRONG ACID:- A substance that readily and almost

irreversibly gives up an H+ and increases [H+]
 STRONG BASE:- A substance that avidly and almost
irreversibly binds H+ and decreases [H+]

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 TERMINOLOGIES (contd)
 WEAK ACID:- A substance that reversibly donates H+
and tends to have less of the effect on [H+]

 WEAK BASE:- A substance that reversibly binds H+ and

tends to have less of the effect on [H+]

 BUFFER or CONJUGATE PAIRS:- A solution that

contains a weak acid and its conjugate base or a weak
base and its conjugate acid

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 TERMINOLOGIES (contd)
 ACIDOSIS:- Any pathologic process that tends to lower
pH
 ALKALOSIS:- Any pathologic process that tends to
increase pH
 METABOLIC DISORDER:- A disorder that primarily
affects [HCO3-]
 RESPIRATORY DISORDER:- A disorder that primarily
affects PaCO2
 SIMPLE ACID-BASE DISORDER:- The presence of only
one pathologic process
 MIXED ACID-BASE DISORDER:- The presence of one
or more primary processes
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 TERMINOLOGIES (contd)
 ACIDEMIA & ALKALEMIA:- The net effect of all primary
processes and compensatory physiological responses on
arterial blood pH

 BASE EXCESS / DEFICIT:- The amount of acid or base

that must be added to return blood pH to 7.4 and PaCO2
to 40 mmHg at full O2 sat. and 37°C
 Represents the metabolic component of an acid-base
disorder
 Positive BE / Negative BD indicates metabolic alkalosis
 Negative BE / Positive BD indicates metabolic acidosis

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 TERMINOLOGIES (contd)
 ANION GAP:- The difference between the major
measured cations and the major measured anions
Anion Gap=[Na+] – ([Cl-] + [HCO3-])=7-14 mEq/L
 DELTA ANION GAP:- The ratio of
(anion gap – 10)/( 24 - HCO3), assess increase in anion
gap relative to decrease in HCO3-
 URINE ANION GAP:- The difference between the major
measured cations and the major measured anions in
urine
UAG = [Na+] + [K+] – [Cl-] = -20 to 0 mEq/L

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 Compensatory mechanisms
Physiological responses to changes in [H+] is characterized by
 Chemical buffers (immediate response)
 Respiratory compensation
 Renal compensation
 Slower
 More effective

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Compensatory mechanisms
Body Buffers
Buffers Sites
Bicarbonate (H2CO3/HCO3-) ECF
Hemoglobin (HbH/Hb-) Blood
Intracellular proteins (PrH/Pr-) ICF
Ammonia (NH3/NH4-) Urine
Phosphate (H2PO4-/HPO422-) Urine
Intracellular K+ ECF
Na+ & Ca2+ from bones Bone
(CaCO3,CaHPO4, NaHCO3)
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 Basic concepts
 Hydrogen ion concentration and pH
 Hydrogen ion concentration is traditionally expressed by pH
which is a logarithmic function of the [H+]
pH=log 1/H+= -log[H+]
 Normal pH of plasma range from 7.35 to 7.45
 When hydrogen ion concentration increases, pH decreases
and vice versa
 [H+]= 24 × (PCO2/HCO3)=40 at pH 0f 7.4

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 Primary acid base disorders
 Respiratory
 When a change in PCO2 is responsible for a change in [H+]
 Increase in PCO2 is respiratory acidosis
 Decrease in PCO2 is respiratory alkalosis
 Metabolic
 When a change in HCO3 is responsible for a change in [H+]
 Decrease in HCO3 is metabolic acidosis
 Increase in HCO3 is metabolic alkalosis

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 Secondary response
 To limit the change in [H+] produced by primary acid base
disorders
 Accomplished by changing the other component of the
PaCO2/HCO3 ratio in the same direction
 Eg:
 In primary respiratory acidosis where PCO2 is
increased,secondary response will involve an increase in HCO3
that will limit the change in [H+]

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 Responses to metabolic Acid base
disorders
 Involves change in minute ventilation that is mediated by
peripheral chemoreceptor located in the carotid body at the
carotid bifurcation in the neck

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 Metabolic acidosis
 Secondary response is increase in minute ventilation and
subsequent decrease in PaCO2
 Response appears in 30-120 mins,can take 12-24hrs to complete
 Change in PaCO2= 1.2 × change in HCO3
 Expected PaCO2=40 –change in PaCO2
 Anion gap calculation and Gap gap calculation

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 Metabolic alkalosis
 Secondary response is decrease in minute ventilation and
subsequent increase in PaCO2
 Change in PaCO2= 0.7 × change in HCO3
 Expected PaCO2= 40 + change in PaCO2

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Responses to respiratory acid base
disorders
 Secondary response to changes in PaCO2 occurs in the
kidneys where HCO3 absorption in proximal tubes is
adjusted to produce appropriate change in plasma HCO3.
 Renal response is relatively slow and can take 2-3 days so
respiratory acid base disorders are separated into acute and
chronic disorders

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 Acute respiratory disorders
 Acute changes in PaCO2 have small effect on plasma HCO3
 For acute respiratory acidosis
 Change in HCO3= 0.1 × change in PaCO2
 Expected HCO3= 24 + change in HCO3
 For acute respiratory alkalosis
 Change in HCO3= 0.2 × change in PaCO2
 Expected HCO3= 24- change in PaCO2

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 Chronic respiratory disorders
 Renal response to an increase in PaCO2 is an increase in
HCO3 reabsorption in the proximal renal tubules,which
raises the plasma HCO3 concentration.
 Response to decrease in PaCO2 is decrease in renal HCO3
reabsorption which lowers plasma HCO3 concentration
 Change in HCO3= 0.4 × change in PaCO2 for both acidosis
and alkalosis
 For chronic respiratory acidosis
 Expected HCO3= 24 + change in HCO3
 For chronic respiratory alkalosis
 Expected HCO3= 24- change in HCO3

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Stepwise approach to acid base
analysis
 Stage 1: identify primary acid base disorder
 PaCO2 and pH used to identify
 Rule 1: if PaCO2 and/or pH is outside normal range,there is
an acid base disorder
 Rule 2: if PaCO2 and pH are both abnormal,compare
directional change
 2a: if PaCO2 and pH change in same direction,there is primary
metabolic acid base disorder
 2b: if PaCO2 and pH change in opposite directions,there is
primary respiratory acid base disorder.

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 Eg:
 a case where arterial pH=7.2 and PaCO2=20.
 Here both are reduced indicating primary metabolic disorder
and as pH is acidic, diagnosis is primary metabolic acidosis

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 Rule 3: if only pH or PaCO2 is abnormal, condition is mixed
metabolic and respiratory disorder.

 3a: if PaCO3 is abnormal, directional change in PaCO2

identifies type of respiratory disorder i.e. high PaCO2 indicates
a respiratory acidosis and the opposing metabolic disorder

 3b: if pH is abnormal ,directional change in pH identifies the

metabolic disorder i.e. low pH indicates metabolic acidosis and
the opposing respiratory disorder

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 Eg:
 a case where pH 7.38 and PaCO2 55mmHg.
 Only PaCO2 is abnormal, so there is mixed disorder.
 As PaCO2 is elevated indicating respiratory acidosis and so the
metabolic disorder must be metabolic alkalosis

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 Stage 2: Evaluate the secondary response
 Goal is to determine if there is an additional acid base disorder

 Proceed to stage 3 if mixed acid base disorder identified in

stage 1

 Rule 4: for a primary metabolic disorder,if measured PaCO2

is higher then expected,there is secondary respiratory
acidosis and if measured PaCO2 is less than expected,there is
secondary respiratory alkalosis

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 Eg: case where PaCO2 =23,pH=7.32 and HCO3=16.

 pH and PCO2 changed in same direction,indicating metabolic

and as pH is acidic,disorder is primary metabolic acidosis
 Now,change in PaCO2= 1.2 × change in HCO3= 1.2 × (24-16)=10
 Expected PaCO2= 40-change in PCO2=40-10=30
 The measured PCO2 is 23 which is lower than expected
PCO2,so there is additional respiratory alkalosis
 So condition is primary metabolic acidosis with a sencodary
respiratory alkalosis

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 Rule 5: for a primary respiratory disorder, a normal or near
normal HCO3 indicates that the disorder is acute

 Rule 6: for a primary respiratory disorder where HCO3 is

abnormal, determine the expected HCO3 for a chronic
respiratory disorder
 6a: for a chronic respiratory acidosis, if HCO3 is lower than
expected, there is an incomplete renal response and if HCO3 is
higher than expected, there is secondary metabolic alkalosis
 6b: for chronic respiratory alkalosis, if HCO3 is higher than
expected, there is incomplete renal response and if HCO3 is
lower than expected there is secondary metabolic acidosis.

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 Eg: patient with PaCO2 23 mm Hg and pH of 7.54 and HCO3
38.

 PaCO2 and pH change in opposite directions so the primary

problem is respiratory and, since the pH is alkaline, this is
primary respiratory alkalosis.
 The HCO3 is abnormal indicating chronic condition
 expected HCO3 for chronic respiratory alkalosis is 24-0.4×
(40-23)=17
 The measured HCO3 is high than expected so there is
secondary metabolic alkalosis

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 Stage 3: use Gaps to evaluate metabolic acidosis
 Helps to identify underlying cause of acidosis

The Anion Gap

 Is an estimate of the relative abundance of unmeasured
anions
 Used to determine if a metabolic acidosis is due to an
accumulation of non-volatile acids (e.g. lactic acid) or a net
loss of bicarbonate (e.g. diarrhea)

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 The Anion Gap….
 By the law of electroneutrality,
Unmeasured anions + measured anions = unmeasured
cations + measured cations,
 Unmeasured anions – unmeasured cations = measured
cations – measured anions,
 Anion Gap = [Na +] – ([Cl -] + [HCO3-])
 Normal value = 7 – 14 mEq/L
 Unmeasured anions = plasma proteins, SO42-, PO42- and
organic anions
 Unmeasured cations = K+, Ca2+, Mg2+

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 The Anion Gap….
 Plasma albumin accounts for the largest fraction of the
anion gap (11 mEq/L)
 Adjusted AG = observed AG + 2.5 x (4.5 - measured
albumin in g/dl)
 Any process that increases “unmeasured anions” or
decreases “unmeasured cations” will increase the anion
gap and vice versa

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 Increased Anion Gap
 Increased production of nonvolatile acids
 Ketoacidosis
 Uremia
 Salycilate toxicity
 Sepsis
 Methanol poisoning
 Ethanol poisoning
 Lactic acidosis
 Ethylene glycol poisoning

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 Normal Anion Gap (Hyperchloremic)
 Increased GI losses of HCO3-
 Diarrhoea
 Anion exchange resin (cholestyramine)
 Ingestion of CaCl2. MgCl2
 Fistulae (pancreatic, billiary or small bowel)
 Increased renal losses of HCO3-
 Renal tubular acidosis
 Carbonic anhydrase inhibitors
 Hypoaldesteronism

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 Normal Anion Gap (Hyperchloremic)
 Dilutional
 Large amount of HCO3- free fluids
 Total parentral nutrition
 Increased intake of chloride containing acids
 Ammonium chloride
 Lysine hydrochloride
 Arginine hydrochloride

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 Urine Anion Gap
 Useful in evaluation of non anion gap metabolic acidosis
to r/o non renal loss of HCO3
 UAG = Unmeasured anions – unmeasured cations
= measured cations – measured anions
= [Na +] + [K +] – [Cl -] = -20 to 0 mEq/L
 The predominant unmeasured urine cations = NH4+
 Large negative urine anion gap = metabolic acidosis with
intact renal acidification (diarrhoea)
 Positive urine anion gap = metabolic acidosis with
impaired renal acidification (RTA)
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 The Delta Anion Gap
 Used to detect additional acid-base disorders in patients
with high anion gap metabolic acidosis
 Assess  in anion gap relative to  in HCO3 -
 Delta anion gap = (anion gap – 10) / ( 24 - HCO3)
 Normal value = 1
 Value <1 = HCO3- has decreased out of proportion to the
elevation of anion gap and suggests the presence of
nonanion gap metaboic acidosis
 Value >1 = the anion gap has increased out of proportion
to the rise in HCO3- and suggests the presence of a
concommitant metabolic alkalosis

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 Example
 A 42 yr old man brought to the ER after he was found
lying in an alley with an empty liquor bottle near by.
P=110/m,BP=120/80mmHg,RR=28/m,T=98.6ºF. The patient was
unresponsive. Pupils were minimally reactive to light, and
fundoscopic exam was normal. Bibasilar crackles were noted.
His deep tendon reflexes were brisk and symmetric, and
plantar reflexes were normal. His history suggested ingestion of
a toxin, some of which are associated with acid-base disorders.

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 The patient’s lab reports were as follows:
 Arterial blood gas pH=7.1
 PaCO2= 35mmHg
 PaO2=90mmHg at room air
 Na+= 145mEq/L
 Cl- =97mEq/L
 HCO3- =12mEq/L
 Blood urea nitrogen=30mg%
 Creatinine=1.5mg%
 Glucose = 110mg%

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 Test the accuracy of the data

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 [H+]=24 × PCO2/HCO3=70
 Then,
 For every 0.1 decrease in pH,multiply H+ sequentially by
1.25. In our case,40×1.25 ×1.25 ×1.25=78
 For every 0.1 increase in pH,multiply H+ sequencially by
0.8
 Comparing both which is close,so test is valid.

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Identify primary disorder

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 Both pH(7.1) & PaCO2 (35mmHg) has decreased, the
primary disorder is metabolic acidosis

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Calculation of the expected compensation

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 Decrease in PaCO2 = 1.2 × (24 – 12) = 14.4 mmHg
 Expected PaCO2 = 40 –14 = 26 mmHg
 Measured PaCO2 = 35 mmHg
  concomitant respiratory acidosis is present

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Calculate the gaps

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 The anion gap = 145 - 97 – 12 = 36 mEq/L
High anion gap metabolic acidosis

 The delta anion gap = (36-10)/(24-12)= 2.2 which is >1

Additional metabolic alkalosis

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 In summary, this patient has a complex triple acid base
disorder:
high anion gap metabolic aciosis secondary to toxic
ingestion (methanol or ethylene glycol), respiratory
acidosis & metabolic alkalosis, probably as a result of
vomiting

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Reference Paul Marino’s ‘the ICU Book’

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Thankyou

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