09 ACID BASE Disterbences

Life is a struggle,
not against sin,

not against money power,
not against malicious animal
magnetism,
but against hydrogen ions
H.L Mencken
contents
Physiology of acid base homeostasis

Arterial sampling
Importance of H ion status
Acidosis
Alkalosis
Compensation
Interpretation of a report
anion gap
Treatment
In a patient who is seriously ill, it was found that

pH= 7.0, PaCO2=70mm, base excess= -12
True or false
A. Respiratory acidosis
B. Metabolic acidosis
C. Compensated acidosis
D. A mixed disturbance
E. std.Bicarbonate is likely to be 12-15
Blood gas analysis

pH
PaCO
PaO
bicarbonate
std. Bicarbonate
base excess
buffer base
O2 saturation
total CO2
Sampling
Usual
arterial
sites
Brachial
Radial
Dorsalis pedis
Femoral
Umbilical
Points
Aseptic technique
use local
2.5 syringe & 23g needle
Rinse with heparin

Expel all air
Analyze immediately
Or place in ice
Note FIO2 & Temp
Acid base balance

pH=7.36-7.44
PaCO2=36-44
HCO3=24-30
std
HCO3=24-30
base excess=0-/+2
Maintenance
chemical buffers
proteins
HCO3
haemoglobin
PO4
Physio.
mechanisms
ventilation
renal handling
PO4, HCO3, NH4
pH notation
H+ concentration in blood is 0.000000036 to

0.000000044
Sorenson in 1909 devised a more convenient system

1 to 0.000000000000001can expressed as pH 0 to 14
pH is negative logarithm to the base 10 of hydrogen
concentration.
1= 10-0 0.00000000000001 =10-14
Pure water H+ = 0.00000001 pH=7

blood pH is 7.36 to 7.44
anything below 7.36 is acidaemia
anything above 7.44 is alkalaemia
Base excess
Amount of acid needed to bring blood back to

normal pH at a PaCO2 of 40 (body temp and 100%
saturation)
gives an estimate of metabolic status (whatever the
pH or the respiratory status is)
Normally 0 range +2 to -2
+ means met. Alkalosis - means met. Acidosis
Standard bicarbonate
Bicarbonate level if the PaCO2is 40
(at body temp and saturation of 100%)
Gives an estimate of metabolic status
(whatever the pH or the respiratory status is)
Has the same significance as base excess but
numerically different
24 mMol/L
In metabolic acidosis it is low
In metabolic alkalosis it is high
H+ homeostasis
Buffers
physiological
respiratory
metabolic
compensation
Buffers in blood
Acid base disturbances
Usually a combination
of a primary & a compensatory
primary metabolic acidosis with a compensatory

resp. Alkalosis
primary resp. Acidosis with a comp. met. Alkalosis
primary metabolic Alkalosis with a compensatory res.
acidosis
primary res. Alkalosis with a comp. metabolic.
Acidosis
sometimes a mixed disturbance
Metabolic component.
Met.
std. Bicarbonate
base excess
buffer base
total bicarbonate
Acidosis
exogenous
endogenous
diabetic ketoacidosis
shock
lactic acidosis
retention of acid
renal failure
tubular acidosis
loss of bases
intestinal
renal
Met.
Alkalosis
gain of bases
loss of acids
vomiting
gastric aspiration
k+ depletion
diuretics
Effects
of
acidaemia
consciousness
contractility
vasodilatation
sympathetic Activity
arrhythmia
hyperkalaemia
Effects
of
alkalaemia
neuromuscular
excitability
vasoconstriction
cardiac output
arrhythmia
Quantification of Res. component

For acute changes
For every 10 mm rise,pH comes down by0.05
For every 10 mm fall, pH goes up by
0.1points
For every 10 mm rise, HCO goes up by
3
1mMol
For every 10 mm fall, HCO falls by 2mMol
3
For chronic changes
HCO changes are more
3
pH changes are less
l o o k a t th e p h a n d th e p a c o 2
a re th e y i n th e c o rre c t d i r e c ti o n
yes
re s .d i s tu rb a n c e
a m o u n t w ro n g
p h c h a n g e to o l i t tl e
m e t. c o m p e n s a ti o n
p h c h a n g e to o m u c h
m e t d i s tu rb a n c e i n th e s a m e d i r e c ti o n
no
(p ro b a b l y a re s . c o m p a n s a tio n )
p ri m a ry i s m e ta b o li c
i s th e a m o u n t c o rre c t
n o m e t. d i s tu rb a n c e
b a s e e x c e s s z e ro
w h a t w o u l d b e th e p h
if n o t fo r th e m e t. d i s tu rb a n c e
0 .0 5 p h p o i n t/1 0 m m ra i s e o f c o 2
0 .1 p h p o in ts fo r 1 0 m m d ro p o f c o 2
m u l t i p l y th e d iffe ra n c e b y 5 0 to
to s e e th e b a s e e x e c e s s
(in a l k a l o s is b y 1 0 0 )
An elderly carpenter, a chronic

smoker, arrived at the
emergency room, cyanotic,
puffing frantically, and
semicomatose. An ABG
obtained while he was
breathing air showed a
PaO2 of 34 mmHg,
PaCO2 of 70 mmHg,
pHa of 7.10.
He is acidotic
CO2 can account for pH
reduction of .15
rest must be metabolic.
Which will appear as a
negative base excess of
7.5
probably due to
hypoxaemia he is having.
In a diabetic patient
pH=7.19 PaCO2=23
Acidaemia
not respiratory
respiratory
compensation
Base excess=17.7
std HCO =9.8
3
HCO3=8.4
Due to respiration
alone pH should be
7.57
Met. Changes has
brought it to 7.19
0.38 pH points
=base exess of-19
std HCO of 8 or so
3
HCO3 of 6.3
In a patient who has taken an overdose of drugs

pH=6.98 & PaCO2=110
Acidotic
Respiration will lower

Respiratory acidosis
pH to 7.05
Difference is metabolic
No compensation
Met. acidosis in addition 0.07 divide by 2 will

give you base excess
of -3.5
Base excess=-3.2
std HCO of 20.5 or so
3
std HCO =21
HCO of 27.5
3
3
HCO3=25
Therapy
Uncompensated
respiratory acidosis
no difficulty
chronic
respiratory acidosis
ventilator treatment needs lots of thinking
metabolic
alkalosis
correct potassium
dilute HCL
Metabolic acidosis
most of the time treatment with buffers
not indicated specially in ketoacidosis
and other high gap acidosis
Bicarbonate
carbicarb
THAM
dichloroacetate
Anion gap
=Na+-[cl- +HCO-3]
normal :10-12meq/l
Increased gap
ketoacidosis
lactic acidosis
chronic renal failure
methyl alcohol
Normal gap
diarrhoea
fistulae
renal tubular acidosis
Overlap exists in ketoacidosis where renal

function is good.
Anion gap in other

conditions
HIGH
Hypokalaemia
Hypomagneceamia
Hypocalcaemia
Metabolic alkalosis
LOW
Hypo-albuminaemia
Multiple myaloma
PROBLEMS OF BICARBONATE
CO2 diffuses into cells
fizzes
adds Na+
overshoot alkalaemia
fluid overload
overall change in mortality is not encouraging
Dose of bicarbonate
1-2 meq/kg for a start
blood gases 15 min. later
aim is to overcome life threatening pHs ie <7.0
HCO3~ deficit (mEq) = 0.5 x lean body wt (kg) x

(desired [HCO3-] - measured [HCO3-])
Formula is outdated
In a patient who is seriously ill, it was found that

pH= 7.0, PaCO2=70mm, base excess= -12
True or false
A .respiratory acidosis
T
B. metabolic acidosis
T
C. compensated acidosis
F
D. a mixed disturbance
T
E.std.bicarbonate is likely to be around 12- 15 T

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Life is a struggle,

not against sin,

Physiology of acid base homeostasis

In a patient who is seriously ill, it was found that

Blood gas analysis

Rinse with heparin

Acid base balance

H+ concentration in blood is 0.000000036 to

Sorenson in 1909 devised a more convenient system

Pure water H+ = 0.00000001 pH=7

Amount of acid needed to bring blood back to

Acid base disturbances

primary metabolic acidosis with a compensatory

sometimes a mixed disturbance

Quantification of Res. component

pH changes are less

An elderly carpenter, a chronic

In a patient who has taken an overdose of drugs

Respiration will lower

Met. acidosis in addition 0.07 divide by 2 will

ventilator treatment needs lots of thinking

Overlap exists in ketoacidosis where renal

Anion gap in other

1-2 meq/kg for a start

blood gases 15 min. later

aim is to overcome life threatening pHs ie <7.0

HCO3~ deficit (mEq) = 0.5 x lean body wt (kg) x

In a patient who is seriously ill, it was found that

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