Acid Base Disorders: Mr. Ahmed Alnaji Mbchb. Mrcs 1+2 Palestinian Board G. Surgery European Gaza Hospital

Acid base disorders
Mr. Ahmed Alnaji

MBChB. MRCS 1+2
Palestinian board G. Surgery
European Gaza Hospital Slide 001
General concepts
• Acid base homeostasis
the equilibrium between the conc. of H, Pco2 and Hco3.
• An acid is a proton or hydrogen ion donor

• A base is a proton or hydrogen ion acceptor
• Normal PH is 7.35-7.45
Buffering system
• Usually consists of weak acid & its conjugated

base HB H+B
• When added alkali the reaction move to the right.
• Protein & phosphates are the main buffers
intracellularly.
• Bicarbonate is the main extracellular buffer.
Handerson-Hasselbach equation
H2CO3 H + HCO3
H2CO3 CO2 + H2O
So…
CO2 + H2O H2CO3 H + HCO3
therefore PH= pka + log base\ acid

= pka + log HCO3\ H2CO3
= pka + log HCO3\ pa CO2
Excretion of excess acid & alkali
• Via the lungs
• It is a rapid response system
• Allows CO2 to be transferred
• Brainstem resp. centers respond directly by

detecting H in the blood.
• In acidosis increase the rate blowing CO2.
Note : CO2 diffuse 20 times more than O2

Respiratory control
• Works within minutes; maximal in 12-24 hours
• Only 50-75% effective in returning pH
• CO2 readily crosses BBB reacting w H2O to

form H2CO3
• H2CO3 splits into H+ & HCO3- & the H+

stimulates an increase or decrease in
respirations
How does lung control CO2 level?
• Shifting the equation to left
• Medullary ,carotid body chemoreceptors

stimulate respiration
OR……Via the kidneys
• More slowly
• Body produce more acid than base
• Any renal dysfunction resulting in acidosis.
• This require buffer system in urine which are:
H + HPO4 H2PO4
H + NH3 NH4
Note kidney controlling HCO3 by reabsorption &

generation in proximal & distal tubules.
Maintenance of PH
• Chemical buffers
• Respiratory system
• Renal system
Effects on cell
• Excitability of the nerve & muscle cells
• Enzyme activity
• K levels
Simple acid-base disorders
Primary Initial Compensat Expected
disorder changes response compensation.
Metabolic HCO3 PCO2 1.2 X HCO3

acidosis Or 1.5xHco3 +8
Metabolic HCO3 PCO2 0.7 X HCO3
alkalosis Or Hco3 +15
Respiratory PCO2 HCO3 acute0.1x pco2
acidosis ch. 0.3 x pco2
Respiratory PCO2 HCO3 acute0.2x pco2

alkalosis ch. 0.5 x pco2
Examples
Comp. met. Comp. met. Comp. resp. Comp. resp.
acidosis alkalosis acidosis alkalosis
Ph = 7.35 Ph = 7.60 Ph = 7.34 Ph = 7.56
Pco2 = 23 Pco2 = 40 Pco2 = 60 Pco2= 20
Hco3 = 10 Hco3 = 35 Hco3 = 31 Hco3= 20

Metabolic acidosis
Causes:
 Increase acids production
 Shock (lactic acid)
 Diabetes (keto acids)
 Decrease renal acids excretion
 Renal failure (sulfuric, phosphoric acid).
 Loss of alkali.
 Diarrhea, small bowel, pancreatic fistula
 Uretrosigmoidostomy
 Renal tubular acidosis
Anion Gap
Is the difference between the measured cation &
the measured anions.
AG = Na – (Cl + HCO3 ) = 10-15
This represents the unmeasured anions
Increase acid production anion gap
Loss of alkali leads to normal anion gap

Note
In hypoalbumineamia
The anion gap decrease 2.3-2.5 meq/l

for every 1 gm. reduction
Causes of metabolic acidosis
Increase anion gap

Increase acids production:
Ketoacidosis, starvation, diabetic, lactic acidosis

,toxic ingestion, alcoholic..
Renal failure.
Cont………….
Normal anion gap (hyperchloremic)
Renal tubules dysfunction:
Renal tubular acidosis (TYPE 1 & 2)
Hypoaldosteronism (TYPE 4)
K sparing diuretics.
Loss of alkali:
Diarrhea, ureterosgmoidestomy, CA inhibitors ,
parentral nutrition ,pancreatic & biliary fistulas.
M.A in surgical patients?
• Shock
• Severe anemia
• CO poisoning
Symptoms
Deep rapid breathing
Some cardiac arrhythmias

Treatment
• Treat the underlying cause
• Bicarbonate only in moderate to sever cases.
HCO3=wt.x0.4x(desired Hco3–measured Hco3)

Give half over 20 minute, rest over 4 h
8.4%NaHco3 1ml=1mmol
CONT…………….
• In nonurgent cases given as continuous infusion over
4-8 hrs. in liter D5W or in half Nacl
• In urgent cases given as a bolus
• The goal is to raise pH to 7.20 or HCO3 to 10 mmol\l

?? (hypernat., hypercapnea, alkalosis, csf acidosis).
Note/ the use of it in lactic acidosis is controversial.

Metabolic alkalosis
Causes
1.Chloride sensitive MA (in surgical units)
 Inadequate fluid resuscitation or diuretics
 Acid loss through the GIT
 Exogenous HCO3 or HCO3 precursor (citrate in blood)
 Early the kidney excreted it rapidly but later on cannot

because volume and Cl. depletion.
Cont…………
2.Chloride resistance M. Alkalosis
 Hyperaldoseronism
 Marked hypokalemia
 Renal failure
 Alkali abuse.
Symptoms
• Chyne -stock breathing
• Arrhythmias
• Carpo -pedal spasm
• Neuromuscular excitability & parasthesia
• confusion
Diagnosis
Urine chloride concentration
• If less than 15 mmol\l suggest Cl. sensitive

causes.
• If more than 20 mmol\l suggest Cl.

resistance causes.
Treatment
• Identify & remove the cause
• Initially correct volume deficit with NaCl
• In edematous pt. Acetazolamide 5mg\kg\day
• In sever alkalemia HCO3 more than 40 use NH4Cl

by liver to NH3 & HCl
NH4Cl req.= 0.2 x wt. x (103-serum Cl)
• HCl correct it rapidly (0.1 N )100 in lit. sterile water
H req. = 0.5 x wt. x (103-serum Cl) over 24 hrs.i.v
centrally.
In metabolic alkalosis
Almost always give potassium
Hypokalemia
In Pyloric Obstruction
Hypovolemic, Hypokalemic, Hypochloremic,

Metabolic Alkalosis
With
Paradoxical Aciduria
Respiratory acidosis
• Inability to excrete CO2 and the causes are
• Respiratory center depression:

CVA, drugs, brain tumor, encephalitis
• Decrease chest wall movement:

trauma, deformity, NM disorders
• Pulmonary diseases
COPD & pneumonia.
Symptoms & treatment
Headache, blurred vision, restless, coma
Treat the cause

There is no indication for NaHCO3 admin.
Respiratory alkalosis
• Result of acute or chronic hyperventilation

caused by:
• Stimulation of respiratory center:

hypoxia, hypermetabolic state, CVA, exercise
• Excess mechanical ventilation:

certain drugs like aspirin , anxiety.
• PULMONARY EMBOLISM
Mixed acid base disorders
• 2 or 3 primary disorders occur simultaneously

• Normal acid-base pattern may conceal mixed
disorders.
• Never we have 4 primary disorders .
• e.g. vomiting with renal failure M&R acidosis

vomiting with pregnancy M&R alkalosis
sepsis & aspirin overdose
M. acidosis & R. alkalosis.
Normal range of ABG
• Ph 7.35-7.45
• H 35-45 mmol\l
• Po2 10-14 pka or 75-100mmhg
• Pco2 4-6 pka or 35-44mmhg
• Hco3 22-26mmol\l
Interpretation of ABG
1. Is the pt. hypoxic

2. Is the pt. acidotic or alkalotic
3. Is the primary dis. Respiratory \ metabolic
4. Is there a diff. in anion gap in case of MA.
In case of mixed disorders
• Calculate the anion gap
• If AG 20 or more
• Then a metabolic acidosis is present regardless of
the PH or bicarbonate concentration
• Again if AG high then Calculate

• the excess AG (total AG – normal AG)
• then added to measured HCO3(23-30).
• If more than 30 so metabolic alkalosis
• If less than 23 metabolic acidosis
example
• PH =7.50 , pCo2 =20 , HCo3 = 15
Na =145 , Cl = 100
• AG = 145 – (100+15 ) = 30
• Excess AG = 30 -12 = 18
• 18 +15 = 33
• Rule 1
PH is above 7.40….the low pCo2 is a primary
abnormality …resp. alkalosis
• Rule 2
AG is high …..metabolic acidosis
• Rule 3
Excess AG is higher than 30 …met. alkalosis
Pneumonia ,vomiting and alcoholic ketoacidosis

Delta-delta
Does another metabolic disturbance exist w metabolic
acidosis.
• Delta HCO3= 24-HCO3
• Delta AG= calculated AG – expected AG
• IF delta HCO3 = delta AG = pure AG metabolic acidosis
• If delta HCO3 ≥ delta AG = non AG metabolic acidosis is

present
• If delta HCO3 ≤ delta AG = metabolic alkalosis is present

Base Excess
• The amount of strong acid that must be added to
each liter of fully oxygenated blood to return the
pH to 7.40 at a temperature of 37°C and a pCO2
of 40 mmHg.
• A base deficit (i.e., a negative base excess) can

be correspondingly defined in terms of the
amount of strong base that must be added.
INTERPRETATION
Base excess beyond the reference range

indicates
• metabolic alkalosis if too high (more than +2 mEq/L)
• metabolic acidosis if too low (less than −2 mEq/L)

By: Mr. Ahmed Alnaji
ABG's:
pH 7.31 PCO2 55 mm Hg HCO3- 35 mEq/L
pH – low = acidosis
PCO2 – high = respiratory acidosis
HCO3 - high = renal compensation

ABG's:
pH – low = acidosis
PCO2 – low = respiratory compensation
HCO3 - low = metabolic acidosis

ABG's:
pH – high = alkalosis
PCO2 – normal; no compensation
HCO3 – high = metabolic alkalosis

(pH-7.51, pCO2-28, HCO3-26)
show
• Partially compensated respiratory acidosis
• Uncompensated respiratory acidosis
• Partially compensated metabolic acidosis
• Normal acid-base balance
• Uncompensated respiratory alkalosis
• A combined metabolic and respiratory alkalosis

(pH-7.51, pCO2-28, HCO3-26)
show
• Partially compensated respiratory acidosis
• Uncompensated respiratory acidosis
• Partially compensated metabolic acidosis
• Normal acid-base balance
• Uncompensated respiratory alkalosis
• A combined metabolic and respiratory alkalosis

(pH-7.25, pCO2-51, HCO3-30)
could be caused by
• Diarrhea
• Anxiety
• COPD
• An ASA overdose
• Sepsis
• Cocaine overdose
• DKA
• Thoracic Surgery
(pH-7.25, pCO2-51, HCO3-30)
could be caused(Partially compensated respiratory A.)
• Diarrhea M.A
• Anxiety R.ALK
• COPD
• An ASA overdose M.A or R.ALK
• Sepsis R.ALK
• Cocaine overdose R.ALK
• DKA M.A
• Thoracic Surgery
(pH-7.19, pCO2-33, HCO3-14)
• Intestinal fistula
• Emphysema
• Anxiety attack
• Diabetic ketoacidosis
• Prolonged vomiting
• Shock
• Pneumonia
• NG suctioning
• Salicylate intoxication
• A starving patient
(partially compensated metabolic acidosis)
• Intestinal fistula
• Emphysema
• Anxiety attack
• Diabetic ketoacidosis
• Prolonged vomiting
• Shock
• Pneumonia
• NG suctioning
• Salicylate intoxication
• A starving patient
uncompensated metabolic
alkalosis?
1. pH 7.32, PCO2 40, HCO3 19
2. pH 7.55, PCO2 20, HCO3 26
3. pH 7.55, PCO2 37, HCO3 30
4. pH 7.49, PCO2 35, HCO3 29
5. pH 7.30, PCO2 50, HCO3 29
6. pH 7.43, PCO2 53, HCO3 30
7. pH 7.44, PCO2 38, HCO3 26
8. pH 7.43, PCO2 32, HCO3 20

uncompensated metabolic
alkalosis?
1. pH 7.32, PCO2 40, HCO3 19 (uncomp met acid)
2. pH 7.55, PCO2 20, HCO3 26 (uncomp resp alk)
3. pH 7.55, PCO2 37, HCO3 30
4. pH 7.49, PCO2 35, HCO3 29
5. pH 7.30, PCO2 50, HCO3 29 (part comp resp acid)
6. pH 7.43, PCO2 53, HCO3 30 (comp met alk)
7. pH 7.44, PCO2 38, HCO3 26 (normal)
8. pH 7.43, PCO2 32, HCO3 20 (comp resp alk)

(pH 7.63, PCO2-24,HCO3–23)?
• Fear
• Emphysema
• Vomiting
• Narcotic overdose
• Anxiety
• Atelectasis
• Renal failure
Uncompensated respiratory
alkalosis
• Fear
• Emphysema
• Vomiting
• Narcotic overdose
• Anxiety
• Atelectasis
• Renal failure
Summary
• Physiology
• Types and causes
• Interpretation of ABGs
• Treatment
THE END

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Acid base disorders

Mr. Ahmed Alnaji

• An acid is a proton or hydrogen ion donor

• Usually consists of weak acid & its conjugated

therefore PH= pka + log base\ acid

• It is a rapid response system

• Allows CO2 to be transferred

• Brainstem resp. centers respond directly by

• In acidosis increase the rate blowing CO2.

Note : CO2 diffuse 20 times more than O2

• Only 50-75% effective in returning pH

• CO2 readily crosses BBB reacting w H2O to

• H2CO3 splits into H+ & HCO3- & the H+

• Shifting the equation to left

• Medullary ,carotid body chemoreceptors

Note kidney controlling HCO3 by reabsorption &

• Excitability of the nerve & muscle cells

Metabolic HCO3 PCO2 1.2 X HCO3

Respiratory PCO2 HCO3 acute0.2x pco2

Ph = 7.35 Ph = 7.60 Ph = 7.34 Ph = 7.56

Pco2 = 23 Pco2 = 40 Pco2 = 60 Pco2= 20

Hco3 = 10 Hco3 = 35 Hco3 = 31 Hco3= 20

AG = Na – (Cl + HCO3 ) = 10-15

This represents the unmeasured anions

Increase acid production anion gap

Loss of alkali leads to normal anion gap

The anion gap decrease 2.3-2.5 meq/l

Increase anion gap

Ketoacidosis, starvation, diabetic, lactic acidosis

Deep rapid breathing

Some cardiac arrhythmias

HCO3=wt.x0.4x(desired Hco3–measured Hco3)

• In urgent cases given as a bolus

• The goal is to raise pH to 7.20 or HCO3 to 10 mmol\l

Note/ the use of it in lactic acidosis is controversial.

 Inadequate fluid resuscitation or diuretics

 Acid loss through the GIT

 Exogenous HCO3 or HCO3 precursor (citrate in blood)

 Early the kidney excreted it rapidly but later on cannot

2.Chloride resistance M. Alkalosis

• Chyne -stock breathing

• Carpo -pedal spasm

• Neuromuscular excitability & parasthesia

• If less than 15 mmol\l suggest Cl. sensitive

• If more than 20 mmol\l suggest Cl.

• In sever alkalemia HCO3 more than 40 use NH4Cl

Almost always give potassium

Hypovolemic, Hypokalemic, Hypochloremic,

• Respiratory center depression:

• Decrease chest wall movement:

Headache, blurred vision, restless, coma

Treat the cause

• Result of acute or chronic hyperventilation

• Stimulation of respiratory center:

• Excess mechanical ventilation:

• 2 or 3 primary disorders occur simultaneously

• e.g. vomiting with renal failure M&R acidosis

1. Is the pt. hypoxic