Chapter 3 Acid-Base

Balance
N805 ADVANCED PATHOPHYSIOLOGY
DR. GRETCHEN CALDWELL
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Acid-Base Balance
pH—What is it?
 Negative logarithm of the H+
concentration
Increasing H+ pH scale Decreasing H+
0 7 14

Very acidic Neutral Very alkaline

 Each number represents a factor of 10.

 If the solution moves from a pH of 7 to a pH of
6,
then the H+ ions have increased 10-fold.
 If H+ is high in number, pH is low (acidic).
 If H+ is low in number, pH is high
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Acid-Base Balance (Cont.)

 Acids are formed as end products of protein, carbohydrate, and fat

metabolism.
 To maintain the body’s normal pH (7.35–7.45) the H+ must be
neutralized by the retention of bicarbonate or excreted.
 Bones, lungs, and kidneys are major organs involved in the regulation
of acid-base balance.
 pH below 6.8 = death.
 pH above 7.8 = death.
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Acid-Base Balance (Cont.)

 Acid-base balance is mainly concerned with two ions

1. Hydrogen (H+)
2. Bicarbonate (HCO3−)
 Alterations of hydrogen and bicarbonate concentrations in body fluids are
common in disease processes.
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Acid-Base Balance (Cont.)
Volatile Acids Nonvolatile Acids
in the Body in the Body
 Sulfuric, phosphoric, and other
 Carbonic acid (H2CO3)
metabolic acids
 Can be eliminated as carbon  Is eliminated by the renal tubules
dioxide (CO2) gas via the lungs with the regulation of HCO3−.
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Acid-Base Balance (Cont.)

 Sources of H+ ions
 CO2 diffuses into the bloodstream where the following reaction occurs:

Regulated by the Lung Regulated by the Kidney

CO2 + H2O  H2CO3  HCO3− + H+
 No Oxygen
Carbohydrates Fats Proteins
Lactic Acid
Glycolysis

Acetyl CoA

TCA
ATP

CO2 + H2O = H2CO3

Electron Transport Chain

+ Oxidative
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Acid-Base Balance (Cont.)
 pH control mechanisms
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Buffering Systems

 Buffer: Chemical that can bind excessive

H+ or OH− without a significant change in pH
 Located in the ICF and ECF.
 Consist of a buffering pair: weak acid and its conjugate base.
 Most important plasma buffering systems: carbonic acid-bicarbonate system and
hemoglobin
 Associate and dissociate very quickly (instantaneous).
 pK Value

 p = -[log]
 K = equilibrium constant for a given reaction
 pK in a buffering pair is the pH at which the buffer is
half dissociated
 When pH equals pK there is an equal concentration of
acid and its conjugate base. \
 pH = pKₐ + log([A⁻]/[HA]).
 [HA] and [A⁻] refer to the equilibrium concentrations
of the conjugate acid–base pair used to create the
buffer solution.
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Carbonic Acid-Bicarbonate Buffering

 Operates in the lung and the kidney.

 The greater the partial pressure of carbon dioxide (pCO 2), the more
carbonic acid is formed.
 At a pH of 7.4, the ratio of bicarbonate to carbonic acid is 20:1.
 Bicarbonate and carbonic acid can increase or decrease, but the ratio must
be maintained.
 Lungs can decrease carbonic acid.
 Kidneys can reabsorb or regenerate bicarbonate but do not act as fast
as the lungs.
 Carbonic Acid-Bicarbonate Buffering (Cont.) 12

 If bicarbonate decreases, then the pH decreases and can cause acidosis.

 pH can be returned to normal if carbonic acid also decreases.
 This type of pH adjustment is called compensation.
 The respiratory system compensates by increasing or decreasing ventilation.
 The renal system compensates by producing acidic or alkaline urine.
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Other Buffering Systems

 Protein buffering
 Proteins have negative charges; as a result, they can serve as buffers for
H+; mainly intracellular buffer with hemoglobin.
 Respiratory and renal buffering
 Respiratory: Acidemia causes increased ventilation; alkalosis slows
respirations
 Renal: Secretion of H+ in urine and reabsorption of HCO3−; dibasic
phosphate and ammonia
 Cellular ion exchange
 Exchanges of K+ for H+ in acidosis and alkalosis
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Acid-Base Imbalances

 Normal arterial blood pH

 7.35–7.45
 Obtained by arterial blood gas (ABG) sampling

 Acidosis
 pH is less than 7.35.
 Systemic increase in H+ concentration

 Alkalosis
 pH is greater than 7.45.
 Systemic decrease in H+ concentration or excess of base
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Acid-Base Imbalances (Cont.)

 Four categories
1. Respiratory acidosis—elevation of pCO2 as a result of ventilation depression

2. Respiratory alkalosis—depression of pCO2 as a result of hyperventilation

3. Metabolic acidosis—depression of HCO3− or an increase in noncarbonic acids
4. Metabolic alkalosis—elevation of HCO3−, usually as a result of an excessive loss of
metabolic acids
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Respiratory Acidosis

 Causes
 Depression of the respiratory center (brainstem trauma, oversedation)
 Respiratory muscle paralysis
 Disorders of the chest wall (kyphoscoliosis, pickwickian syndrome, flail chest)
 Disorders of the lung parenchyma (pneumonitis, pulmonary edema, and chronic
obstructive lung disease)
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Respiratory Acidosis (Cont.)

 Occurs with alveolar hypoventilation

 pH is below 7.35.
 CO2 elevates from hypercapnia.
 Compensation: Is not as effective since kidneys take time but conserve
bicarbonate and eliminate H+
 Manifestations: Headache, restlessness, blurred vision,
apprehension, lethargy, muscle twitching, tremors, convulsions, coma
 Treatment: Restore adequate ventilation; may need mechanical
ventilation; oxygen therapy
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Respiratory Alkalosis

 Causes
 High altitudes
 Hypermetabolic states, such as fever, anemia, and thyrotoxicosis
 Early salicylate intoxication
 Anxiety or panic disorder
 Improper use of mechanical ventilators
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Respiratory Alkalosis (Cont.)

 Occurs with hyperventilation and decreased

plasma CO2 (hypocapnia).
 pH above 7.45
 CO2 is decreased less than 38 mmHg.
 Manifestations: Dizziness, confusion, tingling of extremities
(paresthesias), convulsions, and coma with signs of hypocalcemia
 Treatment: Paper bag; treat hypoxemia and
hypermetabolic states
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Metabolic Acidosis

 Causes
 Lactic acidosis
 Renal failure
 Diabetic ketoacidosis
 Diarrhea
 Starvation
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Metabolic Acidosis (Cont.)

 Noncarbonic acids increase or bicarbonate (base) is lost from ECF or cannot be

regenerated by the kidney.
 pH drops below 7.35.
 HCO3− drops: less than 24 mEq/L
 Compensation: Hyperventilation and renal excretion of excess acid
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Metabolic Acidosis (Cont.)

 Manifestations:
 Headache
 Lethargy
 Kussmaul respirations
 Treatment:
 Buffering solution administration
 Treat the underlying cause(s)
 Base administration
 Correct sodium and water deficits
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Metabolic Acidosis (Cont.)

 Anion gap
 Used cautiously to distinguish different types of metabolic acidosis.
 By rule, anions (−) should equal cations (+).
 Not all normal anions are routinely measured.
 Represents unmeasured negative ions.
 Normal anion gap is 10–12 mEq/L.
 Normal anion gap or elevated anion gap with metabolic acidosis may help determine
the cause.
 To calculate anion gap [ Na + K ] – [ HCO3 + Cl ]
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Metabolic Alkalosis

 Causes
 Prolonged vomiting
 Gastric suctioning
 Excessive bicarbonate intake
 Hyperaldosteronism with hypokalemia
 Diuretic therapy
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Metabolic Alkalosis (Cont.)

 Bicarbonate concentration is increased, usually

from excessive loss of metabolic acids (Cl −)
 pH is elevated.
 HCO3− is elevated.

 Manifestations: Weakness, muscle cramps,

and hyperactive reflexes with signs of
hypocalcemia
 Treatment: Sodium chloride, potassium,
chloride IV (chloride replaces HCO3−)
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Mixed Acid-Base Disorders

 Two or more primary acid-base disorders occurring at the same time.

 Common in hospitalized individuals.
 Degree of compensation is determined.
 Renal and respiratory compensation rarely returns the pH to normal
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Acid-Base Interpretation
Tic-Tac-Toe Method

 Acid or Base?
Normal Lab Values:
 pH 7.35-7.45
 Metabolic or Respiratory?
 PaCO2: 35-45

 HCO3: 22-26  Compensation?

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Example 1

 Lab Values:
Acid Normal Base
 pH: 7.53
 PaCO2: 41
 HCO3: 32
 Acid or Base?
 Metabolic or Respiratory?
 Compensation?
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Example 1

 Lab Values:

Acid Normal Base
pH: 7.53
 PaCO2: 41
 HCO3: 32
PaCO2 pH
 Acid or Base?
 7.35 = ACID
 7.45 = BASE

HCO3
Metabolic or Respiratory?
 Bicarb = Base
 CO2 = Acid
 Compensation?
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Example 2

 Lab Values:

Acid Normal Base
pH: 7.27
 PaCO2: 65
 HCO3: 30
pH HCO3
 Acid or Base?
 7.35 = ACID
 7.45 = BASE

PaCO2
Metabolic or Respiratory?
 Bicarb = Base
 CO2 = Acid
 Compensation?