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Patho Wk 5: Ch.


Part 2 - 1


Differentiate between metabolic/respiratory acidosis and metabolic/respiratory alkalosis.

Describe the meaning of anion gap and explain the significance of an abnormal anion gap in metabolic acidosis.
Electrolyte = a substance which develops an electrical charge in the presence of water

Cation = (+)  Na, K

Anion = (-)  Cl
Acid = Electrolyte that forms a hydrogen cation and an anion in the presence of water

Weak acid – Partially ionizes in water  H2CO3 (Carbonic Acid)

Strong acid – Totally ionizes in water  HCl (Hydrochloric Acid)
Base = A substance that can ACCEPT hydrogen ions

Weak base – Do not bind well with hydrogen  HCO3- (Bicarbonate)

Strong base – Binds well with hydrogen  OH- (Hydroxide); KOH (Potassium hydroxide)
pH = Expression of the hydrogen ion concentration

Ranges from 0 - 14

Neutral = pH of 7

Acidosis = pH LESS than 7

Alkalosis = pH GREATER than 7

Physiological pH = 7.4

Varies depending on body fluid: ABG = 7.35-7.45, Urine = 5-6, Pancreatic fluid = 7.8-8.0
Volatile Acid = CAN be eliminated as CO2 gas via the lungs

EX: Carbonic acid  H2CO3 dissociates to CO2 and H2O
Nonvolatile Acid = CANNOT be eliminated as CO2 gas

EX: Lactic acids & Ketoacids
Buffers = A substance or a thing that helps control the pH of a solution (body wants a normal pH!)

o Control pH – respond to changes in acid-base balance
o Converts a strong acid/base into a weak one – by absorbing excess hydrogen ions or excess hydroxide to
minimize fluctuations in pH

Blood buffering system = Within seconds, ongoing

Respiratory system (/ RR) = 20-30 minutes (RAPID)

Renal system (produce more acidic or alkaline urine) = Several days (SLOW)
BUFFER SYSTEMS – act to keep pH normal

BICARBONATE  Most important (plasma) buffer system!
o Operates both in the lung and the kidney
o Consists of H2CO3 and HCO3- (Carbonic Acid and Bicarbonate)
o How does it work?

CO2 is excreted or retained as needed via lungs

HCO3 is excreted or retained as needed via kidneys

PROTEIN BUFFER SYSTEM  intracellular (imp in blood/intracellular)
o Proteins carry a negative (-) charge
o They can combine with H+ ions
o EX: Hemoglobin

H+ combines with Hgb to form HHgb

HHgb combines with CO2 to form HHgbCO2

Patho Wk 5: Ch. 3

Part 2 - 2

HHgb is a weak acid (Hydrogen hgb)

PHOSPHATE BUFFER SYSTEM  kidneys (imp in blood/intracellular)
o Red blood cells
o Renal tubules

RENAL BUFFERS  phosphate and ammonia via kidneys

HPO4-- (hydrogen phosphate) + H+ (hydrogen)  H2PO4- (dihydrogen phosphate)

This monobasic phosphate is lipid insoluble

Dibasic phosphate HPO4-
Filtered at the glomerulus

75% is reabsorbed

NH3 (ammonia)  NH4+ (ammonium)

NH3 = Enzymatic conversion of glutamine

Not ionized; Lipid soluble


Ionized; Lipid insoluble

BOTH types of renal buffering use the bicarbonate buffering system as well
o CO2  H2CO3
o H2CO3  H+ + HCO3o H+ is secreted from renal tubular cells and is buffered by HPO4-- and NH3
o Hydrogen is secreted
o HCO3- is retained

Cellular Shifts  when buffer systems don’t work:
O ACIDOSIS  K+ leaves, H+ enters

Potassium leaves the cell

Hydrogen ion enters the cell

ALKALOSIS  H+ leaves, K+ enters

Hydrogen leaves the cell

Potassium enters the cell


CO2 is formed by aerobic metabolism throughout the body

CO2 combines with H2O to form carbonic acid

Carbonic anhydrase
o Carbonic acid dissociates to CO2 and H2O

Acidosis  RR s, CO2 s  d pH
Alkalosis  RR s, CO2 s  d pH
Response time = 20-30 minutes

RENAL Control of pH

H2CO3  H+ + HCO3
Na+ is reabsorbed from the tubular fluid

H+ is secreted into the tubular fluid
Na+ joins with HCO3-  NaHCO3

H+ is excreted

Acidosis  d hydrogen ions (H+), b bicarbonate ions  d pH
Alkalosis  d hydrogen ions (H+), d bicarbonate concentration  d pH
Response time = several days

Patho Wk 5: Ch. 3

Part 2 - 3

Normal ABG Values

pH = 7.4 (7.35 - 7.45)

pCO2 = 40 (35 - 45)

HCO3- = 24 (22 - 26)

RESPIRATORY ACIDOSIS  pH < 7.35 with PaCO2 > 45mmHg

CAUSES  any condition (!) resulting in HYPOVENTILATION
o CNS depression

Head injury or drugs
o Impaired respiratory muscle function

Spinal cord injury or neuromuscular disease/”blocks”
o Pulmonary disease

COPD, atelectasis, pneumonia, pneumothorax, airway obstruction, pulmonary edema
o Pain (hurts to breathe)
o Chest wall injury/deformity
o Abdominal distention (ex – ascites)
o Under ventilation on mechanical ventilation

o Respiratory distress or shallow respirations
o Headache, restlessness, or confusion
o Drowsiness or unresponsive
o Tachycardia or dysrhythmia

o Need to breathe!

Drug reversal, BiPap, intubation

Oxygen alone will not correct – must treat underlying cause

RESPIRATORY ALKALOSIS  pH > 7.45 with paCO2 < 35 mmHg

CAUSES  any condition (!) causing HYPERVENTILATION
o Anxiety or fear
o Pain
o Pulmonary embolus
o Increased metabolic demand

Fever, sepsis, pregnancy, thyroid disorders
o Over-ventilation on mechanical vent

o Light-headedness, numbness-tingling
o Confusion, difficulty concentrating
o Dysrhythmia
o Tetany

o Treat underlying cause!
o Watch for respiratory fatigue, may need intubation
o Sedate the patient
o Adjust ventilator

METABOLIC ACIDOSIS  pH < 7.35 and HCO3 < 22 mEq/L


Patho Wk 5: Ch. 3


Part 2 - 4

DECd Base

Diarrhea and intestinal fistulas
INCd Acids (other than CO2)

Renal failure, diabetic ketoacidosis

Starvation ketosis

Anaerobic metabolism, hypoxic tissue


Anti-freeze (ethylene glycol)


o Warm, flushed skin
o Nausea and vomiting
o Restlessness progressing to lethargy, stupor, or coma
o Kussmaul respirations

o Treat underlying cause

METABOLIC ALKALOSIS  pH > 7.45 and HCO3 > 26

o INCd Base (base excess)


Excess bicarbonate use

o DECd Acid (loss of acid)

Vomiting or gastric suctioning


Adrenal disorder

o Dizziness, disorientation, seizures
o Lethargy, coma
o Seizures
o Muscle weakness, twitching, cramps, or tetany
o Hypokalemia

o Treat underlying cause

Correct dehydration and/or hypokalemia


Slow resolution


o Kidney

In acidosis there is an excess of H+

In acidosis the kidneys preferentially eliminate H+

When a H+ is eliminated a K+ is retained.

d K+ retention leads to hyperkalemia
o Cellular

In acidosis H+ is buffered in the cell

As H+ moves into the cell, K+ moves out of the cell

d K+ in the ECF produces hyperkalemia

o Kidney

Patho Wk 5: Ch. 3


Part 2 - 5


Alkalosis is related to  H+ concentration or  base.
In alkalosis the kidneys preferentially retain H+.
When H+ is retained, a K+ is excreted.
d excretion of K+ leads to hypokalemia.
H+ moves from the cell to the ECF.
When H+ moves from the cell, it is replaced by a K+.
The result is hypokalemia.


In ACIDOSIS – Causes d release of Ca++ from plasma proteins  HYPERcalcemia

In ALKALOSIS – Causes d binding of Ca++ to plasma proteins  HYPOcalcemia


Gentle balance between the lungs and kidneys (act as each other’s compensatory mechanism)

Neither system has the ability to overcompensate!
UNcompensated or PARTIALLY compensated = pH NOT normal
 FULLY compensated = pH NORMAL, although other values may still be outside normal range

Compensationfor Respiratory Acidosis = kidneys
o The kidneys retain more HCO3o Serum HCO3- rises above 26 mEq/L
o This balances the acid-base ratio  pH returns to normal

Compensationfor Respiratory Alkalosis = kidneys
o The kidneys excrete more bicarbonate.
o Serum HCO3- falls below 22 mEq/L
o This balances the acid-base ratio  pH returns to normal

Compensationfor Metabolic Acidosis = respiratory system
o Hyperventilation  CO2 is blown off (Blowing off the acid)
o pH returns to normal

Compensationfor Metabolic Alkalosis = respiratory system
o Hypoventilation  CO2 is retained
o pH returns to normal


pH (7.35-7.45) = determines acidosis vs alkalosis

PaO2 (80-100 mmHg) = oxygenation
o < 80 mmHg = hypoxemia
o Newborns = (60-70 mmHg)
o Age >60 = (80 – [1 mmHg for ever year over age 60]) – will  with age

pCO2 (35-45 mmHg) = respiratory component

HCO3 (22-26 mmHg) = metabolic component

SaO2 - Oxygen Saturation (>95%) = saturation of O2 on hemoglobin

Total oxygen content
o Normal = 20ml of oxygen per 100 ml of blood
o The amount of oxygen carried in the blood (RBC’s & Plasma)

Base Excess / Base Deficit

Patho Wk 5: Ch. 3


Part 2 - 6

Ranges from -2 to +2 mEq/L
Negative Value (-) = Metabolic acidosis
Positive Value (+) = Metabolic alkalosis

A-a Gradient – Alveolar-arterial oxygen tension difference
o Normal = 10-15 mmHg
o Provides info about the efficiency of transfer of oxygen into the blood at the alveolar capillary membrane
o Elevated by  FiO2 and Age
o “widened” gradient – bad

a/A ratio – arterial-Alveolar oxygen tension ratio
o Normal = >0.75
o Unaffected by FiO2
o Indicates

V/Q mismatching (some lung tissue not getting O2 – PNA? PE?)

Intrapulmonary shunting

ANION GAP -- normal = 10-12 mEq/L

Anion Gap – difference between cations and anions (+ and -)

Formula = (Na+ + K+) – (HCO3- + Cl-)

Anion gap represents the remaining unmeasurable anions in the ECF
o Phosphates
o Sulfates
o Ketones
o Pyruvate
o Lactate

Elevated anion gap represents metabolic acidosis
o Positive / elevated in lactic acidosis, DKA
o Will either be a positive anion gap acidosis or normal anion gap acidosis

MUDPILES – methanol, uremia, DKA, paraldehyde, isoniazid, lactic acidosis, ethylene glycol, salicylates


Look at the pH
o Is it normal? 7.35-7.45
o Is it abnormal?

Acidosis = <7.35

Alkalosis = >7.45

Look at the pCO2
o Is it normal? 35-45 mm Hg
o Is it abnormal?

 pCO2 = respiratory acidosis

 pCO2 = respiratory alkalosis

Look at the HCO3o Is it normal? 22-22 mm Hg
o Is it abnormal?

 HCO3- = metabolic alkalosis

HCO3- = metabolic acidosis

Look at oxygenation (SaO2)
o Is it normal or abnormal?
o pH 7.28, PaCO2 56, HCO3 25, PaO2 70, SaO2 89%

Respiratory Acidosis (uncompensated) and hypoxemia

pH 7.50, PaCO2 36, HCO3 27, PaO2 92, SaO2 97%

Patho Wk 5: Ch. 3

Part 2 - 7

Metabolic Alkalosis (uncompensated)


pH 7.37, PaCO2 66, HCO3 37, PaO2 70, SaO2 93%

Respiratory Acidosis (fully compensated) and hypoxemia


pH 7.42, PaCO2 48, HCO3 35, PaO2 90, SaO2 93%

Metabolic Alkalosis (fully compensated)