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Patho Wk 5: Ch.

3

Part 2 - 1

ACID/BASE BALANCE
Objectives

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!)

FUNCTIONS:
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
REGULATION OF 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

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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
o PHOSPHATE

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

This monobasic phosphate is lipid insoluble

Dibasic phosphate HPO4-
Filtered at the glomerulus

75% is reabsorbed
o

NH3 (ammonia)  NH4+ (ammonium)

NH3 = Enzymatic conversion of glutamine

Not ionized; Lipid soluble

NH4+

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
O

ALKALOSIS  H+ leaves, K+ enters

Hydrogen leaves the cell

Potassium enters the cell

RESPIRATORY Control of pH

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

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Normal ABG Values

pH = 7.4 (7.35 - 7.45)

pCO2 = 40 (35 - 45)

HCO3- = 24 (22 - 26)

ACID-BASE DISORDERS
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

SIGNS & SYMPTOMS:
o Respiratory distress or shallow respirations
o Headache, restlessness, or confusion
o Drowsiness or unresponsive
o Tachycardia or dysrhythmia

TREATMENT:
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

SIGNS & SYMPTOMS:
o Light-headedness, numbness-tingling
o Confusion, difficulty concentrating
o Dysrhythmia
o Tetany

TREATMENT:
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

CAUSES:

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DECd Base

Diarrhea and intestinal fistulas
INCd Acids (other than CO2)

Renal failure, diabetic ketoacidosis

Starvation ketosis

Anaerobic metabolism, hypoxic tissue

Poisoning

Anti-freeze (ethylene glycol)

ASA

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

TREATMENT:
o Treat underlying cause

METABOLIC ALKALOSIS  pH > 7.45 and HCO3 > 26

CAUSES:
o INCd Base (base excess)

Antacids

Excess bicarbonate use

Dialysis
o DECd Acid (loss of acid)

Vomiting or gastric suctioning

Diuretics

Adrenal disorder

SIGNS & SYMPTOMS:
o Dizziness, disorientation, seizures
o Lethargy, coma
o Seizures
o Muscle weakness, twitching, cramps, or tetany
o Hypokalemia

TREATMENT:
o Treat underlying cause

Correct dehydration and/or hypokalemia

Diamox

Slow resolution

POTASSIUM IMBALANCES

In ACIDOSIS = HYPERkalemia
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

In ALKALOSIS = HYPOkalemia
o Kidney

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Cellular


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.

CALCIUM IMBALANCES

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

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

COMPENSATION

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

WHAT DO THESE VALUES TELL YOU?

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

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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-)
WHAT DOES ANION GAP TELL YOU?

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

INTERPRETATION OF ABGs

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?
ABG INTERPRETATION PRACTICE
o pH 7.28, PaCO2 56, HCO3 25, PaO2 70, SaO2 89%

Respiratory Acidosis (uncompensated) and hypoxemia
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pH 7.50, PaCO2 36, HCO3 27, PaO2 92, SaO2 97%

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Metabolic Alkalosis (uncompensated)

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

Respiratory Acidosis (fully compensated) and hypoxemia

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

Metabolic Alkalosis (fully compensated)