CLINICAL CHEMISTRY 2 FINAL LECTURE: ACID-BASE BALANCE

BLOOD GAS ANALYSIS = Blood pH, pCO2, Bicarbonate Ion and pO2.
Specimen:
1. ARTERIAL BLOOD = Specimen of Choice = Ideal for Blood pH and Blood Gases.
2. Venous Blood = OK but only if Test Ordered is without pO2 Determination = Venous Blood
is already Deoxygenated so pO2 cannot be measured using it.
3. Capillary Blood = Prone to Exposure to ROOM AIR = Causing False Increase in pO2 Values,
False Decrease in pCO2 and False Increase in pH.

***Carbon Dioxide is Acidic = More CO2 = Decreased pH (More Acidic).

***Less CO2 = Increased pH (More Alkaline).

Collection Devices:
1. Plastic Disposable Syringe
- Ideal for ABG Collection.
- Requires 1-3mL of Blood and must be Self-Filling.
- Disadvantage = Possible Leaking of Oxygen Gas through PLASTIC PORES. (May cause
False Decrease in pO2 Levels)
2. Glass Syringe
- Still needs to be Pretreated with Heparin.
- Major Disadvantage = BREAKABLE.
3. Evacuated Tubes
- Not recommended because of presence of VACUUM = Causes Elevated ABG Values.
- If ever used = Green Top with Sodium Heparin = Only for VENOUS BLOOD and NOT Arterial
Blood Gas.

Collection Requirements:
1. Method of Collection = Arterial Puncture = VERY HARD TO LOCATE SINCE VERY DEEP
AND CANNOT BE SEEN WITH TOURNIQUET = Detected only by PALPATING THE PULSE.
2. Ideal Anticoagulant for Arterial Blood Gases = DRIED HEPARIN.
***Do not use Liquid Heparin as it can possibly trigger the Dilutional Effect to Occur which may
cause False Decrease in ABG Values.

3. Maintenance of Anaerobic Environment = Done by Pulling and Pushing Air Out of Syringe.
4. Collection Sites for ABG = Any Site with Pulse = Radial Artery (Wrist), Brachial Artery (Arm) or
Femoral Artery. (Most Common is Brachial Artery)
5. Requires a 90 Degree Angle.

Transport and Storage:

CLSI (Clinical Laboratory Standards Institute) = ABG Specimens must be STORED AT ROOM
TEMPERATURE AND ANALYZED WITHIN 30 MINUTES.

- Any Delay in Analysis = Enhances Cellular Metabolism In Vitro.

- Cells use Oxygen and Glucose for ATP Generation = Falsely Decreased pO2 Values.
- By-Product of Cell Metabolism = CO2 and Lactate = Falsely Increased pCO2 Values.
- Prevention of In Vitro Cell Metabolism = STORE IN ICE.

***Delay = Falsely Decreased pO2, Falsely Increased pCO2 and Falsely Decreased (More Acidic)
pH.
Sources of Error:

1. Patient Hyperventilation due to Nervousness

- Hyperventilation = Increased CO2 Excretion = Decreased pCO2 and Increased pH
(More Alkaline pH).
2. Air Bubbles
- Usually Occurs due to Small Needle Size.
3. Exposure to Room Air
- Increased pO2, Decreased pCO2 and Increased pH (Alkaline).
4. Delay in Analysis
- Refer to Above.

Arterial Blood Gas Analyzers:

1. pO2
a. Clarke Electrode – Measures Amount of Current Flow which is Equal to Amount of Oxygen
Reduced at the Cathode.
o Utilizes the principle of AMPEROMETRY (Current Flow).
o Contains only 1 Electrode for Detection.
b. Transcutaneous Monitoring
o Has a Patch System (attached to the arterial parts of the body).
o Has a Magnet which acts as the Sensor.
o ABG Values are seen directly in the Monitor.

2. pCO2
a. Severinghaus Electrode
o Uses a Glass Membrane (Carbon Dioxide Enters).
o Has 2 Electrodes: Measuring Electrode and Reference Electrode.
o Reference Electrode = Standard = Ag-AgCl (Silver-Silver Chloride).

3. pH Electrode
o Uses a Glass Membrane (Hydrogen Ion Sensitive).
o Has 2 Electrodes: Measuring Electrode and Reference Electrode.
o Reference Electrode = Standard = CALOMEL or Hg-HgCl (Mercury-Mercury
Chloride) = Highly Specific for pH.
o Ag-AgCl (Silver-Silver Chloride) may also be used.

***Comparison between Severinghaus Electrode and pH Electrode:

Both have Glass Membranes used for entry of CO2 (in pCO2) or H+ (in pH Electrode).

Both have 2 Electrodes = Measuring Electrode (for sample) and Reference Electrode (for standard).

Both utilize the principle of POTENTIOMETRY.

Potentiometry – measures change in voltage and applies the NERNST EQUATION to solve the
difference between sample and standard.

***For pO2 (Clarke Electrode) = Amperometry; For pCO2 (Severinghaus Electrode) and pH Electrode
= Potentiometry.

***For pO2 (Clarke Electrode) = Only 1 Electrode; For pCO2 and pH = 2 Electrodes.
Acid-Base Balance Physiology:
Acids – Substances that when in an aqueous solution, DONATES HYDROGEN IONS.
- AKA PROTON DONORS.
Bases – DONATES HYDROXIDE IONS (OH-).
- AKA HYDROGEN ACCEPTORS.

Strong Acids – Totally dissociate (total separation) themselves in water.

Weak Acids – Only partial dissociation in water.

Buffers – Combination of a Weak Acid or Weak Base and its Salt.

- Prevent/Resists Great Changes in pH because of its ability to Form Both a Weak Acid or
Conjugate Base. (Reversible Reaction)
- General Example: HA (Weak Acid) H+ and A- (Conjugate Base).

pCO2 – Partial Pressure of CO2.

- Pressure/Tension Exerted by CO2 Gas Dissolved in Blood.
- CO2 Gas Dissolved in Blood = dCO2.
- Index of Efficiency of Gas Exchange in the Lungs.
- Normal Value = 35 – 45 mmHg. (mmHg is used since pressure is being measured)

TCO2 – Total CO2 Concentration.

- Consists of:
o Ionized Fraction = HCO3- (Bicarbonate), CO3- (Carbonate) and Carbamino
Compounds.
o Unionized Fraction = H2CO3 (Carbonic Acid).
o Physically Dissolved CO2 (dCO2).
o Normal Value = 23-27mmol/L.
- Not a Good Measure of Gas Exchange Efficiency as most compounds consisting the Total
CO2 Concentration are present in different parts of the body and not excreted by the Lungs.

Bicarbonate Ion Concentration

- Equilibrated with CO2 at 40mmHg at 37C. (No idea what this means…)
- Normal Value = 22 – 26 mmol/L.

pO2 – Partial Pressure of Oxygen.

- Pressure Exerted by O2 Gas in Arterial Blood which reflects Availability of O2 in Blood
but Not its Content. (Does not measure oxygen in tissues or hemoglobin)
- Measures HYPOXEMIA (low oxygen in blood).
- Normal Value = 80 – 110 mmHg.

***Memorize all the Normal Values of pH, pCO2, HCO3- and pO2.

***Hypoxemia = Low Oxygen in Blood.

***Hypoxia = General State of Low Oxygen in Tissues.

Balance:
1st Line of Defense to pH Change = Chemical Buffer System = Divided into: Bicarbonate Buffer
(MAIN), Phosphate Buffer and Protein Buffer Systems.

2nd Line of Defense = Physiological Barriers = Divided into: Respiratory Mechanism (CO2
Excretion) and Renal Mechanism (H+ Excretion or HCO3- Retention).

CO2 = Governed by Lungs.

HCO3 (Bicarbonate) = Governed by Kidneys.

HCO3-H2CO3 (Bicarbonate-Carbonic Acid) Buffer System: (MAIN BUFFERING SYSTEM)

CO2 + H2O H2CO3 (Carbonic Acid) HCO3- (Bicarbonate) and H+.
CO2 + H2O Portion = Controlled by Lungs (excrete CO2 or not).
HCO3 + H = Controlled by Kidneys (either conserved/reabsorbed or excreted).

Henderson-Hasselbalch Equation: (MASTER THE RELATIONSHIPS)

or

***6.1 = Indicates Dissociation Constant or pKa Constant. (Must Memorize)

Dissociation Constant = pH at which there is equal concentration of Protonated and
Unprotonated Species.

***0.03 = Indicates Solubility Constant of pCO2 at 37C. (Must Memorize)

𝐌𝐄𝐓𝐀𝐁𝐎𝐋𝐈𝐂 𝐅𝐔𝐍𝐂𝐓𝐈𝐎𝐍 𝐎𝐅 𝐊𝐈𝐃𝐍𝐄𝐘𝐒

pH = = 20/1 or 20:1.
𝐑𝐄𝐒𝐏𝐈𝐑𝐀𝐓𝐎𝐑𝐘 𝐅𝐔𝐍𝐂𝐓𝐈𝐎𝐍 𝐎𝐅 𝐋𝐔𝐍𝐆𝐒

20:1 = Ratio of Metabolic Function of Kidneys/Respiratory Function of Lungs = Since Kidney

Function is Greater and Bicarbonate is Governed by Kidneys = Reason why Blood is SLIGHTLY
ALKALINE.

Remember ROME: Respiratory (CO2) Opposite to pH, Metabolic (HCO3) Equal to pH.
pH = Inversely Proportional to pCO2 (Carbon Dioxide).
pH = Directly Proportional to HCO3 (Bicarbonate).
pH = Inversely Proportional to H+ (Hydrogen).
Increased H+ = Decreased pH (Acidic).
Decreased H+ = Increased pH (Alkaline).
Increased CO2 = Decreased pH (Acidic).
Decreased CO2 = Increased pH (Alkaline).
Increased HCO3 = Increased pH (Alkaline).
Decreased HCO3 = Decreased pH (Acidic).
 1. HCO3 Concentration = Directly Excreted by Kidneys or Altered by Forming H2CO3.
2. H2CO3 = Dissociates into CO2 and H2O.
3. CO2 = Eliminated in Lungs via Expiration.
4. Changes in CO2 Levels = Modify Ventilation/Respiratory Rate.

***Respiratory Rate is NOT SIMILAR with Pulse Rate.

Where does CO2 Come From?
- Waste Product of Aerobic Respiration/ATP Generation.
- Dissociation of Carbonic Acid to CO2 and H2O.

***Carbon Dioxide is usually carried by RBCs via Carboxyhemoglobin. Inside the RBCs, the
enzyme Carbonic Anhydrase converts CO2 and H2O to Carbonic Acid which may dissociate to
Bicarbonate and H+ or dissociate back to CO2 and H2O as needed by the body.

***Formed Bicarbonate = Go Outside Cell = Maintain pH = Requires Chloride to Go Inside Cell

to Maintain Electroneutrality (CHLORIDE SHIFT).

Acid-Base Balance Pathology: (RECALL ELECTRONEUTRALITY CONCEPT IN ELECTROLYTES)

-EMIA = pH in Blood.
-OSIS = Total Condition of Body not only in Blood. (More Big Deal)

1. Respiratory Alkalosis – Caused by HYPERVENTILATION which Gives Off Excess CO2.

- Increased CO2 Release/Excretion = Decreased CO2 Blood Levels = Inversely
Proportional Relationship with pH = Increased pH = Alkalosis.
- ONLY CONCERNED WITH CO2 EXCRETION.
- Compensatory Mechanism of Body:
o Kidneys = Excrete HCO3- = Decrease pH (Regulate).
o Kidneys = Retain H+ = Decrease pH (Regulate).

2. Respiratory Acidosis – Caused by Decreased CO2 Excretion or Increased CO2 Retention.

- Happens in cases of Chronic Obstructive Pulmonary Disease (COPD) and Airway
Obstruction (Strangulation, Choking and Holding Breath).
- Decreased CO2 Excretion or Increased CO2 Retention = Increased Blood CO2 =
Decrease pH = Acidosis.
- Compensatory Mechanism of Body:
o Kidneys = Retain HCO3 = Increase pH (Regulate).
o Kidneys = Excrete H+ = Increase pH (Regulate).

3. Metabolic Acidosis – Caused by Excessive Bicarbonate Excretion or H+

Retention/Production.
- MOST COMMON ACID-BASE BALANCE DISORDER.
- Caused by Renal Tubular Acidosis (impaired H+ Secretion), Diarrhea and Vomiting
(Increased HCO3 Excretion), Ketoacidosis, Tissue Hypoxia and Lactic Acidosis
(Increased Production of Acid due to Anaerobic Respiration).
- Excess HCO3 Excretion or H+ Retention/Production = Decreased pH = Acidosis.
- Compensatory Mechanism of Body:
o Lungs = Trigger Hyperventilation = Excrete CO2 = Increase pH.
***Difference with Hyperventilation in Respiratory Alkalosis and Metabolic Acidosis:
Respiratory Alkalosis = Hyperventilation is PRIMARY CAUSE of condition.
Metabolic Acidosis = Hyperventilation is only a COMPENSATORY/REGULATORY MECHANISM.

***Bicarbonate is Readily Excreted and Unable to be Reabsorbed by Kidneys = In Order to

Conserve Bicarbonate, H+ must be secreted by Renal Tubular Cells to form Carbonic Acid =
Dissociate to CO2 and H2O which are Readily Reabsorbed = Reforms Bicarbonate Again After
Reabsorption.

***Renal Tubular Acidosis = Impaired H+ Secretion = No Bicarbonate Reabsorption = Excessive

Bicarbonate Excretion = Metabolic Acidosis.

4. Metabolic Alkalosis – Caused by Increased H+ Excretion or Increased HCO3- Retention.

- Increased H+ Excretion/Bicarbonate Retention = Increased pH = Alkalosis.
- Caused by the ff:
o Too Much Chloride (Cl-) Loss = Sweating, Vomiting, Nasogastric Suction =
Chloride Loss causes Loss of Negativity = Retain Bicarbonate (HCO3-) to
Maintain Electroneutrality = Metabolic Alkalosis.
o Ingestion of Alkaline Drugs = Self-Explanatory.
o Hyperaldosteronism = Increased Sodium Retention = Gain More Positive
Charge = Retain Bicarbonate (Negative) = Balances and Maintains
Electroneutrality = Metabolic Alkalosis.
- Compensatory Mechanism of Body:
o Lungs = Triggers Hypoventilation = Decrease CO2 Excretion = Increase CO2
Retention = Decrease pH (Regulate).

***Other Cases:
- Hysteria/Panic Attack = Respiratory Alkalosis = Decreased pCO2, Increased pH.
- Strangulation = Respiratory Acidosis = Increased pCO2, Decreased pH.
- Sample Contamination to Room Air = Increased pO2, Decreased pCO2 and Increased pH.

CLINICAL INTERPRETATION OF LABORATORY RESULTS: (MUST MEMORIZE EVERYTHING)

***During Case Studies in Exam, DIRECTLY GO TO LABORATORY RESULTS FOR ABG.
***If pH is not given in the case, SOLVE FOR THE pH using Henderson-Hasselbalch Equation.
- < 7.35 = Acidosis.
- > 7.45 = Alkalosis.
Answer should be in order: Degree of Compensation, Primary Disorder and Degree of Oxygenation.
Degree of Compensation = Check pH.
- Uncompensated = Very Abnormal pH. (High Gap from Normal Values)
- Partially Compensated = +/- 4 than the Normal Values (7.31 – 7.34 for Acidosis or 7.46
– 7.49 for Alkalosis)
- Completely Compensated = Normal pH.

Primary Disorder = Respiratory Alkalosis or Acidosis; Metabolic Alkalosis or Acidosis.

Degree of Oxygenation = Check pO2.

- Adequate Oxygenation = 80 – 110 mmHg.

- Mild Hypoxemia = 60 – 79 mmHg.
- Moderate Hypoxemia = 40 – 59 mmHg.
- Severe Hypoxemia = 39 or below mmHg.
Example 1:
pH = 7.32 (Abnormal)
pCO2 = 40 mmHg (Normal)
HCO3 = 20 mEq/L (Abnormal)
pO2 = 50 mmHg (Abnormal)

Answer = Partially Compensated Metabolic Acidosis with Moderate Hypoxemia.

Example 2:
pH = 7.57 (Abnormal)
pCO2 = 25 mmHg (Abnormal)
HCO3 = 22 mEq/L (Normal)
pO2 = 55 mmHg (Abnormal)

Answer = Uncompensated Respiratory Alkalosis with Moderate Hypoxemia.

Example 3:
pH = 7.42 (Normal)
pCO2 = 60 mmHg (Abnormal)
HCO3 = 38 mEq/L (Abnormal)
pO2 = 85 mmHg (Normal)

Answer = Compensated Respiratory Acidosis / Metabolic Alkalosis with Adequate Oxygenation.

***In questions like these, check the Signs and Symptoms of Patient. If patient has COPD, Airway
Obstruction, Strangulation, Choking = Respiratory Acidosis. If patient has Vomiting, Diarrhea,
Hyperaldosteronism and HYPOVENTILATION = Metabolic Alkalosis.

Example 4:
pH = ______
pCO2 = 40 mmHg
HCO3 = 12 mEq/L
pO2 = 58 mmHg
Solution:

Answer = Uncompensated Metabolic Acidosis with Moderate Hypoxemia.

Example 5:
pH = ______
pCO2 = 25 mmHg
HCO3 = 13 mEq/L
pO2 = 68 mmHg
Solution:

Answer = Partially Compensated Metabolic Acidosis with Mild Hypoxemia.

As observed in the Given, both pCO2 and HCO3 are ABNORMAL. pCO2 of 25mmHg often indicates
Low pCO2 and therefore High pH (Respiratory Alkalosis) while HCO3 of 13mEq/L indicates Low
HCO3 and therefore Low pH (Metabolic Acidosis). The reason why Metabolic Acidosis is the Main
Answer is because the computed pH is 7.34 which falls under Acidic Conditions. (It is impossible
for the case to be Respiratory Alkalosis since the pH Value itself is Acidic)

Example 6:
pH = _____
pCO2 = 48 mmHg
HCO3 = 35 mEq/L
pO2 = 78 mmHg
Solution:

Answer = Partially Compensated Metabolic Alkalosis with Mild Hypoxemia.

Similar to the Previous Problem, both pCO2 and HCO3 Values are ABNORMAL. pCO2 of 48 indicates
Respiratory Acidosis while HCO3 of 35 indicates Metabolic Alkalosis. Since the computed pH
Value is 7.48 (alkaline pH), then the main answer should be Metabolic Alkalosis.

Example 7:

A 28 year old male patient with bronchial problem presents to Hospital ER with Increasing Cough,
Sputum and Dyspnea. His ABG in ER is pH = 7.28; pCO2 = 70 mmHg; pO2 = 50 mmHg; HCO3 = 23
mEq/L. What is his condition?

Answer = Uncompensated Respiratory Acidosis with Moderate Hypoxemia.

Example 8:

A 5 year old girl is brought to the ER due to Constant Vomiting, Diarrhea and Dyspnea. His ABG states
that pH = ____; pCO2 = 23 mmHg; HCO3 = 55 mEq/L; pO2 = 36 mmHg. What is the patient’s condition?

Answer = pH is 8.0; Uncompensated Metabolic Alkalosis with Severe Hypoxemia.

Example 9:

An 18 year old woman was partying at her friend’s house when suddenly she had hyperventilated.
People around the area did not know how to handle a case of Hyperventilation so they decided to rush
the patient to the ER. Upon reaching the ER, the doctor in duty asked for an ABG Result. Which of the
following results would most likely be consistent with the Patient’s Symptom?

a. pH = 7.40; pCO2 = 40; HCO3 = 47; pO2 = 50.

b. pH = 7.30; pCO2 = 50; HCO3 = 47; pO2 = 68.
c. pH = 7.30; pCO2 = 30; HCO3 = 25; pO2 = 78.
d. pH = 7.50; pCO2 = 50; HCO3 = 47; pO2 = 68.
e. pH = 7.50; pCO2 = 30; HCO3 = 25; pO2 = 78.

Answer = E (Since Hyperventilation causes Respiratory Alkalosis = Increased pH, Decreased

pCO2, Normal HCO3)

Example 10:

A case of Corynebacterium diphtheriae infection was sent to a team of Elite Doctors namely: Dr. Afable,
Dra. Villa, Dra. Sunga, Dra. Gokotano, Dra. Uytina, Dra. Toledo, Dra. Estimo, Dra. Grageda and Dra.
Labio. They found out that the patient had a Characteristic Pseudomembrane which was Obstructing
the Patient’s Airway Tract. This Elite Team of Doctors having graduated from BMLS decided to perform
an Arterial Blood Gas Analysis. What is the expected finding of the case?

a. pH = 7.27; pCO2 = 49; HCO3 = 24; pO2 = 37.

b. pH = 7.30; pCO2 = 14; HCO3 = 12; pO2 = 37.
c. pH = 7.35; pCO2 = 30; HCO3 = 34; pO2 = 59.
d. pH = 7.43; pCO2 = 38; HCO3 = 25; pO2 = 76.
e. pH = 7.49; pCO2 = 15; HCO3 = 53; pO2 = 43.

Answer = A (Since Airway Obstruction = Respiratory Acidosis = Decreased pH, Increased pCO2,
Normal HCO3)

***Although Diphtheria does not actually cause Respiratory Acidosis (I only made that shit up), what I
would like to emphasize with this question is that even though you do not know the case… ONLY ONE
WORD/PHRASE will lead you to the correct answer which in this case is Airway Obstruction. Find the
key word in a case study and it will lead you to the right answer.

***Master the Basics of Electrolytes and Acid-Base Balance because the knowledge will go a long way
especially in cases.

***For Tumor Markers, Memorize Memorize Memorize.

***For Trace Elements, Read ULTRA SUMMARIZED TRACE ELEMENTS. (ONLY 5 POINTS IN THE
EXAM, EASY QUESTIONS I THINK)

***CC2 FINALS EXAM = ONLY FINALS COVERAGE and would not include prelims and midterms.

This is it for CC2 Finals Exam. GOD BLESS TO US ALL AND LET’S ALL DO OUR VERY BEST =)
NEVER GIVE UP AND ALWAYS REMEMBER THAT WE ARE ALREADY ONE STEP CLOSER TO
REACHING OUR DREAMS!