ACID-BASE BALANCE

I. Concepts of Acid-Base Balance

Acid, Bases, and Salts

• Acid. An acid is one type of compound that contains the hydrogen ion.
• Base. A base or alkali is a compound that contains the hydroxyl ion.
• Salt. A salt is a combination of a base and an acid and is created when the positive ions of
a base replace the positive hydrogen ions of an acid.
• Important salts. The body contains several important salts like sodium chloride, potassium
chloride, calcium chloride, calcium carbonate, calcium phosphate, and sodium phosphate.

Potential of Hydrogen
• pH. The symbol of pH refers to the potential or power of hydrogen ion concentration within
the solution.
• Low pH. If the pH number is lower than 7, the solution is an acid.
• High pH. If the pH is greater than 7, a solution is basic or alkaline.
• Neutral pH. If the pH is 7, then the solution is neutral.
• Changes. A change in the pH of a solution by one pH unit means a tenfold change in
hydrogen concentration.

Acid-base balance - equilibrium between the acid and base elements of the blood and body fluids.
Body's 3 mechanism to maintain acid-base balance:
1. Buffering mechanism (Bicarbonate-carbonic acid buffer system)
o Acid-base buffer - a solution containing two or more chemical compounds that prevent marked change
in hydrogen ions
o Buffer acts immediately to trap (H+) temporarily until renal and respiratory mechanisms act.

2. Respiratory compensation mechanism

o Lungs
• Under the control of medulla, controls CO2 and the carbonic acid content in the ECF by adjusting the
ventilation (by increasing PaCO2 which is a powerful stimulant for respiration) in response to the
amount of CO2 in the blood.
• Breathing faster or deeper (hyperventilation) - eliminates more CO2 resulting in increase pH.
• Slow, shallow breathing (hypoventilation) - accumulates CO2 and decreases pH.

3.Renal regulation of acid-base balance

o Kidneys - regulates bicarbonate level in the ECF and makes long term adjustment to pH.
• Regenerate and reabsorb bicarb from the renal tubular cells
 • In acidosis, excretes excess hydrogen ions and conserves bicarb ions and vice versa in alkalosis.
• Kidneys cannot compensate for the metabolic acidosis created by kidneys itself.

Acid base imbalance/disturbance:

• Common in the clinical practice, especially in critical units.
• Identification of specific imbalance is important to ascertain the underlying cause of the disorder and
determininng the appropriate treatment.
• It is important to take note of the acidity or alkalinity of the blood (pH) which is maintained by homeostatic
mechanism.
• Blood gas analysis is often used to identify the specific acid-base disturbance and degree of
compensation.
• Diagnosing acid-base imbalance:
o Arterial Blood Gas (ABG)
o Anion gap estimation

Anion Gap estimation

• The difference between measure major positive and negative charges.
• Normal value is 8-14 mEq/L
• The sum of measured cations is greater than of measured anions due to the presence of unmeasured
anions (proteins, phosphates, sulfates, and organic acids as lactic acid and ketones)
• Increased anion gap may be the only clue that metabolic acidosis is present in a mixed acid-base
disorder.

Arterial Blood Gas analysis

• Results from this provides information about alveolar ventilation, oxygenation, and acid-base balance.
• Still it necessary to evaluate the concentration of serum electrolytes (sodium, potassium and chloride) and
CO2 as they are the first sign of an acid-based disorder.
• Health history, PE should always be part of the assessment.

ABG parameters

Parameters Normal Values

• PH (H+) 7.35 - 7.45

• PCO2 partial pressure CO2 35 - 45 mmHg
• PO2 >80 mmHg
• HCO3 bicarbonate 22 - 26 mEq/L
• BE base excess +- 2mEq/L
• Oxygen saturation (SaO2%) >94%

ABG interpretation
1. Classify the pH
• >7.45 alkalosis
• <7.35 acidosis
2.Determine the cause of disturbance
• Evaluate the PaCO2 and HCO3 in relation to pH
• ROME
o Respiratory
o Opposite - value of PaCO2 in relation to pH goes at opposite direction.
• E.G Respiratory acidosis - pH low, PaCO2 high
o Metabolic
o Equal - HCO3 and pH goes in the same direction
• E.G. Metabolic alkalosis - pH high, HCO3 high

3. Determine the compensation (Fully compensated, Partially compensated and uncompensated)

RESPIRATORY ACIDOSIS
• Characterized by:
o pH<7.35
o PaCO2 >45mmHg
• Inadequate excretion of CO2 with inadequate ventilation, resulting to elevated plasma CO2 concentrations
• Caused by depression of respiratory center
o Narcotics/over sedation
o Anesthesia
o Respiratory arrest
o Paralysis of respiratory muscles
o Impaired ventilation
o Airway obstruction
o Mechanical ventilation may be associated with hypercapnia if the rate of ventilation is inadequate and
CO2 retained
• May also be associated in non-emergent situation like sleep apnea.
• Clinical manifestation:
o Increased pulse and respiratory rate (caused by elevated PaCO2)
o Restlessness
o Headache
o Drowsiness
o Disorientation
o Coma
o Dysrhythmias
o Hypotension
o Hyperkalemia as a result of H+ shifts into the cells causing shift of potassium out of the cell.
• Assessment and Diagnosis:
o ABG
o Monitoring serum electrolytes
o Chest x-ray
o Drug screen if overdose is suspected
o ECG to identify cardiac involvement
• Management
• The goal of treatment is to improve ventilation
• Pharmacologic agents may be indicated:
o Bronchodilators to reduce bronchial spasm
o Antibiotics for respiratory infections
o Thrombolytics or anticoagulants for pulmonary emboli
• Pulmonary hygiene when necessary to clear respi tract of mucus and purulent drainage
• Adequate hydration if not contraindicated (2-3L/day) to keep mucous membranes moist facilitating
removal of secretions.
• Supplemental O2 as necessary
• If in mech vent, use appropriately to (avoid increase dead space, insufficient rate or volume settings,
high FiO2) so as not to cause rapid CO2 excretion.
• Placing the patient in a semi-Fowler position facilitates expansion of the chest wall
RESPIRATORY ALKALOSIS (Carbonic Acid Deficit)
• Characterized by:
o pH >7.45
o PaCO2 <35 mmHg
• Is always caused by hyperventilation that results to excessive "blowing off" of CO2 → decrease in plasma
carbonic acid concentration
• Chronic respiratory alkalosis results from chronic hypocapnia (low C02)
• Predisposing factors:
o Chronic hepatic insufficiency and cerebral tumors
• Causes:
o Hypoxemia
o Anemia
o Fever
o Early in the exercise
o Angry
o Psychological dyspnea
• Clinical Manifestation:
o Light headedness - due to vasoconstriction and decreased cerebral blood flow
o Numbness and tingling from decreased calcium
o Tinnitus
o Sometime loss of consciousness
o Tachycardia
o Ventricular and atrial dysrhythmias
o Confusion
o Hypertension
o Blurred vision

• Assessment and Diagnosis

o ABG
o Serum electrolyte evaluation- is indicated to identify any decrease in potassium, as hydrogen is
pulled out of the cells in exchange for potassium; is indicated to identify any decrease in
potassium, as hydrogen is pulled out of the cells in exchange for potassium
o Toxicology screen to rule out salicylate intoxication
• Management:
o Depends of the underlying cause
o If caused by anxiety, instruct to breathe more slowly. Antianxiety agents if indicated
o Treatment of other causes is directed towards correcting the underlying cause.

METABOLIC ACIDOSIS (Base Bicarbonate Deficit)

• Characterized by:
o pH <7.35
o Hco3 < 22 mEq/L
In metabolic acidosis, the respiratory rate increases, causing greater elimination of CO2 (to reduce the acid
load)
• Defined as a primary decreased in plasma HCO3 concentrations
• Chronic metabolic acidosis usually seen with chronic kidney disease.
• Hyperkalemia may accompany metabolic acidosis as a result of the shift of potassium out of the cells
• Hyperventilation decreases the CO2 level as a compensatory action.
• Causes:
o Prolonged severe diarrhea
o Renal failure
o Starvation
o Cardiac arrest
o Tissue hypoxia
o DKA
 o Sepsis
o Shock
o Alcoholic keto acidosis
• Clinical Manifestation: may vary with severity
o Headache
o Confusion
o Drowsiness
o Increased respiratory rate, depth
o Nausea
o Vomiting
o Decreased BP
o Cold and clammy skin
o dysrhythmias
• Assessment and Diagnosis
o ABG
o Hyperkalemia - due to shift of potassium out of the cells.
• Management:
o Directed towards correcting the imbalance
o Sodium bicarb is given when necessary. Caution when giving it during cardiac arrest as it can result to
paradoxical intracellular acidosis.
o In chronic metabolic acidosis, low calcium are treated first to avoid tetany
o Alkalizing agent may be given
o Hemodialysis or peritoneal dialysis

METABOLIC ALKALOSIS
• Characterized by:
o pH >7.45
o HCO3 > 26 mEq/L
• Results from increased bicarb in the ECF
• In metabolic alkalosis, the respiratory rate decreases, causing CO2 to be retained (to increase the acid
load)
• Predisposing factors:
o Those who are on diuretic therapy that promotes potassium excretion (eg thiazide and Furosemide)
o Cystic fibrosis- defect in cystic fibrosus transmembrane regulator (CFTR); excessive sweat NaCl
losses—met.alkalosis
o Chronic ingestion of milk-causes hypercalcemia leading to enhance bicarbonate reabsorption
o External drainage of gastric fluids-- Gastric fluid has an acid pH (usually 1 to 3), and loss of this highly
acidic fluid increases the alkalinity
o Hypokalemia produces alkalosis in two ways: (1) the kidneys conserve potassium, and therefore H+
excretion increases, and (2) cellular potassium moves out of the cells into the ECF in an attempt to
maintain near-normal serum levels (as potassium ions leave the cells, hydrogen ions must enter to
maintain electroneutrality).
• Causes:
o Vomiting of body fluids
o Gastric suction
o Diuretics such as furosemide and thiazide
o IV NaHCO3 administration
o Excessive alkali ingestion from antacid containing bicarbonate
• Clinical Manifestation:
o Tingling of fingers (due to decreased calcium ionization)
o Dizziness (due to decreased calcium ionization)
o Hypertonic muscles (due to decreased calcium ionization)
o Depressed respiration - compensatory action by the lungs
o Atrial tachycardia
o Decreased motility
 o Paralytic ileus
o Frequent PVCs in ECG
o U waves on ECG
o This hypoventilation is more pronounced in semiconscious, unconscious, or debilitated patients than in
alert patients.
• Assessment and Diagnosis
o ABG
o Urine chloride - will help differentiate the cause of metabolic alkalosis if its vomiting, diuretic therapy or
excessing adrenocorticosteroid secretion as the cause of metabolic alkalosis.
• Management:
o Treatment is aimed at correcting the underlying cause.
o Includes restoring normal fluid volume by giving sodium chloring fluids.
o In those with hypokalemia, potassium is given as KCL
o H2 receptor antagonist such as cimetidine to reduce production of gastric hydrogen chloride
o Carbonic anhydrase inhibitors is given to patients who cannot tolerate rapid volume expansion.

ABG INTERPRETATION
What is Normal?
When interpreting ABG results, it is essential to know what ABG values are considered ‘normal’.
From this baseline, you can then begin to recognize significant variations in a patient’s results, which
could indicate clinical deterioration.

The first value is the pH, which measures how many hydrogen ions (H+) are in the sample. This
determines if the blood is acidotic or alkalotic. Normal values for pH range from 7.35 - 7.45.

The next value is the carbon dioxide level, and this will tell you if the problem is respiratory in origin,
as CO2 is regulated by the lungs (Berman et al. 2017). The normal range for P aCO2 is 35 to 45
mmHg.

Finally, bicarbonate ions, or HCO3-, will tell you if the problem is related to metabolic changes in your
patient and refers to the renal system (Berman et al. 2017). Normal is considered to be from 22 to 26
mmol/L.

Normal ABG Levels

pH Hydrogen 7.35 - 7.45

PaCO2 Carbon dioxide 35 - 45 mmHg

HCO3- Bicarbonate 22 - 26 mmol/L

(Castro & Keenaghan 2020)

Put simply, when the numbers in an ABG result fall outside of these ranges, you can then determine
what type of problem the patient is experiencing.

pH: Acidic or Alkalotic?

If the ABG results reveal pH numbers are not within the normal range, the patient’s pH level is either
acidotic or alkalotic.
The lower the number, the more acidotic the patient is. For instance, a pH of 3 is severely acidotic
and requires emergency intervention.

Alkalosis is the opposite. The higher the pH, the more base is in the blood sample, which can disrupt
the normal functioning of the body.

Once you’ve determined whether there is too much acid or too much base, you can move on to
determine the cause of it.(Kaufman 2020)

Respiratory or Metabolic?
After you’ve determined whether the sample is acidic or alkaline, you need to work out if it’s due to
respiratory or metabolic causes.

If the cause is respiratory in nature, the PaCO2 will be out of the normal range, whereas for metabolic
problems the HCO3- will be abnormal. Low PaCO2 points to respiratory alkalosis, and high
HCO3- can indicate metabolic alkalosis. (Kaufman 2020)
Compensated or Uncompensated?
Compensation can be thought of as the body’s attempt at correcting an imbalance: Is one system in
the body trying to compensate for an abnormality in another system? We can investigate this by
looking at the opposing component of the problem.

For example, in an acidosis, we’d look at the level of HCO3-. Whereas, in an alkalosis, to determine if
the body is compensating, we’d look at what the P aCO2 is doing.

If the other level (or component) is within normal ranges, then the problem is non-compensated or
uncompensated. Ultimately, the body is yet to fix the problem or has been unable to fix the problem.

However, if the other component has gone outside its normal reference ranges, we can think of it
as compensation occurring (the body is trying to fix the problem). To assess how well it has been able
to do this, we need to refer back to the pH. If the pH is not within or close to the normal ranges,
then a partial-compensation exists. If the pH is back within normal ranges then a full-
compensation has occurred.

A non-compensated or uncompensated abnormality usually represents an acute change occurring in

the body.

And note - The term partial or fully-compensated is used to describe the level of compensation and
does not necessarily mean the patient’s ABG is normal or that they are healthy.
To Simplify...

Compensated or Respiratory or Acidic or

Uncompensated? Metabolic? Alkalotic? pH PaCO2 HCO3-

Respiratory Acidosis Low High

Respiratory Alkalosis High Low

Metabolic Acidosis Low Low

Metabolic Alkalosis High High

Compensated Respiratory Acidosis Normal High

Compensated Respiratory Alkalosis Normal Low

Compensated Metabolic Acidosis Normal Low

Compensated Metabolic Alkalosis Normal High

Case Study 1
Consider the following:

pH = 7.50

PaCO2 = 47

HCO3- = 32

Q1) Is it an acidosis or an alkalosis?

The pH is 7.50. This is higher than normal, so we have an alkalosis.

Q2) Is the problem of a respiratory or metabolic nature?

Where else is there an alkalosis? The HCO3- is 32, which is high. So we have metabolic alkalosis.

Q3) Is there any compensation occurring? Has the body tried to fix the problem?

We need to look at the other component, in this case, what is the CO2? The CO2 is outside its normal
ranges. It’s 47, which is high. So the body is trying to fix the problem. However, the pH is not yet back
within normal ranges so a partial compensation exists.

Conclusion:

This ABG is an example of a partially compensated metabolic alkalosis.

Case Study 2
Consider the following:

pH = 7.30
PaCO2 = 50

HCO3- = 30

Q1) Is it an acidosis or an alkalosis?

The pH is 7.30. This is lower than normal, so we have an acidosis.

Q2) Is the problem of a respiratory or metabolic nature?

What else is acidotic? The CO2 is 50, which is high. So we have respiratory acidosis.

Q3) Is there any compensation occurring? Has the body tried to fix the problem?

We need to look at the other component, being HCO3- in this case. Is the HCO3- outside its normal
ranges? Yes, normal HCO3- is between 22-28. So the body is trying to fix this problem. Has the body
done a good job at fixing the problem? Is the pH back within normal ranges? No, the pH is not within
normal ranges, so there is partial compensation occurring.

Conclusion:

This ABG is an example of a partially compensated respiratory acidosis.

Note: ABGs should be thought of as a snapshot of how the body is interacting with its environment at
a particular time. They should always be interpreted as part of a wider assessment of a patient’s
respiratory function and in line with your organisation’s policies.

Source:
Hinkle, J.L. & Cheever, K. H. (2018). Brunner & Suddarth’s textbook of medical-surgical nursing (14th Edition
ed.) Philadelphia: Wolters Kluwer.

Interpreting ABGs (Arterial Blood Gases) Made Easy. (n.d.). Retrieved September 13, 2020, from
https://www.ausmed.com/cpd/articles/interpreting-abgs