Echilibrul acido-bazic

Key Points
 Acidosis and alkalosis refer to physiologic processes that cause
accumulation or loss of acid and/or alkali; blood pH may or may not be
abnormal.
 Acidemia and alkalemia refer to an abnormally acidic (pH < 7.35) or
alkalotic (pH > 7.45) serum pH.
 Acid-base disorders are classified as metabolic if the change in pH is
primarily due to an alteration in serum bicarbonate (HCO3−) and
respiratory if the change is primarily due to a change in Pco2 (increase or
decrease in ventilation).
 The pH establishes the primary process (acidosis or alkalosis), changes in
Pco2 reflect the respiratory component, and changes in HCO3− reflect the
metabolic component.
 All acid-base disturbances result in compensation that tends to normalize
the pH. Metabolic acid-base disorders result in respiratory compensation
(change in Pco2); respiratory acid-base disorders result in metabolic
compensation (change in HCO3− ).
 More than one primary acid-base disorder may be present simultaneously.
It is important to identify and address each primary acid-base disorder.
 Initial laboratory evaluation of acid-base disorders includes measurement
of arterial blood gases and serum electrolytes and calculation of the anion
gap.
 Use one of several formulas, rules-of-thumb, or an acid-base nomogram
to determine if laboratory values are consistent with a single acid-base
disorder (and compensation) or if a second primary acid-base disorder is
also present.
 Treat each primary acid-base disorder.

Diagnosis
 Arterial blood gases (ABG)
  Serum electrolytes
 Anion gap calculated
 If metabolic acidosis is present, delta gap calculated Search for
compensatory changes

Evaluation is with ABG and serum electrolytes. The ABG directly measures
arterial pH and Pco2. HCO3− levels on ABG are calculated using the Henderson-
Hasselbalch equation; HCO3− levels on serum chemistry panels are directly
measured and are considered more accurate in cases of discrepancy. Acid-base
balance is most accurately assessed with measurement of pH and Pco2 on arterial
blood. In cases of circulatory failure or during cardiopulmonary resuscitation,
measurements on venous blood may more accurately reflect conditions at the
tissue level and may be a more useful guide to bicarbonate administration and
adequacy of ventilation.
The pH establishes the primary process (acidosis or alkalosis), although it moves
toward the normal range with compensation. Changes in Pco2 reflect the
respiratory component, and changes in HCO3− reflect the metabolic component.
Complex or mixed acid-base disturbances involve more than one primary
process. In these mixed disorders, values may be deceptively normal. Thus, it is
important when evaluating acid-base disorders to determine whether changes in
Pco2 and HCO3− show the expected compensation

Respiratory acidosis is suggested by Pco2> 40 mm Hg; HCO3− should

compensate acutely by increasing 3 to 4 mEq/L for each 10 mm Hg rise in Pco2
sustained for 4 to 12 h (there may be no increase or only 1 to 2 mEq/L, which
slowly increases to 3 to 4 mEq/L over days). Greater increase in HCO3− implies
a primary metabolic alkalosis; lesser increase suggests no time for compensation
or coexisting primary metabolic acidosis.
Metabolic alkalosis is suggested by HCO3−> 28 mEq/L. The Pco2 should
compensate by increasing about 0.6 to 0.75 mm Hg for each 1 mEq/L increase
in HCO3− (up to about 55 mm Hg). Greater increase implies concomitant
respiratory acidosis; lesser increase, respiratory alkalosis.
Respiratory alkalosis is suggested by Pco2< 38 mm Hg. The HCO3− should
compensate over 4 to 12 h by decreasing 5 mEq/L for every 10 mm Hg decrease
in Pco2. Lesser decrease means there has been no time for compensation or a
primary metabolic alkalosis coexists. Greater decrease implies a primary
metabolic acidosis.
Nomograms (acid-base maps) are an alternative way to diagnose mixed
disorders, allowing for simultaneous plotting of pH, HCO3−, and Pco2.