Introduction
irritability, tetany, loss of
An important aspect of clinical chemistry
is information on a patient's acid-base
balance and blood gas homeostasis.
These data often are used to assess
patients in life-threatening situations.
This lecture discusses:
the body's mechanisms to maintain
acid-base balance and
exchange of gases, carbon dioxide and
oxygen,
Definitions: Acid, Base, Buffer
a substance that yields H+ ions in H2O.
Base:
a substance that yields a hydroxyl ion
(OH-).
Buffer:
the combination of a weak acid and its
salt, is a system that resists changes in
pH.
Strong acids vs. Strong Base
have pK value of less than 3.0
Strong base:
have a pK value greater than 9.0
Acid-Base balance
Maintenance of hydrogen ions:
• Body produces mmol of H/day,
• normal concentration of H in ECF
ranges from nmol (pH, )
• Any deviation from the values the
body will try to compensate.
• >44 nmol/L: altered consciousness,
coma- death
• <36 nmol/L: neuromuscular
consciousness- death.
Acid-Base balance
• Because pH is the negative log of
the cH+
• Decrease in H+ ion Increase pH
• Increase H + ions Decrease pH
• Arterial blood pH is controlled by:
1. Buffers
2. Respiratory System
3. and Kidneys
Buffer System: Regulation of H+
• First line of defense to changes in
H+ consist of:
- weak acid (H2CO3) & its salt
(HCO3-)
• Add acid to H2CO3 & HCO3-
system:
- the HCO3- combines with H from
the acid to form H2CO3.
• Add a base to the system:
- H2CO3 combines with OH to
form H2O and HCO3
• Keeps the body at the correct pH ( )
Buffer System: Regulation of H+
Bicarbonate – carbonic acid system has
low buffering capacity but still an
important buffer system for 3 reasons:
1. H2CO3 dissociates into CO2 &
H2O allowing H+ to be eliminated
as CO2 by lungs
2. Changes in CO2 modify the
ventilation rate
3. HCO3- conc. can be altered by
the kidneys
Other systems
• HPO4–2 H2PO4– system
• Proteins are capable of binding H+
• Hemoglobin
Regulation of Acid-Base Balance:
Lungs and Kidneys
• The lungs and kidneys play
important roles in regulating blood
pH.
• The lungs regulate pH through
retention or elimination of CO2
- by changing the rate and volume
of ventilation.
• The kidneys regulate pH by:
- excreting acid, primarily in the
ammonium ion,
- and by reclaiming HCO3- from
the glomerular filtrate.
Regulation of Acid-Base Balance by
Lungs
• End product of aerobic metabolic
process is CO2
- diffuses out the tissue into
plasma and RBC
In Plasma & RBCs:
- a small amount of CO2 is
dissolved
- or combined with proteins to form
carbamino compounds.
- Most of the CO2 combines with
H2O to form H2CO3, which
quickly dissociates into H+ and
HCO3-
- The dissociation of H2CO3
causes the HCO3- concentration
to increase in the RBCs and
diffuse into the plasma.
- To maintain electroneutrality
chloride diffuses into the cell
(chloride shift)
Regulation of Acid-Base Balance by
Lungs
In the lungs:
• The process is reversed.
• Inspired O2 diffuses from the alveoli
into the blood and is bound to
hemoglobin, forming oxyhemoglobin
(O2Hb).
• The H+ that was carried on the
(reduced) hemoglobin in the venous
blood is released to recombine with
HCO3- to form H2CO3,
- which dissociates into H2O and
CO2.
• The CO2 diffuses into the alveoli and
is eliminated through ventilation.
• The net effect of the interaction of
these two buffering systems is a
minimal change in H+ concentration
between the venous and arterial
circulation.
• When the lungs do not remove CO2
at the rate of its production
(hypoventilation) it accumulates in
the blood,
- causing an increase in H+
concentration.
• If, however, CO2 removal is faster
than production (hyperventilation)
- the H+ concentration will be
decreased.
• Consequently, ventilation affects the
pH of the blood.
• A change in the H+ concentration of
blood that results from non-
respiratory disturbances causes the
respiratory center to respond
 - altering the rate of ventilation in
an effort to restore the blood pH
to normal.
• The lungs, by responding within
seconds, together with the buffer
systems, provide the first line of
defense to changes in acid-base
status.
Kidney system
• Main role is reabsorption of
bicarbonate
• Kidneys respond to increase or
decrease in hydrogen ions by
selectively excreting or reabsorbing:
1. Hydrogen ions
2. Sodium
3. Chloride
4. Phosphate
5. Ammonia
6. Bicarbonate
Reabsorption of Bicarbonate
• Reabsorption of bicarbonate (HCO3
–) takes place in the renal tubule
cells.
• Na + is exchanged for H+ ion.
• H+ ion combines with the HCO3 –
and carbonic acid dissociates into
H2O and CO2.
• CO2 diffuses into the tubule cells
combining with H2O forming H2CO3.
• Reabsorption of bicarbonate in the
blood system.
• Urinary H+ combines with HPO4–
and NH3.
Acid-Base Disorders
• Acidosis (decrease pH) → acidemia
• Alkalosis (increased pH)→alkalemia
• metabolic or respiratory
• A disorder caused by ventilatory
dysfunction is termed primary
respiratory acidosis or alkalosis.
• A disorder resulting from a change in
the bicarbonate level is termed a
non-respiratory disorder.
• Technically, the suffix -osis refers to
a process in the body; the suffix -
emia refers to the corresponding
state in blood
• Body's cellular and metabolic
activities are pH dependent
• The body tries to restore acid-base
homeostasis whenever an imbalance
occurs.
• This action is termed compensation
• Done by altering the factor not
primarily affected by the pathologic
process.
- eg., if the imbalance is of
nonrespiratory origin, the body
compensates by altering
ventilation.
- For disturbances of the
respiratory component, the
kidneys compensate by
selectively excreting or
reabsorbing anions and cations.
• Lungs can compensate immediately
but:
- the response is short term
- and often incomplete.
• The kidneys compensate are slower
to respond (2- 4 days) but:
- the response is long term
- and potentially complete
Metabolic (non-respiratory) Acidosis
• Decrease pH, increase H+
• Bicarbonate decreased (<24 mmol/L)
• Caused by:
 - acid producing substance or Metabolic Acidosis
process
Caused by either
- or reduce excretion of acids
i) INCREASED acid production or
Compensation:
ii) IMPAIRED acid excretion. Can occur
1o - Respiratory compensation:
in response to;
- Hyperventilation, decrease CO2
1) High protein diet - protein catabolism
in circulation.
produces
2o - Renal compensation:
phosphoric acid and sulphuric acid.
- increase H ion loss by increasing
2) High fat diet - fat catabolism
H2PO4 and NH4 excretion and
produces fatty acids.
retain HCO3-
- acid-producing substance, such 3) Heavy exercise – stimulates
as ammonium chloride or calcium anaerobic metabolism, producing lactic
chloride, or by excessive acid.
formation of organic acids as
seen with diabetic ketoacidosis 4) Addition of fixed acids
and starvation (e.g. diabetic ketoacidosis).
Respiratory Acidosis Caused by 5) Severe diarrhoea - loss of
hypoventilation bicarbonate from intestines.
• decrease the elimination of CO2 in 6) Alterations in renal function (inability
the lungs, it builds up in the blood to excrete H+).
• decrease in pH, increase in H and
7) Tissue hypoxia (produces lactic acid)
HCO3
8) Ingested substances such as
• Diseases: emphysema, drugs ,
methanol, aspirin (acetylsalicylic acid),
congestive heart failure,
ethylene glycol.
bronchopneumonia.
Metabolic (non-respiratory) alkalosis
Compensation
• HCO3- increased, H+ decreased, pH
• Renal compensation
increased
- increase H+ excretion & increase
• Causes of non-respiratory alkalosis:
reabsorption of HCO3-
- excess administration of
- Emphysema gradually damages
NaHCO3
the air sacs (alveoli) in the lungs,
- ingestion of HCO3– producing
making progressively shorter of
salts such as Na- lactate, citrate
breath
or acetate
- excessive loss of acid through
vomiting
Compensation
• Respiratory compensation
- Hypoventilation with CO2
retention
• Renal compensation
- excrete HCO3- and retain H+
ions.
Metabolic Alkalosis
Relatively rare phenomenon that can
occur in response to;
1) Excessive vomiting - loss of HCI from
stomach (:: retention of (duodenal)
bicarbonate in circulation).
2) Alterations in renal function (f
excretion of titratable acid
e.g., thiazide and loop diuretics 1 Nat
reabsorption ↑ excretion of H+).
3) Excessive ingestion of bicarbonate
antacids paired with renal failure.
4) Volume contraction (e.g via diuretic
therapy 1 plasma [HCO,1).
5) Excess aldosterone (stimulates
collecting duct H+-ATPases to excrete
H+).
• Loss of acid ↑ dissociation of H2CO3
= ↑HCO3→ Increase in pH
REDUCES ventilation rate,
elevating,
• Pco2 levels. → Reduction in renal
absorption and ↑ excretion of HCO,
in the nephron.
• Characterized by ELEVATED
plasma [HCO3-] and pH
Respiratory alkalosis
• Decreased CO2, decreased H+,
increased pH
• Causes of respiratory alkalosis
include:
- hypoxemia;
- chemical stimulation of the
respiratory center by drugs, such
as salicylates (stimulate the
respiratory center to cause
hyperventilation);
- pulmonary fibrosis.
Compensation
Renal compensation
- decrease renal excretion of H+
ions, HCO3- excreted.
- Hypoxemia: an abnormally low
concentration of oxygen in the
blood.
- pulmonary fibrosis causes faster
breathing and more excretion of
CO2
- Salicylates directly stimulate the
respiratory center to cause
hyperventilation
ABG ANALYSIS
ABG-Arterial blood gas
–Measurement of the acidity and
alkalinity of the arterial circulation
–Measure gases and carbon dioxide
4 Important components of ABG
pH
• Measurement of the acidity and
alkalinity of
blood
• NV-7.35-7.45
CO2/PaCO2
• Measurement of carbon dioxide
• NV-35-35
• Controlled by lungs 7.45. Your body is constantly striving to
keep pH in balance.
• Acid
• pH level below 7.35 is Acidosis
– The amount of CO2 is directly
proportional to the • pH level above 7.45 is Alkalosis
number of hydrogen ions-related to acid 3. Determine If the Acid Base is
Respiratory or Metabolic
– The more CO2 in the blood the more
acidic • Next thing you need to determine is
whether the acid base is
HCO3
Respiratory or Metabolic.
• Bicrbonate
• paCO2 = Respiratory
• Nv-22-26
• HCO3 = Metabolic
• Controlled by kidenys
4. Remember ROME
• Lungs and kidenys work-maintain
- Still, it all boils down to mnemonics.
blood ph
The mnemonic RO-ME.
• Basic- the more bicarbonate in the
• Respiratory Opposite
blood, the more basic the blood is
– When pH is up, PaCO2 is down =
PaO2
Alkalosis
• Oxygen
– When pH is down, PaCO2 is up =
• Regulated by the lungs Acidosis
• NV 80-100 • Metabolic Equal
ABG ANALYSIS/INTERPRETATION – When pH is up, HCO3 is up =
Alkalosis
8-STEP GUIDE TO ABG ANALYSIS:
– When pH is down, HCO3 is down =
Tic-Tac-Toe Method
Acidosis
1. Know the Normal Values
5. Tic-Tac-Toe
Know the normal and abnormal ABG
And yes, ABG problems work using the
values when you review the lab reports.
Tic-Tac-Toe method. All you have to do
2. Check for Acidosis or Alkalosis is make a blank chart a bit like a tic-tac-
toe chart.
The first thing you need to determine
when checking ABG results is the
acidity of the blood which is determined
by the value of the pH. The pH level in a
healthy human should be between 7.35
to
6. Mark the Chart = Uncompensated
• Using the lab result values, mark them – Therefore this ABG is METABOLIC
on your Tic-Tac-Toe chart. Now begin ACIDOSIS, PARTIALLY
with this given COMPENSATED
example. • pH 7.1, PaCO2 40, HCO3 18
• pH 7.26, paCO2 32, HCO3 18 • pH is LOW = ACID so place pH under
Acid
– pH is LOW = ACID so place pH under
Acid • PaCO2 is NORMAL = NORMAL so
place
– paCO2 is LOW = BASE so place
paCO2 under PaCO2 under Normal
Base • HCO3 is LOW = ACID so place HCO3
– HCO3 is LOW = ACID so place HCO3 under Acid
under Acid
7. Match It up
– In this step, look at which column
matches up with the pH. In this case
HCO3 goes with pH.
- HCO3 is considered Metabolic
(shown in step 3), and both are
under Acid, so this example implies
Metabolic Acidosis.
8. Determine Compensation
– The last step is to determine if the
ABG is Compensated, Partially
Compensated, or Uncompensated.
– If pH is NORMAL, PaCO2 and HCO3
are both
ABNORMAL = Compensated
– If pH is ABNORMAL, PaCO2 and
HCO3 are both
ABNORMAL = Partially Compensated
– If pH is ABNORMAL, PaCO2 or HCO3
is ABNORMAL