Subject: Clinical Chemistry 2

Lesson: Acid-Base Metabolism, pH and Blood Gases

Professor: Louis John Bejo, RMT, MSPH

• Muscle twitching
• Hand tremor
• Muscle spasms
• Numbness and tingling
• Nausea
• Vomiting
• Lightheadedness
• Confusion
Major Buffer System
Buffer – System that can resist change in pH,
composed of a weak acid or weak base and its
corresponding salt.
Acidosis Four Buffer Systems of clinical importance
 Respiratory Acidosis exist in whole blood:

• Fatigue or Drowsiness 1) The Bicarbonate-Carbonic acid Buffer

System
• Confusion
2) The protein Buffer System
• Shortness of breath
3) The phosphate Buffer System
• Sleepiness
4) The Hemoglobin Buffer System
• Headache
The Bicarbonate-Carbonic acid Buffer System
 Metabolic acidosis
(HCO-3: H2CO3)
• Rapid & Shallow Breathing
 It uses HCO-3 and H2CO3 to minimize
• Confusion pH changes in plasma and
erythrocytes. It is the most important
• Fatigue
buffer system in plasma.
• Headache
 Major extracellular blood buffer.
• Sleepiness
 H2CO3 is a weak acid because it does
• Lack of appetite not completely dissociate into H+ and
HCO-3.
• Jaundice
The Protein Buffer System
• Increased heart rate
 It uses plasma proteins to minimize
• Breath that smells fruity pH changes in blood.
• diabetic acidosis  They have buffering capacity through
(ketoacidosis) charges on their surfaces.
Alkalosis The Phosphate Buffer System (Inorganic
Phosphate)
Fiona Marie Kyla Tunay
BSMT3-L1
Subject: Clinical Chemistry 2
Lesson: Acid-Base Metabolism, pH and Blood Gases
Professor: Louis John Bejo, RMT, MSPH
 It uses HPO-4 and H2PO-4 to minimize
pH changes in the plasma and
erythrocytes.
The Hemoglobin Buffer System
 It uses the hemoglobin in RBC to
minimize pH changes in the blood. It is
the most important intracellular
buffer.
 Hgb is an effective buffer because it
can off-load its oxygen and combine
with CO2 that has diffuse across
gradients.
 1 gram of Hemoglobin carries 1.39mL
of oxygen; each mole of Hgb binds 1
mole of oxygen – more than 95% of
Hgb binds oxygen.
Definition of Terms:
 Acid –
 Base (Alkali) -
 Respiration – process to supply cells
with oxygen for metabolic processes
and remove carbon dioxide produced
during metabolism.
 Partial Pressure – in a mixture of
gases, partial pressure is the amount
of pressure contributed by each gas to
the total pressure exerted by the
mixture.
 Acidemia – occurs when arterial blood
is < 7.35.
 Alkalemia – occurs when arterial
blood is > 7.45.
 Hypercapnia – increased in blood
pCO2.
 Hypocapnia – decreased blood pCO2.
 Partial pressure of Carbon Dioxide
(pCO2) – measured in blood using mm
Hg.
 Concentration of Dissolved Carbon
Dioxide – Includes undissociated
Fiona Marie Kyla Tunay
BSMT3-L1
carbonic acid (H2CO3) and carbon
dioxide dissolved in blood
(represented by pCO2).
 Concentration of Total Carbon Dioxide
– Includes Bicarbonate (primary
component), carbamino-bound CO2,
carbonic acid and dissolved carbon
dioxide.
Regulation of Acid-Base Balance:
Lungs and Kidneys
 Most of the CO2 combines with H2O
to form carbonic acid (H2CO3), which
dissociates immediately into H+ and
bicarbonate (HCO-3 )- the reaction is
accelerated by carbonic anhydrase.
 The dissociation of H2CO3 increase
HCO-3 in RBC causing it to diffuse into
the plasma.
 HCO-3 and H2CO3 are renewable –
even before renal mechanisms restore
the constituents, the lungs alters the
ratio of numerator (HCO-3 ) to
denominator (H2CO3) by blowing off
CO2.
Lungs
 Respiratory control of CO2 excretion
allows rapid and very sensitive
adjustments in blood pH.
 As the lungs eliminate excess CO2 to
resist accumulating H+ , the
proportion between HCO-3 & H2CO3
readjust to 20:1, although the
absolute concentrations of each can
fall below normal.
 By regulating the rate of CO2
excretion, the lungs can maintain the
ratio at or about 20:1, thereby
minimizing pH changes.
 The CO2 diffuses into the alveoli and
is eliminated through ventilation.
 Slow or non-removal of CO2 by the
lungs results to increase in H+ ion
concentration - respiratory acidosis.
Subject: Clinical Chemistry 2
Lesson: Acid-Base Metabolism, pH and Blood Gases
Professor: Louis John Bejo, RMT, MSPH
 Rapid or fast elimination of CO2
results to decrease H+ ion
concentration – respiratory alkalosis.
Kidneys
 The most important function of the
kidneys in acid-base homeostasis is
excretion of acid, which is equivalent
to generation of alkali or reabsorption
of HCO-3 from the glomerular
filtrate(Proximal tubules of the
kidneys).
 Acid is excreted in the form of NH4+
and titrable acid.
 Hydrogen ions are also excreted by
the kidney, both by direct excretion
and through indirect disposal in the
form of ammonium ion.
 HCO-3 concentration is under renal
control, in that the kidneys regulate
both the generation of HCO-3 ions and
their rate of urinary excretion.
 50-100mmol/L of acid must be
excreted daily by the kidneys (urine
pH is 4.5).
Plasma and Urine Bicarbonate
 Increase HCO-3 : IV infusion of lactate,
acetate and HCO-3.
 Decrease HCO-3 : use of diuretics,
reduced reabsorption and chronic
nephritis.
 If HCO-3 is below 25mmol/L or if
plasma CO2 rises above normal, the
tubule can reabsorb all the HCO-3 in
the glomerular filtrate, leaving none
for the excretion in the urine.
 is normally excreted in the urine
(about 10mEq/day).
 The kidneys excrete considerable
amounts of acid and base for acid-
base regulation.
Fiona Marie Kyla Tunay
BSMT3-L1
 Urinary excretion of HCO-3 : when
plasma reached 26-30mmol/L.
Henderson-Hasselbach Equation
pH = pKa+ log conjugate base
weak acid
 It expresses acid-base relationship
and relates the pH of a solution to the
dissociation properties of the weak
acid.
 It indicates that pH depends on the
ratio of HCO-3 / pCO2.
 When the kidneys and the lungs are
functioning properly, a 20:1 ratio of
HCO-3 to H2CO3 will be maintained, and
it is expressed by the Henderson-
Hasselbach equation.
pH = pKa+ log conjugate base
weak acid
 Where:
o pKa = is 6.1; combine
hydration and dissociation
constants of CO2 in blood.
o Conjugate Base = Bicarbonate
o Weak Acid = Carbonic acid
pH = 6.1+ log HCO-3
H2CO3
 Total CO2 = HCO-3 + H2CO3
 HCO-3 = Total CO2 - H2CO3
 H2CO3 = K(constant) x pCO2 [0.03 x
pCO2]
pH = 6.1 + log Total CO2 – (0.03 x pCO2)
0.03 x pCO2
Parameters in the Assessment of Acid-Base
Balance
1. pH
Subject: Clinical Chemistry 2
Lesson: Acid-Base Metabolism, pH and Blood Gases
Professor: Louis John Bejo, RMT, MSPH
2. pCO2
3. HCO3
4. pO2
pH Evaluation
 Normal pH: 7.35 – 7.45
 <7.35 = Acidosis
 >7.45 = Alkalosis
 pH 7.40 is the optimum level for
arterial blood.
 To preserve pH within the narrow
physiologic range, short-term
buffering capacity must neutralize
acids as they are generated, and long-
term corrective measures must
eliminate the acid permanently, but
on continuous basis.
 Parameters in the Assessment of Acid-
Base Balance
 The reference range for arterial blood
(7.35-7.45) pH is only 0.03pH unit
lower for venous blood owing to the
buffering effects of Hemoglobin
known as Chloride-isohydric shift.
 The pH decreases by o.015/each
Celsius above 37°C.
 3 major causes of extra-renal acidosis;
organic acidosis, diarrheal loss of
bicarbonate and acidosis due to
exogenous toxins.
Evaluate Ventilation (Lungs)
 Normal pCO2: 35-45mmHg
 <35 mmHg =
Respiratory Alkalosis
 >45mmHg = Respiratory
Acidosis
 pCo2 is an index of efficiency of gas
exchange and not a measure of CO2
concentration in blood.
Fiona Marie Kyla Tunay
BSMT3-L1
 The lungs regulate pH through
retention or elimination of CO2.
 An Increasing ration of heparin to
blood can cause marked artifactual
rise on measured pCO2 (12-15%) and
parameters calculated from it.
 Whole blood total CO2 is equal to
dissolve CO2 + H2CO3 + HCO3
 Increased pCO2: use of elicit drugs like
barbiturates and morphine and
alcoholism.
Evaluate the Metabolic Process (Kidneys)
 Normal HCO-3 : 21-28mEq/L
 <21mEq/L= Metabolic
Acidosis
 >28mEq/L = Metabolic
Alkalosis
 The kidneys regulate pH by excreting
(NH4 ions) and reabsorption of HCO-3
from the glomerular filtrate.
Evaluate the Degree of Oxygenation
 Normal pO2 : 81-100 mmHg
(adequate oxygenation)
 3 levels of Hypoxemia:
 Mild = 61 – 80 mmHg
 Moderate = 41 – 60 mmHg
 Severe = 40 mmHg or less
 Hypoxemia is low pO2 .
 pO2 changes more rapidly than pCO2
or pH.
 pO2 is 60 -70 % lower in venous blood
after oxygen is released in the
capillary tissues.
 The degree of association or
dissociation of oxygen with
hemoglobin is determined by pO2 and
the affinity of Hgb for O2.
Subject: Clinical Chemistry 2
Lesson: Acid-Base Metabolism, pH and Blood Gases
Professor: Louis John Bejo, RMT, MSPH

 Low pO2 is seen in myocardial and causes greater K+ efflux than

infarction, interstitial pneumonia and organic acid.
severe congestive heart failure.
 Also caused by salicylate poisoning,
 Healthy persons living at higher ethylene glycol and methyl alcohol.
altitudes will show lower ranges of
arterial pO2 because of the naturally  Lab. Findings:
lower partial pressure of oxygen in the  tCO2 = Decreased (95% of
atmosphere and so in the inspired air. tCO2 is bicarbonate)
Four Basic Abnormal States  pCO2 = Normal
1. Metabolic Acidosis  pH = Decreased
2. Metabolic Alkalosis  Compensation:
3. Respiratory Acidosis o Breathing rate increases to
4. Respiratory Alkalosis lower pCO2 =
hyperventilation
Metabolic Acidosis
 After Compensation:
 It is caused by bicarbonate deficiency.
o Low HCO-3 + Low pCO2 + pH
 Ingestion exceeds excretion rate <7.4 (decrease pCO2 = 10-
15mmHg)
 Seen in Diabetic Ketoacidosis(DKA),
Lactic acidosis (alcoholism), renal  The maximal compensation is
failure, and diarrhea. completed within 12 to 24 hours.
o In DKA, due to production of  pCO2 drops 1 to 1.3 mmHg per mEq/L
acetoacetic acid & ß- fall in HCO-3.
hydroxybutyric acid
 Electrolyte Imbalance: Hyperkalemia
o Lactic acidosis = Lactic acid and Hyperchloremia
(DKA and Lactic acidosis are
organic acidosis) Metabolic Alkalosis

o Renal Failure – excess renal  It is caused by Bicarbonate excess.

excretion, reduced acid  Ingestion of excess base
excretion, tubular acidosis
 Decrease elimination of base
 In DKA the chloride remains normal
(normochloremic acidosis) or low with  Loss of acidic fluids
elevated anion gap.  Ingestion of excess
 Diarrhea results in metabolic acidosis antacids(alkali)
via bicarbonate loss.  IV administration of HCO-3
 Metabolic acidosis causes greater  Renal HCO-3 retention
potassium efflux than respiratory
acidosis.  Prolonged diuretics use

 Metabolic Acidosis due to inorganic  Intestinal obstruction

acids: Sulfuric acid, Hydrochloric acid
 Gastric Suction

Fiona Marie Kyla Tunay

BSMT3-L1
Subject: Clinical Chemistry 2
Lesson: Acid-Base Metabolism, pH and Blood Gases
Professor: Louis John Bejo, RMT, MSPH
 Cushing Syndrome
(Glucocorticoid excess)
 Hyperaldosteronism
(Mineralocorticoid excess)
 Vomiting (Loss of
Chloride[HCl] in the stomach)
 Lab Findings:
 tCO2 = Increased
 pCo2 = normal
 pH = Increased
 Compensation: breathing rate
decreases to increase pCO2
(Hypoventilation). The maximal
compensation is completed within 12
to 24 hours.
 Among the four types of acid-
base disorders, compensation
is least effective in metabolic
alkalosis because of
hypoxemia. (it stimulates
ventilation)
 After Compensation:
 HCO-3 increase + pCO2
Incraese + pH >7.4
 2. Metabolic Alkalosis
-
 For every 10mEq/L rise in HCO , the 3
pCO2 rises by 6 mmHg.
 Electrolyte Imbalance: hypokalemia,
hypochloridemia.
Respiratory Acidosis
 It is due to excessive CO2
accumulation. (Hypercapnia)
 It is seen in Chronic
Obstructive Pulmonic Disease
(COPD)[Chronic bronchitis,
emphysema],
 Myasthenia gravis (partial
paralysis of the accessory
muscles for breathing),
Fiona Marie Kyla Tunay
BSMT3-L1
 CNS disease (meningitis)
 Drug overdose (morphine
barbiturates, opiate,
narcotics)
 Lab Findings:
 tCO2 = N
 pCO2 = Increase
 pH = Increase
 Compensation: Kidneys retain HCO-3
because increase pCO2
 After Compensation:
 High pCO2 + high HCO-3 + pH
<7.4
Maximal Compensation requires 5 days but is
90% complete in 3 days.
 Excretion of Acid is another way of
compensating the rise of pCO2.
 Restriction of NaCl intake during the
recovery phase of chronic acidosis
results in the maintenance of a high
serum HCO-3.
 HCO-3 rises 1 mEq/L for each 10mmHg
rise in pCO2.
Respiratory Alkalosis
 It is due to carbon dioxide loss.
(Hypocapnia)
 Observed in the ff. cases:
 Pneumonia
 Pulmonary embolism
 Congestive Heart Failure
 Anxiety
 Severe Pain
 Aspirin Over dosage
 Hepatic Cirrhosis
 Gram-Negative Sepsis
Subject: Clinical Chemistry 2
Lesson: Acid-Base Metabolism, pH and Blood Gases
Professor: Louis John Bejo, RMT, MSPH
 Salicylate overdose
 Progesterone Drugs
 Hypoxia
 Nervousness
 EXCESSIVE CRYING
 Blood pH tends to be extremely high
when respiratory alkalosis is caused
by psychogenic stimulation of the
respiratory center, because the
condition is usually superacute and
therefore there is no time for
compensation.
 High progesterone levels are
responsible for chronic respiratory
alkalosis of pregnancy.
 Among the four types, compensation
is most effective in respiratory
alkalosis – pH after compensation
sometimes return to normal levels.
 When complete compensation does
occur, one should look for evidence of
complicating metabolic acidosis.
 Lab Findings:
 tCO2 = N
 pCO2 = Decrease
 pH = Decrease
 Compensation: decrease reabsorption
of HCO-3
 After Compensation:
 Low pCO2 + low HCO-3 + pH
>7.4
 Compensation is completed
within 2 – 3 days.
 HCO-3 falls 2 mEq/L for each
10 mmHg fall in pCO2.
 Electrolyte Imbalance:
Hypokalemia
Mixed Acid-Base Disorders
Fiona Marie Kyla Tunay
BSMT3-L1
 It refers to a clinical condition in which
two or more primary acid-base
disorders coexist.
 They generally present with one
obvious disturbance with what
appears to be an inappropriate
(excessive or inadequate)
compensation.
 The “inappropriateness” of the
compensatory process is probably the
result of a separate primary disorder.
 When two disorders influence the
blood pH in opposite directions, the
blood pH will be determined by the
dominant disorder.
 If pCO2 and bicarbonate have
changed in opposite directions (e.g.,
pCO2 is high and HCO3 is low), the
presence of a mixed acid-base
disorder is certain.
Oxygen Metabolism
 Oxygen is bound to Hemoglobin.
(Present in RBC in a physically dissolve
state)
 3 Factors that control oxygen
transport:
1. pO2
2. Free diffusion of O2 across
the alveolar membrane
3. Affinity of Hgb for Oxygen
 Under normal circumstances, the
saturation of Hgb with oxygen is 95%
when the pO2 is >110mmHg, greater
than 98% of Hgb binds to Oxygen.
 If a persons oxygen saturation falls
<95% either the individual is not
getting enough oxygen or does not
have enough functional Hgb available
to transport O2. (decrease # of RBC or
presence of non-functional Hgb like
Cyanmethemoglobin and
Carboxyhemoglobin)
Subject: Clinical Chemistry 2
Lesson: Acid-Base Metabolism, pH and Blood Gases
Professor: Louis John Bejo, RMT, MSPH
Clinical Significance of pO2 levels in Blood
 Increased values >95% are observed
in supplemental O2.
 Hypoxemia - causes includes:
 Decreased pulmonary diffusion
 Decreased alveolar spaces due to
resection/compression
 Poor ventilation
 Perfusion (due to obstructed airways
– asthma, bronchitis, emphysema)
Specimen Collection
 Specimen: Arterial Blood
 Anticoagulant: 0.05mL Heparin/mL of
Blood
• Syringe and needle for arterial
blood collection must be
preheparinized by drawing up
heparin into the syringe to
wet its interior; excess
heparin should be expelled
(Excess heparin = Decreased
pH )
• The use of butterfly infusion
sets is not recommended.
• The liquid form of heparin not
recommended because
excessive amounts can dilute
the sample and possibly
contaminate sample if
equilibrated with room air.
• Any air trapped in the syringe
during blood collection should
be immediately expelled at
the completion of the draw.
• Arterial and Venous blood
differ in pH, pCO2 and PO2.
Common Errors in Specimen Collection and
handling
 Form and Concentration of heparin
Fiona Marie Kyla Tunay
BSMT3-L1
 Speed of Syringe Filling
 Maintenance of Anaerobiosis
 Mixing of Samples
 Collection Device
 Transport and Storage
 Time before analysis
Common Analytical Errors
 Temperature error
 Protein coating of electrodes
Specimen Considerations
1. On Standing, pH(Decreased) and
PCO2(Increased) are affected.
2. Blood samples should be chilled to
prevent oxygen consumption by the
RBC and release of acidic metabolites,
thereby altering the pH.
3. Glycolysis results to decrease blood
pH.
4. Excess heparin causes downward
shifting of blood pH – most common
preanalytical error.
5. Lower temperature cause increase O2
solubility in blood and left-shift in the
oxyhemoglobin curve resulting in
more oxygen combining with
hemoglobin.
Quality Control
 The minimum requirement for blood
gas quality control is one sample
every 8 hours and three levels
(acidosis, normal, alkalosis) of control
every 24 hours.
Methods
I. Gasometer
II. Electrodes
Gasometer
A. Van Slyke
Subject: Clinical Chemistry 2
Lesson: Acid-Base Metabolism, pH and Blood Gases
Professor: Louis John Bejo, RMT, MSPH
B. Natelson
1) Mercury – to produce vacuum
2) Caprylic alcohol – anti-foam
reagent
3) Lactic acid
4) NaOH and NaHSO3
Electrodes
A. pH (Potentiometry)
1) Silver-Silver Chloride
Electrode – reference
electrode
2) Calomel electrode (Hg2Cl2) –
reference electrode
3) Gas electrode – most
commonly used for pH
B. pO2 – Clark electrode (polarography -
amperometry)
C. pCO2 – Severinghaus electrode
(potentiometry)
* Modern blood gas analyzers routinely
contain three electrodes that give very rapid
and accurate results for direct measurement
of pH, pCO2 and PO2.
Continuous monitoring for pO2
 This is done by using Transcutaneous
(TC) electrodes placed directly on the
skin of the patient.
 It is commonly used for neonates and
infants; a noninvasive procedure.
Factors affecting blood gases and pH
measurements
1. Temperature
2. Elevated Plasma Proteins
concentrations
3. Bacterial Contamination within the
measuring chamber
Fiona Marie Kyla Tunay
BSMT3-L1
4. Improper transport of the blood
specimen
Temperature
- most important factor
 (37°C ±0.1°C)
 It should be stable for all
measurements.
 For each degree of fever in the
patient, pO2 will fall 7% and pCO2
will rise 3%.
 Decrease pH by 0.015 = +1°C
Elevated Plasma Proteins concentrations
 pO2 test is affected by build up of
proteins on the surface of the
membranes.
 False Increase of pO2
Bacterial Contamination within the
measuring chamber
 If present the bacteria will consume
the O2 and cause low value of pO2.
Improper transport of the blood specimen
 When blood samples are not
transported on ice (during transport
to the laboratory), the pO2 changes
rapidly than pH and pCO2.
 Samples should be kept at room
temperature and analyzed
immediately ()in less than 30 minutes
after blood collection).
Notes to Remember:
 Blood gas results are affected by the
gas mixture the patient is breathing
and by the patients body temp.
 Calculation of base excess uses pH
and pCO2 values.
 Blood gas result should be back at the
physician preferably within 10 mins
Subject: Clinical Chemistry 2
Lesson: Acid-Base Metabolism, pH and Blood Gases
Professor: Louis John Bejo, RMT, MSPH

after draw to obtain maximum benefit

from them.
 Total CO2 = 19 – 24 mmol/L (arterial
blood)

Fiona Marie Kyla Tunay

BSMT3-L1