Acid-Base Balance

Acids & Bases

Normal functioning body requires a balance
between acids and bases
Acid-base balance is a dynamic relationship
which reflects the concentration of
hydrogen ions (H+) in the body.
Chemical reactions occur in the body only
when these substances are in balance
Free H+ constantly being produced & generated
from carbonic acid (H2CO3)
Free H+ determines pH
Chemical reactions depend on pH
Accelerated
Severly depressed, stopped
Chemical reactions depend on enzymes, which are
proteins that act as catalysts, that are easily
destroyed, denatured, in an abnormal pH situation
Deactivated
Acids
Releases H+
Electrolytes that dissociate into (H+) and an
anion
Amount of H+ in a solution determines
acidity
Predominantly carbonic acid (H2CO3)
produced from CO2
Acid Sources
1. Cellular metabolism of glucose,
glycolosis, that produces CO2
2. Diet 50-100 mEq of acid is consumed
daily

CO2 + H2O = (H2CO3) as an acid
dissociates (HCO3-) + free H+
Free H+ must be neutralized to maintain
normal pH
Hgb in RBC + H+ carried to lungs
HCO3- diffuses out of RBC creating a
charge and another anion must move into
the cell to maintain a neutral state
Cl- shift

HCO3-, bicarbonate, + Na+ is transported
by circulation to lungs as NaHCO3
Na+ leaves bicarb combines back with H+
Bases
Accepts H+
Substances that combine with H+
Usually contain OH- (hydroxyl ion)
Dissociates into:
(element) + (OH-)
Predominantly bicarbonate (HCO3-)
produced from (H2CO3)

When an acid is mixed with a
base the (H+) of the acid
combines with the (OH-) of the
base to form H2O, which is
neutral
(Na+) + (Cl-) combine to form a salt:
HCL + NaOH > H2O + NaCL

In a neutralization reaction, an acid
combines with a base to form a salt and
H2O
ACID-BASE BALANCE
Definitions

Acid: a proton, or hydrogen ion donor
Base: a proton, or hydrogen ion receiver
Acid & Base
Weak or strong depending on the ability to
dissociate
Usually occur in pairs
two sides of the same coin
Acid/ base depending on H+
pH
Unit of measurement that indicates how
many (H+) are in a solution
Inversely proportionate, opposite of (H+)
Acid releases H+, > present
Decrease pH or acidosis
Base takes H+, < present
Increase pH or alkalosis
Scale 0-14
Midpoint- 7.0 # (H+) = # (OH-) in pure H2O
pH < 7 indicates more (H+) acidic
pH > 7 indicates less (H+) alkalotic
Each unit represents a change 10X in (H+)
1 unit = 10x
2 units = 100x

pH of Body Fluids
Gastric contents
1- 4
Blood
7.35-7.45

A variation of 0.4 in either direction
can be fatal


Henderson-Hasselbach Equation
Determines normal pH in the bloodstream
Determined by RATIO of base:acid not
amount
Bicarbonate: carbonic acid
HCO3-:H2CO3
Levels may be abnormal and ratio may be
normal
Normal pH ratio 20:1


Bicarbonate buffer system.
BODY REGULATION OF ACID-BASE
BALANCE
The body constantly produces acids through
metabolism
These acids must be constantly eliminated from
the body
Three systems perform this task
Buffer system
Respiratory system
Renal system
Buffer
Chemical substance that prevents large
changes in pH
A substance capable of accepting and
donating H+ ions
the CARBONIC ACID/BICARBONATE
(H2CO3/HCO3-) system is the principle
buffer system used by the body
Removes excess H+
Antacid combines with hydrochloric acid
Donates H+
BUFFER SYSTEM
The fastest performer, works in seconds
Temporary solution
Bicarbonate ions combine with excess hydrogen
ions to form carbonic acid in a dynamic
relationship
HCO3 + H+ H2CO3
buffering is the first defense against
changes in acid-base balance
bicarbonate buffer system is the most
important because there is a higher
concentration of HCO3- in the extra cellular
fluid than other buffers
ability of the body to regulate HCO3


BUFFER SYSTEM
For every molecule of carbonic acid, there are 20
molecules of bicarbonate
Any change in the this 20:1 ratio is immediately
corrected to maintain pH
An increase H+ causes an increase in H2CO3
A decrease in H+ causes a decrease in H2CO3
BUFFER SYSTEM
Carbonic acid is a weak, volatile acid which must
be eliminated
The enzyme carbonic anhydrase causes the
carbonic acid to convert to carbon dioxide and
water
The CO2 and the H2O are easily eliminated by the
lungs and kidneys
The system also works in reverse

Phosphate Buffer Pair
H2PO4- and HPO4
Found in cells concentrated in the tubules of
the kidneys because phosphate is eliminated
in the kidneys
Strong acids buffered in the kidney
RESPIRATORY SYSTEM

Works in 3-12 minutes
Hyperventilation stimulated by an increase pCO2
The lungs eliminate excess CO2 by increasing
respirations, causing a decrease in H+ and an
increase in pH
The lungs can retain more CO2 by slowing
respirations, causing an increase in H+ and a
decrease in pH


RENAL SYSTEM
Can take hours to days to work
Eliminates H+ in the urine and conserves HCO3-
Increase CO2 results in increased H+ secretion
Kidneys can retain bicarbonate ion, causing a
decrease in H+ and an increase in pH
Kidneys can excrete bicarbonate ion, causing an
increase in H+ and a decrease in pH
Most effective
Acid-Base Derangements
Respiratory acidosis-caused by
retention of CO
2
Respiratory alkalosis-caused by
increased respiration and excessive
elimination of CO
2

RESPIRATORY ACIDOSIS

Lower than normal pH caused by retention of CO2
(Alveolar hypoventilation)
Pulmonary system unable to rid the body of enough
CO2
Results in decreased ventilations due to problems
in lungs or respiratory center of the brain
CO2 is increased and the pH is decreased
Treatment is aimed at improving ventilations

What Happens?

Patient hypoventilates, carbon dioxide
builds up in the bloodstream and the pH
drops below normal.
Compensation
Kidneys retain more bicarbonate which raises
the pH level.



Respiratory acidosis.
3
H2CO3
16
HCO3
Causes!

Neuromuscular problems
Depression of respiratory centers in the
brain
Lung disease
Airway obstruction

Respiratory Acidosis
Caused by retention of carbon
dioxide, leading to an increase
in PCO
2

Treatment
Hypoventilating
Decrease ventilations
PaCO2
H2CO3
Respiratory Acidosis
pH
Respiratory Alkalosis
Usually caused by
hyperventilation whereby PCO
2

is decreased
Treatment
Respiratory alkalosis.
25
HCO3-
1
H2CO3
Increase
ventilation
H2CO3
PaCO2
Respiratory Alkalosis
pH
RESPIRATORY ALKALOSIS

Higher than normal pH from increased
respiration and excessive elimination of
CO2
Sudden increase in ventilation (Alveolar
hyperventilation)
Can result from anxiety or following ascent
to high altitude
CO2 is decreased and pH is increased
Treatment is aimed at increasing CO2 level
by having patient rebreath CO2

What Happens?

When pulmonary ventilation increases
above the needed amount, excessive
amounts of CO2 are exhaled. PaCO2 falls
below normal and a reduction of carbonic
acid leads to a rise in the pH
Defense
Hydrogen ions are pulled out of the cells and
into the bloodstream. Hydrogen ions combine
with bicarbonate ions to forms carbonic acid
which lowers the pH
Causes!

Hyperventilation with anxiety
Pain
Drugs (nicotine, xanthines)
Hypermetabolic states
Fever, sepsis, and liver failure

Acid-Base Derangements
Metabolic alkalosis-alkalinity
resulting from diuresis, vomiting,
or over-consumption of sodium
bicarbonate
Metabolic acidosis-acidity
resulting from vomiting, diarrhea,
diabetes, or medication
METABOLIC ACIDOSIS

Lower than normal pH due to increase production
of metabolic acids
Can also result from diarrhea, vomiting, diabetes,
medications (aspirin)
pH is decreased and CO2 level is normal
Treatment is aimed at improving ventilations to
eliminate CO2
Sodium bicarbonate may be administered on rare
occasions
Metabolic Acidosis
Four common forms of metabolic acidosis
Lactic acidosis
Diabetic ketoacidosis (DKA)
Acidosis resulting from renal failure
Acidosis from ingestion of toxins
Treatment
Metabolic acidosis.
What happens?

There is a loss of bicarbonate from extracellular
fluid, accumulation of metabolic acids, or a
combination of both.
Gain acids, lose bases.

Causes!

Diabetes mellitus
Chronic alcoholism
Severe malnutrition or starvation
Poor dietary intake of carbohydrates
Other factors
Lactic acids can make acidosis worse and can occur
secondarily to shock, heart failure, pulmonary disease,
hepatic disorders, seizures, or strenuous exercise.


METABOLIC ALKALOSIS

Higher than normal pH caused by excessive
elimination of H+
pH is increased and CO2 remains normal
Treatment is aimed at correcting underlying cause

Metabolic Alkalosis (rare)
Causes
Loss of hydrogen ions (primarily from the
stomach)
Ingestion of large amounts of absorbable base
sodium bicarbonate or calcium carbonate
Excessive IV administration of alkali
Diuretic use
Treatment
Metabolic alkalosis.
What happens?

A loss of hydrogen ions (acid), and a gain in
bicarbonate or both
PaCo2 greater than 45mm Hg (possibly as high as
60 mm Hg) indicates that the lungs are
compensating for the alkalosis
Renal compensation is more effective but also
slower.

Causes!

Caused by increased diarrhea, prolonged
vomiting, overdosing on antacids
Also associated with hypokalemia
Depleted potassium stores due to excessive
urination or vomiting

COMBINATIONS

Usually both metabolic and respiratory
components are present
Only arterial blood gasses can accurately diagnose
the problem




What condition am I?
20:1 ratio
Normal pH
What would the pH be?
7.35-7.45
Mixed Acid-Base Disturbances
Many conditions, including various forms
of shock, may produce mixed abnormalities
of acid-base regulation
Acid Base Balance
Compensated
HCO3 PCO2 pH

Metabolic Acidosis


Respiratory Acidosis
Acid Base Balance
Compensated
HCO3 PCO2 pH

Metabolic Alkalosis


Respiratory Alkalosis

ABGs
Blood Gases
oxygenation and acid-base status is
determined by measurement of ABGs
arterial blood measured as opposed to
venous blood because it represents a
mixture from all parts of the body
pH and pCO2 are measured directly,
HCO3- and O2 saturation are calculated
Normal Blood Gas Values
pH:
7.40 (7.35-7.45)
pO2:
80-100mmHg
pCO2:
35-45mmHg
SaO2:
>/= 95%
HCO3:
22-26 mmol/L


Acid-Base Evaluations : THE 5
STEP APPROACH

1) Look at the pH - identify the type of
emia/ osis
<7.35 acidemia, acidosis
>7.45 alkalemia, alkalosis


2) Look at the HCO3
- and CO2 values
Determine which process:
either metabolic (HCO3-)
respiratory (pCO2)

is most in keeping with the direction of the
emia

Metabolic Acidosis
pH
decreased
HCO3-
decreased

Metabolic Alkalosis
pH
increased
HCO3-
increased
Respiratory Acidosis
pH
decreased
pCo2
increased
Respiratory Alkalosis
pH
increased
pCO2
decreased
3) Determine if compensation has
occurred
Kidneys compensate in respiratory
disorders
12-24 hours to exert a noticeable difference
Lungs compensate in metabolic disorders
Within minutes



Respiratory acidosis- increased HCO3-,
reabsorption by kidneys result in increased
serum HCO3-
Respiratory alkalosis- decreased HCO3-,
reabsorption by kidneys result in decreased
HCO3-
Metabolic acidosis
HYPERventilation causes decrease pCO2
Metabolic alkalosis
HYPOventilation causes increase pCO2


4) Calculate the anion gap
Anion gap is useful in determining the cause
of the acid-base disorder
increased AG is usually associated with
metabolic acidosis
AG = Na+ - (Cl- + HCO3-) normally
12 (8-16mmol/L)

5) Look at the clinical picture!!!
Respiratory Acidosis
Decrease pH, increase CO2
Respiratory Alkalosis
Increase pH, decrease CO2
Metabolic Acidosis
Decrease pH, decrease HCO3-
Metabolic Alkalosis
Increase pH, increase HCO3-

Mixed Acid Base Derangements
Normal pH
Abnormal CO2 / HCO3-
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Normal
7.37
38
24
98
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Respiratory
Acidosis
7.16
70
25
88
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Respiratory
Acidosis
7.21
68
22
86
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Metabolic acidosis
7. 13
35
20
80
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Metabolic
Alkalosis
7.47
45
34
90
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Respiratory
Acidosis
7.24
66
22
75
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Metabolic Alkalosis
7.52
41
30
90
Acid Base Practice
Melissa is a 23 y/o female who is brought to
the ED because of a decrease LOC. Her
roommate found her with an empty bottle of
secobarbital (Seconal) and a half bottle of
wine near her. Her roommate states that
Melissa has been depressed about her busy
shifts. Her VS are:
HR-120 RR 28 BP 70/40 (next slide)
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Respiratory
Acidosis
7.20
65
26
45
Acid Base Practice
Jordan is a 26 y/o male who is being seen in
his physicians office because of SOB that
as become worse over the last several
months. He has a cough that is productive
of thick, sputum and he states that his feet
swell occasionally, preventing him from
getting his shoes on. He does not have
cyanosis or digital clubbing. He states that
he is a heavy smoker. (next slide)
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Respiratory
Acidosis
7.32
62
34
54
Acid Base Practice
Ryan is a 22 y/o paramedic student, who
began reviewing his notes for an upcoming
exam when he realized he had lost half of
them. He became very anxious. His RR
increased from 12 to 34/min, and after 10
minutes he began to feel tingling in his
fingers and around his mouth. (next slide)
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Respiratory
Alkalosis
7.56
30
24
104
Acid Base Practice
Rocky is a 21 y/o paramedic student, who
became very upset at his instructor over a
bad test score. Because of this situation he
wanted to clear his mind of this bad test
score. He went home, took out his spray
can of gold paint and a plastic bag and
began to sniff this wonderful product. His
girlfriend found him unconscious on the
floor and immediately called 911. (next
slide)
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Respiratory
Acidosis
7.14
78
23
74
Acid Base Practice
In route to the hospital with Rocky, his
respiratory effort showed some
improvement, and now your blood gases
reveal the following. (next slide)
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Metabolic
(respiratory)
Acidosis
7.25
41
17
79
Acid Base Practice
Donie is a 39 y/o who had an abdominal
hysterectomy 2 days ago. She has had an
uncomplicated postoperative course and has been up
walking in his room twice. She is resting in bed
when she suddenly develops left chest pain that
increases with respirations. She describes of feeling
SOB and appears very anxious. VS: RR 32/min
HR 124 irregular, BP 140/86 Temp 98.6 F
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Respiratory
Alkalosis
7.49
29
22
69
Acid Base Practice
Robin is a 40 y/o male with a 20 hx of
alcohol abuse. He has been admitted to
hospitals numerous times over the past 4
years for TX of jaundice, ascites, and other
problems associated with hepatic
dysfunction. Robin admits he has continued
drink heavily. He his lethargic and
confused. VS HR 70, BP 112/70, RR
24/min, temp 99.9 F. (next slide)
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Respiratory
Alkalosis
7.46
21
25
82
Acid Base Practice
Tina is a 36 y/o woman with advanced ovarian CA. A
tumor was surgically removed but evidence of
microscopic remains. Tina received whole-abdomen
irradiation. Subsequently, after 2 weeks of tx, she
experienced diarrhea, which has intensified over the
last 2 to 3 days. The diarrhea is refractory to outpatient
medical management, necessitating hospital admission.
Tina has dry mucus membranes and poor skin tugor.
BS CTA, respiration deep but not labored. She has had
no oral intake for 3 days because of nausea.
BP 100/50, HR 130, RR 24/min (next slide)
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Metabolic
Acidosis
7.32
36
17
90
Acid Base Practice
Cathy is 32 y/o female who has arrived to
the ED with a 4 day history of nausea,
malaise, HA, and febrile of 102.8 F. She has
been vomiting for the last 12 hours and has
not been able to eat or drink anything for a
least 24 hours. Her mucus membranes are
dry, and she has poor skin turgor. VS BP
94/62, HR 118, RR 8/min (next slide)
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Metabolic
Alkalosis
7.51
46
38
90
Acid Base Practice
Stan is a 44 y/o man admitted to the hospital
with confusion, and hx of CHF. He had a
CVA 2 months ago, which has impaired his
swallowing. He has a G-Tube in place with
drainage noted. His skin and mucus
membranes are dry, and his tongue is
furrowed. His VS are BP 100/70, HR
114, RR 12/min (next slide)
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Metabolic
Alkalosis
7.48
45
34
82
Acid Base Practice
Chris is a 28 y/o male who, when found at
home, was arousable but very lethargic with
deep respirations. An empty bottle of ASA
was found in the bathroom. His classmates
state that he has been upset about doing his
paramedic clinicals. They stated they dont
know of prior incidence of drug OD. VS: BP
110/60, HR 84, RR 34/min with deep,
labored (Kussmaul respirations) (next slide)
Acid Base Practice
ABG Values
pH =

PaCO2 =

HCO3 =

PaO2 =
Respiratory
Alkalosis
7.49
14
22
96