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ACID-BASE BALANCE

By:
Husnil Kadri

Biochemistry Departement
Medical Faculty Of Andalas University
Padang


2
CARA TRADISIONAL :
Hendersen-Hasselbalch
(1909)
3
pH = 6.1 + log
[HCO
3
-
]
pCO
2
GINJAL
PARU
BASA
ASAM CO
2
HCO
3
HCO
3
CO
2
Kompensasi
Normal
Normal
4
Carbonic acid/bicarbonate buffer system

The pK
a
of carbonic acid is 6.1
Carbonic acid is the major buffer in ECF
The pH of blood can be determined using
the Henderson-Hasselbalch equation
H
2
CO
3
H
+
+ HCO
3
-
Carbonic acid Bicarbonate ion
pKa = 6.1
ECF:
5
pH = pK
a
+ log [HCO
3
-
]/[H
2
CO
3
]

pH = pK
a
+ log [HCO
3
-
]/0.03 x PCO
2

7.4 = 6.1 + log 20 / 1

7.4 = 6.1 + 1.3

Plasma pH equals 7.4 when buffer ratio is 20/1
The solubility constant of CO
2
is 0.03

Henderson-Hasselbalch equation
DISORDER pH PRIMER RESPON
KOMPENSASI
ASIDOSIS
METABOLIK
HCO
3
- pCO
2

ALKALOSIS
METABOLIK
HCO
3
- pCO
2

ASIDOSIS
RESPIRATORI
pCO
2
HCO
3
-
ALKALOSIS
RESPIRATORI
pCO
2
HCO
3
-
GANGGUAN KESEIMBANGAN ASAM-BASA
TRADISIONAL
Normal Compensatory Response
Any primary disturbance in acid-base
homeostasis invokes a normal
compensatory response.
A primary metabolic disorder leads to
respiratory compensation, and a primary
respiratory disorder leads to an acute
metabolic response due to the buffering
capacity of body fluids.
A more chronic compensation (1-2 days) due
to alterations in renal function.

Mixed Acid - Base Disorder
Most acid-base disorders result from a single primary
disturbance with the normal physiologic compensatory
response and are called simple acid-base disorders.

In certain cases, however, particularly in seriously ill
patients, two or more different primary disorders may
occur simultaneously, resulting in a mixed acid-base
disorder.

The net effect of mixed disorders may be additive (eg,
metabolic acidosis and respiratory acidosis) and result
in extreme alteration of pH;

or they may be opposite (eg, metabolic acidosis and
respiratory alkalosis) and nullify each others effects on
the pH.

DUA VARIABEL
pH atau [H
+
] DALAM PLASMA
DITENTUKAN OLEH
VARIABEL
INDEPENDEN
Stewart PA. Can J Physiol Pharmacol 61:1444-1461, 1983.
VARIABEL
DEPENDEN
Cara Stewart ;
Strong Ions
Difference
pCO
2
Protein
Concentration
pH

INDEPENDENT VARIABLES DEPENDENT VARIABLES
VARIABEL INDEPENDEN
CO
2
STRONG ION DIFFERENCE WEAK ACID
pCO
2
SID A
tot
DEPENDENT VARIABLES
H
+

OH
-

CO3
-
A
-

AH
HCO3-
CO
2
Didalam plasma berada
dalam 4 bentuk
sCO
2
(terlarut)
H
2
CO
3
asam karbonat
HCO
3
-
ion bikarbonat
CO
3
2-
ion karbonat
Rx dominan dari CO
2
adalah rx
absorpsi OH
-
hasil disosiasi air
dengan melepas H
+
.
Semakin tinggi pCO
2
semakin
banyak H
+
yang terbentuk.
Ini yg menjadi dasar dari
terminologi respiratory acidosis,
yaitu pelepasan ion hidrogen akibat
pCO
2
CO
2

STRONG ION DIFFERENCE
Definisi:
Strong ion difference adalah ketidakseimbangan muatan
dari ion-ion kuat. Lebih rinci lagi, SID adalah jumlah
konsentrasi basa kation kuat dikurangi jumlah dari
konsentrasi asam anion kuat. Untuk definisi ini semua
konsentrasi ion-ion diekspresikan dalam ekuivalensi
(mEq/L).
Semua ion kuat akan terdisosiasi sempurna jika berada didalam
larutan, misalnya ion natrium (Na
+
), atau klorida (Cl
-
). Karena
selalu berdisosiasi ini maka ion-ion kuat tersebut tidak
berpartisipasi dalam reaksi-reaksi kimia. Perannya dalam kimia
asam basa hanya pada hubungan elektronetraliti.

Gamblegram
Na
+
140
K
+
4
Ca
++
Mg
++
Cl
-
102
KATION ANION
SID
STRONG ION DIFFERENCE
[Na
+
] + [K
+
] + [kation divalen] - [Cl
-
] - [asam organik kuat
-
]
[Na+] + [K+] - [Cl-] = [SID]
140 mEq/L + 4 mEq/L - 102 mEq/L = 34 mEq/L
SKETSA HUBUNGAN ANTARA SID,H
+
DAN OH
-
SID
()
(+)
[H
+
] [OH
-
]
Dalam cairan biologis (plasma) dgn suhu 37
0
C, SID hampir
selalu positif, biasanya berkisar 30-40 mEq/Liter
Asidosis Alkalosis
Konsentrasi [H+]
Kombinasi protein dan posfat disebut asam
lemah total (total weak acid) [Atot].
Reaksi disosiasinya adalah:
[A
tot
] (KA) = [A
-
].[H
+
]
[Protein H]
[Protein-] + [H+]
WEAK ACID
disosiasi
Gamblegram
Na
+
140
K
+
4
Ca
++
Mg
++
Cl
-
102
HCO
3
-
24
KATION ANION
SID
Weak acid
(Alb-,P-)
Na
140



K

Mg

Ca



Cl
102


P


Alb


HCO
3
= 24




Cl
115


P


Alb


HCO
3
-


Asidosis
hiperkloremi
SID n
SID



Cl
102

Laktat/keto=UA
Keto/laktat
asidosis
CL
95
P
Alb
SID
Alkalosis
hipokloremi
KATION ANION
APLIKASI
H
3
O
+
= H
+
= 40 mEq/L
HCO
3
-


HCO
3
-

KLASIFIKASI GANGGUAN
KESEIMBANGAN ASAM BASA
BERDASARKAN PRINSIP STEWART
Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic acid-base disturbances in
critically ill patients. Am J Respir Crit Care Med 2000 Dec;162(6):2246-51
KLASIFIKASI




ASIDOSIS



ALKALOSIS

I. Respiratori

PCO
2


PCO
2


II. Nonrespiratori (metabolik)






1. Gangguan pd SID






a. Kelebihan / kekurangan air

[Na
+
], SID

[Na
+
], SID


b. Ketidakseimbangan anion
kuat:






i. Kelebihan / kekurangan Cl
-

[Cl
-
], SID [Cl
-
], SID

ii. Ada anion tak terukur


[UA
-
], SID




2. Gangguan pd asam lemah





i. Kadar albumin


[Alb]


[Alb]

ii. Kadar posphate


[Pi]


[Pi]

Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic acid-base disturbances in
critically ill patients. Am J Respir Crit Care Med 2000 Dec;162(6):2246-51
RESPIRASI M E T A B O L I K
Abnormal
pCO2
Abnormal
SID
Abnormal
Weak acid
Alb PO4-
Alkalosis
Asidosis
Turun
Meningkat
Turun
kelebihan
kekurangan
Positif meningkat
Fencl V, Am J Respir Crit Care Med 2000 Dec;162(6):2246-51
AIR Anion kuat
Cl- UA-
Hipo
Hiper
Na
+
= 140 mEq/L
Cl
-
= 102 mEq/L
SID = 38 mEq/L
140/
1/2
= 280 mEq/L
102/
1/2
= 204 mEq/L
SID = 76 mEq/L
1 liter liter
KEKURANGAN AIR - WATER DEFICIT
Diuretic
Diabetes Insipidus
Evaporasi
SID : 38 76 = alkalosis
ALKALOSIS KONTRAKSI
Plasma Plasma
Na
+
= 140 mEq/L
Cl
-
= 102 mEq/L
SID = 38 mEq/L
140/2 = 70 mEq/L
102/2 = 51 mEq/L
SID = 19 mEq/L
1 liter 2 liter
KELEBIHAN AIR - WATER EXCESS
1 Liter
H
2
O
SID : 38 19 = Acidosis
ASIDOSIS DILUSI
Plasma
Na
+
= 140 mEq/L
Cl
-
= 95 mEq/L
SID = 45 mEq/L
2 liter
ALKALOSIS HIPOKLOREMIK
SID ALKALOSIS
GANGGUAN PD SID:
Pengurangan Cl
-
Plasma
Na
+
= 140 mEq/L
Cl
-
= 120 mEq/L
SID = 20 mEq/L 2 liter
ASIDOSIS HIPERKLOREMIK
SID ASIDOSIS
GANGGUAN PD SID:
Penambahan/akumulasi Cl
-
Plasma
Na
+
= 140 mEq/L
Cl
-
= 102 mEq/L
SID = 38 mEq/L
Na
+
= 154 mEq/L
Cl
-
= 154 mEq/L
SID = 0 mEq/L
1 liter 1 liter
PLASMA + NaCl 0.9%
SID : 38
Plasma NaCl 0.9%
2 liter
ASIDOSIS HIPERKLOREMIK AKIBAT
PEMBERIAN LARUTAN Na Cl 0.9%
=
SID : 19 Asidosis
Na
+
= (140+154)/2 mEq/L= 147 mEq/L
Cl
-
= (102+ 154)/2 mEq/L= 128 mEq/L
SID = 19 mEq/L
Plasma
Na
+
= 140 mEq/L
Cl
-
= 102 mEq/L
SID= 38 mEq/L

Cation
+
= 137 mEq/L
Cl
-
= 109 mEq/L
Laktat
-
= 28 mEq/L
SID = 0 mEq/L

1 liter
1 liter
PLASMA + Larutan RINGER LACTATE
SID : 38
Plasma Ringer laktat
Laktat cepat
dimetabolisme


2 liter
=
Normal pH setelah pemberian
RINGER LACTATE
SID : 34 lebih alkalosis dibanding jika diberikan
NaCl 0.9%
Na
+
= (140+137)/2 mEq/L= 139 mEq/L
Cl
-
= (102+ 109)/2 mEq/L = 105 mEq/L
Laktat
-
(termetabolisme) = 0 mEq/L
SID = 34 mEq/L
Plasma
Na
+
= 140 mEq/L
Cl
-
= 130 mEq/L
SID =10 mEq/L
Na
+
= 165 mEq/L
Cl
-
= 130 mEq/L
SID = 35 mEq/L
1 liter
1.025
liter
25 mEq
NaHCO3
SID : 10 35 : Alkalosis, pH kembali normal namun mekanismenya bukan
karena pemberian HCO
3
-
melainkan karena pemberian Na
+
tanpa anion kuat yg
tidak dimetabolisme seperti Cl
-
sehingga SID alkalosis
Plasma;
asidosis
hiperkloremik
MEKANISME PEMBERIAN NA-
BIKARBONAT PADA ASIDOSIS
Plasma + NaHCO
3

HCO
3
cepat
dimetabolisme
Na
+
Na
+
K
HCO
3
-
Cl
-
Cl
-
HCO
3
-
SID
Normal Ketosis
UA = Unmeasured Anion:
Laktat, acetoacetate, salisilat, metanol dll.

A-
A-
Keto
-
SID
K
Lactic/Keto asidosis
Na
Na Na
K K
K
HCO
3
Cl Cl Cl
HCO
3
HCO
3
SID
Normal Acidosis Alkalosis
GANGGUAN PD ASAM LEMAH:
Hipo/Hiperalbumin
-
atau P
-
Alb/P
Alb
-
/P
-
Alb
-
/P
-
SID
SID
Alkalosis
hipoalbumin
/hipoposfate
mi
Asidosis
hiperprotein/
hiperposfatemi
Anion Gap
Described by Gamble in 1939
Electroneutrality
Na+, Cl-, and HCO
3
are measured ions

Na + UC = Cl + HCO
3
+ UA

UC = Sum of unmeasured cations
UA = Sum of unmeasured anions
Anion Gap
Unmeasured Cations:
total 11 mEq/L
Potassium 4
Calcium 5
Magnesium 2
Unmeasured Anions:
total 23 mEq/L
Sulfates 1
Phosphates 2
Albumin 16
Lactic acid 1
Org. acids 3
Anion Gap
Na + UC = Cl + HCO
3
+ UA
140 + 11 = 104 + 24 + 23
151 = 151
UA UC = Na - (Cl + HCO3);
Anion Gap = Na - (Cl + HCO3)
If the anion gap is elevated
Then compare the changes from normal between
the anion gap and [HCO3 -].
If the change in the anion gap is greater than the
change in the [HCO3 -] from normal, then a
metabolic alkalosis is present in addition to a gap
metabolic acidosis.
If the change in the anion gap is less than the
change in the [HCO3 -] from normal, then a non
gap metabolic acidosis is present in addition to a
gap metabolic acidosis.

Anion Gap Acidosis:
Anion gap >12 mEq/L; caused by a
decrease in [HCO3 -]
balanced by an increase in an
unmeasured acid ion from either
endogenous production or exogenous
ingestion (normochloremic acidosis).

Non anion Gap Acidosis:
Anion gap = 8-12 mmol/L; caused by a
decrease in [HCO3 -] balanced by an
increase in chloride (hyperchloremic
acidosis). Renal tubular acidosis is a type
of non gap acidosis


Increased Anion Gap
Normal = 8-15
May differ institutionally
Accumulation of organic acids (ketones,
lactate)
Toxic Ingestions
methanol, ethylene glycol, salicylates
Reduced inorganic acid excretion
phosphates, sulfates
Decrease in unmeasured cations
(unusual)
Increased AG Metabolic Acidosis:
Methanol
Uremia/Renal
Failure
INH, Iron--lactate
Paraldehyde
Lactic Acidosis
Has many etiologies
Cyanide, CO, Toluene,
HS
Poor perfusion
Ethylene glycol
Salicylates
Methyl salicylate
(Oil of wintergreen)
Mg salicylate
Levraut J et al. Int Care
Med 23:417, 1997
Increased Anion Gap
Normal = 8-15
May differ institutionally
ion specific electrodes
Accumulation of organic acids (ketones, lactate)
Toxic Ingestions
methanol, ethylene glycol, salicylates
Reduced inorganic acid excretion
phosphates, sulfates
Decrease in unmeasured cations (unusual)
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Decreased or Negative Anion Gap
Clin J Am Soc Nephrol 2: 162-174, 2007
Low protein most important
Albumin has many unmeasured negative
charges
Normal anion gap (12) in cachectic person
Indicates anion gap metabolic acidosis
Other etiologies of low AG:
Low K, Mg, Ca, increased globulins (Mult.
Myeloma), I intoxication
Negative AG
more unmeasured cations than unmeasured
anions
Bromide, Iodide, Multiple Myeloma
Change in Anion Gap vs HCO
3
In simple AG Metabolic Acidosis
decrease in plasma bicarbonate = increase in
AG

Anion Gap = 1
HCO
3

Helpful in identifying mixed disorders
Respiratory Compensation
for
Metabolic Acidosis:
Occurs rapidly
Hyperventilation
Kussmaul Respirations
Deep > rapid (high tidal
volume)
Is not Respiratory Alkalosis
Metabolic Alkalosis:
Calculation not as
accurate
Hypoventilation
Not Respiratory
Acidosis
Restricted by
hypoxemia
PCO
2
seldom > 50-55
47
Reference
1. Achmadi, A., George, YWH., Mustafa, I. Pendekatan Stewart
Dalam Fisiologi Keseimbangan Asam Basa. 2007
2. Beaudoin, D. Electrolytes and ion sensitive electrodes. PPT.
2003.
3. Ivkovic, A ., Dave, R. Renal review. PPT
4. Kersten. Fluid and electrolytes. PPT.
5. Marieb, EN. Fluid, electrolyte, and acid-base balance. PPT.
Pearson Education, Inc. 2004
6. Rashid, FA. Respiratory mechanism in acid-base homeostasis.
PPT. 2005.
7. Silverthorn, DU. Integrative Physiology II: Fluid and Electrolyte
Balance. Chapter 20, part B. Pearson Education, Inc. 2004
8. Smith, SW. Acid-Base Disorders. www.acid-base.com