ACID –BASE BALANCE

By
Dr Donatus Egwu
Consultant Anaesthetist,
FMC, Keffi
DEFINITIONS
EQUATIONS
BLOOD BUFFERS
METABOLIC ACIDOSIS /ALKALOSIS
RESPIRATORY
ACIDOSIS/ALKALOSIS
EXAMPLES
DEFINITIONS
ACID- a substance that can donate hydrogen ions (H+)
i.e it is a proton donor eg.carbonic acid and lactic acid

BASE- a substance that can accept hydrogen ions (H+)

i.e it is a proton acceptor.eg bicarbonate and ammonia.
BUFFER- buffer is a substance that interacts with an
acid or a base to minimise changes in pH
BUFFER PAIR-This is a combination of a weak acid
and its conjugate base.
carbonic acid/bicarbonate system
H2CO3 = H+ + H2CO3
Acid base
pH-abbreviation for puissance Hydrogen.
Negative logarithm(to base10)of the
hydrogen ion concentration

ACIDAEMIA- pH < 7.35

ALKALAEMIA- pH > 7.45

 ACID –BASE EQUATIONS
Henderson Equation
H+ = k Acid eg H+ =H2CO3
Salt HCO3

Henderson-Hasselbach Equation
pH= pK + log Salt
Acid
Eg pH = pk + log HCO3 or pK + log HCO3
H2CO3 ‘s’ x PaCO2
Where pk = 6.1, ‘s’ = 0.3(solubility coefficient of CO 2)

NOTE: pH is directly proportional to bicarbonate (metabolic

component) but inversely proportional to PaCO 2(repiratory
component)
BLOOD BUFFERS
BICARBONATE -53%
HAEMOGLOBIN -35%
PLASMA PROTEINS- 7%
PHOSPHATE - 5%
Buffering capacity greatest when pH=pK
METABOLIC ACIDOSIS
May result from
i) Gain of acid
 Diabetic ketoacidosis(due to incomplete
oxidation of fat)
 Lactic acidosis(due to incomplete
oxidation of carbohydrates)
 Azotaemic acidosis of renal failure (gain
of organic acids)
ii) Loss of base (eg bicarbonate)
Renal tubular acidosis (renal loss)
Diarrhoeal acidosis (intestinal loss)
METABOLIC ALKALOSIS
Gain of base
-bicarbonate therapy(exogenous source)
-oxidation of lactate, citrate or
acetate(endogenous source)

Loss of acid
-vomiting (loss of hydrochloric)
-diuretic therapy (associated with potassium
loss)
ANION GAP
Defined as the difference between the major measured
cations and the major measured anions:

Anion gap = major plasma cations− major plasma anions

Or
Anion gap =[Na+ ]−([Cl− ]+[HCO3− ])
Or
The difference between the sum of
sodium + potassium and the sum of chloride + bicarbonate
Normal range is 7-14mEq/L

>15meq/l indicates the existence of an anion gap

In reality, an anion gap cannot exist
because electroneutrality must be
maintained in the body;
The sum of all anions must equal the sum
of all cations.
Therefore,
Anion gap =
 unmeasured anions
 − unmeasured cations
Unmeasured cations” include
◦ K + , Ca 2+ , and Mg 2+,
Unmeasured anions” include all
◦ organic anions (including plasma proteins),
◦ phosphates, and
◦ sulfates.
Any process that increases “unmeasured
anions” or decreases “unmeasured
cations” will increase the anion gap.
Conversely, any process that decreases
“unmeasured anions” or increases
“unmeasured cations” will decrease
the anion gap .
Metabolic acidosis can occur with a normal or increased anion gap

Normal anion gap-(hyperchloraemic acidosis)

Increased gastrointestinal losses of HCO3
◦ Diarrhea
Increased renal losses of HCO3−
◦ Diamox therapy
Dilutional
◦ Large amount of bicarbonate-free fluids (eg, 0.9% NaCl)
Total parenteral nutrition (Cl − salts of amino acids)

Increased intake of chloride-containing acids

◦ Ammonium chloride
Increased anion gap
Increased production of endogenous nonvolatile acids
◦ Renal failure
◦ Ketoacidosis
◦ Diabetic ketoacidosis
◦ Lactic acidosis
Ingestion of toxin
◦ Salicylate overdose
◦ Methanol
◦ Ethylene glycol
Rhabdomyolysis
RESPIRATORY DISORDER
RESPIRATORY ALKALOSIS
Alveolar ventilation is increased and
PaCO2 is decreased below <35mmHg

RESPIRATORY ACIDOSIS
Alveolar ventilation is decreased and
PaCO2 is increased above >45mmHg
AETIOLOGY
CNS (trauma, tumour,infection,drugs,CVA)
SpinalCord(trauma,tumour,infection)
Respiratory
muscles(myopathy,diaphragmatic hernia)
Chest wall (traumatic flail chest)
Pleural space(pneumothorax,Haemothorax)
Airway obstruction
Lung parenchyma(infection,tumours)
ARTERIAL BLOOD GASES
INDICATIONS
-Respiratory insufficiency or failure
-Acid-Base disturbances
-Patients on mechanical ventilator
-Patients having oxygen therapy
 Uses of ABG
The test is used to determine,
◦ the pH of the blood,
◦ the partial pressure of carbon dioxide and
◦ oxygen, and the
◦ bicarbonate level.

 Many blood gas analyzers will also report

◦ concentrations of lactate,
◦ hemoglobin, several electrolytes, oxyhemoglobin, carboxyhemoglobin and
methemoglobin.
Also used in pulmonology, to determine gas exchange levels
Other areas of medicine.
Combinations of disorders can be complex and difficult to interpret,
so calculators , nomograms
Extraction & Analysis
An arterial blood gas (ABG) is a blood test that is
performed using blood from an artery.
 It involves puncturing an artery with a thin needle
and syringe and drawing a small volume of blood.
 The most common puncture site is
◦ the radial artery at the wrist, but sometimes
◦ the femoral artery in the groin or other sites are used.
◦ the brachial artery is also used, especially during
emergency situations or with children.
 The blood can also be drawn from an arterial
catheter.
Extraction & Analysis Cont..
The syringe is pre-packaged and contains a small amount of
heparin, to prevent coagulation or needs to be heparinised, by
drawing up a small amount of heparin and squirting it out
again.
 Once the sample is obtained, care is taken to eliminate
visible gas bubbles, as these bubbles can dissolve into the
sample and cause inaccurate results.
 The sealed syringe is taken to a blood gas analyzer.
 If the sample cannot be immediately analyzed, it is chilled in
an ice bath in a glass syringe to slow metabolic processes
which can cause inaccuracy.
Samples drawn in plastic syringes are not iced and are
analyzed within 30 minutes.
Extraction & Analysis Cont..
Contamination with room air will result in
abnormally low carbon dioxide and
(generally) normal oxygen levels.
 Delays in analysis (without chilling) may
result in inaccurately low oxygen and high
carbon dioxide levels as a result of ongoing
cellular respiration.
Lactate level analysis is often featured on
blood gas machines in neonatal wards, as
infants often have elevated lactic acid.
Reference ranges and interpretation

Analyte Range Interpretation

pH 7.35–7.45 The pH or H+ indicates if a patient is

acidotic (pH < 7.35; H+ >45) or
alkalemic (pH > 7.45; H+ < 35)
H+ 35–45 mmol/l See above.

PaO2 9.3–13.3 kpa or 80–100 mmHg A low O2 indicates that the patient
is not respiring properly, and is
hypoxemic. At a PaO2 of less than
60 mm Hg, supplemental oxygen
should be administered. At a PaO2
of less than 26 mm Hg, the patient
is at risk of death and must be
oxygenated immediately.
PaCO2 4.7–6.0 kPa or 35– The carbon dioxide partial pressure (PaCO2) indicates a respiratory problem: for a
45 mmHg constant metabolic rate, the PaCO2 is determined entirely by ventilation. A high PaCO
2 (respiratory acidosis) indicates underventilation, a low PaCO2 (respiratory alkalosis)
hyper- or overventilation. PaCO2 levels can also become abnormal when the
respiratory system is working to compensate for a metabolic issue so as to normalize
the blood pH. An elevated PaCO2 level is desired in some disorders associated with
respiratory failure; this is known as permissive hypercapnia.

HCO3− 22–26 mmol/l The HCO3− ion indicates whether a metabolic problem is present (such as ketoacidosis).
A low HCO3− indicates metabolic acidosis, a high HCO3− indicates metabolic alkalosis.
HCO3− levels can also become abnormal when the kidneys are working to compensate
for a respiratory issue so as to normalize the blood pH.

SBCe 21 to 27 mmol/l the bicarbonate concentration in the blood at a CO2 of 5.33 kPa, full oxygen saturation
and 37 degrees Celsius.
Base Excess −3 to +3 mmol/l The base excess is used for the assessment of the metabolic component
of acid-base disorders, and indicates whether the patient has metabolic
acidosis or metabolic alkalosis. A negative base excess indicates that the
patient has metabolic acidosis (primary or secondary to respiratory
alkalosis). A positive base excess indicates that the patient has metabolic
alkalosis (primary or secondary to respiratory acidosis)

total CO2 (tCO2 (P)c) 25 to 30 mmol/l This is the total amount of CO2, and is the sum of HCO3− and PCO2 by the
formula:
tCO2 = [HCO3−] + α*PCO2, where α=0.226 mM/kPa, HCO3− is expressed in
millimolar concentration (mM) (mmol/l) and PCO2 is expressed in kPa

total O2 (tO2e) This is the sum of oxygen dissolved in plasma and chemically bound to
hemoglobin

Anion Gap 10±4 mEq/L (Range= 7 to The anion gap is measured as the difference between the plasma Na conc.
14mEq/L) and the sum of the plasma Chloride and bicarbonate concentrations
USEFUL FORMULAS FOR ACID- BASE
INTERPRETATIONS

Metabolic Acid-base Disorder

◦ The compensatory response to metabolic acid-base
derangements is an immediate change in minute
ventilation that changes the arterial PCO2 (PaCO2) in the
same direction as the primary change in HCO3
 Compensation for Metabolic Acidosis:
 Expected PaCO2 = (1.5x HCO3) + (8±2)
 Compensation for Metabolic Alkalosis:
 Expected PaCO2 = (0.7 x HCO3) + (21±2)
USEFUL FORMULAS FOR ACID- BASE INTERPRETATIONS

Respiratory Acid- base Disorders

◦ The compensatory response to respiratory acid-base disorder takes
place in the kidneys and involves an adjustment in HCO 3 reabsorption
in the proximal tubules. This response is not immediate, but begins to
appear in 6 to 12 hours, and is fully developed after a few days.
◦ Because of this delay, respiratory acid –base disorders are classified as
acute (uncompensated) or chronic (fully compensated)
 Acute Respiratory Acidosis
 Expected pH = 7.40 – {0.008 X (PaCO2- 40)}
 Acute Respiratory Alkalosis
 Expected pH = 7.40 + {0.008 X (40-PaCO2)}
 Chronic Respiratory Acidosis
 Expected pH = 7.40 – {0.003 x (PaCO2 – 40)}
 Chronic Respiratory Alkalosis
 Expected PH = 7.40 + {0.003 x (40-PaCO2)}
ANALYSIS
CORRELATIONS
a)Correlation between PaCO2 and pH
b)Correlation between PaCO2 and HCO3

c)Correlation between PaO2 and fiO2

Range of Normal Values
pH :7.35-7.45(7.4)
PaCO2:35-45mmHg(40mmHg)
PaO2:80-100mmHg(11-13.3kpa)
HCO3:24-28mEq/l(26)
 Steps for Interpretation
Look at pH :
Always tells you the Primary problem
◦ Is there alkalemia or acidemia present?
◦ pH < 7.35  acidemia
pH > 7.45  alkalemia
 This is usually the primary disorder
 Remember: an acidosis or alkalosis may be present even if the pH is in the normal range (7.35 – 7.45)

Look at PCO2 to confirm or eliminate a respiratory problem

◦ If PCO2 is above 45 = Respiratory Acidosis
◦ If PCO2 is below 35 = Respiratory Alkalosis
◦ If abnormal, does it agree with the pH?
Yes = primary respiratory problem
Opposite of the pH = partial or full compensation (look at pH to determine
degree of compensation)
Normal = no compensation
Steps for Interpretation CONT..
Look at Bicarbonate (HCO3):
◦ If below 22= Metabolic Acidosis present
◦ If above 28 = Metabolic Alkalosis present
◦ If abnormal, does it agree with the pH?
Yes = primary metabolic problem
Opposite of PH = partial or full compensation (look
at pH to determine degree of compensation)
Normal = no compensation
Steps for Interpretation CONT..
Look at PO2:
 If above 80 = Normal limits (adjustment
for aging = 80-(age -60)
 If below 60 = hypoxemia
 
Look at % O2 Saturation
If above 95% = Normal limits
Look at pH to determine significance of finding
 Steps for Interpretation CONT..
 Is the disturbance respiratory or metabolic? 
 What is the relationship between the
direction of change in the pH and the
direction of change in the PaCO2?
 In primary respiratory disorders, the pH and
PaCO2 change in opposite directions;
 In metabolic disorders the pH and PaCO2
change in the same direction.
pH Approximate [H+]
(mmol/L)

7.00 100

7.05 89

7.10 79

7.15 71

7.20 63

7.25 56

7.30 50

7.35 45

7.40 40

7.45 35

7.50 32

7.55 28

7.60 25

7.65 22
Acidosis Respiratory pH ↓  PaCO2  ↑

Acidosis Metabolic& pH ↓ PaCO2  ↓

Alkalosis Respiratory pH ↑ PaCO2  ↓

Alkalosis Metabolic pH ↑ PaCO2   ↑

EXAMPLES
pH=7.25,
PaCO2=60,
HCO3=28
PaO2 =60(on room air).
Interpretation :?
Interpretation:
i.pH shows acidaemia(pH< 7.35)
ii.PaCO2 shows resp.acidosis(>45).this primary
because it is in the same direction as pH(acidaemia)
iii. Increase in HCO3 is only slight and correlates
with an acute increase(i.e 2 mEq/l increase for
20mmhg increase)
iv.PaO2 of 60 shows hypoxaemia

SUMMARY: ACUTE PRIMARY RESPIRATORY

ACIDOSIS WITH HYPOXAEMIA
EXAMPLE 2

pH = 7.32,
PaCO2=70,
HCO3=38,
PaO2=40(on 24% 02)
Answer
Chronic Respiratory acidosis with
metabolic compensation.
Important Note

Incase of Carbon monoxide poisoning the PO2 will be

normal, but life threatening hypoxia may be present.

 Bloodgas analyzers calculate the oxygen saturation of

hemoglobin from PO2, temperature and pH.

 Incases of CO poisoning, the calculation will be falsely

elevated.

 Accurate assessment of Hypoxia in CO poisoning requires

direct measurement of carbooxyhemoglobin and oxygen
saturation of hemoglobin by oximetery or colorimetry
methods.
Thank You For Listening