ACID & BASE BALANCE & IMBALANCE
pH Review
pH = - log [H+]  H+ is really a proton
Range is from 0 - 14
If [H+] is high, the solution is acidic; pH < 7
If [H+] is low, the solution is basic or alkaline ; pH > 7
Definitions
Blood pH range 7.35 – 7.45; Acidosis: < 7.35 Alkalosis: > 7.45
Acids are H+ donors. Bases are H+ acceptors, or give up OH- in solution.
Acids and bases can be:
Strong – dissociate completely in solution HCl, NaOH
Weak – dissociate only partially in soln Lactic acid, carbonic acid
SAQ- Name the first and second line buffer defense systems that the body uses against the pH shift.
First line of defense against pH shift Chemical buffer system
Second line of defense against pH shift Physiological buffers
Q- Why small changes in pH can produce major disturbances
1] Most enzymes function only with narrow pH ranges
2] Acid-base balance can also affect electrolytes (Na+, K+, Cl-)
3] Can also affect hormones
Q-What does the buffering mechanisms do?
Buffer systems
Take up H+ or release H+ as conditions change
Buffer pairs – weak acid and a base
Exchange a strong------ acid or base for a weak one
Results------- in a much smaller--- pH change
Q- How does the Bicarbonate buffer handle acid base disturbances ?
Pair of-- Sodium Bicarbonate (NaHCO3) & carbonic acid (H2CO3)
Maintain a 20:1 ratio : HCO3- : H2CO3
HCl + NaHCO3 ↔ H2CO3 + NaCl
NaOH + H2CO3 ↔ NaHCO3 + H2O
Q- How does Phosphate buffer handle acid base disturbances ?
Major intracellular buffer
H+ + HPO42- ↔ H2PO4-
OH- + H2PO4- ↔ H2O + HPO42-
Q---How does the Hb handle excess of H+ ions?.
Includes hemoglobin, work in blood and ICF
Hemoglobin has 2 groups----
Carboxyl group gives up H+
Amino Group accepts H+
Side chains that can buffer H+ are present on 27 amino acids.
1] Bicarbonate buffer system
2] Phosphate buffer system
3] Protein buffer system
1] Respiratory Mechanism (CO2 excretion)
2] Renal mechanism (H+ excretion)
MCQ-2. What type of acids does Respiratory buffer system manage?
Exhalation of carbon dioxide
Powerful, but only works with volatile acids. Doesn’t affect fixed acids
like lactic acid
CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3-
Body pH can be adjusted by changing rate and depth of breathing
Q- What role does the Kidney buffering system play to manage the
acid base disturbances.
1) Can eliminate large amounts of acid
2) Can also excrete base
3) Can conserve and produce bicarbonates ions
4) Most effective regulator of pH
5) If kidneys fail, pH balance fails
Q- What are the various rates/speed of correction when a body
encounters acid base disturbance.
1) Buffers function almost instantaneously
2) Respiratory mechanisms take several minutes to hours
3) Renal mechanisms may take several hours to days
Q- What are the various responses of the body when it encounters
Acid-Base disturbance/Imbalances
pH< 7.35 acidosis ; pH > 7.45 alkalosis
The body response to acid-base imbalance is called compensation
Compensation may be complete if brought back within normal limits
Partial compensation if range is still outside norms.
- If underlying problem is Metabolic,------ hyperventilation or
hypoventilation can help this is : respiratory compensation.
- If problem is Respiratory, ----------renal mechanisms can bring about
metabolic compensation.
DIAGNOSIS OF ACID-BASE IMBALANCES
-Note whether the pH is low (acidosis) or high (alkalosis)
-Decide which value, pCO2 or HCO3- , is outside the normal range and could be the cause of the problem.
-If the cause is a change in pCO2, the problem is respiratory. If the cause is HCO3- the problem is metabolic.
CLINICAL PRESENTATIONS
Q-What clinical presentations do you see in a case of Acidosis? Q-What clinical presentations do you see in a case of Alkalosis?
1) Principal effect of acidosis: CNS depression through ↓ in 1) Over excitability of central & peripheral NS
synaptic transmission. Deranged CNS function greatest threat 2) Numbness
2) Generalized weakness 3) Light headedness
3) Severe acidosis causes a] Disorientation 4) It can cause: A]
b] Coma Nervousness B]
c] Death Muscle spasms or tetany
C] Convulsions
D] Loss of consciousness E]
Death

What is the mechanism involved in Respiratory acidosis.? SAQ--What are the features of Respiratory Alkalosis?
-Mechanism----Carbonic acid excess caused by blood levels of 1. Carbonic acid deficit ( low blood pCO2 levels).
CO2 above 45 mm Hg.------- ( MCQ) 2. pCO2 lower than 35 mm Hg (hypocapnea).
-Define Hypercapnia – high levels of CO2 in blood > 45 mm Hg. 3. Most common acid-base imbalance.
4. Primary cause of respiratory alkalosis is --hyperventilation.
SAQ- Enumerate the causes of respiratory acidosis? SAQ-What are the causes of Respiratory Alkalosis?
1. Acute conditions: Conditions that stimulate respiratory center:
a. Adult Respiratory Distress Syndrome 1. Oxygen deficiency at high altitudes
b. Pulmonary edema 2. Pulmonary disease & CHD – caused by hypoxia
c. Pneumothorax. 3. Acute anxiety
2. Chronic conditions: 4. Fever, anemia
a. Depression of respiratory center in brain that controls 5. Early salicylate intoxication
6. Cirrhosis
breathing rate – drugs or head trauma
7. Gram-negative sepsis
b. Paralysis of respiratory or chest muscles
c. Emphysema
SAQ-What buffering system come into play to manage SAQ- How does body Compensates for Respiratory Alkalosis
Respiratory Acidosis? 1. Kidneys conserve hydrogen ion.
-Kidneys eliminate hydrogen ion &------ retain bicarbonate ion 2. Excrete bicarbonate ion.
SAQ- What are clinical presentations of Respiratory Acidosis ? SAQ- What are clinical presentations of Respiratory Alkalosis ?
1. Breathlessness 1) Over excitability of central & peripheral NS
2. Restlessness 2) Numbness
3. Lethargy and disorientation 3) Light headedness
4. Tremors, convulsions, coma 4) It can cause: A]
5. Respiratory rate rapid, then gradually depressed Nervousness B]
6. Skin warm and flushed due to vasodilation caused by Muscle spasms or tetany
C] Convulsions
excess CO2
D] Loss of consciousness E]
Death
Treatment of Respiratory Acidosis Treatment of Respiratory Alkalosis
• Restore ventilation • Treat underlying cause
• IV lactate solution • Breathe into a paper bag
• Treat underlying dysfunction or disease • I / V Chloride containing solution – Cl- ions replace lost
bicarbonate ions and maintains electro-neutrality.

METABOLIC ACIDOSIS METABOLIC ALKALOSIS

Q. Define bicarbonate deficit Q. Define bicarbonate excess
Bicarbonate deficit - when blood concentrations of Bicarbonate excess - concentration in blood is greater than 26
bicarbonates drop below 22 mmol/L mmol/L )_( MCQ-
SAQ-What are the causes of Metabolic Acidosis? SAQ-What are the causes of Metabolic Alkalosis?
 Causes: Causes:
1. Loss of bicarbonate through diarrhea or renal dysfunction 1. Excess vomiting leading to loss of stomach acid
2. Accumulation of acids (lactic acid or ketones) 2. Excessive use of Alkaline drugs
3. Failure of kidneys to excrete H+ 3. Certain diuretics--- loss of H+ ions
4. Endocrine disorders- Addison's disease
5. Heavy ingestion of antacids for gastric ulcer cases to
relieve pain---
6. Severe dehydration
SAQ-How does body compensates for Metabolic Acidosis? SAQ-How does body Compensates for Metabolic Alkalosis ?
1. Increased ventilation 1. Alkalosis most commonly occurs with renal dysfunction,
2. Renal excretion of hydrogen ions if possible so can’t count on kidneys
3. K+ exchanges with excess H+ in ECF 2. Respiratory compensation difficult – hypoventilation
( H+ ions go into cells, K+ ions come out of cells) limited by hypoxia
SAQ---What are the symptoms of Metabolic Acidosis ? SAQ----What is clinical presentation of Metabolic Alkalosis?
1. Headache, lethargy 1. Respiration slow and shallow
2. Nausea, vomiting, diarrhea 2. Hyperactive reflexes ; tetany
3. Coma 3. Often related to depletion of electrolytes
4. Death 4. Atrial tachycardia
5. Dysrhythmias
Treatment of Metabolic Acidosis Treatment of Metabolic Alkalosis
• I/V lactate solution • Electrolytes to replace those lost
• I/V chloride containing solution
• Treat underlying disorder

Look at the value that doesn’t

EXAMPLE
correspond to the observed pH change.
A patient is in intensive care because he suffered a severe myocardial infarction 3 days ago.
If it is inside the normal range, there
The lab reports the following values from an arterial blood sample: is no compensation occurring.
-pH 7.3 -HCO3- = 20 mmol / L ( 22 - 26) -pCO2 = 32 mm Hg (35 - 45) If it is outside the normal range, body
Diagnosis: Metabolic acidosis With compensation is partially compensating for problem.

Summary points
• Blood = 7.35 – 7.45;
• < 7.35: Acidosis, > 7.45: Alkalosis
• Three lines of defense to regulate the body’s
acid-base balance
– Blood buffers: Bicarbonate buffer,
Phosphate buffer, Protein Buffers
– Respiratory mechanisms: Exhalation of CO2
– Renal mechanism: eliminate acid,
Reabsorption of HCO3-
• Acidosis- blood pH ↓(Causes, Compensation)
– Metabolic acidosis: bicarbonate ↓
– Respiratory acidosis: carbonic acid ↑
• Alkalosis- blood pH ↑ (Causes, Compensation)
– Metabolic alkalosis: bicarbonate↑
– Respiratory alkalosis : carbonic acid ↓