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
ACID AND BASE BALANCE AND <6.8 or >8.0 death occurs
IMBALANCE 
Acidosis (academia) below 7.35

Alkalosis (alkalemia) above 7.45
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

Small changes in pH can produce major

disturbances

Most enzymes function only with narrow pH
ranges

Acid-base balance can also affect electrolytes
(Na+, K+, Cl-)

Can also affect hormones
The body produces more acids than bases

Acids take in with foods

Acids produced by metabolism of lipids and
proteins

Cellular metabolism produces CO2.

CO2 + H20 ↔ H2CO3 ↔ H+ + HCO3-
Control of Acids
1. 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
 Acids are H+ donors. -Results in a much smaller pH change
 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 solution Bicarbonate buffer
 Sodium Bicarbonate (NaHCO3) and carbonic acid
- Lactic acid, carbonic acid
(H2CO3)
 Maintain a 20:1 ratio : HCO3- : H2CO3

The Body and pH

 HCl + NaHCO3 ↔ H2CO3 + NaCl
Homeostasis of pH is tightly controlled

Extracellular fluid = 7.4
NaOH + H2CO3 ↔ NaHCO3 + H2O

Blood = 7.35-7.45
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Phosphate buffer
 Major intracellular buffer

 H+ + HPO42- ↔ H2PO4-
- 2-
 OH + H2PO4- ↔ H2O + H2PO4

Protein buffers
 Includes hemoglobin, work in blood and ISF
+
 Carboxyl group gives up H
+
 Amino Group accepts H
+
 Side chains that can buffer H are present on 27

amino acids.
2. Respiratory mechanisms
-Exhalation of carbon dioxide
-Powerful, but only works with volatile
acids Acid-Base Imbalances
-Doesn’t affect fixed acids like lactic acid  pH <7,35 acidosis
-CO2 + H2O ↔ H2CO3 ↔ H+ + HCO3-  pH >7.45 alkalosis
-Body pH can be adjusted by changing rate  The body response to acid-base imbalance is
and depth of breathing called compensation
3. Kidney excretion  May be complete if brought back within normal
-Can eliminate large amounts of acid limits
-Can also excrete base  Partial compensation if range is still outside
Can conserve and produce bicarbonate ions norms.
-Most effective regulator of pH
-If kidneys fail, pH balance fails Compensation
 If underlying problem is metabolic,

hyperventilation or hypoventilation can help:

Rates of correction respiratory compensation.
 Buffers function almost instantaneously  If problem is respiratory, renal mechanisms can

 Respiratory mechanisms take several minutes to bring about metabolic compensation.

hours Acidosis
 Renal mechanisms may take several hours to days  Principal effect of acidosis is depression of the

CNS through ↓ in synaptic transmission.

 Generalized weakness

 Deranged CNS function the greatest threat

 Severe acidosis causes:

- Disorientation
- Coma
- Death
Alkalosis
 Alkalosis causes over excitability of the central

and peripheral nervous systems.

 Numbness

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 Lightheadedness  Tremors, convulsions, coma
 It can cause :  Respiratory rate rapid, then gradually depressed
- Nervousness  Skin warm and flushed due to vasodilation caused
- muscle spasms or tetany by excess CO2
- Convulsions
- Loss of consciousness Treatment of Respiratory Acidosis
- Death  Restore ventilation

 IV lactate solution

 Treat underlying dysfunction or disease

***IMAGE IS ALWAYS AFTER DISEASE

Respiratory Acidosis
 Carbonic acid excess caused by blood levels of

CO2 above 45 mm Hg.

 Hypercapnia – high levels of CO2 in blood

 Chronic conditions:

-Depression of respiratory center in brain

that controls breathing rate – drugs or head
trauma
-Paralysis of respiratory or chest muscles
-Emphysema
 Acute conditons:
Respiratory Alkalosis
-Adult Respiratory Distress Syndrome
 Carbonic acid deficit
-Pulmonary edema
 pCO2 less than 35 mm Hg (hypocapnea)
-Pneumothorax
 Most common acid-base imbalance

 Primary cause is hyperventilation

Compensation for Respiratory Acidosis
 Conditions that stimulate respiratory center:
 Kidneys eliminate hydrogen ion and retain

bicarbonate ion -Oxygen deficiency at high altitudes

-Pulmonary disease and Congestive heart
Signs and Symptoms of Respiratory Acidosis failure – caused by hypoxia
 Breathlessness
-Acute anxiety
 Restlessness
-Fever, anemia
 Lethargy and disorientation
-Early salicylate intoxication
-Cirrhosis
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-Gram-negative sepsis  Renal excretion of hydrogen ions if possible
Compensation of Respiratory Alkalosis + +
 K exchanges with excess H in ECF

 Kidneys conserve hydrogen ion

+ +
 ( H into cells, K out of cells)

 Excrete bicarbonate ion Treatment of Metabolic Acidosis

Treatment of Respiratory Alkalosis  IV lactate solution
 Treat underlying cause

 Breathe into a paper bag

-
 IV Chloride containing solution – Cl ions replace

lost bicarbonate ions

Metabolic Alkalosis
 Bicarbonate excess - concentration in blood is
greater than 26 mEq/L
 Causes:
- Excess vomiting = loss of stomach acid
Metabolic Acidosis - Excessive use of alkaline drugs
 Bicarbonate deficit - blood concentrations of - Certain diuretics
bicarb drop below 22mEq/L - Endocrine disorders
 Causes: - Heavy ingestion of antacids
-Loss of bicarbonate through diarrhea or - Severe dehydration
renal dysfunction Compensation for Metabolic Alkalosis
-Accumulation of acids (lactic acid or  Alkalosis most commonly occurs with renal
ketones) dysfunction, so can’t count on kidneys
-Failure of kidneys to excrete H+  Respiratory compensation difficult –
Symptoms of Metabolic Acidosis hypoventilation limited by hypoxia
 Headache, lethargy Symptoms of Metabolic Alkalosis
 Nausea, vomiting, diarrhea  Respiration slow and shallow
 Coma  Hyperactive reflexes ; tetany
 Death  Often related to depletion of electrolytes
Compensation for Metabolic Acidosis  Atrial tachycardia
 Increased ventilation

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 Dysrhythmias  A patient is in intensive care because he suffered a
severe myocardial infarction 3 days ago. The lab
Treatment of Metabolic Alkalosis reports the following values from an arterial blood
 Electrolytes to replace those lost sample:
 IV chloride containing solution - pH 7.3
 Treat underlying disorder - HCO3- = 20 mEq / L ( 22 - 26)
- pCO2 = 32 mm Hg (35 - 45)
Diagnosis: Metabolic acidosis with compensation
Case 2:
 An asthmatic patient is managed poorly in ER and
is allowed to become hypoxic. This results in a
decreased pO2 and the following arterial blood gas
values:
HCO3 Anion pCO2 pH
Normal 24 13 40 7.40
Patient 14 23 80 6.86
 Decreased pH, decreased HCO3 and increased
Anion Gap imply metabolic acidosis with
respiratory conditions (MIXED DISTURBANCE)
 Hypoxia leads to an increased lactic acid level
(result to decreased pH and increased Anion Gap)

Diagnosis of Acid-Base Imbalances

1. Note whether the pH is low (acidosis) or high
(alkalosis)
2. 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.
3. Look at the value that doesn’t correspond to the
observed pH change. If it is inside the normal range,
there is no compensation occurring. If it is outside
the normal range, the body is partially
compensating for the problem.
Summary:
 Parameters of interest:

A. pH
B. pCO2
Example: C. HCO3
D. pO2
Evaluate the pH
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 Normal pH = 7.35-7.45  Syringe and needle for arterial blood collection
 < - Acidosis must be preheparinized by drawing up heparin
 > - Alkalosis into the syringe to wet its interior.
Evaluate the ventilation (Lungs)  Temperature error and protein coating of
 Normal pCO2 = 35-45mmHg electrodes – common analytical errors
 <35mmHg = Respiratory alkalosis

 >45mmHg = Respiratory acidosis

 pCO2 = an index or efficiency of gas exchange,

not a measure of CO2 concentration in the blood

 The lungs regulate pH through retention or

elimination of CO2
 Total CO2 = 19-24mmol/L (whole blood arterial),

22-26mmol/L (whole blood venous)

Evaluate the kidney metabolic process(kidney)
 Normal HCO3 = 21-28mEq/L

 <21mEq/L = metabolic acidosis

 >28mEq/L = metabolic alkalosis

 The kidneys regulate pH by excreting acid (NH4

ions) and reabsorption of HCO3 from the

glomerular filtrate
Evaluate the degree of oxygenation
 Normal pO2 = 81-199mmHg (adequate

oxygenation)
 Hypoxemia = low pO2

o Mild = 61-80mmHg
o Moderate = 41-60mmHg
o Severe = 40mmHg or less
 pO2 = reflects the availability of the gas in the

blood but not its content Specimen consideration:

 The degree of association or dissociation of
1. On standing, pH and pO2 (decreased) and pCO2
oxygen with Hgb is determined by pO2 and the (increased) are affected
affinity of Hgb for O2. 2. Blood samples should be chilled to prevent
Four Basic Abnormal States oxygen consumption by the RBC and release of
1. Metabolic Acidosis acidic metabolites, thereby altering the pH
2. Metabolic Alkalosis 3. Glycolysis results to decrease blood pH
3. Respiratory Acidosis – hypoventilation which 4. Excess heparin causes downward shifting of
leads to pCO2 blood pH – most common pre-analytic error
4. Respiratory Alkalosis – hyperventilation which Methods
leads to decrease pCO2 Gasometer
Methods for blood gases and pH A. Vanslyke
 Specimen - Arterial Blood B. Natelson
1. Mercury – to produce vacuum
2. Caprylic alcohol - anti-foam reagent

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3. Lactic Acid -It is essential that the electrode sample
4. NaOH and NaHSO3 chamber be maintained at constant
Electrodes temperature for all measurements
A. pH (potentiometry) -For each degree of fever in the patient, pO2
1. Silver-silver chloride electrode – reference will fall 7% and pCO2 will fall 7% and pCO2
electrode will rise 3%
2. Calomel electrode (HgCl2) – reference electrode 2. Elevated plasma protein concentrations
3. Glass electrode – most commonly used for pH -pO2 test is affected by build-up proteins on
the surface of the membrane
3. Bacterial contamination within the measuring
chamber, if present will consume oxygen and cause
low value of pO2
4. Improper transport of the blood specimen –
should be transported with ice, the pO2 changes
rapidly than pH and pCO2.
Others:
1. Anion Gap – is the difference between
the unmeasured anions and
unmeasured cations
–Created by the concentration
difference between the commonly
measured cations (sodium and
potassium) and commonly measured
anions (chloride and bicarbonate)
–used to monitor recovery from
diabetic ketoacidosis
Arterial Puncture for arterial gas
 Done by arterial puncture (radial, brachial,

femoral artery)
 Peripheral venous sample – used for pulmonary

function or O2 transport is not being assessed

 Ideally 1-3 mL, self-filling, plastic, disposable

syringe containing appropriate amount and type of

anticoagulant
 Heparin (lyophilized or liquid)

Modern blood gas analyzer. This device is  Collected at proper temperature since decrease

capable of reporting pH, pCO2, pO2, SatO2, Na+, temperature increases O2 solubility
K+, Cl-, Ca2+, Hemoglobin (total and derivatives:  Put in ice-slurry immediately after the draw which

O2Hb, MetHb, COHb, HHb, CNHb, SHb), minimizes metabolism, but too long increases K.
Hematocrit, Total bilirubin, Glucose, Lactate  Adequately mixed the specimen

and Urea. (Cobas b 221 – Roche Diagnostics)  Avoid bubbles

 Decrease time of transport

Factors affecting blood gases and pH measurement  Analyze within 30 minutes
1. Temperature (37C±0.1˚) most important factor
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