Acid base balance 3

July/21
 Acid base disorders
When bicarb is high - metabolic alkalosis
When bicarb is low - metabolic acidosis

When carbonic acid (Co2) is high- resp

acidosis
When carbonic acid (Co2) is low- resp alkalosis
ACIDEMIA
ALKALEMIA
 DEFENCE SYSTEM
THREE TIER

BUFFERS - first line - immediate

PULMONARY MECHANISM few mts to hours
KIDNEYS hours to days. Sustained, long term
Bicarbonate carbonic acid buffer
pH = pK + log base/acid

7.4 = 6.1 + log bicarb/carbonic acid

7.4 = 6.1 + log bicarb/ pCo2 x 0.03 (sol

constant of Co2)
Disturbance of acid/base balance involves
bicarb buffer pair.
 Metabolic acidosis
When bicarbonate level decreases.
Blood pH decrease.
 Types of metabolic acidosis
High anion gap metabolic acidosis HAGMA
Normal anion gap metabolic acidosis NAGMA

Cations = anions in the body.

Na+ + K+ = cl- + HCO3- + anion gap
136 + 4 = 100 +24 + Anion gap
Anion gap = 16 mEQ /L =8 to 18 meq /L
Anion gap represents the unmeasured anions
in the body.
It is made up of albumin, lactate, urate,
ketoacids, phosphates, sulphates etc.
When one of these is increased anion gap
increases, with a decrease in bicarbonate.
High anion gap metabolic acidosis
KARMEL
Ketoacidosis-
Diabetic ketoacidosis
Starvation ketoacidosis
Alcoholic ketoacidosis
Aspirin toxicity
Renal failure
Methanol poisoning
Ethylene glycol poisoning
Lactic acidosis
Normal anion gap metabolic acidosis
Also called hyperchloremic metabolic acidosis.
There is a decrease in bicarbonate level along
with an increase in chloride level.

Diarrhoea
Ureterosigmoidostomy
Renal tubular acidosis.
Carbonic anhydrase inhibitors- acetazolamide.
 HYPERKALEMIA
When blood H+ increases, it tends to go into
ICF.
K+ comes out of the cells and causes
hyperkalemia.
When acidosis gets corrected, it can result in
hypokalemia unless it is monitored closely.
Compensation
Hyperventilation.
This decreases carbonic acid concentration in
an effort to bring the ratio closer to 20.
This is short lived.
Kidney compensation of excreting acids sets in
later of excreting H+ ions, generating bicarb,
excretion of titratable acids and ammonium
excretion.
 Metabolic alkalosis
Decrease in H+, Increase in pH
Increase in blood Bicarbonate concentration.
4 mechanisms for metabolic alkalosis ;

A loss of H ions from body

B shift of H into ICF
C alkali administration
D contraction alkalosis
/hypermineralocorticoids.
Hypokalemia in metabolic alkalosis
Hypokalemia is associated with metabolic
alkalosis:
Vomiting/NG suction /aldosterone excess
cause hypokalemia.
When there is hypokalemia , K+ tends to shift
out of cells , and H+ shifts into cells causing
metabolic alkalosis.
 Metabolic alkalosis can be classified
into chloride responsive and chloride
resistant
Chloride responsive condition urine chloride is
<10 mmol/L.
Vomiting
Nasogastric aspiration.
Chloride resistant metabolic alkalosis
Urine chloride >20meq/L

In hypokalemia.
Alkalotic agents ( alkali administration)
Hyperaldosteronnism -
 Compensatory mechanism
Hypoventilation.
Renal mechanism: conservation of H+ and
excretion of bicarbonate.

HYPOKALEMIA SHOULD BE CORRECTED

 Respiratory acidosis
Cause:
CO2 retention High carbonic acid.
Causes:
Lung causes:
Pneumonia, asthma,
Depression of respiratory centre by sedatives
/narcotics.
COPD
 Compensatory mechanism
H+ buffered by Hb, protein buffers.
Kidneys respond by excreting H+ and
conserving bicarbonate.
 Respiratory alkalosis
Deficit of carbonic acid.
pH increased.
 Causes
Hyperventilation.
Fever
High altitudes
Hysterical/anxiety
Increased intracranial pressure
Drugs that stimulate respiratory centre -
salicylates
 compensation
Increased excretion of bicarbonate and
conserve H+ by kidneys.
Diagnostic tests in acid base balance
Blood gas analysis
pH
pO2
pCO2
Serum bicarb
Potassium levels especially in metabolic
acidosis and alkalosis.
 Assessment of A-B balance

Arterial blood Mixed venous blood

range range

pH 7.40 7.35-7.45 pH 7.33-7.43

pCO 40 mmHg 35 45 pCO2 41 51

pO2 95 mmHg 80 95 pO2 35 49

Saturation 95 % 80 95 Saturation 70 75

BE 2 BE

HCO3- 24 mEq/l 22 - 26 HCO3- 24 - 28

Acid base problems
 Acid base balance
Normal pH = 7.4
S. bicarb = 24 meq/L
pCO2 = 40 mmHg
S. Cl- = 100 mEq/L
Normal anion gap = 12 mEq/L
Patient brought to casualty in a comatose state.

Blood sugar - 490mg%

Serum bicarbonate - 17 meq/L

What is the diagnosis.

What are the other investigations to be done.
Following a hungerstrike a factory worker was
brought to casualty in coma.

How will you manage him.

A person was rescued from a trench. He was
semiconscious.

Blood sugar - 40 mg%

Serum bicarbonate - 15 meq/L

Comment.
 Increased anion gap
M-Methanol
U-Uremia (chronic renal failure)
D-Diabetic ketoacidosis
P-Paraldehyde
I-Infection, Iron, Isoniazid
L-Lactic acidosis
E-Ethylene glycol (Note: Ethanol is sometimes included in this
mnemonic as well, although the acidosis caused by ethanol is
actually primarily due to the increased production of lactic
acid found in such intoxication.)
S-Salicylates
2. Normal anion gap acidosis

There's the older mnemonic USED CAR:

U : uterosigmoidostomy
S : saline administration (in the face of renal dysfunction)
E : endocrine (Addisons, spironolactone, triamterene, amiloride,
primary hyperparathyroidism)
D : diarrhea

C : carbonic anhydrase inhibitors

A : ammonium chloride
R : renal tubular acidosis

and a newer mnemonic RAGE:

R : renal tubular acidosis, respiratory acidosis

A : acetazolamide, ammonium chloride
G : GI (diarrhea, enteroenteric fistula, ureterosigmoidostomy)
E : endocrine (same as above endocrine list)
 Metabolic alkalosis
Excess bicarb.
Seen in vomiting,nasogastric aspiration
hyperaldosteronism
Leads to compensatory mechanisms:
Hypoventilation
Renal mechanisms of conserving H+and losing
bicarb.
 Respiratory acidosis
Accumulation of CO2 H2CO3.
Pneumonia,
Rib fracture
Asthmatic
Narcotics depression of respiratory centre
COPD
 Respiratory alkalosis
Hyperventilation
Hysterical
Salicylate poisoning
Acid base parameters of a patient given
below:

pH - 7.6
pCO2 - 40 mm Hg
HCO3 - 37 mEq/L

interpret
Acid base parameters:

pH 7.5
pCO2 25 mm Hg
HCO3 24 mEq/L

Comment
Acid base parameters:

pH 7.55
pCO2 28 mm Hg
HCO3 24 mEq/L

Comment
Acid base parameters:

pH 7.25
pCO2 70 mm Hg
HCO3 24 mEq/L

Comment
Acid base parameters:

pH 7.56
pCO2 25 mm Hg
HCO3 24 mEq/L

Comment
Acid base parameters:

pH 7.3
pCO2 65 mm Hg
HCO3 27 mEq/L
Comment
Acid base parameters:

pH 7.25
pCO2 40 mm Hg
HCO3 16 mEq/L

Comment
Acid base parameters:

pH 7.48
pCO2 40 mm Hg
HCO3 35 mEq/L

Comment
Acid base parameters:

pH 7.2
pCO2 65 mm Hg
HCO3 30 mEq/L

Comment
Acid base parameters:

pH 7.5
pCO2 40 mm Hg
HCO3 32 mEq/L

Comment
Acid base parameters:

pH 7.25
pCO2 40 mm Hg
HCO3 14 mEq/L

Comment
Acid base parameters:

pH 7.25
pCO2 60 mm Hg
HCO3 32 mEq/L

Comment
Acid base parameters:

pH 7.6
pCO2 40 mm Hg
HCO3 42 mEq/L

Comment
Acid base parameters:

pH 7.25
pCO2 60 mm Hg
HCO3 25 mEq/L

Comment
Acid base parameters:

pH 7.55
pCO2 30 mm Hg
HCO3 24 mEq/L

Comment
Acid-Base Disorders
Acid- base parameters of a patient is given below,

pH - 7.60
pCo2 - 40 mm of Hg
HCO3 - 37 mEq/L

Interpret the values

Acid- base parameters of a patient is given below,

pH - 7.56
pCo2 - 25 mm of Hg
HCO3 - 24 mEq/L

Interpret the values

Acid- base parameters of a patient is given below,

pH - 7.25
pCo2 - 40 mm of Hg
HCO3 - 16 mEq/L

Interpret the values

Acid- base parameters of a patient is given below,

pH - 7.50
pCo2 - 25 mm of Hg
HCO3 - 24 mEq/L

Interpret the values

Acid- base parameters of a patient is given below,

pH - 7.25
pCo2 - 60 mm of Hg
HCO3 - 25 mEq/L

Interpret the values

Acid- base parameters of a patient is given below,

pH - 7.55
pCo2 - 30 mm of Hg
HCO3 - 24 mEq/L

Comment
Acid- base parameters of a patient is given below,

pH - 7.5
pCo2 - 40 mm of Hg
HCO3 - 32 mEq/L

Interpret the values

Investigation findings of a patient is given,
comment on it

pH - 7.25
pCo2 - 40 mm of Hg
HCO3 - 14 mEq/L
Acid- base parameters of a patient is given below,

pH - 7.2
pCo2 - 65 mm of Hg
HCO3 - 30 mEq/L

Interpret the values

Acid- base parameters of a patient is given below,

pH - 7.48
pCo2 - 40 mm of Hg
HCO3 - 35 mEq/L

Interpret the values

Acid- base parameters of a patient suffering from
dyspnea is given below,

pH - 7.25
pCo2 - 70 mm of Hg
HCO3 - 24 mEq/L

What is the condition?

Acid- base parameters of a patient is given below,

pH - 7.3
pCo2 - 65 mm of Hg
HCO3 - 27mEq/L

Interpret the values

Patient is brought to casualty in a comatose state.

Blood sugar - 490mg%

Serum HCO3 - 17 meq/L

What is the diagnosis?

What other investigations are to be done?
A 45 year old lady is brought to casualty in semiconscious
state. Respiration was deep and rapid. Random blood
sugar was found to be 480 mg%

How will you proceed?

Following a factory strike, an employee on
hunger strike was brought to emergency
dept.

How will you manage?

A patient was rescued from a trench.
He was semiconscious, apathetic.

Blood Sugar was found to be 40 mg %

Serum HCO3 - 15 meq/L

Comment
A 14 year old boy was brought to the after-noon op with
history of severe vomiting since early morning.

What are the investigations to be done for the

management?
Acid- base parameters of a patientin ICU on
ventilator support is given, comment on it

pH - 7.55
pCo2 - 28 mm of Hg
HCO3 - 24 mEq/L
A 65 old man brought to casualty with severe dyspnoea,
restlessness and fever. On examination he was febrile, on
auscultation with breath sounds.

Bed side x-ray was taken; Radiologist gave a diagnosis of

Bronchopneumonia.

What are the Acid- Base parameters to be done to arrive

at a diagnosis?