Moderator:

DR. R. K. YADAV (MD)

Presented by : Ashish
jaisawal
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 Acid - Base balance is primarily
concerned with two ions:
 Hydrogen (H+)
 Bicarbonate (HCO3- )

H + HCO3 -
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 Maintenance of an acceptable pH range in the
extracellular fluids is accomplished by three
mechanisms:
 1) Chemical Buffers
 React very rapidly
(less than a second)
 2) Respiratory Regulation
 Reacts rapidly (seconds to minutes)
 3) Renal Regulation
 Reacts slowly (minutes to hours)
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 Chemical Buffers
 The body uses pH buffers in the blood to guard against
sudden changes in acidity
 A pH buffer works chemically to minimize changes in the
pH of a solution

Buffer
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 Respiratory Regulation
 When breathing is increased,
the blood carbon dioxide level
decreases and the blood
becomes more Base
 When breathing is decreased,
the blood carbon dioxide level
increases and the blood becomes more Acidic
 By adjusting the speed and depth of breathing, the
respiratory control centers and lungs are able to regulate
the blood pH minute by minute

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 Kidney Regulation
 Excess acid is excreted by the
kidneys, largely in the form of
ammonia
 The kidneys have some ability to
alter the amount of acid or base
that is excreted, but this generally
takes several days

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HOW TO BEGIN
 What tests do we use?
 ABG and Electrolytes
 What is normal pH
 7.4 +/- 0.5
 What is normal PCO2?
 40 +/- 5
 What is normal HCO3?
 24 +/- 4
 What is an anion gap?
 The unmeasured anions- albumin, phosphate, sulfate,
lactate.
 What is the normal anion gap?
 12 +/- 2
 How do you calculate the anion gap?
 Na+ - (Cl + HCO3)
 ABG analysis

Look at the pH.

 pH < 7.35, acidosis
 pH > 7.45, alkalosis

Respiratory or Metabolic
Look at PCO2, HCO3-

If the change in PCO2 correlates with the pH Main pathology is metabolic

• If low pH ----- pCO2 low ----- metabolic ( acidosis)

• If high pH ----- pCO2 high ----- metabolic (alkalosis)

If the change in PCO2 NOT correlates with the pH Main pathology is

respiratory

• If low pH ----- pCO2 high ----- respiratory ( acidosis)

• If high pH ----- pCO2 low ----- respiratory ( alkalosis)
 Simple or mixed disorder
 Calculates expected compensation
 Determine anion gap (AG)

Calculates expected compensation

 Metabolic acidosis
PaCO2= (1.5 x HCO3-) + 8 ± 2
or PaCO2 = [HCO3-] + 15

Metabolic alkalosis
PaCO2= (0.7 x HCO3-) + 21 ± 2

or PaCO2= [HCO3-] + 15

Acid - Base
 For primary metabolic acidosis or alkelosis

if PCO2 > expected --- respiratory acidosis

if PCO2 < expected --- respiratory alkalosis

Acid - Base
 Respiratory alkalosis
Acute pH= 7.4 + 0.008 ( 40 - pCO2)

Chronic pH= 7.4 + 0.003( 40 - pCO2)

 Respiratory acidosis
Acute pH= 7.4 - 0.008 ( pCO2 - 40)

Chronic pH= 7.4 - 0.003 ( pCO2 - 40)

Acid - Base
 Respiratory alkalosis
Acute- [HCO3-] will 0.2 mmol/L per mmHg change
in PaCO2
Chronic- [HCO3-] will 0.4 mmol/L per mmHg
change in PaCO2
Respiratory acidosis
Acute -[HCO3-] will 0.1 mmol/L per mmHg change
in PaCO2
Chronic -[HCO3-] will 0.4 mmol/L per mmHg change
in PaCO2

Acid - Base 6/9/99

 Primary Respiratory alkalosis
Acute pH > expected ----- metabolic alkalosis

Chronic Ph< expected ----- metabolic acidosis

 Primary Respiratory acidosis

Acute pH < expected ----- metabolic acidosis

Chronic pH > expected ----- metabolic alkalosis

Acid - Base
 Determine anion gap (AG) – AG = NA – (HCO3+ CL)
 High AG metabolic acidosis
 Non AG acidosis – determined by delta gap

 Delta gap
 Delta HCO3 = HCO3 (electrolytes) + change in AG
 Delta gap < 24 = non AG acidosis
 Delta gap > 24 = metabolic alkalosis

 Note: The key to ABG interpretation is following the

above steps in order.
Serum Electrolytes Arterial Blood Studies
Sodium 134 mEq/L PO2 89 mm Hg
Potassium 3.8 mEq/L PCO2 32 mm Hg
Chloride 83 mEq/L pH 7.48
HCO3 24 mEq/L HCO3 24 mEq/L
Which of the following is the most likely
explanation of these laboratory findings?
(A) Respiratory alkalosis
(B) Respiratory alkalosis and metabolic acidosis
(C) Metabolic acidosis
(D) Respiratory alkalosis, metabolic acidosis, and
metabolic alkalosis
(E) Metabolic alkalosis, respiratory alkalosis, and
respiratory acidosis
pH = 7.48 implies primary respiratory alkalosis

Anion gap: 134 – 107 = 27

Metabolic acidosis
Excess Anion gap 27 – 12 = 15
15 + 24 exceeds 30

Metabolic alkalosis
Which of the following is the most likely
explanation of these laboratory findings?
(A) Respiratory alkalosis
(B) Respiratory alkalosis and metabolic acidosis
(C) Metabolic acidosis
(D) Respiratory alkalosis, metabolic acidosis, and
metabolic alkalosis
(E) Metabolic alkalosis, respiratory alkalosis, and
respiratory acidosis
 M ethanol
 U remia
 D iabetic Ketoacidosis, Ketoacidosis
 P araldehyde
 I ron, Isoniazid (INH)
 L actic Acidosis
 E thanol, Ethylene glycol
 S alicylates

Acid - Base
 Drunk
 Hx of drug use
 Fruity breath
 Kussmaul’s breathin
 hypotension

Acid - Base
 Chemistries
 BUN, Cr, glucose
 Lactate level
 Ketones
 Ethanol level
 Salicylate level
 UA

Acid - Base
 Treat underlying condition

 Remember:
 Methanol
 Ethanol
 Ethylene Glycol
 Salicylates
 Can Be Removed via Dialysis

Acid - Base
  When to administer??
pH < 7.2
HCO3 < 15 meq/L

(Deleterious – hypokalemia, hypocalcimia,

hypernatraemia, paradoxical acidosis)

 How to administer –
(desired HCO3 – actual HCO3) x 0.5 x weight

Acid - Base
 H yperalimentation
 A cetazolamide, amphotericin
 R TA
 D iarrhea
 U reteral Diversions
 P ancreatic fistula
 S aline resucitation

Acid - Base
IF YES THINK About
 Ileostomy
 Diarrhea
 Enteric Fistula

Acid - Base
IF NO: What is the urine pH?
 if > 5.5
 Type I RTA
 if < 5.5, then CHECK Potassium
 if K is low = RTA type II
 if K is High = RTA type IV

Acid - Base
 P araproteinemias, Multiple myeloma
 L ithium intoxication
 E xcessive Calcium and Magnesium
 A lbumin is low (hypoalbuminemia)
 B romism

Acid - Base
 Volume Contraction:
 NG suction
 Vomitting
 Diuretics
 Post Hypercapnia
 Hypokalemia
 Hypomagnesemia
 Carbenicillin, Penicillin

Acid - Base
 Adrenal Disorders
 Glucocorticoid Excess
 Mineralcorticoid Excess
 Exogenous Steroids
 Alkali Ingestion
 Bartter’s Syndrome

Acid - Base
 Muscle cramps
 Weakness
 Hypoxia
 Arrhythmias

Acid - Base
 Volume repletion
 Correct Electrolytes
 Spironolactone (hyperaldo)
 Treat Underlying process

Acid - Base
 Pulmonary Disease
 Pneumothorax
 Effusion
 COPD
 ARDS
 PE
 Inappropriate Vent setting

Acid - Base
 Musculoskeletal Disease
 Guillain Barre
 Myasthenia gravis
 CNS
 Sedatives
 Trauma
 Infxn
 Neoplasm

Acid - Base
 ADEQUATE VENTILATION

Acid - Base
 Pulmonary Disease
 Pulmonary Edema
 Pneumonia
 PE
 Inappropriate Vent settings

Acid - Base
 CNS
 Increased Respiratory drive
 Infection
 CVA
 Trauma
 Anxiety
 Drugs
 Salicylates
 Catecholamines

Acid - Base
 Sepsis
 Fever
 Pregnancy
 Liver Disease
 Anemia
 Carbon monoxide poisoning

Acid - Base
 TREAT UNDERLYING CAUSE

Acid - Base
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