Acid/Base balance

MO GBESSAY
 Some acid-base basics:
• Normal pH 7.35-7.45
• Usually closely regulated by the kidney and
plasma buffers e.g. bicarbonate

• CO2 is an ACIDIC GAS (normal 4.7-6KPa)

• HCO3 is ALKALINE (normal 22-28mmol/L)
 Introduction
• Allow us to identify acute and chronic disease
processes
• Necessary in urgent situations
• A normal pH does not exclude an acid-base disorder
• If the primary disorder is an acidosis, then the body
will compensate by creating an alkalosis and vice
versa.
• If the primary disorder is respiratory, the body will
compensate with metabolic process.
 Normal Values
Arterial pH: 7.35 – 7.45
Serum HCO3: 22-28mmol/L
Arterial pCO2: 4.7-6.0Kpa
Arterial PaO2: 8-10Kpa
 Evaluation/Practical Approach
Step 1: Look at the Ph to determine whether Acidosis or
Alkalosis

Step 2: Look at pCO2 and HCO3 to determine primary

disorder.
 If the change is consistent with the change in Ph then
it’s a respiratory process.
If the change is HCO3 is consistent with the change in Ph
then it’s a metabolic process
Step 3: Look to see if there is a secondary disorder.
 Practical approach to acidosis:
Is it respiratory? Is it metabolic?

• LOOK AT THE HCO3

• LOOK AT THE CO2
– Is it low?
– Is it raised?
– If it is this is a METABOLIC
– If it is, this is a RESPIRATORY
acidosis
acidosis
– E.g. lactic acidosis
– E.g. acute T2RF

– Is it low? – Is it high?
– This is a metabolic acidosis – This is a respiratory acidosis
with respiratory compromise with metabolic compromise
– E.g. sepsis – E.g. chronic T2RF
 Examples:
ABG 1 ABG 2
• pH: 7.35 (7.35-7.45) • pH: 7.15 (7.35-7.45)
• pO2: 8.0 (10–14) • pO2: 11.1 (10–14)
• pCO2: 7.2 (4.5–6.0) • pCO2: 3.2 (4.5–6.0)
• HCO3: 31 (22-26) • HCO3: 16 (22-26)
 Metabolic Acidosis
Ph Less than 7.35 Increased Anion Gap MA
• HCO3 low • M: Methanol
• Uraemia
Anion Gap : Na – (Cl + HCO3) • Diabetiketoacidosis
• Paraldehyde
Normal: 8-12 • Ishemia/Isoniazid/Iron
• Lactic Acidosis
• Ethylene glycol
• Rhabdomyolysis
• Starvation/Salycyclates
 Causes of a metabolic acidosis
Increased production of acid Loss of bicarbonate/ingestion
of H+ ions
• Lactic acid:
– Shock, infection, hypoxia • Diarrhoea
• Urate: • Addisons disease
– Renal failure
• Renal tubular acidosis
• Ketones:
– Diabetes, alcohol
• Drugs:
– Aspirin OD or methanol
 Alkalosis
Respiratory Metabolic

• LOOK AT THE CO2: • LOOK AT THE HCO3

– Is it low? – Is it high?
– If yes, this is a respiratory – If yes, this is a metabolic
alkalosis alkalosis
– E.g. hyperventilation – E.g. vomiting

– It is unlikely to be raised as
respiratory alkalosis is usually
short lived.
 Alkalosis
ABG 3 ABG 4
• pH: 7.48 (7.35-7.45) • pH: 7.56 (7.35-7.45)
• pO2: 12.1 (10–14) • pO2: 10.7 (10–14)
• pCO2: 3.5 (4.5–6.0) • pCO2: 5.0 (4.5–6.0)
• HCO3: 22 (22-26) • HCO3: 31 (22-26)
 Causes of a metabolic alkalosis
• Vomiting
• K+ depletion
• Burns
• Ingestion of alkali
 More examples:
• 22 year old boy presenting unwell with polyuria and
polydipsia
– pH: 7.12 (7.35-7.45)
– pO2: 11.5 (10–14)
– pCO2: 3.2 (4.5–6.0)
– HCO3: 17 (22-26)
– Potassium: 5.5
– Glucose: 22
• WHAT DOES THIS SHOW AND WHAT IS THE CAUSE
OF THE ACIDOSIS?
 More examples:
• 18 year old girl comes in after taking and
overdose:
– pH: 7.48 (7.35-7.45)
– pO2: 12.5 (10–14)
– pCO2: 3.5 (4.5–6.0)
– HCO3: 22 (22-26)
Any questions?