ACID-BASE

IMBALANCES
DR. EMMANUEL SANDY
DEPARTMENT OF CHEMICAL PATHOLOGY
COMAHS-USL
 PRETEST Short story

• An ambitious 23 year old

European man wanted to be the
first to cross the Sahara Desert
entirely on foot. Some miles
into his expedition, he became
very thirsty and exhausted the
drinking water he had on him.
 Short story

• The man proceeded hopeful

that he will get water along the
way.

• When he got to an oasis after

several miles, he drank water
and died shortly after...
Why did he die?

What killed him?

NORMAL VALUES
• pH = 7.35 – 7.45
• pCO2 = 4.5 – 6.1 kPa(35-45mmHg)
• [ HCO3] = 22 – 26 mmol/L
• SaO2 = 95 – 98%
• pO2 = 83 – 108mmHg
• Base Excess = -2 + 2 mEq
• Normal Anion Gap = 12 +/- 2 (8 – 16)/(10 – 20)
Regulating Acid-Base Balance
 Regulating Acid-Base Balance

• Low pH = acidic
• High pH = alkalinic
• Body fluids maintained between pH of
7.35 and 7.45 by
• Buffers
• Respiratory system
• Renal system
Figure 52-10 Carbonic acid–bicarbonate ratio and
pH.

• Prevent excessive
changes in pH
• Major buffer in ECF
is HCO3 and
H2CO3
• Other buffers
include:
– Plasma
proteins
– Hemoglobin
– Phosphates
KEY CONCEPTS
ACIDOSIS: A condition characterized by a decrease in blood ph. Can
be;
• Metabolic or respiratory in origin
• The decrease in pH can be due to:
1. a decrease in [HCO3]- Metabolic acidosis
2. an increase in Pco2- respiratory acidosis
ALKALOSIS: A condition characterized by an increase in blood pH. The
condition can be;
• Metabolic or respiratory in origin
• An increase in pH can be due to;
1. An increase in [HCO3]- Metabolic alkalosis
2. A decrease in Pco2- Respiratory alkalosis
 COMPENSATION
• This is a physiological mechanism operated by the acid-base system in
attempt to bring the pH imbalance back to normal.
• The process tries to bring the HCO3/CO2 ratio back towards normal.
• Two types exists.
 COMPENSATION
1. Metabolic Compensation: Occurs when lung function is
compromised, and the kidneys attempt to increase the excretion of
hydrogen ions via renal route.
• Slow to take effect
• Comes into effect over 2-4 days
 COMPENSATION
 The compensation occurs in two forms:
a) Respiratory acidosis(decrease pH due to increase pCO2), more H+ is
excreted and more HCO3- is generated by the kidneys, increasing
blood HCO3-.
b) Respiratory alkalosis(increase pH due to decrease pCO2), less H+ is
excreted and lessHCO3- is generated by the kidneys, increasing
blood HCO3-.
 COMPENSATION
2. Respiratory compensation: The lungs alter the rate and depth of
respiration, which is affected directly by the blood pH.
• Respiratory compensation is quick
• Comes into effect within 15-30mins.
 The compensation occurs in two forms:
a) Metabolic acidosis(decrease pH due to decrease HCO3-) the rate
and depth of respiration are increased(hyperventilation), decreasing
blood pCO2.
b) Metabolic alkalosis(increased pH due to increased HCO3-) the rate
and depth of respiration are decreased(hypoventilation), increasing
blood pCO2.
ACID-BASE IMBALANCES
• Acid Base Dis.: pH pCO2 HCO3-
• Metabolic acidosis   
• Respiratory acidosis   
• Metabolic alkalosis   
• Respiratory alkalosis   
ACTUAL AND STANDARD
BICARBONATE(SBC)
• Actual bicarbonate is the bicarbonate concentration actually found in
the patient’s blood.
• SBC is the bicarbonate concentration calculated from the pH of a
blood sample equilibrated to a pCO2 of 5.3kpa, and is the value used
to assess whether a metabolic change is present.
CORRECTION
• After tx of primary dz, diseased part in the acid-base imbalance must
rid the body of the accumulated acid or base which caused the
abnormality.
• The non-diseased part must rid the body of the compensatory
changes.
ANION GAP
• Concept useful in establishing the cause of metabolic acidosis.
• Blood is always electro neutral, even if there is an A-B disturbance i.e.,
it always contain equal amount of positive and negative ions.
• E.g., Na+, K+, Ca2+, Mg2+, Cl-, HCO3-, proteins, organic anions, etc.
• ANION GAP = (Na+ + K+) – (Cl- + HCO3-)
• ANION GAP = 10 – 20mmol/L
Anion Gap therefore reflects the concentration of those anions which
are actually present in serum, but are routinely unmeasured,
including negatively charged proteins, phosphates, sulphates, and
organic acids.
If the AG bigger than normal, it is because one of the these
unmeasured anions is increased.
CAUSES OF INCREASED ANION GAP
• Ketoacidosis (diabetic) DR MAPLES
• Uremia (renal failure)
• Salicylate intoxication
• Starvation
• Methanol intoxication
• Alcohol ketoacidosis
• Unmeasured osmoles (intoxication)
• Lactic acidosis
LABORATORY ACID-BASE( OR BLOOD
GAS ANALYSIS)
 When you request a blood gas analysis, always remember to send;
• Arterial or capillary blood- pO2 and pCO2 values.
• A heparinized sample- anticoagulation.
• In a sealed syringe- to prevent O2 and CO2 diffusing out of the
sample.
• On ice- to prevent ongoing RBC metabolism.
INTERPRETING ACID-BASE DATA
1. Look at the pH and decide whether it is normal, low or high.
2. Look at pCO2 and SBC and decide which is the primary abnormality i.e., which
change can cause this pH ?
Decreased pH=decreased base/increased acid
Increased pH=increased base/decreased acid
3. Look at the non-causative component and decide whether compensation is present
or not. Compensatory change is always in the same direction as the primary change.
4. In respiratory acid-base disturbances, look at the pO2 to assess respiratory function.
APPROACH TO ACID-BASE
DISTURBANCES
• History & physical examination
• Arterial blood gas for pH, pCO2, (HCO3)
• Use the HCO3 from ABG to determine compensation
• Serum Na, K, Cl, CO2 content
• Use CO2 content to calculate anion gap
• Calculate anion gap
• Anion gap = {Na - (Cl + CO2 content)}
• Determine appropriate compensation
• Determine the primary cause
CASE 1
• Calculate the anion gap and explain its significance, for a diabetic
patient with : Na+ = 136 mmol/l; K+ = 5 mmol/l; Cl- = 97 mmol/l;
HCO3- = 13 mmol.
ANSWERS
• (136 + 5) - (97 + 13) = 31 i.e., increased anion gap. This means that
unmeasured anions are present, probably ketone anions
CASE 2
• A 30 year old woman was admitted to the Trauma Unit following a
motor vehicle accident. On examination she had multiple fractures
and a cold cyanosed periphery. Her pulse was 140, barely palpable,
and her blood pressure was un-recordable.
The following laboratory findings were obtained : Na+ 138 mmol/l
(135 - 145), K+ 6 mmol/l (3.5 - 5.5), Cl- 90 mmol/l (97 - 107), HCO3-
14 mmol/l (22 - 26), glucose 6 mmol/l (3.9 - 5.6), urea 8 mmol/l (1.7 -
6.7), creatinine 90 µmol/l (75 - 115), arterial blood gases : pH 7.1,
pCO2 4.4 kPa, SBC 10 mmol/l.
 QUESTIONS
• i. Comment on and interpret all the biochemical data (using correct
biochemical terms).
ii. Explain the likely cause for this acid-base disturbance. iii.
If it were necessary to confirm this diagnosis, how could you do this?
iv.
Which HCO3- result should be used to calculate the anion gap ?
v. Explain the K+ result.
vi. How should the acid-base disturbance in this patient be treated
ANSWERS
• i. Metabolic acidosis with partial respiratory compensation. Anion gap
= 40 i.e., increased. Mild hyperkalaemia. Increased urea and normal
creatinine.
ii. Clinically shocked. Probable cause - lactic acidosis due to poor
tissue perfusion. Pre-renal uraemia indicates poor renal perfusion iii.
Seldom necessary to do, but can measure lactate. iv.
Actual bicarbonate, not SBC. v.
Acidosis leads to H+ shifting into cells, thereby displacing K+ from
intracellular anionic binding sites.
vi. Rehydration; treat patient’s physical injuries. Bicarbonate therapy
probably not necessary. Monitor pH, HCO3- and especially K+ levels.
CASE 3
• A 60 year old man presented with shortness of breath, which had
developed gradually over several years. He had been a heavy smoker
since age 20. On examination he was short of breath at rest and
centrally cyanosed. He had a barrel-shaped chest and a marked
expiratory wheeze. CXR showed hyperinflation and other signs
consistent with emphysema.
Arterial blood gases : pH =7.2, pO2 = 8.0 kPa, pCO2 = 9.0 kPa, SBC= 36
mmol.
 QUESTIONS
• i.) Comment on and interpret all the biochemical data (using correct
biochemical terms).
ii.) Explain the likely cause for this acid-base disturbance.
iii.) If he were given oxygen to breathe by face mask, what would
happen to these parameters ?
iv.) If he were intubated and ventilated so that his pCO2 was rapidly
decreased to normal, what would happen to his pH ?
v.) How do these biochemical results differ from those in a patient
with an acute asthma attack?
ANSWERS
• i.) Respiratory acidosis with partial metabolic compensation. Hypoxia. ii.) COAD
- based on history, examination, CXR findings and compatible acid-base findings.
The history is chronic, therefore there has been ample time for metabolic
compensation to occur. iii.) The pO2 would increase,
and this would reduce one of the stimuli to his respiratory centre, i.e., the hypoxic
stimulus. This would reduce his ventilatory drive and ventilatory rate and
therefore further increase his pCO2, worsening the respiratory acidosis.
iv.) The mechanism described above would not operate,
because his ventilatory rate would be maintained artificially. However, rapid
correction of his pCO2 to normal while his HCO3- is still high would lead to a
metabolic alkalosis. v.) Acute
condition, therefore no metabolic compensation. At the same level of pCO2, the
pH would be much lower.
CASE 4
• An 18 year old woman was admitted to hospital repeatedly over a
period of 6 weeks with a history of nausea, weight loss, weakness and
“fainting”. Each episode had similar biochemical findings and
responded to potassium supplementation. Na+ 140 mmol/l, K+ 2.4
mmol/l, Cl- 87 mmol/l, urea 7 mmol/l, creat 50 umol/l, HCO3- 39
mmol/l, pH 7.53, pCO2 6.4 kPa.
 QUESTIONS
• i. Comment on and interpret all the biochemical data (using correct
biochemical terms).
ii) What do the biochemical features suggest?
iii. What would analysis of the patient’s urine reveal ? iv.
Explain the likely cause for this biochemical picture.
• i. Metabolic alkalosis with partial respiratory compensation. Severe
hypokalaemia. Increased urea and low creatinine.
ii) Low chloride suggests vomiting as the cause of the metabolic
alkalosis. Pre-renal uraemia indicates poor renal perfusion and
suggests dehydration. Low creatinine indicates small muscle bulk.
iii) Low urine Cl- (< 5 mmol/l) and acid urine ph.
iv. Bulimia Nervosa- a serious potentially life-threatening eating
disorder. People with bulimia may secretly binge and then purge.
CASE 5
• A young man was involved in a road traffic accident and sustained
severe chest injuries. He was struggling to breathe and in great
distress, but fully conscious. pH 7.24, pCO2 8 kPa, pO2 8 kPa, SBC 25
mmol/l.
i. Comment on and interpret all the biochemical data (using correct
biochemical terms).
ii. Work out the possible causes for this acid-base disturbance
ANSWERS
• i. Respiratory acidosis with no metabolic compensation. Hypoxia.
ii. Acute respiratory acidosis in this situation could have been
caused by a crush injury to the chest, multiple rib fractures causing a
"flail" chest segment, or acute lung collapse. Acute airway
obstruction would also be a possibility. Head injury would be a less
likely possibility, since the patient is conscious.
CASE 6
• A young woman is admitted to hospital unconscious following a fall.
Her respiratory rate is persistently rapid. pH 7.48, pCO2 3.9 kPa, pO2
12 kPa, SBC19 mmol/l.
i. Comment on and interpret all the biochemical data (using correct
biochemical terms).
ii. Work out the possible causes for this acid-base disturbance.
ANSWERS
• i. Respiratory alkalosis with almost complete metabolic
compensation. No hypoxia.
ii. Chronic respiratory alkalosis without hypoxia can only be due to
hyper stimulation of the respiratory centre. Possible causes include
the obvious one of brain stem injury, but the possibility of drug
ingestion must not be overlooked.
 CASE 7 ASSINGMENT
• A young man had been complaining to his GP of tiredness and weight loss.
On questioning he admitted to excessive thirst and passing more urine than
normal. He was scheduled for assessment in hospital the following day, but
by then he was feeling drowsy and unwell, and vomiting. On admission he
was found to have a BP of 95/60 with a pulse rate of 120/min and cold
extremities. His breathing was deep and sighing.
Na+ 130mmol/l, K+ 5.8mmol/l, Cl- 105mmol/l, urea18 mmol/l,
creat 140umol/l, glu32 mmol/l, HCO3- 5mmol/l, pH 7.05, pCO2 2kPa i.
Comment on and interpret all the biochemical data (using correct
biochemical terms). ii.
Work out the possible causes for this acid-base disturbance.
THANK YOU