Acid Base Disorders

Hasan Al-Dorzi, MD
Pulmonary and Critical Care
Consultant, Intensive Care Department

Acid Base Balance

The body produces acids daily

15000 mmol of CO2
50-100 mEq of nonvolatile acids

The body prevents pH changes by three

systems:
Physiologic buffers
Respiratory system
Renal system

Acid-Base Balance

Buffers bind or release hydrogen ion to

limit the change in pH
Main body buffers:
Bicarbonate
+
H + HCO3 H2CO3 H2O + CO2
Intracellular protein puffers: hemoglobin

Bone

Reservoir of bicarb and phosphate

Acid-Base Balance
Respiratory system
Changes in pH sensed by chemoreceptors
Peripherally (carotid bodies)
Centrally (medulla oblongata)

Drop in pH

Increased minute ventilation

Lowers PaCO2

Increase in pH

Decreased ventilatory effort

Increases PaCO2

Acid-Base Balance
Renal system
Plays no role in acute compensation
6-12hrs Acidosis
Active excretion of H+
Retention of HCO3

>6hrs of Alkalosis
Active excretion of HCO3 Retention of H+

pH
pH
The negative logarithm of the hydrogen ion
concentration
Henderson Hasselbalch equation:
pH = 6.1 + log [HCO3-]/ 0.03 PCO2

Normal pH is 7.35-7.45
Value <7.35 is acidemia
Value >7.45 is alkalemia

Acid Base Disorders

Disturbances of acid base metabolism:

Acidosis process that increases [H+]
by increasing PCO2 or by reducing
[HCO3-]
Alkalosis process that reduces [H+]
by reducing PCO2 or by increasing
[HCO3-]
Hence, we can 4 acid-base disturbances

Acid Base Disorders

Hence, we can have 4 primary acidbase disturbances:

Respiratory acidosis
Respiratory alkalosis
Metabolic acidosis
Metabolic alkalosis

Compensatory processes try to

correct pH
Mixed primary processes can exist

Respiratory Acidosis

CO2 Ventilation leading to ph

Causes
CNS depression
Pleural disease
COPD/ARDS
Musculoskeletal disorders
Compensation for metabolic alkalosis

Respiratory Acidosis

Acute vs Chronic
Acute - little kidney involvement.

pH by 0.08 for each 10 mmHg in CO2

HCO3 increase by ~1 for each 10 mmHg
in CO2

Chronic - Renal compensation via

synthesis and retention of HCO3 (Cl to
balance charges hypochloremia)

pH by 0.03 for each 10 mmHg in CO2

HCO3 increase by 3 for each 10 mmHg in
CO2

Respiratory Alkalosis

CO2, Ventilation leading to pH

CO2 HCO3 (Cl to balance charges
hyperchloremia)
Decreased HCO3 reabsorption and
decreased ammonium excretion to
normalize pH
Causes

Intracerebral hemorrhage
Salicylate and Progesterone drug usage
Anxiety
Cirrhosis of the liver
Sepsis

Respiratory Alkalosis

Acute vs. Chronic

Acute - HCO3 by 2 mEq/L for every 10
mmHg in PCO2
Chronic - HCO3 by 4 mEq/L of HCO3 for
every 10 mmHg in PCO2

Metabolic acidosis

Two types:
Normal anion gap or non-anion gap
High anion gap or anion gap

Cations = Anions

Anion gap= Na+ - (Cl- + HCO3-)

Normal anion gap= 8-12

Anion Gap

HCO3Na+

Cl-

Addition of
exogenous acids

ie, Formate-

or

Creation of
endogenous acids

Anion Gap

HCO3Na+

Cl-

Excessive loss
of HCO3-

or

Inability to
excrete H+

Anion Gap

HCO3Na+

Cl-

Delta Gap

Checks for hidden metabolic

process
Based on the 1:1 concept:
AG = HCO3

(Normal HCO3 = 24)

Metabolic Acidosis

HCO3 leading to pH
12-24 hours for complete activation
of respiratory compensation
The degree of compensation is
assessed via the Winters Formula
PCO2 = 1.5(HCO3) +8 2

The Causes
Anion gap= Na+ (HCO3- + Cl-)

Metabolic Gap
Acidosis

M - Methanol
U - Uremia
D - DKA
P - Paraldehyde
I - INH
L - Lactic Acidosis
E - Ehylene Glycol
S - Salicylate

Non Gap Metabolic

Acidosis

Acetazolamide
Renal tubular acidosis
Diarrhea
Pancreatic Fistula

Metabolic alkalosis
Saline-responsive
Usually due to loss
of hydrogen ions
from the stomach
or in the kidneys

Urinary chloride
level <20 mEq/L

Examples:
1) Vomiting/Gastric
suction
2) Diuretics
3) Colonic adenomas

metabolic alkalosis
Saline-resistant
Usually associated
with mineralcorticoid
excess leading to
Na+ reabsorption and
secretion of K+ and H+

Urinary chloride
>20mEq/L

Examples
1)
Primary
aldosteronism
2)
Exogenous steroids
3)
Adenocarcinoma
4)
Bartters Syndrome
5)
Cushings disease
6)
Ectopic
adrenocorticotropic
hormone

Metabolic Alkalosis

HCO3 leads to pH
Causes

Vomiting
Diuretics
Hypokalemia
Hyperaldosteronism
Cushings syndrome

PCO2 by 0.7 for every 1mEq/L in HCO3

Mixed Acid-Base Disorders

Patients may have two or more acidbase disorders at one time

E.g. Metabolic acidosis and metabolic
acidosis
E.g. Respiratory acidosis and metabolic
acidosis

Arterial Blood Gas Interpretation

Check validity of laboratory

measurements

H+ = 24 x PaCO2 HCO3
H+ = 80 last 2digits of pH
ie, pH=7.20 ------ H+ = 80-20=60
ie, pH=7.44 ------ H+ = 80-44=36

Arterial Blood Gas Interpretation

Step 1
Check pH
Determine if acidosis or alkalosis
If acidosis pH = decreased
If alkalosis pH = increased
Step 2
Check pCO2
If pCO2 is increased it is being retained
If pCO2 is decreased it is being blown off

Arterial Blood Gas Interpretation

Step 3
Check HCO3
If increased acid is being excreted
If decreased acid is being added
Step 4
Determine primary process

Anion GAP

Calculation of AG is useful approach to

analyze metabolic acidosis
AG = (Na+ (Cl- + HCO3-)

Step 5: Determine Compensation

Metabolic Acidosis
PaCO2 decreases 1.2 mmHg per 1
meq/L bicarbonate fall
Winters formula: PCO2= 1.5 HCO3 + 8
2
Metabolic Alkalosis
PaCO2 increases 6-7 mmHg per 10
meq/L bicarbonate rise

Step 5: Determine Compensation

Acute Respiratory Acidosis

Bicarbonate increases 1 meq/L per 10
mmHg PaCO2 rise
Chronic Respiratory Acidosis
Bicarbonate increases 4 meq/L per 10
mmHg PaCO2 rise

Step 5: Determine Compensation

Acute Respiratory Alkalosis

Bicarbonate decreases 2 meq/L per 10
mmHg PaCO2 fall
Chronic Respiratory Alkalosis
Bicarbonate decreases 4 meq/L per 10
mmHg PaCO2 fall

Other Components of ABGs

Bicarbonate (HCO3-)

Calculated from the CO2 and pH using the

Henderson-Hasselbach equation
Allows assessment of the metabolic component
of acid-base balance

Base excess (or deficit)

A measure of the amount of acid or alkali that

must be added to a sample under standard
conditions to return the pH to 7.4
Calculated from the pH and PaCO2

Case # 1

A 65 year old man who is a heavy

smoker presents to the Emergency
department because of shortness of
breath and sputum production of one
day duration.
ABGs showed pH=7.30, PO2: 54 mm
Hg, PCO2=52 mm Hg, HCO3=25,
BE=+1, O2 saturation=85% on room
air.

Case # 1

This patient has:

a) type I respiratory failure
b) type II respiratory failure

This patient has:

a) Respiratory acidosis
b) Metabolic acidosis

Analysis of case 1

Check for internal consistency: 50= 24 x50/25 OK

pH is 7.30= acidemia
PCO2 is high = respiratory acidosis
HCO3: slightly elevated = metabolic alkalosis
Primary process= respiratory acidosis
Acute vs chronic: history suggests it is acute
Compensation: 10 increase in PCO2, 1 increase in HCO3:
OK
Diagnosis= primary acute respiratory acidosis

Case # 2

A 65 yo man presents after motor

vehicle collision. He has facial
injuries and requires to be intubated.
He is now on mechanical ventilation.
ABGs: 7.26 / 40 / 65 / 12 on FiO2 =1.0
Serum chemistry: Na= 140 / K= 3.5 / Cl= 104 /
HCO3= 12

Case # 2
This patient has
a) type I respiratory failure
b) type II respiratory failure
c) None of the above
This patient has
a) Acidemia
b) Acidosis
c) alkalosis

Analysis of case 2

Check for internal consistency

Patient has academia
Patient has metabolic acidosis
Anion gap is high = 140 -116= 24
Drop in HCO3 = increase in anion gap
Winters formula: expected PCO2= (1.5 x 12) +8
+/- 2:= 24-28
But on ABGs, PCO2 = 40: higher than expected

Diagnosis: primary metabolic acidosis (high AG)

and primary respiratory acidosis

Case # 2

His acid base disorder can be

explained by:
Shock state
Ethanol intoxication
Severe vomiting before presentation to
the hospital
Severe dehydration and diarrhea

Case # 3

A 65 yo man presents with nausea and

vomiting.
ABGs: 7.4 / 41 / 85 / 22
Na- 137 / K- 3.8 / Cl- 90 / HCO3- 22
Does this patient have any acid-base disorder?

Case # 3

Anion Gap = 137 - (90 + 22) = 25

anion gap metabolic acidosis
Winters Formula = 1.5(22) + 8 2
= 39 2
compensated
Delta Gap = 25 - 10 = 15
15 + 22 = 37
metabolic alkalosis

This patient is alcoholic!!!

Case # 4

22 year old female presents for

attempted overdose. She has
history of chronic headache.
On exam she is experiencing
respiratory distress.

Case # 4

ABG - 7.47 / 19 / 123 / 14

Na- 145 / K- 3.6 / Cl- 109 / HCO317

Case # 4

Anion Gap = 145 - (109 + 17) = 19

anion gap metabolic acidosis
Winters Formula = 1.5 (17) + 8 2
= 34 2
uncompensated: primary respiratory
alkalosis
Delta Gap = 19 - 10 = 9
9 + 17 = 26
no metabolic alkalosis

Case # 5

47 year old male experienced crush

injury at construction site.
ABG - 7.3 / 32 / 96 / 15
Na- 135 / K-5 / Cl- 98 / HCO3- 15 /
BUN- 38 / Cr- 1.7
CK- 42,346

Case # 5

Anion Gap = 135 - (98 + 15) = 22

anion gap metabolic acidosis
Winters Formula = 1.5 (15) + 8 2
= 30 2
compensated

Summary
pH

PaCo2

HC03
normal

Respiratory acidosis
normal
Respiratory Alkalosis
normal
Metabolic Acidosis
normal
Metabolic Alkalosis

Thank You