ACID-BASE BALANCE

By:
Husnil Kadri

Biochemistry Departement
Medical Faculty Of Andalas University
Padang
CARA
TRADISIONAL :

Hendersen-Hasselbalch
(1909)

2
 HCO
Normal
[HCO
GINJAL]
BASA - HCO
3
3

3
pH = 6.1 + log Kompensasi

Normal pCO2
PARU
ASAM COCO
2 2

3
Carbonic acid/bicarbonate buffer system
pKa = 6.1
ECF: H2CO3 H+ + HCO3-
Carbonic acid Bicarbonate ion

The pKa of carbonic acid is 6.1

Carbonic acid is the major buffer in ECF
The pH of blood can be determined using
the Henderson-Hasselbalch equation

4
Henderson-Hasselbalch equation
pH = pKa + log [HCO3-]/[H2CO3]

pH = pKa + log [HCO3-]/0.03 x PCO2

7.4 = 6.1 + log 20 / 1

7.4 = 6.1 + 1.3

Plasma pH equals 7.4 when buffer ratio is 20/1

The solubility constant of CO2 is 0.03
5
GANGGUAN KESEIMBANGAN ASAM-
BASA TRADISIONAL

DISORDER pH PRIMER RESPON

KOMPENSASI

ASIDOSIS HCO3- pCO2

METABOLIK

ALKALOSIS HCO3- pCO2

METABOLIK

ASIDOSIS pCO2 HCO3-

RESPIRATORI

ALKALOSIS pCO2 HCO3-

RESPIRATORI
Normal Compensatory Response
Any primary disturbance in acid-base
homeostasis invokes a normal
compensatory response.
A primary metabolic disorder leads to
respiratory compensation, and a primary
respiratory disorder leads to an acute
metabolic response due to the buffering
capacity of body fluids.
A more chronic compensation (1-2 days) due
to alterations in renal function.
 Mixed Acid - Base Disorder
Most acid-base disorders result from a single primary
disturbance with the normal physiologic compensatory
response and are called simple acid-base disorders.

In certain cases, however, particularly in seriously ill

patients, two or more different primary disorders may
occur simultaneously, resulting in a mixed acid-base
disorder.

The net effect of mixed disorders may be additive (eg,

metabolic acidosis and respiratory acidosis) and result
in extreme alteration of pH;

or they may be opposite (eg, metabolic acidosis and

respiratory alkalosis) and nullify each others effects on
the pH.
Cara Stewart ;
pH atau [H+] DALAM PLASMA
DITENTUKAN OLEH

DUA VARIABEL

VARIABEL VARIABEL
INDEPENDEN DEPENDEN

Stewart PA. Can J Physiol Pharmacol 61:1444-1461, 1983.

INDEPENDENT VARIABLES DEPENDENT VARIABLES

Strong Ions
Difference

pCO2
pH

Protein
Concentration
VARIABEL INDEPENDEN

CO2 STRONG ION WEAK ACID

DIFFERENCE

pCO2 SID Atot

DEPENDENT VARIABLES

H+ HCO3-

OH- AH

CO3- A-
 CO2

CO2 Didalam plasma berada

dalam 4 bentuk Rx dominan dari CO2 adalah rx
sCO2 (terlarut) absorpsi OH- hasil disosiasi air
H2CO3 asam karbonat dengan melepas H+.
Semakin tinggi pCO2 semakin
HCO3- ion bikarbonat
CO32- ion karbonat
banyak H+ yang terbentuk.
Ini yg menjadi dasar dari terminologi
respiratory acidosis, yaitu
pelepasan ion hidrogen akibat
pCO2
 STRONG ION DIFFERENCE

Definisi:
Strong ion difference adalah ketidakseimbangan muatan
dari ion-ion kuat. Lebih rinci lagi, SID adalah jumlah
konsentrasi basa kation kuat dikurangi jumlah dari
konsentrasi asam anion kuat. Untuk definisi ini semua
konsentrasi ion-ion diekspresikan dalam ekuivalensi
(mEq/L).

Semua ion kuat akan terdisosiasi sempurna jika berada didalam

larutan, misalnya ion natrium (Na+), atau klorida (Cl-). Karena
selalu berdisosiasi ini maka ion-ion kuat tersebut tidak
berpartisipasi dalam reaksi-reaksi kimia. Perannya dalam kimia
asam basa hanya pada hubungan elektronetraliti.
 STRONG ION
DIFFERENCE
Gamblegram
Mg++
Ca++
K+ 4
SID

[Na+] + [K+] + [kation divalen] - [Cl-] - [asam organik kuat-]

Na+
140 Cl-
102

[Na+] + [K+] - [Cl-] = [SID]

140 mEq/L + 4 mEq/L - 102 mEq/L = 34 mEq/L

KATION ANION
SKETSA HUBUNGAN ANTARA SID,H+ DAN
OH-

[H+] [OH-]
Konsentrasi [H+]

Asidosis Alkalosis

() SID (+)

Dalam cairan biologis (plasma) dgn suhu 370C, SID hampir

selalu positif, biasanya berkisar 30-40 mEq/Liter
 WEAK ACID

[Protein H] [Protein-] + [H+]

disosiasi

Kombinasi protein dan posfat disebut asam

lemah total (total weak acid) [Atot].
Reaksi disosiasinya adalah:

[Atot] (KA) = [A-].[H+]

Gamblegram
Mg++
Ca++
K+ 4 HCO3-
24 SID
Weak acid
(Alb-,P-)

Na+
140
Cl-
102

KATION ANION
 APLIKASI

H3O+ = H+ = 40 mEq/L
K
Mg HCO3- SID
Ca HCO3 = 24 SID n
HCO3
Alb
-
SID
P
Alb
Laktat/keto=UA
P
Alb
Na P
140 Keto/laktat
Asidosis
hiperkloremi
asidosis
Cl
CL
Cl
115
95
102
Alkalosis
hipokloremi

KATION ANION
KLASIFIKASI GANGGUAN
KESEIMBANGAN ASAM BASA
BERDASARKAN PRINSIP STEWART

Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic acid-base disturbances in

critically ill patients. Am J Respir Crit Care Med 2000 Dec;162(6):2246-51
KLASIFIKASI
ASIDOSIS ALKALOSIS
I. Respiratori PCO2 PCO2

II. Nonrespiratori (metabolik)

1. Gangguan pd SID

a. Kelebihan / kekurangan air [Na+], SID [Na+], SID

b. Ketidakseimbangan anion
kuat:
i. Kelebihan / kekurangan Cl- [Cl-], SID [Cl-], SID

ii. Ada anion tak terukur [UA-], SID

2. Gangguan pd asam lemah

i. Kadar albumin [Alb] [Alb]

ii. Kadar posphate [Pi] [Pi]

Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic acid-base disturbances in

critically ill patients. Am J Respir Crit Care Med 2000 Dec;162(6):2246-51
 RESPIRASI M E T AB O L I K

Abnormal Abnormal Abnormal

pCO2 SID Weak acid

Alb PO4-
AIR Anion kuat

Cl- UA-

Alkalosis Turun kekurangan Hipo Turun

Asidosis Meningkat kelebihan Hiper Positif meningkat

Fencl V, Am J Respir Crit Care Med 2000 Dec;162(6):2246-51

KEKURANGAN AIR - WATER DEFICIT
Diuretic
Diabetes Insipidus
Evaporasi

Plasma Plasma

Na+ = 140 mEq/L

Cl- = 102 mEq/L
140/1/2 = 280 mEq/L
SID = 38 mEq/L
102/1/2 = 204 mEq/L
1 liter liter
SID = 76 mEq/L

SID : 38 76 = alkalosis

ALKALOSIS KONTRAKSI
KELEBIHAN AIR - WATER EXCESS

Plasma

1 Liter 140/2 = 70 mEq/L

Na+ = 140 mEq/L H2O 102/2 = 51 mEq/L
Cl- = 102 mEq/L SID = 19 mEq/L
SID = 38 mEq/L 1 liter 2 liter

SID : 38 19 = Acidosis

ASIDOSIS DILUSI
GANGGUAN PD SID:
Pengurangan Cl-

Plasma

Na+ = 140 mEq/L

Cl- = 95 mEq/L
SID = 45 mEq/L 2 liter

SID ALKALOSIS

ALKALOSIS HIPOKLOREMIK
GANGGUAN PD SID:
Penambahan/akumulasi
Cl-

Plasma

Na+ = 140 mEq/L

Cl- = 120 mEq/L
SID = 20 mEq/L 2 liter

SID ASIDOSIS

ASIDOSIS HIPERKLOREMIK
PLASMA + NaCl 0.9%

Plasma NaCl 0.9%

Na+ = 140 mEq/L Na+ = 154 mEq/L

Cl- = 102 mEq/L Cl- = 154 mEq/L
SID = 38 mEq/L 1 liter SID = 0 mEq/L 1 liter

SID : 38
ASIDOSIS HIPERKLOREMIK AKIBAT
PEMBERIAN LARUTAN Na Cl 0.9%

Plasma

= Na+ = (140+154)/2 mEq/L= 147 mEq/L

Cl- = (102+ 154)/2 mEq/L= 128 mEq/L

SID = 19 mEq/L 2 liter

SID : 19 Asidosis
PLASMA + Larutan RINGER LACTATE

Plasma Ringer laktat

Laktat cepat
dimetabolisme
Cation+ = 137 mEq/L
Na = 140 mEq/L
+
Cl- = 109 mEq/L
Cl- = 102 mEq/L Laktat- = 28 mEq/L
SID= 38 mEq/L 1 liter 1 liter
SID = 0 mEq/L

SID : 38
Normal pH setelah pemberian
RINGER LACTATE

Plasma

= Na+ = (140+137)/2 mEq/L= 139 mEq/L

Cl- = (102+ 109)/2 mEq/L = 105 mEq/L
Laktat- (termetabolisme) = 0 mEq/L 2 liter
SID = 34 mEq/L

SID : 34 lebih alkalosis dibanding jika diberikan

NaCl 0.9%
 MEKANISME PEMBERIAN NA-
BIKARBONAT PADA ASIDOSIS

Plasma;
asidosis Plasma + NaHCO3
hiperkloremik

25 mEq
NaHCO3 HCO3 cepat
Na+ = 140 mEq/L Na = 165 mEq/L dimetabolisme
+

Cl- = 130 mEq/L Cl- = 130 mEq/L

SID =10 mEq/L 1 liter 1.025 SID = 35 mEq/L
liter

SID : 10 35 : Alkalosis, pH kembali normal namun mekanismenya

bukan karena pemberian HCO3- melainkan karena pemberian Na+ tanpa anion kuat
yg tidak dimetabolisme seperti Cl- sehingga SID alkalosis
UA = Unmeasured Anion:
Laktat, acetoacetate, salisilat,
metanol dll.

K K HCO3- SID
HCO3- SID
Keto-

A A-
-
Na+ Na+

Cl- Cl-
Lactic/Keto asidosis

Normal Ketosis
GANGGUAN PD ASAM LEMAH:
Hipo/Hiperalbumin- atau P-

K K K
HCO3 SID
HCO3 SID HCO3 SID
Alb-/P-
Alb-/P- Alb/P

Na Na Asidosis Na Alkalosis
hiperprotein/ hipoalbumin
Cl hiperposfatemi
Cl Cl /hipoposfate
mi

Normal Acidosis Alkalosis

 Anion Gap
Described by Gamble in 1939
Electroneutrality
Na+, Cl-, and HCO3 are measured ions

Na + UC = Cl + HCO3 + UA

UC = Sum of unmeasured cations

UA = Sum of unmeasured anions
 Anion Gap
Unmeasured Cations: Unmeasured Anions:
total 11 mEq/L total 23 mEq/L
Potassium 4 Sulfates 1
Calcium 5 Phosphates 2
Magnesium 2 Albumin 16
Lactic acid 1
Org. acids 3
 Anion Gap

Na + UC = Cl + HCO3 + UA
140 + 11 = 104 + 24 + 23
151 = 151

UA UC = Na - (Cl + HCO3);
Anion Gap = Na - (Cl + HCO3)
 If the anion gap is elevated
Then compare the changes from normal between
the anion gap and [HCO3 -].
If the change in the anion gap is greater than the
change in the [HCO3 -] from normal, then a
metabolic alkalosis is present in addition to a gap
metabolic acidosis.
If the change in the anion gap is less than the
change in the [HCO3 -] from normal, then a non
gap metabolic acidosis is present in addition to a
gap metabolic acidosis.
 Anion Gap Acidosis:
Anion gap >12 mEq/L; caused by a
decrease in [HCO3 -]
balanced by an increase in an
unmeasured acid ion from either
endogenous production or exogenous
ingestion (normochloremic acidosis).
 Non anion Gap Acidosis:

Anion gap = 8-12 mmol/L; caused by a

decrease in [HCO3 -] balanced by an
increase in chloride (hyperchloremic
acidosis). Renal tubular acidosis is a type
of non gap acidosis
 Increased Anion Gap
Normal = 8-15
May differ institutionally

Accumulation of organic acids (ketones,

lactate)
Toxic Ingestions
methanol, ethylene glycol, salicylates
Reduced inorganic acid excretion
phosphates, sulfates
Decrease in unmeasured cations
(unusual)
 Increased AG Metabolic Acidosis:
Methanol Lactic Acidosis
Uremia/Renal Has many etiologies
Cyanide, CO, Toluene,
Failure
HS
INH, Iron--lactate Poor perfusion
Paraldehyde Ethylene glycol
Salicylates
Methyl salicylate
(Oil of wintergreen)
Mg salicylate

Levraut J et al. Int Care

Med 23:417, 1997
 Increased Anion Gap
Normal = 8-15
May differ institutionally
ion specific electrodes

Accumulation of organic acids (ketones,

lactate)
Toxic Ingestions
methanol, ethylene glycol, salicylates
Reduced inorganic acid excretion
phosphates, sulfates
Decrease in unmeasured cations (unusual)
Decreased or Negative Anion Gap
Clin J Am Soc Nephrol 2: 162-174, 2007

Low protein most important

Albumin has many unmeasured negative
charges
Normal anion gap (12) in cachectic person
Indicates anion gap metabolic acidosis
Other etiologies of low AG:
Low K, Mg, Ca, increased globulins (Mult.
Myeloma), I intoxication
Negative AG
more unmeasured cations than unmeasured
anions
Bromide, Iodide, Multiple Myeloma
44
Change in Anion Gap vs HCO3
In simple AG Metabolic Acidosis
decrease in plasma bicarbonate = increase in
AG

Anion Gap = 1
HCO3

Helpful in identifying mixed disorders

Respiratory Compensation
for

Metabolic Acidosis: Metabolic Alkalosis:

Occurs rapidly Calculation not as
Hyperventilation accurate
Kussmaul Respirations Hypoventilation
Deep > rapid (high tidal Not Respiratory
volume) Acidosis
Is not Respiratory Alkalosis
Restricted by
hypoxemia
PCO2 seldom > 50-55
Reference
1. Achmadi, A., George, YWH., Mustafa, I. Pendekatan Stewart
Dalam Fisiologi Keseimbangan Asam Basa. 2007
2. Beaudoin, D. Electrolytes and ion sensitive electrodes. PPT.
2003.
3. Ivkovic, A ., Dave, R. Renal review. PPT
4. Kersten. Fluid and electrolytes. PPT.
5. Marieb, EN. Fluid, electrolyte, and acid-base balance. PPT.
Pearson Education, Inc. 2004
6. Rashid, FA. Respiratory mechanism in acid-base homeostasis.
PPT. 2005.
7. Silverthorn, DU. Integrative Physiology II: Fluid and Electrolyte
Balance. Chapter 20, part B. Pearson Education, Inc. 2004
8. Smith, SW. Acid-Base Disorders. www.acid-base.com

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