ACID BASE BALANCE

OR
Homeostasis of Blood pH
OR
Regulation of Blood pH

Dr Anissa Atif Mirza

 Synopsis
• Introduction
• Sources of Acids and Bases in body
• What is Acid Base Balance?
• Mechanisms Regulating Blood pH.
• Significance of Maintaining Acid Base
Balance
• Acid Base Imbalance and their conditions.
• Diagnostic Tests
 Introduction

• Acid Base Balance is a

physiological and
biochemical mechanism
associated to body/blood
pH.
 What Is pH?
• pH is a Hydrogen ion concentration.
• pH = - log [H+]
• Different compartment of human
body has specific pH.
• pH has role in Enzyme activity.
Why blood pH is Altered?
• Addition of various
acids or alkalies by
metabolic activities
alters body/blood pH.
 Sources and Types
of
Acids and Alkalies
Added During
Metabolic Life Processes
•Acids are H
+

donors.
•Bases are H +

acceptors, or give
up OH in solution.
-
8
Acids and Bases can be strong or weak:

• A strong acid or base is one that dissociates

completely in a solution
- HCl, NaOH, and H2SO4

• A weak acid or base is one that dissociates

partially in a solution
-H2CO3, C3H6O3, and CH2O, Lactate.
• Acidic Substances of body:
– Carbonic acid(H2CO3)
– Phosphoric acid( H3PO4)
– Sulphuric acid (H2SO4)
• Organic Acids:
– Lactate, Acetoactate, Pyruvate
• Alkaline Substances of body:
– Citrate
– Bicarbonates.
What is Acid Base Balance?
Homeostatic Mechanisms
That
Regulate Blood/Body pH
• Acid Base balance is a
homeostatic mechanism
• Carried out to regulate the
altered pH of blood and other
body compartments to its normal
constant range.
• Maintenance of Acid
Base balance
• Is a prime requisite to
maintain normal
healthy and active life.
 Acid-Base Balance
• It is the regulation of HYDROGEN ions.

(The more Hydrogen ions, the more acidic the solution and the
LOWER the pH)

– The acidity or alkalinity of a solution is measured as

pH
 Acid Base Balance Regulates pH

Why it is Very Essential To Regulate

pH?
• pH of blood and other body
compartments are precisely
regulated.
• pH is always tried to be
maintained to its normal constant
range.
• Acid Base Balance
maintains the blood pH at
normal constant narrow
range of 7.35-7.45.
• pH of the medium directly
affects the enzyme activities
• Optimum pH is an essential
requisite for enzyme activities
and normal metabolism.
• It is prerequisite for
regulating blood/body pH:
• To maintain normal/optimal
Enzyme activities
• Normal metabolism
• Normal Coordination
• Normal Health
Factors Regulating
Acid Base Balance

22
Acid Base Balance is Regulated By

• First Line of Defense

Blood Buffer System
• Second Line of Defense
–Respiratory Mechanism
• Third Line of Defense
Renal Mechanism
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)

24
 Role of Blood Buffer System

• First line of defense in

mechanism of Acid Base
Balance.
• Acids (H+) added are
neutralized by the salt part of
buffer.
 Extracellular Buffers
• Bicarbonate Buffer
–NaHCO3/H2CO3 (20:1 at 7.4 pH)
• Phosphate Buffer
–Na2HPO4/NaH2PO4 (4:1 at 7.4 pH)
• Protein Buffer
–Na-Protein/H-Protein
 Intracellular Buffers
• Bicarbonate Buffer
–KHCO3/H2CO3
• Phosphate Buffer
–K2HPO4/KH2PO4
• Protein Buffer
–K-Hb/H-Protein
 Mechanism Action of Buffer Systems

• Buffers mixture of weak acids

and its salts
• Resist change in pH of blood
when small amount of acids or
alkalis added to the medium.
• Buffers act quickly but not
permanently
 Bicarbonate Buffer System
Respiratory Buffer System
• Acid - Base balance is primarily concerned
with Bicarbonate Buffer mechanism :
– H2CO3/ Hydrogen (H+)
– Bicarbonate (HCO3- ) (Alkali Reserve)

H +
HCO3 -
30
 Bicarbonate Buffer
• Bicarbonate Buffer- Chief Buffer
system of Blood.
• NaHCO3 the salt part of buffer
neutralizes the strong and non
volatile acids added to blood.
• It constitutes Alkali reserve(HCO3-)
 Bicarbonate Buffer
• Sodium Bicarbonate (NaHCO3) and carbonic
acid (H2CO3)
• Maintain a 20:1 ratio : HCO3- : H2CO3

HCl + NaHCO3 ↔ H2CO3 + NaCl

NaOH + H2CO3 ↔ NaHCO3 + H2O

33
• Action of Bicarbonate
(NaHCO3) converts strong
dissociable acid into weak
non dissociable acid
(H2CO3) and a neutral salt
without altering the pH.
• Weak acid H2CO3 formed during
buffering action of Bicarbonate buffer
is then expired out by Lungs.

• Thus Bicarbonate buffer is connected

to the respiratory system

• Bicarbonate buffer is also termed as

Respiratory buffer.
• Alkali reserve is represented by the
concentration of NaHCO3 in the blood.

• Alkali reserve concentration(HCO3-)

determines the strength of buffering action
towards added H+ ions by acids.

• More the concentration of Alkali reserve

,more is the buffering action and vice a versa.
• The blood buffers are effective
as long as
• The acid load added is not very
high and
• The alkali reserve (HCO3 -) is not
exhausted.
 Phosphate Buffer/Urine Buffer

Na2HPO4/NaH2PO4 (4:1 at 7.4

pH)

• H+ + HPO42- ↔ H2PO4-

• OH- + H2PO4- ↔ H2O + H2PO42-

38
 Phosphate Buffer Mechanism
• When H+ ions added they are
neutralized/fixed by Na2HPO4
(Alkaline Phosphate) and converted
to NaH2PO4 (Acid Phosphates).
• These acid phosphates then
excreted out through kidneys as
acidic urine.
• Thus Phosphate Buffer is connected to
Excretory system .

• Phosphate Buffer also termed as

Urine Buffer.
• When an alkali enters it is
buffered by the acid phosphate
NaH2PO4 which converted to
Na2HPO4 alkaline phosphate.
• Excreted in urine making it
alkaline urine.
 Protein Buffers
• Includes hemoglobin, work in blood.
• Carboxyl group gives up H+
• Amino Group accepts H+
• The Imidazole group of Histidine
present in Hb structure has buffering
capacity.
42
 Role of Respiratory Mechanisms

• Respiratory system plays

second line of defense
mechanism of Acid Base
Balance.
• Role of respiration in acid base
balance is short term
regulatory process.
• H2CO3 formed from Bicarbonate Buffer, is
exhaled out through respiratory system.

• Increased H2CO3 stimulates the respiratory

centre in Medulla Oblongata.

• This in turn stimulates hyperventilation

which promptly removes H2CO3 from blood
by expiration.
• Exhalation of H2CO3 is as carbon dioxide
by activity of enzyme Carbonic Anhydrase
of Lungs.

• H+ + HCO3- ↔ H2CO3 ↔ CO2 + H20

• Respiratory mechanism is
powerful, but only works with
volatile acids.
• Doesn’t affect fixed acids like
lactic acid.
• Blood pH can be adjusted
through respiratory
mechanism
• By changing rate and depth
of breathing.
• Low H2CO3 concentration in
blood depresses respiratory
centre ,causes hypoventilation
i.e slow and shallow
respiration.
• This retains H2CO3 in blood.
•If Nervous centre /
Respiratory system
fails.
•Acid Base Balance
fails.
 Generation of bicarbonate by RBC

LACK OF AEROBIC ACTIVITY,DIFFUSION OF CARBONDIOXIDE,H+ BUFFERED BY HHb.

50
 Events in lungs and tissue

lung tissue

HCO3- HCO3-

HHb HHb

O2
O2

H+ H+
H2CO3 HbO2 HbO2 H2CO3
H 2O CO2
CO2 H2O
Isohydric transport
EXPIRED AIR of co2 METABOLISM
51
 Role of Renal Mechanism

• Renal mechanism is the third

line of defense mechanism.
• Role of renal mechanism is
long term regulatory process.

52
• The acid and alkaline phosphates
formed during phosphate buffering
mechanism are filtered from blood
and excreted out through urine.

• Thus the phosphate buffer system is

directly connected to renal
mechanism.
• Renal mechanism conserve and
produce Bicarbonate ions ( Alkali
reserve).

• Renal Mechanism is the most

effective regulator of blood pH.

• If kidneys fail, pH balance fails.

• Renal System maintains Acid Base Balance through:

–Reabsorption of Bicarbonate (HCO3-) ions.

–Excretion of H+ ions

–Excretion of titrable acids(Acid Phosphates)

–Excretion of Ammonium ions

(Glutaminase activity)
 REABSORPTION OF BICARBONATE

~Conservation of Bicarbonate
~Urine is free of HCO3-
~Simultaneous excretion of H+

56
 EXCRETION OF TITRABLE ACIDS

~measure of acid excreated by kidney

~no. of millilitres of N/10 NaOH required to titrate 1 litre of urine to pH 7.4
~role of phosphate buffer

57
 Excretion Of H+ ions

~Elimination of nonvolatile acid

~Excretion of H+
~Occurs in PCT
~Regeneration of bicarbonate
~H+ combine with non carbonate base and excreated 58
 EXCRETION OF AMMONIUM ION

NH3 is obtained from Deamination of Glutamine

NH4+ cant diffuse back
2/3 of body acid load liberated in the form of NH4+

59
 Rates of correction
• Buffers function almost
instantaneously
• Respiratory mechanisms take
several minutes to hours
• Renal mechanisms may take
several hours to days
60
62
63
 MECHANISM FOR REGULATION OF ACID BASE BALANCE

• Buffer system: temporary solution

• Respiratory mechanism provide short time regulation
• Renal mechanism : permanent solution
• Urine pH < plasma pH ,4.5-9.5
• Eliminate nonvolatile acid, buffered by cation
(principally Na+)
• Maintain alkali reserve
 Acid Base Imbalance
OR
Conditions Of Acid Base
Disturbances
 The Body and pH
• Homeostasis of blood pH is tightly
controlled by mechanisms of Acid
Base Balance.
• Extracellular fluid = 7.4
• Blood pH regulated to = 7.35 – 7.45

66
 Occurrence of Acid Base Imbalance

• When Factors involved in

homeostatic mechanisms to
regulate Acid Base Balance fails to
work efficiently.
• Does not maintain the altered pH
of blood to normal constant range.
• Results into Acid Base Imbalance.
 ACIDOSIS / ALKALOSIS

• Two major disturbances

in Acid-Base balance
–Acidosis
–Alkalosis
Conditions Of Acid Base Imbalance

• Acidosis /Acidemia
( Decreased pH/Increased H+ ions)

• Alkalosis/Alkalemia
(Increased pH/Decreased H+ ions)
• Acidosis (Acidemia) below 7.35
• Alkalosis (Alkalemia) above 7.45
• Blood pH < 6.8 or > 8.0 death
occurs
 ACIDOSIS / ALKALOSIS
• Acidosis
–A condition in which the blood has too much acid (or too little base),
frequently resulting in a decrease in blood pH.

• Alkalosis
–A condition in which the blood has too much base (or too
little acid), occasionally resulting in an increase in blood pH.

71
72
74
 Effect of Altered pH
• Altered pH may
seriously disturbs the
vital processes.
• Might lead to fatality.
• Most enzymes function only
with narrow pH ranges.
• Extremes of pH affects the
enzymatic action by
protonation or deprotonation
at the active sites of Enzymes.
• Makes Enzymes inactive.
• Inactivated Enzymes affect
metabolic reactions and
metabolic pathways.
• Metabolism gets deranged .
• Leads to metabolic syndromes.
pH also affect excitability of
Nerve and Muscle cells

pH Excitability

pH Excitability
78
 ACID-BASE REGULATION
• Enzymes, Hormones and ion distribution
are all affected by Hydrogen ion
concentrations

79
 ACIDOSIS / ALKALOSIS
• pH changes have dramatic effects on normal cell
function
1) Changes in excitability of nerve and muscle
cells
2) Influences Enzyme activity
3) Influences K+ levels/Retention of K+

80
 CHANGES IN CELL EXCITABILITY
• pH decrease (more acidic) depresses the
central nervous system
– Can lead to loss of consciousness
• pH increase (more basic)causes over
excitability of nervous system.
– Tingling sensations, nervousness, muscle
twitches
 INFLUENCES ON ENZYME ACTIVITY
• pH increases or decreases can alter the shape of
the enzyme rendering it non-functional
• Changes in enzyme structure can result in
accelerated or depressed metabolic actions
within the cell

82
 INFLUENCES ON K LEVELS +

• If H+ concentrations are high (acidosis) than H+ is

secreted in greater amounts
• This leaves less K+ than usual excreted.
• The resultant K+ retention can affect cardiac
function and other systems

K+
Na+

H+

83
 Small changes in pH can produce major
disturbances

• Acid-base balance can also

affect Electrolytes (Na+, K+, Cl-)
• Can also affect Hormones

84
 ACID-BASE IMBALANCE
• Derangements of
• Hydrogen/Carbonic
acid (H+/H2CO3)
• Bicarbonate
(HCO3-)
concentrations
In body fluids are
common in
conditions of Acid
Base Imbalance
 Acid-Base Imbalances

• pH< 7.35 Acidosis

• pH > 7.45 Alkalosis
4 Types of Primary Acid-Base Disorders
Acid Base Imbalances Biochemical
Change
Respiratory Acidosis Increased H2CO3
 PCO2
Respiratory Alkalosis Decreased H2CO3
 PCO2
Metabolic Acidosis
  HCO 

3

Metabolic Alkalosis
  HCO3  87
RESPIRATORY ACIDOSIS

90
 Respiratory Acidosis

• Primary Carbonic acid excess

• Increased H2CO3/Increased pCO2
• Defect in respiratory centre of brain
• Defect in respiratory organ system
• Decreased elimination of H2CO3 by
the lungs.
• Hypoventilation
• Increased blood levels of
CO2 above 45 mm Hg.
• Hypercapnia – high levels
of pCO2 in blood

92
 RESPIRATORY ACIDOSIS
• Respiratory acidosis
develops when the lungs
don't expel CO2
adequately.
• This can happen in
diseases that severely
affect the lungs.

93
• Chronic conditions:
– Depression of respiratory center in brain that
controls breathing rate – drugs or head trauma
– Paralysis of respiratory or chest muscles
– Emphysema
– Asthma
– Pneumonia
– Pulmonary edema
– Obstruction of respiratory tract
– Congestive Cardiac Failure
 HYPOVENTILATION
Causes Respiratory Acidosis
• Hypo = “Under”

Elimination of CO2

H +

pH
 RESPIRATORY ACIDOSIS

CO2 CO2
-
HCO 3 CO2
CO2

H 2CO 3

2 : 20

-breathing is suppressed holding CO2 in body

-pH = 7.1
96
 RESPIRATORY ACIDOSIS
• 1) Obstruction of air passages
– Vomit, Anaphylaxis, Tracheal Cancer

97
 RESPIRATORY ACIDOSIS
• 2) Decreased Respiration
– Shallow, slow breathing
– Depression of the respiratory centers in the brain
which control breathing rates
• Drug overdose

98
 RESPIRATORY ACIDOSIS
• 4) Collapse of lung
– Compression injury, open thoracic wound

Left lung
collapsed

99
 Respiratory Acidosis
• Acute conditions:
–Adult Respiratory Distress
Syndrome
–Pulmonary edema
–Pneumothorax

100
Compensation for Respiratory Acidosis

• Kidneys eliminate
hydrogen ion and retain
bicarbonate ions.

101
Signs and Symptoms of Respiratory Acidosis
• Breathlessness
• Restlessness
• Lethargy and disorientation
• Tremors, convulsions, coma
• Respiratory rate rapid, then gradually
depressed
• Skin warm and flushed due to vasodilation
caused by excess CO2

102
 Treatment of Respiratory Acidosis

• Restore ventilation
• IV lactate solution
• Treat underlying
dysfunction or disease

103
RESPIRATORY ALKALOSIS

104
 Respiratory Alkalosis
• Primary Carbonic acid deficit
• Decreased H2CO3
• pCO2 less than 35 mm Hg (hypocapnea)
• Most common acid-base imbalance
• Primary cause is hyperventilation
• Washes out excessive quantity of H2CO3
through expiration process of lungs.

105
• Stimulation of respiratory
centre in brain
• Hyperventilation
 Respiratory Alkalosis
• Conditions that stimulate respiratory center:
– Oxygen deficiency at high altitudes
– Pulmonary disease and Congestive heart failure –
caused by hypoxia
– Respiratory center lesions
– Acute anxiety
– Fever, anemia
– Early salicylate intoxication
– Cirrhosis
– Gram-negative sepsis/Meningitis
107
 RESPIRATORY ALKALOSIS
• Anxiety is an
emotional disturbance
• The most common
cause of
hyperventilation, and
thus respiratory
alkalosis, is noted in
anxiety
108
 RESPIRATORY ALKALOSIS
• Respiratory center lesions
– Damage to brain
centers responsible for
monitoring breathing
rates
• Tumors
• Strokes

109
 RESPIRATORY ALKALOSIS
• High Altitude
– Low concentrations of O2 in the arterial blood
reflexly stimulates ventilation in an attempt to
obtain more O2
– Too much CO2 is “blown off” in the process

110
 RESPIRATORY ALKALOSIS
• Fever
– Rapid shallow breathing
blows off too much CO2

111
 RESPIRATORY ALKALOSIS
• Salicylate poisoning
(Aspirin overdose)
– Ventilation is stimulated
without regard to the status
of O2, CO2 or H+ in the body
fluids

112
 RESPIRATORY ALKALOSIS
• Kidneys compensate by:
– Retaining hydrogen ions
– Increasing bicarbonate excretion
HCO3-
HCO3-
H+
H+
HCO3- HCO3-
H+
H+ H+
HCO3-
HCO3- H+
HCO3-
H+
HCO3- H+
HCO 3
-
H+
HCO3- H
+

H+ 113
 HYPERVENTILATION
Causes Respiratory Alkalosis
• Hyper = “Over”

Elimination of CO2

H +

pH 114
 Compensation of Respiratory Alkalosis

• If kidneys are functioning normal

• The conditions of respiratory
acidosis or alkalosis are
compensated.
• Kidneys conserve hydrogen ion
• Excrete bicarbonate ion
115
 Treatment of Respiratory Alkalosis

• Treat underlying cause

• Breathe into a paper bag
• IV Chloride containing solution
Cl- ions replace lost
bicarbonate ions
116
METABOLIC ACIDOSIS

117
 Metabolic Acidosis
• Primary Alkali deficit
• Bicarbonate deficit - blood concentrations of
bicarbonate drop below 22mEq/L
• Causes:
– Loss of bicarbonate through diarrhea or renal
dysfunction.
– Overproduction production of acids (lactic acid or
ketones)
– Failure of kidneys to excrete H+
118
 METABOLIC ACIDOSIS
• Occurs when there is a decrease in the normal
20:1 ratio
– Decrease in blood pH and bicarbonate level
• Excessive H+ or decreased HCO3-

-
H2CO3 HCO 3 3-
HCO
H 2CO 3

== 7.4
7.4
1 : 10
20 119
 METABOLIC ACIDOSIS
• Any acid-base imbalance
not attributable to CO2 is
classified as metabolic
– Metabolic production of
Acids
– Or loss of Bases

120
 METABOLIC ACIDOSIS
• The causes of metabolic acidosis can be grouped
into five major categories
– 1) Ingesting an acid or a substance that is
metabolized to acid
– 2) Abnormal Metabolism
– 3) Kidney Insufficiencies
– 4) Strenuous Exercise
– 5) Severe Diarrhea

121
 METABOLIC ACIDOSIS
• 1) Ingesting An Acid
– Most substances that cause acidosis when
ingested are considered poisonous
– Examples include
wood alcohol
(methanol) and
antifreeze
(ethylene glycol)
– However, even an overdose
of aspirin (acetylsalicylic acid)
can cause metabolic acidosis
122
 METABOLIC ACIDOSIS
• 2) Abnormal Metabolism
– The body can produce excess acid as a result of several
diseases
• Ketoacidosis
• Type I Diabetes Mellitus
• Uncontrolled Diabetes mellitus
• Prolonged Starvation
• Lacticacidosis
• Shock
• Haemorrhage
• Violent Exercise-
 METABOLIC ACIDOSIS
• Unregulated diabetes
mellitus causes
ketoacidosis
– Body metabolizes fat
rather than glucose
– Accumulations of
metabolic acids (Keto
Acids) cause an
increase in plasma H+

124
 METABOLIC ACIDOSIS

• 3) Kidney Insufficiencies
– This type of kidney malfunction is called renal
tubular acidosis or uremic acidosis and may
occur in people with kidney failure or with
abnormalities that affect the kidneys' ability
to excrete acid
 METABOLIC ACIDOSIS
• 3) Kidney Insufficiencies
– Kidneys may be unable to rid
the plasma of even the
normal amounts of H+
generated from metabolic
acids
– Kidneys may be also unable to
conserve an adequate
amount of HCO3- to buffer the
normal acid load

126
 METABOLIC ACIDOSIS
• 4) Strenuous Exercise
– Muscles resort to anaerobic glycolysis during
strenuous exercise
– Anaerobic respiration leads to the production
of large amounts of lactic acid

Enzymes
C6H12O6 2C3H6O3 + ATP (energy)
Lactic Acid

127
 METABOLIC ACIDOSIS

• 5) Severe Diarrhea
– Fluids rich in HCO3- are released and reabsorbed
during the digestive process
– During diarrhea this HCO3- is lost from the body
rather than reabsorbed
 METABOLIC ACIDOSIS

• 5) Severe Diarrhea
– The loss of HCO3- without a corresponding loss of
H+ lowers the pH
– Less HCO3- is available for buffering H+
– Prolonged deep (from duodenum) vomiting can
result in the same situation
 Symptoms of Metabolic Acidosis

• Headache, lethargy
• Nausea, vomiting, diarrhea
• Coma
• Death

130
Compensation for Metabolic Acidosis

• Increased ventilation.
• Renal excretion of hydrogen ions
if possible.
• K+ exchanges with excess H+ in
ECF.
• H+ into cells, K+ out of cells.
131
 Treatment of Metabolic Acidosis
• IV lactate solution

132
METABOLIC ALKALOSIS

133
 Metabolic Alkalosis
• Bicarbonate Excess - concentration in blood is
greater than 26 mEq/L
• Causes:
– Excess vomiting = loss of stomach acid
– Excessive use of alkaline drugs
– Certain diuretics
– Endocrine disorders
– Heavy ingestion of antacids
– Severe dehydration
– Cushings Syndrome
– Prolonged exposure to x rays and UV rays
134
 METABOLIC ALKALOSIS
• Elevation of pH due to an increased 20:1 ratio
– May be caused by:
• An increase of bicarbonate
• A decrease in hydrogen ions
– Imbalance again cannot be due to CO2
– Increase in pH which has a non-respiratory
origin

7.4 135
 METABOLIC ALKALOSIS
• Can be the result of:
– 1) Ingestion of Alkaline Substances
– 2) Vomiting ( loss of HCl )

136
 METABOLIC ALKALOSIS
• Baking soda (NaHCO3) often used as a remedy
for gastric hyperacidity
– NaHCO3 dissociates to Na+ and HCO3-

137
Compensation for Metabolic Alkalosis

• Alkalosis most commonly occurs

with renal dysfunction, so can’t
count on kidneys.
• Respiratory compensation
difficult – hypoventilation limited
by hypoxia.
138
 Symptoms of Metabolic Alkalosis

• Respiration slow and shallow

• Hyperactive reflexes ; tetany
• Often related to depletion of
electrolytes
• Atrial tachycardia
• Dysrhythmias
139
 Treatment of Metabolic Alkalosis

• Electrolytes to replace
those lost
• IV chloride containing
solution
• Treat underlying disorder
140
 Acidosis
• Principal effect of acidosis is depression of the CNS through ↓ in
synaptic transmission.

• Generalized weakness

• Deranged CNS function the greatest threat

• Severe acidosis causes

– Disorientation
– Coma
– Death

141
 Alkalosis
• Alkalosis causes over excitability of the central and
peripheral nervous systems.
• Numbness
• Light headedness
• Severe Alkalosis causes :
– Nervousness
– muscle spasms or Tetany
– Convulsions
– Loss of consciousness
– Death

142
 Compensation Of
Acid Base Imbalance

• The body response to acid-base imbalance is

called compensation
• May be complete compensation if altered pH
brought back within normal limits
• Partial compensation if pH range is still
outside norms.
• Uncompensated if pH range is very out from
norms.
• If underlying problem is respiratory, renal
mechanisms can bring about metabolic
compensation.

• If underlying problem is metabolic,

hyperventilation or hypoventilation can help :
respiratory compensation.
 ACIDOSIS

decreased failure of metabolic production absorption of prolonged

removal of kidneys to acid of keto acids metabolic acids diarrhea
CO2 from excrete from GI tract
lungs acids

accumulation accumulation excessive loss

of CO2 in blood of acid in blood of NaHCO3
from blood

deep
vomiting
from
respiratory metabolic GI tract
increase in
acidosis plasma H+ acidosis
concentration kidney
disease
(uremia)
depression of
nervous system 145
 ALKALOSIS
anxiety overdose high prolonged ingestion of excess
of certain altitudes vomiting excessive aldosterone
drugs alkaline drugs

hyperventilation loss of acid accumulation

loss of CO2 and of base
H2CO2 from
blood

respiratory metabolic
alkalosis alkalosis
decrease
in plasma H+
concentration

overexcitability
of nervous
system 146
 Organ dysfunction
And
Acid Base Imbalance

• CNS – respiratory acidosis (suppression) and alkalosis

(stimulation)
• Pulmonary – respiratory acidosis (COPD) and alkalosis
(hypoxia, pulmonary embolism)
• Cardiac – respiratory alkalosis, respiratory acidosis,
metabolic acidosis (pulmonary edema)
• GIT – metabolic alkalosis (vomiting) and acidosis
(diarrhea)
• Liver – respiratory alkalosis, metabolic acidosis (liver
failure)
• Kidney – metabolic acidosis (RTA) and alkalosis (1st
Aldosterone)
 Organ Dysfunction
• Endocrine
– Diabetes mellitus – metabolic acidosis
– Addisons Disease/Adrenal insufficiency – metabolic
acidosis.(Decreased H+ ions excretion)
– Cushing’s Syndrome – metabolic alkalosis
(Increased Cortisol- Increased H+ ions excretion)
– Primary aldosteronism – metabolic alkalosis
• Drugs/toxins
– Toxic alcohols – metabolic acidosis
– ASA/Aspirin – metabolic acidosis and respiratory
alkalosis( Causes Hyperventilation)
– Theophylline overdose – respiratory alkalosis
 ACID – BASE DISORDERS
Clinical State Acid-Base Disorder
Pulmonary Embolus Respiratory Alkalosis

Cirrhosis Respiratory Alkalosis

Pregnancy Respiratory Alkalosis

Diuretic Use Metabolic Alkalosis

Vomiting Metabolic Alkalosis

Chronic Obstructive Pulmonary Disease Respiratory Acidosis

Shock Metabolic Acidosis

Severe Diarrhea Metabolic Acidosis

Renal Failure Metabolic Acidosis

Respiratory Alkalosis,
Sepsis (Bloodstream Infection)
Metabolic Acidosis 149
150
Anion Gap
• Sum of anion and cations is always equal
• Sodium and Potassium accounts for 95% of
cations
• Chloride and bicarbonate accounts for 68% of
anions
• There is difference between measured anion
and cation
• The unmeasured anions constitute the
ANION GAP.
• They are protein anions ,sulphates ,phosphates
and organic acid(Unmeasured Anions)
• AG can be calculated as (Na+ + K+)—(HCO3- + Cl-)
• High anion gap acidosis: renal failure, DM
• Normal anion gap acidosis: diarrhea
• Hyperchloremic acidosis
 Calculation Of Anion Gap
• Na ++ K+ = Cl- + HCO3 - + A-
• 136+ 4 = 100 + 25
• A- = 15 mEq/L
• Normal AG is typically 12 ± 4
mEq/L.
• If AG is calculated using K+, the
normal AG is 16 ± 4 mEq/L
Significance of Anion Gap Calculation

• Calculation of Anion gap

and its values help in
diagnosing conditions of
Acid Base Balance and
Imbalance.
• The anion gap is increased in conditions
such as metabolic acidosis:
• That result from elevated levels of
metabolic acids (metabolic acidosis)
–Lactic acidosis
–Diabetic Ketoacidosis
–Renal Failure
• A low anion gap occurs in conditions
that cause a fall in unmeasured
anions
• (primarily albumin) OR a rise in
unmeasured cations
 Calculate the Anion Gap

• 1. Calculate the anion gap as described.

• 2. An anion gap ,over 25 suggests a severe
metabolic acidosis.
• 3. Causes of an high anion gap: ethylene
glycol, lactic acid, methanol, paraldehyde,
aspirin, renal failure, ketoacidosis (diabetic or
ethanol).
 Anion Gap Acidosis:
• Anion gap >12 mmol/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).
Metabolic Acidosis and the Anion gap

1. Normal gap 2. Increased gap

1.  Acid 2.  Acid
1. Renal “HCO3” 2. GI “HCO3” prod elimination
losses losses

Lactate Renal disease

Proximal RTA DKA
Diarrhea Ketosis
Distal RTA
Toxins
Alcohols
Salicylates
Iron
 Henderson Hasselbalch Equation
• pH= pka +log [HCO3-]/[H2CO3]
• At pH 7.4 the ratio of HCO3-/H2CO3 is
1:20.
• A buffer is most effective when
pH=pKa
• When concentration of salt and acid
are equal.
 Significance of Henderson Hasselbalch
Equation

• The equation helps in

calculating pH of Buffers.
• The equation helps in
assessing status of Acid
Base balance.
 Stepwise Approaches
• 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
DIAGNOSTIC LAB VALUES
&
INTERPRETATION
• Arterial Blood
Gas(ABG )Analyzer
determines Acid Base
Balance and Imbalance.
 Diagnosis of Acid-Base Imbalances
1. Note whether the pH is low (acidosis) or
high (alkalosis)
2. Decide which value, pCO2 or HCO3- , is
outside the normal range
3. If the cause is a change in pCO2,/H2CO3 the
problem is respiratory.
4. If the change is in HCO3- the problem is
metabolic.
169
 Normal Arterial Blood Gas (ABG)
Lab Values:
• Arterial pH: 7.35 – 7.45
• HCO3-: 22 – 26 mEq/L
• PCO2: 35 – 45 mmHg
• TCO2: 23 – 27 mmol/L
• PO2: 80 – 100 mmHg
• Base Excess: -2 to +2
• Anion Gap: 12 – 14 mEq/L
 Example
• A patient is in intensive care because he
suffered a severe myocardial infarction 3 days
ago. The lab reports the following values from
an arterial blood sample:
– pH 7.3
– HCO3- = 20 mEq / L ( 22 - 26)
– pCO2 = 32 mm Hg (35 - 45)

171
 Diagnosis
• Metabolic acidosis
• With compensation

172
 Questions
• Long Essays.
• What is acid-base balance? Describe the homeostatic mechanism
by which the blood pH is regulated.
• Short Notes
• Blood Buffer System.
• Role of Kidney in acid-base balance.
• Hb as Buffer system.
• Acid-Base imbalance.
• Metabolic Acidosis.
• Difference between acidosis & alkalosis.
• Anion Gap.
 END

ACID - BASE BALANCE

THANKS

174
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