ACID-BASE BALANCE

Acid Base balance made simple.

pH

 Measure of acidity (excess hydrogen ions or H+)

ACIDIC - TOO MUCH ACID - Lower than 7.35 means that there is too much acid in your
system.
NORMAL - Just right! pH between 7.35 and 7.45 is perfect for homeostasis.
ALKALINE - NOT ENOUGH ACID - It just means NOT acidic enough.
pH higher than 7.45 is considered Alkaline.

Test yourself (answer on the space next to the question)

Your patient has a ph of 6.9 Is he acidic or alkalotic? _______________
Your patient has a ph of 7.4 Is he acidic or alkalotic? _______________
Your patient has a ph of 7.7 Is he acidic or alkalotic? _______________
Your patient has a ph of 7.25 Is he acidic or alkalotic? _______________
Your patient has a ph of 7.43 Is he acidic or alkalotic? _______________
Your patient has a ph of 8.0 Is he acidic or alkalotic? _______________

REALLY IMPORTANT

You take in oxygen by inhaling, your body turns oxygen into carbon dioxide, you exhale and
remove the carbon dioxide from your body.
Carbon dioxide is "respiratory acid." When you're not breathing adequately, you are not getting
rid of this "respiratory acid" and it builds up in the tissues. The extra CO2 molecules combine
with water in your body to form carbonic acid and makes your pH go up. This is bad.

How do we measure it?

We can measure the amount of respiratory acid in the arterial blood using blood gases. They
measure the amount of each gas in your blood. We measure the pH, the amount of carbon
dioxide (PaCO2) and the amount of oxygen in the blood (PaO2).

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PaCO2 is the partial pressure of carbon dioxide.

We can measure it to see how much respiratory acid (CO2) there is in the blood. We use arterial
blood gas tests to check it. How much respiratory acid (CO2) should there be? The normal value
is 35-45 mmHg (mmHg just means millimeters of mercury, its a measurement of pressure.) The
(a) in PaCO2 just stands for arterial. If you measured venous blood gasses, the levels are different
and PvCO2 is used. If CO2 is HIGH, it means there is a buildup of respiratory acids because he's
not breathing enough CO2 away. If your pH is acidic, and your CO2 is HIGH, its considered
respiratory acidosis. If CO2 is LOW, it means there are not enough respiratory acids because he's
probably hyperventilating too much CO2 away. When pH is high, and CO2 is low, this is called
Respiratory Alkalosis.

Quick Rule for testing

Inadequate breathing - Respiratory Acidosis - PH will be low, CO2 level will be high, because
he's not breathing it off.

Hyperventilating patients - Respiratory Alkalosis - PH will be high, CO2 levels will be low,
because they're breathing off too much CO2.

Making it simple:

If your CO2 is LOW, then DECREASE rate and depth of ventilations.

If your CO2 is HIGH, then INCREASE rate and depth of ventilations.

Review

Respiratory Acidosis
NOT Breathing adequately - NOT exhaling enough means you aren't getting rid of CO2
therefore pCO2 (percent of Co2 is HIGH!)
Clinical Presentation: Altered LOC, Tachycardic, Diaphoresis, headache
Cause: Crappy or no respirations (COPD, Overdose, Pneumonia, Smoke inhalation,
Pneumothorax, airway obstruction)
Treatment - Increase rate and depth of ventilations - Bag them, so you get rid of some CO2 for
them.

Respiratory Alkalosis
Blowing off too much CO2, as in hyperventilation. When there is not enough CO2 in the blood,
the body uses bicarb to compensate for the lack of respiratory acid. (Metabolic compensation)
Clinical Presentation: Numbness or muscle twitch in fingers, toes, seizures
Cause: Shock, DKA Kussmaul Respirations - Deep and FAST breathing! (The body is trying to
compensate for its metabolic acidosis by producing a respiratory alkalosis on purpose.) Caused
by (anxiety, pain, fever, hypotension, hypoxia, CHF, PE, Sepsis)
Treatment: decrease rate and depth of ventilations. (Calm them down or stop bagging so fast.)

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Metabolic
Metabolic just means it has to do with metabolism. Metabolism just means the chemical changes
that sustain life. Oxygen combines with glucose to create energy. Carbon dioxide is a waste
product of this process. CO2 is then carried from the blood to the alveoli to the lungs for
expiration. We blow off this respiratory acid when ventilations are sufficient. Your body
produces a buffer known as bicarbonate that is alkaline and it binds up with excess acids and turns
it neutral. Bicarbonate is like Tums for your bloodstream.

HCO3 is the amount of bicarbonate in the bloodstream. HCO3 is just the chemical name for
bicarbonate. Normal is 22-26/mEq/l (milliequivalents per liter) This measures how much Tums
are in your blood binding up the excess acid. If your HCO3 (Tums) level is 10, it means that there
is not enough of it, and so the acid in your blood just builds up and the overall pH of your body
goes DOWN! This is called Metabolic Acidosis. To fix it, we bring bicarbonate levels up by
administering Bicarb via IV! If there's too much, it binds up too much acid and there isn't enough,
so now your pH goes alkaline! This is called Metabolic Alkalosis. Fix it by keeping your patient
stable long enough for the bicarb to work itself out.

Metabolic Acidosis
Acid in the blood is used to combine with oxygen and metabolize it. If you do not have enough
oxygen rich blood circulating, the acid is not used and builds up.
Clinical Presentation: Tachycardia, Pulmonary edema, Tachypnea, confusion or coma
Cause: Cardiac arrest, renal failure, DKA, diarrhea for a long time, ASA or antifreeze Overdose
Treatment - Increase rate and depth of Ventilations. Consider Bicarbonate - Its like Tums for
your blood. It binds up the acid in your body and turns it neutral.

Metabolic Alkalosis
Too much bicarbonate, not enough acid
Clinical Presentation: Seizures, Headache, Dysrhythmias
Cause: Diuretics, cystic fibrosis, chewing tobacco, penicillin, overzealous bicarb administration
Treatment: Keep them alive long enough for their body to use up the excess bicarb.

Handy Dandy Quick Reference

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Test yourself (answer on the space next to the question)

If you have blood gases, first consider whether your patient is acidotic or alkalotic by evaluating
the pH. Then, determine whether the cause is respiratory or metabolic.

Your patient has a PH of 7.25, a CO2 of 60mmHg and HCO3 22 _______________

Your patient has a PH of 7.5, a CO2 of 45mmHg and HCO3 40 _______________
Your patient has a PH of 7.4, a CO2 of 40mmHg and HCO3 25 _______________
Your patient has a PH of 7.25, a CO2 of 50mmHg and HCO3 22 _______________
Your patient has a PH of 7.55, a CO2 of 24mmHg and HCO3 22 _______________

Kidneys
The kidneys also have a fail safe switch on them. If your pH is too high when it hits the kidney
filter, your kidney senses it and flushes MORE acid out with your urine. Similarly, if your
kidneys sense that you don't have enough acid, they kick out less acid into your urine.
Unfortunately, the kidneys take awhile to process it, so it takes hours or days for it to
compensate.

Field Note:
Your dialysis patients are chronically acidotic because their kidneys are not participating in the
compensation system. So, if your dialysis patient crashes, assuring adequate ventilations and
bicarb administration is even more vital.

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