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Belfast City

Hospital
1

Principles of Acid Base


Balance Interpretation
Dr Bernard Silke, M.D., D.Sc., F.R.C.P,
Clinical Pharmacologist,
Consultant Physician,
Belfast City Hospital, N. Ireland

Department of Therapeutics, Queens University

Principles of Acid-base
balance interpretation
The material in these slides is not original - it
represents a collage taken from several sources

The graphic representations are mainly based on


Human Acid-Base Physiology by Oliver Holmes
Chapman & Hall Medical, London, 1993, 0-412-47610-X

A useful internet site is http://www.northland.cc.mn.us/Terry_Wiseth/acidbase%20balance/ppframe.htm

Line drawing were prepared with SmartDraw.


Any feedback or requests (b.silke@qub.ac.U.K.)
3

Principles of Acid-base
balance interpretation
Acid-base balance -- main concern two ions:
Hydrogen (H+)
Bicarbonate (HCO3-)

Derangement is common in disease processes


H+ has special significance due to the narrow
range compatible with living systems

Enzymes, hormones and ion distribution are all


affected by H+ concentrations
4

Principles of Acid-base
balance interpretation
CO2 25 Mol / day
CO2 + H2O

H2CO3

H+ + HCO3-

Non-carbonic acids 70 mmol/day


Food
Medication
Metabolic intermediates
Lactic acid
Pyruvic acid
Acetoacetic acid

Principles of Acid-base
balance interpretation
E.C.F. acceptable pH range maintained by :
1) Chemical buffers
react very rapidly (< 1 sec)

2) Respiratory regulation
reacts rapidly (sec to min)

3) Renal regulation
reacts slowly (min to hr)
6

Principles of Acid-base
balance interpretation
Acids can be defined as a proton (H+) donor
Molecules that dissociate in solution to H+
Physiologically important acids include :
Carbonic acid (H2CO3)
Phosphoric acid (H3PO4)
Pyruvic acid
Lactic acid
7

Principles of Acid-base
balance interpretation
Bases can be defined as a proton (H+) acceptor
Molecules capable of accepting a H+ ion
Physiologically important bases include :
Bicarbonate (HCO3-)
Biphosphate (HPO4-2)

Principles of Acid-base
balance interpretation
A buffer consists of a buffer pair; it is a mixture
of a weak acid and its salt
Weak acid HA

H+ + A-

Acid

Base

Apply the law of mass action :


[H+] * [A-] / [HA] = K
[H+] = K * [HA] / [A-]
9

Principles of Acid-base
balance interpretation
- log[H+] = -logK - log[HA] / [A-]
(1) pH = pK + log [A-] / [HA]
pH = 6.1 + log [HCO3-] / [CO2]
pH = 6.1 + log 24 / 1.2 = 7.4

Henderson
Hasselbalch
Normality

Under normal physiological conditions pH can


be calculated from the 20:1 ratio of bicarbonate
and carbonic acid to lie close to 7.4
10

Principles of Acid-base
balance interpretation

Maintained within narrow limits


pH 7.35 to 7.45

pH = Alkalemia (high blood pH)


pH = Acidemia (low blood pH)
pH 6.7 to 7.9 compatible with life
11

Principles of Acid-base
balance interpretation
pH scale expresses [H+] in H2O solutions
Water ionizes to a limited extent to form equal
amounts of H+ and OH- ions

H2O

H+ + OHacid

base

Pure H2O is neutral (pH = 7.0 : H+ = OH-)


Acid (pH < 7.0 : H+ > OH-)
Base (pH > 7.0 : H+ < OH-)
12

Principles of Acid-base
balance interpretation
Acidosis / alkalosis are physiological conditions
where either :
A relative increase in H+ ion (acidosis)
A relative increase in HCO3- ion (alkalosis)

Deviations from this ratio [HCO3-] / [H2CO3] used


to identify acid-base imbalances (pH 7.4 -- 20:1)

Normal levels 24 and 1.2 mEq / L (HCO3- / H2CO3)


13

Principles of Acid-base
balance interpretation
Acidosis a decrease in 20:1 base to acid ratio :
An increase in H+ ion concentration
A decrease in amount of HCO3- ion
Excessive acid or deficient base

Acidosis an increase in the base to acid ratio :


An decrease in number of H+ ions
An increase in amount of HCO3Base excess or acid deficit
14

C A R B O N D IO X ID E D IF F U S IO N
R e d B lo o d C e ll
C l-

( c h lo r i d e s h i f t )

C O

+ H 20

+ H 2C O

3
HCO

P la s m a
CO

T is s u e s

C O 2 d iffu s e s in to th e R
is h y d r a te d u n d e r in flu
c a r b o n ic a n h y d r a s e . H
d iffu s e s in to th e p la s m

BC and
ence of
C O 3a.

15

Principles of Acid-base
balance interpretation
The ratio [HCO3-] / [H2CO3] determines the
acid-base status
pH = 6.1 + log 24 / 1.2 = 7.4 (Normal status)
Add 12 mM of strong acid to 1L of E.C.F.
pH = 6.1 + log 12 / 13.2 = 6.06 (Closed system)
pH = 6.1 + log 12 / 1.2 = 7.1 (Open system)
16

Principles of Acid-base
balance interpretation
To minimize the pH alteration requires
alteration of the [HCO3-] / [H2CO3] ratio

The ability to regulate the PCO2 limits the pH


change that would otherwise occur ; this
makes the HCO3- / H2CO3 system a near perfect
buffer (respiratory adjustment)

The HCO3- level is under separate renal


physiological control (metabolic adjustment)

17

Principles of Acid-base
balance interpretation

Intracellular Buffers

Proteins
Haemoglobin
Phosphate

Bone buffers
Extracellular Buffers

Proteins
Phosphate
Bicarbonate

Acidosis - an excess of
unwanted acid in the
blood; pH may be normal
Alkalosis - an excess of
unwanted alkali in the
blood; pH may be normal

18

Principles of Acid-base
balance interpretation
Most important buffer : CO2- bicarbonate pair
Other buffers termed non-bicarbonate
Legitimate to consider these protein buffer
Blood buffer capacity is approx.. 48 mmol
50% of buffering due to CO2- bicarbonate pair
Acid base status cannot be assessed purely from
a knowledge of the bicarbonate status

19

Principles of Acid-base
balance interpretation
W h o le b lo o d b u f f e r in g o f a n a c id lo a d
CO

F ix e d
a c id

N o n -H C O

B ic a r b o n a te

b u ffe rs
P la s m a
R B C 's

H a e m o g lo b in
P la s m a p r o t e in s
P h o s p h a te

100%
35%
18%
35%
7%
5%
20

Principles of Acid-base
balance interpretation
Components of Acid-base disorder
Respiratory indicated by PCO2
Metabolic indicated by the blood line shift

Standard bicarbonate
The bicarbonate concentration in mM in the
plasma of oxygenated whole blood equilibrated
with a PCO2 of 5.3 kPa at 37oC
< 22 mM metabolic acidosis : > 26 mM alkalosis

21

Principles of Acid-base
balance interpretation
The variables of the Henderson-Hasselbalch
equation are [H+] , [HCO3-] and [CO2]

Each pair - can be plotted on linear or log scale


The following convention has been adopted to plot
[HCO3-] as a linear function of [PCO2]

To determine the standard [HCO3-], [PCO2] is


manipulated and these changing relationships are
easy to visualize and interpret

22

50
40
N o rm a l
b lo o d li n e

30
N

20
10

H C O

C o n c e n t r a t io n ( m M )

Principles of Acid-base
balance interpretation

20
2 .6 6

40
5 .3

60
8

P C O

80
1 0 .7

100 m m H g
1 4 .4 k P a

23

Principles of Acid-base
balance interpretation
In the system
Iso-pH lines are linear and pass through origin
pH relationships easy to appreciate
Blood line is curved, resembling the carbon
dioxide dissociation curve
However not desirable as a normogram method
Siggaard-Andersen normogram - uses log plots
for both axes and consequently the third
variable is a straight line (BE & buffer base)
24

Principles of Acid-base
balance interpretation
Standard HCO3- - imperfect measure of acid-base
status. Incomplete representation of buffers

Only estimates the HCO3- / H2CO3 contribution


Measure both [HCO3-] and [Pr-] components
because the latter is 50% of buffering capacity

This measure is termed the Base Excess


To measure directly a process of back titration
25

Principles of Acid-base
balance interpretation
S ta n d a rd
b ic a r b o n a te
(m M )

40

N ew
b lo o d li n e
N o rm a l
b lo o d li n e

30
N

20
10

H CO

C o n c e n t r a t io n ( m M )

50

20
2 .6 6

40
5 .3

60
8

80
1 0 .7

100 m m H g
1 4 .4 k P a

26

Principles of Acid-base
balance interpretation
Base Excess is the change from normal of the
concentration of [HCO3-] and [Pr-] buffer base

To estimate directly, first remove respiratory


component. Equilibrate blood at 37 oC and PCO2
of 5.3 kPa and back titrate to pH 7.4

Quantitatively Base Excess is the amount of acid


(mM) to be added to 1 L of whole blood to return
pH to 7.4 (normal range 2.5 mM)

27

Principles of Acid-base
balance interpretation
Knowledge of the HCO3- and PCO2 defines a
point on the acid-base chart

Insufficient information to calculate Base Excess


and estimate the extent of blood buffering

BE calculated from amount of strong acid or


base required to restore pH (back titration)

Siggaard-Andersen normogram - obviate need


28

C o n c e n t r a t io n ( m M )

10

40

P o s it iv e B a s e E x c e s s

30
20

N e g a t iv e B a s e E x c e s s

H C O

50

Principles of Acid-base
balance interpretation

20
2 .6 6

40
5 .3

60
8

P C O

80
1 0 .7

100 m m H g
1 4 .4 k P a

29

Principles of Acid-base
balance interpretation
Compensated

Respiratory Metabolic
component component

Respiratory No
acidosis
Yes

High

Zero

High

High

Metabolic
alkalosis

No

Zero

High

Yes

High

High

30

50
40

P C O 2 h ig h
B .E . p o s

P C O 2 lo w
B .E . n e g

P C O 2 h ig h
B .E . n e g

20
10

H C O

P C O 2 lo w
B .E . p o s

30

C o n c e n t r a t io n ( m M )

Principles of Acid-base
balance interpretation

20
2 .6 6

40
5 .3

60
8

P C O

80
1 0 .7

100 m m H g
1 4 .4 k P a

31

Principles of Acid-base
balance interpretation
Carbon dioxide is a respiratory gas
In aqueous solution it is a weak acid
CO2 + H2O = H+ + HCO3-

Hypoventilation, with CO2 accumulation,


acidification of ECF - respiratory acidosis

Hyperventilation with CO2 washout leads


to respiratory alkalosis
32

Principles of Acid-base
balance interpretation
Hypoventilation - pulmonary ventilation reduced
Respiratory movements may be increased
Conditions causing respiratory acidosis:
Depressed respiratory centre (drug abuse)
Obstructive airways disease
Inhaled foreign object
Bronchoconstriction (Acute asthma)
33

Principles of Acid-base
balance interpretation
40

B
2

30
1

20

10
1 A c u te r e s p ir a to r y a c id o s is
2 R e n a l c o m p e n s a t io n

H C O

C o n c e n t r a t io n ( m M )

50

20
2 .6 6

40
5 .3

60
8

P C O

80
1 0 .7
2

100
1 4 .4

m m H g
kP a

34

Principles of Acid-base
balance interpretation

PCO2
mm Hg
[HCO3-]
mM
[H+]
nM

Uncompensated Renal (HCO3-)


compensation
High
High
80 (10.7)
80 (10.7)
High
High
29
48
High
Normal
67
40
Acute
Chronic
(min to hr)
(hr to days)

35

Principles of Acid-base
balance interpretation
40

B
2

30
1

20

10
1 A c u te r e s p ir a to r y a c id o s is
2 R e n a l c o m p e n s a t io n

H C O

C o n c e n t r a t io n ( m M )

50

20
2 .6 6

40
5 .3

60
8

P C O

80
1 0 .7
2

100
1 4 .4

m m H g
kP a

36

Principles of Acid-base
balance interpretation
Respiratory acidosis - increase in PCO2
Rise in H+ is buffered by blood buffers
Acute - lack of physiological compensation
Compensation is due to renal HCO3- retention
Compensation not restore blood chemistry
Adjusts [HCO3- ] / [CO2] ratio to restore pH
37

50
3

40

2
1

30
N o rm a l
b lo o d li n e

20

C o n c e n t r a t io n ( m M )

Principles of Acid-base
balance interpretation

C o
1
2
3

H C O

10

20
2 .6 6

40
5 .3

60
8

P C O

m
P
C
O

p e n s a t io n
a r tia l
o m p le te
ve r

80
1 0 .7

100 m m H g
1 4 .4 k P a

38

Principles of Acid-base
balance interpretation
Hyperventilation - pulmonary ventilation
Loss of CO2 exceeding production rate
Conditions causing respiratory alkalosis:
Anxiety and emotional disturbances
Salicylate poisoning (overdose)
Assisted ventilation
High altitude (low environmental O2)
39

Principles of Acid-base
balance interpretation
40
30
20

10

1 A c u t e r e s p ir a t o r y a lk a lo s is
2 R e n a l c o m p e n s a t io n

H C O

C o n c e n t r a t io n ( m M )

50

20
2 .6 6

40
5 .3

60
8

P C O

80
1 0 .7
2

100
1 4 .4

m m H g
kP a

40

Principles of Acid-base
balance interpretation
Non-respiratory disturbances termed metabolic
Large variety of primary abnormalities --> in
excess of non-respiratory acid / alkali

Excessive intake of acid or alkali or renal defects


Ingestion of acid or alkali (mouth, injection etc.)
Excessive GI losses (vomiting, diarrhoea)
Abnormal metabolism (diabetes mellitus)
Renal failure or tubular defects

41

Principles of Acid-base
balance interpretation
Metabolic acidosis may result from exercise
Accumulation of tissue metabolites, including
lactic acid consequent on anaerobic metabolism

Diabetes mellitus accumulation of ketone bodies


Aceto-acetic acid and -OH butyric acid

Non-volatile or fixed acids - not blown off


Other diseases include CHF and renal failure
42

Principles of Acid-base
balance interpretation
I n it ia l r e s p o n s e t o a c u t e m e t a b o lic a c id o s is
H

+ P r-

+ HCO

HPr
3

B u ffe r
b a s e in
b lo o d

H 2O + C O

E x c re te d fro m
t h e lu n g s
43

Principles of Acid-base
balance interpretation

PCO2
mm Hg
[HCO3-]
mM
[H+]
nM

Uncompen
sated
High
80 (10.7)
Normal
40
Low
12
Acute
(min to hr)

Respiratory
(PCO2)
High
72 (9.4)
Low
30
Low
10
Chronic
(hr to days)

Renal
(HCO3-)
High
50 (6.66)
Low
35
Low
17
Chronic
(hr to days)

44

50
40

1 A c u te m e ta b o lic a c id o s is
2 P a r tia l r e s p ir a t o r y c o m p e n s a tio n
3 R e n a l c o m p e n s a tio n

30
20

N
1

10

N e w b lo o d
lin e

HCO

C o n c e n t r a t io n ( m M )

Principles of Acid-base
balance interpretation

20
2 .6 6

40
5 .3

P C O

60
8
2

80
1 0 .7

100
1 4 .4

m m H g
kP a

45

Principles of Acid-base
balance interpretation
Fixed acid accumulation usually gradual :
uncommon for acute uncompensated process

Uncompensated would be represented as a


reduced HCO3- and pH without change in PCO2

Partial respiratory compensation is achieved by


a further reduction in PCO2

Renal compensation involves HCO3- retention


46

Principles of Acid-base
balance interpretation
40
30
N o rm a l
b lo o d li n e

20
10

H C O

C o n c e n t r a t io n ( m M )

50

20
2 .6 6

40
5 .3

60
8

P C O

80
1 0 .7

100 m m H g
1 4 .4 k P a

47

Principles of Acid-base
balance interpretation
80 yr. old male

O2 10.28 kPa

Nursing home

pCO2 3.04 kPa

Previous CVA * 3

B.E.

Debilitated

pH 7.34

Poor QOL

Na+

Recent gradual

K+ 7.7 mEq/l

-10.5 mm/l
135.4 mEq/l

deterioration with

Cl- 100.2 mEq/l

mental obtundation

Cr. 930 umol/l

48

Principles of Acid-base
balance interpretation
40

1 M e ta b o lic a c id o s is
( r e n a l in s u f f ic ie n c y )
2 R e s p ir a to r y c o m p e n s a tio n
( K u s s m a u l)

30
N

20
10

N e w b lo o d
lin e

HCO

C o n c e n t r a t io n ( m M )

50

20
2 .6 6

40
5 .3

P C O

60
8
2

80
1 0 .7

100
1 4 .4

m m H g
kP a

49

Principles of Acid-base
balance interpretation
Aspirin - therapeutic dosage
Central respiratory stimulation (alkalosis)
Renal compensation with HCO3- loss
Compensated respiratory alkalosis

Aspirin overdose with toxicity


Changes resemble metabolic acidosis
Low plasma HCO3- and normal PCO2
Combined respiratory and metabolic acidosis

50

Principles of Acid-base
balance interpretation
40
30
20

10

1 A c u t e r e s p ir a t o r y a lk a lo s is
2 R e n a l c o m p e n s a t io n

H C O

C o n c e n t r a t io n ( m M )

50

20
2 .6 6

40
5 .3

60
8

P C O

80
1 0 .7
2

100
1 4 .4

m m H g
kP a

51

Principles of Acid-base
balance interpretation
25 yr. old female

pH

7.25

Chronic depression

pCO2

8.0 kPa

Unconscious

pO2

10.7 kPa

Overdose

HCO3-

29

BE

0 mM

barbiturates

Hypoventilation
52

H C O 3 - C o n c e n t r a t io n ( m M )

Principles of Acid-base
balance interpretation
50
40
30
1

20
10

1 A c u te r e s p ir a to r y a c id o s is

20
2 .6 6

40
5 .3

60
8

P C O

80
1 0 .7

100 m m H g
1 4 .4 k P a

53

Principles of Acid-base
balance interpretation
It is also possible to represent change in acid
base status after Davenport (ABC of acid-base
chemistry) in terms of pH / HCO-3 relationships

Changes in CO2 move the relationship up and to


the left (increase) or down / right (decrease)

Metabolic changes (addition or subtraction of


acid) are represents as Iso-CO2 line changes
54

Principles of Acid-base
balance interpretation
30

A c u te R e s p ir a to r y
a c id o s is ( p C O 2 = 8 k P a )

26

P la s m a H C O

( m E q / l)

34

22
A c u te R e s p ir a to r y
a lk a lo s is ( p C O 2 = 2 .7 k P a )

18
14
7 .2

7 .3

7 .4

pH

7 .5

7 .6

7 .7

55

Principles of Acid-base
balance interpretation
C o m p e n s a t e d R e s p ir a to r y
a c id o s is ( p C O 2 = 8 k P a )

30
26

P la s m a H C O

( m E q / l)

34

22
18
14
7 .2

7 .3

7 .4

pH

7 .5

7 .6

7 .7

56

Principles of Acid-base
balance interpretation
30
26

P la s m a H C O

( m E q / l)

34

22
18
C o m p e n s a te d R e s p ir a to r y
a lk a lo s is ( p C O 2 = 2 .7 k P a )

14
7 .2

7 .3

7 .4

pH

7 .5

7 .6

7 .7

57

Principles of Acid-base
balance interpretation
C o m p e n s a te d M e ta b o lic
a lk a lo s is ( p C O 2 = 5 .3 k P a )

30

U n c o m p e n s a te d M e ta b o lic
a lk a lo s is ( p C O 2 = 5 .3 k P a )

26

P la s m a H C O

( m E q / l)

34

22
18

U n c o m p e n s a te d
M e ta b o lic
a c id o s is
(p C O 2
= 2 .7 k P a )
C o m p e n s a te d M e ta b o lic
a c id o s is ( p C O 2 = 2 .7 k P a )

14
7 .2

7 .3

7 .4

pH

7 .5

7 .6

7 .7

58

Principles of Acid-base
balance interpretation
18 yr. old male

pH

7.1

Drink driving

pCO2

8.0 kPa

RTA & unconscious

pO2

10.7 kPa

Multiple injuries,

HCO3-

18

BE

- 10 mM

shock, rib fractures

Crushed legs
59

Principles of Acid-base
balance interpretation
5 0 1 M e t a b o lic a c id o s is
40
30
N

20

N e w b lo o d
lin e

HCO

C o n c e n t r a t io n ( m M )

2 R e s p ir a to r y d e p r e s s io n

10

20
2 .6 6

40
5 .3

P C O

60
8
2

80
1 0 .7

100
1 4 .4

m m H g
kP a

60

Principles of Acid-base
balance interpretation
45 yr. old female

pH

7.65

Post bowel surgery

pCO2

4.0 kPa

IPP ventilation

pO2

11.6 kPa

Naso-gastric suction

HCO3-

32

BE

10 mM

61

50

1 L o s s o f a c id
2 H y p e r v e n tila tio n

40

N e w b lo o d
lin e

30
N

20

H C O

C o n c e n t r a t io n ( m M )

Principles of Acid-base
balance interpretation

10

20
2 .6 6

40
5 .3

P C O

60
8
2

80
1 0 .7

100
1 4 .4

m m H g
kP a

62

Principles of Acid-base
balance interpretation
75 yr. old male

pH

7.35

Smoker 30+ many yr.

pCO2

7.9 kPa

Severe COAD

pO2

8.0 kPa

Frequent

HCO3-

35

BE

8 mM

hospitalization with
acute exacerbation

63

Principles of Acid-base
balance interpretation
35 yr. old male

pH

7.35

Fit athlete

pCO2

3.8 kPa

Astronomer

pO2

11.5 kPa

Relocated to site

HCO3-

18

BE

- 5 mM

observatory 10,000 ft

Blood gases at 1 mth


64

The End

65