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Acid-Base Physiology2012
Objectives Understand normal mechanisms and
regulation of acid-base balance Interpret blood gases Understand the effects of acidosis
and alkalosis Evaluate and manage acidosis and
alkalosis
Normal Physiology Acid-base balance maintained by normal
pulmonary excretion of CO2 and renal excretion of acid
Organic buffers: HCO3-, HPO4, protein anions, carbonate 90% of bicarb is reabsorbed by kidney
Renal excretion – H+ combines with urinary titratable acids (phosphates) or ammonia to form ammonium
Henderson-Hasselbach equation:pH = 6.1 + log (HCO3 ÷ (0.03 x PCO2))
Compensatory MechanismspH is determined by ratio of HCO3 and PCO2
Body responds to changes in pH by attempting to normalize the pH Buffering Respiratory – alterations in paCO2 Renal – alterations in bicarbonate
excretion
Compensatory Mechanisms Compensated metabolic acidosis:
1.2 mmHg in pCO2 for every 1 meq/L in HCO3 Compensated metabolic alkalosis:
0.7 mmHg in pCO2 for every 1 meq/L in HCO3 Compensated respiratory acidosis:
Acute- 1 meq/L for every 10 mmHg in pCO2 Chronic- 3.5 meq/L for every 10 mmHg in
pCO2 Compensated respiratory alkalosis:
Acute- 2 meq/L for every 10 mmHg in pCO2 Chronic- 4 meq/L for every 10 mmHg in pCO2
Blood Gas Interpretation General guidelines:
1) Is it acidosis or alkalosis?Acidosis – pH < 7.38Alkalosis – pH > 7.42
2) Is it primary respiratory or metabolic?Evaluate paCO2 and bicarbonate
3) Is there compensation?Calculations from previous slides
Blood Gas Interpretation 4) If respiratory disturbance, is it acute or
chronic? Respiratory acidosis:
Acute decrease in pH = 0.08 x (paCO2-40)/10 Chronic decrease in pH = 0.03 x (paCO2-40)/10
Respiratory alkalosis Acute increase in pH = 0.08 x (40-paCO2)/10 Chronic increase in pH = 0.03 x (40-paCO2)/10
5) If metabolic disturbance, is there an anion gap?
Check serum Na, Cl, HCO3
Case #1 pH 7.16, pCO2 70, HCO3 24 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical Scenario?
Case #1 pH 7.16, pCO2 70, HCO3 24 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical Scenario?
Case #1 pH 7.16, pCO2 70, HCO3 24 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical Scenario?
Case #1 pH 7.16, pCO2 70, HCO3 24 Acidosis or alkalosis? Respiratory or metabolic? Compensated?
No … likely acute Clinical Scenario?
Case #1 pH 7.16, pCO2 70, HCO3 24 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical Scenario?
2 yo receiving deep sedation by the adult ED attending who gives him 4 mg morphine, respiratory rate is 6
Acute Respiratory Acidosis Respiratory pathophysiology – airway
obstruction, severe pneumonia, chest trauma, pneumothorax
Acute drug intoxication (narcotics, sedatives)
Residual neuromuscular blockade CNS disease (head trauma, decreased
consciousness)
Bicarbonate is often normal, kidneys have not had time to compensate
Case #2 pH 7.6, pCO2 23, HCO3 22 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case #2 pH 7.6, pCO2 23, HCO3 22 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case #2 pH 7.6, pCO2 23, HCO3 22 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case #2 pH 7.6, pCO2 23, HCO3 22 Acidosis or alkalosis? Respiratory or metabolic? Compensated?
No … likely acute Clinical scenario?
Case #2 pH 7.6, pCO2 23, HCO3 22 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
4 mo mechanically ventilated pt who was bagged during transport to CT scan by an overeager intern
Respiratory Alkalosis Pain, anxiety Hypoxemia Interstitial lung
disease Severe congestive
heart failure (pulmonary edema)
Pulmonary emboli Drugs – salicylates,
methylxanthines, nicotine
Sepsis, fever Hepatic failure –
encephalopathy Pregnancy Thyrotoxicosis CNS hemorrhage Overagressive
mechanical ventilation
Case #3 pH 7.29, pCO2 26, HCO3 12 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case #3 pH 7.29, pCO2 26, HCO3 12 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case #3 pH 7.29, pCO2 26, HCO3 12 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Compensatory Mechanisms Compensated metabolic acidosis:
1.2 mmHg in pCO2 for every 1 meq/L in HCO3
Compensated metabolic alkalosis: 0.7 mmHg in pCO2 for every 1 meq/L in HCO3
Compensated respiratory acidosis: Acute- 1 meq/L for every 10 mmHg in pCO2 Chronic- 3.5 meq/L for every 10 mmHg in pCO2
Compensated respiratory alkalosis: Acute- 2 meq/L for every 10 mmHg in pCO2 Chronic- 4 meq/L for every 10 mmHg in pCO2
Case #3 pH 7.29, pCO2 26, HCO3 12 Acidosis or alkalosis? Respiratory or metabolic? Compensated?
Yes … 1.2 mmHg decrease in pCO2 for every 1 meq/L decrease in HCO3
Clinical scenario?
Case #3 pH 7.29, pCO2 26, HCO3 12 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
10 yo dev delayed pt admitted with diarrhea, med list reveals mom has been giving Miralax every 4 hours
Metabolic Acidosis Anion gap
Metabolic Acidosis Anion gap
Lactic acidosis DKA Toxic ingestions (salicylates, ethylene
glycol, ethanol, isopropyl alcohol, paraldehyde, methanol)
Renal failure – uremia
Metabolic Acidosis Nonanion gap
Metabolic Acidosis Nonanion gap
RTA Diarrhea Hypoaldosteronism Potassium-sparing diuretics Pancreatic loss of bicarbonate Ureteral diversion Carbonic anhydrase inhibitors Acid administration (ArgCl, NaCl)
Case #4 pH 7.47, pCO2 46, HCO3 32 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case #4 pH 7.47, pCO2 46, HCO3 32 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case #4 pH 7.47, pCO2 46, HCO3 32 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Compensatory Mechanisms Compensated metabolic acidosis:
1.2 mmHg in pCO2 for every 1 meq/L in HCO3 Compensated metabolic alkalosis:
0.7 mmHg in pCO2 for every 1 meq/L in HCO3
Compensated respiratory acidosis: Acute- 1 meq/L for every 10 mmHg in pCO2 Chronic- 3.5 meq/L for every 10 mmHg in
pCO2 Compensated respiratory alkalosis:
Acute- 2 meq/L for every 10 mmHg in pCO2 Chronic- 4 meq/L for every 10 mmHg in pCO2
Case #4 pH 7.47, pCO2 46, HCO3 32 Acidosis or alkalosis? Respiratory or metabolic? Compensated?
Yes … 0.7 mmHg increase in pCO2 for every 1 meq/L increase in HCO3
Clinical scenario?
Case #4 pH 7.47, pCO2 46, HCO3 32 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
5 yo s/p appendectomy with NG tube left to suction on 7CH for 5 days
Metabolic Alkalosis Chloride-responsive (urine Cl < 10
meq/L) Gastric acid loss (vomiting, NG suction) Contraction alkalosis (often due to loop or
thiazide diuretics) Posthypercapnia syndrome
Metabolic Alkalosis Chloride-resistant
Mineralocorticoid excess Renal chloride wasting (Bartter
syndrome) Exogenous alkali (milk-alkali syndrome,
massive blood transfusion) Hypokalemia
Case #5 pH 7.30, pCO2 89, HCO3 42 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clincial scenario?
Case #5 pH 7.30, pCO2 89, HCO3 42 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clincial scenario?
Case #5 pH 7.30, pCO2 89, HCO3 42 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clincial scenario?
Compensatory Mechanisms Compensated metabolic acidosis:
1.2 mmHg in pCO2 for every 1 meq/L in HCO3 Compensated metabolic alkalosis:
0.7 mmHg in pCO2 for every 1 meq/L in HCO3
Compensated respiratory acidosis: Acute- 1 meq/L for every 10 mmHg in
pCO2 Chronic- 3.5 meq/L for every 10 mmHg
in pCO2 Compensated respiratory alkalosis:
Acute- 2 meq/L for every 10 mmHg in pCO2 Chronic- 4 meq/L for every 10 mmHg in pCO2
Case #5 pH 7.30, pCO2 89, HCO3 42 Acidosis or alkalosis? Respiratory or metabolic? Compensated?
Yes … 3.5 meq/L increase in HCO3 for every 10 mmHg increase in CO2
Clincial scenario?
Case #5 pH 7.30, pCO2 89, HCO3 42 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clincial scenario?
35 yo CF patient on the Peds floor with end-stage lung disease
Chronic Respiratory Acidosis Chronic lung diseases (BPD, CF) Neuromuscular disorders Severe restrictive lung disease Severe obesity
Case #6 pH 6.84, pCO2 82, HCO3 14 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case #6 pH 6.84, pCO2 82, HCO3 14 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Blood Gas Interpretation 4) If respiratory acidosis or alkalosis, is it
acute or chronic? Respiratory acidosis:
Acute decrease in pH = 0.08 x (paCO2-40)/10
Chronic decrease in pH = 0.03 x (paCO2-40)/10
Respiratory alkalosisAcute increase in pH = 0.08 x
(40-paCO2)/10Chronic increase in pH = 0.03 x (40-
paCO2)/10
Case #6 pH 6.84, pCO2 82, HCO3 14 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case #6 pH 6.84, pCO2 82, HCO3 14 Acidosis or alkalosis? Respiratory or metabolic? Compensated?
No … Combined acidosis
Clinical scenario?
Case #6 pH 6.84, pCO2 82, HCO3 14 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
2 mo found down at home, hypoperfusion leading to lactic acidosis, hypoventilation leading to respiratory acidosis
Case # 7 pH 7.46, pCO2 24, HCO3 16 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case # 7 pH 7.46, pCO2 24, HCO3 16 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case # 7 pH 7.46, pCO2 24, HCO3 16 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case # 7 pH 7.46, pCO2 24, HCO3 16 Acidosis or alkalosis? Respiratory or metabolic? Compensated?
Well … 2 meq/L decrease in HCO3 for every 10 mmHg decrease in CO2
Combined respiratory alkalosis & metabolic acidosis
Clinical scenario?
Case # 7 pH 7.46, pCO2 24, HCO3 16 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Anxious 5 yo who is hyperventilating and has a history of RTA
Case #8 pH 7.45, pCO2 54, HCO3 36 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case #8 pH 7.45, pCO2 54, HCO3 36 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case #8 pH 7.45, pCO2 54, HCO3 36 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
Case #8 pH 7.45, pCO2 54, HCO3 36 Acidosis or alkalosis? Respiratory or metabolic? Compensated?
No … 0.7 mmHg increase for every 1 meq/L predicts pCO2 of 48
Combined metabolic alkalosis and respiratory acidosis
Clinical scenario?
Case #8 pH 7.45, pCO2 54, HCO3 36 Acidosis or alkalosis? Respiratory or metabolic? Compensated? Clinical scenario?
1 yo with vomiting for 3 days who presents to the ED with lethargy and decreased arousal, hypoventilating
Physiologic Effects of Acidosis Shifts the oxygen-hemoglobin
dissociation curve to the right Decreased affinity for O2
Physiologic Effects of Acidosis Pulmonary effects – vasoconstriction
decreases pulmonary blood flow Cardiac effects – depressed
contractility Neurologic effects – increased cerebral
blood flow, increased ICP Extracellular shift of K+
hyperkalemia Sympathetic overactivity, resistance to
catecholamines
Physiologic Effects of Alkalosis Shifts the oxygen-hemoglobin
dissociation curve to the left Stronger bond between Hb and O2 Decreased O2 delivery to tissues
Physiologic Effects of Alkalosis Cardiac arrhythmias Lungs – vasodilation increases
pulmonary blood flow Neurologic effects – headache,
seizures, altered mental status Decreased cerebral blood flow from
vasoconstriction
Decreased levels of ionized Ca++ Intracellular shift of potassium
severe hypokalemia
Management - Respiratory Acidosis Treat the underlying disorder Assist or increase ventilation
Secure airway if necessary Increase tidal volume or respiratory rate if
mechanically ventilated Noninvasive ventilation Bronchodilators
Reverse sedative medications
Management – Respiratory Alkalosis Treat the underlying disorder Decrease ventilation
Decrease respiratory rate Decrease tidal volume
Sedation and pain control Reassurance for anxious patients
Management - Metabolic Disorders Acidosis
Treat the underlying disorder Consider bicarb administration depending on
etiology Dialysis in the setting of renal failure
Alkalosis Treat the underlying disorder Chloride-responsive: replete chloride (NaCl, KCl,
ArgCl) Carbonic-anydrase inhibitors if diuresis needed
Conclusion The body has compensatory mechanisms to
maintain acid-base balance. Blood gases should be interpreted in a
systematic way to determine the etiology of the acid-base disturbance.
Acidosis causes pulmonary vasoconstriction, cardiac depression, arterial vasodilation, & decreased O2 affinity.
Alkalosis causes pulmonary vasodilation, arterial vasoconstriction, & increased O2 affinity.
Management of acid-base disorders primarily involves treatment of the underlying disorder.
Everyone always has slides of their kids …
QUESTIONS?
References www.uptodate.com www.emedicine.com Morganroth ML. Six steps to acid-base
analysis: clinical applications. The Journal of Critical Illness. 1990;5:460-69.
Morganroth ML. An analytic approach to diagnosing acid-base disorders. The Journal of Critical Illness. 1990;5:138-50.