Welcome To Seminar

on
Acid-Base Disorder

Dr. Prafulla Paudel

Jahurul Islam Medical College
 ACIDS

Acids can be defined as:

- A proton (H+) donor.
- Substances which dissociates in solution to release H+
 BASES

Bases can be defined as:

- A proton (H+) acceptor.
- Substances capable of accepting a H+
 pH

pH = -log[H+], where log is the base 10 logarithm and [H +] stands for

the hydrogen ion concentration in units of moles per liter solution.

Normal pH of arterial blood = 7.35 to 7.45. In order for normal

metabolism to take place, the body must maintain this narrow range
at all time.
 Acidemia = Increase in [H+] concentration in blood
(i.e. blood pH<7.35)

 Alkalemia = Decrease in [H+] concentration in blood

(i.e. blood pH>7.45)
 Acidosis = Physiological processes that cause acid
accumulation or alkali loss.

 Alkalosis = Physiological processes that cause alkali

accumulation or acid loss.
 The blood pH compatible for life is 6.8-7.8, beyond which
life cannot exist.

 Homeostatic mechanisms keep pH within a normal range

(7.35-7.45). These mechanisms consists of buffer systems,
the kidneys and the lungs.
 pH of a buffer system may be determined from the
Henderson-Hasselbach equation

pH=pKa+log10([HCO3-]/[H2CO3])
Where, pKa= negative base10 logarithm of the acid base constant (-log10Ka)
[HCO3-]= conjugate base
[H2CO3]= weak acid
Acid-Base regulation

 Chemical Buffers (1st line defense)

-Reacts very rapidly (seconds)
 Respiratory regulation (2nd line defense)
-Reacts rapidly (seconds to minutes)
 Renal regulation (3rd line defense)
-Reacts slowly (minutes to hours)
 Chemical buffers

During metabolic activity, body produces both volatile(e.g. H2CO3) and

non volatile (e.g H3PO4,H2SO4) acids. Volatile acids are execrated via
lungs and non volatile acids are excreted via kidney. But before their
excretion, they may decrease the normal pH. During this time, buffers
absorb the H+ and prevents the change of normal pH.
e.g. HCO3-+H+(from metabolic acid)→H2CO3
Buffers act within seconds and they are 1st line defense. But they can’t
eliminate H+ from the body and only keep them tied up until the
excretion of H+ via lungs and kidney. Thus buffers maintain normal pH
or acid base balance.
 Chemical Buffers

Types of chemical buffers

1. Bicarbonate buffer
2. Protein buffer
3. Phosphate buffer
 Bicarbonate buffer

 H2O + CO2 ↔ H2CO3 ↔ HCO3- + H+

Water and carbon dioxide confuse to form carbonic acid which then
separates to hydrogen ion and a bicarbonate ion. These reactions are
reversible. Hydrogen ion can bind with bicarbonate ion to form
carbonic acid which can dissociate to form carbon dioxide and water.
So, these molecules function in buffering system.
Bicarbonate can remove excess hydrogen ions during acidosis
Carbonic acid can divide to produce needed hydrogen ions during
alkalosis.
Protein buffer

 Protein buffer
1.Plasma protein buffer
2.Hemoglobin buffer
 Plasma protein buffer

Proteins act as amphoteric substances, i.e. they can act as both acid
and bases. In acidosis, proteins accept H+ from the body fluid. In
alkalosis, proteins release H+ to the body fluid.

In Acidosis, protein- + H+→Hprotein

In Alkalosis, Hprotein→ H+ + protein-

Protein buffer is also known as the master buffer because of their high
concentration especially within the cells. About 60-70% of the total
chemical buffering occurs inside the cells and most of this results
from intracellular protein buffers.
 Hemoglobin buffer system
Hemoglobin of RBC is an important blood buffer. It mainly buffers the fixed acids, besides being
involved in the transport of gases (O2 and CO2). So, Hb is important in the respiratory regulation of
pH.
 Haemoglobin can accept H+ as it has histidine, which is a basic amino acid. Moreover,
deoxygenated haemoglobin has higher tendency to accept H+ ( it's a better base as compared
to oxygenated haemoglobin)
 At the level of tissues, where CO2 is more, haemoglobin accepts H+. This is due to the fact that
most of the CO2 is present as H2CO3( bicarbonate) in the body, and H2CO3 remains in an
ionized state as H+ and bicarbonate ion. Thus haemoglobin accepts H+ ( Haldane effect)
 At the level of the lungs, where O2 is more haemoglobin releases H+ and combines with O2
( oxyhaemoglobin is a stronger acid). The released H+ can combine with bicarbonate ion form
H2CO3. the latter dissociates to release CO2 to be exhaled.
 As the CO2 enters the blood from the tissues, the enzymes carbonic anhydrase present in RBC
catalyzes the formation of H2CO3. HCO3- and H+ are released on dissociation of H2CO3. Hb
acts as a buffer and immediately binds with H+ and helps to transport CO2 as HCO3- with a
minimum change in pH.
 Figure of hb buffer
Why hemoglobin buffer is more important than
plasma protein buffers?

 The Hb in blood has six times the buffering capacity of the

plasma proteins. This is because of the fact that-
1.Hb is present in large amount in blood.
2.The Hb molecule contains 38 histidine residues. So it can
accept h+.
3.The imidazole groups of deoxyhemoglobin dissociates less
than those of oxyhemoglobin making Hb a weaker acid and
therefore a better buffer than oxyhemoglobin.
 Phosphate buffer
-plays a major role in buffering renal tubular fluid and intracellular fluids.
Mechanism of action:
- the main elements of the phosphate buffer system are H2PO4- and HPO42-. When a strong
acid such as HCL is added to a mixture of these two substances, the H+ is accepted by the base
HPO42- and converted to H2PO4-
HCL+Na2HPO4→NaH2PO4+NaCL
So, HCL is replaced by a weak acid, NaH2PO4, and the decrease in pH is minimized.

When a strong base, such as NAOH is added to the buffer system, the OH- is buffered by the
H2PO4- to form additional amount of HP042- + H2O.
NaOH+NaH2PO4→Na2HPO4+H20
So, a strong base, NaOH is replaced by a weak base, NaH2PO4 causing a slight increase in pH.
Phosphate buffer

The phosphate buffer is especially important in the tubular

fluids of the kidneys, for two reasons:
1. Phosphate usually becomes greatly concentrated in the
tubules, thereby increasing the buffering power of the
phosphate system.
2. The tubular fluid usually has a considerably lower pK than
the extracellular fluid does, bringing the operating range
of the buffer closer to the pk(6.8) of the system.
 Renal regulation
1. Excretion of H+
 Renal regulation
2. Reabsorption of bicarbonate
 Renal regulation
3. Excretion of titratable acid
Titratable acidity is the measure of the acid excreted in the urine. This can
be estimated by titrating urine back to the normal pH of the blood (7.4). In
quantitative terms, titratable acidity refers to the number of milliliters of
N/10 NaOH require to 1 liter of urine to pH 7.4. It reflects the H + excreted
into the urine which result into fall of pH from 7.4. (that of blood). The
excreted H+ are actually buffered in the urine by phosphate buffer.
 Renal regulation
4) Excretion of ammonium ion in the urine
 Respiratory regulation

 Hyperventilation
 Hypoventilation
 Hyperventilation

 Raised [H+] stimulates respiratory center

↓

↑respiration(hyperventilation)
↓

↑CO2 elimination
↓

↓PCO2
↓

↑ratio of HCO3-/PCO2
↓

↑pH
↓

pH becomes normal
 Hypoventilation
Decreased [H+] inhibits respiratory center
↓

↓respiration(hypoventilation)
↓

↓CO2 elimination
↓

↑PCO2
↓

↓ratio of HCO3-/PCO2
↓

↓pH
↓

pH becomes normal
 Buffers of intracellular fluids

The H+ ions generated in the cells are exchanged for Na+ and
K+ ions. It occurs particularly in skeletal muscles which
reduces the potential danger of H+ accumulation in the cell.
 Anion gap

-difference between the main measured cations (Na+ + K+)

and anions ( Cl- + HCO3-) in plasma.
-is around 15mmol/L (range= 8-18 mmol/L)
-alteration in the anion gap leads to Acid-base disorder
 What is acid-base disorder?

 Disturbance of H+ ion concentration in the body fluid is

called acid base disorder.
 How acid base disorder occur?

  pH (H+ ion concentration) is dependent on the relative concentration (ratio) of

Blood
bicarbonate (HCO3-) and carbonic acid (H2CO3). Normally, there are 20 parts of bicarbonate to
one part of carbonic acid. If either bicarbonate or carbonic acid is increased or decreased so
that the 20:1 ratio is no longer maintained, acid base imbalance occur .

CO2+H2OH2CO3↔H++HCO3-
Parameters of acid base disorder

 pH: 7.35-7.45
 PCO2: 34-45 mm Hg
 HCO3: 24-28 mmol/L
 Anion gap: 15mmol/L (range= 8-18 mmol/L)
 Serum electrolyte especially K+ concentration
Classification of acid-base disorders

1. Simple acid base disorders

here, the pH change occurs due to change of either HCO3- or pCO2

2. Mixed or complex acid-base disorders

here, the pH change occurs due to change of both HCO3 and pCO2
Simple acid base disorders

1. Metabolic acidosis
2. Metabolic alkalosis
3. Respiratory acidosis
4. Respiratory alkalosis
Metabolic acidosis

⸋↓ in blood [HCO3-]
⸋ ↓blood pH (decrease in H+ of blood)
 Metabolic acidosis
Causes
A) Normal anion gap
a) Inorganic acid addition - therapeutic infusion or poisoning with NH4CL,HCL
b) loss of bicarbonate from GIT or in urine
-Severe diarrhea
-Small bowel fistula
-Renal tubular acidosis
-Urinary tract obstruction
B)High anion gap
a) Severe uncontrolled diabetes mellitus (ketoacidosis)
b) Lactic acidosis-(metformin)
c) Renal failure
d) Drug intoxication (aspirin,manitol,ethanol,etc)
e) Starvation(ketosis)
- Here, bicarbonates are utilized in buffering H+. So, its concentration decreases .
 Metabolic acidosis

Compensation in metabolic acidosis

CO2+H2O ↔ H2CO3↔ ↑H+ +↓ HCO3-
So, for compensation
↓H+ and ↑HCO3- and ↓CO2

 hyperactive breathing to blow off CO2

 kidney conserve HCO3- and eliminate H+ ions in acidic urine
 Metabolic acidosis

Treatment of metabolic acidosis

 Treating the underlying cause
For example- control diabetes with insulin or treat poisoning by
removing the toxic substances from the blood. Occasionally dialysis
is needed to treat severe overdoses and poisonings.

 Bicarbonate can be given IV if acidosis is severe to provide

temporary relief
Metabolic alkalosis

⸋↑ blood HCO3-
⸋ ↑blood pH (decrease in H+ of blood)
 Metabolic alkalosis
Causes
1. Excessive vomiting
-loss of H+ via acid rich fluids → ↑HCO3-
2. Excess intake of NaHCO3
-during therapeutic purposes like to control gastric acidity → ↑HCO 3-
3. Hypokalemia
- H+ are retained inside the cells to replace missing k +→ ↓H+ → ↑HCO3
4. Cushing syndrome
-hyper secretion of aldosterone causing retention of Na + and loss of K+ from the body
leading to hypokalemia.
5. Gastric outlet obstruction
6. Diuretics (except CA inhibitors and K-sparing drugs)
-increase acid loss into the urine
 Metabolic alkalosis

Compensation in metabolic alkalosis

CO2+H2O↔ H2CO3↔ ↓H+ +↑ HCO3-

So, for compensation

↑H+ and ↓HCO3- and ↑CO2

 breathing suppressed to hold CO2

 kidney conserve H+ and eliminate HCO3+ ions in
alkaline urine
 Metabolic alkalosis

Treatment of metabolic alkalosis

1. Treating the underlying cause
2. Provision of adequate IV fluid, especially isotonic
sodium chloride.
3. Potassium chloride may be needed in critical ill patients
4. Severe alkalosis (pH<7.55) may require treatment with
acidifying agents like NH4Cl, HCL or acetazolamide
Respiratory acidosis

⸋↑pCO2 level (↑H2CO3) greater than 45 mm of Hg

⸋↓blood pH below 7.35
 Respiratory acidosis
 

Causes-
{hypoventilation → inadequate excretion of CO2}
1.Lung diseases like - severe asthma, pneumonia, acute pulmonary edema,
atelectasis, pneumothorax, etc
2.Impaired respiratory muscles like muscular dystrophy,
myasthenia gravis, GBS.
3. Obstruction in air ways passage
4. Chest deformities
5. Depression of respiratory center by drugs like opiates,
narcotics, drugs overdose
 Respiratory acidosis

Compensation in Respiratory acidosis

↑CO2+H2O↔ H2CO3↔ ↑H+ +↓ HCO3-
⸋ For compensation ↓CO2 and ↓H+ and ↑HCO3-
So,
high levels of CO2 in the blood stimulates the parts of the brain that regulate
breathing, which in turn stimulates faster and deeper breathing.
And, kidney
a) reabsorbs HCO3- ions
b) eliminate H+ ion in acidic urine by buffering action of ammonia and
phosphate buffer.
Respiratory acidosis
 Respiratory acidosis

Treatment of respiratory acidosis

1. Improve ventilation
2. Mechanical ventilation; if PCO2 is high (>50 mm Hg)
3. Pharmacological agents like bronchodilators, antibiotics,
thrombolytic.
Respiratory alkalosis

⸋↓pCO2 level (↓H2CO3) lesser than 35 mm of Hg

⸋↑blood pH above 7.45
 Respiratory alkalosis

Causes
→Prolong hyperventilation resulting in exhalation of CO2 by lungs.
1. High altitude →Hypoxemia
2. Severe anemia
3. Salicylate poisoning
4. Cerebrovascular accidents, stroke, subarachnoid
hemorrhage
5. Severe anxiety
 Respiratory alkalosis

Compensation in respiratory alkalosis

∙↓CO2 + H2O ↔ H2CO3 ↔ ↓H+ + ↑HCO3-
So, for compensation
↑CO2 ↑H+ and ↓HCO3-
∙decrease respiratory rate to retain CO2
∙kidney conserve H+ and eliminate HCO3+ ions in alkaline
urine
Respiratory alkalosis
 Respiratory alkalosis

Treatment of respiratory alkalosis

1. Treating the underlying cause
2. If the cause is anxiety, the patient is instructed to breath
more slowly to allow CO2 to accumulate or to breath in close
system (such as a plastic bag)
3. Sedative to relieve hyperventilation in very anxious patient
4.Adjustment of ventilator settings.
 
Acid base disorders along with the concentration of
bicarbonate and carbonic acid in plasma
Acid base disorders with primary changes and compensatory mechanism
 Mixed or complex acid base disorder

In these case both HCO3- and PCO2 disturb the pH simultaneously

TYPES
A. Double phase
B. Triple phase
 Double phase

1. Respiratory acidosis + Metabolic acidosis

2. Respiratory acidosis + Metabolic alkalosis
3. Respiratory alkalosis + Metabolic acidosis
4. Respiratory alkalosis + Metabolic alkalosis
5. Metabolic acidosis + Metabolic alkalosis

Note: Respiratory acidosis + Respiratory alkalosis never co-exist

 Triple phase

 Metabolic acidosis + Metabolic alkalosis +

Respiratory acidosis
 Metabolic acidosis + Metabolic alkalosis +
Respiratory alkalosis
 What is Compensation?

 When the body uses the buffer, renal and respiratory

system to attempt to maintain a pH that is NORMAL, this
is called compensation.
If changes in pH doesn’t normalize, and if the value of either
pCO2 or HCO3 is abnormal, the disturbance is called
Uncompensated

If changes in pH don’t normalize, the disturbance is called

Partially compensated

If changes in pH normalize, it is called Fully compensated

Normal parameters to diagnose Acid-Base disorders
 Example 1

pH = 7.17 HCO3- = 12 PCO2 = 35

Here, acidosis is due to HCO3- . So, it is Metabolic acidosis.

PCO2 is normal and respiratory system is not doing anything to correct disorder.
So, it is Uncompensated metabolic acidosis.
 Example 2

pH = 7.54, pCO2 = 24, HCO3- =25

Here, alkalosis is due to pCO2 . So, it is Respiratory alkalosis.

HCO3- is normal and renal system is not doing anything to correct disorder.
So, it is Uncompensated respiratory alkalosis.
 Example 3

 pH=7.32 , pCO2 = 22 , HCO3- = 18

Here, acidosis is due to HCO3- . So, it is metabolic acidosis.

But, pCO2 is on alkaline side. That means respiratory system is trying to compensate pH.
So, it is Partially compensated metabolic acidosis.
 Example 4
pH= 7.45, pCO2= 48, HCO3- =48

Here, pH is normal. That means it is fully compensated.

Both pCO2 and HCO3- are abnormal. But HCO3- is more deviated than pCO2 . So it is metabolic
alkalosis.
So, it is Fully compensated metabolic alkalosis.
 Example 5
pH= 7.10 pCO2= 82, HCO3- =14

Here, HCO3- =low , pCO2 = high . So, it is acidosis.

Thus, it is combined Metabolic and respiratory acidosis.