ACID BASE BALANCE

Hydrogen Ion and pH

Importance: Membrane integrity Metabolic enzyme reactions Concentration: 0.0000001 mg/L pH = power of hydrogen pH = -log [H+] = 10 -7 = pH 7.0

Hydrogen Ion and pH

greater the H+ = more acidic = lower pH lesser the H+ = more basic = higher pH body fluid pH = 7.35 7.45 (narrow range)

H+
concentration

pH

Mechanisms for Regulation

Regulation of Acid-Base Balance

A. Buffer Systems
BUFFERS absorb excessive hydrogen (H+) (acid) or hydroxyl ion (OH-) (base) contains salts of either weak acids or weak bases that either:

combine with H+ when H+ increase in body fluids release H+ when H+ decrease in body fluids

3 MAJOR BUFFERS

1. PO43- buffer system

Reaction:
HPO42monohydrogen phosphate ion

H+
hydrogen ion

H2PO4dihydrogen phosphate ion

2. Proteins

amino acid side chains contains:

Carboxyl group Amine group

( -COOH ) ( -NH2 )

Reaction: -COOcarboxyl group

H+
hydrogen ion

-COOH
carboxyl group

-NH2
amine group

H+
hydrogen ion

-NH3
ammonium group

3. Bicarbonate (HCO3-)
Reaction:
CO2 + H2O H2CO3 H+ + HCO3carbon dioxide water carbonic acid hydrogen ion bicarbonate ion

B. Respiratory System

responds rapidly to a change in pH and function to bring the pH back to its normal range

C. Kidneys

powerful regulator of pH, but responds more slowly than does the respiratory system nephrons secretion of H+ into the urine and reabsorption of bicarbonate directly regulates pH

Nephrons are Microscopic Tubules That Form the Urine

Insert fig 23-4

ACIDOSIS and ALKALOSIS

ACIDOSIS

pH falls below 7.35 major effect: CNS malfunctions can become comatose

ALKALOSIS

pH increases above 7.45 major effect: hyperexcitability of the nervous system

Respiratory Acidosis and Alkalosis

Respiratory acidosis
Increased PCO2 Increased carbonic acid Increased H+ = low pH (<7.35) Increased bicarbonate

Respiratory alkalosis
Decreased PCO2 Decreased carbonic acid Decreased H+ = high pH (>7.45) Decreased bicarbonate

Respiratory Acidosis
RISK FACTORS Acute lung condition that impair alveolar gas exchange (pneumonia, edema, aspiration, neardrowning) Chronic lung disease (asthma, emphysema) Overdose of narcotics or sedatives Brain injury that affects the respiratory center MANIFESTATIONS Breathlessness, restlessness and apprehension Increased PR and RR, gradually becomes depressed Headache, dizziness Confusion, LOC Convulsions Warm, flushed skin

Respiratory Acidosis
Hypoventilation

Hypercapnia (PaCO2

pH blood

Hyperventilation

Renal buffering 48-72 hours

Compensation

Blow off CO2

Hydrogen (H+) excretion

Bicarbonate retention

Return the pH to normal

Return pH to normal

When hypoventilation causes hypercapnia, blood pH falls. If this state persists, respiratory acidosis results. Compensatory mechanisms can be initiated to return the pH to normal.

Respiratory Alkalosis
RISK FACTORS Hyperventilation due to: Extreme anxiety Elevated body temperature Overventilation with a mechanical ventilator Hypoxia Salicylate overdose MANIFESTATIONS Shortness of breath, chest tightness Light-headedness, numbness, tingling of the extremities Difficulty concentrating Tremulousness, blurred vision

Respiratory Alkalosis
Hyperventilation

Hypercapnia (PaCO2

pH blood

Hypoventilation

Renal buffering 48-72 hours

Compensation

Retain CO2

Hydrogen (H+) retention

Bicarbonate excretion

Return the pH to normal Return pH to normal

When hyperventilation causes hypocapnia, the blood pH elevates. If this state persists, respiratory alkalosis results. Compensation by the lungs and kidneys will usually be initiated to return the pH to normal.

Metabolic Acidosis and Alkalosis

Metabolic acidosis Increased H+ = low pH (<7.35) Decreased bicarbonate Heavier breathing causes decreased PCO2 Metabolic alkalosis Decreased H+ = high pH (>7.45) Increased bicarbonate Lighter breathing causes increased PCO2

Metabolic Acidosis
RISK FACTORS Conditions that nonvolatile acids in the blood ( renal impairment, DM, starvation ) Conditions that bicarbonate ( prolonged diarrhea ) Excessive infusion of chloride-containing IV fluids ( NaCl ) MANIFESTATIONS Kussmauls respirations Lethargy, confusion Headache Weakness Anorexia, nausea, vomiting and diarrhea

Metabolic Acidosis
Loss of base or Production of excess acid

serum pH

Hyperventilation

Renal buffering

Compensation

PaCO2

Hydrogen (H+) excretion

Bicarbonate retention

Serum pH

Serum pH

When base is lost or acid is produced excessively, the serum pH falls. If this state persists, metabolic acidosis results. Compensatory mechanisms will usually be initiated to attempt to return the serum pH toward normal.

Metabolic Alkalosis
RISK FACTORS
Excessive acid losses due to: Vomiting Gastric suction Excessive use of K-losing diuretics Excessive adrenal corticoid hormones due to: Cushings syndrome Hyperaldosteronism Excessive bicarbonate intake from: Antacids Parenteral NaHCO3

MANIFESTATIONS
Decreased RR and depth Dizziness Numbness and tingling of the extremities Hypertonic muscles, tetany

Metabolic Alkalosis
Excess base or loss of acid

serum pH

Hypoventilation

Renal buffering

Compensation

PaCO2

Hydrogen (H+) retention

Bicarbonate excretion

Serum pH

Serum pH

When base is accumulated or acid is lost, the serum pH elevates. If this state persists, metabolic alkalosis results. Compensatory mechanisms will usually be initiated to attempt to return pH toward normal.

Arterial Blood Gases

performed to evaluate the clients acid-base balance and oxygenation arterial blood provides a truer reflection of gas exchange in the pulmonary system

Normal Values of ABGs

pH PaO2 PaCO2 HCO3-

7.35 7.45 80 100 mmHg 35 45 mmHg 22 26 mEq/L -2 to +2 mEq/L 95 98%

Base excess
O2 saturation

Interpreting ABGs
1. Look at the pH: a. if pH less than 7.35 = acidosis b. if pH greater than 7.45 = alkalosis
2. Look at the PaCO2: a. if PaCO2 less than 35 = more CO2 exhaled b. if PaCO2 greater than 45 = less CO2 exhaled

3. Assess the pH and PaCO2 relationship for a possible respiratory problem: a. if pH less than 7.35 (acidosis) and PaCO2 is greater than 45 mmHg, retained CO2 respiratory acidosis b. if pH greater than 7.45 (alkalosis) and PaCO2 is less than 35 mmHg, lack of CO2 respiratory alkalosis

4. Look at the bicarbonate: a. if HCO3 is less than 22 mEq/L = lower bicarbonate level b. if HCO3 is greater than 26 mEq/L = higher bicarbonate level

5. Assess pH, HCO3, and base excess (BE) values for a possible metabolic problem: a. if pH less than 7.35 (acidosis), HCO3 less than 22 mEq/L and BE below -2mEq/L = low bicarbonate levels = metabolic acidosis b. if pH greater than 7.45 (alkalosis), HCO3 greater than 26 mEq/L and BE above +2 mEq/L = high bicarbonate level = metabolic alkalosis

6. Look for evidence of COMPENSATION: a. Respiratory acidosis: pH < 7.35 PaCO2 > 45 mmHg If : HCO3 is greater than 26 mEq/L = kidneys maintaining bicarbonate to minimize acidosis = RENAL COMPENSATION b. Respiratory alkalosis: pH > 7.45 PaCO2 < 35 mmHg If : HCO3 is less than 22 mEq/L = kidneys excreting bicarbonate to minimize alkalosis = RENAL COMPENSATION

pH < 7.35 HCO3 < 22 mEq/L If : PaCO2 is less than 35 mmHg = CO2 being blown off to minimize acidosis = RESPIRATORY COMPENSATION

c. Metabolic acidosis:

pH > 7.45 HCO3 > 26 mEq/L If: PaCO2 is greater than 45 mmHg = CO2 being retained to compensate for excess base = RESPIRATORY COMPENSATION

d. Metabolic alkalosis:

EXERCISES
1.

pH 7.30 pCO2 55 mmHg HCO3 25 mmHg

pH 7.49 pCO2 38 mmHg HCO3 32 mmHg

2.

3.

pH pCO2 HCO3
pH pCO2 HCO3

7.28 42 mmHg 19 mmHg

7.51 29 mmHg 25 mmHg

4.

5. pH 7.30 pCO2 38 mmHg HCO3 19 mmHg 6. pH 7.33 pCO2 33 mmHg HCO3 19 mmHg

7. pH 7.35 pCO2 29 mmHg HCO3 19 mmHg

8. pH pCO2 HCO3 9. pH pCO2 HCO3

7.28 55 mmHg 26 mmHg 7.32 55 mmHg 31 mmHg

10. pH pCO2 HCO3

7.35 55 mmHg 34 mmHg

Thank you!