Dr.

Muhammad Younus
FCPS FRCS(Glasg)

Surgical Unit II
Holy Family Hospital Rawalpindi

3 Year Lecture
rd

ACID BASE
HOMEOSTASI
S

Acid-Base homeostasis
Cellular biochemical processes are
greatly influenced by acid-base status
of body fluids
Acid-base status is determined by [H+]
expressed as pH
Acid-base homeostasis is regulation of
[H+] to maintain a stable pH

Acid-Base homeostasis
Arterial Blood pH
Maintained at 7.35-7.45 (average 7.4)
A decrease by 0.3 =doubling of [H+]
An increase by 0.3=halving of [H+]

Acid-Base homeostasis
Arterial Blood pH
A change of 0.2 in either direction is
considered serious
pH <6.9 or >7.9 : usually fatal if lasts
for more than a short time

Acid-Base homeostasis
Arterial Blood pH
regulated by various buffering systems
Bicarbonate: Carbonic Acid is the most
important buffer in the blood
Lungs
Kidneys

Acid-Base homeostasis
Arterial Blood pH
bicarbonate to carbonic acid ratio is
20:1
Alteration in this ratio alters the pH
a decrease in the ratio = increased
acidity
an increase in the ratio = decreased
acidity

Diagnosis of Acid-Base
Disturbances

Diagnosis
Settings in which the disorder has
developed
Clinical evaluation
Arterial blood gas analysis (ABGs)

Arterial Blood Sampling

Arterial puncture
Possible Problems:
Vessel spasm
Intraluminal clotting
Bleeding & haematoma formation
Transient obstruction of blood flow
Infection

Arterial Blood Sampling

Radial Artery at the wrist: The best as
it is
Superficial
Easy to palpate & stabilize
Good collateral supply (ulnar artery)

Arterial Blood Sampling

Radial Artery puncture
Confirmation of collateral supply
by a modified Allen's test

Arterial Blood Sampling

Radial Artery puncture
Insert 20 or 21 gauge needle with a
heparinised syringe at 30 - 40 angle
Collect 3-5ml blood
Apply pressure for
5 min after removing
needle

A Practical Approach to
ABG
Blood Gas Parameters

A Practical Approach to
ABG
Blood Gas Parameters
Parameters

Normal Values

pH

7.35-7.45

pO2

100

pCO2

40

[HCO3 - ]

24 m mol/L

Base excess

+/- 2 m mol/L

A Practical Approach to
ABG
Disturbances in the
respiratory component (pCO2) or
metabolic component (HCO3-)
can lead to alterations in pH
Metabolic Acidosis
(Too little HCO3-)

Metabolic Alkalosis
(Too much HCO3-)

Respiratory Acidosis
(Too much CO2)

Respiratory Alkalosis
(Too little CO2)

A Practical Approach to
ABG
Step 1
Check the pH
pH < 7.35

Acidosis

pH > 7.45

Alkalosis

A Practical Approach to
ABG
Step 2
Check the pCO2
pH < 7.35 PCO2 < 40: metabolic acidosis
pH < 7.35 PCO2 > 40: respiratory
acidosis

A Practical Approach to
ABG
Step 2
Check the pCO2
pH > 7.45 PCO2 < 40: respiratory
alkalosis
pH > 7.45 PCO2 > 40: metabolic alkalosis

Arterial Blood Gases

pCO2
Indicates alveolar ventilation
Raised pCO2 = retention of CO2
Indicates decreased alveolar ventilation
Leads to Acidosis (Respiratory Acidosis)

Arterial Blood Gases

pCO2
Low pCO2 =
Indicates increased alveolar ventilation
Leads to Alkalosis (Respiratory Alkalosis)

Arterial Blood Gases

[HCO3-]
Decreased [HCO3-] = decreased Base
in blood
Leads to Acidosis (Metabolic
Acidosis)

Arterial Blood Gases

[HCO3-]
Increased [HCO3-] = increased Base
in
blood
Leads to Alkalosis (Metabolic
Alkalosis)

Arterial Blood Gases

Base Excess
Amount of strong acid / base needed to
return pH of blood back to 7.4
Normal base excess = +/-2meq

Arterial Blood Gases

Base Excess
Metabolic Alkalosis =

+ive

Metabolic Acidosis =

-ive

Rough estimate
Base Excess=[HCO3 -]-25

Compensatory Changes
When a primary acid-base disorder
exists, the body attempts to return the
pH to normal via the other half of
acid base metabolism

Compensatory Changes
Kidney compensates for respiratory
acid-base changes
Respiration compensates for
metabolic
acid-base changes

Compensatory Changes
Primary Disorder

Compensatory Mechanism

Metabolic acidosis

Increased ventilation

Metabolic alkalosis

Decreased ventilation

Respiratory acidosis

Increased renal reabsorption of HCO3Increased renal excretion of H+

Respiratory alkalosis

Decreased renal reabsorption of HCO3Decreased renal excretion of H+

Compensatory Changes
Primary metabolic acidosis
hyperventilation excretes excess CO2=
compensatory respiratory alkalosis
Primary metabolic alkalosis
hypoventilation retains CO2 =
compensatory respiratory acidosis
Respiratory compensation is a rapid
process

Compensatory Changes
Primary respiratory acidosis
kidney retains HCO3 - =
compensatory metabolic alkalosis
Primary respiratory alkalosis
kidney excretes HCO3 - =
compensatory metabolic acidosis
Renal compensation is a slow process

Acid-Base Disorders In
Surgical Patients

Respiratory Acidosis
pH

CO2

Occurs when alveolar ventilation is

insufficient to excrete metabolically
produced CO2

Respiratory Acidosis
Causes
Respiratory Center Depression
Anesthetic agents
Sedatives/narcotic analgesics

Muscle relaxants
Thoracic / upper abdominal incisions
Chronic obstructive pulmonary
diseases
Chronic bronchitis

Respiratory Acidosis
Treatment
O2 therapy
Narcotic antagonists
Postoperative pain relief
Assisted ventilation

Respiratory Alkalosis
pH

CO2

Occurs as a result of acute or chronic

hyperventilation

Respiratory Alkalosis
Causes
Excessive pulmonary ventilation
(patient on ventilator)
Peroperative
ICU
Hyperpyrexia
Sepsis
Pain
CNS infection / head injury
Hysterical patients

Respiratory Alkalosis
Features
Pallor
Fall in blood pressure
Tetany (fall in serum ionized Ca++ levels)
Respiratory arrest

Respiratory Alkalosis
Treatment
Treatment of cause (pain, anxiety,
sepsis)
Monitoring minute volume & blood
gases
Capnograph in ventilated patients

Metabolic Acidosis
pH

HCO3-

Accumulation of nonvolatile acids or

loss of alkali

Metabolic Acidosis
Causes
Increased acid production
Diabetes mellitus
Lactic acidosis
Sepsis
Drugs (salicylates, phenformin)

Metabolic Acidosis
Causes
Decreased acid excretion
Sepsis
Renal failure
Shock
Ureterocolic Anastomosis
Increased loss of HCO3Diarrhea
Pancreatic fistula

Metabolic Acidosis
Features
Rapid, deep (sighing) breathing
Acidic urine
Pallor

Metabolic Acidosis
Treatment
Treatment of the cause
HCO3- administration

Metabolic Alkalosis
pH

HCO3A condition of base excess or

a deficit of any acid other than
H2CO3

Metabolic Alkalosis
Features
Cheyne-Stokes respiration
Tetany

Metabolic Alkalosis
Treatment
Correction of the cause

Eid Mubarik