Acid Base Alteration in ICU
• Acids: is a substance that can donate hydrogen ions.
• Base: is a substance that can accept or combine with hydrogen ions.
• In the body, weak acids and weak bases regulate acid-base balance to prevent sudden changes
in the pH of the body fluids.
• PH means stable Hydrogen ions (H+).
• H+ is really a proton that is range from 0 - 14
• If [H+] is high, the solution is acidic; pH < 7
• If [H+] is low, the solution is basic or alkaline ; pH > 7
• Normal pH = 7.35 - 7.45
• 7.35 = acidosis 7.45 = alkalosis.
The Body and pH
• Homeostasis of pH is tightly controlled
• Extracellular fluid = 7.4
• Blood = 7.35 – 7.45
• < 6.8 or > 8.0 death occurs
• Acidosis (acidemia) below 7.35
• Alkalosis (alkalemia) above 7.45
Small changes in pH can produce major disturbances
• Most enzymes function only with narrow pH ranges
• Acid-base balance can also affect electrolytes (Na+, K+, Cl-) and hormones.
• pH: Measurement of acidity or alkalinity, based on the hydrogen (H+) 7.35 – 7.45
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• Pao2: The partial pressure oxygen that is dissolved in arterial blood. 80-100 mm Hg.
• PCO2: The amount of carbon dioxide dissolved in arterial blood 35– 45 mmHg
• HCO3: The calculated value of the amount of bicarbonate in the blood 22 – 26 mmol/L
• B.E: The base excess indicates the amount of excess or insufficient level of bicarbonate. -2 to
+2 mEq/L (A negative base excess indicates a base deficit in blood)
• SaO2: The arterial oxygen saturation. >95%
Changes in body system functions that occur in an acidic state
❑ decreases the force of cardiac contractions, decreases the vascular response to catecholamine's,
❑ Diminished response to the effects and actions of certain medications.
An alkalotic state
❑ interferes with tissue oxygenation
❑ Affect normal neurological and muscular functioning.
➢ Significant changes in the blood pH above 7.8 or below 6.8 will interfere with cellular
functioning, and if uncorrected, will lead to death.
H2O + CO2 H2CO3 HCO3 + H+
➢ There are two buffers that work in pairs Carbonic acid (H2CO3) and base bicarbonate
(NaHCO3).
➢ These buffers are linked to the respiratory and renal compensatory system
The Respiratory buffer response
• The blood pH will change acc.to the level of H2CO3 present.
• This triggers the lungs to either increase or decrease the rate and depth of ventilation
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• Activation of the lungs to compensate for an imbalance starts to occur within 1-3 minutes
The Renal Buffer Response
• The kidneys excrete or retain bicarbonate (HCO3-).
• If blood pH decreases, the kidneys will compensate by retaining HCO3
• Renal system may take from hours to days to correct the imbalance.
Respiratory Acidosis
• Is defined as a pH less than 7.35 with a paco2 greater than 45 mmHg.
• Acidosis –accumulation of CO2 combines with water in the body to produce carbonic acid, thus
lowering the pH of the blood.
• Any condition that results in hypoventilation can cause respiratory acidosis.
Causes
• Alveolar hypoventilation
• Increased CO2 production
Alveolar hypoventilation
• Central nervous system depression.
• Neuromuscular disorders.
• Chest wall abnormalities.
• Pleural abnormalities.
• Airway obstruction.
• Parenchymal lung disease.
• Ventilator malfunction.
Increased CO2 production
• Large carbohydrate load
• Malignant hyperthermia.
• Intense shivering.
• Prolonged seizure activity.
• Thyroid storm.
• Extensive thermal injury.
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Primary Acid-Base Disorders Respiratory acidosis
Primary Defect Alveolar Hypoventilation (↑Pco2)
Effect on pH ↓
Compensatory Response ↑ Renal HCO3 − reabsorption (↑HCO3)
S & S of Respiratory Acidosis
• Respiratory: Dyspnea, respiratory distress and/or shallow respiration.
• Nervous: Headache, restlessness, and confusion. If co2 level extremely high drowsiness and
unresponsiveness may be noted.
• CVS: Tachycardia and dysrhythmia
Management
• Increase the ventilation.
• Causes can be treated rapidly include pneumothorax, pain and CNS depression r/t medication.
• If the cause cannot be readily resolved, mechanical ventilation.
Respiratory Alkalosis
• Central stimulation (Pain, anxiety, ischemia, stroke, tumor, infection and fever)
• Peripheral stimulation (hypoxia, high altitude, pulmonary disease, severe anemia)
• Iatrogenic (ventilator induced)
Primary Acid-Base Disorders Respiratory alkalosis
Primary Defect Alveolar Hyperventilation (↓Pco2)
Effect on pH ↑
Compensatory Response ↓ Renal HCO3 − reabsorption (↓HCO3)
Signs & symptoms
• CNS: Light Headedness, numbness, tingling, confusion, inability to concentrate and blurred
vision.
• Dysrhythmias and palpitations
• Dry mouth, diaphoresis and tetanic spasms of the arms and legs.
Management
• Resolve the underlying problem
• Monitor for respiratory muscle fatigue
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• When the respiratory muscle become exhausted, acute respiratory failure may occur
Metabolic Acidosis
• Increased anion gap
• Normal anion gap (hyperchloremic)
Increased anion gap
1-Increased production of endogenous non-volatile acids:
➢ Ketoacidosis (diabetic and starvation) and lactic acidosis.
➢ Inborn errors of metabolism.
2-Ingestion of toxin.
3-Rhabdomyolysis.
Normal anion gap or hyperchloremic: Plasma [Cl-] increase to take place of the HCO3- ion lost.
1- Increased gastrointestinal losses of HCO3 (Diarrhea, Fistulae and Ureterosigmoidostomy)
2- Increased renal losses of HCO3 (Renal tubular acidosis, Carbonic anhydrase inhibitors and
Hypoaldosteronism)
3- Dilutional (Large amount of bicarbonate-free fluids).
Primary Acid-Base Disorders Metabolic acidosis
Primary Defect Loss of HCO3− or gain of H+(↓HCO3-)
Effect on pH ↓
Compensatory Response Alveolar hyperventilation to ↑ pulmonary CO2 excretion (↓Pco2)
Sign & symptoms
• CNS: Headache, confusion and restlessness progressing to lethargy, then stupor or coma.
• CVS: Dysrhythmias
• Kussmaul’s respirations
• Warm, flushed skin as well as nausea and vomiting
Management
• Treat the cause
• Hypoxia of any tissue bed will produce metabolic acids as a result of anaerobic metabolism
even if the pao2 is normal
• Restore tissue perfusion to the hypoxic tissues
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• The use of bicarbonate is indicated for known bicarbonate - responsive acidosis such as seen
with renal failure
Metabolic Alkalosis
• Loss of Acid
• Increased Bicarbonate Levels
• Decreased Extracellular Fluid Volume
• Alterations in Extracellular Electrolyte Levels
Loss of Acid
• Excessive vomiting can result in acid loss.
• Vomiting also causes alkalosis indirectly because of the loss of chloride in the vomit.
Increased Bicarbonate Levels
• Ingestion of bicarbonate in the form of bicarbonate-containing antacids used to treat indigestion
• Bicarbonate solutions may be used during cardiopulmonary resuscitation
Decreased Extracellular Fluid Volume
• Volume contraction causing less bicarbonate to be filtered across the glomerulus.
• A greater percentage of the filtered bicarbonate is reabsorbed back into the peritubular
capillaries if the rate of blood flow is also reduced.
Alterations in Extracellular Electrolyte Levels
• For example, a decrease in extracellular chloride may cause metabolic alkalosis as chloride
diffuses out of the cell and hydrogen ion shifts into the intracellular compartment
(hypochloremic alkalosis).
• Likewise, hypokalemia may cause metabolic alkalosis because of increased hydrogen excretion
by the kidneys.
Primary Acid-Base Disorders Metabolic alkalosis
Primary Defect Gain of HCO3− or loss of H+ (↑HCO3-)
Effect on pH ↑
Compensatory Response Alveolar hypoventilation to ↓ pulmonary CO2 excretion (↑Pco2)
Signs/symptoms
• CNS: Dizziness, lethargy disorientation, seizures & coma.
• M/S: weakness, muscle twitching, muscle cramps and tetany.
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• Nausea, vomiting and respiratory depression.
• It is difficult to treat.
Stepwise approach to ABG interpretation
Step 1: Acidemic or Alkalemic?
Step 2: Is the primary disturbance respiratory or metabolic?
Step 3; assess the compensation
Step: 1
• Assess the pH –acidotic/alkalotic. If above 7.5 – alkalotic. If below 7.35 – acidotic
Step 2:
• Assess the paCO2 level. PH decreases below 7.35, the paCO2 should rise.
• If pH rises above 7.45 paCO2 should fall.
If pH and paCO2 moves in opposite direction – primary respiratory problem
Step: 2
• Assess HCO3 value. If pH increases the HCO3 should also increase
• If pH decreases HCO3 should also decrease
• They are moving in the same direction primary problem is metabolic
Step: 3
• A patient can be uncompensated or partially compensated or fully compensated
• pH remains outside the normal range
• pH has returned within normal range- fully compensated though other values may be still
abnormal
• Be aware that neither the system could overcompensate
Step: 3
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• Determine if there is a compensatory mechanism working to try to correct the pH. If have primary
respiratory acidosis will have increased PaCO2 and decreased pH. Compensation occurs when the
kidneys retain HCO3.
• In an uncompensated state – when the pH and paCO2 moves in the same direction: the primary
problem is metabolic.
• The decreasing paco2 indicates that the lungs acting as a buffer response (blowing of the excess
CO2)
• If evidence of compensation is present but the pH has not been corrected to within the normal
range, this would be described as metabolic disorder with the partial respiratory compensation.
• The pH and the HCO3 moving in the opposite directions, we would conclude that the primary
disorder is respiratory and the kidneys acting as a buffer response: are compensating by retaining
HCO3 to return the pH to normal range.
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