Class: II

DR .Manidip Chakraborty
Assistant Professor
Biochemistry
Acid-Base Disorders

Acid Base
Classification of Acid-Base Disturbances

1. Acidosis (fall in pH)

a. Respiratory acidosis:
Primary excess of carbonic acid.
b. Metabolic acidosis:
Primary deficit of bicarbonate.
2. Alkalosis (Rise in pH)
a. Respiratory alkalosis:
Primary deficit of carbonic acid.
b. Metabolic alkalosis:
Primary excess of bicarbonate
3. Compensatory responses
a. Uncompensated
b. Partially compensated
c. Fully compensated.
 Acid-Base Disorders
Primary Compensatory
Change response

Metabolic Acidosis HCO3 PCO2

Alkalosis HCO3  PCO2

Respiratory Acidosis Acute  PCO2  HCO3

Chronic  PCO2  HCO3

Alkalosis Acute PCO2  HCO3

Chronic PCO2  HCO3

 Normal paCO2, low HCO3, and a pH less than 7.30

 Occurs as a result of increased production of acids

and/or failure to eliminate these acids

 Respiratory system is not compensating by increasing

alveolar ventilation (hyperventilation)
 paCO2 less than 30, low HCO3, with a pH of 7.3-7.4

 Patients with chronic metabolic acidosis are unable to

hyperventilate sufficiently to lower paCO2 for complete
compensation to 7.4
 Necessary to know about AG in metabolic acidosis

 It represents unmeasured anions in plasma (proteins,

phosphates, sulfates& organic ions like acetoacetate,
lactate)

 Formula
 AG =Na –(Cl+HcO3)

 Its normal value=10-12 mmol/l

 Concept Of Anion Gap
Na+ + K+ + UC = Cl- + HCO3- + UA

UC UA
K+
HCO3-
Na+ - Anion Gap
Cl K+
HCO3-
Na+
Anion Gap (AG): Cl-
Na+ – (Cl- + HCO3-)

Normal value is : 10 - 12
K+ ↑ed Anion Gap

Na+ HCO3-

Cl-
High AG Metabolic acidosis
High anion gap acidosis (Organic acidosis) :

HCO3 consumed in buffering excess H+

 HIGH ANION GAP METABOLIC ACIDOSIS

Methanol toxicity
Uremia of renal failure, Ketoacidoses

Diabetes mellitus,

Paraldehyde toxicity, paracitamol propylene glycol

INH/Iron toxicity,ischemia
Lactic acidosis
Ethylene glycol toxicity, Ethyl alcohol toxicity,
Salicylate toxicity, starvation
 Normal AG
K+
HCO3-

Na+ Cl-

Normal AG Hyperchloremic
Metabolic acidosis
Normal anion gap acidosis (Inorganic acidosis) :

Loss of HCO3-rich fluid from Kidney or GIT

 Normal Anion Gap Metabolic
Acidosis

D = Diarrhoea
A = Acetazolamide ( Carbonic anhydrase inhibitor)
R = Renal Tubular Acidosis
U = Ureteral diversion
Metabolic Alkalosis May be due to………

Primary excess of bicarbonate.

Alkalosis occurs when
a) excess base is added,
b) base excretion is defective or
c) acid is lost.
All these will lead to an excess of bicarbonate, so
that the ratio becomes more than 20.
Metabolic Alkalosis types………..
Type Causes Changes

Prolonged Urine Chloride <10 mmol/L;

Chloride vomiting, Hypovolemia, increased loss
Responsive Nasogastric of Cl, K, H ions. Increased
suction, Upper reabsorption of Na with
Alkalosis; GI obstruction bicarbonate; Loss of H+ and
Contractio K+. Hypokalemia leads to
alkalosis due to H+-K+
n alkalosis exchange.
Cl is reabsorbed along with
Na.
Hence urine chloride is low.
Alkalosis responds to
administration of NaCl
Loop Blocks Aldosterone secretion occurs
diuretics reabsorption of causing Na retention and
Na, K and Cl wastage of K+ and H+
Type Causes Changes

Chloride Mineralocorti-coid Urine chloride > 20 mmol/L

excess, Primary Defective renal Cl- reabsorption
resistant and secondary Associated with an underlying
metabolic hyper aldo- cause where excess
alkalosis steronism, mineralocorticoid activity results
Glucocorticoid in Bartter’s syndrome, increased
excess, Cushing’s, sodium retention with wastage of
Adrenal tumor H and K ions at the renal tubules

Exogenous Intravenous Excess base enters the body or

base bicarbonate, potential
Massive blood generation of bicarbonate from
transfusion, metabolism of organic acids like
Antacids, Milk lactate, ketoacids,
alkali syndrome, citrate and salicylate
Sodium Citrate
overload
Causes:

  Elimination of CO2

Types:

• Acute

• Chronic

Conditions:

• Factors directly depressing Respiratory Centre

• Conditions affecting the respiratory apparatus

• Others
• CO2 above normal with drop in extracellular pH.

• Disorder of ventilation.

• Rate of CO2 elimination << than production

• 5 main categories:

– CNS depression

– Pleural disease

– Lung diseases such as COPD and ARDS

– Musculoskeletal disorders

– Compensatory mechanism for metabolic alkalosis

 paCO2 is elevated with a pH in the
acceptable range

 Renal mechanisms increase the

excretion of H+ within 24 hours and
may correct the resulting acidosis
caused by chronic retention of CO2 to a
certain extent
 Causes
 Chronic lung disease ( COPD)
 Neuromuscular disease
 Extreme obesity
 Chest wall deformity
 paCO2 is low and the pH is alkalotic
 The increase in pH is accounted for
entirely by the decrease in paCO2
 Bicarbonate and base excess will be in
the normal range because the kidneys
have not had sufficient time to
establish effective compensatory
mechanisms
• Two stages of compensation

 First stage:

RBC & Tissue buffers provide H+ ions that consume some

amount of HCO3-

 Second stage operational in prolonged akalosis.

Dependant on decreased renal reclamation of HCO3- as in

metabolic alkalosis.
CONCEPT…..
 Metabolic acidosis: ∆ PaCO2 = ∆ HCO3 (Actually 1.0 – 1.5 times)
Metabolic alkalosis: ∆ PaCO2 = 0.5 ∆ HCO3 (Actually 0.5 – 1.0 times)
Respiratory acidosis:
a. Acute: Change in PaCO2 by 10 changes HCO3 by 1
b. Chronic: Change in PaCO2 by 10 changes HCO3 by 3.5

Respiratory alkalosis:
a. Acute; Change in PaCO2 by 10 changes HCO3 by 2
Change in PaCO2 by 10 changes pH by 0.08
b. Chronic: Change in PaCO2 by 10 changes HCO3 by 5
Change in PaCO2 by 10 changes pH by 0.03
CONFUSED????

LETS MAKE
IT EASY…….
Change in PaCO2 by 10 changes HCO3 by
 STEP 1: OXYGENATION STATUS

 STEP 2: VENTILATORY STATUS

 STEP 3: ACID BASE STATUS

A. Oxemia status:
Look PaO2; 80 – 100 Normal
60 – 79 Mild Hypoxia
40 – 59 Moderate Hypoxia
< 40 Severe Hypoxia
 Look at PaCO2: 35 – 45 mm Hg : Normal

(Except in Pregnancy where hyperventilation is a normal

physiology; so PaCO2 will be low normally)

If PaCO2 is Low : Pt is Hyperventilating

If PaCO2 is High : Pt is Hypoventilating

1. First, does the patient have an acidosis or an
alkalosis

2. Second, what is the primary problem – metabolic

or respiratory

3. Third, is there any compensation by the patient –

respiratory compensation is immediate while
renal compensation takes time
 pH 7.35 to 7.45
 paCO2 36 to 44 mm Hg
 HCO3 22 to 26 meq /L
 Base deficit -3 to +3
 Po2 70 to 100 mm of Hg
 So2 94 to 100%
pH < 7.35
 Acidosis (metabolic and/or
respiratory)
pH > 7.45
 Alkalosis (metabolic
and/or respiratory)
paCO2 > 45 mm Hg
 Respiratory acidosis
(alveolar hypoventilation)
paCO2 < 35 mm Hg
 Respiratory alkalosis
(alveolar
hyperventilation)

HCO3 < 22 meq/L

 Metabolic acidosis

HCO3 > 26 meq/L

 Metabolic alkalosis
So
paCO2 > 45 with a pH < 7.35 represents a respiratory
acidosis

paCO2 < 35 with a pH > 7.45 represents a respiratory

alkalosis

For a primary respiratory problem, pH and paCO2

move in the opposite direction
And

HCO3 < 22 with a pH < 7.35 represents a metabolic

acidosis

HCO3 > 26 with a pH > 7.45 represents a metabolic

alkalosis

For a primary metabolic problem, pH and HCO3 are in

the same direction, and paCO2 is also in the same
direction
NOW LOOK FOR COMPENSATION………
Stages of Compensation
It would be extremely
unusual for either the
respiratory or renal system
to overcompensate
FOR VIVA………
Respiratory Acidosis Respiratory Alkalosis
A. Pneumonia A. High altitude
B. Bronchitis, Asthma , COPD B. Hyperventilation
C. Pneumothorax C. Hysteria
D. Narcotics, Sedatives D. Febrile conditions
E. Paralysis of respiratory E. Septicemia
muscles F. Meningitis
F. CNS trauma G. Congestive Cardiac Failure
G. Ascites, Peritonitis

Metabolic Acidosis Metabolic Alkalosis

i. High anion gap A. Severe vomiting
A. Diabetic ketosis B. Cushing Syndrome
B. Lactic acidosis C. Milk alkali syndrome
C. Renal failure D. Diuretic therapy (K loss)
ii. Normal anion gap
A. Renal tubular acidosis
B. CA Inhibitors
C. Diarrhea
LETS SOLVE THE
PROBLEMS ON ACID
BASE BALANCE
Q.1

The result of an ABG report are as

follows…
PH : 7.5
HCO3- : 24 mmol/L
Pco2: 25 mmHg
Po2: 90 mmHg

DIAGNOSIS?????
ANSWER IS………

RESPIRATORY
ALKALOSIS
ACUTE OR UN COMPENSATED
Q.2

A patient with Chronic Obstructive Pulmonary

disease was admitted with respiratory infection. The
ABG results are as follows…

PH: 7.2

Pco2 : 65mmHg

Po2: 70 mmHg

Hco3- : 32 mm Hg
DIAGNOSIS?????
ANSWER IS………..

RESPIRATORY ACIDOSIS

ACUTE/UNCOMPENSATED
Q.3

A young lady who had consumed a large

dose of aspirin in a suicidal attempt was
admitted in hospital. Her blood gas
analysis report shows…

PH: 7.5

PCO2: 16 mmHg DIAGNOSIS???

Hco3- : 22 mmHg

Anion Gap : 26 meq/L

ANSWER IS……..

RESPIRATORY ALKALOSIS
IN PRESENCE OF
METABOLIC ACIDOSIS

THIS IS AN EXAMPLE OF MIXED ACID BASE DISORDER

SOMETIMES
THINGS ARE
NOT ALWAYS
EASY………..
THE ABG REPORT IS AS
FOLLOWS……

PH: 7.37

PCO2: 27 mmHg

HCO3- : 18 mmol/L
DIAGNOSIS?????