lOMoARcPSD|29437696
Clinical Chemistry 2-Acid-Base Balance
ACID BASE BALANCE ➡ When a strong base is added, H2CO3 will combine with
the OH- ions to form H2O and the weaker conjugate base
Terms To Remember ⭐ HCO3-
• ACID - a substance that can donate/yield hydrogen ions (H+) ➡ Why is it the most important buffer system in ECF?
when dissolved in water (pH < 7.0) 1. H2CO3 dissociates into CO2 and H2O allowing
• BASE - substance that can accept hydrogen ions and can yield
CO2 to be eliminated by the lungs and H+ as
hydroxyl ions when dissolved in water (pH > 7.0)
water.
• BUFFER -
2. Changes in CO2 modify the ventilation
- the combination of a weak acid or a weak base and its salt.
(respiratory) rate.
- A system which resists changes in pH
3. HCO3- concentration can be changed by the
• ACIDOSIS
kidneys.
- Blood pH < 7.35
- Increased H+ ion
Compensatory Mechanisms ⭐
- Corresponding state in the blood: Acidemia
- Increased CO2 retained in the system • LUNGS
- Decreased bicarbonate in the system (e.g. Increased ➡ Regulates the levels of carbonic acid (H2CO3) in the
urination) blood.
• ALKALOSIS ➡ H2CO3 is broken down to CO2 and H2O —- CO2 is
- Blood pH > 7.45 exhaled by the lungs.
- Decreased H+ ion ➡ Through this process, H2CO3 is removed and blood
- Corresponding state in the blood: Alkalemia becomes basic.
- Increased bicarbonate in system (e.g. Decreased urination) ➡ Hyperventilation (Fast Respiration) = Increased loss of
H2CO3 = decreased acidity (too basic) = high pH ⬆
Buffer Systems ⭐
➡ Hypoventilation (Slow respiration) = Conservation of
•Plasma Proteins System
H2CO3 = increased acidity (less basic) = low pH ⬇
➡ Nearly all proteins can function as buffers.
• KIDNEYS
➡ Proteins are made up of amino acids that contain
➡ Regulates bicarbonate (HCO3) through reabsorption
positively charged amino groups and negatively
➡ Increased urination = Increased loss of HCO3 =
charged carboxyl groups.
acidosis
➡ Charged regions of proteins can bind hydroxyl and
➡ Decreased urination (Increased water retention) = HCO3
hydrogen ions.
• Hemoglobin/Oxyhemoglobin Buffer System is retained = alkalosis
➡ Hemoglobin is the principal protein inside the RBC.
➡ During conversion of CO2 into bicarbonate, the liberated Acid-Base Imbalances ⭐
H+ ions are buffered by hemoglobin which is reduced by the •RESPIRATORY ACIDOSIS
dissociation of oxygen. •Problem is in ventilation, perfusion, diffusion
➡ Process is reversed in pulmonary capillaries to reform CO2 •Acute RA: pH falls abnormally low
which can diffuse into air sacs to be exhaled. •Chronic RA: pH in normal limits
•RBC and Plasma Phosphates System •Lungs retain a lot of CO2.
➡ Phosphates are found in the blood in TWO forms: •CO2 mixes with water and forms carbonic acid
1. Sodium dihydrogen phosphate - weak acid • When HCO3 breaks down, H ions are released leading to
2. Sodium monohydrogen phosphate - weak base decreased pH (acidosis)
• The pK for the phosphate buffer is 6.8 which allows this •In RBCs, 2,3-DPG pushes out oxygen in the system as
buffer to function within its optimal buffering range at hydrogen competes with binding sites and CO2 enters =
physiological pH.
decreases arterial oxygen in the system
•Bicarbonate-Carbonic Acid System
•In the CSF and medulla, H+ and CO2 accumulate = brain
➡ Weak acid: carbonic acid (because it does not completely detects abnormal increase in CO2 levels and acidity in CSF
dissociate into H+ and HCO-) •What happens in the lungs?
➡ Salt of its conjugate base: bicarbonate ➡The lungs are stimulated and causes shallow and
➡ When H ions are added to the bicarbonate-carbonic acid
rapid respiration = HYPERVENTILATION (to
solution, the HCO3- will combine with the H+ to form removed excess CO2 in the system)
H2CO3. •What happens in the brain?
- Increases the amount of carbonic acid, while consuming ➡ VASODILATION of cerebral blood vessels as a
the bicarbonate ions.
result of hypercapnia = increased blood volume to
brain leading to:
• Headaches
ALSENALISTA-MLS3B
Downloaded by Mae Chaela P. Demotor ([email protected])
lOMoARcPSD|29437696
Clinical Chemistry 2-Acid-Base Balance
• Confusion ➡ This stimulates the carotid and aortic bodies of the
• Lethargy medulla in the heart, and this increases the heart
• Nausea rate WITHOUT increasing blood pressure.
• Vomitting
➡ Causes angina along with ECG changes.
• What happens in the kidney?
➡ Patient becomes restless, and shows visible symptoms of
➡ Kidneys are stimulated to increase the removal of
anxiety.
ammonium ions but bicarbonate (base) will be
•What happens in the brain?
conserved along with Na = decreased urination ➡ VASOCONSTRICTION of cerebral blood vessels
➡ Acidic urine
decreasing cerebral blood flow
➡ pH will be increased
➡ Hypocapnia overexcites the medulla and the pons
• What happens to the cell?
➡ Visible increasing anxiety in the patient
➡ H+ will go inside the cell.
➡ Diaphoresis is also seen along with dsypnea
➡ K+ will go outside. (In acidosis, there is ➡ Hypoventilation continues
HYPERKALEMIA) ➡ Dizziness = lack of blood to the brain
➡ Oxygen levels of cell drop = cells will turn to ➡ Tingling of fingers and toes
anaerobic respiration for energy = LACTIC ACID ➡ Cerebral and peripheral hypoxia will happen
PRODUCTION (arrhythmias, muscle pain) ➡ Severe alkalosis INHIBITS calcium ionization
• Causes: causing increased nerve excitability and muscle
✦ Neuromuscular problems contraction (CNS AND HEART ARE OVERWHELMED)
• Myasthenia gravis ➡ Decreasing levels of consciousness because RBCs
• Poliomyelitis cannot deliver oxygen due to vasoconstriction,
• Spinal cord injury ➡ Hyperflexia, carpopedal spasms, tetany, arrhythmia,
✦ Respiratory center depression seizures, and coma.
• CNS trauma •What happens in the kidneys?
• Brain lesions (infection) ➡ When hypocapnia lasts > 6 hours, the kidneys will now
• Obesity be stimulated and will remove bicarbonate (base)
• Primary hypoventilation ➡ Increased urination of the base to retain the acid
• Use of certain drugs
which might help slow down respiration
✦ Lung Disease
(hypoventilation)
• COPD
•Causes:
• Acute asthma attacks
✦ Hyperventilation
• Chronic bronchitis
• Acute respiratory distress syndrome •Severe pain
✦ Airway obstruction •Anxiety
•Salicylate intoxication
• Retained secretions
•Use of certain drugs
• Tumors
✦Hypermetabolic states
• Anaphylaxis
• Laryngeal spasm •Fever
•Liver failure
• RESPIRATORY ALKALOSIS
•Sepsis
• Results from alveolar hyperventilation and
✦Conditions affecting respiratory control center
hypocapnia
✦Others:
• pH is > 7.45 and pCO2 is < 35 mmHg
•Acute hypoxia secondary to high altitude
• May be acute — sudden increased ventilation
•Pulmonary disease
• May be chronic — difficult to identify
•Severe anemia
• Increased removal of CO2 because of hyperventilation.
•Pulmonary embolus
• pH will increase, and CO2, H and bicarbonate levels
•Hypotension
decrease.
•METABOLIC ACIDOSIS
• What happens to the cell?
•pH level < 7.35
➡ There is increased removal of H+ from the cell and K+
•HCO3 level < 22 mmol/L
enters the cell = HYPOKALEMIA •MA depresses the CNS and if left untreated may lead to
➡ H+ will combine with bicarbonate to produce carbonic arrhythmias, coma, and even heart attack.
acid in the blood. = bicarbonate and pH start to •MA is generally caused by HCO3 loss from the ECF or
decrease metabolic acid accumulation
• What happens in the heart? •May arise from (but not limited to) kidney disorders.
➡ CO2 levels are decreased = HYPOCAPNIA •As H+ accumulates, plasma bicarbonates and proteins will
bind to them
ALSENALISTA-MLS3B
Downloaded by Mae Chaela P. Demotor ([email protected])
lOMoARcPSD|29437696
Clinical Chemistry 2-Acid-Base Balance
• What happens in the lungs? •When HCO3 increases in bloodstream, symptoms do not
➡As pH starts to decrease continuously, it stimulates show because of the buffers
chemoreceptors in the medulla of the brain to increase •Problem starts to rise when buffers become inadequate =
increased pH and rising pCO2
respiration (this compensation occurs within minutes
•This will stimulate the medulla of the brain to signal the lungs
but is still not enough 💔 )
to reabsorb CO2 (hypoventilation) = when CO2 is
➡pH and bicarbonate will decrease, pCO2 will start to
reabsorbed it binds with water to form carbonic acid
drop, along with rapid deeper respirations
•What happens in the kidneys?
(hyperventilation)
➡ Kidneys will increase urination = alkaline urine =
• What happens in the kidneys?
bicarbonate levels will start to return to normal
➡ Because of accumulation of acids/loss of bicarbonate,
•What happens in the cells?
the H ions in the urine are buffered by phosphate or
➡ Potassium will enter the cell in exchange for H+ to
ammonia = acidic urine
➡ Sodium and bicarbonate will be reabsorbed and compensate for alkalosis = HYPOKALEMIA
➡ Symptoms: anorexia, muscle weakness, and even loss
their levels will slowly return to normal = decreased
of reflexes
urination
➡ As H+ declines, Ca2+ also decreases = nerves tend
• What happens in the cells?
to be more permeable to Na = Na stimulates the
➡ H ions will go inside the cell and K+ will exit from the
nerve cells = EXCITABILITY of CNS and PNS
cell = HYPERKALEMIA ➡Symptoms: tetany, deligirence, irritability, disorientation,
➡ Diarrhea can also be observed along with weakness or seizures
flaccid paralysis, and tingling and numbness of the
•Causes:
extremities
✦ Hypokalemia
➡ Bradycardia is also possibly observed
➡ Excess H ions will alter the normal potassium-sodium- •Use of diuretics and other drugs
✦ Excessive acid loss from the GI tract
calcium balance (electroneutrality) = reduced
•Vomitting
excitability of nerve cells = signs and symptoms of
•Pyloric stenosis
progressive CNS depression (lethargy, dull headache, •Nasogastricnemia
confusion, stupor, and coma) ✦Other causes:
• Causes: •Cushing’s disease
✦ Ketone overproduction •Overcorrection of acidosis
• Diabetes mellitus (Type I DM, especially) •Kidney disease e.g. renal artery stenosis
• Chronic alcoholism •Multiple transfusions (blood is slightly alkaline)
• Severe malnutrition
• Starvation
ACID BASE
• Hyperthyroidism pH pCO2 H2CO3 HCO3
IMBALANCES
• Severe infection with fever
✦ Lactic acidosis Respiratory
Normal
• Shock Acidosis
• Heart failure
• Pulmonary disease Respiratory
Normal
• Hepatic disorder Alkalosis
• Seizures
Metabolic
• To a normal extent, strenuous exercise Normal Normal
Acidosis
✦ Kidney disorders
• Renal insufficiency Metabolic
Normal Normal
• Renal failure with acute tubular necrosis Alkalosis
✦ GI disorders
• Renal diarrhea
• Intestinal malabsorption ACID BASE
PRIMARY COMPENSATION
• Pancreatic or hepatic fistula IMBALANCES
• Urinary diversion to the ileum
Respiratory Acidosis Kidneys retain HCO3 and excrete H+
• Hyperaldosteronism
• METABOLIC ALKALOSIS Respiratory Alkalosis Kidneys excrete HCO3 and retain H+
• pH > 7.45
• HCO3 level > 26 mmol/L Metabolic Acidosis Hyperventilate (blow off CO2)
• Generally caused by loss of H+ (acid), a gain of HCO3
(base) or both. Metabolic Alkalosis Hypoventilate (retain CO2)
ALSENALISTA-MLS3B
Downloaded by Mae Chaela P. Demotor ([email protected])
lOMoARcPSD|29437696
Clinical Chemistry 2-Acid-Base Balance
BLOOD GAS REFERENCE VALUES
ACID BASE
SECONDARY COMPENSATION
IMBALANCES
Derived Reference
Respiratory Acidosis Hyperventilation (blow off CO2) Parameter Measure of
From Range
Respiratory Alkalosis Hypoventilation (retain CO2)
pH H+ pH electrode 7.35 to 7.45
Kidneys decrease urination and retain
Metabolic Acidosis pCO2
sodium and bicarbonate (acidic urine) pCO2 ppCO2 35 to 45 mmHg
electrode
Kidneys increase urination (alkaline
Metabolic Alkalosis pO2 ppO2 pO2 electrode 80 to 110 mmHg
urine)
HCO3 Bicarbonate Calculated 22 to 26 mmol/L
EXAMPLES:
Bicarbonate
TCO2 and Carbonic Calculated 23 to 27 mmol/L
acid
ACID BASE
pH pCO2 H2CO3 HCO3
IMBALANCES 1.0 to 1.35
H2CO3 Carbonic acid Calculated
mmol/L
Metabolic
Normal Normal Hgb
Alkalosis O2 Sat Oximeter > 95%
oxygenation
Partially
Compensated
HENDERSON-HASSELBACH EQUATION
Metabolic
Alkalosis
Fully
Compensated
Normal
Metabolic
Alkalosis
ACID BASE
pH pCO2 H2CO3 HCO3
IMBALANCES
Respiratory
Normal
Acidosis
Partially
Compensated
Respiratory
Acidosis
Fully
Compensated
Normal
Respiratory
Acidosis
ALSENALISTA-MLS3B
Downloaded by Mae Chaela P. Demotor ([email protected])
