pH Review

Acid and Base Balance and • pH = - log [H+]

Imbalance • H+ is really a proton
• Range is from 0 - 14
Dénes Molnár • If [H+] is high, the solution is acidic; pH < 7
• If [H+] is low, the solution is basic or
alkaline ; pH > 7

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• Acids are H+ donors.
• Bases are H+ acceptors, or give up OH- in The Body and pH
solution.
• Homeostasis of pH is tightly controlled
• Acids and bases can be:
• Extracellular fluid = 7.4
– Strong – dissociate completely in
solution • Blood = 7.35 – 7.45
• HCl, NaOH • < 6.8 or > 8.0 death occurs
– Weak – dissociate only partially in • Acidosis (acidemia) below 7.35
solution • Alkalosis (alkalemia) above 7.45
• Lactic acid, carbonic acid

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Feto-maternal acid-base Maternal & fetal acid-base

parameters balance at the end of delivery
Mother Fetus
pO2 mmHg 90-100 23-25
pCO2 mm/Hg 30-32 42-46 Mother Fetus
pH 7.4-7.44 7.3-7.35 pH 7.37-7.39 7.25-7.3
St HCO3 mE/l 21.3 22.4 St HCO3 20,3 mE/l 18-20 mE/l
pCO2 30 mmHg 50-52 mmHg
BE -4.8-5.2 mE/l -4-7.2 mE/l

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 Venous blood Arterial blood

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Small changes in pH can produce The body produces more acids

major disturbances
• Most enzymes function only with narrow
pH ranges
• Acid-base balance can also affect
electrolytes (Na+, K+, Cl-)
• Can also affect hormones
than bases
• Acids take in with foods
• Acids produced by metabolism of lipids
and proteins
• Cellular metabolism produces CO2.
• CO2 + H20 ↔ H2CO3 ↔ H+ + HCO3-

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 How the Body defends against Control of Acids
fluctuations in pH
1. Buffer systems
• Three Systems in the body: Take up H+ or release H+ as conditions
change
1. Buffers in the blood
Buffer pairs – weak acid and a base
2. Respiration through the lungs
Exchange a strong acid or base for a
3. Excretion by the kidneys
weak one
Results in a much smaller pH change

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Bicarbonate buffer Phosphate buffer

• Sodium Bicarbonate (NaHCO3) and
carbonic acid (H2CO3)
• Maintain a 20:1 ratio : HCO3- : H2CO3
HCl + NaHCO3 ↔ H2CO3 + NaCl
• Major intracellular buffer
• H+ + HPO42- ↔ H2PO4-
• OH- + H2PO4- ↔ H2O + H2PO42-

NaOH + H2CO3 ↔ NaHCO3 + H2O

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 Protein Buffers
• Includes hemoglobin, work in blood and ISF
• Carboxyl group gives up H+
• Amino Group accepts H+
• Side chains that can buffer H+ are present on
27 amino acids.
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3. Kidney excretion
• Can eliminate large amounts of acid
• Can also excrete base
• Can conserve and produce bicarb ions
• Most effective regulator of pH
• If kidneys fail, pH balance fails
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2. Respiratory mechanisms
• Exhalation of carbon dioxide
• Powerful, but only works with volatile
acids
• Doesn’t affect fixed acids like lactic acid
• CO2 + H20 ↔ H2CO3 ↔ H+ + HCO3-
• Body pH can be adjusted by changing rate
and depth of breathing
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Rates of correction
• Buffers function almost instantaneously
• Respiratory mechanisms take several
minutes to hours
• Renal mechanisms may take several
hours to days
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There are 4 Types of Acid-
base Imbalances
• Respiratory Alkalosis
• Respiratory Acidosis
• Metabolic Alkalosis
• Metabolic Acidosis
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Acid-Base Imbalances
• pH< 7.35 acidosis
• pH > 7.45 alkalosis
• The body response to acid-base
imbalance is called compensation
• May be complete if brought back within
normal limits
• Partial compensation if range is still
outside norms.
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 Compensation Acidosis
• Principal effect of acidosis is depression of the
• If underlying problem is metabolic, CNS through ↓ in synaptic transmission.
hyperventilation or hypoventilation can • Generalized weakness
help : respiratory compensation. • Deranged CNS function the greatest threat
• If problem is respiratory, renal • Severe acidosis causes
mechanisms can bring about metabolic – Disorientation
compensation. – coma
– death

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Alkalosis
• Alkalosis causes over excitability of the central
and peripheral nervous systems.
• Numbness
• Lightheadedness
• It can cause :
– Nervousness
– muscle spasms or tetany
– Convulsions
– Loss of consciousness
– Death

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 Respiratory Acidosis Respiratory Acidosis
• Carbonic acid excess caused by blood • Acute conditons:
levels of CO2 above 45 mm Hg. – Adult Respiratory Distress Syndrome
• Hypercapnia – high levels of CO2 in blood – Pulmonary edema
• Chronic conditions: – Pneumothorax
– Depression of respiratory center in brain that
controls breathing rate – drugs or head
trauma
– Paralysis of respiratory or chest muscles
– Emphysema

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Compensation for Respiratory Signs and Symptoms of

Acidosis Respiratory Acidosis
• Kidneys eliminate hydrogen ion and retain • Breathlessness
bicarbonate ion • Restlessness
• Lethargy and disorientation
• Tremors, convulsions, coma
• Respiratory rate rapid, then gradually
depressed
• Skin warm and flushed due to vasodilation
caused by excess CO2
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 Treatment of Respiratory Acidosis
• Restore ventilation
• IV lactate solution
• Treat underlying dysfunction or disease

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Respiratory Alkalosis Respiratory Alkalosis

• Conditions that stimulate respiratory
• Carbonic acid deficit
center:
• pCO2 less than 35 mm Hg (hypocapnea) – Oxygen deficiency at high altitudes
• Most common acid-base imbalance – Pulmonary disease and Congestive heart
• Primary cause is hyperventilation failure – caused by hypoxia
– Acute anxiety
– Fever, anemia
– Early salicylate intoxication
– Cirrhosis
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– Gram-negative sepsis 36

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 Compensation of Respiratory
Alkalosis
• Kidneys conserve hydrogen ion
• Excrete bicarbonate ion
Treatment of Respiratory Alkalosis
• Treat underlying cause
• Breathe into a paper bag
• IV Chloride containing solution – Cl- ions
replace lost bicarbonate ions

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Metabolic Acidosis
• Bicarbonate deficit - blood concentrations of
bicarb drop below 22mEq/L
• Causes:
– Loss of bicarbonate through diarrhea or renal
dysfunction
– Accumulation of acids (lactic acid or ketones)
– Failure of kidneys to excrete H+

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 Symptoms of Metabolic Acidosis Systemic effects of metabolic
acidosis
• Headache, lethargy
• Nausea, vomiting, diarrhea • Cardiovascular
• Coma 1. Heart: Bradycardia; arrhythmias;
• Death reduced contractility
2. Vascular: Arteriolar dilation; increased
venous tone

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Systemic effects of metabolic Systemic effects of Metabolic

acidosis acidosis
• Gastrointestinal: Gastric distention; • Metabolic/Hormonal
Intestinal effects 1. Protein wasting
• Renal: Sodium/potassium wasting; Uric 2. Organic acid synthesis;
acid retention; Hypercalciuria 3. Aldosterone secretion may be
• Electrolytes: increased;
Potassium,calcium,magnesium,phospho 4. Parathyroid hormone;
rus
5. Action on bone enhanced;
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6. Vitamin D activation may be impaired

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 Compensation for Metabolic
Acidosis
• Increased ventilation
• Renal excretion of hydrogen ions if
possible
• K+ exchanges with excess H+ in ECF
• ( H+ into cells, K+ out of cells)
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Treatment of Metabolic Acidosis
• IV lactate solution
• Met ac. – NaHCO3
NaHCO3 = NaHCO3(aiming at) –
actual NaHCO3 × f ×Body wt.
F = adult 0.3, infant 0.4, newborn 0.5
Do not increase NaHCO3 above 15 mE/l
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Metabolic Alkalosis
• Bicarbonate excess - concentration in
blood is greater than 26 mEq/L
• Causes:
– Excess vomiting = loss of stomach acid
– Excessive use of alkaline drugs
– Certain diuretics
– Endocrine disorders
– Heavy ingestion of antacids
– Severe dehydration
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 Compensation for Metabolic
Alkalosis
• Alkalosis most commonly occurs with
renal dysfunction, so can’t count on
kidneys
• Respiratory compensation difficult –
hypoventilation limited by hypoxia
Symptoms of Metabolic Alkalosis
• Respiration slow and shallow
• Hyperactive reflexes ; tetany
• Often related to depletion of electrolytes
• Atrial tachycardia
• Dysrhythmias

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Treatment of Metabolic Alkalosis

• Electrolytes to replace those lost
• Treat underlying disorder
• Metabolic alkalosis – it can be corrected
by administration of NaCl and KCl within
3-6 days. In acute cases: 2-4 mE/bwt kg
NH4Cl or arginin-HCl

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Diagnosis of Acid-Base Imbalances 3. Look at the value that doesn’t correspond
to the observed pH change. If it is inside
1. Note whether the pH is low (acidosis) or the normal range, there is no
high (alkalosis) compensation occurring. If it is outside the
normal range, the body is partially
2. Decide which value, pCO2 or HCO3- , is
compensating for the problem.
outside the normal range and could be
the cause of the problem. If the cause is
a change in pCO2, the problem is
respiratory. If the cause is HCO3- the
problem is metabolic.

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Example Diagnosis
• A patient is in intensive care because he • Metabolic acidosis
suffered a severe myocardial infarction 3 • With compensation
days ago. The lab reports the following
values from an arterial blood sample:
– pH 7.3
– HCO3- = 20 mEq / L ( 22 - 26)
– pCO2 = 32 mm Hg (35 - 45)

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 Anion gap
• Anion gap = Na+ - Cl- - HCO3-
• Normal value is 8-16 (medium: 12)
• Gap vs non-gap metabolic acidosis

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