Undergraduate Clinical Pharmacy Program

Fall 2018
Acid-Base Balance
Normal pH of blood??????
Hypocapnia?????
Acidosis and Alkalosis?????
 Normal Acid-Base Balance
•Normal pH 7.35-7.45
•Narrow normal range
•Compatible with life 6.8 – 7.8
•< 6.8 or > 7.8 incompatible with life
___/______/___/______/___
6.8 <7.35 7.45˃ 7.8
Acid Acidosis Alkalosis Alkaline
 Acid- Base balance

Balance maintained by:

• Buffering systems

• Lungs

• Kidneys
 Buffer Systems

Bicarbonate • most important

buffer • Active in ECF and ICF

Phosphate • (Na2PO42-/NaH2PO4- )
buffer • Active in ICF fluid

Protein
buffer

Hemoglobin
 Bicarbonate-Carbonic Acid
• Body’s major buffer
• Carbonic acid - H2CO3 (Acid)
• Bicarbonate – HCO-3 (Base)
 Bicarbonate-Carbonic Acid
• Body’s major buffer
• Carbonic acid - H2CO3 (Acid)
• Bicarbonate - HCO3 (Base)

1.2 mEq/L 24 mEq/L

H2CO3 ……………… HCO3
1 20

pH = 7.4
 How does the buffer work
CO2 +H2O H2CO3 H+ + HCO3-
hyperventilation

Increase in
H+

Reaction shift
 How does the buffer work
CO2 +H2O H2CO3 H+ + HCO3-
hypoventilation

decrease in
H+

Reaction shift
Sources of endogenous acids:
• Carbonic acid formation: CO2 produced
metabolically combines with water in blood to form
H2CO3

• Inorganic acids: high protein diet (sulfuric acid and

phosphoric acid)

• Organic acids resulting from metabolism: lactic acid

• Drugs as corticosteroids, enhance catabolism of

muscle proteins thus cause endogenous acid
production
Endogenous bases:
• Generated from anionic amino acids in diet
(glutamate and aspartate)

• Generated from carbohydrate metabolism

Acid- Base balance
 Respiratory regulation

Hyperventilation Hypoventilation
Blow off CO2 Retain CO2
pH pH

➢Rapid regulation……. Seconds to

minutes
➢Measured by PCO2
normal value (35-45 mm Hg)
 Renal Regulation
Retention of Retention of
HCO-3 / Excretion H+ / Excretion
of H+ Of HCO-3
pH pH

➢Slow regulation……. Hours to days

➢Measured by HCO-3
normal value (22-26 mEq/L)
 Pathophysiological changes in Acid-
Base Imbalances

Acidosis Alkalosis

disorders that disorders that

lower arterial elevate arterial
pH to < 7.35 pH to > 7.45

Acidemia Alkalemia
pH <7.35 pH>7.45
 Acidosis • Increase in blood
(acidemia) carbonic acid (pCO2)
Hypercapnia
pH< 7.35 • Decrease in
bicarbonate

• Increase in
Alkalosis bicarbonate
(alkalemia) • Decrease in carbonic
acid (pCO2)
pH> 7.45 Hypocapnia
 Acid-Base Imbalances
• change in body function that
Primary causes abnormality in pCO2 or
serum HCO-3
change
• compensatory mechanism that
Secondary act to minimize the changes in
pH caused by the primary
change change

• presence of one primary disorder

Acid base with appropriate secondary
response
disorder
 Metabolic versus Respiratory
acid-base disorders

Metabolic Respiratory
• Systemic • respiratory
alterations alterations
• Change in the • Change in the
plasma bicarbonate PCO2, reflecting an
concentration and increase or decrease
result from the in alveolar
addition or loss of ventilation.
nonvolatile acid or
alkali to or from the
extracellular fluid.
 Acid Base disorders
Four Basic Types of Imbalance

• Respiratory Acidosis
• Respiratory Alkalosis
• Metabolic Acidosis
• Metabolic Alkalosis
 Respiratory Acidosis
(acidosis due to respiratory change)

Exhaling of Carbonic
Hypoventilation CO2 acid builds H2CO3
inhibited up

pH <7.35
 Respiratory Acidosis
(acidosis due to respiratory change)

CO2 +H2O H2CO3 H+ + HCO3-

increase in PCO2
(Hypercapnia)
decrease elimination H2CO3
of CO2

pH
Causes:
Any compromise in the essential components of breathing
 Acid-Base Imbalances
• Normal

1.2 mEq/L 24 mEq/L

H2CO3 ……………… HCO3
1 20

7.4
Respiratory Acidosis

1 13
7.21
 Respiratory Acidosis
• Compensation: How?
• Opposite regulating mechanism
• Problem = depressed breathing,
build up of CO2 in blood
• Response - Kidney retains HCO3
(Response ….. Slow)
 Causes
• Airway obstruction
• Cardiac arrest (acute) depression of medullary
respiratory center
• Central nervous system trauma
• Chronic bronchitis, extensive pneumonia
• Chronic metabolic alkalosis Why?????????
• Drugs ( opioids, general anesthetics, hypnotics,
alcohol and sedatives)
 Signs and symptoms
• Restlessness caused by hypoxemia
• Change in the level of consciousness
• Headache
Diagnosis
• PaCO2 > 45mmHg
• Hyperkalemia Why???????
• Acidic urine Why??????????
 Respiratory Alkalosis
(alkalosis due to respiratory change)

Exhaling of Carbonic
Hyperventilation CO2 acid H2CO3
increased decreases

pH >7.45
 CO2 +H2O H2CO3 H+ + HCO3-

decrease in PCO2
(Hypocapnia)
Increase elimination
of CO2 H2CO3

pH

Causes:
Pulmonary hyperventilation
 Acid-Base Imbalances
• Normal

1.2 mEq/L 24 mEq/L

H2CO3 ……………… HCO3
1 20

7.4
Respiratory Alkalosis

1 40
7.70
 Causes
• Pulmonary: severe hypoxemia, pneumonia,
acute asthma
• Non-pulmonary: anxiety, fever, aspirin
toxicity, metabolic acidosis, central nervous
system disease
 Signs and symptoms

• Deep, rapid breathing, CNS and

neuromascular disturbances
• Dizziness due to decreased cerebral blood
flow
 Respiratory Alkalosis
• Compensation:
• Problem = excess “blowing off”
of CO2
• Result = decrease in carbonic
acid and increase in HCO3
• Response: Kidney excretes excess
bicarbonate (Basic urine)
 Metabolic Acidosis
(acidosis due to metabolic change)

gain in H+
(lactic acid or ketoacidosis)
Low plasma Low pH
bicarbonate (< 7.35)
loss of HCO3
(renal failure and diarrhea)
 CO2 +H2O H2CO3 H+ + HCO3-

loss of HCO3-
decrease in PCO2
(Hypocapnia) Hyperventilation to expel CO2

That’s why chronic metabolic acidosis can result in

Respiratory alkalosis (hyperventilation is its main cause)
 Acid-Base Imbalances
• Normal

1.2 mEq/L 24 mEq/L

H2CO3 ……………… HCO3
1 20

7.4
Metabolic Acidosis

1 10
7.10
 Causes
• Excessive fat metabolism in absence of
carbohydrates: diabetic ketoacidosis, chronic
alcoholism, mal nutrition or a low – carbohydrate,
high fat diet producing more ketoacids than the
metabolic process can handle.
FAT BURN ON FLAME OF CARBOHYDRATES
• Anaerobic carbohydrate metabolism causing an
increase in lactic acid level
• Diarrhea or loss of sodium bicarbonate from the
intestine
• Salycilate intoxication (overuse of aspirin)
 Signs and symptoms

• Headache and lethargy progressing to

drowsiness coma and death if condition is
severe and untreated
• Deep , rapid breathing to expel CO2
• Fruity smelling breath from fat catabolism
and excretion of acetone through the lungs
in diabetes mellitus
 Metabolic Acidosis
• Compensation:
• Problem = low HCO3 (base) or high
H+ ion (acid)
• Response: Lungs hyperventilate
• Get rid of CO2
Renal: increase H+ secretion and
reabsorption of HCO3-
 Metabolic Alkalosis
• Bicarbonate excess
• High pH (> 7.45)
• Loss of H+ ion or gain of HCO3
• Most common causes vomiting,
gastric suctioning
• Other: Abuse of antacids, K+
wasting diuretics(hypokalemia)
 Metabolic Alkalosis
(alkalosis due to metabolic change)

Loss of H+ ion
(Vomiting and gastric
suction)
increase High pH
gain of HCO3 plasma
(antacids abuse and bicarbonate (> 7.45)
K+ wasting diuretics)
 CO2 +H2O H2CO3 H+ + HCO3-

Increase in HCO3-
increase in PCO2
(Hypercapnia) Hypoventilation to retain CO2

That’s why chronic metabolic alkalosis can result in

Respiratory acidosis (hypoventilation its main cause)
 Acid-Base Imbalances
• Normal

1.2 mEq/L 24 mEq/L

H2CO3 ……………… HCO3
1 20

7.4
Metabolic Alkalosis

1 30
7.58
 Causes
• Chronic vomiting (causes of critical acid
loss)
• Excessive intake of absorbable alkali,
bicarbonate of soda or other antacids, IV
fluids with high concentration of
bicarbonate (causes of bicarbonate
retention)
• Alteration in extracellular electrolytes level
including low chloride (hypochloremia),
low plasma potassium (hypokalemia)
 Signs and symptoms
• Slow shallow respiration
• Nausea, vomiting
 Metabolic Alkalosis
• Compensation:
• Problem = too much base
• Response: Lungs compensate by
hypoventilating
• Retain CO2
• Renal: excrete less acid and more base
Interpreting arterial blood gas
values (ABGs)
• pH 7.35 - 7.45
• PaCO2 35 - 45 mmHg
• HCO3 22 - 26 mEq/L
 Interpreting ABGs
1. Start with pH
– Normal?
– Acidosis?
– Alkalosis?
___/______/___/______/___
6.8 7.35 7.45 8.0
Acidosis Alkalosis
 Interpreting ABGs
2. Assess PaCO2
(respiratory value)
_____/________/______
35 45
Respiratory Respiratory
Alkalosis Acidosis
 Interpreting ABGs
3. Evaluate metabolic indicators
Bicarbonate (HCO3) 22-26
 Interpreting ABGs
HCO3
_______/_______/________
22 26
Metabolic Metabolic
acidosis alkalosis
 Practice Problem
• 80 year old female with severe
pneumonia, fever
• pH = 7.25
• PaCO2 = 55 mm Hg
• HCO3 = 24 mEq/L
Practice Problems
What is the problem?
Acidosis or alkalosis?
Respiratory or metabolic?
Compensation
1) Is it an acidosis or an alkalosis?
What is the pH? Is there an acidosis (<7.35) or alkalosis
(>7.45)?
2) Is the problem respiratory or metabolic in nature?
Look for the match. If the CO2 matches the altered pH the
problem is associated with the respiratory system. If the HCO3-
corresponds with the altered pH, then the problem is metabolic
in nature.
3) Is there any compensation occurring? Has the body tried to
fix the problem?
Has the other component (opposite to where the problem lies)
gone outside of its reference range? And to what effect? Has the
body done a good job of fixing the problem?
Compensated = the pH is close to or within normal ranges
Uncompensated = the pH is outside of normal ranges
 Thank you

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