ACID

ACID –– BASE
BASE BALANCE
BALANCE
&
& ABG
ABG ANALYSIS
ANALYSIS

BY
Dr.mohanakrishna
 Acid-Base Balance
• Ions balance themselves like a see-saw.
• Solutions turn into acids when
concentration of hydrogen ions rises
and turns to a base when it falls.
• Acid-Base Balance is measured on a
numerical value scale known as the “pH
scale”.
• pH- The concentration of hydrogen ions
• Normal pH values are 7.35- 7.45
• <7.35 pH indicates an acid
• >7.45 pH indicates an base (Alkalosis)
• A neutral solution such as water has a pH
of 7.0
• Blood has a pH of 7.4 with a variance of .05
 ACIDOSIS- ALKALOSIS
• Any condition that increases Carbonic acid
or decreases Bicarbonate base causes
acidosis.
• Any condition that increases Bicarbonate
base or decreases Carbonic acid causes
alkalosis.
• Metabolic disturbances tend to affect the
Bicarbonate side and respiratory
disturbances tend to affect the Carbonic
acid side.
4 divisions of acidosis- alkalosis
• 1. Respiratory Acidosis
• 2. Respiratory Alkalosis
• 3. Metabolic Acidosis
• 4. Metabolic Alkalosis
 RESPIRATORY ACIDOSIS
• Caused by retention of Carbon dioxide, leading to
an increase in pCO2.
• Reduction in alveolar ventilation may occur as a
result of the following:
1. Respiratory Depression including respiratory &
cardiac arrest, neuromuscular impairment, and
medications such as sedatives and hypnotics.
2. Chest wall injury including flail chest and
pneumothorax.
3. ………. Pulmonary processes including obstructed
…. Airway, COPD, and pulmonary edema.
• Patients with respiratory acidosis should
be treated by improving ventilation to
eliminate CO2.
• Assisting the ventilation will decrease
pCO2.
• Supplemental oxygen should be
administered to help correct hypoxia,
which can lead to acidosis.
 RESPIRATORY ALKALOSIS
• Hyperventilation may cause decreased
pCO2 because of excessive CO2
elimination, resulting in elevated blood pH.
• Treatment involves treating the
underlying cause of hyperventilation
• Causes of hyperventilation:
Sepsis, peritonitis, shock, and respiratory
ailments.
• Intracerebral hemorrhage, Salicylate and
Progesterone drug usage
• Cirrhosis of the liver
 METABOLIC ACIDOSIS
• Results from an accumulation of acid or
loss of a base
• 4 most common causes are lactic
acidosis, diabetic ketoacidosis, acidosis
from renal failure, and acidosis from
ingestion of toxins.
• Treatment of metabolic acidosis varies
which may include induced respiratory
alkalosis, IV administration of
A Bicarbonate.
 METABOLIC ALKALOSIS
• Results from loss of Hydrogen ions
• Treatment involves correcting underlying
problem, IV diuretics, isotonic IV solutions,
hypokalemia treated with Potassium
Causes
 Vomiting
 Diuretics
 Chronic diarrhea
 Hypokalemia
 Renal Failure
 MIXED ACID-BASE
DISTURBANCES
• Various forms of shock may produce
abnormalities of acid- base regulation.
• Patients can have a combination of
either metabolic or respiratory acidosis
or alkalosis.
• When this is present, there can be
either a mixed state acidosis or
alkalosis, compensated or partially
compensated.
 Alkalosis - manifestations
Respiratory : Hyperventilation, parathesias
of extremities & perioral area, spasm,
lightheadedness, muscle cramps, tetany
Metabolic : Hypoventilation (compensatory
mechanism), hypovolemia, muscle weakness,
muscle cramps, postural dizziness,
Hypokalemia, polyuria & polydypsia
Note: Increased pH of the CSF causes
increased irritability of central & peripheral
nervous system
 Acidosis-manifestations
Respiratory : Hypoventilation, H/A,
blurred vision, fatigue, weakness, mental
derangements, tremors, asterixis,
delirium, somnolence, papilledema
Metabolic : Hyperventilation as a
compensatory mechanism, lethargy to
coma, N&V
Both : Dysrhythmias, hypotension,
decreased cardiac contractility, reduced
responsiveness to inotropic agents
 Anion gap
• Anion gap is an 'artificial' and
calculated measure that is
representative of the unmeasured
ions in plasma or serum
• [Na+] ) − ( [Cl−]+[HCO3−] daily usage
• [Na+]+[K+] ) − ( [Cl−]+[HCO3−] with
potassium
• In normal health there are more
measurable cations compared to
measurable anions in the serum;
therefore, the anion gap is usually
positive
• 'unmeasured' anions include sulphates
and a number of serum proteins.

• The average anion gap for healthy

adults is 12-16 mEq/L
 High anion gap acidosis
• Lactic acidosis Toxins :
Ethylene glycol
• Ketoacidosis
Lactic acid
• Diabetic Methanol
ketoacidosis
Propylene Glycol
• Alcohol abuse Phenformin
• Renal failure Aspirin
Cyanide
Iron
Isoniazid
 Normal anion gap acidosis
• Gastrointestinal loss of HCO3− (i.e.,
diarrhea)
• Proximal RTA also known as type 2 RTA
• Distal RTA also known as type 1 RTA
• Ingestion of Ammonium chloride and
Acetazolamide.
• Total parenteral nutrition
• Some cases of ketoacidosis
• Mineralocorticoid deficiency (Addison's
disease)
 Why ABG?

Systemic diseases are often

accompanied by alterations in

acid-base regulations
 ABG - BASICS

• Definitions

• Acid base disorders

• How to interpret ABG

 Definitions
• pH :Is the negative logarithm of H+
activity
• Acidosis :Is a process that acidifies body
fluids, lowers plasma HCO3- and if
unopposed, will lead to fall in PH
• Alkalosis: Is a process that alkalizes body
fluids and if uncorrected , leads to rise in
PH
 Definitions

• Buffers : are pH stabilizers

– Four major buffers
• Bicarbonate

• Plasma proteins

• Hemoglobin

• phosphates
Approach to a patient with
acid base disorder
Three stages
• First : Initial clinical assessment
• Second: Acid-base diagnosis
• Finally: Clinical diagnosis
 Case 1
• A 20yr old woman is in the emergency
department following an attempted
suicide. She was stuporous & having
seizures. She was markedly
hyperventilating.

Clinical assessment
Acid-base disturbance
Clinical diagnosis
 6 steps of ABG
evaluation
1. pH : assess the net deviation of pH
2. Pattern: of HCO3- & PCO2
3. Clues: check for additional clues
4. Compensation: assess the
compensation
5. Formulation and diagnosis
6. Confirmation of diagnosis
 The 7 Easy Steps to ABG
Analysis

• Is the pH normal?
• Is the CO2 / HCO3 normal?
• Is it respiratory or metabolic disturbance?
• If respiratory is it acute or chronic?
• If metabolic acidosis is the AG ed?
• Is there appropriate compensation?
• Is the PaO2 and the PAO2 normal?
 pH
• 7.35 – 7.45
• Any deviation
• < 7.35 – acidosis must be present
• > 7.40 – alkalosis must be present
• pH – normal
– No acid – base disorder
– Compensating disorders
Pco2 & Hco3

• Respiratory or Metabolic?
• Pco2 :
– Pco2 > 45mmHg » respiratory acidosis
– Pco2 < 35mmHg » respiratory alkalosis
• [HCo3-] :
– [HCo3-]<20mmol/L»Metabolic acidosis
– [HCo3-]>28mmol/L»Metabolic alkalosis
 Respiratory

Primary respiratory disorder

Acute
Δ Expected pH=0.008xΔ Pco2
Chronic
Δ Expected pH=0.017xΔ Pco2
Compensation
• Primary respiratory disorders
– Compensation is renal
– Develops in 3-5 days
• Primary metabolic disorders
– Compensation is respiratory
– Occurs with in 12hrs
 Respiratory acidosis
ACUTE (6-24hrs)

• 1 for10 rule
• The [HCo3-] will increase by
1mmol/L for every 10mmHg
elevation in Pco2 above 40mmHg
• Expected [HCo3-] =
24+1{(Actual Pco2-40)/10}

pH decreased Pco2 increased [HCo3-] increased

 Respiratory acidosis
CHRONIC (1-4days)

• 4 for 10 rule
• The [HCo3-] will increase by
4mmol/L for every 10mmHg elevation
in Pco2 above 40mmHg
• Expected [HCo3-]=
24+4 { (Actual Pco2-40) /10 }

pH decreased Pco2 increased [HCo3-] increased

 Respiratory alkalosis
ACUTE

• 2for10rule (1/10)
• The [HCo3-] will decrease by
2mmol/L for every 10mmHg
decrease in Pco2 below 40mmHg
• Expected [HCo3-] =
24-2{(40-Actual Pco2)/10}

pH increased ,Pco2 decreased, [HCo3-] decreased

 Respiratory alkalosis
CHRONIC

• 5for10rule (4/10)
• The [HCo3-] will decrease by
5mmol/L for every 10mmHg
decrease in Pco2 below 40mmHg
• Expected [HCo3-] =
24-5{(40-Actual Pco2)/10}

pH increased ,Pco2 decreased, [HCo3-] decreased

 RESPIRATORY DISORDER
compensation

• Acidosis
– Acute: 1 for 10
– Chronic: 4 for 10
• Alkalosis
– Acute: 2 for 10
– Chronic: 5 for 10
 Metabolic Acidosis

• 1.5 + 8 rule ( winter’s formula)

• Expected Pco2 = 1.5 x [HCo3-] + 8 ± 2
• Maximal compensation may take 12-
24hrs to reach
• The limit of compensation is a Pco2 of
about 10mmHg

pH decreased Pco2 decreased [HCo3-] decreased

 Metabolic Alkalosis
• 0.7+ 21 rule
• Expected Pco2 = 0.7 x [HCo3-] + 21 ±
1.5
• Maximal compensation may take 12-
24hrs to reach
• The limit of compensation is a Pco2 of
about 10mmHg
pH increased ,Pco2 increased, [HCo3-] increased
 METABOLIC
• Acidosis
– 1.5 + 8 rule
• Alkalosis
– 0.7 + 21 rule
 Anion Gap
• AG=[Na+]-([Cl-]+[HCo3-])
• The normal AG is 12-16mEq/L
• AG 16-20mEq/L-abnormal may or may
not be due to acidosis
• If AG>20mEq/L,high AG acidosis
probably present
• If AG>30mEq/L,high AG acidosis is
almost certainly present, regardless
of HCo3- & pH
 Delta anion gap
• Is the difference between patient’s
anion gap & normal anion gap
• ΔAG=Observed AG-Upper normal AG
• ΔHCo3- =Lower normal HCo3- -
Observed HCo3-
• Uncomplicated high AG acidosis ΔAG=
ΔHCo3-
• Any significant deviation from this
implies a mixed acid – base disorder
 Delta ratio
Delta ratio =
• Increase in AG / Decrease in the
HCo3- (ΔAG/ΔHCo3-)
• Normal – should be equal to 1
• >2 – concurrent metabolic alkalosis
• < 0.8- combined high AG & normal AG
acidosis
 BE
• Is a measure of the quantity of
acid or base in millieqivalent
needed to titrate 1L of blood to a
pH of 7.4 at a temperature of
370C and a Paco2 of 40 mmHg.
• Amount of bicarbonate needed
= 0.3xBW(Kg)xBE/2
 Standard bicarbonate
• Is a calculated HCo3- value that would exist if
the patient’s Paco2 were 40mmHg and the Hb
were 100% saturated with oxygen

• Standard HCo3- >26mEq/L=Met. alkalosis

• Standard HCo3- <22mEq/L=Met. acidosis

Case scenarios

Shall we start?
 At a glance

Disease pH pCO2 HCO3

Met. acidosis

Met. alkalosis

Resp.acidosis

Resp.alkalosis
 Case 1
• A 44yr old lady with a long H/O indigestion
begins to vomit at home. She became
unwell after 4 days & admitted to hospital
with marked muscle weakness.
• ABG:pH -7.65,Paco2-48mmHg, Pao2
87mmHg, Hco3- 40mmol/L,K+ 2.1mmol/L
• what is the diagnosis?
• What treatment would you give?
 At a glance

Disease pH pCO2 HCO3

Met. acidosis

Met. alkalosis
7.65 48 40

Resp.acidosis

Resp.alkalosis
• Compensation : 0.7+ 21 rule
Pco2: 0.7 x HCO3 + 21 ± 1.5
= 49 ± 1.5 (pCO2=48)
• Simple metabolic alkalosis with
respiratory compensation
• Treatment :
– ECFV expansion with 0.9%Nacl with
K+ supplementation
 Case 2
• A 56yr old man who smoked heavily for many
years, developed worsening of cough with purulent
sputum- admitted because of difficulty in
breathing, drowsy and cyanosed.
• ABG: pH 7.2, PCo2 71mmHg,Hco3-
28mmol/L,Pao2 47mmHg
• What is the diagnosis?
• Is it compensated?
• What is the treatment?
 At a glance

Disease pH pCO2 HCO3

Met. acidosis

Met. alkalosis

Resp.acidosis
7.2 71 28

Resp.alkalosis
• Acute : ΔpH =0.008 x Δ Pco2
– 0.008 x 31=0.248 » 7.40+0.248 = 7.152
• Compensation : 1 for10 rule
Expected [HCo3-] =
24+1{(Actual Pco2-40)/10}
= 24+31/10 = 27
Acute respiratory acidosis with
metabolic compensation
• Treatment : treat hypoxia, MV and
treatment of respiratory infection if
any
 Case 3
• A 13yr old school boy was brought to the
causality having become acutely unwell. He
was alert and agitated. RR- 35/min. He
complains of tingling and numbness in the
hands
• ABG: pH 7.5, PCo2 21mmHg,Hco3-
22mmol/L,Pao2 120mmHg
• What is the diagnosis?
• Is it compensated?
• What is the treatment?
 At a glance

Disease pH pCO2 HCO3

Met. acidosis

Met. alkalosis

Resp.acidosis

Resp.alkalosis 7.5 21 22
• Acute : ΔpH =0.008 x Δ Pco2
– 0.008 x 19 = 0.152 » 7.40+0.152 = 7.55
• Compensation : 2for10 rule
Expected [HCo3-] =
24-2{(40- Actual Pco2 )/10}
= 24-38/10 = 20.2
Acute respiratory alkalosis with
metabolic compensation
• Cause :?psychogenic hyperventilation
– Fear,pain,infection……
• Treatment : reassurance, sedation if
required
 Case 4
• The following lab findings were found in a
65yr old ( uremia & vomiting)

• ABG: pH 7.5, PCo2 50mmHg,Hco3-

39mmol/L
• Na+ 155, K+ 5.5, Cl- 90,BUN 121,
glucose 77mg/dl
• What is the acid-base status?
 At a glance

Disease pH pCO2 HCO3

Met. acidosis

Met. alkalosis 7.51 50 39

Resp.acidosis

Resp.alkalosis
• Compensation : 0.7+ 21 rule
Pco2: 0.7 x HCO3- + 21 ± 1.5
= 48.3 ± 1.5 (pCO2=48)
• Metabolic alkalosis with respiratory
compensation
• AG=Na+ -(Cl-+ HCO3-)
– 155-(90 + 39) = 26
• High AG Metabolic Acidosis
• Acid base status:
Metabolic alkalosis with respiratory
compensation and High AG Metabolic Acidosis
 Case 6
• A 72yr old man is admitted in shock
with70mmHg systolic BP. He had a H/O COPD
on medication.
• Initial ABG: pH7.1,PCo2-70mmHg,Hco3-
21mmol/L,Pao2 35mmHg,SaO2-58%
• He was intubated
• Subsequent ABG: pH7.3,PCo2-
40mmHg,Hco3-19mmol/L,Pao2
87mmHg.AG: 22mEq/L
• What is the acid base disorder?
 At a glance

Disease pH pCO2 HCO3

Met. acidosis 21

Met. alkalosis

Resp.acidosis 70
7.1

Resp.alkalosis
• Acute : ΔpH =0.008 x Δ Pco2
– 0.008 x 30=0.24 » 7.40-0.24 = 7.16
• Compensation : 1 for10 rule
Expected [HCo3-] =
24+1{(Actual Pco2-40)/10}
= 24+30/10 = 27
• But the measured [HCo3-] =21
Acute respiratory acidosis and
metabolic acidosis
• Oxygenation:PAO2=65.7;P(A-a)O2=
30.7 : PaO2/FiO2= 166
• After intubation
pH7.3,PCo2-40,Hco3-19mmol/LAG: 22mEq/L
• pH slightly acidotic
• ? primary metabolic acidosis
• Compensation1.5 + 8 rule:
• Expected Pco2 = 1.5 x [HCo3-] + 8 ± 2=36.5 ±2
• The measured Pco2 is 40mmHg
• Also patient has AG of 22
• So though the pH is apparently normal the
patient has metabolic acidosis
 Case 7
• A 60yr old known diabetic admitted with
gluteal abscess.

• ABG: pH7.18,PCo2-
18mmHg,Hco3-9mmol/L .Na+
138,K+ 4.1,Cl- 11OmEq/L
• What is the acid base disturbance?
• Whether compensated?
• Clinical diagnosis?
 At a glance

Disease pH pCO2 HCO3

Met. acidosis 7.18 18 9

Met. alkalosis

Resp.acidosis

Resp.alkalosis
• Compensation 1.5 + 8 rule
• Expected Pco2 = 1.5 x [HCo3-] + 8 ± 2
= 1.5 x9 + 8 =21.5 ± 2
• AG=138-(110+9)=19
• Metabolic acidosis with
respiratory compensation
 Case 8
• A 20yr old woman is in the emergency
department following an attempted suicide
with asprin.She was stuporous & having
seizures. She was markedly
hyperventilating.
• ABG: pH7.50,PCo2-12mmHg,Hco3-
9mmol/L .Na+ 140,K+ 4.0,Cl- 1O4mEq/L
• What is the acid base disorder?
• What is the clinical diagnosis?
 At a glance

Disease pH pCO2 HCO3

Met. acidosis

Met. alkalosis

Resp.acidosis

Resp.alkalosis 7.50 12 9
• Acute : ΔpH =0.008 x Δ Pco2
– 0.008 x 28 = 0.224 » 7.40+0.224 =7.62
• But the pH is 7.5 (» associated met. Acidosis)
• Compensation : 2for10 rule
• Expected [HCo3-] =24-2{(40-Actual Pco2 )/10}
= 24-38/10 = 20.2
• But the measured [HCo3-] is 9
• AG = 27 » associated met. Acidosis.

Acute respiratory alkalosis AND

metabolic acidosis
 Case 9
• A 40yr old man for decortication for
loculated empyema
• ABG: pH7.415,PCo2-25.2mmHg, Pao2-
78.3mmHg, Sao2 94%,Hb- 7.8mg
%,Hco3-16mmol/L,BE—7.3
• Na+ 140,K+ 4.0,Cl- 1O4mEq/L
• What is the acid base disorder?
• What is the clinical diagnosis?
 At a glance

Disease pH pCO2 HCO3

Met. acidosis

Met. alkalosis

Resp.acidosis

Resp.alkalosis 7.415 25 16
• Acute : ΔpH =0.008 x Δ Pco2
– 0.017 x 25.3 = 0.430 » 7.40+0.430 =7.83
– 0.008 x 25.3 = 0.202 » 7.40+0.202 =7.602
• But the pH is 7.415 (» associated met.
Acidosis)
• Compensation : 2for10 rule
• Expected [HCo3-] =24-2{(40-Actual Pco2 )/10}
= 24-2 {(40-25 )/10 } =21
• But the measured [HCo3-] is 16
• AG = » associated met. Acidosis.

Acute respiratory alkalosis AND

metabolic acidosis
Summary
• Both Pco2 & Hco3 are low
– Metabolic acidosis (pH low)
– Respiratory alkalosis (pH high)
– Mixed
• Pco2 & Hco3 are high
– Metabolic alkalosis (pH high)
– Respiratory acidosis (pH low)
– Mixed
• Pco2 & Hco3 are in opposite directions
– A mixed disorder MUST be present
We did it!!

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