ACID-BASE BALANCE
ACID-BASE HOMEOSTASIS
• Buffers
Intracellular proteins and phosphates
Extracellular bicarbonate-carbonic acid system
• Compensation
Respiratory – changes in ventilation mediated by hydrogen sensitive
chemoreceptors found in the carotid body and brainstem
Metabolic – kidneys increase or decrease bicarbonate reabsorption in
response to respiratory acidosis or alkalosis
METABOLIC DERANGEMENTS: Metabolic
Acidosis
• METABOLIC ACIDOSIS
increased intake of acids
increased generation of acids
increased loss of bicarbonate
Compensation:
• producing buffers (extracellular bicarbonate and intracellular buffers from
bone and muscle)
• increasing ventilation (Kussmaul’s respirations)
• Increasing renal reabsorption and generation of bicarbonate
• Kidneys increase secretion of hydrogen and thus increase urinary excretion of
NH4+
Metabolic Acidosis
• Evaluation of a patient with a low serum bicarbonate level and
metabolic acidosis includes determination of the anion gap (AG), an
index of unmeasured anions.
AG = (Na) – (Cl + HCO3)
• The normal AG is <12 mmol/L and is due primarily to the albumin
effect, so that the estimated AG must be adjusted for albumin
(hypoalbuminemia reduces the AG).
Corrected AG = actual AG – [2.5(4.5 – albumin)]
Metabolic Acidosis
Increased AG Normal AG
1. ingestion of exogenous acid such as 1. Exogenous acid administration
from ethylene glycol, salicylates, or (HCl or NH4+)
methanol 2. loss of bicarbonate due to GI disorders
2. increased endogenous acid from the such as diarrhea and fistulas or
following: ureterosigmoidostomy
• β-Hydroxybutyrate and acetoacetate 3. Renal tubular acidosis
in ketoacidosis Carbonic anhydrase inhibitor
• Lactate in lactic acidosis
• Organic acids in renal insufficiency
Severe Metabolic Acidosis in Surgical Patients
• Due to Lactic Acidosis
• in circulatory shock, lactate is produced in the presence of hypoxia from
inadequate tissue perfusion.
Treatment: restore perfusion with volume resuscitation
Metabolic Alkalosis
Metabolic Alkalosis
• Majority have hypokalemia
• Hypochloremic and hypokalemic metabolic alkalosis can occur from
isolated loss of gastric contents in infants with pyloric stenosis or
adults with duodenal ulcer disease
TREATMENT
1. Replacement of Volume Deficit with Isotonic Saline
2. Potassium Replacement once adequate urine out put is achieved
RESPIRATORY DERANGEMENTS: Respiratory
Acidosis
• associated with the retention of CO2 secondary to decreased alveolar
ventilation
• compensation is primarily a renal mechanism, which is a delayed
response
Respiratory Acidosis
• Treatment
• Directed at the underlying cause
• Ensure adequate ventilation
• noninvasive bilevel positive airway pressure
• endotracheal intubation to increase minute ventilation
Respiratory Alkalosis
• Mostly due to acute and secondary to alveolar hyperventilation
• Causes
1. Pain
2. Anxiety
3. Neurologic Disorders
4. Drugs
5. Fever
6. Gram Negative Bacteremia
7. Thyrotoxicosis
8. Hypoxemia
Respiratory Alkalosis
• Acute hypocapnia can cause an uptake of potassium and phosphate
into cells and increased binding of calcium to albumin
• TREATMENT
1. underlying cause
2. direct treatment of the hyperventilation using controlled
ventilation
