AfraTafreeh.

com

Acid-Base Principles
Jason Ryan, MD, MPH
Acid-Base Balance
• Normal arterial pH: 7.37 to 7.42
• Tightly controlled
• Lungs: excrete carbon dioxide
• Kidneys: excrete acid & produce bicarbonate
AfraTafreeh.com

Public Domain Patrick J. Lynch, medical illustrator

 AfraTafreeh.com

Henderson-Hasselbalch Equation
Maintained by kidneys

[HCO3-]
pH = 6.1 + log
0.03*pCO2

Maintained by lungs
Arterial Blood Gas
HCO3-: 24
• Normal HCO3- = 22 – 26 mEq/L
PCO2: 40
• Normal pCO2 = 35 – 45 mmHg
• Normal pH = 7.37-7.42 pH: 7.4

AfraTafreeh.com

Twitter/Public Domain
 AfraTafreeh.com

Acid-Base Disorders
• Acidosis/alkalosis
• Disorder-altering H+ levels
• Acidemia/alkalemia
• Presence of low or high pH in bloodstream
• Acidosis without acidemia occurs in mixed disorders
• i.e. acidosis + alkalosis at same time
Acidosis Effects
• Hyperventilation
• Myocardial depression (↓ contractility)
• Cerebral vasodilation
• CO2: major cerebral autoregulator
• CO2 → ↓ pH: increased cerebral blood flow
AfraTafreeh.com
• Increased intracranial pressure → headaches
• Hyperkalemia RobinH/Wikipedia
• High H+ shifts into cells in exchange for K+

[HCO3-]
pH = 6.1 + log
0.03*pCO2
 AfraTafreeh.com

Alkalosis Effects
• Hypoventilation
• Cerebral vasoconstriction
• Decrease in cerebral blood flow
• Hypokalemia
Acid-Base Disorders
• Metabolic Disorders
• Excess or insufficient HCO3-
• Metabolic acidosis (↓ HCO3-)
• Metabolic alkalosis (↑ HCO3-) [HCO3-]
• Respiratory disorders pH = 6.1 + log
AfraTafreeh.com
• Excess or insufficient CO2
• Respiratory acidosis (↑ CO2) 0.03*pCO2
• Respiratory alkalosis (↓ CO2)
 AfraTafreeh.com

Acid-Base Problems
• Given pH, CO2, HCO3-
• What is the disorder?

Flikr/Public Domain
Acid-Base Problems
1. Check the pH
• pH < 7.37 = acidosis
• pH > 7.42 = alkalosis
2. Check the HCO3- and pCO2
• Increased or decreased?
AfraTafreeh.com
• HCO3- : normal 22-26 mEq/L
• pCO2 from ABG: normal 35-45mmHg
 AfraTafreeh.com

Acid-Base Problems
3. Determine acid-base disorder
• Acidosis + ↓ HCO3- = metabolic acidosis
• Acidosis + ↑pCO2 = respiratory acidosis
• Alkalosis + ↑HCO3- = metabolic alkalosis
• Alkalosis+ ↓ pCO2 = respiratory alkalosis

[HCO3-]
pH = 6.1 + log
0.03*pCO2
Acid-Base Problems
4. Calculate anion gap (metabolic acidosis)
5. Use special formulas to check for mixed disorders
• Combined respiratory/metabolic
• Two metabolic disorders
AfraTafreeh.com
 AfraTafreeh.com

Compensatory Changes
• HCO3- and CO2 are not independent
• Abnormal HCO3- → Abnormal CO2
• Abnormal CO2 → Abnormal HCO3-
• This is called compensation

[HCO3-]
pH = 6.1 + log
0.03*pCO2
Compensatory Changes
• Respiratory disorders → abnormal CO2
• Compensation: HCO3- (renal)
• Metabolic disorders → Abnormal HCO3-
• Compensation CO2 (respiratory)
AfraTafreeh.com

[HCO3-]
pH = 6.1 + log
0.03*pCO2
 AfraTafreeh.com

Compensatory Changes

Acid-Base Disorder Primary Abnormality Compensation

Metabolic Acidosis ↓ HCO3- ↓ CO2
Metabolic Alkalosis ↑ HCO3- ↑ CO2
Respiratory Acidosis ↑ CO2 ↑ HCO3-
Respiratory Alkalosis ↓ CO2 ↓ HCO3-

[HCO3-]
pH = 6.1 + log
0.03*pCO2
Compensatory Changes
• Most acid-base disorders: HCO3- and CO2 abnormal
• One is “culprit” causing disorder
• Other is compensatory change

AfraTafreeh.com

[HCO3-]
pH = 6.1 + log
0.03*pCO2
 AfraTafreeh.com

Compensatory Changes
• Simple disorders
• Culprit and compensatory change: same direction
• HCO3- and pCO2 both increased or both decreased

Example 1
pH = 7.30 (acidosis)
HCO3- = low
pCO2 = low
Metabolic acidosis with respiratory compensation

[HCO3-]
pH = 6.1 + log
0.03*pCO2
Compensatory Changes
• Simple disorders
• Culprit and compensatory change: same direction
• Both increased or both decreased

Example 2
AfraTafreeh.com
pH = 7.30 (acidosis)
HCO3- = high
pCO2 = high
Respiratory acidosis with metabolic compensation
 AfraTafreeh.com

Respiratory Compensation
• Hyperventilation or hypoventilation
• Alters CO2
• Compensates for metabolic disorders (HCO3-)
• Hyperventilation
• Physiologic response to metabolic acidosis
• Kussmaul breathing = deep, labored breathing
• Trying to blow off CO2

Patrick J. Lynch, medical illustrator

Respiratory Compensation
• Hyperventilation
• Blows off CO2
• Plasma CO2 level falls
• Less H+ in blood
[HCO3-]
• pH rises
pH = 6.1 + log
• Hypoventilation AfraTafreeh.com 0.03*pCO2
• Retains CO2
• Plasma CO2 level rises
• More H+ in blood
• pH falls
 AfraTafreeh.com

Renal Compensation
• Acidosis [HCO3-]
• Serum bicarbonate increases pH = 6.1 + log
• Excess H+ filtered/secreted
• Bicarbonate reabsorbed 0.03*pCO2
• Bicarbonate generated
• Alkalosis
• Reverse of acidosis

Public Domain
Compensation Timeframe
• Respiratory compensation to metabolic disorders
• Occurs in minutes
• Rapid change in respiratory rate
• Metabolic compensation to respiratory disorders
• Chronic, significant compensation in days from kidneys
AfraTafreeh.com

Public Domain
 AfraTafreeh.com

Mixed Disorders
• Two disorders at same time
• Metabolic acidosis AND respiratory acidosis
• Metabolic acidosis AND metabolic alkalosis
• Two metabolic acidoses
• Occurs in many pathologic states
• Example: vomiting and diarrhea
Mixed Disorder Recognition
• Determine “expected” response
• Expected HCO3- for respiratory disorder
• Expected CO2 for metabolic disorder
• If actual ≠ expected → 2nd disorder present
• Compensation back to normal pHAfraTafreeh.com
very rare
• Normal pH usually implies a mixed disorder
 AfraTafreeh.com

Mixed Disorder Recognition

• If actual ≠ expected, determine abnormality
• Example: CO2 higher than expected
• Example: HCO3- lower than expected
• Usual rules then apply for determining 2° disorders:
• ↑ CO2 = respiratory acidosis
• ↓ CO2 = respiratory alkalosis
• ↓ HCO3- = metabolic acidosis
• ↑ HCO3- = metabolic alkalosis
Compensation Formulas
• Winter’s Formula
• Metabolic Alkalosis Formula
• Acute/Chronic Respiratory Equations
• Delta-Delta
AfraTafreeh.com
 AfraTafreeh.com

Metabolic Acidosis
• Compensatory respiratory alkalosis (↓ CO2)
• Hyperventilation
• Winter’s Formula:
• Calculates expected CO2
• If actual CO2 ≠ expected, mixed disorder

pCO2 = 1.5 (HCO3-) + 8 +/- 2

Metabolic Acidosis
• Compensatory respiratory alkalosis (↓ CO2)
• Hyperventilation
• Winter’s Formula: pCO2 = 1.5 (HCO3-) + 8 +/- 2
• Calculates expected CO2
• If actual CO2 ≠ expected, mixed disorder
AfraTafreeh.com

Example 1
pH = 7.23 (acidosis)
HCO3- = 9 mEq/L (nl = 24)
pCO2 = 22 mmHg (nl=40)
Expected pCO2 = 1.5 (9) + 8 = 22 +/- 2
 AfraTafreeh.com

Metabolic Acidosis
• Compensatory respiratory alkalosis (↓ CO2)
• Hyperventilation
• Winter’s Formula: pCO2 = 1.5 (HCO3-) + 8 +/- 2
• Calculates expected CO2
• If actual CO2 ≠ expected, mixed disorder

Example 2
pH = 7.10 (acidosis)
HCO3- = 12 mEq/L (nl = 24)
pCO2 = 40 mmHg (nl=40)
Expected pCO2 = 1.5 (12) + 8 = 26 +/- 2
pCO2 > expected
Concomitant Respiratory Acidosis
 1) Check the pH <7.37 >7.42
Acidosis Alkalosis

2) Check the HCO3– and ↓ HCO3– ↑ pCO2 ↑ HCO3– ↓ pCO2

pCO2 (<24) (>40) (>24) (<40)

3) Determine Acid–Base Metabolic Respiratory Metabolic Respiratory

Disorder AfraTafreeh.com
Acidosis* Acidosis Alkalosis Alkalosis

4) Calculate Anion Gap

(*Metabolic Acidosis)

5) Use special formulas Winter’s Acute/Chronic Metabolic Acute/Chronic

to check for mixed Formula, Respiratory Alkalosis Respiratory
disorder Delta–Delta Formulas Formula Formulas

Slide Credit: Christian Gronbeck