Acid-Base Balance

Interactive Tutorial

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Objectives:
Define acid base balance/imbalance

Explain the pathophysiology of organs

involved in acid base balance/imbalance

Identify normal/abnormal and
compensated/uncompensated
lab values
Explain symptoms related to acid base
imbalances and compensated vs.
uncompensated
Appropriate interventions and expected
outcomes

Main Menu:
Acid-Base Pretest

The Buffer Systems

Acid-Base Review test

Metabolic Distubances

Respiratory Disturbances

Acid-Base Compensation

Diagnostic Lab Values

ABG Interpretation
& Case Studies

Acid-Base Pretest:
What is the normal

range for arterial

blood pH?
7.38 7.46

7.40 7.52

7.35 7.45

Acid-Base Pretest:
What 2 extracellular substances work together

to regulate pH?
Sodium bicarbonate
& carbonic acid

Carbonic acid
& bicarbonate

Acetic acid & carbonic acid

Acid-Base Pretest:
Characterize an acid & a base based on the

choices below.
Acids release hydrogen (H+) ions
& bases accept H+ ions.

Acids accept H+ ions & bases

release H+ ions

Both acids & bases can release

& accept H+ ions

Acid-Base Pretest:
Buffering is a normal body mechanism

that occurs rapidly in response to acidbase disturbances in order to prevent

changes in what?
HCO3-

H2CO3

H+

Acid-Base Pretest:
What are the two systems in the body that

work to regulate pH in acid-base balance &

which one works fastest?
The Respiratory & Renal systems
Renal

The Respiratory & Renal systems

Respiratory

The Renal & GI systems

Renal

Acid-Base Balance:
Homeostasis of bodily fluids at a normal

arterial blood pH
pH is regulated by extracellular carbonic
acid (H2CO3) and bicarbonate (HCO3-)
Acids are molecules that release
hydrogen ions (H+)
A base is a molecule that accepts or
combines with H+ ions

Acids and Bases can be

strong or weak:
A strong acid or base is one that

dissociates completely in a solution

- HCl, NaOH, and H2SO4
A weak acid or base is one that

dissociates partially in a solution

-H2CO3, C3H6O3, and CH2O

The Body and pH:

Homeostasis of pH is controlled through
Protein
Buffer
system

HCO3Buffer
system

K+ - H+
Exchange

extracellular & intracellular buffering

systems
Respiratory: eliminate CO2
Renal: conserve HCO3- and eliminate
H+ ions
Electrolytes: composition of extracellular
(ECF) & intracellular fluids (ICF)
- ECF is maintained at 7.40

Quick Review: Click the Boxes

A donator of H+ ions
An Acid is:
w/ pH <7.0

An acceptor of H+
A Base is:
ions w/ pH >7.0

Regulated by EC
pH is: H2CO3 & HCO3

Controlled by EC
pH is:
& IC buffer systems

Eliminates CO2

Conserves HCO3Renal System:

Eliminates H+ ions

Respiratory System:

Respiratory Control Mechanisms:

Works within minutes to control pH; maximal in

12-24 hours
Only about 50-75% effective in returning pH to
normal
Excess CO2 & H+ in the blood act directly on
respiratory centers in the brain
CO2 readily crosses blood-brain barrier
reacting w/ H2O to form H2CO3
H2CO3 splits into H+ & HCO3- & the H+
stimulates an increase or decrease in
respirations

Renal Control Mechanisms:

Dont work as fast as the respiratory

system; function for days to restore pH

to, or close to, normal
Regulate pH through excreting acidic or
alkaline urine; excreting excess H+ &
regenerating or reabsorbing HCO3 Excreting acidic urine decreases acid in
the EC fluid & excreting alkaline urine
removes base
H+ elimination
& HCO3conservation

Mechanisms of Acid-Base
Balance:
The ratio of HCO3- base to the volatile H2CO3
Phosphate
Buffer
system

Ammonia
Buffer
system

determines pH
Concentrations of volatile H2CO3 are regulated
by changing the rate & depth of respiration
Plasma concentration of HCO3- is regulated by
the kidneys via 2 processes: reabsorption of
filtered HCO3- & generation of new HCO3-, or
elimination of H+ buffered by tubular systems to
maintain a luminal pH of at least 4.5

Acid-Base Balance Review test:

The kidneys regulate pH by excreting

HCO3- and retaining or regenerating H+

TRUE

FALSE

Acid-Base Review test:

H2CO3 splits into HCO3- & H+ & it is the

H+ that stimulates either an increase or

decrease in the rate & depth of
respirations.
TRUE

FALSE

Acid-Base Review test:

Plasma concentration of HCO3- is

controlled by the kidneys through

reabsorption/regeneration of HCO3-, or
elimination of buffered H+ via the tubular
systems.
TRUE

FALSE

Acid-Base Review test:

The ratio of H+ to HCO3- determines

pH.
TRUE

FALSE

Acid-Base Review test:

Secreted H+ couples with filtered HCO3-

& CO2 & H2O result.

TRUE

FALSE

Metabolic Disturbances:
Alkalosis: elevated HCO3- (>26 mEq/L)

Causes include: Cl- depletion (vomiting,

prolonged nasogastric suctioning),
Cushings syndrome, K+ deficiency,
massive blood transfusions, ingestion of
antacids, etc.

Acidosis: decreased HCO3- (<22 mEq/L)

Causes include: DKA, shock, sepsis, renal

failure, diarrhea, salicylates (aspirin), etc.

Compensation is respiratory-related

Metabolic Alkalosis:
Caused by an increase in pH (>7.45)

related to an excess in plasma HCO3

Caused by a loss of H+ ions, net gain in

HCO3- , or loss of Cl- ions in excess of
HCO3-

Most HCO3- comes from CO2 produced

during metabolic processes,

reabsorption of filtered HCO3-, or
generation of new HCO3- by the kidneys
Proximal tubule reabsorbs 99.9% of
filtered HCO3-; excess is excreted in
urine

Metabolic Alkalosis
Manifestations:
Signs & symptoms (s/sx) of volume

depletion or hypokalemia
Compensatory hypoventilation,
hypoxemia & respiratory acidosis
Neurological s/sx may include mental
confusion, hyperactive reflexes, tetany
and carpopedal spasm
Severe alkalosis (>7.55) causes
respiratory failure, dysrhthmias, seizures
& coma

Treatment of Metabolic Alkalosis:

Correct the cause of the imbalance

May include KCl supplementation for K+/Cldeficits

Fluid replacement with 0.9 normal saline

or 0.45 normal saline for s/sx of volume

depletion
Intubation & mechanical ventilation may
be required in the presence of
respiratory failure

Metabolic Acidosis:
Primary deficit in base HCO3- (<22

mEq/L) and pH (<7.35)

Caused by 1 of 4 mechanisms

Increase in nonvolatile metabolic acids,

decreased acid secretion by kidneys,
excessive loss of HCO3-, or an increase in
Cl-

Metabolic acids increase w/ an

accumulation of lactic acid,

overproduction of ketoacids, or
drug/chemical anion ingestion

Metabolic Acidosis Manifestations:

Hyperventialtion (to reduce CO2 levels),

& dyspnea
Complaints of weakness, fatigue,
general malaise, or a dull headache
Pts may also have anorexia, N/V, &
abdominal pain
If the acidosis progresses, stupor, coma
& LOC may decline
Skin is often warm & flush related to
sympathetic stimulation

Treatment of Metabolic Acidosis:

Treat the condition that first caused the

imbalance
NaHCO3 infusion for HCO3- <22mEq/L
Restoration of fluids and treatment of
electrolyte imbalances
Administration of supplemental O2 or
mechanical ventilation should the
respiratory system begin to fail

Quick Metabolic Review:

Metabolic disturbances indicate an

excess/deficit in HCO3- (<22mEq/L or

>26mEq/L
Reabsorption of filtered HCO3- &
generation of new HCO3- occurs in the
kidneys
Respiratory system is the compensatory
mechanism
ALWAYS treat the primary disturbance

Respiratory Disturbances:
Alkalosis: low PaCO2 (<35 mmHg)

Caused by HYPERventilation of any

etiology (hypoxemia, anxiety, PE,
pulmonary edema, pregnancy, excessive
ventilation w/ mechanical ventilator, etc.)

Acidosis: elevated PaCO2 (>45 mmHg)

Caused by HYPOventilation of any etiology

(sleep apnea, oversedation, head trauma,
drug overdose, pneumothorax, etc.)

Compensation is metabolic-related

Respiratory Alkalosis:
Characterized by an initial decrease in

plasma PaCO2 (<35 mmHg) or

hypocapnia
Produces elevation of pH (>7.45) w/ a
subsequent decrease in HCO3- (<22
mEq/L)
Caused by hyperventilation or RR in
excess of what is necessary to maintain
normal PaCO2 levels

Respiratory Alkalosis
Manifestations:
S/sx are associated w/ hyperexcitiability

of the nervous system & decreases in

cerebral blood flow
Increases protein binding of EC Ca+,
reducing ionized Ca+ levels causing
neuromuscular excitability
Lightheadedness, dizziness, tingling,
numbness of fingers & toes, dyspnea, air
hunger, palpitations & panic may result

Treatment of Respiratory
Alkalosis:
Always treat the underlying/initial cause
Supplemental O2 or mechanical

ventilation may be required

Pts may require reassurance,
rebreathing into a paper bag (for
hyperventilation) during symptomatic
attacks, & attention/treatment of
psychological stresses.

Respiratory Acidosis:
Occurs w/ impairment in alveolar

ventilation causing increased PaCO2

(>45 mmHg), or hypercapnia, along w/
decreased pH (<7.35)
Associated w/ rapid rise in arterial
PaCO2 w/ minimal increase in HCO3- &
large decreases in pH
Causes include decreased respiratory
drive, lung disease, or disorders of
CW/respiratory muscles

Respiratory Acidosis
Manifestations:
Elevated CO2 levels cause cerebral

vasodilation resulting in HA, blurred

vision, irritability, muscle twitching &
psychological disturbances
If acidosis is prolonged & severe,
increased CSF pressure & papilledema
may result
Impaired LOC, lethargy/coma, paralysis
of extremities, warm/flushed skin,
weakness & tachycardia may also result

Treatment of Respiratory
Acidosis:
Treatment is directed toward improving

ventilation; mechanical ventilation may

be necessary
Treat the underlying cause

Drug OD, lung disease, chest

trauma/injury, weakness of respiratory
muscles, airway obstruction, etc.

Eliminate excess CO2

Quick Respiratory Review:

Caused by either low or elevated PaCO2

levels (<35 or >45mmHg)

Watch for HYPOventilation or
HYPERventilation; mechanical
ventilation may be required
Kidneys will compensate by conserving
HCO3- & H+
REMEMBER to treat the primary
disturbance/underlying cause of the
imbalance

Compensatory Mechanisms:
Adjust the pH toward a more normal

level w/ out correcting the underlying

cause
Respiratory compensation by
increasing/decreasing ventilation is
rapid, but the stimulus is lost as pH
returns toward normal
Kidney compensation by conservation of
HCO3- & H+ is more efficient, but takes
longer to recruit

Metabolic Compensation:
Results in pulmonary compensation

beginning rapidly but taking time to

become maximal
Compensation for Metabolic Alkalosis:

HYPOventilation (limited by degree of rise

in PaCO2)

Compensation for Metabolic Acidosis:

HYPERventilation to decrease PaCO2

Begins in 1-2hrs, maximal in 12-24 hrs

Respiratory Compensation:
Results in renal compensation which

takes days to become maximal

Compensation for Respiratory Alkalosis:

Kidneys excrete HCO3-

Compensation for Respiratory Acidosis:

Kidneys excrete more acid

Kidneys increase HCO3- reabsorption

DIAGNOSTIC LAB VALUES &

INTERPRETATION

Normal Arterial Blood Gas (ABG)

Lab Values:
Arterial pH: 7.35 7.45
HCO3-: 22 26 mEq/L
PaCO2: 35 45 mmHg

TCO2: 23 27 mmol/L
PaO2: 80 100 mmHg
SaO2: 95% or greater (pulse ox)

Base Excess: -2 to +2
Anion Gap: 7 14

Acid-Base pH and HCO3 Arterial pH of ECF is 7.40

Acidemia: blood pH < 7.35 (increase in H+)

Alkalemia: blood pH >7.45 (decrease in
H+) If HCO3- levels are the primary
disturbance, the problem is metabolic
Acidosis: loss of nonvolatile acid & gain of
HCO3Alkalosis: excess H+ (kidneys unable to
excrete) & HCO3- loss exceeds capacity of
kidneys to regenerate

Acid-Base PCO2, TCO2 & PO2

If PCO2 is the primary disturbance, the

problem is respiratory; its a reflection of

alveolar ventilation (lungs)

PCO2 increase: hypoventilation present

PCO2 decrease: hyperventilation present

TCO2 refers to total CO2 content in the

blood, including CO2 present in HCO3

>70% of CO2 in the blood is in the form of

HCO3PO2 also important in assessing respiratory
function

Base Excess or Deficit:

Measures the level of all buffering

systems in the body hemoglobin,

protein, phosphate & HCO3 The amount of fixed acid or base that
must be added to a blood sample to
reach a pH of 7.40
Its a measurement of HCO3- excess or
deficit

Anion Gap:
The difference between plasma

concentration of Na+ & the sum of

measured anions (Cl- & HCO3-)
Representative of the concentration of
unmeasured anions (phosphates,
sulfates, organic acids & proteins)
Anion gap of urine can also be
measured via the cations Na+ & K+, & the
anion Cl- to give an estimate of NH4+
excretion

Anion Gap
The anion gap is increased in conditions

such as lactic acidosis, and DKA that

result from elevated levels of metabolic
acids (metabolic acidosis)

A low anion gap occurs in conditions that

cause a fall in unmeasured anions
(primarily albumin) OR a rise in
unmeasured cations
A rise in unmeasured cations is seen in
hyperkalemia, hypercalcemia, hypermagnesemia, lithium intoxication or
multiple myeloma

Sodium Chloride-Bicarbonate
Exchange System and pH:
The reabsorption of Na+ by the kidneys

requires an accompanying anion

- 2 major anions in ECF are Cl- and
HCO3 One way the kidneys regulate pH of ECF is
by conserving or eliminating HCO3- ions in
which a shuffle of anions is often necessary
Cl- is the most abundant in the ECF & can
substitute for HCO3- when such a shift is
needed.

Acid-Base Interpretation
Practice:
Please use the following key to interpret

the following ABG readings.

Click on the blue boxes to reveal the
answers
Use the
button to return to the key at
any time
Or use the Back to Key button at the
bottom left of the screen

Acid-Base w/o Compensation:

Parameters:

pH

PaCO2

Metabolic
Alkalosis

Normal

Metabolic
Acidosis

Normal

Respiratory
Alkalosis
Respiratory
Acidosis

HCO3-

Normal
Normal

Interpretation Practice:
pH: 7.31

Resp.
Acidosis
Right!

PaCO2: 48

Resp.
Try Alkalosis
Again

HCO3-: 24

Try Again
Metabolic
Acidosis

pH: 7.47

Resp.Again
Alkalosis
Try
Metabolic
Alkalosis
Right!
Metabolic
Acidosis
Try Again

PaCO2 : 45
HCO3- : 33

Back to Key

Interpretation Practice:
pH: 7.20
HCO3-: 14

Try
Again
Metabolic
Alkalosis
Try
Again
Resp.
Acidosis
Metabolic
Right! Acidosis

pH: 7.50

Try Again
Metabolic
Alkalosis

PaCO2 : 29

Right!
Resp. Alkalosis
Resp.Again
Acidosis
Try

PaCO2: 36

HCO3- -: 22

Back to Key

Acid-Base Fully Compensated:

Parameters:

pH

Metabolic
Alkalosis

Normal
>7.40

Metabolic
Acidosis

Normal
<7.40

Respiratory
Alkalosis
Respiratory
Acidosis

Normal
>7.40
Normal
<7.40

PaCO2

HCO3-

Interpretation Practice:
pH: 7.36
PaCO2: 56

Compensated
Resp. Alkalosis
Try Again
Compensated
Metabolic Acidosis
Try Again

HCO3-: 31.4

Right!Resp. Acidosis
Compensated

pH: 7.43

Compensated
Resp. Alkalosis
Right!

PaCO2 : 32

Compensated
Metabolic Alkalosis
Try Again

HCO3: 21

Try Again
Compensated
Metabolic Acidosis

Back to Key

Acid-Base Partially Compensated:

Parameters:
Metabolic
Alkalosis
Metabolic
Acidosis

Respiratory
Alkalosis
Respiratory
Acidosis

pH

PaCO2

HCO3-

Interpretation Practice:
pH: 7.47

Partially Compensated Metabolic Alkalosis

HCO3-: 33.1

Right!
PartiallyTry
Compensated
Again Resp. Alkalosis
Partially Compensated
Try AgainMetabolic Acidosis

pH: 7.33

Partially Compensated
Try AgainMetabolic Alkalosis

PaCO2: 49

PaCO2 : 31

PartiallyTry
Compensated
Again Resp. Acidosis

HCO3- : 16

Right! Metabolic Acidosis

Partially Compensated

Back to Key

Case Study 1:
Mrs. D is admitted to the ICU. She has

missed her last 3 dialysis treatments.

Her ABG reveals the following:

pH: 7.32
PaCO2: 32
HCO3-: 18

The=pH
is:
Low, WNL
7.35-7.45
The PaCO
Low, WNL
= 35-45mmHg
2 is:
The HCO
Low, WNL
= 22-26mEq/L
3 is:

Assess the pH, PaCO2 & HCO3-. Are the

values high, low or WNL?

Case Study 1 Continued:

What is Mrs. Ds acid-base imbalance?
Partially Compensated
Right!Metabolic Acidosis

Try Again
Fully Compensated
Resp. Acidosis
Remember the difference between full &

partial compensation. Go back & use

the appropriate key if necessary.

Case Study 2:
Mr. M is a pt w/ chronic COPD. He is

admitted to your unit pre-operatively.

His admission lab work is as follows:

pH: 7.35
PaCO2: 52
HCO3-: 50

The pH is:
WNL = 7.35-7.45
The PaCO
High, WNL
= 35-45mmHg
2 is:
The HCO
High, WNL
= 22-26mEq/L
3 is:

Assess the above labs. Are they

abnormal or WNL?

Case Study 2 Continued:

What is Mr. Ms acid-base disturbance?
Fully Compensated
Metabolic Acidosis
Try Again
Fully Compensated
Right!Resp. Acidosis

Think about appropriate interventions- if

the problem is metabolic, the respiratory

system compensates & vice versa

Case Study 3:
Miss L is a 32 year old female admitted

w/ decreased LOC after c/o the worst

HA of her life. She is lethargic, but
arouseable; diagnosed w/ a SAH.
Her ABG reads:

pH: 7.48
PaCO2: 32
HCO3-: 25

The=pH
is:
High; WNL
7.35-7.45
The PaCO
Low; WNL
= 35-45mmHg
2 is:
The HCO
High; WNL
= 22-26mEq/L
3 is:

What is the significance of her ABG

values?

Case Study 3 Continued:

What is Miss Ls imbalance?
Resp.
Alkalosis
Right!

Try Again
Metabolic
Alkalosis
Great Job! Youve reached the end of

the tutorial & I hope you found it helpful.

Thank you!

REFERENCES:
http://www.healthline.com/galecontent/acid-basebalance?utm_medium=ask&utm_source=smart&utm_campaign=article
&utm_term=Acid+Base+Equilibrium&ask_return=Acid-Base+Balance.
Retrieved 3/5/09.
Porth, C.M. (2005). Pathophysiology Concepts of Altered Health States (7th
ed.). Philadelphia: Lippincott Williams & Wilkins.
http://en.wikipedia.org/wiki/Dissociation_(chemistry). Retrieved 3/6/09.
http://www.clt.astate.edu/mgilmore/pathophysiology/Acid and Base.ppt#1.
Retrieved 3/6/09.
http://www.uhmc.sunysb.edu/internalmed/nephro/webpages/Part_E.htm.
Retrieved 3/6/09.
http://medical-dictionary.thefreedictionary.com/Volatile+acid. Retrieved
3/6/09.

REFERENCES
http://wiki.answers.com/Q/How_does_the_phosphate_buffer_system_help_
in_maintaining_the_ph_of_our_body. Retrieved 3/10/09.

Alspach, J.G. (1998). American Association of Critical-Care Nurses Core

Curriculum for Critical Care Nursing (5th ed.). Philadelphia: Saunders.
http://medical-dictionary.thefreedictionary.com. Retrieved 4/14/09.
Acid-Base Balance & Oxygenation Power Point. (2007). Milwaukee:
Froedtert Lutheran Memorial Hospital Critical Care Class.