Acid-Base Analysis

Pediatric Critical Care Medicine Emory University Childrens Healthcare of Atlanta

Sources of acids
Volatile acids H2O + dissolved CO2 Non-volatile acids Inorganic acid Organic acid

H2CO3

H+ + HCO3Lactic acid Keto acid

Henderson-Hasselbalch
pH = pKa + log [A-] [HA] and

pH = pKa + log [HCO3-] = 6.1 + log [HCO3-] s x PCO2 0.03 x PCO2

H+ + HCO3H2CO3 CO2 + H2O

Anion Gap [Na+] = [CL- + HCO3-] ~ 10-15

Acid-Base States
Acidosis: pH<7.35
Metabolic: increased acid or decreased in bicarb Respiratory: increased PCO2

Alkalosis: pH>7.45
Metabolic: increased bicarb or loss of H+ Respiratory: decreased PCO2

Compensation
Acute:
Minutes Respiratory: PCO2 regulation

Chronic
Hours to days Renal: via regulation of bicarb excretion

Acidosis: Respiratory
Decrease PCO2 excretion via hypoventilation
Respiratory etiology CNS pathology Intoxication

pH decreases 0.08 unit/10 mmHg increase in PaCO2 Bicarb and base excess are normal

Acidosis: Metabolic
Change in pH by increased in acid or decrease in bicarb Anion Gap Acidosis: MUD PILES
Methanol Uremia Diabetic ketoacidosis Paraldehyde Iron, isoniazid (INH) Lactic acid Ethanol, ethylene glycol Salicylates

Non-Anion Gap Acidosis: USEDCARP

Uretorostomy Small bowel fistula Extra Chloride Diarrhea Carbonic anhydrase inhibitors (acetazolamide) Adrenal insufficiency RTA Pancreatic fistula

Alkalosis: Respiratory
Decrease in PCO2 by hyperventilation Compensate by increase renal excretion of HCO3-

Alkalosis: Metabolic
Increase in H+ loss or increase in HCO3 PaCO2 increase by 0.5-1/1 mEq/L of increase in HCO3-

Nomenclature
pH Uncompensated metab acidosis Compensated metab acidosis Uncompensated metab alkalosis Compensated metab alkalosis pCO2 [HCO3] BE

N N

N N

Partial Pressure
Gas Air at sea level Oxygen Nitrogen 20.9% 79.0% % Total Partial Pressure 760 159 600

Alveolar gas at sea level Oxygen Nitrogen CO2 Water

CO2

13.3% 75.2% 5.3% 6.2%

101 572 40 47

pCO2
0 40 Atmosphere alv

pO2
160 100

45

systemic circulation

97

Capillary ~47 <54 >55

~47 <39

extravascular fluid cells

~5 <1

Cells

Endothelium ECF

RBC

CO2

5%

Dissolved CO2 = pCO2

30% CO2

CO2 + Hb = HbCO2

CarboxyHgb

CO2

65%

CO2 + H2O = HCO3 + H+

Utilizes carbonic anhydrase

CO2

CO2 Transport

Excretion of CO2
Metabolic rate determines how much CO2 enters blood Lung function determines how much CO2 excreted
minute ventilation alveolar perfusion blood CO2 content

Hgb dissociation curve

% Sat 20 40

100
75 50 pO2 25 60 80 100

Dissociation curve
% Sat
120 100

Shifts
80 60 40 20 0 0 20 40 60 pO2 80 100 120

Alveolar oxygen equation

Inspired oxygen = 760 x .21 = 160 torr Ideal alveolar oxygen = PAO2 = [PB - PH2O] x FiO2 - [PaCO2/RQ] = [760 - 47] x 0.21 - [40/0.8] = [713] x 0.21 -[50] = 100 torr or 100 mmHg If perfect equilibrium, then alveolar oxygen equals arterial oxygen. ~5% shunt in normal lungs

Normal Oxygen Levels

FiO2 0.30 0.40 0.50 0.80 1.0 PaO2 >150 >200 >250 >400 >500

Predicting respiratory part of pH

Determine difference between PaCO2 and 40 torr, then move decimal place left 2, ie: IF PCO2 76: 76 - 40 = 36 x 1/2 = 18 7.40 - 0.18 = 7.22 IF PCO2 = 18: 40 -18 = 22 7.40 + 0.22 = 7.62

Predicting metabolic component

Determine predicted pH Determine difference between predicted and actual pH 2/3 of that value is the base excess/deficit

Deficit examples
If pH = 7.04, PCO2 = 76 Predicted pH = 7.22 7.22 - 7.40 = 0.18 18 x 2/3 = 12 deficit If pH = 7.47, PCO2 = 18 Predicted pH =7.62 7.62 - 7.47 = 0.15 15 x 2/3 = 10 excess

Hypoxemia - etiology
Decreased PAO2 (alveolar oxygen) Hypoventilation Breathing FiO2 <0.21 Unde rventilated alveoli (low V/Q) Zero V/Q (true shunt) Decreased mixed venous oxygen content Increased metabolic rate Decreased cardiac output Decreased arterial oxygen content

Blood gases
PaCO2: pH relationship For every 20 torr increase in PaCO2, pH decreases by 0.10 For every 10 torr decrease in PaCO2, pH increases by 0.10 PaCO2: plasma bicarbonate relationship PaCO2 increase of 10 torr results in bicarbonate increasing by 1 mmol/L Acute PaCO2 decrease of 10 torr will decrease bicarb by 2 mmol/L

Sources of blood acids

INFORMATION

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Sources of blood acids

INFORMATION

25