Acid-Base disorders

DR. SHERIF EL DESOKY Prof. JAMEELA KARI

PEDIATRICS

DEPARTMENT KING ABDULAZIZ UNIVERsITY

HOSPITAL

Learning objectives:
By the end of this lecture, you should be able to: Recognize normal acid base regulation Recognize the clinical acid-base relationship. Outline the causes of respiratory acidosis Outline the causes of respiratory alkalosis Outline the causes of metabolic acidosis Outline the causes of metabolic alkalosis Discuss the role of the kidney in handling the HCO3.

Content of the lecture: Physiology of acid base balance. Case of respiratory acidosis (chest). Case of metabolic acidosis (Diabetic keto acidosis , renal tubular acidosis) Example of metabolic alkalosis Example of respiratory alkalosis

"Potential of Hydrogen" (pH)

The acidity or alkalinity of a solution is measured as pH. The more acidic a solution, the lower the pH.

The more alkaline a solution , the higher the pH.

Water has a pH of 7 and is neutral. The pH of arterial blood is normally between 7.35 and 7.45

Buffer Systems
"Ability
of weak acid and its corresponding base to resist change in pH of a solution upon adding a strong acid or base"

Regulate pH by binding or releasing Hydrogen

Most important buffer system:
Bicarbonate-Carbonic Acid Buffer System (Blood Buffer systems act instantaneously and thus constitute the bodys first line of defense against acidbase imbalance)

Clinically Significant Acid-Base Pairs Acid

Carbonic acid (H2CO3)

Base Bicarbonate (HCO3-) Dibasic PO4 (HPO4-) Ammonia (NH3) Lactate (H5C3O2-)

Monobasic PO4 (H2PO4)

Ammonium (NH4+) Lactic acid (H6C3O2)

Respiratory Regulation
Lungs
help regulated acid-base balance by eliminating or retaining carbon dioxide pH may be regulated by altering the rate and depth of respirations changes in pH are rapid,
occurring within minutes

normal CO2 level

35 to 45 mm Hg

Renal Regulation
Kidneys
the long-term regulator of acid-base balance slower to respond
may take hours or days to correct pH

kidneys maintain balance by excreting or conserving bicarbonate and hydrogen ions normal bicarbonate level
22 to 26 mEq/L.

ABG interpretation

Is it Respiratory or Metabolic?
1. Respiratory Acidosis 2. Respiratory Alkalosis

Increased pCO2 >50

Decreased pCO2<30 Decreased HCO3 <18

3. Metabolic Acidosis
4. Metabolic Alkalosis

Increased HCO3 >30

Compensated or Uncompensated what does this mean?

1. Evaluate pHis it normal? Yes
2. Next evaluate pCO2 & HCO3
pH normal + increased pCO2 + increased HCO3 = compensated respiratory acidosis pH normal + decreased HCO3 + decreased pCO2 = compensated metabolic acidosis

Compensated vs. Uncompensated

1. Is pH normal? No 2. Acidotic vs. Alkalotic 3. Respiratory vs. Metabolic

pH<7.30 + pCO2>50 + normal HCO3 uncompensated respiratory acidosis pH<7.30 + HCO3<18 + normal pCO2 uncompensated metabolic acidosis pH>7.50 + pCO2<30 + normal HCO3 uncompensated respiratory alkalosis pH>7.50 + HCO3>30 + normal pCO2 uncompensated metabolic alkalosis

= =

=
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Causes of Acidosis
Respiratory
Hypoventilation Impaired gas exchange

Metabolic
Ketoacidosis
Diabetes

Lactic Acidosis
Decreased perfusion Severe hypoxemia

Renal Failure

Renal Tubular Acidosis Severe Diarrheal illness

Acidemia- Physiologic Effects

Cardiovascular
Mild acidemia--Tachycardia Severe acidemia -- Bradycardia Decreased fibrillation threshold Decreased contractility

Neuromuscular
Increase in CBF -- Headaches/Confusion Due to hypercarbia or pH ??

Causes of Alkalosis
Respiratory Hyperventilation due to:
Hypoxemia Metabolic acidosis Neurologic

Metabolic Hypokalemia Gastric suction or vomiting Hypochloremia

CNS Lesions CNS Trauma Infection

Alkalemia- Physiology
CV
Mild--Slight increase contractility Oxyhgb curve shift left ( decrease O2 delivery to tissue). Regional vasoconstriction

Assessing Oxygenation
Normal value for arterial blood gas 80100mmHg Normal value for venous blood gas 40mmHg Normal SaO2
Arterial: 97% Venous: 75%

Important points for assessing tissue oxygenation

This is the O2 thats really available at the tissue level. Is the Hb normal?
Low Hb means the ability of the blood to carry the O2 to the tissues is decreased

Is perfusion normal?
Low perfusion means the blood isnt even getting to the tissues

Respiratory Acidosis
Alveolar hypoventilation Retained Co2 drives release of free H+ If acute, pH by .08 for pCo210 mm Correct any underlying cause

Respiratory Alkalosis
min. Vent. pCo2 & pH Most common causes
Response to hypoxemia Response to acute metabolic acidosis CNS malfunction

Correct underlying cause Rarely life-threatening

Metabolic Acidosis
Causes
High anion gap = Na - (Cl + HC03)(eg.LA) Normal-anion gap (Hyperchloremic)

Treatment
Correction of underlying cause Administer bicarbonate for lifethreatening acidosis

Metabolic Alkalosis
Usually results from excess acid losses Causes
Loss of gastric juices Diuretic therapy Adrenal cortical hormone excess Hepatic coma(hyper ammonemia ) Administration of exogenous base

Almost always accompanied by low K+ Treatment

Gastrointestinal losses can create acid-base disturbances

Vomiting:
Loss of H+ leading to alkalosis

Highly acidic, pH =1.0

Secretes HCO3-

Diarrhea:

Loss of HCO3leading to acidosis

pH varies from 4.0 to 8.0

Approach to ABG
Check serum pH
Acidemia or Alkalemia ?

Check PCO2

Is disturbance respiratory or metabolic ? Is respiratory disturbance acute ?? Change in pH= -0.08 x (d Pco2/10) Is respiratory disturbance non acute ?? Bicarb change = 1-5 x (d Pco2/10)

Approach to ABG
Check PaO2 ?? -Good guide to patient course.. Not important with regard to Oxygen Delivery.. SaO2 - 90 % acceptable for Oxygen delivery.

 Metabolic acidosis
Increased Acid Generation ??

Metabolic alkalosis
Urine chloride > 20 meq/L
(Chloride Unresponsive - Eg.Adrenal excess)

Urine chloride < 10 meq/L

(Chloride Responsive -dehydration)

Primary problem is never exceeded by compensation...

Lets Practice

Case 1; 12 year old diabetic presents with Kussmaul breathing

pH : 7.05 pCO2: 12 mmHg pO2: 108 mmHg HCO3: 5 mEq/L BE: -30 mEq/L
Severe partly compensated metabolic acidosis without hypoxemia due to ketoacidosis

9 year old w/hx of asthma, audibly wheezing x 1 week, has not slept in 2 nights; presents sitting up and using accessory muscles to breath w/audible wheezes

Case 2;

pH: 7.51 pCO2: 25 mmHg pO2 55 mmHg HCO3: 22 mEq/L BE: -2 mEq/L
Uncompensated respiratory alkalosis with severe hypoxia due to asthma exacerbation

If the previous child was untreated or came later:

pH: 7.28 pCO2: 55 mmHg pO2 35 mmHg HCO3: 28 mEq/L BE: +6 mEq/L
Partially compensated respiratory acidosis with severe hypoxia due to asthma exacerbation

Case 3; 7 year old post op presenting with chills, fever and hypotension pH: pCO2: pO2: HCO3: BE: 7.25 32 mmHg 55 mmHg 10 mEq/L -15 mEq/L

Uncompensated metabolic acidosis due to low perfusion state and hypoxia causing increased lactic acid

Case 4
A 6 year old girl with severe gastroenteritis is admitted to the hospital for fluid rehydration, and is noted to have a high [HCO3-] on hospital day #2. An ABG is ordered: ABG: pH PCO2 HCO3PO2 7.47 46 32 96 Chem : Na+ K+ ClHCO3130 3.2 86 33

Urine pH: 5.8

GE, SEVERE VOMITING

Hypokalemic hypocholiremic metabolic alkalosis

Thank you