Clinical Cases:

Acid-Base Balance
Mrs Sarah Curtis DipRCPath
Royal Liverpool Hospital

pH

pCO2

High (>6kPa)

Base excess

Interpretation

Positive
(>2.5)

Primary respiratory
acidosis with renal
compensation

Normal
(-2.5 to +2.5)

Primary respiratory
acidosis

Negative
(<-2.5)

Mixed respiratory
and metabolic
acidosis

Normal (4.5-6kPa)

Negative
(<-2.5)

Primary metabolic
acidosis

Low (<4.5kPa)

Negative
(<-2.5)

Primary metabolic
acidosis with
respiratory
compensation

Acidaemia
Low pH
(<7.35)

pH

pCO2

Base excess
Positive
(>2.5)

Interpretation
Mixed respiratory
and metabolic
alkalosis

Normal
(-2.5 to +2.5)

Primary respiratory
alkalosis

Negative
(<-2.5)

Primary respiratory
alkalosis with renal
compensation

Normal (4.5-6kPa)

Positive
(>2.5)

Primary metabolic
alkalosis

High (>6kPa)

Positive
(>2.5)

Primary metabolic
alkalosis with
respiratory
compensation

Low (<4.5kPa)
Alkalaemia
High pH
(>7.45)

Case 1: Interpret these blood gases

PCO2 < 4.5 kPa

Partial
respiratory
compensation

pH < 7.35
Acidaemic

PO2 > 14.0 kPa

Consistent with
hyperventilation
and O2 therapy

Lactate
Metabolic acidosis

Breathing 35 % O2
(room air 21 %)

Base XS < -2.5 mmol/L

Primary metabolic
acidosis

Standard bicarbonate
< 22 mmol/L
Primary metabolic
acidosis

Glucose
?Stress-induced

iCa < 1.15 mmol/L

Hypocalcaemic

Unusual expect relative

hypercalcaemia in acidaemia as
displacement of Ca2+ from proteins by H+

Case 1: Interpret the biochemistry

Hint: Think about acid-base disorders

D&V 2/7
Furosamide

Metabolic acidosis
or respiratory
alkalosis

AKI and acidotic..

Why is K not
increased?
Acute kidney injury
Metabolic acidosis

? Release of intracellular
phosphate from ATP
Phosphate
AKI, lactic acidosis;
will precipitate calcium!

Metabolic
acidosis

Apparent
normocalcaemia!!

Ketones
Metabolic acidosis

Conclusion:
Additive (mixed) primary metabolic acidosis
Lactate
Ketones
AKI

Partial respiratory compensation

pH <7.35 therefore compensation incomplete

Metformin overdose

Case 2: Interpret these blood gases

pH = 7.40
?No acid-base disorder
PCO2 > 6.0 kPa
Respiratory
acidosis

PO2 < 11.3 kPa

Hypoxic

Standard bicarbonate
> 26 mmol/L
Primary respiratory
acidosis

Base XS > 2.5 mmol/L

Renal compensation

Case 2: Interpret these blood gases

What has changed?

pH < 7.35
Acidaemic
PCO2 > 6.0 kPa
Respiratory
acidosis
PO2 < 11.3 kPa
Hypoxic
Standard bicarbonate
> 26 mmol/L
Primary respiratory
acidosis
Base XS > 2.5 mmol/L
Renal compensation

Conclusion:
Primary respiratory acidosis
Initially fully compensated (renal)
Subsequent decompensated (partial
renal)

COPD

Case 3: Interpret these blood gases

PCO2 > 6.0 kPa

Respiratory acidosis
(Maximum PCO2 that can be
achieved with compensation
is 8.0 kPa this is another
primary disorder!)

pH > 7.40
Alkalaemic

PO2 < 11.3 kPa

Hypoxic

Glucose
?Diabetic

Lactate
Primary
metabolic
acidosis

Standard bicarbonate
> 26 mmol/L
Primary respiratory
acidosis

Breathing 100% O2
iCa < 1.15 mmol/L
Hypocalcaemic

Base XS > 2.5 mmol/L

Primary metabolic alkalosis
Cl < 99 mmol/L
Hypochloraemic

K < 3.5 mmol/L

Hypokalaemic

Conclusion:
Primary metabolic alkalosis
Hypokalaemia (EtOH xs)

Primary metabolic acidosis

Lactate (fitting)
EtOH xs

Primary respiratory acidosis

PCO2, PO2 on 100 % O2 therapy

Alcohol xs + Fitting