CLINICAL CHEMISTRY II

Blood Gases & Acid-Base Balance

Definitions
ACID
a substance that can yield a hydrogen ion (H+) or hydronium ion (H3O+) when dissolved in water

BASE
a substance that can yield a hydroxyl ion (OH-) when dissolved in water

INTRODUCTION

Definitions
BUFFER
the combination of a weak acid or weak base and its salt; a system that resists changes in pH

pH
the negative (or inverse) log of the hydrogen ion concentration; -log[H+] or log 1/[H+]

INTRODUCTION

Definitions
ACIDOSIS
a pH below the reference range

ALKALOSIS
a pH above the reference range

INTRODUCTION

Definitions
PARTIAL PRESSURE
the pressure exerted by an individual gas in the atmosphere; equal to the barometric pressure times the percentage for the gas

pO2
the partial pressure of oxygen

pCO2
the partial pressure of carbon dioxide

INTRODUCTION

Maintenance of H+
The arterial pH is controlled by systems that regulate the production and retention of acids and bases, including
buffers the respiratory center and lungs the kidneys

PHYSIOLOGIC THEORY

Buffer Systems
The bicarbonate-carbonic acid system; HCO3- and H2CO3
when acid is added to the bicarbonate-carbonic acid system, HCO3- will combine with the H+ from the acid to form H2CO3 when a base is added, the H2CO3 will combine with the OHgroup to form H2O and HCO3-

PHYSIOLOGIC THEORY

Buffer Systems
The bicarbonate-carbonic acid system is important for three reasons
1. 2. 3. H2CO3 dissociates into CO2 and H2O, allowing H+ to be eliminated as CO2 by the lungs changes in pCO2 modify the ventilation rate HCO3- concentration can be altered by the kidneys

PHYSIOLOGIC THEORY

Buffer Systems
Other buffer systems
the phosphate buffer system; HPO4-- and H2PO4 the plasma proteins

PHYSIOLOGIC THEORY

Respiratory System
Plasma
the end product of most aerobic metabolic processes is CO2 in the plasma, small amounts of CO2 remain as dCO2 or combine with proteins to form carbamino compounds; most of the CO2 combines with H2O to form H2CO3, which quickly dissociates into H+ and HCO3-

PHYSIOLOGIC THEORY

Respiratory System
Lungs
inspired O2 diffuses from the alveoli into the blood and is bound to hemoglobin, forming oxyhemo-globin;
o the H+ that was carried on the (reduced) hemoglobin in the venous blood is released to recombine with HCO3- to form H2CO3, which dissociates into H2O and CO2

the CO2 diffuses into the alveoli and is eliminated through ventilation

PHYSIOLOGIC THEORY

Renal System
Kidneys
the kidneys main role in maintaining acid-base homeostasis is to reclaim HCO3- from the glomerular filtrate and add it to the blood

PHYSIOLOGIC THEORY

the Henderson-Hasselbalch Equation

Equation that mathematically expresses the dissociation characteristics of weak acids and bases:
pH = pK + log [cA-]/[cHA+] or pH = 6.1 + log [bicarbonate]/[carbonic acid]

PHYSIOLOGIC THEORY

Daltons law
in a gas mixture, the total barometric pressure equals the sum of the individual components
for example, in atmospheric air pAtm = pO2 + pCO2 + pN2 + pH2O

PHYSIOLOGIC THEORY

Source
Venous blood
if pulmonary function or O2 transport is not being assessed

Arterial blood
radial, brachial, femoral

Arterial lines

SPECIMEN

Handling
dry heparin ice water slurry immediate transport to lab

SPECIMEN

pH electrode system
Measuring electrode
a glass membrane sensitive to H+ is placed around an internal Ag-AgCl electrode

Reference electrode
calomel (Hg-HgCl) or Ag-AgCl

Voltmeter (potentiometry)
millivoltmeter

METHODS OF ASSAY

pCO2 (Severinghaus) electrode system

Modified pH electrode (potentiometry)
an outer semipermeable membrane allows CO2 to diffuse into a bicarbonate buffer; the CO2 that diffuses across the membrane reacts with the buffer, forming carbonic acid, which then dissociates into bicarbonate plus H+; the change in activity of the H+ is measured by the pH electrode and related to pCO2

METHODS OF ASSAY

pO2 (Clark) electrode system

anode gas-permeable membrane cathode ampmeter (amperometry)

METHODS OF ASSAY

Reference Range (Arterial)

pH: 7.35-7.45 pH units pCO2: 35-45 mm Hg pO2: 80-110 mm Hg HCO3-: 22-26 mmol/L Total CO2: 23-27 mmol/L SO2: > 95%

CLINICAL CORRELATIONS

Reference Range (Venous)

pH: 7.32-7.42 pH units pCO2: 40-50 mm Hg pO2: 30-50 mm Hg

CLINICAL CORRELATIONS

Panic Values
pH: < 7.2 or > 7.6 pO2: < 40 mm Hg pCO2: < 20 mm Hg or > 70 mm Hg

CLINICAL CORRELATIONS

Metabolic Acidosis
Etiology
excessive formation of organic acids

o diabetic ketoacidosis; starvation

decreased excretion of acids

o renal tubular acidosis

excessive loss of bicarbonate

o diarrhea; drainage from a biliary, pancreatic or intestinal fistula

CLINICAL CORRELATIONS

Metabolic Acidosis
Etiology (continued)
direct administration of an acid-producing substance

o ammonium chloride; calcium chloride

CLINICAL CORRELATIONS

Metabolic Acidosis
Compensation
respiratory: hyperventilation; an increase in alveolar ventilation
o

an increase in the rate or depth of breathing ...blowing off CO2

CLINICAL CORRELATIONS

Respiratory Acidosis
Etiology
hypoventilation; a decrease in alveolar ventilation:

o emphysema; bronchopneumonia; asphyxiation (strangulation or aspiration) o congestive heart failure, with decreased cardiac output o effects of drugs--barbiturates, morphine, or alcohol

CLINICAL CORRELATIONS

Respiratory Acidosis
Compensation
metabolic (renal): the kidneys increase the excretion of H+ and increase the reabsorption of HCO3-

CLINICAL CORRELATIONS

Metabolic Alkalosis
Etiology
A gain in HCO3-

excess administration of sodium bicarbonate; ingestion of bicarbonate-producing salts such as sodium lactate, citrate, or acetate
Excessive loss of acid

vomiting; nasogastric suctioning prolonged use of diuretics that augment renal excretion of H+

CLINICAL CORRELATIONS

Metabolic Alkalosis
Compensation
respiratory: hypoventilation, increasing the retention of CO2

CLINICAL CORRELATIONS

Respiratory Alkalosis
Etiology
hyperventilation; an increased rate of alveolar ventilation; causing excessive elimination of CO2 by the lungs

o stimulation of the respiratory center by drugs, such as salicylates o an increase in environmental temperature; fever o hysteria o pulmonary emboli; pulmonary fibrosis

CLINICAL CORRELATIONS

Respiratory Alkalosis
Compensation
metabolic (renal): the kidneys compensate by excreting HCO3and retaining H+

CLINICAL CORRELATIONS

Assessment of Oxygen Status

pO2
the partial pressure of oxygen

Oxygen saturation
the ratio of O2 that is bound to hemoglobin, compared with the total amount the hemoglobin could bind

NOTES

Assessment of Oxygen Status

Pulse oximetry
differentiates between the absorption of light due to oxyhemoglobin and deoxyhemoglobin in the capillary bed and calculates hemoglobin saturation through the tissue of the toe, finger, or ear

Fractional oxyhemoglobin (FO2Hb)

the ratio of the concentration of oxyhemoglobin to the concentration of total hemoglobin

NOTES

Co-Oximetry
Principle
spectrophotometric, based on the fact that each type of hemoglobin has a characteristic absorbance curve

Application
measurement of oxyhemoglobin, O2Hb; deoxyhemoglobin, HHb; carboxyhemoglobin, COHb; and methemoglobin, MetHb

NOTES

Hemoglobin-Oxygen Dissociation
Oxygen dissociates from hemoglobin in a characteristic fashion
if this dissociation is graphed with the pO2 on the x-axis and percent SO2 on the y-axis, the resulting curve is sigmoid, or slightly S-shaped

NOTES

Oxygenation
Adequate tissue oxygenation requires:
available atmospheric oxygen adequate ventilation gas exchange between the lungs and arterial blood loading of O2 onto hemoglobin adequate hemoglobin adequate transport (cardiac output) release of O2 to the tissues

NOTES

Oxygenation
Factors that influence tissue oxygenation:
destruction of the alveoli (e.g. emphysema) pulmonary edema airway blockage (e.g. asthma, bronchitis) inadequate blood supply (e.g. pulmonary embolism or congestive heart failure)

NOTES

Oxygenation
Factors that influence tissue oxygenation
the concentration and type(s) of hemoglobin the presence of nonoxygen substances, such as carbon monoxide (CO) the pH the temperature of the blood the levels of pO2 the level of 2,3-DPG

NOTES

Correction to Patient Temperature

because pH is temperature-dependent, blood gas instruments are maintained at 37 + 0.05o C accordingly, the blood pH must be corrected to the patients body temperature, because significant deviations occur in patients with high fever or low body temperature

NOTES