Acid Base Physiology By Heidi Allen, DVM, Dipl. ACVIM
Mar 26, 2015
Acid Base Physiology
By Heidi Allen, DVM, Dipl. ACVIM
Why is assessing acid-base status important?
Assessing the tachypnic animalLow oxygenation vs. blowing off CO2
Assessing vomiting animalsMetabolic alkalosis with high outflow
obstruction vs. metabolic acidosis
Diabetic animalsKetoacidosis vs. ketosis alone
Why is assessing acid-base status important?
Renal failure animalsDo you need to supplement NaHCO3?
Dyspnic animalsAll though arterial blood gas is best we can
make some assessments using venous samples.
Acid-Base Physiology
pH = -log [H+] ↑H+ ≈ ↓pH ↓H+ ≈ ↑pH
Carbonic acid equation H+ + HCO3 H2CO3 H20 + CO2
Acid-Base Physiology
Metabolic acidosis
Defined as an increase in H+
Metabolic Acidosis
CausesLactic acidosis
DehydrationHypovolemiaHypoxiaAnemia
Ketoacidosis
Metabolic Acidosis
Causes Renal failure
Decreased ability to excrete H+Increased excretion of HCO3
Gastrointestinal loss of HCO3
Renal tubular acidosis
Metabolic Acidosis
Causes Miscellaneous
Aspirin overdoseMethanolEthanol
Metabolic Acidosis
What effect does an increased H+ have on the carbonic acid equation?
H+ + HCO3 H2CO3 H20 + CO2
.
Metabolic Acidosis
↑H+ Causes a mild shift to the right
↑H+ + HCO3 H2CO3 H20 + CO2
Leading to HCO3, & CO2
Metabolic Acidosis
Unfortunately this shift is not enough to overcome the increased hydrogen so H+ is still very
elevated.
H, HCO3, PCO2, & pH
Metabolic Acidosis
Compensatory mechanismsExtracellular buffering (decrease in HCO3) Intracellular buffering
Hydrogen enters cells in exchange for K, proteins, phosphate, and bone carbonate
Respiratory compensation (takes 1-2 hrs)Renal hydrogen excretion (takes 2-5 days)
Metabolic Acidosis
Respiratory Compensation
– Blow off CO2
H+ + HCO3 H2CO3 H20 + ↓CO2
Allows equation to be pulled further to the right, decreasing H+ and HCO3
Compensated Metabolic Acidosis
H+ + HCO3 H2CO3 H20 + CO2
End result:Mildly increased H+
Mildly decreased pHDecreased HCO3
Decreased CO2 (compensation)
Acid-Base Physiology
Metabolic alkalosis
Defined as a ↓H+
Metabolic Alkalosis
CausesHigh outflow GI obstruction
Loss of hydrogen and chlorideDiuretic therapyIatrogenic
Metabolic Alkalosis
CausesHypokalemia
Compensation for hypokalemia is to move K out of cells using H-K exchange
Hydrogen goes into cells causing loss of H in blood stream and metabolic alkalosis
Metabolic Alkalosis
What effect does decreased H+ have on the carbonic acid equation?
H+ + HCO3 H2CO3 H20 + CO2
Metabolic Alkalosis
↓H+ Causes a mild shift to the left
↓H+ + HCO3 H2CO3 H20 + CO2
Leading to HCO3 & CO2
Metabolic Alkalosis
Unfortunately this shift is not enough to overcome the decreased
hydrogen so H+ is still very low.
H+ + HCO3 H2CO3 H20 + CO2
H, HCO3, CO2, & pH
Metabolic Alkalosis
Respiratory Compensation
– Retain CO2
H+ + HCO3 H2CO3 H20 + ↑CO2
Allows equation to be pulled further to the left, increasing H+ but also increasing
HCO3
Compensated Metabolic Alkalosis
H+ + HCO3 H2CO3 H20 + CO2
End result:Mildly decreased H+
Mildly increased pH Increased HCO3
Increased PCO2 (compensation)
Acid-Base Physiology
Respiratory alkalosis
Defined as a ↓CO2
Respiratory Alkalosis
CausesHypoxemia
In some cases of respiratory disease oxygen can not get into blood stream but CO2 can get out.
In these cases the body increases respiratory rate in response to hypoxemia which PCO2
Respiratory Alkalosis
CausesHypoxemia Examples
Mild to moderate pneumonia or CHFPTEInterstitial fibrosis
Respiratory Alkalosis
CausesStimulation of respiratory center
Intracranial diseaseHepatic encephalopathyGram negative sepsisRapid correction of metabolic acidosis
Over compensationLast 24-48 hrs
Respiratory Alkalosis
What effect does ↓CO2 have on the body?
H+ + HCO3 H2CO3 H20 + CO2
Respiratory Alkalosis
↓CO2 Causes a shift to the right
H+ + HCO3 H2CO3 H20 + ↓CO2
Leading to ↓H+ & ↓HCO3 & ↑pH
Respiratory Alkalosis
See both an acute
and a chronic
Metabolic
compensatory
response.
Respiratory Alkalosis
Acute compensationUse nonbicarbonated buffersCl/HCO3 exchange in cell membranesSimilar for both dogs and catsOccurs with in 15 minutes
Respiratory Alkalosis
Chronic compensationDogs
Renal adaptationIncrease H+ retentionIncrease HCO3 excretionTakes 2-5 days to reach steady state
Maybe a similar mechanism in cats
Compensated Respiratory Alkalosis
Unfortunately this is not enough to override the ↓CO2
Compensated Respiratory Alkalosis
↓H+ + HCO3 H2CO3 H20 + CO2
End result:Mildly decreased H+
Mildly increased pHDecreased PCO2
Decreased HCO3 (Compensation)
Acid-Base Physiology
Respiratory acidosis
Defined as a ↑CO2
Respiratory Acidosis
Causes of Respiratory acidosisCongestive heart failurePrimary lower airway diseaseUpper airway diseaseOthers
Respiratory Acidosis
What effect does an increased CO2 have on the carbonic acid equation?
H+ + HCO3 H2CO3 H20 + CO2
Respiratory Acidosis
↑CO2 Causes a shift to the left
H+ + HCO3 H2CO3 H20 + ↑CO2
Leading to ↑H+ & ↑HCO3
Respiratory Acidosis
See both an acute
and a chronic
Metabolic
compensatory
response.
Respiratory Acidosis
Acute compensationCan not use HCO3 buffersUse proteins such as hemoglobin
H2CO3 + Buf HBuf +HCO3
Can cause an increase in HCO3
1Meq/L per 10 mmHg PCO2
Works poorly as a buffer
Respiratory Acidosis
Chronic compensationDogs
Renal adaptationIncrease H+ excretionIncrease HCO3 retentionTakes 2-5 days to reach steady state
Cats may not be able to compensate
Respiratory Acidosis
Metabolic Compensation
– Increased HCO3
↓H+ + ↑HCO3 H2CO3 H20 + CO2
-- Allows equation to be pulled back to the right, decreasing H+
Compensated Respiratory Acidosis
Unfortunately this is not enough to override the ↑CO2
Compensated Respiratory Acidosis
↑H+ + HCO3 H2CO3 H20 + CO2
End result:Mildly increased H+
Mildly decreased pH Increased PCO2
Increased HCO3 (Compensation)
Normal values
Venous blood gases
Canine Feline
pH – 7.397 pH – 7.343
PCO2 – 37.4 PCO2 – 38.7
HCO3 – 22.5 HCO3 – 20.6
PO2 – 52.1 (?)
Normal values
Arterial blood gases
Canine Feline
pH – 7.407 pH – 7.386
PCO2 – 36.8 PCO2 – 31.0
HCO3 – 22.2 HCO3 – 18.0
PO2 – 92.1 PO2 – 106.8
Acid Base Analysis
1. Is the patient acidic or alkalotic?
2. Does the PCO2 or HCO3 match the pH?
3. If PCO2 matches then it is respiratory, if HCO3 matches it is metabolic.
4. The other value measures compensation.
Maggie 10-year-old F/S Lab
Maggie 10-year-old F/S Lab
History of acute collapse 1 hr ago
Presents with pale gums, tachypnea, tachycardia, poor pulses
PCV/TS/ Venous Blood gas/Glucose
Maggie 10-year-old F/S Lab
PCV/TS – 36%/5.8
Venous blood gas-pH – 7.1PCO2- 35HCO3- 14
Blood glucose - 78
Maggie 10-year-old F/S Lab
What is her acid/base status?
Maggie 10-year-old F/S Lab
pH – 7.1PCO2- 35HCO3- 14
Classified as uncompensated metabolic acidosis
Maggie 10-year-old F/S Lab
20 minutes post initial presentation obtained arterial blood gas (On O2)
pH – 7.28 HCO3- 5.0
PCO2- 10.1 PO2 – 189
Maggie 10-year-old F/S Lab
Now what is her acid/base status?
Maggie 10-year-old F/S Lab
pH – 7.28 HCO3- 5.0
PCO2- 10.1 PO2 – 189
Classified as compensated metabolic acidosis
Maggie 10-year-old F/S Lab
How do her clinical signs match up? Tachycardia, pale gums, poor pulses Tachypnea
Venous blood gas- Arterial blood gas pH – 7.1 pH – 7.28 PCO2- 35 PCO2 – 10.1
HCO3- 14 HCO3 – 5.0PO2 – 189
Does she need oxygen?
Tom 9-year-old M/C DMH
Tom 9-year-old M/C DMH
Presented for acute GI signs
Developed CHF post abdominal exploratory
Treated with Lasix
Tom 9-year-old M/C DMH
48 hrs post Lasix therapy Venous blood gas was performedpH – 7.553PCO2- 40.5HCO3- 35.7
Tom 9-year-old M/C DMH
What is his acid/base status?
Tom 9-year-old M/C DMH
pH – 7.553PCO2- 40.5HCO3- 35.7
Classified as a metabolic alkalosis with respiratory compensation
Missy – 12-year-old F/S Bichon
Missy – 12-year-old F/S Bichon
History of acute onset respiratory distress
Presents with grade IV/VI heart murmur, crackles bilaterally, cyanosis
Thoracic radiographs, venous blood gas
Missy – 12-year-old F/S Bichon
Thoracic radiographs – cardiomegally, diffuse alveolar pattern
Venous blood gas- pH – 7.15PCO2 – 56HCO3 - 20
Missy – 12-year-old F/S Bichon
What is her acid/base status?
Missy – 12-year-old F/S Bichon
pH – 7.15PCO2 – 56HCO3 - 20
Classified as uncompensated respiratory acidosis
Toby 12-year-old M/C Westie
Toby 12-year-old M/C Westie
History of chronic cough x 2 years
Recent worsening of cough
Decreased appetite, lethargy x 1 week
Increased respiratory rate, unwilling to walk this evening
Toby 12-year-old M/C Westie
Physical examinationDepressed, pale pink mm, 5% dehydratedTachypnic and slightly dyspnicThoracic auscultation – fine crackles
bilaterally, harsh BV soundsThoracic radiographs, venous blood gas
Toby 12-year-old M/C Westie
Thoracic radiographs – diffuse bronchointerstitial pattern
Venous blood gas –pH 7.35PCO2 – 43HCO3 - 30
Toby 12-year-old M/C Westie
What is his acid/base status?
Toby 12-year-old M/C Westie
pH 7.35PCO2 – 43HCO3 - 30
Classified as a compensated respiratory acidosis
Questions
Therapy for Acid Base Disorders
Metabolic Acidosis
Detrimental effects of AcidosisDecreased myocardial contractility
when pH < 7.2Predispose heart to VPCsPeripheral insulin resistance Obtunded state or coma
Metabolic Acidosis Treatment
IV fluids to address dehydration or hypovolemia – Use pH balanced fluids such as LRS
or Norm R
Metabolic Acidosis Treatment
Blood transfusions for anemia
Metabolic Acidosis Treatment
NaHCO3 supplementUse only when dehydration,
hypovolemia, and anemia have been addressed
pH is < 7.2Do not use when body has not shown
compensation with a low PCO2
Metabolic Acidosis Treatment
NaHCO3 supplement.3 x [Wt(Kg)] x BE
BE = Normal HCO3 (24) – HCO3 of patient
If pH < 7.1 then bolus 25%Give 50% over 12 hrs.
Metabolic Acidosis Treatment
NaHCO3 supplementMonitor acid-base status q 6 hrs Stop supplement when pH is 7.2Recheck acid-base status 6 hrs later
to make sure further supplementation is not needed.
Metabolic Alkalosis
Renal physiologyNormally expect the kidney to excrete
HCO3 and conserve H+
Normal human patients given 1,000 mEq NaHCO3 /day for 2 weeks excreted virtually all of the HCO3
Metabolic alkalosis has significantly less HCO3 load
- Burton David Rose, 1994
Metabolic Alkalosis
Renal physiology Hypochloremic
metabolic alkalosisDecreased Cl- to
Macula Densa Increased Renin
excretion Increases distal
tubule H+ secretion
Metabolic Alkalosis
Renal physiologyHypochloremic
metabolic alkalosis
H+-ATPase pump in collecting tubule.
Metabolic Alkalosis
Renal physiologyHypokalemia
Increased H+/K+ exchange leading to influx of H+ into cells. This leads to H+ secretion in renal tubules.
Severe hypokalemia causes renal excretion of Cl-
Metabolic Alkalosis
TreatmentIV fluids - .9% NaCl
Replenishes Cl-
Acidic fluidWith out Cl- you can not encourage H+
retention and HCO3 excretionK+ supplementationCorrect primary problem
Respiratory Acidosis and Alkalosis
TreatmentNo specific treatment necessaryTherapy directed towards the primary
problem.
Acid Base Physiology