ACID-BASE BALANCE

By:
Husnil Kadri
Biochemistry Departement
Medical Faculty Of Andalas University
Padang

CARA
TRADISIONAL :

Hendersen-Hasselbalch
(1909)
2

Normal

pH = 6.1 + log
Normal

[HCO ]
GINJAL
BASA
3

HCO
HCO 3
3

Kompensasi

ASAM
pCO2
PARU

CO
CO22

Carbonic acid/bicarbonate buffer system

pKa = 6.1
ECF:

H2CO3 H+
Carbonic acid

HCO3Bicarbonate ion

The pKa of carbonic acid is 6.1

Carbonic acid is the major buffer in ECF
The pH of blood can be determined using
the Henderson-Hasselbalch equation
4

Henderson-Hasselbalch equation
pH = pKa + log [HCO3-]/[H2CO3]
pH = pKa + log [HCO3-]/0.03 x PCO2
7.4 = 6.1 + log

20 / 1

7.4 = 6.1 + 1.3

Plasma pH equals 7.4 when buffer ratio is 20/1
The solubility constant of CO2 is 0.03
5

GANGGUAN KESEIMBANGAN ASAMBASA TRADISIONAL

DISORDER

pH

PRIMER

RESPON
KOMPENSASI

ASIDOSIS
METABOLIK

HCO3-

pCO2

ALKALOSIS
METABOLIK

HCO3-

pCO2

ASIDOSIS
RESPIRATORI

pCO2

HCO3-

ALKALOSIS
RESPIRATORI

pCO2

HCO3-

Normal Compensatory Response

Any primary disturbance in acid-base
homeostasis invokes a normal
compensatory response.
A primary metabolic disorder leads to
respiratory compensation, and a primary
respiratory disorder leads to an acute
metabolic response due to the buffering
capacity of body fluids.
A more chronic compensation (1-2 days) due
to alterations in renal function.

Mixed Acid - Base Disorder

Most acid-base disorders result from a single primary
disturbance with the normal physiologic compensatory
response and are called simple acid-base disorders.
In certain cases, however, particularly in seriously ill
patients, two or more different primary disorders may
occur simultaneously, resulting in a mixed acid-base
disorder.
The net effect of mixed disorders may be additive (eg,
metabolic acidosis and respiratory acidosis) and result in
extreme alteration of pH;
or they may be opposite (eg, metabolic acidosis and
respiratory alkalosis) and nullify each others effects on
the pH.

Cara Stewart ;
pH atau [H+] DALAM PLASMA
DITENTUKAN OLEH
DUA VARIABEL
VARIABEL
INDEPENDEN

VARIABEL
DEPENDEN

Stewart PA. Can J Physiol Pharmacol 61:1444-1461, 1983.

INDEPENDENT VARIABLES

DEPENDENT VARIABLES

Strong Ions
Difference

pCO2

Protein
Concentration

pH

VARIABEL INDEPENDEN

CO2

STRONG ION
DIFFERENCE

pCO2

SID

WEAK ACID

Atot

DEPENDENT VARIABLES

H+

HCO3OH-

AH
CO3-

A-

CO2
CO2 Didalam plasma berada
dalam 4 bentuk
sCO2 (terlarut)
H2CO3 asam karbonat
HCO3- ion bikarbonat
CO32- ion karbonat

Rx dominan dari CO2 adalah rx

absorpsi OH- hasil disosiasi air

dengan melepas H+.
Semakin tinggi pCO2 semakin

banyak H+ yang terbentuk.

Ini yg menjadi dasar dari

terminologi respiratory acidosis,

yaitu pelepasan ion hidrogen akibat
pCO2

Definisi:
Strong ion difference adalah ketidakseimbangan muatan
dari ion-ion kuat. Lebih rinci lagi, SID adalah jumlah
konsentrasi basa kation kuat dikurangi jumlah dari
konsentrasi asam anion kuat. Untuk definisi ini semua
konsentrasi ion-ion diekspresikan dalam ekuivalensi
(mEq/L).
Semua ion kuat akan terdisosiasi sempurna jika berada didalam
larutan, misalnya ion natrium (Na+), atau klorida (Cl-). Karena
selalu berdisosiasi ini maka ion-ion kuat tersebut tidak
berpartisipasi dalam reaksi-reaksi kimia. Perannya dalam kimia
asam basa hanya pada hubungan elektronetraliti.

STRONG ION
DIFFERENCE

Gamblegram

Mg++
Ca++

K+ 4

SID

[Na+] + [K+] + [kation divalen] - [Cl-] - [asam organik kuat-]

Na+
140
Cl102
[Na+]

140 mEq/L

[K+]
+

4 mEq/L -

KATION

[Cl-]
102 mEq/L

ANION

[SID]
=

34 mEq/L

[H+]

[OH-]

Konsentrasi [H+]
Asidosis

()

Alkalosis

SID

( +)

Dalam cairan biologis (plasma) dgn suhu 370C, SID hampir

selalu positif, biasanya berkisar 30-40 mEq/Liter

WEAK ACID
[Protein-] + [H+]

[Protein H]
disosiasi

Kombinasi protein dan posfat disebut asam

lemah total (total weak acid) [Atot].
Reaksi disosiasinya adalah:

[Atot] (KA) = [A-].[H+]

Gamblegram
Mg++
Ca++

K+ 4

HCO324
Weak acid
(Alb-,P-)

Na+
140

KATION

Cl102

ANION

SID

H3O+ = H+ = 40 mEq/L

K
Mg
Ca

HCO33--
HCO3 = 24
HCO
Alb
3

P
Alb
Laktat/keto=UA
P

Na
140

Alb
P

Keto/laktat
Asidosis
hiperkloremi
asidosis

Cl
CL
Cl
115
95
102
Alkalosis
hipokloremi
KATION

ANION

SID
SID n

SID

Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic acid-base disturbances in

critically ill patients. Am J Respir Crit Care Med 2000 Dec;162(6):2246-51

I. Respiratori

ASIDOSIS
PCO2

ALKALOSIS
PCO2

II. Nonrespiratori (metabolik)

1. Gangguan pd SID
a. Kelebihan / kekurangan air
b. Ketidakseimbangan anion
kuat:
i. Kelebihan / kekurangan Clii. Ada anion tak terukur

[Na+], SID

[Cl-], SID

[Na+], SID
[Cl-], SID

[UA-], SID

2. Gangguan pd asam lemah

i. Kadar albumin

[Alb]

[Alb]

ii. Kadar posphate

[Pi]

[Pi]

Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic acid-base disturbances in

critically ill patients. Am J Respir Crit Care Med 2000 Dec;162(6):2246-51

RESPIRASI

M E T AB O L I K

Abnormal
pCO2

Abnormal
SID

AIR

Anion kuat

Cl-

Alkalosis

Turun

kekurangan

Hipo

Asidosis

Meningkat

kelebihan

Hiper

Fencl V, Am J Respir Crit Care Med 2000 Dec;162(6):2246-51

Abnormal
Weak acid

Alb

PO4-

UA-

Turun
Positif

meningkat

KEKURANGAN AIR - WATER DEFICIT

Diuretic
Diabetes Insipidus
Evaporasi
Plasma

Plasma

Na+ = 140 mEq/L

Cl- = 102 mEq/L
SID = 38 mEq/L

1 liter

140/1/2 = 280 mEq/L

102/1/2 = 204 mEq/L
SID = 76 mEq/L

SID : 38 76 = alkalosis
ALKALOSIS KONTRAKSI

liter

KELEBIHAN AIR - WATER EXCESS

Plasma

Na+ = 140 mEq/L

Cl- = 102 mEq/L
SID = 38 mEq/L

1 Liter
H2O
1 liter

2 liter

SID : 38 19 = Acidosis
ASIDOSIS DILUSI

140/2 = 70 mEq/L
102/2 = 51 mEq/L
SID = 19 mEq/L

GANGGUAN PD SID:
Pengurangan ClPlasma

Na+ = 140 mEq/L

Cl- = 95 mEq/L
SID = 45 mEq/L

SID

ALKALOSIS

ALKALOSIS HIPOKLOREMIK

2 liter

GANGGUAN PD SID:
Penambahan/akumulasi
ClPlasma

Na+ = 140 mEq/L

Cl- = 120 mEq/L
SID = 20 mEq/L

SID

ASIDOSIS

ASIDOSIS HIPERKLOREMIK

2 liter

PLASMA + NaCl 0.9%

Plasma

NaCl 0.9%

Na+ = 140 mEq/L

Cl- = 102 mEq/L
SID = 38 mEq/L

Na+ = 154 mEq/L

Cl- = 154 mEq/L
SID = 0 mEq/L

1 liter

SID : 38

1 liter

ASIDOSIS HIPERKLOREMIK AKIBAT

PEMBERIAN LARUTAN Na Cl 0.9%
Plasma

Na+ = (140+154)/2 mEq/L= 147 mEq/L

Cl- = (102+ 154)/2 mEq/L= 128 mEq/L
SID = 19 mEq/L

2 liter

SID : 19 Asidosis

PLASMA + Larutan RINGER LACTATE

Plasma

Ringer laktat
Laktat cepat
dimetabolisme

Na = 140 mEq/L
Cl- = 102 mEq/L
SID= 38 mEq/L
+

1 liter

SID : 38

Cation+ = 137 mEq/L

Cl- = 109 mEq/L
Laktat- = 28 mEq/L
SID = 0 mEq/L

1 liter

Normal pH setelah pemberian

RINGER LACTATE
Plasma

Na+ = (140+137)/2 mEq/L= 139 mEq/L

Cl- = (102+ 109)/2 mEq/L = 105 mEq/L
Laktat- (termetabolisme) = 0 mEq/L

2 liter

SID = 34 mEq/L

SID : 34 lebih alkalosis dibanding jika

NaCl 0.9%

diberikan

MEKANISME PEMBERIAN NABIKARBONAT PADA ASIDOSIS

Plasma;

Plasma + NaHCO3

asidosis
hiperkloremik

Na+ = 140 mEq/L

Cl- = 130 mEq/L
SID =10 mEq/L

25 mEq
NaHCO3

1 liter

1.025
liter

HCO3 cepat
Na = 165 mEq/L dimetabolisme
+

Cl- = 130 mEq/L

SID = 35 mEq/L

SID : 10 35 : Alkalosis, pH kembali normal namun mekanismenya

bukan karena pemberian HCO3- melainkan karena pemberian Na+ tanpa anion kuat
yg tidak dimetabolisme seperti Cl- sehingga SID alkalosis

UA = Unmeasured Anion:
Laktat, acetoacetate, salisilat,
metanol dll.
K

HCO3-

HCO3-

SID

KetoA-

A
Na+

SID

Na+
Cl-

ClLactic/Keto asidosis

Normal

Ketosis

GANGGUAN PD ASAM LEMAH:

Hipo/Hiperalbumin- atau PK

HCO3

K
SID

Na
Cl

Normal

SID

K
HCO3

Alb-/P

Alb-/P-

Na

HCO3

Alb/P

Na
Asidosis
hiperprotein/
hiperposfatemi
Cl

Acidosis

SID

Alkalosis
hipoalbumin
Cl /hipoposfate
mi

Alkalosis

Anion Gap
Described by Gamble in 1939
Electroneutrality
Na+, Cl-, and HCO3 are measured ions

Na + UC = Cl + HCO3 + UA
UC = Sum of unmeasured cations
UA = Sum of unmeasured anions

Anion Gap
Unmeasured Cations:
total 11 mEq/L
Potassium 4
Calcium
5
Magnesium 2

Unmeasured Anions:
total 23 mEq/L
Sulfates
1
Phosphates 2
Albumin
16
Lactic acid 1
Org. acids 3

Anion Gap
Na + UC = Cl + HCO3 + UA
140 + 11 = 104 + 24 + 23
151 = 151
UA UC = Na - (Cl + HCO3);
Anion Gap = Na - (Cl + HCO3)

If the anion gap is elevated

Then compare the changes from normal between
the anion gap and [HCO3 -].
If the change in the anion gap is greater than the
change in the [HCO3 -] from normal, then a
metabolic alkalosis is present in addition to a gap
metabolic acidosis.
If the change in the anion gap is less than the
change in the [HCO3 -] from normal, then a non
gap metabolic acidosis is present in addition to a
gap metabolic acidosis.

Anion Gap Acidosis:

Anion gap >12 mEq/L; caused by a
decrease in [HCO3 -]
balanced by an increase in an
unmeasured acid ion from either
endogenous production or exogenous
ingestion (normochloremic acidosis).

Non anion Gap Acidosis:

Anion gap = 8-12 mmol/L; caused by a
decrease in [HCO3 -] balanced by an
increase in chloride (hyperchloremic
acidosis). Renal tubular acidosis is a type
of non gap acidosis

Increased Anion Gap

Normal = 8-15
May differ institutionally

Accumulation of organic acids (ketones,

lactate)
Toxic Ingestions
methanol, ethylene glycol, salicylates
Reduced inorganic acid excretion
phosphates, sulfates
Decrease in unmeasured cations
(unusual)

Increased AG Metabolic Acidosis:

Methanol
Uremia/Renal
Failure
INH, Iron--lactate
Paraldehyde

Lactic Acidosis
Has many etiologies
Cyanide, CO, Toluene,
HS
Poor perfusion

Ethylene glycol
Salicylates
Methyl salicylate
(Oil of wintergreen)

Mg salicylate
Levraut J et al. Int Care
Med 23:417, 1997

Increased Anion Gap

Normal = 8-15
May differ institutionally
ion specific electrodes

Accumulation of organic acids (ketones,

lactate)
Toxic Ingestions
methanol, ethylene glycol, salicylates

Reduced inorganic acid excretion

phosphates, sulfates

Decrease in unmeasured cations (unusual)

Decreased or Negative Anion Gap

Clin J Am Soc Nephrol 2: 162-174, 2007

Low protein most important

Albumin has many unmeasured negative
charges
Normal anion gap (12) in cachectic person
Indicates anion gap metabolic acidosis

Other etiologies of low AG:

Low K, Mg, Ca, increased globulins (Mult.
Myeloma), I intoxication

Negative AG
more unmeasured cations than unmeasured
anions
Bromide, Iodide, Multiple Myeloma

44

Change in Anion Gap vs HCO3

In simple AG Metabolic Acidosis
decrease in plasma bicarbonate = increase in
AG

Anion Gap = 1
HCO3
Helpful in identifying mixed disorders

Respiratory Compensation
for

Metabolic Acidosis:
Occurs rapidly
Hyperventilation
Kussmaul Respirations
Deep > rapid (high tidal
volume)
Is not Respiratory Alkalosis

Metabolic Alkalosis:
Calculation not as
accurate
Hypoventilation
Not Respiratory
Acidosis
Restricted by
hypoxemia
PCO2 seldom > 50-55

Reference
1.
2.
3.
4.
5.
6.
7.
8.

Achmadi, A., George, YWH., Mustafa, I. Pendekatan Stewart

Dalam Fisiologi Keseimbangan Asam Basa. 2007
Beaudoin, D. Electrolytes and ion sensitive electrodes. PPT.
2003.
Ivkovic, A ., Dave, R. Renal review. PPT
Kersten. Fluid and electrolytes. PPT.
Marieb, EN. Fluid, electrolyte, and acid-base balance. PPT.
Pearson Education, Inc. 2004
Rashid, FA. Respiratory mechanism in acid-base homeostasis.
PPT. 2005.
Silverthorn, DU. Integrative Physiology II: Fluid and Electrolyte
Balance. Chapter 20, part B. Pearson Education, Inc. 2004
Smith, SW. Acid-Base Disorders. www.acid-base.com

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