acid-basebalance · a n i l k a t w g u d h (o m n r s g c e m y)...

Anil Kantiwal Gudha ( OM Nursing Academy )

Introduction :-

Body � Homeostasis � िलए Acid-Base Balance ब�त मह�वपणू�� और Body की लगभग सभीPhysiological Activities, Acid-Base � Status पर �नभ�र करती �।

Acid :-

An Acid Contain Hydrogen ion ( H+ ).

Acid यह Hydrogen ion ( H+ ) को Donate कर� � ( Proton Donor )

Acid की pH 7 � कम होती �

Taste - Acid �वाद � Sour हो� �

Eg. - HCL ( Hydrochloric acid )

Base :-

Base contain Hydroxide ion ( OH- )

Base वो हो� � जो Hydrogen ion ( H+ ) को �हण कर� � ( Proton Acceptor )

Base की pH 7 � अ�धक होती �

Taste - Base �वाद � कड़� हो� �

Eg. - NaOH ( Sodium Hydroxide )

pH ( Power/Potencial of Hydrogen ) :-

pH Scale - Invented by Dr. Soren Sorensen

Acidic :- अगर pH Scale � pH 7 � कम हो रही � तो H+ की Concentration बढ़�गी ।

Alkaline :-य�द pH Scale � pH 7 � �यादा बढ़ रही � तो H+ की Concentration घ�गंी ।

Acid-Base Balance

OM Nursing Academy

Anil Kantiwal Gudha

pH Increase = H+Concentration Decrease

pH Decrease = H+Concentration Increase


Acid Base Balance is maintain by following Mechanisms :-

1. Chemical Regulation

2. Physiological Regulation

3. Potassium Exchange

1. Chemical Regulation :-

यह Buffers � द�वारा �कया जा� वाला immediate regulation � जो Acid-Base imbalance को �छ हीseconds � maintain कर �ता �

Blood Buffer System :-

1. Buffer एक ऐसा substance होता � जो Acid-Base Balance को maintain कर� � िलए Hydrogenion ( H+ ) को Absorb और release कर सकता � ।

2. Body Fluid have four types of Buffer System.

1) Carbonic acid & Bicarbonate

2) Phosphate Buffer

3) Plasma Protein - Albumin

4) Hemoglobin

1. Carbonic acid & Bicarbonate :-

CO2 + H2O H2CO3. H++ HCO3

Acidosis ( Increase H+Concentration )

H++ HCO3 H2CO3

Alkalosis ( Decrease H+Concentration )

H2CO3 H++ HCO3-

The System maintains a pH of 7.4 with a ratio of 20 parts Bicarbonate (HCO3 - ) to 1 partCarbonic acid ( H2CO3 ).


Bicarbonate (HCO3 - ) : Carbonic acid ( H2CO3 )

20 : 1

24 mEq/L : 1.2 mEq/L

Lungs, Carbonic acid की Concentration को control करता � ( By CO2 Excreation )

Lungs Excreat 13000-30000 mEq/day Volatile Acid in form of Carbonic acid as CO2.

Kidney , Bicarbonate की concentration को control करती �

Kidney Excreat 50 mEq/Day of NonVolatile acids.

2. Phosphate Buffer System :-

Phosphate Buffer System यह cells एव Bंody fluid � उपि�थत रहता � तथा म�ुयतः Kidneys �active होता �

Acidosis :- ( Increase H+ Concentration )

H++ HPO4 2- H2PO4- ( Dihydrogen Phosphate )

जब Blood � हाइ�ोजन आयन� की स�ंया बढ़ जाती � ( ph घटती � ), तब हाइ�ोजन आयन ( H+ ) फॉ�फ�टआयन को �वीकार कर� � ता�क Blood � हाइ�ोजन और हाइ�ो�साइड आयन� की concentration � बीचसतंलुन बनाए रखा जा स�।

Alkalosis :- ( Decrease H+ Concentration )

H2PO4- H+ + HPO4 - ( Monohydrogen Phosphate ).

जब Blood � Hydrogen ions की स�ंया कम होती � ( pH बढ़ती � ) तब Blood � Hydrogen ions कोबढ़ा� � िलए Dihydrogen Phosphate ions हाइ�ोजन ions को release कर� � ।

3. Plasma Protein System ( Albumin ) :-

Plasma Protein � Hydrogen ion ( H+ ) को attract और release कर� की ability पायीजाती � ।

Most important intracellular buffer, Protein are extremely abundant in the Cell.


4. Hemoglobin System :-

【In Peripheral Tissue】 CO2 यह RBC � diffuse होकर Carbonic acid बनाती �, Carbonic Acidयह H+ तथा Bicarbonate (HCO3) � ट�ट जाता �, Hydrogen Ion ( H+ ) हीमो�लो�बन � साथ जड़ु जाता �एव Bंicarbonate ( HCO3 ) Chloride ion � साथ आपस � Exchange हो� � इ� Chloride Shift /Hamburger phenomena � नाम � भी जाना जाता � ।

【In lungs】 Reverse Chloride shift take place ( यहंा Hemoglobin CO2 की जगह O2 � जड़ुता � तथाCO2 को release करता � ।

Chloride Shift

Blood � O2 Level � response � Chloride कोिशकाओ �ं अदंर और बाहर की ओर जा� �

�य��क एक RBC � िजत� chloride ions अदंर आ� � उत� Bicarbonate ions RBC � बाहर च� जा� �और िजत� Bicarbonate ions RBC � अदंर आ� � उत� ही chloride ions RBC � बाहर च� जा� � ।

RBC


2. Physiologial regulation :-

A. Respiratory Mechanism :- ( in Lungs )

It takes few Minnut to balance.

In Acidosis - Respiratory rate and depth increased.

In Alkalosis - Respiratory rate and depth Decreased.

B. Renal Mechanism :- ( in Kidney )

It takes few hours to several days to balance.

In Acidosis - the pH is decrease and Excess Hydrogen ions secreted into tubules &combine with buffer for recreation in Urine.

In Alkalosis - the pH is increase and Excess Bicarbonate Secreated into tubules &combined with Sodium & Excreted in Urine.

3. Potassium Exchange :-

In Acidosis - Acidosis � ECF � Hydrogen ion की माा बढ़ जाती � तब Hydrogen ions ECF � ICf(Intra cellular fluid ) � जा� लग� �, इस� फल�व�प ICF की electrically neutral बना� रख� � िलएPotassium ions cell � बाहर आ जा� � और Hyperkelemia की condition उ�प�न हो जाती � ।

In Alkalosis - Alkalosis की condition � ECF की तलुना � ICF � �यादा Hydrogen ions उपि�थतहो� �, ICF � �यादा H+ हो� � कारण H+ ICF � ECF � जा� लग� �, ICF की electrically को neutralबना� रख� � िलए Potassium ions, ECF � ICF � move कर� लग� � और Hypokelemia कीcondition उ�प�न हो जाती � ।

★ याद कर� की Trick

In Acidosis In AlkalosisNormal Conditions

Hyperkelemia Hypokalemia


Introduction :-

Acid base Imbalance is an abnormality of human body's normal balance of acids andBase that causes plasma pH to deviate out of normal range ( 7.35 to 7.45 ).

Classification :-

Acid-Base Imbalance

Acidosis Alkalosis

Respiratory Acidosis Metabolic Acidosis Respiratory Alkalosis Metabolic Alkalosis

1. Respiratory Acidosis :-

Respiratory Acidosis � Alveolar Hypoventilation � कारण Blood � H+ ions कीConcentration बढ़ जाती � ।

pH = Decrease ( Below 7.35 )

H+Concentration = Increase

PCO2Level = increase ( more than 45 mmHg )

Acid Base Imbalance


Causes :- Respiratory Acidosis is caused by Primarily defects in the function of the lungs orChanges in normal Respiratory pattern.

A. Respiratory Disease :-

Asthma

COPD

Atelectasis

Bronchiectasis, Bronchitis

Pulmonary Edema, Pulmonary emboli

Pneumonia

Emphysema

B. Respiratory Centre Depress :- ( Medulla Oblongata )

Brain trauma

Brain Tumour

C. CNS Depressant :-

Sedatives

Narcotics

Anesthesia

Alcohol

Clinical Manifestation :-

Hypoventilation

Hyperkelemia

Drowsiness, Dizziness, Headache, Coma

Seizures

Ventricular fibrillation

Management :-

O2Therapy

Semi-fowler's position

Suctioning

Increase Deep breath and Cough

Endotracheal tube / Mechanical Ventilation


2. Respiratory Alkalosis :-

Alveolar Hyperventilation � कारण Blood � H+ ions की Concentration कम हो जाती � ।

pH = Increase ( Above 7.45 )

H+Concentration = Decrease

PCO2Level = Decrease ( Below 35 mmHg )

Causes :-

Any condition that Causes Over Stimulation of Respiration.

Hyperventilation

Hypoxia ( Hypoxia Stimulate Respiratory centre Brain stem, which causes an increase inthe Respiratory rate in order to increase O2 , this cause Hyperventilation.

Hysteria

Over Ventilation by Mechanical Ventilator

Pain

Pregnancy

Fever

Psychological and Emotional Condition.


Initially Hyperventilation causes Tachypnea.

Hypokalemia

Hypocalcemia ( tetany )

Lethargy, Confusion, Tachycardia

Convulsions

Nausea, Vomiting, Epigastric Pain

Management :-

Encourage appropriate Breathing Pattern.

Voluntary holding the Breathing.

Provide CO2Breaths ( Rebreathing into paper bag )

Provide care for Ventilator patient.

Injection Calcium gluconate for tetany.

CO2Breathing with paper bag


3. Metabolic Acidosis :-

Increase H+ ion caused by abnormal Metabolic process.


H+Concentration = Increase

HCO3Level = Decrease ( less than 22 mEq/Liter )

Causes :-

Renal failure

Diabetes mellitus / Diabetic Ketoacidosis ( DKA ).

Severe Diarrhoea

Increase lactic Acid.

Ileostomy

Malnutrition & Starvation

Excessive ingestion of Acetylsalicylic Acids [ Aspirin ].

High fat Diet.


Kussmaul's Respiration

Hyperkelemia

Drowsiness, confusion

Headache, coma

Dysrhythmia, warm flush skin

Nausea & Vomiting, Diarrhoea

Management :-

Give Insulin as Prescribed in DM & treat underlined causes of Acidosis.

4. Metabolic Alkalosis :-

Deficit of Carbonic Acid and a Decrease in Hydrogen ion concentration.

pH = Decrease ( Above 7.45 )

H+Concentration = Decrease

HCO3Level = Decrease ( more than 27 mEq/Liter )

Causes :-

Massive Blood Transfusion

Excessive Vomiting


GI Suctioning

Antacid Uses

Diuretic

Hyperaldosteronism ( retention of Na+

Infusion of excess Soda Bicarbonate.


Hypoventilation

Hypokalemia, Hypocalcemia

Tremors, Tetany, Muscle cramp

Seizures

Drowsiness

Tachycardia, Dysrhythmia

Management :-

Treat underlined causes of Acidosis.

Clinical Evaluation of Disturbance in Acid Base Status :-

● Anion Gap :-

Anion gap यह acid base status � आ� Disturbance को Evaluate कर� � िलए काम � �� ।( Mostly Anion gap is Used for Evaluation of Metabolic Acidosis ).

Anion gap � routine clinical investigation � दौरान �छ ही Cations और Anions को measureकर� �,

सामा�यतः measured cation सो�डयम होता � तथा unmeasured cations पो�िशयम, क�ि�शयम और��नीिशयम, इसी �कार measured Anions �लोराइड ( cl- ) व बाइकाब��ट ( HCO3- ) हो� � तथाUnmeasured anions फॉ�फ�ट, स�फ�ट, �ोटी�स ( ए��यिूमन ) व अ�य anions ज�ै lactate.

Unmeasured anions और Unmeasured Cations की concentrations � बीच � अतंर कोAnion Gap कह� � ।

Anion Gap Calculation :-

Anion gap = [Na+] - [ cl- ] - [ HCO3- ]

= 144 - 108 - 24 mEq/Liter

= 12 mEq/Liter

Normal Anion gap is 8 - 16 mEq/Liter


● ABG Analysis ( Arterial Blood Gas Analysis ) :-

ABG Analysis द�वारा Arterial Blood � उपि�थत O2 एव CंO2 गसै� की माा को measure कर� � िलए�कया जाता � । इस� lungs एव Kंidney की working ability को भी evaluate कर सक� � ।

Purpose :- Acid Base imbalance को Diagnose कर� �त ।ु

Allen's Test :-

Allen's Test यह ABG Analysis कर� � िलए कर� � । ( By taking Blood sample from Artery )

Site - the most common site for Arterial puncture is Radial Artery at the wrist.

Use Pre-Heparinized ABG Syringe - Syringe should be flushed with 0.5 ml of 1:1000Heparin solution and emptied.

Procedure :-

Pressure on Radial Artery and Ulnar Artery

Ask the Patient to clench Fist at Several times

Remove Pressure from Ulnar Artery

Pinkness Return within 6 Second Pinkness not Return

Withdraw sample from Radial Artery Do not sample from Radial Artery

ABG Syringe को Sample �� तरु�त बाद Cold chain की सहायता � Lab � �ज � ।ं

Capillary Refill time = 2-3 Seconds

Capillary Refill time is check by Pinch finger pad and Nail bud.


ABG Report Interpretation :-

Normal ABG Value :-

pH - 7.35 - 7.45 Acid Base Imbalance indicator

PCO2 - 35 - 45 mmHg Respiratory function Indicator

HCO3- - 22 - 27 mEq/L Metabolic function indicator

PO2 - 80 - 100 mm Hg

SaO2 - 95 - 100%

In Respiratory Condition :-

ABG � Respiratory Condition - CO2 Level �नध��रत करता �

Normal PCO2 level is :- 35 - 45 mmHg

अगर Blood की pH बढ़�गी तो PCO2 घ�गी,

अगर Blood की pH घ�गी तो PCO2 बढ़�गी ।

In Metabolic Condition :-

ABG � Metabolic condition, HCO3-Bicarbonate level �नध��रत कर� �

Normal Bicarbonate level is :- 22 - 27 mEq/L

अगर Blood की pH level घटा �आ � तो HCO3- level भी घटा �आ िम�गा,

अगर Blood की pH level बढ़ा �आ � तो HCO3- level भी बढ़ा �आ िम�गा ।

Respiratory Acidosis :-


PCO2Level = increase ( more than 45 mmHg )


Types of Respiratory Acidosis :- ( According to Compensation )

1. Respiratory Acidosis ( Uncompensated ) :-

Eg.- pH- 7.33 , PCO2 - 48 mmHg , HCO3- - 24 mEq/L

Interpretation :-

pH - 7.33 Decrease Acidosis

PCO2 - 48 mmHg Increase Respiratory

HCO3-= 24 mEq/L Normal √

ABG Report Result is :- Respiratory Acidosis ( Uncompensated )

2. Compensated Respiratory Acidosis :-

Compensated Respiratory Acidosis � pH normal हो ( 7.35 - 7.39 ) , PaCO2 सामा�य � बढ़ा�आ हो तथा इस� साथ HCO3- भी बढ़ा �आ हो तो , इस condition को Compensated RespiratoryAcidosis कह� �

Eg. - pH- 7.35 , PCO2 - 48 mmHg , HCO3- - 29 mEq/L

Interpretation :-

pH - 7.35 pH normal (With lower level ) Acidosis


HCO3-= 29 mEq/L Increase ×

ABG Report Result is :- Respiratory Acidosis ( Compensated )

3. Partially Compensated Respiratory Acidosis :-

Partially Compensated Respiratory Acidosis � pH abnormal ( Below 7.35 ) , PaCO2सामा�य � बढ़ा �आ हो तथा इस� साथ HCO3- भी बढ़ा �आ हो तो , इस condition को PartiallyCompensated Respiratory Acidosis कह� � ( इस� तीन� Value [ pH, PaCO2, HCO3- ] abnormalही िम�गी ) ।

Eg. - pH- 7.32, PCO2 - 52 mmHg , HCO3- - 32 mEq/L

Interpretation :-



HCO3-= 32 mEq/L Increase ×


Respiratory Alkalosis :-

pH = increase ( more than 7.45 )

PCO2Level = Decrease ( Below 35 mmHg )

Types of Respiratory Alkalosis :- ( According to Compensation )

1. Respiratory Alkalosis ( Uncompensated ) :-


Interpretation :-

pH - 7.48 increase Alkalosis

PCO2 - 32 mmHg Decrease Respiratory

HCO3-= 23 mEq/L Normal √

ABG Report Result is :- Respiratory Alkalosis ( Uncompensated )

2. Compensated Respiratory Alkalosis :-

Compensated Respiratory Alkalosis � pH normal हो ( 7.40 - 7.45 ) , PaCO2 सामा�य � घटा�आ हो तथा इस� साथ HCO3- भी घटा �आ हो तो , इस condition को Compensated RespiratoryAlkalosis कह� �


Interpretation :-

pH - 7.45 pH normal (With Upper level ) Alkalosis

PCO2 - 32 mmHg Decrease Respiratory

HCO3-= 19 mEq/L Decrease ×

ABG Report Result is :- Respiratory Alkalosis ( Compensated )

3. Partially Compensated Respiratory Alkalosis :-

Partially Compensated Respiratory Alkalosis � pH abnormal ( Above 7.45 ) , PaCO2सामा�य � घटा �आ हो तथा इस� साथ HCO3- भी घटा �आ हो तो , इस condition को PartiallyCompensated Respiratory Alkalosis कह� � ( इस� तीन� Value [ pH, PaCO2, HCO3- ]abnormal ही िम�गी ) ।


Interpretation :-


pH - 7.47 Increase Alkalosis

PCO2=31 mmHg Decrease Respiratory

HCO3-= 20 mEq/L Decrease ×

ABG Report Result is :- Respiratory Alkalosis ( Partially Compensated )

Metabolic Acidosis :-


HCO3Level = Decrease ( less than 22 mEq/Liter )

Types of Metabolic Acidosis :- ( According to Compensation )

1. Metabolic Acidosis ( Uncompensated ) :-


Interpretation :-


PCO2 - 40 mmHg Normal √

HCO3-= 18 mEq/L Decrease Metabolic

ABG Report Result is :- Metabolic Acidosis ( Uncompensated )

2. Compensated Metabolic Acidosis :-

Compensated Metabolic Acidosis � pH normal हो ( 7.35 - 7.39 ) , PaCO2 सामा�य � घटा �आहो तथा इस� साथ HCO3- भी घटा �आ हो तो , इस condition को Compensated Metabolic Acidosisकह� �


Interpretation :-

pH - 7.35 pH normal (With lower level ) Acidosis

PCO2 - 30 mmHg Decrease ×


ABG Report Result is :- Metabolic Acidosis ( Compensated )


3. Partially Compensated Metabolic Acidosis :-

Partially Compensated Metabolic Acidosis � pH abnormal ( Below 7.35 ) , PaCO2 सामा�य� घटा �आ हो तथा इस� साथ HCO3- भी घटा �आ हो तो , इस condition को Partially CompensatedMetabolic Acidosis कह� � ( इस� तीन� Value [ pH, PaCO2, HCO3- ] abnormal ही िम�गी ) ।


Interpretation :-


PCO2 - 33 mmHg Decrease ×


ABG Report Result is :- Metabolic Acidosis ( Partially Compensated ).

Metabolic Alkalosis :-

pH = increase ( Above 7.45 )

HCO3Level = increase ( more than 27 mEq/Liter )

Types of Metabolic Alkalosis :- ( According to Compensation )

1. Metabolic Alkalosis ( Uncompensated ) :-


Interpretation :-


PCO2 - 42 mmHg Normal √

HCO3-= 31 mEq/L Increase Metabolic

ABG Report Result is :- Metabolic alkalosis ( Uncompensated )

2. Compensated Metabolic Alkalosis :-

Compensated Metabolic Alkalosis � pH normal हो ( 7.40 - 7.45 ) , PaCO2 सामा�य � बढ़ा �आहो तथा इस� साथ HCO3- भी बढ़ा �आ हो तो , इस condition को Compensated Metabolic Alkalosisकह� �



Interpretation :-

pH - 7.45 pH normal (With Upper level ) Alkalosis

PCO2 - 49 mmHg Increase ×


ABG Report Result is :- Metabolic Alkalosis ( Compensated )

3. Partially Compensated Metabolic Alkalosis :-

Partially Compensated Metabolic Alkalosis � pH abnormal ( Above 7.45 ) , PaCO2 सामा�य� बढ़ा �आ हो तथा इस� साथ HCO3- भी बढ़ा �आ हो तो , इस condition को Partially CompensatedMetabolic Alkalosis कह� � ( इस� तीन� Value [ pH, PaCO2, HCO3- ] abnormal ही िम�गी ) ।


Interpretation :-


PCO2 - 47 mmHg Increase ×


ABG Report Result is :- Metabolic Alkalosis ( Partially Compensated )

Summary Chart (Acid Base Imbalance )

acid-basebalance · a n i l k a t w g u d h (o m n r s g c e m y)...

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