Oxygen and CO2 transportOxygen and CO2 transport
Acid- base balanceAcid- base balance
Biochemistry II
Lecture 9 2008 (J.S.)
1
Transport of O2 and CO2Transport of O2 and CO2
O2 INSPIRED AIR CO2 EXPIRED AIR
Lungs
O2 INSPIRED AIR CO2 EXPIRED AIR
HCO3
– + HHb+
Lungs
HbO + H O + CO
HbO2 + H+ + HCO3
–
HbO2 + H2O + CO2
HCO3
– + HHb+ HbO2 + H2O
CO2 PRODUCED
Tissues
CO2 PRODUCED
HbO2 + H+ + HCO3
–
HCO3
– + HHb+ + O2
2
Inspired and expired air – partial pressures:
pO2 pCO2 pH2O
Inspired air 21 kPa 0.03 kPa 0.76 kPaInspired air 21 kPa 0.03 kPa 0.76 kPa
Expired air 15.3 kPa 4.4 kPa 6.3 kPa
Partial pressures of oxygen and carbon dioxide in blood:
pO2 pCO2
Arterial blood 12.0 (9.2 – 15.5) kPa 5.3 (4.6 – 6.0) kPa
Mixed venous blood (central) 6.7 (5.3 – 8.0) kPa 6.7 (5.4 – 8.0) kPa
3
Arterial blood ≈ 9.2 mmol O / lArterial blood ≈ 9.2 mmol O2 / l
(200 ml O2 / l)
Blood in capillaries:
Tissue
Blood in capillaries:
Plasma Erythrocytes
HbO2 (97% saturation)HbO2 (97% saturation)
O2
consumption
O2
2.3 mmol / l extracted
(50 ml / l)
stimulated by H+
(Bohr effect)
(50 ml / l)
CO2
production
CO2
+ 1.8 mmol / l
(+ 40 ml / l)
Hb (~73% saturation)CO2
H2O
H CO(+ 40 ml / l)
Cl–
HCO3
–
Cl–
HbH+
H+
HCO3
–
H2CO3
Anion antiporter
(band 3 protein)
THE CHLORIDE SHIFT
Cl–Cl–
HbH+
(0.7 mmol H+/mmol Hb)
(Central) venous blood ≈ 6.9 mmol O2 / l
(150 ml O / l)
THE CHLORIDE SHIFT
4
(150 ml O2 / l)
Transport of oxygen
Molecular oxygen in blood exists in two forms:
– O associated with haemoglobin, and– O2 associated with haemoglobin, and
– O2 dissolved but not associated with any other substance.
The concentration of total O c tO = c HbO + c O .The concentration of total O2 c tO2 = c HbO2 + c O2 .
Freely dissolved O2 is given by pO2 × ααααO2 (the concentrational solubility
coefficient in blood ααααO2 = 0.01 mmol/l kPa (at 37 ºC); the solubility of dioxygencoefficient in blood ααααO2 = 0.01 mmol/l kPa (at 37 ºC); the solubility of dioxygen
is very low when compared with CO2 with the ααααCO2 = 0.23). Only about 2 % of the oxygen
is transported physically dissolved in the blood.
Haemoglobin (4Fe) can bind four molecules O , at complete saturation.Haemoglobin (4Fe) can bind four molecules O2, at complete saturation.
At c tHb(1Fe) = 9.2 mmol/l, blood is able to bind 9.2 mmol O2 /l,
i.e. 234 ml O2 /l (37 ºC), when the blood does not contain anyi.e. 234 ml O2 /l (37 ºC), when the blood does not contain any
methaemoglobin (MetHb) or carbonylhaemoglobin (HbCO).
The reference method for haemoglobin in human blood measures the total haemoglobin
concentration, which includes also MetHb and HbCO which have lost permanently orconcentration, which includes also MetHb and HbCO which have lost permanently or
temporarily the capability of reversible O2 binding at physiological pO2.
c tHb = c HbO2 + c HbH+ + c HbCO + c MetHb
5
Oxygen associated with haemoglobin
The oxygen saturation curve
(the oxygen dissociation curve, ODC)
Shift to the right:
acidification (Bohr effect)
increase in pCOincrease in pCO2
increased temperature
increased 2,3-BPG
Position of the ODC:
p50 cca 3.55 kPa,p50 cca 3.55 kPa,
normal range 3.0 – 4.0 kPa
Normally, the arterial blood is approximately 97% saturated with oxygen.Normally, the arterial blood is approximately 97% saturated with oxygen.
After release of oxygen to the tissue, mixed venous blood is about 75% saturated.
Factors that decreased the Hb-O2 affinity (right-shifted curve) facilitate the
release of oxygen. In the case of increased Hb-O affinity, release of oxygen is
6
release of oxygen. In the case of increased Hb-O2 affinity, release of oxygen is
impeded.
Oxygen uptake
The arterial oxygen tension (a)pO2 indicates the uptake function of the lungs.
Under normal physiological circumstances the available haemoglobin in the
arterial blood becomes approximately 97 % saturated in the pulmonaryarterial blood becomes approximately 97 % saturated in the pulmonary
capillaries.
The remaining 3 % will normally not become oxygenated due to anatomic shunts (or
Oxygen transport
the match between ventilation and perfusion in the lungs that is expressed by the
alveolar-arterial pO2 difference Aa∆pO2).
Oxygen transport
depends on the concentration of O2 transported by haemoglobin:
(a)c tO2 = c tHb × sO2 × (1 – COHb – MetHb) + pO2 × 0.01(a)c tO2 = c tHb × sO2 × (1 – COHb – MetHb) + pO2 × 0.01
Normal range: women 7.1 – 8.9 mmol/l
men 8.4 – 9.9 mmol/l
Oxygen release
to the tissue is determined by the oxygen tension gradient between the
capillaries and the tissue, and by the affinity of haemoglobin to oxygencapillaries and the tissue, and by the affinity of haemoglobin to oxygen
(the position of the saturation curve, its normal range p50 3.4 – 3.8 kPa).
A rough estimate can be obtained from the blood oxygen absorption curve.
7
A rough estimate can be obtained from the blood oxygen absorption curve.
The crucial quantity in the O2 supply to the tissues is the end-capillary pO2
and the central mixed-venous blood ( )pO (the extraction oxygen tension).vand the central mixed-venous blood ( )pO2 (the extraction oxygen tension).v
Low values (< 4.5 kPa) are indicative of tissue hypoxia. The critical value
at 3.5 kPa reflects the minimum O supply to sustain aerobic metabolism.
Under normal physiological circumstances the rate of oxygen consumption
is fairly constant,
at 3.5 kPa reflects the minimum O2 supply to sustain aerobic metabolism.
is fairly constant,
the arterio-venous oxygen content difference av∆∆∆∆cO2 is about 2.3 mmol/l.
c tO2 / mmol l–1
full saturation of real Hb
x
– 2.3 real measured values
in arterial blood
x
in arterial blood
pO2 / kPa
anticipated mixed
venous pO2
8
Transport of COTransport of CO2
Carbon dioxide is the end product of cellular metabolism. Adult humansCarbon dioxide is the end product of cellular metabolism. Adult humans
produce about 300 – 400 litres CO2 per day (~ 15 – 20 mol/d) and this
amount may be higher, e.g., with the increase in physical activity.
Molecules of carbon dioxide are nonpolar. They freely diffuse acrossMolecules of carbon dioxide are nonpolar. They freely diffuse across
plasma membranes. In tissues, capillary blood CO2 content increases by
40 – 50 ml CO2 / l.40 – 50 ml CO2 / l.
The total blood CO2 content is in the range 450 – 550 ml / l, from which
more than 85 % in the form of HCO3
–,more than 85 % in the form of HCO3
–,
about 5 % physically dissolved CO2 and H2CO3, and
approximately 10 % as carbamino compounds R–NH-COO–.approximately 10 % as carbamino compounds R–NH-COO .
Carbamino compounds originate by attaching CO2 to amino groups –NH2 ofCarbamino compounds originate by attaching CO2 to amino groups –NH2 of
various proteins, predominantly of haemoglobin within red blood cells.
9
Acid-base balanceAcid-base balance
Metabolism produces large quantities of acids:
– CO2 is the product of numerous decarboxylations included in oxidative
Metabolism produces large quantities of acids:
– CO2 is the product of numerous decarboxylations included in oxidative
breakdown of nutrients (tissue respiration, 15 – 20 mol CO2 daily).
Carbon dioxide dissolves in water to form volatile carbonic acid:Carbon dioxide dissolves in water to form volatile carbonic acid:
CO2 + H2O H2CO3 H+ + HCO3
–
The lungs control the exchange of carbon dioxide between the blood and
the external atmosphere.the external atmosphere.
– Non-volatile acids – products of the metabolism of sulfur-containing– Non-volatile acids – products of the metabolism of sulfur-containing
amino acids cysteine and methionine (sulfuric acid), phosphoruscontaining
compounds (phosphoric acid), and some carboxylic acids
(e.g. lactate, acetoacetate, and 3-hydroxybutyrate, unless they are(e.g. lactate, acetoacetate, and 3-hydroxybutyrate, unless they are
completely oxidized to CO2 and water).
They represent about 30 – 80 mmol H+ per day that cannot be removedThey represent about 30 – 80 mmol H per day that cannot be removed
through the lungs, and must be excreted by the kidney into the urine.
11
Although thre is a large production of acidic metabolites in the body,Although thre is a large production of acidic metabolites in the body,
concentrations of H+ ions in biological fluids are maintained in the very
narrow range:
[H+] in blood = 45 – 35 nmol / l
pH = 7.35 – 7.45
The human body is more tolerant of acidaemia (acidosis) than of
alkalaemia (alkalosis).alkalaemia (alkalosis).
Steep decreases in pCO2 or increases in [HCO3
–] may be life-threatening.
The limit blood pH values compatible with life areThe limit blood pH values compatible with life are
pH 6.80 i.e. [H+] ≈ 160 nmol / l , four times higher than the normal [H+],
pH 7.70 i.e. [H+] ≈ 20 nmol / l , decrease in [H+] by more than 50 %.
Changes in hydrogen ion concentration are minimized by means of
– buffer systems, both intracellular and extracellular,
– removal of CO through pulmonary ventilation, and– removal of CO2 through pulmonary ventilation, and
– reabsorption of HCO3
– and H+ ion excretion in the renal tubules;
– the liver also has certain role in maintaining the acid-base status.
12
– the liver also has certain role in maintaining the acid-base status.
Proteins and phosphates are the main intracellular buffers.Proteins and phosphates are the main intracellular buffers.
H+ ions pass plasma membranes in exchange for K+ ions –
acidaemia may thus lead to an increased plasma K+ concentration, and
alkalaemia to hypokalaemia.
Buffer systems comprising the total blood buffer bases (BBb)
alkalaemia to hypokalaemia.
Buffer systems comprising the total blood buffer bases (BBb)
Buffer system Blood Plasma ErythrocytesBuffer system Blood Plasma Erythrocytes
HCO3
– 0.50 0.27 0.23
Haemoglobin – 0.25Haemoglobin – 0.25
Plasma proteins 0.20 –
Phosphate 0.05 0.01 0.04
0.45
Phosphate 0.05 0.01 0.04
ΣΣΣΣ 1.00 0.48 0.52
Concentration of buffer bases in blood BBb 48 ± 3 mmol / l
Concentration of buffer bases in plasma BBp 42 ± 3 mmol / l
13
Concentration of buffer bases in plasma BBp 42 ± 3 mmol / l
Cooperation of buffer systemsCooperation of buffer systems
If the concentration of H+ increases, the H+ increment is distributed to all
buffer systems proportionally to their contribution to the total buffer bases.buffer systems proportionally to their contribution to the total buffer bases.
Additional H+
0.50 0.25 0.20 0.05
[HCO3
–] [Hb] [HbO2] [proteinn–] [HPO4
2–]
[CO2+HHCO3] [HHb+] [HHbO2
+] [Hprotein(n–1)–] [HHPO4
–]
pKa 6.10 pKa 8.2 pKa 6.6 pKa 5.1 pKa 6.8
Each of these buffers has its own Henderson-Hasselbalch equation, from
which it is possible to calculate the resulting change in the ratio cbase/cacid.
The knowledge of the change in the ratio cbase/cacid of one of the blood
buffers enables to deduce the changes in the other buffer systems.
14
The hydrogen carbonate (bicarbonate) buffering system
Carbonic acid H2CO3 is a weak acid, that originates in the reaction
The hydrogen carbonate (bicarbonate) buffering system
2 3
of carbon dioxide with water:
CO2 + H2O H2CO3 H+ + HCO3
–CO2 + H2O H2CO3 H+ + HCO3
–
In blood plasma, CO2 equilibrates with H2CO3 very slowly, but the reaction
is catalyzed by extremely efficient carbonate dehydratase within erythrocytes.is catalyzed by extremely efficient carbonate dehydratase within erythrocytes.
The "effective" constant of H CO dissociation is
[H+] [HCO3
–]
K (H CO ) = and for plasma (37 °C) pK = 6.10
The "effective" constant of H2CO3 dissociation is
[CO2+ H2CO3]
Keff (H2CO3) = and for plasma (37 °C) pKeff = 6.10
15
Henderson–Hasselbalch equation for HCO –/H CO in blood:Henderson–Hasselbalch equation for HCO3
–/H2CO3 in blood:
pH = pK (H CO ) + log
[HCO3
–] metabolic component
In these equations, the concentrations
pH = pKeff(H2CO3) + log
[CO2 + H2CO3]
[HCO3 ]
respiratory component
In these equations, the concentrations
[HCO3
-] and [CO2+H2CO3] are expressed in mmol/l,
not in the basal SI unit mol/l !
[HCO3
–]
0.23 × pCO2
pH = 6.10 + log
pCO2 in kilopascals;0.23 × pCO2
pCO2 in kilopascals;
(the solubility coefficient of CO2
is 0.03 if pCO2 is measured in mmHg)
At pH 7.40, the ratio c(HCO3
–)/c(CO2+H2CO3) equals 20, e.g., 24 mmol/l / 1.2 mmol/l..
The HCO –/H CO buffer is the most important of the blood buffering systemsThe HCO3
–/H2CO3 buffer is the most important of the blood buffering systems
– it depends on the intensive cellular metabolism, and
– changes in this system also reflect changes in other buffers.
16
– changes in this system also reflect changes in other buffers.
Parameters used in the evaluation of acid-base status
The classical concept of Astrup, Siggaard-Andersen, et al.The classical concept of Astrup, Siggaard-Andersen, et al.
Modern blood analyzers measure pH and pCO2,
as well as many supplementary parameters (e.g. pO , concentrations of
Normal values in arterial blood:
pH = 7.40 ± 0.05
as well as many supplementary parameters (e.g. pO2, concentrations of
haemoglobin, Na+, K+, änd Cl–).
pH = 7.40 ± 0.05
pCO2 = 5.33 ± 0.5 kPa
Values of other parameters are estimated by calculations based onValues of other parameters are estimated by calculations based on
known or derived relationships to the measured analytes:
actual [HCO3
-] = 24.0 ± 3.0 mmol / l by calculation based onactual [HCO3 ] = 24.0 ± 3.0 mmol / l by calculation based on
Henderson-Hasselbalch equation
"standard" [HCO3
-] is calculated, when pCO2 value is outside the normal"standard" [HCO3 ] is calculated, when pCO2 value is outside the normal
range; it is the value that would be measured in a given sample,
if the sample had normal pCO2 and was saturated by O2.
base excess BE (positive or negative), normal range 0 ± 3 mmol / l;base excess BE (positive or negative), normal range 0 ± 3 mmol / l;
BE is the excess or the deficit in buffer base concentration, in which
the sample would differ (at normal pCO2 and saturated by O2) from
17
the sample would differ (at normal pCO2 and saturated by O2) from
the normal buffer base concentration in blood 48 ± 3 mmol / l.
Values of actual [HCO3
–], "standard" [HCO3
–], and base excess can be also
acquired from the Siggaard-Andersen alignment nomogram:
Example:
acquired from the Siggaard-Andersen alignment nomogram:
"standard" [HCO3
–]
BEactual [HCO3
–]
18
Buffer base plasma BBp
- normal value 42 ± 3 mmol / l- normal value 42 ± 3 mmol / l
Components:Components:
hydrogen carbonate ~ 24 mmol / l
plasma proteins ~ 16 mmol / l (albumin ~ 12 mmol / l)
phosphates (HPO 2–/H PO –) ~ 2 mmol / l
Buffer base concentration in blood BBb
phosphates (HPO4
2–/H2PO4
–) ~ 2 mmol / l
Buffer base concentration in blood BBb
- normal value 48 ± 3 mmol / l
BBb is higher than that of plasma (by about 6 mmol / l). Due to haemoglobin and
organic phosphates, the concentration of buffer bases in red blood cells is aboutorganic phosphates, the concentration of buffer bases in red blood cells is about
56 mmol / l.
As an approximate estimate of BBblood can serve the value of BBplasma, to whichAs an approximate estimate of BBblood can serve the value of BBplasma, to which
0.67 × c(haemoglobin 1Fe) is added.
19
Blood pH values lower than 7.35 - acidaemia,
Basal terms
Blood pH values lower than 7.35 - acidaemia,
higher than 7.45 - alkalaemia.
Processes evoking these deviationsProcesses evoking these deviations
- acidosis – the accumulation of H+ in the body that results in acidaemia,
- alkalosis – a decrease in H+ concentration in the body- alkalosis – a decrease in H concentration in the body
Classification of acid-base disorders
Respiratory disorderRespiratory disorder
- the primary change in pCO2 due to low pulmonary ventilation
or a disproportion between ventilation and perfusion of the lung.or a disproportion between ventilation and perfusion of the lung.
Metabolic disorder
- the primary change in buffer base concentration (not only
HCO –, but also due to changes in protein, phosphate, andHCO3
–, but also due to changes in protein, phosphate, and
strong ions concentrations).
Quite pure (isolated) forms of respiratory or metabolic disorders don't exist in fact,Quite pure (isolated) forms of respiratory or metabolic disorders don't exist in fact,
because of rapid initiation of compensatory mechanisms; however, full stabilization
of the disorder may settle in the course of hours or days.
20
of the disorder may settle in the course of hours or days.
Ions in blood plasma / serum
Changes in main plasma ions concentrations may have considerable effects on
acid-base status. It is very useful to know the values even if pH, pCO2, and
base excess appear to be in the normal range.base excess appear to be in the normal range.
Deviations of [Cl–], and namelyDeviations of [Cl ], and namely
changes in [Na+]/[Cl–] ratio indicate
metabolic acid-base disorders.
Both acidaemia and alkalaemia mayBoth acidaemia and alkalaemia may
be causes of life-threatening
changes in K+ concentrations.
21
Examination of acid-base status
Anaerobic sampling of blood
Arterial blood from a. femoralis
"Arterialized" capillary blood
from the ear lobe from the heel in infants
Arterial blood from a. femoralis
from the ear lobe from the heel in infants
The blood sample is usable during the limited time period:
up to 4 hours after sampling, if chilled in ice-cold water;up to 4 hours after sampling, if chilled in ice-cold water;
at room temperature, measurement of pO2 within 5 minutes,
the other acid-base parameters within 30 minutes.
22
the other acid-base parameters within 30 minutes.
Direct measurement of pCO2 and pO2
pCO electrode
Direct measurement of pCO2 and pO2
pO2 electrode
(Clark's oxygen electrode)pCO2 electrode
anode
electrolyte
(Clark's oxygen electrode)
combined
glass electrode
NaHCO3
solution inert cathode
– 600 mV
O diffuses from the sample throughCO diffuses from the sample
sample
sample
O2 diffuses from the sample through
polypropylene membrane into the
electrolyte, where it is reduced to
peroxide ion O 2– (principle of
CO2 diffuses from the sample
through silicone membrane into the
NaHCO3 solution, the change in pH
is measured (combined glass peroxide ion O2
2– (principle of
polarography); electric current
proportionate to pO2 is measured.
3
is measured (combined glass
electrode).
23
proportionate to pO2 is measured.
Evaluation of an acid-base disturbance type and its compensationEvaluation of an acid-base disturbance type and its compensation
(the concept of P. Astrup and O. Siggaard-Andersen)
Entries:Entries:
pCO2 / kPa - measured
BE / mmol/lBE / mmol/l
calculated or acquired
from the S.-A. nomogram
ARAc – acute respiratory acidosis ARAlk – acute respiratory alkalosisARAc – acute respiratory acidosis ARAlk – acute respiratory alkalosis
AMAc – acute metabolic acidosis AMAlk – acute metabolic alkalosis
U – stabilized disturbance
NH – area of physiological values
Engliš, M.: Prakt. Lék. 1972: 52, 558
24
Engliš, M.: Prakt. Lék. 1972: 52, 558
Acute respiratory or metabolic disorders – blue areasAcute respiratory or metabolic disorders – blue areas
Stabilized respiratory or metabolic disorders
(effect of compensatory activities of the lung or the kidney) – red areas
The primary respiratory disorder leads to a compensatory change in HCO3
–
reabsorption by the kidney, which reaches its maximal effectivity in 5 – 7 days.reabsorption by the kidney, which reaches its maximal effectivity in 5 – 7 days.
In the primary metabolic disorder, a change in blood pH evokes a rapid change
in the pulmonary ventilation rate (during 2 – 12 hours).
25
Combined acid-base disordersCombined acid-base disorders
Mixed respiratory and metabolic acid-base disorders result in a greater
change in blood pH than simple disorders.change in blood pH than simple disorders.
Metabolic acid-base disorders may sometimes escape our attention,
if they are caused by changes in independent variables of oppositeif they are caused by changes in independent variables of opposite
direction. In these mixed metabolic disturbances, the blood pH and
[HCO3
–] or base excess can have normal values, in spite of this the[HCO3 ] or base excess can have normal values, in spite of this the
composition of body fluids is changed remarkably.
For example, a starving patient (→ ketoacidosis) is losing chlorides due toFor example, a starving patient (→ ketoacidosis) is losing chlorides due to
intensive vomiting (→ hypochloridaemic alkalosis) and the mixed disturbance
may pass unnoticed.
New concept of the evaluation of metabolic components in acid-base
disorders was proposed by Stewart, Fencl, et al.
It is based on the idea, that acid-base status is determined by three independentIt is based on the idea, that acid-base status is determined by three independent
variables: pCO2, strong ion difference, and non-volatile weak acids (proteins
and phosphates).
26
Interpretive concept of acid-base disorders (Stewart, Fencl, et al.)
Acid-base status of the body is determined
by three independent variables:
– pCO ,– pCO2,
– balanced concentrations of "strong" ions expressed by
means of the strong ion difference (SIDeff), andmeans of the strong ion difference (SIDeff), and
– concentration of non-volatile weak acids that act as buffer
bases (plasma proteins and inorganic phosphates).
Primary acid-base disorders thus can be classified as
– respiratory, initiated by an increase or decrease in pCO2, and– respiratory, initiated by an increase or decrease in pCO2, and
– metabolic (non-respiratory) that may have their causes in
– abnormal values of SIDeff due to
- water excess or deficit (changes in both SID and [Na+], or
eff
- water excess or deficit (changes in both SID and [Na+], or
- imbalance of strong ions (excess or deficit of chloride ions,
excess of unmeasured anions;excess of unmeasured anions;
– changes in non-volatile buffer bases caused by
- decrease in plasma albumin concentration, and
- decrease or increase in plasma phosphate concentration.
27
- decrease or increase in plasma phosphate concentration.
Effective "strong ion difference" (SIDeff)
SIDeff = [Na+] + [K+] + 3 – [Cl–] – [UA–]
Effective "strong ion difference" (SIDeff)
SIDeff = [Na+] + [K+] + 3 – [Cl–] – [UA–]
The value SIDeff determinates the concentration
of plasma buffer bases BBp
.
SIDeff
tration of plasma buffer bases BBp
.
Normal range = 42 ± 3 mmol / l)
UA–
SIDeff then can be calculated from measurable
concentrations of plasma buffer bases::
SIDeff = [HCO3
– ] + 0.28 Alb(g/l) + 1.8 [Pi]
Strong ion ratio [Na+]+[K+] / [Cl–] (normal value 1.35 – 1.43)Strong ion ratio [Na+]+[K+] / [Cl–] (normal value 1.35 – 1.43)
is occasionally used as another sign of strong ion imbalance
that is typical for hyperchloridaemic acidosis or
hypochloridaemic alkalosis).
28
hypochloridaemic alkalosis).
Unmeasured anions (UA–)Unmeasured anions (UA–)
SIDeff
[UA–] = [Na+] + [K+] + 3 – [Cl–] – SIDeff
UA–
Normal range 8 ± 2 mmol / l
Components: sulfateComponents: sulfate
lactate
acidic ketone bodies
the other carboxylic acids
Corrected value for water content:
the other carboxylic acids
[UA–]corr = [UA–] × 140 / [Na+]measured
Corrected value for water content:
29
Anion gap (AG) – a simple accessory parameterAnion gap (AG) – a simple accessory parameter
that may call an attention to the possible increase in UA–:
HCO3
–
AG = [Na+] + [K+] + 3 – [Cl–] – [HCO3
–]
Usual values 19 ± 2 mmol/l.
AG AG represents the "space" filled in by
unmeasured anions,
Usual values 19 ± 2 mmol/l.
unmeasured anions,
proteins, and
phosphates.
In hypoproteinaemia, AG value should be corrected:
AGcorr = AGobserved + 0.25 × (Albref – Albmeasured)
(decrease in albumin by 1 g/l enables an increase
In hypoproteinaemia, AG value should be corrected:
(decrease in albumin by 1 g/l enables an increase
in HCO3
– by 1 mmol/l)
30
Assessment of the metabolic components in acid-base disorders
(Stewart and Fencl)
Entries: pH
Na+ mmol/l
K+ mmol/l
(Stewart and Fencl)
K mmol/l
Cl– mmol/l
HCO3
– mmol/l
phosphate mmol/lphosphate mmol/l
albumin g/l
Modification of laboratory data:Modification of laboratory data:
– correction of [Cl–] value for the actual water content:
[Cl–]corr = [Cl–] × 140 / [Na+]measuredcorr measured
– calculation of SIDeff:
SIDeff = [HCO3
– ] + 0.28 Alb(g/l) + 1.8 [Pi]
– calculation of UA– value and its correction for actual water content:– calculation of UA– value and its correction for actual water content:
[ UA–]corr = ([Na+] + [K+] + 3 – [Cl–] – SIDeff) × 140 / [Na+]measured
– calculation of the electric charge of albumin (dependence on pH):– calculation of the electric charge of albumin (dependence on pH):
[Alb–] = 0.125 × Alb(g/l) × (pH – 5.17) or the value found in the table 1
– calculation of the electric charge of phosphates (dependence on pH):
– × ×
31
[Pi
–] = [Pi] × (0.309 × pH – 0.469) or the value found in the table 2
Electric charge of albumin (mmol/l) – the dependence on pHTable 1
g / l
Electric charge of phosphates (mmol/l) – the dependence on pH
mmol / l
Table 2
mmol / l
32
Quantitative assessment of the ABS metabolic components (Stewart and Fencl)
Analyte Reference Real Acidosis Alkalosis
value value
Na+ mmol/l 140 – +Na+ mmol/l 140 – +
Cl–
corr. mmol/l 102 + –
UA–
corr. mmol/l 8.0 + –UA–
corr. mmol/l 8.0 + –
Phosphate– mmol/l 2.0 + –
Albumin– mmol/l 12.0 + –Albumin– mmol/l 12.0 + –
33
Examples:
Analyte Reference Real Acidosis Alkalosis
value value
Na+ mmol/l 140 – excess water + dehydrationNa+ mmol/l 140 – excess water + dehydration
Cl–
corr. mmol/l 102 + diarrhoea – vomiting, HCl loss
UA–
corr. mmol/l 8.0 + – lactate,
ketone bodies,,
formate, glycolateUA–
corr. mmol/l 8.0 + – Phosphate–
mmol/l 2.0 + renal failure – Albumin–
mmol/l 12.0 + - – hypoalbuminaemia
formate, glycolate
Albumin– mmol/l 12.0 + - – hypoalbuminaemia
34