Disorders of Acid-base Balance

Maintenance of acid-base homeostasis is a vital function of the living organism. Deviations of systemic acidity in either direction can impose adverse consequences and when severe can threaten life itself. Acid-base disorders frequently are encountered in the outpatient and especially in the inpatient setting. Effective management of acid-base disturbances, commonly a challenging task, rests with accurate diagnosis, sound understanding of the underlying pathophysiology and impact on organ function, and familiarity with treatment and attendant complications [1]. Clinical acid-base disorders are conventionally defined from the vantage point of their impact on the carbonic acid-bicarbonate buffer system. This approach is justified by the abundance of this buffer pair in body fluids; its physiologic preeminence; and the validity of the isohydric principle in the living organism, which specifies that all the other buffer systems are in equilibrium with the carbonic acid-bicarbonate buffer pair. Thus, as indicated by the Henderson equation, [H+] = 24 PaCO2/[HCO 3] (the equilibrium relationship of the carbonic acid-bicarbonate system), the hydrogen ion concentration of blood ([H+], expressed in nEq/L) at any moment is a function of the prevailing ratio of the arterial carbon dioxide tension (PaCO2, expressed in mm Hg) and the plasma bicarbonate concentration ([HCO 3], expressed in mEq/L). As a corollary, changes in systemic acidity can occur only through changes in the values of its two determinants, PaCO2 and the plasma bicarbonate concentration. Those acid-base disorders initiated by a change in PaCO2 are referred to as respiratory disorders; those initiated by a change in plasma bicarbonate concentration are known as metabolic disorders. There are four cardinal acid-base disturbances: respiratory acidosis, respiratory alkalosis, metabolic acidosis, and metabolic alkalosis. Each can be encountered alone, as a simple disorder, or can be a part of a mixeddisorder, defined as the simultaneous presence of two or more simple Horacio J. Adrogué Nicolaos E. Madias