Acid-base balance and acid-base disturbance

I. regulation of acid-base balance

1. origin of acid and base in the body volatile acid: H2CO3 (15mol/day) sulfuric acid 1) acids phosphoric acid fixed acid: uric acid (90mmol/L) mesostate 2) base: salt of organic acid; NH3

2. regulation of acid-base balance 1) role of buffer HCO-3/H2CO3 53% Hb-/HHb buffer system HbO-2/HHbO2 35% Pr-/HPr 7% Phosphate 5% Henderson-Hasselbalch pH = pKa + lg [HCO-3]/[H2CO3] = 6.1 + lg 20/1 = 6.1 + 1.3 =7.4 buffer of fixed acid: HCO-3/H2CO3 buffer of volatile acid: Hb-/HHb

 CO2 CO2+H2O C.A. H2CO3 HCO-3 Cl

H+--Hb-

RBC

2) respiratory regulation
alteration of ventilation alteration of breathe out of CO2 PaCO2 [H+] PaO2 PaCO2 central peripheral (receptor) (80mmHg) respiration

inhibition of respiratory center

3) cellular action exchanges of H+ and K+

4) renal regulation acidification of proximal renal tubule

Na+

Na+ ClHCO-3 H2CO3 NH3

K+ Na+ HCO-3
C.A.

H+ H2CO3

H2O+CO2

H2 0

H+ Cl- NH3

 acidification of distal renal tubule

H+-pump

H2CO3 H+ NH3

NH+4

HCO-3 H2O+CO2 K+

H+K+NH3

.parameters of acid-base
1. pH important and inexact parameter normal range: 7.35~7.45 2. PaCO2 partial pressure of CO2 of dissolved in arterial plasma (respiratory parameter) normal range: 4.4~6.25kPa(33~46mmHg) primary change: respiratory acidosis PaCO2 respiratory alkalosis PaCO2 secondary change: metabolic acidosis PaCO2 metabolic alkalosis PaCO2

3. standard bicarbonate(SB) and actual bicarbonate(AB) SB: [HCO-3] in plasma under standard condition (38; PO2=150mmHg; PCO2=40mmHg) AB: [HCO-3] in plasma under actual condition Normal range: 22~27mmol/L ; AB=SB 4. buffer base(BB) sum of all buffer base in blood normal range: 45 ~ 55mmol/L 5. base excess(BE) normal range: 3mmol/L

6. anion gap (AG)

+
Na+
HCO-3

Cl-

AG

Normal range: 12 2 mmol/L

. simple acid-base disturbance

1. metabolic acidosis
concept: the primary disturbance is a decrease of [HCO-3] in the arterial plasma 1) cause and pathogenesis lactic acidosis: hypoxia, diabetes liver disease ketoacidosis: diabetes, starvation metabolic acidosis in severe renal failure: fixed acids increased AG salicylic acid acid poisoning: intake food

 metabolic acidosis in normal AG

GI: (loss of HCO-3)

diarrhea; intestinal suction intestinal fistula biliary fistula

early renal failure: NH3 secretion H+ secretion Renal tubular acidosis: H+ secretion depressant of C.A. acetazolamide intake of ClNaCl, NH4Cl Hyperkalemia

kidney: (loss of HCO-3)

2) compensatory regulation buffer: respiratory compensation cellular compensation renal compensation

H+ secretion NH3 secretion [HCO-3] / [H2CO3] = 20:1 compensation acidosis [HCO-3] / [H2CO3] < 20:1 decompensation acidosis (SB AB BB BE PaCO2 AB < SB) : C.A. [H+]

3) effect on body cardiovascular system hyperkalemia arrhythmia [H+] : contractility peripheral resistance central nervous system [H+] ATP , -amino butyric acid (somnolence, coma) 4) principles of treatment

2. respiratory acidosis
concept: The primary disturbance is an elevation in plasma [H2CO3] 1) cause and pathogenesis Barbital depression of CNS head injury CO2 breathe paralysis of respiratory muscles out disease of airway or lung chest injury inhalation of CO2

2) compensation buffer: Hb-/HHb cells: exchange of H+ and K+ kidney: secretion of H+ and NH3 (PaCO2 SB AB BB BE ABSB) 3) effect on body CNS CO2 CO2 narcosis respiration cardiovascular system

4) principles of treatment NaCO3

3. metabolic alkalosis concept: the primary disturbance is

an increase of [HCO-3] in the arterial plasma

1) causes and pathogenesis

digestive tract vomiting; gastric suction(loss of HCl) loss diuretics distal flow rate of H+ (furosemide) blood volume ADS kidney hyperaldosteronism H+-Na+exchange
H+-K+exchange between

cell

Hypokalemia

intra- and extrarenal secretion of H+

hypochloremia renal secretion of H+

NaHCO3 intake transfusion of banked blood of base (citrate) 2) compensation of the body respiration compensation are limited (hypoxia) cells compensation hypokalemia kidney pH inhibition of carbonic anhydrase (C.A.)
secretion of H+ (SB AB BB BE PaCO2 ABSB)

3) effects on body
inhibition of glutamate decarboxylase

CNS

-amino butyric acid

dysphoria

insanity
pH
brain-vessel contraction dizziness brain
hypoxia
delirium

O2 dissociation curve shifting to left

Coma
tic

neuromuscle pH free Ca2+ hypokalemia arrhythmia

4) principles of treatment loss of H+ digestive tract diuretic ; hypokalemia

hyperaldosteronism

0.9%NaCl; KCl

antisterone; diamox()

4. respiratory alkalosis
concept: the primary disturbance is decrease of [H2CO3] in plasma 1) cause and pathogenesis hypotonic hypoxia pneumonia hyperventilation hysteria(); fever; [NH3] hyperthyroidism() misoperation of ventilator

respiration (slight inhibition)

cells (exchange of H+-K+) kidney secretion of H+ (PaCO2 ; SB AB BB BE ; ABSB) 3) effects on body It is as same as metabolic alkalosis. dizziness and convulsion are happened easily () () 4) principles of treatment inhalation of 5%CO2 2) compensation

IV. Mixed acid-base disturbance

1. dual acid-base disturbance
1) metabolic acidosis plus respiratory acidosis
heart beat [HCO-3] pH respiration stop character PaCO2 2) metabolic alkalosis plus respiratory alkalosis hepatic NH3 PaCO2 character [HCO- ] pH failure diuretic 3 3) respiratory acidosis plus metabolic alkalosis

pulmonary heart disease diuretic

pH

4) respiratory alkalosis plus metabolic acidosis infective shock pH fever 5) metabolic acidosis plus metabolic alkalosis ketoacidosis(diabetes) pH vomiting 2. triple acid-base disturbance 1) respiratory acidosis; metabolic acidosis and alkalosis pulmonary heart disease; vomiting 2) respiratory alkalosis; metabolic acidosis and metabolic alkalosis fever; vomiting; diarrhea (food poisoning)

discuss of case
method: 1. pH 2. primary factor and parameter 3. secondary factor and compensation 4. expected range of compensation 1: patient, female, 46, chronic pyelitis pH 7.32 PaCO2 28mmHg CO2 .CP. 19.2ml% SB 13.6mmol/L BE -15.3mmol/L

The scope of compensatory

responses of acid-base disorders
acute respiratory acidosis :
[HCO-3]=0.1PaCO2 1.5

chronic respiratory acidosis: [HCO-3]=0.4PaCO2 3.0 acute respiratory alkalosis :

[HCO-3]=0.2PaCO2 2.5

chronic respiratory alkalosis:[HCO-3]=0.5PaCO22.5 metabolic acidosis: metabolic alkalosis:

PaCO2 =1.2[HCO-3] 2.0 PaCO2 =0.7[HCO-3] 5.0

2:
patient, male, 45, chronic bronchitis pH 7.26 PaCO2 60mmHg BB 46.2mmol/L SB 22mmol/L BE -7.5mmol/L after treatment pH 7.34 PaCO2 70mmHg BB 58mmol/L BE 5.5mmol/L

3. patient, male, 47, purulent appendicitis, he was treated with abdominal suction and persistent gastrointestinal decompression after operation. pH 7.56 PaCO2 50mmHg CO2 .CP. 90ml% SB 34mmol/L BE 10mmol/L K+ 3.2mmol/L Cl105mmol/L

4.
, 3, 20+/ T 39.8 1200ml.