Acid-base balance and

1

• Acid-base balance and
• acid-base disturbance

2

• 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

3

• 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

4

• ????????????
• CO2
• Cl-

CO2H2O
C.A. H2CO3
HCO-3
H--Hb- RBC
5

• 2) respiratory regulation
• alteration of ventilation
• alteration of breathe out of CO2
• PaCO2 central
• H peripheral respiration
• PaO2 (receptor)
• PaCO2 (gt80mmHg)
• inhibition of respiratory center
• 3) cellular action exchanges of H and K

6
4) renal regulation? acidification of proximal
renal tubule ?? ????? ??
K
Na H
H2CO3 Na
C.A. HCO-3 H2OCO2
NH3

• 
  Na Cl-
• 
  HCO-3
• 
  
• 
  H2CO3
• 
  H20
• ?H ?Cl- ???????NH3??

7

• ? acidification of distal renal tubule
• 
  H-pump
• 
  NH4
• ?H??K??,??NH3??,
• ?????????

???????
H2CO3 H
NH3 HCO-3 H2OCO2
K
8

• ?.parameters of acid-base
• 1. pH important and inexact parameter
• normal range 7.357.45
• 2. PaCO2 partial pressure of CO2 of dissolved
• in arterial plasma (respiratory parameter)
• normal range 4.46.25kPa(3346mmHg)
• primary change
• respiratory acidosis PaCO2
  
• respiratory alkalosis PaCO2
• secondary change
• metabolic acidosis PaCO2
  
• metabolic alkalosis PaCO2

9

• 3.  standard bicarbonate(SB)
• and actual bicarbonate(AB)
• SB HCO-3 in plasma under standard condition
• (38? PO2150mmHg PCO240mmHg)
• AB HCO-3 in plasma under actual condition
• Normal range 2227mmol/L ABSB
• 4. buffer base(BB)
• sum of all buffer base in blood
• normal range 45 55mmol/L
• 5. base excess(BE)
• normal range 3mmol/L

10

• 6.  anion gap (AG)
• 
  -
• Normal range 12 2 mmol/L

Na
Cl-
HCO-3
AG
11

• ?. 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

12

• 
  diarrhea
• GI
  intestinal suction
• (loss of
  intestinal fistula
• HCO-3)
  biliary fistula
• ? metabolic
• acidosis in
  early renal failure
• normal AG
  NH3 secretion
• 
  H secretion
• 
  Renal tubular acidosis
• 
  H secretion
• kidney
  depressant of C.A.
• (loss of
  acetazolamide
• HCO-3)
  intake of Cl-
• 
  NaCl, NH4Cl
• 
  Hyperkalemia

13

• 2) compensatory regulation
• ? buffer
• ? respiratory compensation
• ? cellular compensation
• ? renal compensation
• H C.A. H
  secretion
•   NH3
  secretion
• HCO-3 / H2CO3 201 compensation
• 
  acidosis
• HCO-3 / H2CO3 lt 201 decompensation
• 
  acidosis
• (SB AB BB BE PaCO2 AB lt SB)

14

• 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

15

• 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

16

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

17

• 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

18

• digestive tract
• vomiting gastric suction(loss
  of HCl)
• ?loss diuretics distal
  flow rate
• of H (furosemide) blood
  volume ADS
• kidney hyperaldosteronism
  H-Naexchange
• 
  H-Kexchange between
• Hypokalemia intra-
  and extra-cell
• 
  renal secretion of H
• hypochloremia
• 
  renal secretion of H

19

• 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 ABgtSB)

20

• 3) effects on body
• inhibition of glutamate
  decarboxylase
• ? CNS ?-amino butyric acid
  dysphoria
• 
  insanity
• pH brain-vessel
  dizziness
• contraction
  brain delirium
• O2 dissociation
  hypoxia Coma
• curve shifting to
  left
• ? neuromuscle pH free Ca2
  tic
• ? hypokalemia arrhythmia

21

• 4)  principles of treatment
• loss of H digestive tract
• diuretic hypokalemia 0.9NaCl
  KCl
• hyperaldosteronism
• antisterone diamox(????)

22

• 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

23

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

24

• IV. Mixed acid-base disturbance
• 1. dual acid-base disturbance
• 1) metabolic acidosis plus respiratory
  acidosis
• heart beat
  HCO-3
• respiration stop character
  PaCO2 pH
• 2) metabolic alkalosis plus respiratory
  alkalosis
• hepatic NH3
  PaCO2
• failure diuretic character
  HCO-3 pH
• 3) respiratory acidosis plus metabolic
  alkalosis
• pulmonary heart disease
• diuretic
  pH

25

• 4) respiratory alkalosis plus metabolic
  acidosis
• infective shock
• fever pH
• 5) metabolic acidosis plus metabolic
  alkalosis
• ketoacidosis(diabetes)
• vomiting pH
• 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)

26

• 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

27

• The scope of compensatory
• responses of acid-base disorders
• acute respiratory acidosis
  ?HCO-30.1?PaCO2 1.5
• chronic respiratory acidosis ?HCO-30.4?PaCO2
  3.0
• acute respiratory alkalosis
  ?HCO-30.2?PaCO2 2.5
• chronic respiratory alkalosis?HCO-30.5?PaCO2
  2.5
• metabolic acidosis ?PaCO2
  1.2?HCO-3 2.0 
• metabolic alkalosis ?PaCO2
  0.7?HCO-3 5.0

28

• ?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

29

• ?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
• Cl- 105mmol/L

30

• ?4.
• ??, 3??, ????????????????20?/?,???????
• ??T 39.8?,??,????,?????,?????
• ?????????,????????1200ml.
• ??????,???,???,??,
• ??,????????