ACID-BASE DISORDERS

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ACID-BASE DISORDERS

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1. ACID-BASE DISORDERS NITIN BHATT, M.D. DIRECTOR, I.C.U. VAMC, RENO
2. ACID_BASE DISORDERS • 12000 to 15000 mEq of volatile acids are produced daily by body and excreted as CO2 by lungs • 1 mEq / kg / day of non-volatile acids (sulfuric and phosphoric acids) are produced daily by body and excreted by the kidneys • The pH of body fluids is determined by the amount of acid produced, the buffering capacity and the acid excretion by lungs and the kidneys • The most important buffers in the body are, hemoglobin, plasma proteins and bicarbonate
3. Addition of acid • First the acid binds to extracellar buffers, then intracelluar buffers and finally to alkaline salts in bones. • PCO2 is lowered by stimulation of respiratoty center • Finally, the kidneys increase the excretion of acids. • If all these mechanisms fail, patient develops acidemia
4. ACID-BASE DISORDERS • ACIDEMIA: lower than normal arterial blood pH • ALKALEMIA: higher than normal arterial blood pH • ACIDOSIS: a process that tends to acidify body fluids and may lead to acidemia. Could result from metabolic or respiratory dysfunction or compensatory response. • ALKALOSIS: a process that tends to alkalinize body fluids and may lead to alkalemia. Could result from metabolic or respiratory dysfunction or compensatory response. • Acidosis and alkalosis may or may not be associated with abnormal pH in the same direction..
5. ACID_BASE DISORDERS • SIMPLE ACID BASE DISORDER: when there is only one primary disorder • MIXED ACID BASE DISORDER: when there are two or more primary disorders present at the same time
6. ACID-BASE DISORDERS • NORMAL ANION GAP = 12 • NORMAL PH = 7.40 • NORMAL PCO2 = 40 • NORMAL HCO3 = 24
7. ACID-BASE DISORDERS DEFINITIONS METABOLIC ACIDOSIS = HCO3 12 METABOLIC ALKALOSIS = HCO3 >24 RESPIRATORY ALKALOSIS = PCO2 40 or PCO2 higher than expected for primary metabolic abnormality. HIGH ANION GAP (>12-20) always indicates primary metabolic acidosis. We do not compensate for abnormality of one system with compensation by the same system( MET OR RESP).
8. ACID BASE DISORDERS • PRIMARY PRIMARYCOMPENSATORY DISORDERABNORMALITYCHANGE MET. ACIDOSIS LOWER HCO3 LOWER PCO2 MET. ALKALOSIS HIGHER HCO3 HIGHER PCO2 RESP. ACIDOSIS HIGHER PCO2 HIGHER HCO3 RESP. ALKALOSIS LOWER PCO2 LOWER HCO3 REMEMBER: compensatory response never brings the pH back to normal, therefore, if the pH is in acidic direction, it tells you that the process or processes in acidic direction are the primary disorders.
9. ACID_BASE DISORDERS Compensatory Process • Tends to return ratio of HCO3 to PCO2 back toward normal and therefore normalize the arterial pH • Does not return pH to normal except in primary respiratory alkalosis of chronic duration. • Require normal function of kidneys and lungs • Lack of appropriate compensation suggests second primary disorder • Compensatory response creates second lab abnormality • Appropriate degree of compensation can be predicted.
10. ACID_BASE DISORDERS Metabolic Acidosis • Caused by excess acid production which overwhelms renal capacity to excrete acids ( DKA ) , loss of alkali (diarrhea) or renal failure • Tissues and RBCs act to increase the serum HCO3 by exchanging intracellular Na & K for extracellular H , resulting in increased serum K and HCO3 • Increased pulmonary ventilation leads to decreased PaCO2 and change in pH toward normal • HCO3 12 always suggest primary metabolic acidosis
11. ACID_BASE DISORDERS Urinary Anion-Gap • Useful in differential diagnosis of hyperchloremic acidosis • Calculated as U. Na + U. K – U. Cl • A negative U. Anion Gap ie Cl >> Na + K suggests appropriate urinary NH4 excretion and G.I. loss of HCO3 • A positive U. Anion Gap ie. Cl
12. ACID-BASE DISORDERS: EQUATIONS
13. ACID-BASE DISORDERS • RESPIRATORY ACIDOSIS ACUTE: 10 INCR. IN PCO2 LEADS TO 1 INCR. IN HCO3 CHRONIC: 10 INCR. IN PCO2 LEADS TO 3-3.5 INCR. IN HCO3 • RESPIRATORY ALKALOSIS ACUTE; 10 DECR. IN PCO2 LEADS TO 2 DECR. IN HCO3 CHRONIC 10 DECR. IN PCO2 LEADS TO 4-5 DECR. IN HCO3 • METABOLIC ACIDOSIS PCO2 = LAST 2 DIGITS OF pH • METABOLIC ALKALOSIS 1 MEQ INCR. IN HCO3 LEADS TO 0.6-0.7 INNCR. IN PCO2
14. PCO2-HCO3 buffer system • CO2 gas  CO2 dissolved + H2O • CO2 + H2O  H2CO3  H + HCO3 • H= K x H2CO3÷ HCO3 • H2CO3 or PCO2 represents respiratory system function • HCO3 represents kidney or metabolic system
15. ACID-BASE DISORDERS HENDERSON HASSELBALCH EQUATION Ph = Pk + log HCO3/ H2CO3 Rearranging the above per Kassier and Bliech H = 24 X PCO2/HCO3 ( H= Hydrogen ion conc.) H at normal pH of 7.40 is 40 Nanamol/Liter therefore, 40 = 24 X 40 (PCO2)/24(HCO3)

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