AB balance Acidosis Alkalosis

- log [H+] = pH

AB values in plasma [ H+] (nmol/l) 38 – 42 pH 7.36 – 7.44 PCO2 (kPa) 5.0 – 5.5 [ HCO3- ] (nmol/l) 22 – 26

AB values in plasma [ H+] (nmol/l) 38 – 42 pH 7.36 – 7.44 PCO2 (kPa) 5.0 – 5.5 [ HCO3- ] (nmol/l) 22 – 26 Base excess ­2.5 – +2.5 Anion gap = (Na++K+) - (Cl-+HCO3-)

x x Changes in ABB Acidosis Alkalosis Respiratory Metabolic PCO2 Acidemia Alkalemia Respiratory Metabolic x PCO2 [ H+], [ HCO3- ]

ABB Buffers Compensation Bicarbonate HCO3- / CO2 Buffers Non-bicarbonate Hb- / oxy-Hb- H2PO4-, NH4+ Lungs Compensation Kidney + Liver

METABOLIC ACIDOSIS I 1. Cause – increased production / intake H+ Diabetes mellitus, starvation -oxidation FA  ketoacids Exrcise, hypoxia anaerobic glykolysis  lactate Poisoning by acid

METABOLIC ACIDOSIS II 2. Cause – kidney disorder Disfunction loss of HCO3 retention H+ Disfunction lumen proximal tubule blood H + H2O HCO3- + H+ HCO3- resorption CAIV OH - CAII HCO3- CO2 CO2 H+ ATPáza ATP H + H2O H+ elimination OH - HCO3- resorption HCO3- CAII CO2

METABOLIC ACIDOSIS III 3. Cause / result – hyperkalemia ATP Na+ K+ [ H+] [ K+] Acidosis  Hyperkalemia

Henderson - Hasselbach equation - log [H+] = pH H+ + HCO3- = CO2 + H2O [HCO3-] ———— PCO2 pH = pKa + log 6.1 e‘kweižn

Henderson - Hasselbach - log [H+] = pH H+ + HCO3- = CO2 + H2O pH = 6.1 + log [HCO3-] ———— PCO2 [HCO3-] [CO2] 8.0 7.4 7.0

MAC H+ H+ + HCO3-  CO2 + H2O [HCO3-] [CO2] 8.0 7.4 7.0

MAC H+ 2H+ + HCO3-  CO2 + H2O [HCO3-] [CO2] 8.0 7.4 7.0

MAC H+ 2H+ +2HCO3-  CO2 + H2O [HCO3-] [CO2] Buffer 8.0 7.4 7.0

MAC H+ 2H+ +2HCO3-  2CO2+ 2H2O [CO2] [HCO3-] 8.0 7.4 7.0

MAC H+ 2H+ +2HCO3-  2CO2+ 2H2O [HCO3-] [CO2] 8.0 7.4 7.0 Chemoreceptors stimulation

MAC H+ 2H+ +2HCO3-  2CO2+ 2H2O Expiration by lungs [HCO3-] [CO2] 8.0 7.4 7.0 1) Buffer: Bicarbonate Chemoreceptors stimulation 2) Lungs: hyperventilation 3) Kidney:  elimination H+ ,  resorption HCO3-

Metabolic acidosis - summary acetoacetát a β-hydroxybutyrát

Compensation of MAL METABOLIC ALKALOSIS Cause: Increased bicarb. uptake infusion HCO3- Vomiting loss of H+ Hypokalemia Alkalosis  Hypokalemia Compensation of MAL Hypoventilation - impossible ! Kidney:  elimination HCO3- !!!

Compensation of RAC RESPIRATORY ACIDOSIS retention CO2  [H+]  pH Cause: Lung, thorax disorder CO2 + H2O  H+ + HCO3- Compensation of RAC 2) Kidney:  elimination H+ , NH4+ , resorption HCO3- 1) Buffers: non-bicarbon. bufers

RESPIRATORY ALKALOSIS Cause: Hyperventilation, high altitude decrease of PCO2 [H+]  pH CO2 + H2O  H+ + HCO3- Compensation of RAL 1) Buffer inf.: non-bicarb. adding H+ 2) Kidney:  elimination HCO3-,  sekretion H+

Questions Questions

Q 11 Q11: Match each item in the top (lettered) column with appropriate item in the bottom (numbered) column. “Increased” or “decreased” is used with reference to normal physiological values. Diabetic ketoacidosis Hypoventilation Excessive ingestion of sodium bicarbonate   Increased plasma pH, increased plasma bicarbonate, alkaline urine Decreased plasma pH, decreased plasma bicarbonate, acidic urine Decreased plasma pH, increased plasma bicarbonate, acidic urine Increased plasma pH, increased plasma bicarbonate, alkaline urine c. Decreased plasma pH, decreased plasma bicarbonate, acidic urine a. A11: a – 2 b – 3 c - 1 Decreased plasma pH, increased plasma bicarbonate, acidic urine b

What pH would be in the urine of vegetarian? Vegetarians food rich in HCO3- Increased uptake of basis  Compensation by kidney HCO3- in urine Alcalic urine 

What is the first aid in panic attack, why? Hyperventilation Decrease of PCO2 on plasma   First aid: reinhalation of CO2 Ventilation into the bag 

Lung illness Lung illness Restrictive Obstructive air passage (AP) Bronchoconstriction Inflammation, mucus Bronchus tumour Surrounding compression – nodule … Lung fibrosis Edema Atelektasis Pneumothorax … Atelektáza – zkolabovaná část plic-bez vzduchu-např ucpání hlenem, při operaci, velký plicní odpor collaps weaken [ˈwiːkən] oslabit (se) ,  Mucus_mju:k s Whistling pískoty Nodule nodju:l zduřelá uzlinka  Resistance AP  Lung compliance Expiratory whistling  Respiratory motion Inspiratory position of the thorax Weakened breading 27

Why not to serve oxygen to the patient with COPD ? Chronic obstructive pulmonary disease Retention of CO2  Chronic respiratory acidosis Adaptation of central chemoreceptors  Periferal chemoreceptors - stimulated by low pO2  100%O2 might abolish this hypoxic drive ! O2

What is the cause of death in MAC? Na+ [ K+] [ H+] Diarrhea loss of HCO3- in GIT  Metabolic acidosis Hyperkalemia Change in RMP, depolarization  Neuromuscular irritability  Vetricular fibrilation  EKG

transport in distal tubule Hypo-, hyper-calcemia transport in distal tubule Arthur C. Guyton, John E. Hall, Textbook of Medical Physiology Elsevier, 10th edition (2000) 

Cell response to intracellular acidosis or alkalosis Boron

Buffer systems

HCO3- proximal, ascending loop Proximal tubule, thick ascending loop of Henle, early distal tubule HCO3- proximal, ascending loop Na+-H+ exchanger Arthur C. Guyton, John E. Hall, Textbook of Medical Physiology Elsevier, 10th edition (2000)  33

Arthur C. Guyton, John E. Hall, Textbook of Medical Physiology Dist tub HCO3- Late distal tubule and collecting duct Cl- - HCO3- exchange Urine H+ incerased 900x Arthur C. Guyton, John E. Hall, Textbook of Medical Physiology Elsevier, 10th edition (2000)  34

Phosphate buffer Proximal and early distal tubule 35 Arthur C. Guyton, John E. Hall, Textbook of Medical Physiology Elsevier, 10th edition (2000)  35

Role of liver in ABB proteine metabolism ammonia (NH3) ammonium ion (NH4+) 36

Arthur C. Guyton, John E. Hall, Textbook of Medical Physiology Proximal tubule, thick ascending limb of the loop of Henle, distal tubule NH4+ proxi Arthur C. Guyton, John E. Hall, Textbook of Medical Physiology Elsevier, 10th edition (2000)  37

Arthur C. Guyton, John E. Hall, Textbook of Medical Physiology Collecting duct NH4+ collect ammonia (NH3) ammonium ion (NH4+) Arthur C. Guyton, John E. Hall, Textbook of Medical Physiology Elsevier, 10th edition (2000)  38

Transport CO2 1. 2. in plasma

Diagnosis of Acid-Base Imbalances Acidosis or alcalosis? Note whether the pH is low (acidosis) or high (alkalosis) Respiratory or metabolic? Decide which value, pCO2 or HCO3- , is outside the normal range and could be the cause of the problem. If the cause is a change in pCO2, the problem is respiratory. If the cause is HCO3- the problem is metabolic. No or partial compensation? Look at the value that doesn’t correspond to the observed pH change. If it is inside the normal range, there is no compensation occurring. If it is outside the normal range, the body is partially compensating for the problem

Example A patient is in intensive care because he suffered a severe myocardial infarction 3 days ago. The lab reports the following values from an arterial blood sample: pH 7.3 HCO3- = 20 mEq / L ( 22 - 26) pCO2 = 32 mm Hg (35 - 45) ??Diagnosis?? Acidosis Metabolic With compensation

summary Full compensation - pH in normal rank (7.35 - 7.45) numbness [nʌmnɪs] noun (podstatné jméno) necitlivost , znecitlivění , zmrtvění (po umrtvení ap.) Full compensation - pH in normal rank (7.35 - 7.45) Partial compensation - pH still shifted

Respiratory acidosis kongestivní srdeční selhání kongestivní srdeční selhání – městnavé srdeční selhání. Je provázeno výrazným zadržením vody a sodíku v těle s tvorbou otoků, popř. i hromaděním tekutiny v tělesných dutinách hrudní, břišní, srov. transudát. Tento stav je jedním z příkladů sekundárního hyperaldosteronismu. K odstranění nadbytečné tekutiny se podávají mj. diuretika, důležité je však i omezení příjmu soli v potravě. Srov. městnání kongesce

Respiratory alkalosis

Metabolic acidosis

Metabolic alkalosis

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