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ACID-BASE DISORDERS I.M.SIALA, MD.

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Presentation on theme: "ACID-BASE DISORDERS I.M.SIALA, MD."— Presentation transcript:

1 ACID-BASE DISORDERS I.M.SIALA, MD

2 Acid-base disorders Proper Cell Function Blood Pressure Pulse
Temperature Hemoglobin Ca, K, … Hydrogen Ion Concentration NORMAL RANGE

3 Hydrogen Ion Concentration
may change out of the normal range: 1- physiological: during daily metabolism 2- Pathological: e.g diabetic keto-acidosis If not corrected  major cell dysfunction

4 pH and H+ concentration
The blood pH represents the H+ concentration [ pH = the negative log of H+].  (H+) concentration   pH (acidosis)  (H+) concentration   pH (alkalosis) The body will try to restore the pH to normal “Compensatory mechanisms”. Complete (if pH returns to normal range)or Incomplete (if pH approches normal ranges but still abnormal.

5 Compensatory mechanisms
Body buffers CO2-bicarbonate system H+ + HCO3  H2CO3  H2O + CO2 Hemoglobin Hydroxyapatite REGULATED BY LUNG REGULATED BY KIDNEY

6 Lungs Hyperventilation  wash out CO2 Hypoventilation  retain CO2 Response is immediate Kidneys Proximal tubule: All HCO3 is filtered  body reabsorb ONLY its requirements  rest lost in urine Distal tubule Na is reabsorbed in exchange of K or H+.  K H+ is excreted more  alkalosis  K H+ is excreted less  acidosis Kidney needs 6 – 12 hours to start its compensating mechanisms.

7 H+ + HCO3 H2CO3 H2O + CO2 Alkalosis Acidosis

8 Acid base disturbances
Arterial blood sample Normal values A 2 ml syringe Heparinized Radial/ femoral artery Draw 1 ml of blood Send for analysis immediately or send in an ice pack PH PaCO2 35 – 45 mmHg 40 + 5 HCO3 21 – 28 mmol\l 25 +3 PaO2 83 – 108 mmHg Heparinized syringe Radial artery

9 Acid-base disorders Acidosis Alkalosis

10 ACIDOSIS

11 ACIDOSIS ALKALI HCO3 ACID PaCO2 ALKALI HCO3 ACID PaCO2

12 COMPANSATED METABOLIC ACIDOSIS
HCO3 HCO3 CO2 CO2 HCO3 CO2 CO2 ACID PaCO2 ALKALI HCO3

13 RESPIRATORY ACIDOSIS COMPANSATED RESPIRATORY ACIDOSIS CO2 HCO3 HCO3
ACID PaCO2 ALKALI HCO3

14 ALKALOSIS

15 ALKALOSIS ACID PaCO2 ACID PaCO2 ALKALI HCO3 ALKALI HCO3

16 RESPIRATORY ALKALOSIS
COMPANSATED RESPIRATORY ALKALOSIS RESPIRATORY ALKALOSIS CO2 HCO3 CO2 CO2 HCO3 HCO3 HCO3 ACID PaCO2 ALKALI HCO3

17 METABOLIC ALKALOSIS COMPANSATED METABOLIC ALKALOSIS CO2 HCO3 HCO3 CO2
ACID PaCO2 ALKALI HCO3

18 Acid-base disorders Acidosis Metabolic Respiratory Alkalosis

19 Metabolic acidosis Definition:
a pH< 7.36 due to a reduction in plasma HCO3-. PaCO2 will  secondary to hyperventilation .

20 Anion gap = Plasma Na+ - (Cl- + HCO3-)
Unmeasured Anions: albumin, phosphate, sulphate, lactate, ketoacids, others. Unmeasured Cations: calcium, Mg, globulins, K. + - Anion Gap HCO3_ Na+ Cl- “Anion gap represents the difference between readily measured anions and cations” Anion gap = Plasma Na+ - (Cl- + HCO3-) N= 8 – 14 mmol\l

21 Aetiology of metabolic acidosis
Increased Anion gap acidosis: Lactic acidosis Ketoacidosis Diabetic Alcohol Toxins Methanol Ethylene glycol Salicylate Uraemia ARF CRF + - Anion Gap Anion Gap HCO3_ Na+ Cl- Normal Anion gap acidosis Hyperchloremic acidosis GIT HCO3- loss Diarrhea Pancreatic drainage Ureterosigmoidostomy Renal tubular acidosis Drugs CA inhibitors + - HCO3_ Anion Gap Na+ Cl-

22 Metabolic acidosis Clinical picture A- due to acidosis:
Deep & rapid breathing, Kussmaul`s breathing. Altered state of consciousness Hypotension in severe cases B- Due to primary disease

23 Arterial blood gas findings
pH low<7.36 or in the lower limit of normal HCO3- low <21 mmol\l PaCO2 low < 35 mmHg

24 Treatment A- treat the underlying disease. B- control the acidosis;
Correct fluid & electrolyte disturbances Indications of parentral Na HCO3: in severe acidosis pH <7.1 GI loss or RTA HCO3 can be given as replacement therapy, usually orally.

25 RESPIRATORY ACIDOSIS Definition: a pH < 7.36 due to
increased retention of CO2 as a result of  alveolar ventilation

26 Respiratory Physiology

27 Aetiology a-Acute b-Chronic Airway obstruction
Foreign body Laryngospasm Severe bronchospasm Respiratory center depression Morphine overdose CVA Trauma Neuromuscular High cervical cord resection Myasthenia gravis Gullian Barre syndrome Organophosphorus Restrictive defects Pneumothorax Flail chest Cardiac Arrest & sever pulmonary oedema COAD Neuromuscular MS Muscular dystrophies Motor neuron disease Diaphragmatic paralysis Chest wall deformities Kyphoscolisis Ankylosing spodylitis Primary alveolar hypoventilation-Obesity

28 RESPIRATORY ACIDOSIS Clinical Picture:
A-Features of CO2 retention Headache Altered level of consciousness(severe) Myoclonus &hyperreflexia Astrexis Central cyanosis Collapsing pulse Warm periphery Papilloedema B-Features of the underlying illness.

29 Acute chronic RESPIRATORY ACIDOSIS pH low <7.36 low <7.36 or at
lower limit of normal PaCO2 high >45 mmHg HCO3 Normal high >28 mmol\l

30 Respiratory failure Type I respiratory failure:
PaO2 < 60 mmHg with normal or low PaCO2 Type II respiratory failure: PaCO2 >55 mmHg irrespective of O2 value.

31 Treatment A- Treat the underlying cause
B- Treat carbon dioxide retention Naloxone if Narcotic overdose is suspected Low oxygen concentration Mechanical ventilation in severe cases

32 METABOLIC ALKALOSIS Definition:
a pH > 7.44 due to an increase in plasma HCO3 PaCO2 may  . In normal renal function it is rare, why?

33 Aetiology Loss of H+, Cl, & Na Associated with EC volume depletion
Mineralocorticoid excess Bartter`s syndrome 1o & 2o Aldosteronism Cushing syndrome Adrenal enzyme deficiency Hyperreninism Exogenous mineralocorticoids Carbenoxolone Exogenous alkali NaHCO3(Baking soda) Blood transfusions-citrate Antacids Loss of H+, Cl, & Na Associated with EC volume depletion GIT loss Vomiting Aspiration of gastric contents Loss through kidney Diuretics Carbenicillin, penicillins K depletion

34 METABOLIC ALKALOSIS Clinical picture
A- Features of underlying illness B- Features related to metabolic alkalosis; Tetany Due to acute fall in ionized Ca level Manifest Latent Chvostok sign Traussau sign Altered state of consciousness

35 Arterial blood gas picture
pH >7.44 or in the Upper limit of normal in compensated cases HCO3 >28 mmol\l PaCO2 >45 mmHg or normal

36 Treatment A- Correct the metabolic alkalosis;
Correct EC volume depletion  enhance HCO3 excretion B- Treat the underlying cause; mineralocorticoid excess Correct  K

37 RESPIRATORY ALKALOSIS
Definition: pH>7.44 due to CO2 washout as a result of hyperventilation

38 Aetiology Hypoxia Voluntary CNS Disease Drugs Aspirin Hepatic Failure
CVA Infections Trauma Tumours Drugs Aspirin Hepatic Failure Gram Negative Septicaemia Heat Exposure Mechanical overventilation

39 Clinical picture A- features of the underlying cause.
Anxiety B- Features of Alkalosis; Tetany Parasthesia, numbness around the mouth, tingling in hands & feet

40 Arterial blood gas pH high >7.44 PaCO2 low<35 mmHg
HCO3 normal or low<21 mmol\l

41 Treatment A- Treat the underlying cause B- Supportive measures;
Rebreathing in a paper bag in Hyperventilation syndrome + sedation

42 RESPIRATORY ALKALOSIS
Summary pH PaCO2 HCO3 METABOLIC ACIDOSIS (OR LOW NORMAL) Compensatory METABOLIC ALKALOSIS (OR HIGH NORMAL) RESPIRATORY ACIDOSIS RESPIRATORY ALKALOSIS

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