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1、AcidosisandAlkalosis Case Case A22 year oldwomanwhohadbeeninjuredinanaccidentreceived6litersofisotonicsaline Theplasma Na 135mmol l K 3 8mmol l Cl 115mmol l and HCO3 18mmol l ThebloodpH7 28 andthePaCO239mmHg Theurinarysodium65mmol l potassium15mmol l andchloride110mmol l Thepatient sserumalbumin2 7g
2、 dlaftertheinfusionofsaline Herbloodpressurewas98 52mmHg andherpulseratewas102beats m Shehadbeenhealthybeforetheaccident wasreceivingnomedications anddidnotuseanyillicitdrugs Theaccidentoccurredwhenaspeedingcarranthrougharedlight hittinghercaronthedriver sside Theaccidenthascausedmultipleribfracture
3、s acompoundleftfemoralfracture apelvicfracture andnumerousbruises Sheisintheemergencydepartmentforstabilizationofherconditionbeforeshecanbesenttotheoperatingroomforstabilizationofherlegandpelvis Case A22 year oldwomanwhohadbeeninjuredinanaccidentreceived6litersofisotonicsaline Theplasma Na 135mmol l
4、 K 3 8mmol l Cl 115mmol l and HCO3 18mmol l ThebloodpH7 28 andthePaCO239mmHg Theurinarysodium65mmol l potassium15mmol l andchloride110mmol l Thepatient sserumalbumin2 7g dlaftertheinfusionofsaline Herbloodpressurewas98 52mmHg andherpulseratewas102beats m Shehadbeenhealthybeforetheaccident wasreceivi
5、ngnomedications anddidnotuseanyillicitdrugs Theaccidentoccurredwhenaspeedingcarranthrougharedlight hittinghercaronthedriver sside Theaccidenthascausedmultipleribfractures acompoundleftfemoralfracture apelvicfracture andnumerousbruises Sheisintheemergencydepartmentforstabilizationofherconditionbefore
6、shecanbesenttotheoperatingroomforstabilizationofherlegandpelvis 什么酸碱紊乱 代谢 呼吸 AG酸中毒 高氯性简单 复杂性 Acidproductioninthebody Carbonicacid themetabolismofcarbohydratesandfats primarilyderivedfromthediet resultsintheproductionofapproximately15 000mmolofCO2perday Non carbonicacid Organic lactate metabolizedbyt
7、heliverandkidneyInorganic themetabolismofproteinsandothersubstancesresultsinthegenerationofnoncarbonicacids 50 100mEq 1mEq kg Methionine glucose urea SO4 2 2H Arginine glucose orCO2 urea H R H2PO4 H2O ROH 0 8HPO42 0 2H2PO4 1 8H Thehomeostaticresponsetoacidload Chemicalbufferingbytheextracellularandi
8、ntracellularbuffers ChangesinalveolarventilationtocontrolthePCO2 AlterationsinrenalH excretiontoregulatetheplasmaHCO3 concentration Chemicalbuffering ExtracellularbuffersIntracelluar bone Henderson Hasselbalchequation Eq 1 H HCO3 H2CO3H2O CO2PCO2 Eq 2 H 24x HCO3 orbytheHenderson Hasselbalchequation
9、HCO3 Eq 3 pH 6 10 log 0 03PCO2 Henderson Hasselbalchequation Eq 1 H HCO3 H2CO3H2O CO2PCO2 Eq 2 H 24x HCO3 orbytheHenderson Hasselbalchequation HCO3 Eq 3 pH 6 10 log 0 03PCO2Acidosis PCO2 1 5XHCO3 8 Chemicalbuffering ExtracellularbuffersIntracelluarbuffer bone Ca release osteoclastactivation Thehomeo
10、staticresponsetoacidload Chemicalbufferingbytheextracellularandintracellularbuffers ChangesinalveolarventilationtocontrolthePCO2 AlterationsinrenalH excretiontoregulatetheplasmaHCO3 concentration Thehomeostaticresponsetoacidload Chemicalbufferingbytheextracellularandintracellularbuffers Changesinalv
11、eolarventilationtocontrolthePCO2 AlterationsinrenalH excretiontoregulatetheplasmaHCO3 concentration RENALHYDROGENEXCRETION 1 reabsorptionofthefilteredHCO3 2 excretionofthe50to100meqofH producedperdayFormationoftitratableacidExcretionofNH4 intheurine Collectingtubule TubularLumen Peritubularcapillary
12、 H H2O2 OH CO2 3HCO3 CA H Cl ATPase ATPase H K ExcretionofH inaintercalatedcells H H Collectingtubule TubularLumen Peritubularcapillary H H2O2 OH CO2 3HCO3 CA H HPO42 H2PO4 Cl ATPase ATPase H K ExcretionofH inaintercalatedcells Collectingtubule TubularLumen Peritubularcapillary H H2O2 OH CO2 3HCO3 C
13、A H NH3 NH4 Cl H ATPase NH3 ExcretionofH inaintercalatedcells CanbestimulatedbylowK Acid basebalance Thekidneysmustexcretethe50to100meqofnoncarbonicacidgeneratedeachday ThedailyacidloadisexcretedasNH4 andH2 PO4 ThedailyacidloadalsocannotbeexcretedunlessvirtuallyallofthefilteredHCO3 hasbeenreabsorbed
14、 becauseHCO3 lossintheurineisequivalenttoaddingH ionstothebody Regulation TheextracellularpHtheeffectivecirculatingvolume aldosterone andtheplasmaK concentration CanbeindependentofserumpH Stepsinacid basediagnosis Obtainarterialbloodgas ABGs andelectrolytessimultaneouslyCompare HCO3 onABGsandelectro
15、lytestoverifyaccuracyCalculateaniongap AG Know4causesofhighAGacidosisKetoacidsisLacticacidacidosisRenalfailureToxinsKnow2causesofhyperchloremicornongapacidosisBicarbonatelossfromGI RTAEstimatecompensatoryresponseCompare AGand HCO3 Comparechangein Cl withchangein Na Henderson Hasselbalchequation Eq 1
16、 H HCO3 H2CO3H2O CO2PCO2 Eq 2 H 24x HCO3 orbytheHenderson Hasselbalchequation HCO3 Eq 3 pH 6 10 log 0 03PCO2Acidosis PCO2 1 5XHCO3 8 Metabolicacidosis Influxoforganicacidintoplasma highaniongap KetoacidosisLacticacidosisPoisoningAccumulationofendogenousacids highaniongap RenalfailureExternallossesofbicarbonate normalaniongap hyperchloremic GIlossRenalloss AnionGap AG Na Cl HCO3 12 2albumin negativecharged LowserumalbuminwillreduceAG Paraprotein Igorlightchains MM positivecharged Presenceoflargea
