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pH = 7
The catabolism of glucose and fatty acids produces CO2 and H2O, effectively carbonic acid.
About
Respiratory elimination of CO2 and cellular buffers handle this acid load.
Production
tissue respiration
Amount
20,000 lungs
Disposal
Lactate
FF/acids
glycolysis
lipolysis
1300
600
ketogenesis ureagenesis
400 1140
H2SO4
40
CELL METABOLISM Volatile H+ CO2 Non-volatile H+ abnormal metabolic acids (lactic, acetoacetic, hydroxybutyric, formic,glycolic)
EXTERNAL FLUID
BLOOD IN CAPILLARIES
B + H+
pH -log[H+]
BH+
HA H+ + A[H+][A-] Ka [HA]
[HA]
Rearrange:
[H+] = Ka
[A-]
pKa -log Ka
and pH = -log[H+]
plasma
H+ + HCO3- H2CO3
pKa ~ 6.1
urine
H+ + NH3
NH4 +
pKa = 9.0
urine
H+ + HPO4-- H2PO4-
pKa = 6.8
cell
H+ + protein- proteinH
pKa = 7.0
Buffering
Buffering: Limitation of the change in H+ in the face of a tendency to change
Base- + H+
Hbase
H2CO3 + OH-
HCO-3 + H2O
The CO2 - HCO3- buffer system is important in the plasma H+ + HCO3- H2CO3 CO2 + H2O
[HCO3-]
[H2CO3]
pH = 6.1 + log
Cl-
Cl-
CO2 + H2O
dehydratase
H2CO3
H+ + HCO-3
Hb-
HCO-3
erythrocyte
HbH
Cl-
Cl-
CO2 + H2O
dehydratase
H2CO3
H+ + HCO-3
Hb-
HCO-3
erythrocyte
HbH
Recovery
of Filtered
Bicarbonate in Kidneys
The Kidney
Reabsorbs 4500 mmol of HCO3 per day Generates new HCO3 to replenish buffer stores The Proximal tubule does most of the work The Distal tubule eliminates H+ = to the nonvolatile acid production
H+ excretion directly and as H2PO42Ammonium excretion (oxoglutarate goes to liver; H+ used for gluconeogenesis)
Liver:
Lactate used for gluconeogenesis Oxoglutarate from kidney used for gluconeogenesis
(0.030)(paCO2)
pH = 6. 1 + log ( metabolic component) (respiratory component) HCO3 & CO2 &
_
CO2 = HCO3 =
_
pH pH
RESPIRATORY
ACIDOSIS ALKALOSIS pCO2 pCO2
METABOLIC
ACIDOSIS ALKALOSIS BICARB. BICARB.
Metabolic acidosis
Anion Gap
A mathematical concept (Na+ + K+ ) - ( Cl- + HCO3-) < 7-17 mmol/L The gap consists of other ions, mainly Ca2+, Mg+, PO42-, sulfate-, organic anions (e.g. lactate, acetoacetate) The sum of anion and cation in plasma must be the same (electroneutrality) Overproduction of e.g. lactate will increase the anion gap, indicating that the concomitant acidosis is of the metabolic type as will decreased excretion of acid anions as in renal failure. Therefore an increased anion gap is a useful marker of metabolic acidosis
Evaluating a low serum HCO3 A low serum HCO3- can be due to:
Metabolic acidosis
High anion gap acidosis Hyperchloremic acidosis
Respiratory alkalosis
Compensatory Response
In simple metabolic acidosis the high [H+] stimulates respiration resulting in a compensatory fall in the PCO2 (secondary respiratory alkalosis) which brings the [H+] back towards, but never to, normal.
(1) Maximum compensation occurs in 12-24 hours (2) For a given [HCO3] the final PCO2 level can be calculated from: PCO2 = 1.5 x [HCO3] + 8 (+/- 2) (3) The limit of compensation is a PCO2 of about 10 mmHg
Metabolic alkalosis
Loss of Hydrogen Ions Vomiting Ingestion of Alkali Potassium Deficiency
Metabolic alkalosis
Metabolic Alkalosis
Saline Responsive (ECV contraction, Urine [Cl] <20 mmol/L) Gastrointestinal -Vomiting, Gastric suction, Chloride diarrhoea Renal -Diuretic therapy Exogenous alkali -Bicarbonate (IV, oral), Antacids (eg Mg carbonate) Organic acid salts (eg, lactate, citrate, acetate) Saline Unresponsive (ECV expansion, Urine [Cl] >20 mmol/L) Mineralocorticoid excess Primary hyperaldosteronism, Cortisol & Mineralocorticoid excess Cushing's syndrome
This is carried out by the kidney (renal bicarbonate retention) and occurs in the following situations:
Volume depletion Potassium depletion
Hypercapnia
Thus when evaluating the subject with metabolic alkalosis attention should be given to the possible causes of generation and of maintenance. From a management point of view metabolic alkalosis can be classified as either saline responsive or saline unresponsive
Compensation
The compensatory process is decreased respiratory exchange and high pCO2 Response reaches its maximum in 12-24 h pCO2~ 60 mmHg. For each 1mmol/L rise of HCO3-, pCO2 should increase by 0.7 mmHg Expected pCO2 mm Hg: 0.9 X (HCO3-) + 9
Respiratory disorders
Compensatory response
Secondary metabolic acidosis HCO3 level will decrease Acute: HCO3 will decrease upto 18mmol/L Chronic:HCO3 will decrease upto 12 mmol/L Resp.alkalosis; Can be completely compensated. pH will be normal