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Acid Base Balance

Acid Base Balance


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Published by: mohdmaghyreh on Apr 04, 2009
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Acid-B ase B alan ce in Ne onate s

Dr Mohd Maghayreh PRTH-IRBID

The negative logarithm of hydrogen ion concentration, pH= -log {H+}, and corresponds to a pH of range of 7.35 to 7.45.

A downward shift in pH below 7.35

An upward shift in pH above 7.45. Buffer A substance that can minimize changes in pH when acid or base are added to the system

Maintenance of Acid-Base Balance
The main systems that maintain pH include:
  

The body’s buffer systems. The respiratory system. The kidneys

Maintenance of Acid-Base Balance (cont.)
Extracellular buffers include:  The bicarbonate-carbonic acid system.  Phosphates.  Plasma proteins. Intracellular buffers include:  Hemoglobin.  Organic phosphates.

Maintenance of Acid-Base Balance
 The

plasma bicarbonate-carbonic acid buffer system:  The most important extracellular buffer.  The acid component [carbonic acid (H2CO3)] is regulated by the lungs.  The base component [bicarbonate (HCO3-)] is regulated by the kidneys

Maintenanc e of Acid- Bas e Balanc e (cont.)
 Maintenance

of normal pH depends on excretion of volatile acids (e.g. carbonic acid) from the lungs.  Kidneys contribute to maintenance of the acid-base balance by reabsorbing the filtered bicarbonate, secreting hydrogen ions as titratable acids, and excreting ammonium ions

Classification of Acid-Base Disorders

Metabolic acidosis Occurs as a result of increased amounts of nonvolatile acid or decreased amounts of HCO3- in the extracellular fluid. Metabolic alkalosis Occurs as a result of increased amounts of HCO3- in the extracellular fluid

Classification of Acid-Base Disorders (cont.)

Respiratory acidosis Due to hypoventilation and decreased excretion of volatile acid (CO2). Respiratory alkalosis Due to hyperventilation and increased excretion of volatile acid (CO2).

Evaluation of Acid-Base Balance
 Blood

gas measurement should be the starting point for the evaluation of any acid-base disorders; pH and PaCO2 are directly measured, and from these HCO3- is calculated.

Evaluation of Acid-Base Balance

Important parameters in diagnosing acidbase disturbance:
 

 

Type: acidosis or alkalosis (by pH). Cause: metabolic or respiratory (by PaCO2 and bicarbonate) Response: uncompensated or compensated. Form: simple or mixed.

Classification of Acid-Base Disorders (cont.)
Acid-base disorders are also classified according to the number of causes giving rise to the disorder:

Simple acid-base disorder
When only one primary acid-base abnormality and its compensatory mechanism occur.

Mixed acid-base disorder
When a combination of simple acid-base disturbances occurs.

Evaluation of Acid-Base Balance
Metabolic Respiratory Acidosis

Decrease Increased PaCO2 d HCO3-

Increased HCO3-

Decreased PaCO2


Evaluation of Acid-Base Balance

A nomogram can help in the diagnosis of primary disturbance; it describes the expected compensatory response to a primary abnormality in either PaCO2 or HCO3-. If compensation in a given patient differs from that predicted, the patient either has not had enough time to compensate for a simple acid-base disturbance or has a mixed acidbase disorder

Evaluation of Acid-Base Balance
 Analysis

of blood gas values must be considered according to patient history and physical findings and with understanding of expected compensatory responses to identify the primary disturbance

Nomogram for Diagnosis of Simple Acid-Base Disorders

Compensatory Mechanisms in Primary Acid-Base Disorders
Acid-base disorder Primary event Compensatio Rate of n compensatio n Metabolic acidosis
Decreased PaCO2 For 1meq/l ↓ in HCO3→Pco2 ↓ by 11.5mmHg For 1meq/l ↓in HCO3→Pco2↓ by 11.5mmHg

Normal anion gap

Decreased HCO3-

Increased anion gap

 Increased

acid production  Increased acid intake

Decreased PaCO2

Compensatory Mechanisms in Primary Acid-Base Disorders (cont.)
Acid-base Primary disorder event Compensatio Rate of n compensation

Respiratory alkalosis
Acute decreased PCO2 decreased PCO2 decreased HCO3 decreased HCO3 For 10mmHg ↓in PCO2 →HCO3 ↓by 1 meq/l For 10mmHg ↓in PCO2 →HCO3 ↓s by 2-5meq/l


Types of Acid-Base Disorders
Metabolic acidosis  Common problem, especially in critically ill newborn.  Occurs either when the fall in pH is caused by the accumulation of acid other than H2CO3 and thus results in loss of available HCO3-, or alternatively, by the direct loss of HCO3- from body fluids.

Metabolic Acidosis
Causes of metabolic acidosis are divided into:
 Metabolic  Metabolic

acidosis with an elevated anion gap. gap. acidosis with a normal anion

Metabolic Acidosis (cont.)
 The

anion gap reflects the difference between the unmeasured cations and the unmeasured anions.  The unmeasured cations are serum potassium, calcium and magnesium.  The unmeasured anions normally include the serum proteins, phosphates, sulfates and organic acids

Metabolic Acidosis (cont.)
 The

anion gap is estimated using the following formula:
Anion gap= [Na+] – ([Cl -] + [HCO3-]

 The

normal range of serum anion gap in newborns is 8 to 16 meq/L with slightly higher values in very premature newborns.

Metabolic Acidosis with an Elevated Anion Gap
 It

indicates the accumulation of strong acids due to increased intake or production, or to decreased excretion. is most frequently due to: acidosis secondary to tissue hypoxia

 It

 Lactic

Metabolic Acidosis with an Elevated Anion Gap (cont.)
 Inborn

error of metabolism.  Renal failure.  Late metabolic acidosis.  Toxins such as benzyl alcohol .

Metabolic Acidosis with a Normal Anion Gap

It occurs as a result of HCO3- loss from the extracellular space through the kidneys or gastrointestinal tract. It is most frequently due to: • Renal bicarbonate loss:

• Bicarbonate wasting due to immaturity. • Renal tubular acidosis. • Carbonic anhydrase inhibitors.

Metabolic Acidosis with a Normal Anion Gap (cont.)

• Gastrointestinal bicarbonate loss:

• Small bowel drainage such as ileostomy and • Diarrhea.

• Aldosterone deficiency. • Excessive chloride in intravenous fluids

Complications of Acidosis
 Arteriolar

vasoconstriction followed by

dilatation.  Depression of cardiac contractility.  Systemic hypotension.  Pulmonary edema.  Arrhythmias.

Management of Metabolic Acidosis

The most important approach to treat metabolic acidosis is correcting the underlying cause, usually by improving circulating blood volume and/or cardiac output. In cases of significant metabolic acidosis (base deficit >10-12, arterial PH < 7.25), it may be useful to give exogenous base (buffer) to correct pH. The most widely used buffer is sodium bicarbonate (NaHCO3).

Management of Metabolic Acidosis

The dose of sodium bicarbonate required to correct the pH can be estimated using the following formula: NaHCO3 (mEq) = base deficit X body weight X 0.3

NaHCO3 should not be given if ventilation is inadequate because its administration results in an increase in PaCO2 with no improvement in pH .

Management of Metabolic Acidosis (cont.)

NaHCO3 should be administered slowly and diluted 1:1 with D5 or sterile water. Give half of the calculated total correction dose for initial therapy to avoid overcorrection of metabolic acidosis. Subsequent doses of sodium bicarbonate are then based on the results of repeated blood gas measurements.

Metabolic Alkalosis
It is characterized by a primary increase in the extracellular HCO3concentration, sufficient to raise the arterial pH above 7.45.

Causes of Metabolic Alkalosis in Newborns

Excessive loss of hydrogen from the gastrointestinal tract or kidneys as a result of:

• • •

Continuous nasogastric aspiration. Persistent vomiting. Diuretics treatment (This will induce equivalent rise in extracellular HCO3-).

Gain of bicarbonate as occurs during administration of NaHCO3 in attempting to correct metabolic acidosis.

Respiratory Acidosis (cont.)

The initial increase in PaCO2 is buffered by the non-HCO3- intracellular buffers without noticeable renal compensation for at least 12-24 hours. Renal metabolic compensation reaches its maximum levels within 3 to 5 days, and its effectiveness is influenced by the functional maturity of proximal tubular HCO3- transport.

Respiratory Acidosis (cont.)
 Directed

towards improving alveolar ventilation and treating the underlying disorder. ventilation often must be provided by mechanical ventilation in sick patients.

 Adequate

Respiratory Alkalosis

Occurs when a primary decrease in PaCO2 results in an increase in the arterial pH > 7.45. The initial hypocapnea is acutely titrated by intracellular buffers, and metabolic compensation by the kidneys returns pH towards normal within 1 to 2 days. This is the only simple acid-base disorder in which the pH may be completely normalized by the compensatory mechanisms.

Causes of Respiratory Alkalosis
Hyperventilation: In spontaneously breathing newborns it is most often caused by:
    

Fever. Sepsis. Retained fetal lung fluid. Mild aspiration pneumonia. Central nervous system disorders.

Causes of Respiratory Alkalosis
 In

the NICU, the most frequent cause of respiratory alkalosis is increased alveolar ventilation secondary to hyperventilation of the intubated newborn.

Complications of Respiratory Alkalosis

 There

is a suggested association between hypocapnia and development of periventricular leukomalacia and bronchopulmonary dysplasia in ventilated preterm infants.

Management of Respiratory Alkalosis
 Treatment

of neonatal respiratory alkalosis consists of specific management of the underlying process causing hyperventilation.

Respiratory Acidosis

Occurs when a primary increase in PaCO2 develops secondary to impairments in alveolar ventilation resulting in an arterial pH of less than 7.35. Common problem in newborns, and can be due to many causes such as HMD, pneumonia, PDA and bronchopulmonary dysplasia.

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