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Bob Marley was a hero figure, in the classic mythological sense. His departure from this planet came at a point when his vision of One World, One Love -- inspired by his belief in Rastafari -- was beginning to be heard and felt. The last Bob Marley and the Wailers tour in 1980 attracted the largest audiences at that time for any musical act in Europe. Bob's story is that of an archetype, which is why it continues to have such a powerful and evergrowing resonance: it embodies political repression, metaphysical and artistic insights, gangland warfare and various periods of mystical wilderness. And his audience continues to widen: to westerners Bob's apocalyptic truths prove inspirational and life-changing; in the Third World his impact goes much further. Not just among Jamaicans, but also the Hopi Indians of New Mexico and the Maoris of New Zealand, in Indonesia and India, and especially in those parts of West Africa from wihch slaves were plucked and taken to the New World, Bob is seen as a redeemer figure returning to lead this

In the clear Jamaican sunlight you can pick out the component parts of which the myth of Bob Marley is comprised: the sadness, the love, the understanding, the Godgiven talent. Those are facts. And although it is sometimes said that there are no facts in Jamaica, there is one more thing of which we can be certain: Bob Marley never wrote a bad song. He left behind the most remarkable body of recorded work. "The reservoir of music he has left behind is like an encyclopedia," says Judy Mowatt of the I-Threes. "When you need to refer to a certain situation or crisis, there will always be a Bob Marley song that will relate to it. Bob was a musical prophet." The tiny Third World country of Jamaica has produced an artist who has transcended all categories, classes, and creeds through a combination of innate modesty and profound wisdom. Bob Marley, the Natural Mystic, may yet prove to be the most significant musical artist of the twentieth century. Bob Marley gave the world brilliant and evocative music; his work stretched across nearly two decades and yet still remains timeless and universal. Bob Marley & the Wailers worked their way into the very fabric of our lives. "He's taken his place alongside James Brown and Sly Stone as a pervasive influence on r&b", says the American critic Timothy White, author of the acclaimed Bob Marley biography CATCH A FIRE: THE LIFE OF BOB MARLEY. "His music was pure rock, in the sense that it was a public expression of a private truth."

It is important to consider the roots of this legend: the first superstar from the Third World, Bob Marley was one of the most charismatic and challenging performers of our time and his music could have been created from only one source: the street culture of Jamaica. The days of slavery are a recent folk memory on the island. They have permeated the very essence of Jamaica's culture, from the plantation of the mid-nineteenth century to the popular music of our own times. Although slavery was abolished in 1834, the Africans and their descendants developed their own culture with half-remembered African traditions mingled with the customs of the British. This hybrid culture, of course, had parallels with the emerging black society in America. Jamaica, however, remained a rural community which, without the industrialisation of its northern neighbour, was more closely rooted to its African legacy. By the start of the twentieth century that African heritage was given political expression by Marcus Garvey, a shrewd Jamaican preacher and entrepreneur who founded the Universal Negro Improvement Association (UNIA). The organisation advocated the creation of a new black state in Africa, free from white domination. As the first step in this dream, Garvey founded the Black Star Line, a steamship company which, in popular imagination at least, was to take the black population from America and the Caribbean back to their homeland of Africa.

A few years later, in 1930, Ras Tafari Makonnen was crowned Emperor of Ethiopia and took a new name, Haile Selassie, The Emperor claimed to be the 225th ruler in a line that stretched back to Menelik, the son of Solomon and Sheba. The Marcus Garvey followers in Jamaica, consulting their New Testaments for a sign, believed Haile Selassie was the black king whom Garvey had prophesied would deliver the Negro race. It was the start of a new religion called Rastafari. Fifteen years later, in Rhoden Hall to the north of Jamaica, Bob Marley was born. His mother was an eighteen-year-old black girl called Cedella Booker while his father was Captain Norval Marley, a 50-year-old white quartermaster attached to the British West Indian Regiment. The couple married in 1944 and Robert Nesta Marley was born on February 6, 1945. Norval Marley's family, however, applied constant pressure and, although he provided financial support, the Captain seldom saw his son who grew up in the rural surroundings of St. Ann to the north of the island. For country people in Jamaica, the capital Kingston was the city of their dreams, the land of opportunity. The reality was that Kingston had little work to offer, yet through the Fifties and Sixties, people flooded to the city. The newcomers, despite their rapid disillusion with the capital, seldom returned to the rural parishes. Instead, they squatted in the shanty towns that grew

up in western Kingston, the most notorious of which was Trench town (so named because it was built over a ditch that drained the sewage of old Kingston.) Bob Marley, barely into his teens, moved to Kingston in the late Fifties. Like many before them, Marley and his mother eventually settled in Trenchtown. His friends were other street youths, also impatient with their place in Jamaican society. One friend in particular was Neville O'Riley Livingston, known as Bunny, with whom Bob took his first hesitant musical steps.

The two youths were fascinated by the extraordinary music they could pick up from American radio stations. In particular there was one New Orleans station broadcasting the latest tunes by such artists as Ray Charles, Fats Domino, Curtis Mayfield and Brook Benton. Bob and Bunny also paid close attention to the black vocal groups, such as the Drifters, who were extremely popular in Jamaica. When Bob quit school he seemed to have but one ambition: music. Although he took a job in a welding shop, Bob spent all his free time with Bunny, perfecting their vocal abilities. They were helped by one of Trench Town's famous residents, the singer Joe Higgs who held informal lessons for aspiring vocalists in the tenement yards. It was at one of those sessions that Bob and Bunny met Peter McIntosh, another youth with big musical ambitions. In 1962 Bob Marley auditioned for a local music entrepreneur called Leslie Kong. Impressed by the quality of Bob's vocals, Kong took the young singer into the studio to cut some tracks, the first of which, called "Judge Not", was released on Beverley's label. It was Marley's first record. The other tunes -- including "Terror" and "One Cup of Coffee" -- received no airplay and attracted little attention. At the very least, however, they confirmed Marley's ambition to be a singer. By the following year Bob had decided the way forward was with a group. He linked up with Bunny and Peter to form The Wailing Wailers. The new group had a mentor, a Rastafarian hand drummer called Alvin Patterson, who introduced the youths to Clement Dodd,, a record producer in Kingston. In the summer of 1963 Dodd auditioned The Wailing Wailers and, pleased with the results, agreed to record the group.

It was the time of ska music, the hot new dance floor music with a pronounced back-beat. Its origins incorporated influences from Jamaica's African traditions but, more immediately, from the heady beats of New Orleans' rhythm & blues disseminated from American radio stations and the burgeoning sound systems on the streets of Kingston. Clement Sir Coxsone - Dodd was one of the city's finest sound system men. The Wailing Wailers released their first single, "Simmer Down", on the Coxsone label during the last weeks of 1963. By the following January it was number one in the Jamaican charts, a position it held for the next two months. The group -- Bob, Bunny and Peter together with Junior Braithwaite and two back-up singers, Beverly Kelso and Cherry Smith -- were big news. "Simmer Down" caused a sensation in Jamaica and The Wailing Wailers began recording regularly for Coxsone Dodd's Studio One Company. The groups' music also found new themes,

identifying with the Rude Boy street rebels in the Kingston slums. Jamaican music had found a tough, urban stance. Over the next few years The Wailing Wailers put out some thirty sides that properly established the group. For country people in Jamaica, the capital Kingston was the city of their dreams, the land of opportunity. The reality was that Kingston had little work to offer, yet through the Fifties and Sixties, people flooded to the city. The newcomers, despite their rapid disillusion with the capital, seldom returned to the rural parishes. Instead, they squatted in the shanty towns that grew up in western Kingston, the most notorious of which was Trench town (so named because it was built over a ditch that drained the sewage of old Kingston.) Bob Marley, barely into his teens, moved to Kingston in the late Fifties. Like many before them, Marley and his mother eventually settled in Trenchtown. His friends were other street youths, also impatient with their place in Jamaican society. One friend in particular was Neville O'Riley Livingston, known as Bunny, with whom Bob took his first hesitant musical steps.

The two youths were fascinated by the extraordinary music they could pick up from American radio stations. In particular there was one New Orleans station broadcasting the latest tunes by such artists as Ray Charles, Fats Domino, Curtis Mayfield and Brook Benton. Bob and Bunny also paid close attention to the black vocal groups, such as the Drifters, who were extremely popular in Jamaica. When Bob quit school he seemed to have but one ambition: music. Although he took a job in a welding shop, Bob spent all his free time with Bunny, perfecting their vocal abilities. They were helped by one of Trench Town's famous residents, the singer Joe Higgs who held informal lessons for aspiring vocalists in the tenement yards. It was at one of those sessions that Bob and Bunny met Peter McIntosh, another youth with big musical ambitions. In 1962 Bob Marley auditioned for a local music entrepreneur called Leslie Kong. Impressed by the quality of Bob's vocals, Kong took the young singer into the studio to cut some tracks, the first of which, called "Judge Not", was released on Beverley's label. It was Marley's first record. The other tunes -- including "Terror" and "One Cup of Coffee" -- received no airplay and attracted little attention. At the very least, however, they confirmed Marley's ambition to be a singer. By the following year Bob had decided the way forward was with a group. He linked up with Bunny and Peter to form The Wailing Wailers. The new group had a mentor, a Rastafarian hand drummer called Alvin Patterson, who introduced the youths to Clement Dodd,, a record producer in Kingston. In the summer of 1963 Dodd auditioned The Wailing Wailers and, pleased with the results, agreed to record the group.

It was the time of ska music, the hot new dance floor music with a pronounced back-beat. Its origins incorporated influences from Jamaica's African traditions but, more immediately, from the heady beats of New Orleans' rhythm & blues disseminated from American radio stations and the burgeoning sound systems on the streets of Kingston. Clement Sir Coxsone - Dodd was one of the city's finest sound system men. The Wailing Wailers released their first single, "Simmer Down", on the Coxsone label during the last weeks of 1963. By the following January it was number one in the Jamaican charts, a position it held for the next two months. The group -- Bob, Bunny and Peter together with Junior Braithwaite and two back-up singers, Beverly Kelso and Cherry Smith -- were big news. "Simmer Down" caused a sensation in Jamaica and The Wailing Wailers began recording regularly for Coxsone Dodd's Studio One Company. The groups' music also found new themes, identifying with the Rude Boy street rebels in the Kingston slums. Jamaican music had found a tough, urban stance. Over the next few years The Wailing Wailers put out some thirty sides that properly established the group. As a last throw of the dice Bob Marley walked into the Basing Street Studios of Island Records and asked to see its founder Chris Blackwell. The company, of course, had been one of the prime movers behind the rise of Jamaican music in Britain; indeed Blackwell had launched Island in Jamaica during the late fifties. By 1962, however, Blackwell had realised that, by re-locating Island to London, he could represent all his Jamaican rivals in Britain. The company was re-born in May, 1962, selling initially to Britain's Jamaican population centered mostly in London and Birmingham. The hot ska rhythm, however, quickly became established as a burgeoning dance floor beat with the then growing Mod culture and, in 1964, Blackwell produced a worldwide smash with 'My Boy Lollipop', a pop/ska tune by the young Jamaican singer Millie.

Through the Sixties Island had grown to become a major source of Jamaican music, from ska and rock steady to reggae. The company had also embraced white rock music, with such bands and artists as Traffic, Jethro Tull, King Crimson, Cat Stevens, Free and Fairport Convention so, when Bob Marley made his first moves with Island in 1971, he was connecting with the hottest independent in the world at that time. Blackwell knew of Marley's Jamaican reputation. The group was offered a deal unique in Jamaican terms. The Wailers were advanced 4000 to make an album and, for the first time, a reggae band had access to the best recording facilities and were treated in much the same way as, say, their rock group contemporaries. Before this deal, it was considered that reggae sold only on singles and cheap compilation albums. The Wailers' first album Catch A Fire broke all the rules:

it was beautifully packaged and heavily promoted. It was the start of a long climb to international fame and recognition. Years later the acclaimed reggae dub poet Linton Kwesi Johnson, commenting on Catch A Fire, wrote: "A whole new style of Jamaican music has come into being. It has a different character, a different sound. . . what I can only describe as International Reggae. It incorporates elements from popular music internationally: rock and soul, blues and funk. These elements facilitated a breakthrough on the international market." Although Catch A Fire was not an immediate hit, it made a considerable impact on the media. Marley's hard dance rhythms, allied to his militant lyrical stance, came in complete contrast to the excesses of mainstream rock. Island also decided The Wailers should tour both Britain and America; again a complete novelty for a reggae band.

Marley and the band came to London in April 1973, embarking on a club tour which hardened The Wailers as a live group. After three months, however, the band returned to Jamaica and Bunny, disenchanted by life on the road, refused to play the American tour. His place was taken by Joe Higgs, The Wailers' original singing teacher. The American tour drew packed houses and even included a weekend engagement playing support to the young Bruce Springsteen. Such was the demand that an autumn tour was also arranged with seventeen dates as support to Sly & The Family Stone, then the number one band in black American music. Four shows into the tour, however, The Wailers were taken off the bill. It seems they had been too good; support bands should not detract from the main attraction. The Wailers nevertheless made their way to San Francisco where they broadcast a live concert for the pioneering rock radio station, KSAN. The bulk of that session was finally made available in February 1991, when Island released the commemorative album, Talkin' Blues. In 1973 The Wailers also released their second Island album, Burnin, an LP that included new versions of some of the band's older songs: 'Duppy Conqueror', for instance, "Small Axe" and "Put It On" -- together with such tracks as 'Get Up Stand Up' and "I Shot The Sheriff". The latter, of course, was a massive worldwide hit for Eric Clapton the following year, even reaching number one in the U.S. singles' chart. In 1974 Marley spent much time of his time in the studio working on the sessions that eventually provided Natty Dread, an album that included such fiercely committed songs as 'Talkin' Blues', "No Woman No Cry", "So Jah Seh," "Revolution", "Them Belly Full (But We Hungry)" and "Rebel Music (3 o'clock Roadblock)". By the start of the next year, however, Bunny and Peter had quit the group; they were later to embark on solo careers (as Bunny Wailer and Peter Tosh) while the band was re-named Bob Marley & The Wailers. Natty Dread was released in February 1975 and, by the summer, the band was on the road again. Bunny and Peter's missing harmonies were replaced by the I-Threes, the female trio comprising Bob's wife Rita together with Marcia Griffiths and Judy Mowatt. Among the concerts were two shows at the Lyceum Ballroom in London which, even now, are remembered as highlights of the decade.

The shows were recorded and the subsequent live album, together with the single"No Woman No Cry", both made the charts. Bob Marley & The Wailers were taking reggae into the mainstream. By November, when The Wailers returned to Jamaica to play a benefit concert with Stevie Wonder, they were obviously the country's greatest superstars. Rastaman Vibration, the follow-up album in 1976, cracked the American charts. It was, for many, the clearest exposition yet of Marley's music and beliefs, including such tracks as "Crazy Baldhead", "Johnny Was", "Who the Cap Fit" and, perhaps most significantly of all, "War", the lyrics of which were taken from a speech by Emperor Haile Selassie. Its international success cemented Marley's growing political importance in Jamaica, where his firm Rastafarian stance had found a strong resonance with the ghetto youth. By way of thanking the people of Jamaica, Marley decided on a free concert, to be held at Kingston's National Heroes Park on December 5, 1976. The idea was to emphasise the need for peace in the slums of the city, where warring factions had brought turmoil and murder. Just after the concert was announced, the government called an election for December 20. The campaign was a signal for renewed ghetto war and, on the eve of the concert, gunmen broke into Marley's house and shot him. In the confusion the would-be assassins only wounded Marley, who was hastily taken to a safe haven in the hills surrounding Kingston. For a day he deliberated playing the concert and then, on December 5, he came on stage and played a brief set in defiance of the gunmen.

It was to be Marley's last appearance in Jamaica for nearly eighteen months. Immediately after the show he left the country and, during early 1977, lived in London where he recorded his next album, Exodus. Released in the summer of that year, Exodus properly established the band's international status. The album remained on the UK charts for 56 straight weeks, and its three singles - "Exodus", "Waiting in Vain" and "Jammin" - were all massive sellers. The band also played a week of concerts at London's Rainbow Theatre; their last dates in the city during the seventies. In 1978 the band capitalised on their chart success with Kaya, an album which hit number four in the UK the week after release. That album saw Marley in a different mood; a collection of love songs and, of course, homages to the power of ganja. The album also provided two chart singles, "Satisfy My Soul" and the beautiful "Is This Love". There were three more events in 1978, all of which were of extraordinary significance to Marley. In April he returned to Jamaica to play the One Love Peace Concert in front of the Prime Minister Michael Manley and the Leader of the Opposition Edward Seaga.

He was then invited to the United Nations in New York to receive the organisation's Medal of Peace. At the end of the year Bob also visited Africa for the first time, going initially to Kenya and then on to Ethiopia, spiritual home of Rastafari. The band had earlier toured Europe and America, a series of shows that provided a second live album, Babylon By Bus. The Wailers also broke new ground by playing in Australia, Japan and New Zealand: truly international style reggae. Survival, Bob Marley's ninth album for Island Records, was released in the summer of 1979. It included "Zimbabwe", a stirring anthem for the soon-to-be liberated Rhodesia, together with "So Much Trouble In The World", "Ambush In The Night" and "Africa Unite"; as the sleeve design, comprising the flags of the independent nations, indicated, Survival was an album of pan-African solidarity. At the start of the following year -- a new decade -- Bob Marley & The Wailers flew to Gabon where they were to make their African debut. It was not an auspicious occasion, however, when the band discovered they were playing in front of the country's young elite. The group, nevertheless, was to make a quick return to Africa, this time at the official invitation to the government of liberated Zimbabwe to play at the country's Independence Ceremony in April, 1980. It was the greatest honour ever afforded the band, and one which underlined the Wailer's importance in the Third World. The band's next album, Uprising, was released in May 1980. It was an instant hit, with the single, "Could You Be Loved" a massive worldwide seller. Uprising also featured "Coming In From the Cold", "Work" and the extraordinary closing track, "Redemption Song". The Wailers embarked on a major European tour, breaking festival records throughout the continent. The schedule included a 100,000-capacity crowd in Milan, the biggest show in the band's history. Bob Marley & The Wailers, quite simply, were the most important band on the road that year and the new Uprising album hit every chart in Europe. It was a period of maximum optimism and plans were being made for an American tour, in company with Stevie Wonder, that winter.

At the end of the European tour Marley and the band went to America. Bob played two shows at Madison Square Garden but, immediately afterwards, was taken seriously ill. Three years earlier, in London, Bob hurt a toe while playing football. The wound had become cancerous and was belatedly treated in Miami, yet it continued to fester. By 1980 the cancer, in its most virulent form, had begun to spread through Marley's body. He fought the disease for eight months, taking treatment at the clinic of Dr. Joseph Issels in Bavaria. Issels' treatment was controversial and non-toxic and, for a time anyway, Bob's condition seemed to stabilise. Eventually, however, the battle proved too much. At the start of

May Bob Marley left Germany for his Jamaican home, a journey he did not complete. He died in a Miami hospital on Monday May 11, 1981. The previous month, Marley had been awarded Jamaica's Order Of Merit, the nation's third highest honour, in recognition of his outstanding contribution to the country's culture. On Thursday May 21, 1981, the Hon. Robert Nesta Marley O.M. was given an official funeral by the people of Jamaica. Following the service - attended by both the Prime Minister and the Leader of the Opposition - Marley's body was taken to his birthplace at Nine Mile, on the north of the island, where it now rests in a mausoleum. Bob Marley was 36-years-old. His legend, however, has conquered the years. Contraction Alkalosis and Hypokalemia Contraction alkalosis occurs whenever there is a loss in bodily fluid that does not contain HCO3- . In this setting, which is most commonly due to diuretics, the extracellular volume contracts around a fixed quantity of HCO3- resulting in a rise in [HCO3-]. Note that in this setting, the total body bicarbonate is the same as shown in the figure below. The direct effect of contraction is largely minimized by the release of H+ from cell buffers, thereby lowering the plasma [HCO3-] toward normal. However, if ECF reduction by diuretics result in hypovolemia, then as in vomiting, the release of angiotensin and aldosterone will be stimulated. This then leads to an increase in HCO3- absorption and increased H and K secretion. The increase in potassium secretion result in the development of hypokalemia which also plays a very important role in maintaining the alkalosis.

Hypokalemia Hypokalemia is very commonly associated with metabolic alkalosis. This is due to 2 factors: 1) the common causes of metabolic alkalosis (vomiting, diuretics, mineralocorticoid excess) directly induce both H+ and K loss (via aldosterone) and thus also cause hypokalemia and 2) hypokalemia is a very important cause of metabolic alkalosis. Hypokalemia causes metabolic alkalosis by three mechanisms. The initial effect is by causing a transcellular shift in which K leaves and H+ enters the cells, thereby raising the extracellular pH. The second effect is by

causing a transcellular shift in the cells of the proximal tubules resulting in an intracellular acidosis, which promotes ammonium production and excretion. Thirdly, in the presence of hypokalemia, hydrogen secretion in the proximal and distal tubules increases. This leads to further reabsorption of HCO3-. The net effect is an increase in the net acid excretion. Posthypercapnia The normal stimulus to respiratory acidosis is a compensatory increase in HCO3- reabsorption by the kidney and thus an increase in plasma [HCO3-]. Treatment with mechanical ventilation in this disorder leads to a rapid reduction in the pCO2. The plasma HCO3- will however remain elevated, resulting in the development of metabolic alkalosis. The maintenance of alkalosis in this setting is unclear. However chronic respiratory acidosis is thought to be associated with Clloss in the urine leading to hypovolemia and hypochloremia. Restoration of Cl- and volume balance tends to correct the disorder. Mineralocorticoid excess The common causes of metabolic alkalosis cause and maintain metabolic alkalosis due to hypovolemia induced secondary hyperaldosteronism which leads to increased acid excretion and hypokalemia. Conditions of mineralocorticoid excess such as Conn's syndrome, excess steroid administration and Cushing's syndrome produce a state of hyperaldosteronism which also leads to metabolic alkalosis and hypokalemia. In these conditions, the extracellular volume is expanded and the patient may have hypertension. In these patients, metabolic alkalosis is perpetuated by the effects of hypokalemia (not hypovolemia) which leads to increased ammonium production, hydrogen secretion and bicarbonate reabsorbtion Diagnosis of Metabolic Alkalosis Once it has been determined that a patient has metabolic alkalosis, the etiology is usually obvious from the history. If there is no pertinent history, then one can assume that the alkalosis is due to one of the three most common causes: 1) vomiting, 2) diuretics, 3) mineralocorticoid excess. To differentiate between these conditions, it is usually helpful to measure the urinary chloride concentration. In causes of metabolic alkalosis associated with a reduction in the ECV, there will be a stimulus for avid Na and Cl reabsorption to replenish extracellular volume. In these setting urinary Cl should be expected to be very low, less than 25 meq/L. Urinary Na is not a reliable measure of extracellular volume in this setting because if the alkalosis is such that not all of the filtered HCO3- can be reabsorbed, then some will be excreted with Na and the urinary Na may be high. Thus, it may appear that the volume status is euvolemic or hypervolemic when it is not. If the urinary Cl is low, indicating a hypovolemic state, then administration of NaCl and water to replenish the extracellular volume should stop the stimulus for aldosterone production and in turn should lead to appropriate excretion of excess HCO3- and improvement of hypokalemia. Thus, leading to correction of the metabolic alkalosis. Such causes of metabolic alkalosis are said to be saline responsive. See table below. In contrast, states of mineralocorticoid excess are associated with an expanded volume and sometimes hypertension. The urinary Cl will be high (> 40 meq/L). In these patients, administration of saline would further expand the extracellular volume and worsen hypertension.

It would not correct the alkalosis which is primarily due to hypokalemia. Such causes of metabolic alkalosis are said to be saline resistant. Urine Cl < 25 meq/L Saline Responsive Vomiting or nasogastric suction Diuretics Posthypercapnia Cystic Fibrosis Low chloride intake Urine Cl > 40 meq/L Saline Unresponsive Primary mineralocorticoid excess Exogenous Alkali load Barrter's or Gitelman's syndrome Severe Hypokalemia (K< 2.0)

Causes of saline resistant metabolic alkalosis can further be distinguished based on whether or not the patient is hypertensive. Mineralocorticoid excess states tend to be associated with hypertension while exogenous alkali load, Barrters and Gitelman's syndrome are associated with normal blood pressure. Treatment Saline - Responsive metabolic alkalosis

Re-expand volume with Normal Saline ( Primary Therapy) Supplement with Potassium to treat hypokalemia (alkalosis associated with severe hypokalemia will be resistant to volume resuscitation until K is repleted)

H+ blockers or PPIs if vomiting/NG suction to prevent further losses in H+ ions Discontinue diuretics Acetazolamide if NS contraindicated due to CHF. (Monitor for hypokalemia) HCl or NH4Cl in emergency. (HCl can cause hemolysis, NH4Cl should not be used in liver disease) Hemodialysis in patients with marked renal failure Saline Unresponsive metabolic alkalosis (Mineraldocorticoid excess) Surgical removal of mineralocorticoid producing tumor Aldosterone inhibitor ACE inhibitor. Discontinue steroids

Potassium repletion (only intervention needed to treat the alkalosis)

Respiratory Acidosis

Respiratory acidosis is a clinical disorder characterized by a low arterial pH (< 7.36), an elevation in the pCO2 (hypercapnia) and a compensatory increase in the plasma [HCO3-]. Hypercapnia also occurs in metabolic alkalosis, but this is rather a response to the high arterial pH, which distinguishes the two. Pathophysiology As mentioned previously, breakdown of carbohydrates and fats result in the endogenous production of up to 20 mol of CO2. This CO2, if not excreted via ventilation will combine with H2O to form carbonic acid in the following reaction: CO2 + H2O H2CO3 (CA) H+ + HCO3Any increase in PCO2 due to increased CO2 production is rapidly handled by increased alveolar ventilation. Because of the lungs excellent capacity to excrete excess CO2, increases in PCO2 are always due to hypoventilation and never to increased CO2 production. Hypoventilation can occur with any interference in the respiratory process. See table. Common etiologies are neuromuscular disorders, CNS depression, disorders of the chest wall, chronic obstructive lung disease and acute airway obstruction. For a discussion on the compensatory mechanisms of respiratory acidosis, click here. Causes of respiratory acidosis A) CNS depression 1. Opioids 2. Oxygen in patient with chronic hypercapnia 3. Central sleep apnea 4. CNS lesion 5. Extreme obesity (Pickwickian syndrome) B) Neuromuscular disorders 1. Myasthenia gravis 2. Guillain-Barre 3. ALS 4. Poliomyelitis 5. Muscular dystrophy 6. Multiple Sclerosis C) Chest wall or Thoracic Cage Abnormality 1. Kyphoscoliosis 2. Flail Chest 3. Myxedema 4. Rib Fracture 5. Scleroderma 4) Disorders affecting gas exchange 1. COPD 2. Severe asthma or pneumonia 3. Pneumothorax or Hemothorax

4. Acute pulmonary edema 5) Airway obstruction 1. Aspiration of foreign body 2. Obstructive sleep apnea 3. Laryngospasm Symptoms Symptoms are caused by acute respiratory acidosis and not by chronic respiratory acidosis and usually include neurologic abnormalities. Initial symptoms include headache, blurry vision, restlessness, and anxiety, which can progress to tremors, asterixis, delirium, and somnolence or coma (CO2 narcosis). Severe hypercapnia increases cerebral blood flow and cerebrospinal fluid pressure. Signs of increased intracranial pressure such as papilledema may be seen. The tendency to develop neurologic abnormalities in acute respiratory acidosis is due to the rapid reduction in CSF pH. CO2 is lipid soluble and rapidly crosses the blood brain border, leading to a decline in CSF pH. In contrast, HCO3- is a polar compound that does not readily cross the blood border and thus is not available to counteract the actions of CO2. Thus acute respiratory acidosis promotes a greater fall in CSF pH than acute metabolic acidosis, which may explain why neurologic abnormalities are seen less often in the latter. In chronic respiratory acidosis, the CO2 accumulates at a much slower rate, allowing renal compensation to return the arterial pH and ultimately CSF pH toward normal. Therefore neurologic abnormalities are also seldom seen in chronic respiratory acidosis. Treatment Respiratory Alkalosis Respiratory Alkalosis is an acid base disturbance characterized by elevated arterial pH, hyperventilation resulting in a low pCO2 and a usually compensatory decrease in plasma HCO3concentration. Pathophysiology Respiratory Alkalosis results from an elevation in alveolar ventilation that causes a fall in the partial pressure of dissolved carbon dioxide. The fall in PCO2 causes a compensatory fall in plasma HCO3- concentration as was decribed previously. The causes of Respiratory Alkalosis are shown in the table below. It is very commonly induced by what the body or patient perceives as a stressor. The stressor which is often associated with anxiety, pain, and infection stimulates the CNS leading to hyperventilation. Other common causes are hypoxemia, sepsis, liver failure and PE. Aspirin intoxication is an interesting cause of respiratory alkalosis which can also cause an elvated anion gap acidosis. Treat underlying disorder Supply oxygen Corticosteroids and bronchodilators to reduce airway inflammation and resistance. Mechanical ventilator if ventilation fails.

A) CNS stimulation 1. pain 2. Anxiety, Psychosis 3. Fever 4. CVA 5. Meningitis, encephalitis 6. Tumor, trauma 7. Drugs: Salicylate (also causes metabolic acidosis), methylaxanthines, theophylline, aminophyllines. 8. Pregnancy, progesterone B) Hypoxemia or tissue hypoxia 1. High altitude 2. Pulmonary disease: pneumonia, interstitial fibrosis, PE, pulmonary edema 3. CHF 4. Hypotension 5. Severe anemia 6. Aspiration C) Chest Receptors stimulation 1. Flail Chest 2. Hemothorax 3. PE 4) Miscellaneous disorders 1.Gram negative septicemia (very early clinical sign of septicemia) 2. Hepatic failure 3. Mechanical hyperventilation 4. Heat exposure 5. Recovery from metabolic acidosis Clinical Manifestations Clinical manifestations of respiratory alkalosis vary according to duration and severity and depend on the underlying disease process. In acute respiratory alkalosis, acute onset of hypocapnia can cause cerebral vasoconstriction. Therefore, an acute decrease in PCO2 reduces cerebral blood flow and can cause neurologic symptoms, including dizziness, mental confusion, syncope, seizures, paresthesias, numbness around the mouth. This acute drop in PCO2, result in a substantial drop in CSF pH not seen in chronic respiratory alkalosis or metabolic alkalosis. In metabolic alkalosis, the change in CSF pH occurs much slower due to the relative inability of HCO3- to cross the blood brain barrier in comparison to CO2. In addition some complaints may be unrelated to the change in pH. For example, patients with psychogenic hyperventilation often complain of chest tightness, headache, dyspnea, and other

somatic symptoms that may be related to anxiety and not alkalemia. Acute respiratory alkalosis also causes intracellular shift of potassium and phosphates potentially resulting in hypokalemia and hypophosphatemia. The hypokalemia is usually mild. Hypocalcemia typically results, due to an increase in albumin bound calcium and may lead to tetany and a positive Chvostek or Trousseau sign. Treatment Treat the underlying cause: oxygen, diuretics, etc. For anxious patient, reassurance, rebreathing into paper bag (raises the inspired PCO2). Teach breath holding techniques during episodes. If intubated, reduce minute ventilation by adjusting rate, tidal volume.

Usually self limited since muscles weakness will suppress ventilation. If the PaCO2 is corrected rapidly in patients with chronic respiratory alkalosis, metabolic acidosis may develop due to the previous compensatory drop in serum bicarbonate. Mixed Acid Base Disorders Mixed acid base disorders occur when there is more than one primary acid base disturbance present simultaneously. They are frequently seen in hospitalized patients, particularly in the critically ill. When to suspect a mixed acid base disorder: 1. The expected compensatory response does not occur 2. Compensatory response occurs, but level of compensation is inadequate or too extreme 3. Whenever the PCO2 and [HCO3-] becomes abnormal in the opposite direction. (i.e. one is elevated while the other is reduced). In simple acid base disorders, the direction of the compensatory response is always the same as the direction of the initial abnormal change. 4. pH is normal but PCO2 or HCO3- is abnormal 5. In anion gap metabolic acidosis, if the change in bicarbonate level is not proportional to the change of the anion gap. More specifically, if the delta ratio is greater than 2 or less than 1. 6. In simple acid base disorders, the compensatory response should never return the pH to normal. If that happens, suspect a mixed disorder. Mixed metabolic disorders
a. Anion Gap and Normal Anion Gap Acidosis.

This mixed acid base disorder is identified in patients with a delta ratio less than 1 which signifies that the reduction in bicarbonate is greater than it should be, relative to the change in the anion gap. Thus, implicating that there must be another process present requiring buffering by HCO3-, i.e a concurrent normal anion gap acidosis. Example: Lactic acidosis superimposed on severe diarrhea. (note: the delta ratio is not particularly helpful here since the diarrhea will be clinically obvious) Progressive Renal Failure

DKA during treatment Type IV RTA and DKA

b. Anion Gap Acidosis and Metabolic Alkalosis

This mixed acid base disorder is identified in patients with a delta ratio greater than 1, which signifies a reduction in bicarbonate less than it should be, relative to the change in the anion gap. This suggests the presence of another process functioning to increase the bicarbonate level without affecting the anion gap, i.e. metabolic alkalosis. Examples: Lactic acidosis, uremia, or DKA in a patient who is actively vomiting or who requires nasogastric suction. Patient with lactic acidosis or DKA given sodium bicarbonate therapy.

c. Normal Anion Gap Acidosis and Metabolic Alkalosis

This diagnosis can be quite difficult, because the low HCO3- and low PCO2 both move back toward normal when metabolic alkalosis develops. Also, unlike elevated anion gap acidosis, the anion gap will not indicate the presence of the acidosis. Example: In patients who are vomiting and with diarrhea (note: all acid base parameters may fall within the normal range)

Mixed respiratory and respiratorymetabolic disorders Having a good knowledge of compensatory mechanisms and extent of compensation will aid in identifying these disorders. Remember; compensation for simple acid-base disturbances always drives the compensating parameter (ie, the PCO2, or [HCO3-]) in the same direction as the primary abnormal parameter (ie, the [HCO3-] or PCO2). Whenever the PCO2 and [HCO3] are abnormal in opposite directions, ie, one above normal while the other is reduced, a mixed respiratory and metabolic acid-base disorder exists. Rule of thumb: When the PCO2 is elevated and the [HCO3-] reduced, respiratory acidosis and metabolic acidosis coexist. When the PCO2 is reduced and the [HCO3-] elevated, respiratory alkalosis and metabolic alkalosis coexist

The above examples both produce very extreme acidemia or alkalemia and are relatively easy to diagnose. However more often, the disorder is quite subtle. For example, in cases of metabolic acidosis, the HCO3- is low and PCO2 low. If the PCO2 is normal or not aqequately reduced, this may indicate a subtle coexisting respiratory acidosis. Mixed acid base disorders usually produce arterial blood gas results that could potentially be explained by other mixed disorders. Oftentimes, the clinical picture will help to distinguish. It is important to distinguish mixed acid base disorders because work up and management will depend on accurate diagnosis.
a. Chronic Respiratory Acidosis with superimposed Acute Respiratory Acidosis

Example: Acute exacerbation of COPD secondary to acute pneumonia

COPD patient with worsening hypoventilation secondary to oxygen therapy or sedative administration

b. Chronic Respiratory Acidosis and Anion Gap Metabolic Acidosis

Example: COPD patient who develops shock and lactic acidosis


c. Chronic Respiratory Acidosis and Metabolic Alkalosis

Example: Pulmonary insufficiency and diuretic therapy or COPD patient treated with steroids or ventilation (important to recognize as alkalemia will reduce acidemic stimulus to breathe)

d. Respiratory Alkalosis and Metabolic Acidosis

Example: Salicylate intoxication Gram negative sepsis Acute cardiopulmonary arrest Severe pulmonary edema

Please note that it is impossible to have more than one respiratory disorder in the same mixed disorder(i.e. concurrent respiratory alkalosis and respiratory acidosis) Practice Cases These case studies are provided to give you practice dealing with some of the topics that were discussed in the acid base tutorial. Each case contains a clinical presentation followed by evaluative studies. Answers are provided after each case but it would probably be best if you formulate your own answer to each question before reading below for the answer.

ThirdField.com Bob Marley Lyrics


Song: 400 Years

400 years (400 years, 400 years. And it's the same The same (wo-o-o-o) philosophy I've said it's four hundred years; (400 years, 400 years.

Wo-o-o-o)

Wo-o-o-o, wo-o-o-o)

Look, how long (wo-o-o-o) And the people they (wo-o-o-o) still can't see. Why do they fight against the poor youth of today? And without these youths, they would be gone All gone astray

Come on, let's make a move: (make a move, make a move. Wo-o-o-o, wo-o-o-o)

I can (wo-o-o-o) see time (wo-o-o-o) - time has come, And if-a fools don't see (fools don't see, fools don't see. I can't save the youth: The youth (wo-o-o-o) is gonna be strong. So, won't you come with me; I'll take you to a land of liberty Where we can live - live a good, good life And be free. Wo-o-o-o)

Look how long: 400 years, (400 years, 400 years) Way too long! (wo-o-o-o)

That's the reason my people (wo-o-o-o) - my people can't see. Said, it's four hundred long years (400 years, 400 years. Wo-o-o-o) Give me patience (wo-o-o-o) - same philosophy.

It's been 400 years, (400 years, 400 years) Wait so long! How long? Wo-o-o-o, wo-o-o-o.

400 long, long years.