PLENARY DISCUSSION

ASIHS PATIENT
GROUP 2
ANATHARAO A/L SUBRAMANIAM DIAN PRATIWI BURNAMA FAJAR SATRIA PRATAMA KHALIDAH KEVIN MAULANDA MEIVITA WULANDARI SONYA VIESKA TIARA RAHMA ZAIN VEGGY PRATAMA ANANDA PUTRA WIDYATUL AINA

Scenario 3 ; Asihs Patient

Asih is a medical school student who are undergoing their clinical pediatrics section. One day, he gets a patient, a boy aged 5 years who were admitted to hospital because of a loss of consciousness. Typical symptoms in children are kussmaul respiratory and growth retardation. Blood gas analysis showed a significant decrease in the levels of bicarbonate and anion gap within normal limits. laboratory results of urine showed the pH of the urines is alkaline. Doctors suspect the child is suffering kidney disease. based on this, Asih try to analyze what happened to the child. How do you explain what happened to the child?

Learning objective
1. 2. 3. 4. 5. Regulation of acid-base balance Factors affecting the acid-base balance as well as water and electrolyte Buffer mechanism in maintaining acid-base balance Regulation of fluid-electrolyte Acid-base balance disorders as well as water and electrolytes

1. BODY REGULATION OF ACID-BASE BALANCE

Refers to precise regulation of free H+ concentration in body fluids Acids Group of H+ containing substances that dissociate in solution to release free H+ and anions(H2CO3) Bases Substance that can combine with free H+ and remove it from solution(HCO3) pH Designation used to express the concentration of H+ pH 7 neutral pH less than 7 acidic pH greater than 7 basic

BUFFER SYSTEM
The fastest performer, works in seconds Bicarbonate ions combine with excess hydrogen ions to form carbonic acid in a dynamic relationship
HCO3 + H+ H2CO3

For every molecule of carbonic acid, there are 20 molecules of bicarbonate Any change in the this 20:1 ratio is immediately corrected to maintain pH An increase H+ causes an increase in H2CO3 A decrease in H+ causes a decrease in H2CO3

BUFFER SYSTEM
Carbonic acid is a weak, volatile acid which must be eliminated The enzyme carbonic anhydrase causes the carbonic acid to convert to carbon dioxide and water The CO2 and the H2O are easily eliminated by the lungs and kidneys Buffers system in the body Bicarbonate: most important ECF buffer Phosphate: important ICF and renal tubular buffer HPO4-- + H+ H2PO4 Ammonia: important renal tubular buffer NH3 + H+ NH4+ Proteins: important ICF and ECF buffers Largest buffer store in the body Albumins and globulins, such as Hb

RESPIRATORY SYSTEM
Works in minutes The lungs eliminate excess CO2 by increasing respirations, causing a decrease in H+ and an increase in pH The lungs can retain more CO2 by slowing respirations, causing an increase in H+ and a decrease in pH

Respiratory System
The respiratory system can activate changes in pH within 1 to 3 minutes and can eliminate or conserve Co2. As discussed, when a strong acid is present in the body, the bicarbonate, carbonic acid buffer pair is activated to buffer the acid. This results in a net increase of carbonic acid, which dissociates into Co2 and H2O. Carbon dioxide is then eliminated by the lungs. An increase in H+ concentration in the blood stimulates the breathing center in the medulla to increase the respiratory rate, which facilitates CO2 elimination. If, on the other hand, pH is elevated secondary to an increase in HCO3-, the respiratory center is inhibited, and the respiratory rate decreases. This results in CO2 retention, which then becomes available to form carbonic acid, which buffers the excess bicarbonate. The respiratory system is thus able to compensate for changes in pH related to metabolic disorders by regulating Pc02, which alters the bicarbonatecarbonic acid ratio. The respiratory system cannot, however, produce any loss or gain of hydrogen ions. Respiratory compensation is activated within minutes and is usually fully functional within I to 2 days.

RENAL SYSTEM
Can take hours to days to work Kidneys can retain bicarbonate ion, causing a decrease in H+ and an increase in pH Kidneys can excrete bicarbonate ion, causing an increase in H+ and a decrease in pH

Renal System
Renal compensation is a slower process, requiring I to 2 days for complete activation. The kidneys react to changes in pH by regulating the excretion or conservation of HC03A low pH stimulates excretion of H+ into the urine. As H+ enters the urine, it displaces another positive ion, usually Na+. At the same time, HC03- is reabsorbed in exchange for the H+. The Na+ is then reabsorbed into the tubule cell, where it combines with HC03- to form NaHC03 which is then available to buffer other H+ in the blood. The rale of H+ excretion, and therefore the rate of HC03- reabsorption, is proportionate to arterial Pc02. This reaction is reversed for increases in pH.

The transport of H+ in the renal tubules is facilitated by the buffer's phosphate and ammonia, which is classified as a base. Most ammonia is converted to urea by the liver and is eliminated from the body in urine. The remaining ammonia combines with H+ to form the ammonium ion (NH4+) in the renal tubules. NH4+ also displaces Na+ and is eliminated in the urine. The Na+ is then reabsorbed into the tubule cells, where it combines with HC03- to form NaHC03, which is absorbed into the blood to buffer excess H+. The amount of H+ excreted in the urine can be measured by determining the amount of alkali required to neutralize the urine and is called titratable acidity. As a result of H+ and NH4+ excretion, urine usually has an acidic pH of 6. In the clinical setting, checking urine pH can be a useful indicator of the degree of renal compensation when assessing acid-base status. For example, a low or acidic blood pH will be accompanied a few days later by a low or acidic urine pH when renal compensatory mechanisms are active. The reverse is true in alkalotic states.

2. FACTORS THAT EQUILIBRIUM LIQUID AND ACID BASE

AFFECT THE ELECTROLYTE

1.age fluid composition in adult women in about 50% of the body weight fluid composition in adult men 60% of body weight on children's body fluid composition 75% of body weight in the elderly komposis 40-50% of body fluid loss dsri Berst 2. Climate the colder the climate, the less caitan that ekskresikan by the body, and vice versa.

3.diet diet affect fluid and electrolyte intake, when nutrient intake is not strong, the body will burn fat prtotein and, thus serum albumin and protein reserves will decline. 4.stress stress will lead to increased cell metabolism, thereby increasing the levels of sodium and water retention in the body 5. ill sunburn this will lead to a lot of liquid which is excreted in the body surface. cardiovascular-renal disease

FACTORS THAT AFFECT ACID-BASE BALANCE 1. Hydrogen ion concentration in the body 2.konsentrasi bicarbonate ions in the body 3.Partial pressure carbon dioxide in the body

3. Buffer System on Acid-Base Balance

1. Bicarbonate Buffer System Consist of a weak acid H2CO3 and bicarbonate salt NaHCO3. When a strong acid such as HCl is added to a solution of bicarbonate buffer, an increase in H ions released by the HCl will be supported by HCO3. H + HCO3 H2CO3 CO2 + H2O When strong bases such as NaOH is added to a solution of bicarbonate buffer, ion OH from NaOH joined H2CO3 to form HCO3 extra. NaOH + H2CO3 NaHCO3 + H2O

Henderson-Hasselbalch equation

pH= pKa + log [HCO3] / [H2CO3]

Increasing the concentration of bicarbonate ions causes the pH to rise, shifting the acid-base balance toward alkalosis. Increasing the concentration of H2CO3 cause decreased pH, acidbase balance shifts toward acidosis.

2. Phosphate buffer system Plays an important role in supporting the renal tubular fluid and intracellular fluid. The main elements of phosphate buffer system is H2PO4 and HPO4. When a strong acid such as HCl is added to the phosphate buffer solution, hydrogen accepted by HPO4 converted to H2PO4.
HCl + Na2HPO4 NaH2PO4 + NaCl

When strong bases such as NaOH is added to the phosphate buffer system, OH supported by H2PO4 to form a number of additions HPO4 + H2O
NaOH + NaH2PO4 Na2HPO4 + H2O

3.

Protein Is an important intracellular buffer. Diffusion elements of bicarbonate buffer system causing pH in intracellular fluid change when there is a change of extracellular fluid pH. 60-70% of total chemical buffering fluid inside the cells and mostly produced by the intracellular protein. The slow movement of hydrogen ions and bicarbonate ions through the cell membrane often slow intracellular protein maximum capacity up to several hours to buffer acid-base disturbances.

4. The Ammonia Buffer System

This ammonia buffer system occurs in 3 steps: 1) synthesis of NH4+ from glutamine, an amino acid in the proximal tubule, thick ascending loop of Henle & distal tubules 2) recycling & reabsorption of NH3 in the kidneys medulla, & 3) buffering of H+ ions by NH3 in the collecting tubules

4. Fluid Electrolyte Balance

Distribution of Body Fluids Intracellular = inside the cell; 42% of body weight Extracellular = outside the cell, 17% of body weight
Interstitial = contains lymph; fluid between cells and outside blood vessels Intravascular = blood plasma found inside blood vessels Transcellular = fluid that is separated by cellular barrier,

Body fluids contain Electrolytes

Anions negative charge
Cl, HCO3, SO4

Cations positive charge

Na, K, Ca

Electrolytes are measured in mEq Minerals are ingested as compounds and are constituents of all body tissues and fluids Minerals act as catalysts

Electrolytes in Body Fluids Normal Values

Sodium (Na+) 35 145 mEq/L Potassium (K+) 3.5 5.0 mEq/L Ionized Calcium (Ca++) 4.5 5.5 mg/dL Calcium (Ca++) 8.5 10.5 mg/dL Bicarbonate (HCO3) 24 30 mEq/L Chloride (Cl--) 95 105 mEq/L Magnesium (Mg++) 1.5 2.5 mEq/L Phosphate (PO4---) 2.8 4.5 mg/dL

Regulation of Body Fluids

Homeostasis is maintained through
Fluid intake Hormonal regulation Fluid output regulation

Fluid Intake
Thirst control center located in the hypothalamus Osmoreceptors monitor the serum osmotic pressure When osmolarity increases (blood becomes more concentrated), the hypothalamus is stimulated resulting in thirst sensation
Salt increases serum osmolarity

Hypovolemia occurs when excess fluid is lost Average adult intake

2200 2700 mL per day
Oral intake accounts for 1100 1400 mL per day Solid foods about 800 1000 mL per day Oxidative metabolism 300 mL per day

Those unable to respond to the thirst mechanism are at risk for dehydration
Infants, patients with neuro or psych problems, and older adults

Hormonal Regulation
ADH (Antidiuretic hormone)
Stored in the posterior pituitary and released in response to serum osmolarity Pain, stress, circulating blood volume effect the release of ADH
Increase in ADH = Decrease in urine output = Body saves water

Renin-angiotensin-aldosterone mechanism

Makes renal tubules and ducts more permeable to water

Changes in renal perfusion initiates this mechanism Renin responds to decrease in renal perfusion secondary to decrease in extracellular volume Renin acts to produce angiotensin I which converts to angiotensin II which causes vasoconstriction, increasing renal perfusion Angiotensin II stimulates the release of aldosterone when sodium concentration is low

Hormonal Regulation
Aldosterone
Released in response to increased plasma potassium levels or as part of the renin-angiotensin-aldosterone mechanism to counteract hypovolemia Acts on the distal portion of the renal tubules to increase the reabsorption of sodium and the secretion and excretion of potassium and hydrogen Water is retained because sodium is retained Volume regulator resulting in restoration of blood volume

Atrial Natriuretic Peptide (ANP)

ANP is a hormone secreted from atrial cells of the heart in response to atrial stretching and an increase in circulating blood volume ANP acts like a diuretic that causes sodium loss and inhibits the thirst mechanism Monitored in CHF

Fluid Output Regulation

Organs of water loss
Kidneys Lungs Skin GI tract

Fluid Output Regulation

Kidneys are major regulatory organ of fluid balance
Receive about 180 liters of plasma to filter daily 1200 1500 mL of urine produced daily Urine volume changes related to variation in the amount and type of fluid ingested

Skin
Insensible Water Loss
Continuous and occurs through the skin and lungs Can significantly increase with fever or burns

Sensible Water Loss occurs through excess perspiration

Can be sensible or insensible via diffusion or perspiration

500 600 mL of insensible and sensible fluid lost through skin each day

Fluid Output Regulation

Lungs
Expire approx 500 mL of water daily Insensible water loss increases in response to changes in resp rate and depth and oxygen administration

GI Tract
3 6 liters of isotonic fluid moves into the GI tract and then returns to the ECF 200 mL of fluid is lost in the feces each day
Diarrhea can increase this loss significantly

Regulation of Electrolytes
Major Cations in body fluids
Sodium (Na+) Potassium (K+) Calcium (Ca++) Magnesium (Mg++)

Sodium Regulation
Most abundant cation in the extracellular fluid
Major contributor to maintaining water balance
Nerve transmission Regulation of acid-base balance Contributes to cellular chemical reactions

Sodium is taken in via food and balance is maintained through aldosterone

Potassium Regulation
Major electrolyte and principle cation in the extracellular fluid
Regulates metabolic activities Required for glycogen deposits in the liver and skeletal muscle Required for transmission of nerve impulses, normal cardiac conduction and normal smooth and skeletal muscle contraction Regulated by dietary intake and renal excretion

Calcium Regulation
Stored in the bone, plasma and body cells

99% of calcium is in the bones and teeth 1% is in ECF 50% of calcium in the ECF is bound to protein (albumin) 40% is free ionized calcium Is necessary for
Bone and teeth formation Blood clotting Hormone secretion Cell membrane integrity Cardiac conduction Transmission of nerve impulses Muscle contraction

Magnesium Regulation
Essential for enzyme activities Neurochemical activities Cardiac and skeletal muscle excitability Regulation
Dietary Renal mechanisms Parathyroid hormone action

50 60% of magnesium contained in bones

1% in ECF Minimal amount in cell

Anions
Chloride (Cl-)
Major anion in ECF Follows sodium

Bicarbonate (HCO3-)

Is the major chemical base buffer Is found in ECF and ICF Regulated by kidneys
Buffer ion found in ICF Assists in acid-base regulation Helps to develop and maintain bones and teeth Calcium and phosphate are inversely proportional Promotes normal neuromuscular action and participates in carbohydrate metabolism Absorbed through GI tract Regulated by diet, renal excretion, intestinal absorption and PTH

Phosphate (PO4---)

5. Acid-base balance disorders as well as water and electrolytes

Acid-Base Imbalance

RESPIRATORY ACIDOSIS
PaCO2 & pH
A primary disorder where the first change is an elevation of PaCO2, resulting in decreased pH. Compensation (bringing pH back up toward normal) is a secondary retention of HCO3 by the kidneys; this elevation of HCO3- is not metabolic alkalosis since it is not a primary process. Primary Event HCO3 pH ~ --------PaCO2 Compensatory Event HCO3 pH ~ -------- PaCO2

Metabolic acidosis
A primary acid-base disorder where the first change is a lowering of HCO3-, resulting in decreased pH. Compensation (bringing pH back up toward normal) is a secondary hyperventilation; this lowering of PaCO2, Renal excretion of hydrogen ions & K+ exchanges Primary Event Compensatory Event HCO3 pH ~ -----------PaCO2 HCO3 pH ~ ----------- PaCO2

Metabolic Alkalosis
A primary acid-base disorder where the first change is an elevation of HCO3-, resulting in increased pH.

Compensation is a secondary hypoventilation (increased PaCO2), Compensation for metabolic alkalosis is less predictable
than for the other three acid-base disorders. Primary Event
HCO3 pH ~ ------------

Compensatory Event
HCO3--------

pH ~

PaCO2

PaCO2

Respiratory Alkalosis
A primary disorder where the first change is a lowering of PaCO2, resulting in an elevated pH. Compensation is a secondary lowering(excreting)HCO3 by the kidneys. Primary Event Compensatory Event

HCO3 pH ~ ------ PaCO2

HCO3 pH ~ ------- PaCO2

Water Electrolyte Disorders

Hipovolemia is a diminution of the circulating volume of Blood due to multiple factors like Hemorrhage, dehydration, burns, among others. Dehydration is the loss of water and salts essential for normal body function. Dehydration occurs when the body loses more fluid than it takes in. Hyponatremia is a medical term which refers to a dangerously low level of sodium in the body.

Water Electrolyte Disorders

Edema is swelling that is caused by fluid trapped in your bodys tissues. Edema happens most often in the feet, ankles, and legs, but can affect other parts of the body, such as the face, hands, and abdomen. It can also involve the entire body.

Hyperkalemia is defined as a condition in which the serum potassium level is greater than 5.3 mEq/L. Any of 3 pathogenetic mechanisms can cause hyperkalemia: excessive intake, decreased excretion, and shift from intracellular to extracellular space.