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HCO3 & CO2 = pH
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CO2 & HCO3 = pH
Understanding Normal Acid-Base Handling
Respiratory elimination of CO2 and cellular buffers handle this acid load.
The Kidney
• Reabsorbs 4500 mEq of HCO3 per day
• Generates new HCO3 to replenish buffer stores
• The Proximal tubule does most of the work
Luminal membrane carbonic anhydrase
This is stimulated
by an PCO2
Understanding Normal Acid-Base Handling
The Kidney
• The Distal tubule reclaims the remainder of the HCO3
Uses cytoplasmic carbonic anhydrase
Also eliminates H+ = to the nonvolatile acid production
Stimulated by aldosterone
and PCO2
HCO3-
HCO3- H+ secretion and HCO3-
regeneration
H+
Urine
To Blood Kidney
Bicarbonate CO2 + H2O
reabsorption HCO3
HCO3- HCO3- + H+ H+ CO2
Ammonium Glutamine
excretion
HCO3- HCO3- NH4+ NH4+
Understanding Normal Acid-Base Handling
HCO3 H+
Blood
Understanding Normal Acid-Base Handling
Metabolic Acidosis
Metabolic Alkalosis
Respiratory Acidosis
Respiratory Alkalosis
Mixed Acid-Base Disturbances
• Definition
– Combination of two or more of the 4
simple disturbances (primary)
• Examples
– Mixed respiratory-metabolic disorders
– Mixed metabolic disorders
Compensatory Responses in Simple
Acid-Base Disorders
In 3,102 trauma patients. Serum HCO3 measurement shows a strong linear correlation
and similar predictive ability compared with the arterial BD. Serum HCO3 may be safely
and accurately substituted for arterial BD measurement in critically injured patients.
FitzSullivan et al., Am J of Surg. Volume 190, Issue 6, Pages 827-994 (December 2005)
Metabolic Acidosis
Why Acidosis is Bad
Changes in Cardiac Output with Declining pH
• Dichloroacetate
– Promotes oxidation of lactate (pyruvate dehydrogenase) →→ acetyl-coenzyme A
+ carbon dioxide
– 252 patients with lactic acidosis, placebo-controlled, randomized trial of
intravenous sodium dichloroacetate
– Only 12 percent of the dichloroacetate-treated patients and 17 percent of
Stacpoole P., et al. N Engl J Med 1992; 327:1564-1569, Nov 26, 1992.
Treatment of Lactic Acidosis
Arterial ([H+]a) and mixed venous ([H+]v) hydrogen ion concentrations at baseline (B), during ventricular fibrillation (VF), and during cardiopulmonary
resuscitation (CPR). Open circles, sodium chloride (NaCl) controls; solid circles, bicarbonate; solid squares, Carbicarb; open squares, THAM. [up arrow]
Indicates the timing of buffer dose administration.
Bar-Joseph, et al., Crit Care Med, Volume 26(8), August 1998, pp 1397-1408.
NaCl vs. NaHCO3 vs. Carbicarb vs. THAM
Arterial lactate, and arterial bicarbonate (HCO3) concentrations during control measurements (C), during ventricular fibrillation (VF), and during
cardiopulmonary resuscitation (CPR). Mean +/- SEM values. Open circles, sodium chloride (NaCl) controls; solid circles, bicarbonate; solid
squares, Carbicarb; open squares, THAM. [up arrow]Indicates the timing of buffer dose administration
Bar-Joseph, et al., Crit Care Med, Volume 26(8), August 1998, pp 1397-1408.
THAM in Acute Lung Injury
KALLET et al., Am. J. Respir. Crit. Care Med., Volume 161, Number 4, April 2000, 1149-1153.
THAM in Acute Lung Injury
KALLET et al., Am. J. Respir. Crit. Care Med., Volume 161, Number 4, April 2000, 1149-1153.
Tromethamine Buffer Modifies the Depressant Effect of Permissive
Hypercapnia on Myocardial Contractility in Patients with Acute
Respiratory Distress Syndrome
• Several studies have indicated that at the same extracellular pH, hypercapnic acidosis
induces more myocardial depression and decrease in intramyocardial pH than
metabolic acidosis.
• Hypercapnia causes rapid diffusion of CO2 into myocytes, and the resultant
intracellular acidosis impairs myocardial contractility.
• Only 12 patients
Diarrhea
Below the pylorus - HCO3 is added to the gut with a
gain of H+ to the blood
HCO3 H+
To Blood
Evaluating a Low Serum HCO3
Normally: UNa +
+ UK+ - UCl- = -UNH4+ = < -20 in the face of acidemia
H2CO3
Proximal Renal Tubular Acidosis
HCO3-
HCO3-
Impaired (diminished) H+ secretion and HCO3-
HCO3- absorption
regeneration
H+
HCO3-
Distal RTA’s
HCO3-
HCO3-
A. Impaired (diminished) H+
secretion hence diminished HCO3-
H+ regeneration
Metabolic alkalosis
Respiratory acidosis
HCO3-
Increased -
HCO3-
absorption
H+
HCO3-
Evaluating an Elevated Serum HCO3
Evaluating an Elevated Serum HCO3
Evaluating an Elevated Serum HCO3
Treatment of Metabolic Alkalosis
Compensation:
Respiratory alkalosis: Acute resp alkalosis
HCO3 2 mEq/L per 10 mmHg PCO2
Chronic resp acidosis
HCO3 5 mEq/L per 10 mmHg PCO2
Respiratory Acid-Base Disorders
Respiratory Acidosis
• Central - drugs (anesthetics, morphine, sedatives), stroke, infection
• Airway - obstruction, asthma
• Parenchyma - emphysema, pneumoconiosis, bronchitis, adult respiratory
distress syndrome
• Neuromuscular - poliomyelitis, kyphoscoliosis, myasthenia, muscular
dystrophies
• Miscellaneous - obesity, hypoventilation
Compensation:
Respiratory acidosis: Acute respiratory acidosis
HCO3 1 mEq/L per 10 mmHg PCO2
Chronic respiratory acidosis
HCO3 4 mEq/L per 10 mmHg PCO2
Normal Lab Values
The answer:
35-year-old man admitted to the hospital with pneumonia and the following
lab values:
Is the respiratory acidosis compensated for? Yes, the HCO3 should be 36 mEq/L
Thus the HCO3 > the anion gap, this means the HCO3 went down more than the
anion gap went up.
Something made the HCO3 drop further, the two disorders that decrease the HCO3
even further are:
Hyperchloremic metabolic acidosis or compensation for a respiratory alkalosis.
152 104 30
3.6 15 1.0 ABG: 7.42/24/115
Does the patient have an acidosis or alkalosis? Don’t know the pH is normal
The anion gap went up more than the HCO3 went down.
So, what does this mean?
Thus there is something keeping the HCO3 up.
19yo college student was found by roommate on floor.
Diaphoretic and comatose.
BP 150/80, P 155/min and regular, RR 40/min
152 104 30
3.6 15 1.0 ABG: 7.42/24/115
The answer: High anion gap met acidosis with met alkalosis with resp alkalosis