酸中毒和碱中毒课件.pptx
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1、酸中毒和碱中毒酸中毒和碱中毒CaseCaseA 22-year-old woman who had been injured in an accident received 6 liters of isotonic saline,The plasma Na 135 mmol/l,K 3.8 mmol/l,Cl 115 mmol/l,and HCO3 18 mmol/l.The blood pH 7.28,and the PaCO2 39 mm Hg.The urinary sodium 65 mmol/l,potassium 15 mmol/l,and chloride 110 mmol/l.
2、The patients serum albumin 2.7 g/dl after the infusion of saline.Her blood pressure was 98/52 mmHg,and her pulse rate was 102 beats/m.She had been healthy before the accident,was receiving no medications,and did not use any illicit drugs.The accident occurred when a speeding car ran through a red li
3、ght,hitting her car on the drivers side.The accident has caused multiple rib fractures,a compound left femoral fracture,a pelvic fracture,and numerous bruises.She is in the emergency department for stabilization of her condition before she can be sent to the operating room for stabilization of her l
4、eg and pelvis.CaseA 22-year-old woman who had been injured in an accident received 6 liters of isotonic saline,The plasma Na 135 mmol/l,K 3.8 mmol/l,Cl 115 mmol/l,and HCO3 18 mmol/l.The blood pH 7.28,and the PaCO2 39 mm Hg.The urinary sodium 65 mmol/l,potassium 15 mmol/l,and chloride 110 mmol/l.The
5、patients serum albumin 2.7 g/dl after the infusion of saline.Her blood pressure was 98/52 mmHg,and her pulse rate was 102 beats/m.She had been healthy before the accident,was receiving no medications,and did not use any illicit drugs.The accident occurred when a speeding car ran through a red light,
6、hitting her car on the drivers side.The accident has caused multiple rib fractures,a compound left femoral fracture,a pelvic fracture,and numerous bruises.She is in the emergency department for stabilization of her condition before she can be sent to the operating room for stabilization of her leg a
7、nd pelvis.什么酸碱紊乱?什么酸碱紊乱?代代谢、呼吸?、呼吸?AG酸中毒、高酸中毒、高氯性性简单简单/复复杂杂性?性?Acid production in the bodyCarbonic acid:the metabolism of carbohydrates and fats(primarily derived from the diet)results in the production of approximately 15,000 mmol of CO2 per day.Non-carbonic acid:Organic:lactate,metabolized by the
8、liver and kidneyInorganic:the metabolism of proteins and other substances results in the generation of noncarbonic acids(50 100 mEq,1mEq/kg).Methionine glucose +urea +SO4(2-)+2 H+Arginine+glucose(or CO2)+urea +H+R-H2PO4 +H2O ROH +0.8 HPO42-/0.2 H2PO4-+1.8 H+The homeostatic response to acid load 1.Ch
9、emical buffering by the extracellular and intracellular buffers.2.Changes in alveolar ventilation to control the PCO2.3.Alterations in renal H+excretion to regulate the plasma HCO3-concentration.Chemical bufferingExtracellular buffersIntracelluar:boneHenderson-Hasselbalch equation(Eq.1)H+HCO3-H2CO3
10、H2O +CO2 PCO2(Eq.2)H+=24 x HCO3-or by the Henderson-Hasselbalch equation HCO3-(Eq.3)pH =6.10 +log 0.03 PCO2 Henderson-Hasselbalch equation(Eq.1)H+HCO3-H2CO3 H2O +CO2 PCO2(Eq.2)H+=24 x HCO3-or by the Henderson-Hasselbalch equation HCO3-(Eq.3)pH =6.10 +log 0.03 PCO2Acidosis:PCO2=1.5 X HCO3+8 Chemical
11、bufferingExtracellular buffersIntracelluar buffer:bone,Ca+release,osteoclast activationThe homeostatic response to acid load 1.Chemical buffering by the extracellular and intracellular buffers.2.Changes in alveolar ventilation to control the PCO2.3.Alterations in renal H+excretion to regulate the pl
12、asma HCO3-concentration.The homeostatic response to acid load 1.Chemical buffering by the extracellular and intracellular buffers.2.Changes in alveolar ventilation to control the PCO2.3.Alterations in renal H+excretion to regulate the plasma HCO3-concentration.RENAL HYDROGEN EXCRETION(1)reabsorption
13、 of the filtered HCO3-(2)excretion of the 50 to 100 meq of H+produced per day1.Formation of titratable acid2.Excretion of NH4+in the urineCollecting tubuleTubular LumenPeritubular capillaryH+H2O2OH-+CO23HCO3-CAH+Cl-ATPaseATPaseH+K+Excretion of H+in a intercalated cellsH+H+Collecting tubuleTubular Lu
14、menPeritubular capillaryH+H2O2OH-+CO23HCO3-CAH+HPO42-H2PO4Cl-ATPaseATPaseH+K+Excretion of H+in a intercalated cellsCollecting tubuleTubular LumenPeritubular capillaryH+H2O2OH-+CO23HCO3-CAH+NH3NH4+Cl-H+-ATPaseNH3Excretion of H+in a intercalated cellsCan be stimulated by low KAcid-base balanceThe kidn
15、eys must excrete the 50 to 100 meq of noncarbonic acid generated each day.The daily acid load is excreted as NH4+and H2(PO4).The daily acid load also cannot be excreted unless virtually all of the filtered HCO3-has been reabsorbed,because HCO3-loss in the urine is equivalent to adding H+ions to the
16、body.Regulation:The extracellular pH the effective circulating volume,aldosterone,and the plasma K+concentrationCan be independent of serum pHMetabolic acidosisInflux of organic acid into plasma(high anion gap)KetoacidosisLactic acidosisPoisoningAccumulation of endogenous acids(high anion gap)Renal
17、failureExternal losses of bicarbonate(normal anion gap;hyperchloremic).GI lossRenal lossAnion GapAG=Na+-Cl-HCO3-=122albumin:negative charged.Low serum albumin will reduce AG.Paraprotein(Ig or light chains,MM):positive charged.Presence of large amount of paraprotein reduces AG.Anion GapCauses of a Hi
18、gh Anion Gap Metabolic AcidosisTypes and Causes of Lactic AcidosisTypes and Causes of Lactic AcidosisRenal failureWith mild to moderate reductions in GFR,the acidosis reflects decreased ammoniagenesis and is therefore hyperchloremic.As kidney failure worsens,the kidney loses its ability to excrete v
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