ACID – BASE BALANCE

1. ACID – BASE BALANCE Prof.DR. Dr. Rifki Muslim, SpB,SpU

2. Normal blood pH : 7,35 – 7,45 • Acid-base regulation by kidney  4 methodes : • Carbonic anhydrase mechanism Filtrate Tubular cell Blood HCO3- H+ H2CO3 HCO3- CO2 H2O CO2 + H2O ↓ c.a H2CO3 H+ HCO3-

3. `2. Sodium-Potassium exchange mechanism Filtrate Tubular cell Blood HCO3- K+ H+ Na+ H2CO3 H+ HCO3- K+ Na+

4. 3. Secretion of Amonia mechanism Filtrate Tubular cell Blood Cl- HCO3- H+ + NH3 NH4Cl H2CO3 H+ HCO3- NH3 Amino acid glutamin

5. 4. Hydrogen Sodium Phosphat System Filtrate Tubular cell Blood Na+ HPO4 HCO3- NaH2PO4 H2CO3 H+ HCO3-

6. Fluid Balance Filtration per day : • Water 180 lt • NaCl 1500 gr • NaHCO3 1500 gr > 99% rearbsopsi • Glucouse 250 gr Fluid regulation depend on : • Water intake • Water loss  renal or extra renal • ADH

7. Distribution of water in the body ♂ 50 % of total body mass ♀ 60 % of total body mass 1/3 ICF (intra cellular fluid) 2/3 ECF (extra cellular fluid) ECF  25 % plasma  75 % lymph fluid

8. Balance water intake ↓ water intake ↑ or diuretic ↓ ↓ osmoreceptor osmoreceptor ↓ ↓ hypothalamus hypothalamus ↓ ↓ ADH ↑ ADH ↓ ↓ ↓ urine ↓ urine ↑

9. Electrolyte Imbalance • Hiponatremia - blood level < 135 mEq/L - most often - causes e.q : - hysteric polydipsy - renal failure - cirrhosis - nephrotic syndrome - vomite & diarrhae - water intoxication

10. Clinical finding • Nausea & vomite • Headache • Convulsion • Unconsciusness  coma • Stop breathing  dead Therapy : - IV NaCl Hypertonic - causal

11. 2. Hypernatremia Etilogy : - sodium intake >> - dehydration - renal water loss Clinical finding : - irritable - delier - hyperreflexia - coma

12. Therapy : • Stop sodium intake • More water intake • Causal

13. 3. Hyperkalemia Blood level > 5 mEq/L Causes : - hard physical activity - tissue necrotic - high intake - insuline deficiency - renal failure - drug intoxication (digitalis, fluoride, cyclosporin, heparin, coteimoxazol, ß adrenergic agonist)

14. Clinical findings : • Early stadium : none • Late stadium : - flaccid palsy - short breathing - anxiety - weak reaction - palpitation

15. ECG : - tall T - ST depressed - bradycardy - prolong : PR + QRS - aritmia  cardiac arrest Tx : - stop kalium intake (e.q. fruit) - IV Ca-gluconat/Ca-chloride/insuline - sodium bicarbonat - resonim (kalitake) - furosemid - hemodialysa - PD

16. 4. Hypokalemia Blood level < 2,5 mEq/L Causes : - low intake - vomite & diarrhae - renal tubular acidosis (RTA) - drugs (diuretic, theophyline, insuline, peniccilin, aminoglycoside, cysplatin, amphotericin B)

17. Clinical findings : - muscle weakness, spasm, paralytic - paralytic ileus - coronary spasm - depressed T wave & ST segmen Tx : - more K intake (oral/IV) - causal

18. 5. Calcium imbalance Urine calcium ↑ : - metabolic acidosis - growth hormon - thyroid hormon - drugs (e.g osmotic diuretic, vasodilatator, thyrocalcitonin, mineralocorticoid)

19. Urine calcium ↓ : - metabolic alkalosis - parathyroid hormon - drugs (e.g. thiazide, vit D, phospat)

20. 5.1. Hypocalcemia - vit D deficiency, hypoparathyroidism, hypophosphatemia - acute pancreatitis - renal failure - post op gastrectomy or by pass - malignancy Tx : more intake (oral/IV)

21. 5.2. Hypercalcemia Causes : - hyperparathyroidism - malignancy - vit D / vit A intoxication - hyperthyroidism - milk, alkaly syndrome

22. 6.1. Hypophosphatemia Causes : - antacid - burn - low intake - ketoacidosis - alkoholisme Clinical findings : - damage of white & red cell - thrombocitopenia - CNS disorders (weakness, parasthesia, convulsion, coma)

23. 6.2. Hyperphosphatemia • Too much intake • Renal failure • Cytostatica 7.1. Hypomagnesemia Causes : - low intake - post resection of gut, gaster & fistula biliaris - kwarshiokor - diureticum, etc.

24. Symptom : - disorders of muscle & nerve (weakness, tremor, etc) - delier, psychotic Tx : more intake 7.2. Hypermagnesemia Causes : renal failure Symptom : speech disorders, plegic, dyspneu Tx : hemodialysis