Acid, Base, Electrolytes

Balance and Alterations

Fluid Compartments

Fluid Compartments: 20 40 60 Rule

Fluid Movement

Water and Electrolyte Balance

Input = output Hormones

Anions follows passively

Na+ / K+

Renin Aldosterone ANP Reproductive Hormones GCC Calcitonin PTH ADH

ClHCO3PO4=

Ca++ / Mg++

H2O

Water

Intake Loss

Normal Abnormal

Osmosis Hormonal control Capillary Dynamics

CHP COP IHP IOP

Osmosis

Capillary Dynamics

Capillary Pressures

Fluid Shift to third space

Edema Effusion Transudate

Low cell Low protein Types: Nonseptic, Septic Contents

Exudate

High cell High protein

Edema

Causes

Obstruction Overload Inflammation hypoalbuminemia Angioedema Lymphedema Localized

Vessels

Types

Pitting Weeping Dependent

Generalized

Pulmonary Edema

Pleural Effusion

Terminology

Isotonic

Hypovolemia Hypervolemia Hyperosmolar

Hypertonic
Hypotonic

Hypo-osmolar

Functions of electrolytes

Electrolyte Fluid Composition

Hormones that regulate Electrolytes

Aldosterone ANP PTH Cacitriol Calcitonin

Cations

+ charge Location Function Hormonal Controls Alterations

HypoHyper-

Hyponatremia

< 135 mEq/L Etiology

Clinical Signs

Decreased Na+ (diet) Increased H20 Diuretics Hiridosis Addisons Disease DM Diarrhea CRF

H20 shift to ICF Cells swell CNS sensitive

V/D Lethargy Confusion Seizures

Muscle weakness

Hyponatremia

Hypernatremia

> 147 mEq/l Etiology

Clinical Signs

Excessive intake Hyperaldosteronism Drowning (salt water) H20 loss

Osmotic shrinkage CNS sensitive

DI Renal Fever / Sweat Burns Diarrhea

Lethargy Irritability Hemorrhage Seizures Coma

Muscle weakness

Hypokalemia

< 3.5 mEq/l Etiology

Clinical Signs

Decreased RMP

Decreased intake ANS V/D Diuretic Sweating Digitalis Insulin excess

Heart dysrhythmia Sphincter weakness

Bradycardia AV blocks PVCs

Delayed cardiac repolarization

ST segment depression T decreased/inverted

Hyperkalemia

> 5.5 mEq/l Etiology

Clinical Signs

Increased intake Insulin deficiency Hemolysis Hypoxia CRF Diuretics Burns Extensive surgeries

Inactivate Na+ channels

Muscle weakness Muscle paralysis paralysis Peaked T wave Widened QRS

Cardiac dysrhythmia

Hypocalcemia

< 8.5 mg/dL Etiology

Clinical Signs

NMJ irritability

Nutritional deficiency Osteoblastic metastasis PTH deficiency Hyperphosphatemia Increased protein binding Chelation therapy

Muscle Spasm Dyspnea Seizures Colic Tetany

Cardiac Dysrhythmia

Hypercalcemia

> 10.5 mg/dL Etiology

Clinical Signs

NMJ decreased

Cancer Hyperparathyroidism Bone remodeling Increased reanal filtering

Fatigue Lethargy Weakness Cardiac dysrhythmia

Bone loss Urolithiasis

Hypomagnesemia

< 1.5 mEq/l Seen with hypokalemia and hypocalcemia Etiology

Clinical Signs

Decreased threshold

Decreased dietary intake GI loss

Tetany Vertigo Nystagmus hyperreflexia Seizures

Muscle spasms

Malabsorption Maldigestion Diarrhea

Cardiac Dysrhythmia

CRF

Hypermagnesemia

> 2.5 mEq/l Etiology

Clinical Signs

Excess intake (antacids) Decreased renal excretion

Increased threshold for depolarization

CRF Adrenal insufficiency

Muscle weakness Decreased reflexes Hypotension Cardiac dysrhythmia Bradycardia

Decrease Na+ current

Anions

Chloride ECF Alterations

Phosphate ICF, stored in bones Alterations

Hypochloremia

Hypophosphatemia

< 95 mEq/L Accompanies hyponatremia Severe vomiting Diuretics > 103 mEq/L Accompanies hypernatremia

Hyperchloremia

< 2.7 mg/dL Antacid use Prolonged decrease cam cause Rickets/Osteomalacia > 4.5 mg/dL Renal failure Overuse of laxatives Hypoxia

Hyperphosphatemia

Acid Base Terms

Define

pH Acid

Strong Weak Volatile : CO2 from CH20 and Fat Metabolism Nonvolatile: H2SO4, H2PO4 from protein metabolism Strong Weak

Base

Salt Buffer

Acid Sources

pH

Define

pH = log (1/[H+]) pH = -log [H3O+] H2O + H2O H3O+ + OH-

Water Dissociation Scale Blood values

Venous Arterial Acidemia Alkalemia

Abnormal Values

pH formula and scale

Acid Base Chart

pH of Solutions

Acid Base Regulation for Balance

Systems

Chemical Buffer Systems Respiratory System Renal Seconds to Minutes Minutes to Hours Hours to Days / Weeks

Time

Strength Problems (reference 7.4 as normal average):

+ / - 0.1 changes result in respiratory rate changes + / - 0.2 to 0.3 changes result in CV and Nervous changes + / - 0.4 to 0.5 changes result in death

Chemical Buffer Systems

Define 3 types

Name of System Buffer formula or name of chemical Location Effectiveness [pKa buffer = pH location] Why important

pH changes with/without buffers

Bicarbonate Chemical Buffer

H2CO3, HCO3Plasma buffer pK = 6.1 Important:

Can measure components

pCO2 = 40 mmHg HCO3- = 24 mM HCO3- @ kidneys CO2 @ lungs pH = 6.1 + log(24 / 0.03x40)

Can adjust concentration / ratio of components Recalculate pH of buffer system in ECF using Henderson-Hasselbach

pH = 6.1 + log (20/1) pH = 7.4

Bicarbonate Buffer System

Phosphate Chemical Buffer

H2PO4-, HPO4= ICF, Urine pK = 6.8 Important

Intracellular buffer

Renal Tubular Fluids

ICF pH = ~ 6.5 6.8

Urine pH ranges 6.0 7.0

Protein Chemical Buffer

Proteins

With Histadine: AA contain imidazole ring, pKa = 7.0 R-COOH R-COO- + H+ R-NH2 R-NH3+

ICF (hemoglobin), ECF pK = 7.4 Important

Most numerous chemicals Most powerful chemical buffer

Proteins in acid base

Hemoglobin

CO2 transport and RBC buffer

Respiratory for A/B Balance

Occurs in minutes CO2 only Rate changes

Respiratory Controls for Acid /Base balance

Volatile Acid: CO2 pH changes in CSF Respiratory Rate

Pons Medulla Oblongata

pCO2 pO2

Chemoreceptors

CO2 and pH

Increase CO2

Increase H+

Decrease pH Increase pH

Decrease CO2
Decrease H+

Renal Control for Long Term Acid / Base Balance

Renal processes in A/B balance

Renal Physiology

Filtration

Remove metabolic acids: Ketones, Uric acid Filter Base [HCO3-] @ Renal Filtration Membrane

Reabsorption

Base @ PCT Reverse CO2 equation to create HCO3H+ @ PCT, late DCT and Cortical CD CO2 equation to create H+ for secretion

Secretion

Renal Mechanisms for A/B

Renal Ion Exchanges

Na+ / K+ antiporter Na+ / H+ antiporter Na+ / HCO3- cotrans H+ / K+ ATPase H+ ATPase Cl- / HCO3exchanger

Renal Buffer Mechanisms

Normal Acid Base Values

Respiratory and Renal Balance

Acid-Base Problems

Acidosis

State of excess H+ Blood pH < 7.35 State of excess HCO3Blood pH >7.45

Acidemia

Alkalosis Alkalemia

Classifying Respiratory Acid Base Problems (pCO2 changes)

Respiratory Acidosis

Respiratory Rate Decreases Any Respiratory Disease

Respiratory Membrane RBC / Hemoglobin Respiratory Alkalosis

Obstruction Pneumonia Gas exchange / transport problems

Respiratory Rate Increases

Classifying Metabolic Acid Base Balance Problems (H+/ HCO3-)

Systems

Renal Endocrine GI Cardiovascular / Fluid administration Retain Acid Lose Base Retain Base Lose Acid

Metabolic Acidosis Metabolic Alkalosis

Other System diseases in Metabolic Acid/Base Problems

GI

Vomiting Diarrhea Medications : Antacids DM Hyperaldosteronism

Endocrine

Metabolism

Increase acid production

Ketones

Compensation

Adjustments for Acid/Base Balance

Imbalance

Compensation

Respiratory Acidosis

Incr pCO2 Decr pCO2 Decr HCO3Incr H+ Incr HCO3Decr H+

Increase renal acid excretion, Incr HCO3Decrease renal acid excretion, decr HCO3Hyperventilate to lower pCO2 Hypoventilate to increase pCO2

Respiratory Alkalosis

Metabolic Acidosis

Metabolic Alkalosis

Summary for A/B Balance

Questions?

Water and electrolytes