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Acid, Base, Electrolytes
Balance and Alterations
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Fluid Compartments
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Fluid Compartments:20 – 40 – 60 Rule
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Fluid Movement
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Water and Electrolyte Balance Input = output Hormones
• Na+ / K+• Renin
• Aldosterone
• ANP
• Reproductive Hormones
• GCC
• Ca++ / Mg++• Calcitonin
• PTH
• H2O• ADH
Anions follows passively• Cl-
• HCO3-
• PO4=
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Water Intake Loss
• Normal
• Abnormal Osmosis Hormonal control Capillary Dynamics
• CHP
• COP
• IHP
• IOP
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Osmosis
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Capillary Dynamics
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Capillary Pressures
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Fluid Shift to third space
Edema Effusion Transudate
• Low cell
• Low protein Exudate
• Types: Nonseptic, Septic
• Contents
• High cell
• High protein
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Edema Causes
• Obstruction• Overload• Inflammation• hypoalbuminemia
Vessels• Angioedema• Lymphedema
Types• Localized
• Pitting• Weeping• Dependent
• Generalized
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Pulmonary Edema
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Pleural Effusion
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Terminology
Isotonic• Hypovolemia
• Hypervolemia
Hypertonic• Hyperosmolar
Hypotonic• Hypo-osmolar
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Functions of electrolytes
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Electrolyte Fluid Composition
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Hormones that regulate Electrolytes
Aldosterone ANP PTH Cacitriol Calcitonin
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Cations
+ charge Location Function Hormonal Controls Alterations
• Hypo-
• Hyper-
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Hyponatremia
< 135 mEq/L Etiology
• Decreased Na+ (diet)
• Increased H20
• Diuretics
• Hiridosis
• Addison’s Disease
• DM
• Diarrhea
• CRF
Clinical Signs• H20 shift to ICF
• Cells swell
• CNS sensitive• V/D
• Lethargy
• Confusion
• Seizures
• Muscle weakness
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Hyponatremia
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Hypernatremia
> 147 mEq/l Etiology
• Excessive intake
• Hyperaldosteronism
• Drowning (salt water)
• H20 loss
• DI
• Renal
• Fever / Sweat
• Burns
• Diarrhea
Clinical Signs• Osmotic shrinkage
• CNS sensitive
• Lethargy
• Irritability
• Hemorrhage
• Seizures
• Coma
• Muscle weakness
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Hypokalemia
< 3.5 mEq/l Etiology
• Decreased intake
• ANS
• V/D
• Diuretic
• Sweating
• Digitalis
• Insulin excess
Clinical Signs• Decreased RMP
• Heart dysrhythmia• Bradycardia
• AV blocks
• PVCs
• Sphincter weakness
• Delayed cardiac repolarization• ST segment depression
• T decreased/inverted
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Hyperkalemia
> 5.5 mEq/l Etiology
• Increased intake
• Insulin deficiency
• Hemolysis
• Hypoxia
• CRF
• Diuretics
• Burns
• Extensive surgeries
Clinical Signs• Inactivate Na+
channels• Muscle weakness
• Muscle paralysis
• paralysis
• Cardiac dysrhythmia• Peaked T wave
• Widened QRS
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Hypocalcemia
< 8.5 mg/dL Etiology
• Nutritional deficiency
• Osteoblastic metastasis
• PTH deficiency
• Hyperphosphatemia
• Increased protein binding
• Chelation therapy
Clinical Signs• NMJ irritability
• Muscle Spasm
• Dyspnea
• Seizures
• Colic
• Tetany
• Cardiac Dysrhythmia
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Hypercalcemia
> 10.5 mg/dL Etiology
• Cancer
• Hyperparathyroidism
• Bone remodeling
• Increased reanal filtering
Clinical Signs• NMJ decreased
• Fatigue
• Lethargy
• Weakness
• Cardiac dysrhythmia
• Bone loss
• Urolithiasis
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Hypomagnesemia
< 1.5 mEq/l Seen with hypokalemia
and hypocalcemia Etiology
• Decreased dietary intake
• GI loss
• Malabsorption
• Maldigestion
• Diarrhea
• CRF
Clinical Signs• Decreased threshold
• Tetany
• Vertigo
• Nystagmus
• Muscle spasms
• hyperreflexia
• Seizures
• Cardiac Dysrhythmia
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Hypermagnesemia
> 2.5 mEq/l Etiology
• Excess intake (antacids)
• Decreased renal excretion
• CRF
• Adrenal insufficiency
Clinical Signs• Increased threshold
for depolarization
• Muscle weakness
• Decreased reflexes
• Hypotension
• Decrease Na+ current
• Cardiac dysrhythmia
• Bradycardia
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Anions Chloride ECF Alterations
• Hypochloremia• < 95 mEq/L
• Accompanies hyponatremia
• Severe vomiting
• Diuretics
• Hyperchloremia• > 103 mEq/L
• Accompanies hypernatremia
Phosphate ICF, stored in bones Alterations
• Hypophosphatemia• < 2.7 mg/dL
• Antacid use
• Prolonged decrease cam cause Rickets/’Osteomalacia
• Hyperphosphatemia• > 4.5 mg/dL
• Renal failure
• Overuse of laxatives
• Hypoxia
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Acid Base Terms Define
• pH• Acid
• Strong• Weak• Volatile : CO2 from CH20 and Fat Metabolism• Nonvolatile: H2SO4, H2PO4 from protein metabolism
• Base• Strong• Weak
• Salt• Buffer
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Acid Sources
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pH Define
• pH = log (1/[H+])• pH = -log [H3O+]
Water Dissociation• H2O + H2O
H3O+ + OH- Scale Blood values
• Venous• Arterial
Abnormal Values• Acidemia• Alkalemia
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pH formula and scale
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Acid Base Chart
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pH of Solutions
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Acid Base Regulation for Balance Systems
• Chemical Buffer Systems• Respiratory System• Renal
Time• Seconds to Minutes• Minutes to Hours• Hours to Days / Weeks
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
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Chemical Buffer Systems
Define 3 types
• Name of System
• Buffer formula or name of chemical
• Location
• Effectiveness [pKa buffer = pH location]
• Why important
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pH changes with/without buffers
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Bicarbonate Chemical Buffer H2CO3, HCO3- Plasma buffer pK = 6.1 Important:
• Can measure components• pCO2 = 40 mmHg• HCO3- = 24 mM
• Can adjust concentration / ratio of components • HCO3- @ kidneys• CO2 @ lungs
• Recalculate pH of buffer system in ECF using Henderson-Hasselbach• pH = 6.1 + log(24 / 0.03x40)
• pH = 6.1 + log (20/1)• pH = 7.4
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Bicarbonate Buffer System
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Phosphate Chemical Buffer
H2PO4-, HPO4= ICF, Urine pK = 6.8 Important
• Intracellular buffer• ICF pH = ~ 6.5 – 6.8
• Renal Tubular Fluids• Urine pH ranges 6.0 – 7.0
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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
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Proteins in acid base
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Hemoglobin
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CO2 transport and RBC buffer
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Respiratory for A/B Balance
Occurs in minutes CO2 only Rate changes
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Respiratory Controls for Acid /Base balance
Volatile Acid: CO2 pH changes in CSF Respiratory Rate
• Pons
• Medulla Oblongata
Chemoreceptors• pCO2
• pO2
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CO2 and pH
Increase CO2• Increase H+
• Decrease pH
Decrease CO2• Decrease H+
• Increase pH
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Renal Control for Long Term Acid / Base Balance
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Renal processes in A/B balance
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Renal Physiology Filtration
• Remove metabolic acids: Ketones, Uric acid
• Filter Base [HCO3-] @ Renal Filtration Membrane
Reabsorption• Base @ PCT• Reverse CO2 equation to
create HCO3- Secretion
• H+ @ PCT, late DCT and Cortical CD
• CO2 equation to create H+ for secretion
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Renal Mechanisms for A/B
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Renal Ion Exchanges
Na+ / K+ antiporter Na+ / H+ antiporter Na+ / HCO3- cotrans H+ / K+ ATPase H+ ATPase Cl- / HCO3-
exchanger
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Renal Buffer Mechanisms
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Normal Acid Base Values
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Respiratory and Renal Balance
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Acid-Base Problems
Acidosis• State of excess H+
Acidemia• Blood pH < 7.35
Alkalosis• State of excess HCO3-
Alkalemia• Blood pH >7.45
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Classifying Respiratory Acid Base Problems (pCO2 changes)
Respiratory Acidosis• Respiratory Rate Decreases
• Any Respiratory Disease
• Obstruction
• Pneumonia
• Gas exchange / transport problems
• Respiratory Membrane
• RBC / Hemoglobin
Respiratory Alkalosis• Respiratory Rate Increases
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Classifying Metabolic Acid Base Balance Problems (H+/ HCO3-) Systems
• Renal • Endocrine• GI• Cardiovascular / Fluid administration
Metabolic Acidosis• Retain Acid• Lose Base
Metabolic Alkalosis• Retain Base• Lose Acid
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Other System diseases in Metabolic Acid/Base Problems
GI • Vomiting
• Diarrhea
• Medications : Antacids Endocrine
• DM
• Hyperaldosteronism Metabolism
• Increase acid production
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Ketones
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Compensation
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Adjustments for Acid/Base Balance
Imbalance• Respiratory Acidosis
• Incr pCO2
• Respiratory Alkalosis• Decr pCO2
• Metabolic Acidosis• Decr HCO3-
• Incr H+
• Metabolic Alkalosis• Incr HCO3-
• Decr H+
Compensation• Increase renal acid
excretion, Incr HCO3-
• Decrease renal acid excretion, decr HCO3-
• Hyperventilate to lower pCO2
• Hypoventilate to increase pCO2
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Summary for A/B Balance
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Questions?
Water and electrolytes