Acid-Base Balance. OM Nursing Academy. Anil Kantiwal Gudha. Introduction :- Acid :- Base :- ph ( Power/Potencial of Hydrogen ) :-

Transcription

1 Acid-Base Balance OM Nursing Academy Anil Kantiwal Gudha Introduction :- Body Homeostasis लए Acid-Base Balance ब त मह वप ण और Body क लगभग सभ Physiological Activities, Acid-Base Status पर नभर करत Acid :- An Acid Contain Hydrogen ion ( H + ). Acid यह Hydrogen ion ( H + ) क Donate कर ( Proton Donor ) Acid क ph 7 कम ह त Taste - Acid व द Sour ह Eg. - HCL ( Hydrochloric acid ) Base :- Base contain Hydroxide ion ( OH - ) Base व ह ज Hydrogen ion ( H + ) क हण कर ( Proton Acceptor ) Base क ph 7 अ धक ह त Taste - Base व द कड़ ह Eg. - NaOH ( Sodium Hydroxide ) ph ( Power/Potencial of Hydrogen ) :- ph Scale - Invented by Dr. Soren Sorensen Acidic :- अगर ph Scale ph 7 कम ह रह त H + क Concentration बढ़ग Alkaline :-य द ph Scale ph 7 य द बढ़ रह त H + क Concentration घ ग ph Increase = H + Concentration Decrease ph Decrease = H + Concentration Increase

2 Acid Base Balance is maintain by following Mechanisms :- 1. Chemical Regulation 2. Physiological Regulation 3. Potassium Exchange 1. Chemical Regulation :- यह Buffers दव र कय ज व ल immediate regulation ज Acid-Base imbalance क छ ह seconds maintain कर त Blood Buffer System :- 1. Buffer एक ऐस substance ह त ज Acid-Base Balance क maintain कर लए Hydrogen ion ( H + ) क Absorb और release कर सकत 2. Body Fluid have four types of Buffer System. 1) Carbonic acid & Bicarbonate 2) Phosphate Buffer 3) Plasma Protein - Albumin 4) Hemoglobin 1. Carbonic acid & Bicarbonate :- CO2 + H2O H2CO3. H + + HCO3 Acidosis ( Increase H + Concentration ) H + + HCO3 H2CO3 Alkalosis ( Decrease H + Concentration ) H2CO3 H + + HCO3 - The System maintains a ph of 7.4 with a ratio of 20 parts Bicarbonate (HCO3 - ) to 1 part Carbonic acid ( H2CO3 ).

3 Bicarbonate (HCO3 - ) : Carbonic acid ( H2CO3 ) 20 : 1 24 meq/l : 1.2 meq/l Lungs, Carbonic acid क Concentration क control करत ( By CO2 Excreation ) Lungs Excreat meq/day Volatile Acid in form of Carbonic acid as CO2. Kidney, Bicarbonate क concentration क control करत Kidney Excreat 50 meq/day of NonVolatile acids. 2. Phosphate Buffer System :- Phosphate Buffer System यह cells एव Body fluid उप थत रहत तथ म यत Kidneys active ह त Acidosis :- ( Increase H + Concentration ) H + + HPO4 2- H2PO4 - ( Dihydrogen Phosphate ) जब Blood ह इ जन आयन क स य बढ़ ज त ( ph घटत ), तब ह इ जन आयन ( H + ) फ फट आयन क व क र कर त क Blood ह इ जन और ह इ स इड आयन क concentration ब च स त लन बन ए रख ज स Alkalosis :- ( Decrease H + Concentration ) H2PO4 - H + + HPO4 - ( Monohydrogen Phosphate ). जब Blood Hydrogen ions क स य कम ह त ( ph बढ़त ) तब Blood Hydrogen ions क बढ़ लए Dihydrogen Phosphate ions ह इ जन ions क release कर 3. Plasma Protein System ( Albumin ) :- Plasma Protein Hydrogen ion ( H + ) क attract और release कर क ability प य ज त Most important intracellular buffer, Protein are extremely abundant in the Cell.

4 4. Hemoglobin System :- In Peripheral Tissue CO2 यह RBC diffuse ह कर Carbonic acid बन त, Carbonic Acid यह H + तथ Bicarbonate (HCO3) टट ज त, Hydrogen Ion ( H + ) ह म ल बन स थ ज ड़ ज त एव Bicarbonate ( HCO3 ) Chloride ion स थ आपस Exchange ह इ Chloride Shift / Hamburger phenomena न म भ ज न ज त RBC In lungs Reverse Chloride shift take place ( य ह Hemoglobin CO2 क जगह O2 ज ड़त तथ CO2 क release करत Chloride Shift Blood O2 Level response Chloride क शक ओ अ दर और ब हर क ओर ज य क एक RBC जत chloride ions अ दर आ उत Bicarbonate ions RBC ब हर च ज और जत Bicarbonate ions RBC अ दर आ उत ह chloride ions RBC ब हर च ज

5 2. Physiologial regulation :A. Respiratory Mechanism :- ( in Lungs ) It takes few Minnut to balance. In Acidosis - Respiratory rate and depth increased. In Alkalosis - Respiratory rate and depth Decreased. B. Renal Mechanism :- ( in Kidney ) It takes few hours to several days to balance. In Acidosis - the ph is decrease and Excess Hydrogen ions secreted into tubules & combine with buffer for recreation in Urine. In Alkalosis - the ph is increase and Excess Bicarbonate Secreated into tubules & combined with Sodium & Excreted in Urine. 3. Potassium Exchange :Normal Conditions In Acidosis In Alkalosis Hyperkelemia Hypokalemia In Acidosis - Acidosis ECF Hydrogen ion क म बढ़ ज त तब Hydrogen ions ECF (Intra cellular fluid ) ज लग, इस फल व प ICF क electrically neutral बन रख Potassium ions cell ब हर आ ज और Hyperkelemia क condition उ प न ह ज त ICf लए In Alkalosis - Alkalosis क condition ECF क त लन ICF य द Hydrogen ions उप थत ह, ICF य द H ह क रण H ICF ECF ज लग, ICF क electrically क neutral बन रख लए Potassium ions, ECF ICF move कर लग और Hypokelemia क condition उ प न ह ज त + य द कर + क Trick

6 Acid Base Imbalance Introduction :- Acid base Imbalance is an abnormality of human body's normal balance of acids and Base that causes plasma ph to deviate out of normal range ( 7.35 to 7.45 ). Classification :- Acid-Base Imbalance Acidosis Alkalosis Respiratory Acidosis Metabolic Acidosis Respiratory Alkalosis Metabolic Alkalosis 1. Respiratory Acidosis :- Respiratory Acidosis Alveolar Hypoventilation क रण Blood H + ions क Concentration बढ़ ज त ph = Decrease ( Below 7.35 ) H + Concentration = Increase PCO2 Level = increase ( more than 45 mmhg )

7 Causes :- Respiratory Acidosis is caused by Primarily defects in the function of the lungs or Changes in normal Respiratory pattern. A. Respiratory Disease :- Asthma COPD Atelectasis Bronchiectasis, Bronchitis Pulmonary Edema, Pulmonary emboli Pneumonia Emphysema B. Respiratory Centre Depress :- ( Medulla Oblongata ) Brain trauma Brain Tumour C. CNS Depressant :- Sedatives Narcotics Anesthesia Alcohol Clinical Manifestation :- Hypoventilation Hyperkelemia Drowsiness, Dizziness, Headache, Coma Seizures Ventricular fibrillation Management :- O2 Therapy Semi-fowler's position Suctioning Increase Deep breath and Cough Endotracheal tube / Mechanical Ventilation

8 2. Respiratory Alkalosis :- Alveolar Hyperventilation क रण Blood H + ions क Concentration कम ह ज त ph = Increase ( Above 7.45 ) H + Concentration = Decrease PCO2 Level = Decrease ( Below 35 mmhg ) Causes :- Any condition that Causes Over Stimulation of Respiration. Hyperventilation Hypoxia ( Hypoxia Stimulate Respiratory centre Brain stem, which causes an increase in the Respiratory rate in order to increase O2, this cause Hyperventilation. Hysteria Over Ventilation by Mechanical Ventilator Pain Pregnancy Fever Psychological and Emotional Condition. Clinical Manifestation :- Initially Hyperventilation causes Tachypnea. Hypokalemia Hypocalcemia ( tetany ) Lethargy, Confusion, Tachycardia Convulsions Nausea, Vomiting, Epigastric Pain Management :- Encourage appropriate Breathing Pattern. Voluntary holding the Breathing. Provide CO2 Breaths ( Rebreathing into paper bag ) Provide care for Ventilator patient. Injection Calcium gluconate for tetany. CO2 Breathing with paper bag

9 3. Metabolic Acidosis :- Increase H + ion caused by abnormal Metabolic process. ph = Decrease ( Below 7.35 ) H + Concentration = Increase HCO3 Level = Decrease ( less than 22 meq/liter ) Causes :- Renal failure Diabetes mellitus / Diabetic Ketoacidosis ( DKA ). Severe Diarrhoea Increase lactic Acid. Ileostomy Malnutrition & Starvation Excessive ingestion of Acetylsalicylic Acids [ Aspirin ]. High fat Diet. Clinical Manifestation :- Kussmaul's Respiration Hyperkelemia Drowsiness, confusion Headache, coma Dysrhythmia, warm flush skin Nausea & Vomiting, Diarrhoea Management :- Give Insulin as Prescribed in DM & treat underlined causes of Acidosis. 4. Metabolic Alkalosis :- Deficit of Carbonic Acid and a Decrease in Hydrogen ion concentration. ph = Decrease ( Above 7.45 ) H + Concentration = Decrease HCO3 Level = Decrease ( more than 27 meq/liter ) Causes :- Massive Blood Transfusion Excessive Vomiting

10 GI Suctioning Antacid Uses Diuretic Hyperaldosteronism ( retention of Na + Infusion of excess Soda Bicarbonate. Clinical Manifestation :- Hypoventilation Hypokalemia, Hypocalcemia Tremors, Tetany, Muscle cramp Seizures Drowsiness Tachycardia, Dysrhythmia Management :- Treat underlined causes of Acidosis. Clinical Evaluation of Disturbance in Acid Base Status :- Anion Gap :- Anion gap यह acid base status आ Disturbance क Evaluate कर लए क म ( Mostly Anion gap is Used for Evaluation of Metabolic Acidosis ). Anion gap routine clinical investigation द र न छ ह Cations और Anions क measure कर, स म यत measured cation स डयम ह त तथ unmeasured cations प शयम, क शयम और न शयम, इस क र measured Anions ल र इड ( cl - ) व ब इक ब ट ( HCO3 - ) ह तथ Unmeasured anions फ फट, स फट, ट स ( ए य मन ) व अ य anions ज lactate. Unmeasured anions और Unmeasured Cations क concentrations ब च अ तर क Anion Gap कह Anion Gap Calculation :- Anion gap = [Na + ] - [ cl - ] - [ HCO3 - ] = meq/liter = 12 meq/liter Normal Anion gap is 8-16 meq/liter

11 ABG Analysis ( Arterial Blood Gas Analysis ) :- ABG Analysis दव र Arterial Blood उप थत O2 एव CO2 ग स क म क measure कर लए कय ज त इस lungs एव Kidney क working ability क भ evaluate कर सक Purpose :- Acid Base imbalance क Diagnose कर त Allen's Test :- Allen's Test यह ABG Analysis कर लए कर ( By taking Blood sample from Artery ) Site - the most common site for Arterial puncture is Radial Artery at the wrist. Use Pre-Heparinized ABG Syringe - Syringe should be flushed with 0.5 ml of 1:1000 Heparin solution and emptied. Procedure :- Pressure on Radial Artery and Ulnar Artery Ask the Patient to clench Fist at Several times Remove Pressure from Ulnar Artery Pinkness Return within 6 Second Withdraw sample from Radial Artery Pinkness not Return Do not sample from Radial Artery ABG Syringe क Sample त रत ब द Cold chain क सह यत Lab ज Capillary Refill time = 2-3 Seconds Capillary Refill time is check by Pinch finger pad and Nail bud.

12 ABG Report Normal ABG Value :- ph PCO mmhg HCO meq/l Acid Base Imbalance indicator Respiratory function Indicator Metabolic function indicator PO mm Hg SaO % In Respiratory Condition :- ABG Respiratory Condition - CO2 Level नध रत करत Normal PCO2 level is : mmhg अगर Blood क ph बढ़ग त PCO2 घ ग, अगर Blood क ph घ ग त PCO2 बढ़ग In Metabolic Condition :- ABG Metabolic condition, HCO3 - Bicarbonate level नध रत कर Normal Bicarbonate level is : meq/l अगर Blood क ph level घट आ त HCO3 - level भ घट आ म ग, अगर Blood क ph level बढ़ आ त HCO3 - level भ बढ़ आ म ग Respiratory Acidosis :- ph = Decrease ( Below 7.35 ) PCO2 Level = increase ( more than 45 mmhg )

13 Types of Respiratory Acidosis :- ( According to Compensation ) 1. Respiratory Acidosis ( Uncompensated ) :- Eg.- ph- 7.33, PCO2-48 mmhg, HCO meq/l ph Decrease Acidosis PCO2-48 mmhg Increase Respiratory HCO3 - = 24 meq/l Normal ABG Report Result is :- Respiratory Acidosis ( Uncompensated ) 2. Compensated Respiratory Acidosis :- Compensated Respiratory Acidosis ph normal ह ( ), PaCO2 स म य बढ़ आ ह तथ इस स थ HCO3 - भ बढ़ आ ह त, इस condition क Compensated Respiratory Acidosis कह Eg. - ph- 7.35, PCO2-48 mmhg, HCO meq/l ph ph normal (With lower level ) Acidosis PCO2-48 mmhg Increase Respiratory HCO3 - = 29 meq/l Increase ABG Report Result is :- Respiratory Acidosis ( Compensated ) 3. Partially Compensated Respiratory Acidosis :- Partially Compensated Respiratory Acidosis ph abnormal ( Below 7.35 ), PaCO2 स म य बढ़ आ ह तथ इस स थ HCO3 - भ बढ़ आ ह त, इस condition क Partially Compensated Respiratory Acidosis कह ( इस त न Value [ ph, PaCO2, HCO3 - ] abnormal ह म ग ) Eg. - ph- 7.32, PCO2-52 mmhg, HCO meq/l ph Decrease Acidosis PCO2-52 mmhg Increase Respiratory HCO3 - = 32 meq/l Increase

14 Respiratory Alkalosis :- ph = increase ( more than 7.45 ) PCO2 Level = Decrease ( Below 35 mmhg ) Types of Respiratory Alkalosis :- ( According to Compensation ) 1. Respiratory Alkalosis ( Uncompensated ) :- Eg.- ph- 7.48, PCO2-32 mmhg, HCO meq/l ph increase Alkalosis PCO2-32 mmhg Decrease Respiratory HCO3 - = 23 meq/l Normal ABG Report Result is :- Respiratory Alkalosis ( Uncompensated ) 2. Compensated Respiratory Alkalosis :- Compensated Respiratory Alkalosis ph normal ह ( ), PaCO2 स म य घट आ ह तथ इस स थ HCO3 - भ घट आ ह त, इस condition क Compensated Respiratory Alkalosis कह Eg. - ph- 7.45, PCO2-32 mmhg, HCO meq/l ph ph normal (With Upper level ) Alkalosis PCO2-32 mmhg Decrease Respiratory HCO3 - = 19 meq/l Decrease ABG Report Result is :- Respiratory Alkalosis ( Compensated ) 3. Partially Compensated Respiratory Alkalosis :- Partially Compensated Respiratory Alkalosis ph abnormal ( Above 7.45 ), PaCO2 स म य घट आ ह तथ इस स थ HCO3 - भ घट आ ह त, इस condition क Partially Compensated Respiratory Alkalosis कह ( इस त न Value [ ph, PaCO2, HCO3 - ] abnormal ह म ग ) Eg. - ph- 7.47, PCO2-31 mmhg, HCO meq/l

15 ph Increase Alkalosis PCO2 = 31 mmhg Decrease Respiratory HCO3 - = 20 meq/l Decrease ABG Report Result is :- Respiratory Alkalosis ( Partially Compensated ) Metabolic Acidosis :- ph = Decrease ( Below 7.35 ) HCO3 Level = Decrease ( less than 22 meq/liter ) Types of Metabolic Acidosis :- ( According to Compensation ) 1. Metabolic Acidosis ( Uncompensated ) :- Eg.- ph- 7.30, PCO2-40 mmhg, HCO meq/l ph Decrease Acidosis PCO2-40 mmhg Normal HCO3 - = 18 meq/l Decrease Metabolic ABG Report Result is :- Metabolic Acidosis ( Uncompensated ) 2. Compensated Metabolic Acidosis :- Compensated Metabolic Acidosis ph normal ह ( ), PaCO2 स म य घट आ ह तथ इस स थ HCO3 - भ घट आ ह त, इस condition क Compensated Metabolic Acidosis कह Eg. - ph- 7.35, PCO2-30 mmhg, HCO meq/l ph ph normal (With lower level ) Acidosis PCO2-30 mmhg Decrease HCO3 - = 18 meq/l Decrease Metabolic ABG Report Result is :- Metabolic Acidosis ( Compensated )

16 3. Partially Compensated Metabolic Acidosis :- Partially Compensated Metabolic Acidosis ph abnormal ( Below 7.35 ), PaCO2 स म य घट आ ह तथ इस स थ HCO3 - भ घट आ ह त, इस condition क Partially Compensated Metabolic Acidosis कह ( इस त न Value [ ph, PaCO2, HCO3 - ] abnormal ह म ग ) Eg. - ph- 7.33, PCO2-33 mmhg, HCO meq/l ph Decrease Acidosis PCO2-33 mmhg Decrease HCO3 - = 18 meq/l Decrease Metabolic ABG Report Result is :- Metabolic Acidosis ( Partially Compensated ). Metabolic Alkalosis :- ph = increase ( Above 7.45 ) HCO3 Level = increase ( more than 27 meq/liter ) Types of Metabolic Alkalosis :- ( According to Compensation ) 1. Metabolic Alkalosis ( Uncompensated ) :- Eg.- ph- 7.48, PCO2-42 mmhg, HCO meq/l ph Increase Alkalosis PCO2-42 mmhg Normal HCO3 - = 31 meq/l Increase Metabolic ABG Report Result is :- Metabolic alkalosis ( Uncompensated ) 2. Compensated Metabolic Alkalosis :- Compensated Metabolic Alkalosis ph normal ह ( ), PaCO2 स म य बढ़ आ ह तथ इस स थ HCO3 - भ बढ़ आ ह त, इस condition क Compensated Metabolic Alkalosis कह Eg. - ph- 7.45, PCO2-49 mmhg, HCO meq/l

17 ph ph normal (With Upper level ) Alkalosis PCO2-49 mmhg Increase HCO3 - = 31 meq/l Increase Metabolic ABG Report Result is :- Metabolic Alkalosis ( Compensated ) 3. Partially Compensated Metabolic Alkalosis :- Partially Compensated Metabolic Alkalosis ph abnormal ( Above 7.45 ), PaCO2 स म य बढ़ आ ह तथ इस स थ HCO3 - भ बढ़ आ ह त, इस condition क Partially Compensated Metabolic Alkalosis कह ( इस त न Value [ ph, PaCO2, HCO3 - ] abnormal ह म ग ) Eg. - ph- 7.47, PCO2-47 mmhg, HCO meq/l ph Increase Alkalosis PCO2-47 mmhg Increase HCO3 - = 31 meq/l Increase Metabolic ABG Report Result is :- Metabolic Alkalosis ( Partially Compensated ) Summary Chart (Acid Base Imbalance )

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