Equilibrio Acido Base

Trastornos ácido-base César Henríquez R4 Medicina Interna I Hospital Clinico San Carlos Madrid, España

[object Object],[object Object],[object Object],Equilibrio Acido-base

Regulación del equilibrio ácido-base ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Ecuación de Henderson-Hasselbalch ,[object Object],= pK α + lg = 6.1 + lg = 6.1 + lg = 7.4 dCO 2 = α × PaCO 2 disolubilidad pK α = 6.1 α = 0.03 [HCO 3 - ]=24mmol/L PaCO 2 =40mmHg [HCO 3 - ] [H 2 CO 3 ] [HCO 3 - ] α · PaCO 2 24 0.03 × 40 20 1

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],1. Tampón sanguineo

Sistema de tampón Bicarbonato (HCO 3 - /H 2 CO 3 ) ,[object Object],[object Object],[object Object],[object Object],CO 2 H 2 O H + + HCO 3 - H 2 CO 3 + pulmón riñón ventilación H + secreción HCO 3 - reabsorción

2. Regulación respiratoria ,[object Object],pH = pK α + lg = pK α + lg [HCO 3 - ] [H 2 CO 3 ] [HCO 3 - ] α · PaCO 2

Regulación de ventilación alveolar ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

3. Regulación renal ,[object Object],pH = pK α + lg = pK α + lg [HCO 3 - ] [H 2 CO 3 ] [HCO 3 - ] α · PaCO 2

Conservación del Bicarbonato ,[object Object],[object Object]

HCO 3 - y H + en el túbulo proximal CA Na + (filtered) (CA)

ATPase + HPO 4 2- H 2 PO 4 - Cl - (filtered) Regeneración del HCO 3 - o secreción de H + en el túbulo distal y colector Urine acidification Urine pH: 4.5-4.8 ～ 8.0

Pruebas de laboratorio ,[object Object],[object Object],[object Object],[object Object],pH = pK α + lg = pK α + lg [HCO 3 - ] [H 2 CO 3 ] [HCO 3 - ] α · PaCO 2

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

2. PaCO 2 (presión parcial del CO 2 en sangre arterial) ,[object Object],[object Object],[object Object],[object Object],[object Object],pH = pK α + lg = pK α + lg PARAMETRO RESPIRATORIO [CO 2 ] dissolved +H 2 O H 2 CO 3 [HCO 3 - ] [H 2 CO 3 ] [HCO 3 - ] α · PaCO 2

3. [HCO 3 - ] ,[object Object],[object Object],[object Object],[object Object],[object Object],PARAMETRO METABOLICO

4. Hiato Aniónico (HA) ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Na + Cl - HCO 3 - AN CN Measured cation Measured anion

Trastornos simples del equilibrio ácido-base

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Clasificación del trastornos simples acido-base [HCO 3 - ] primariamente↓, de 20 a 10 Si [H 2 CO 3 ] secundariamente↓, de 1 a 0.5-> pH norm Si [H 2 CO 3 ] secundariamente ↓, de 1 a 0.8-> pH↓ Parámetro metabólico pH = pK α + lg [HCO 3 - ] [H 2 CO 3 ] = 6.1 + lg [HCO 3 - ] α · PaCO 2 = 6.1+ lg 20 1 =7.4 Parámetro respiratorio

(Ⅰ). Acidosis Metabólica ,[object Object],H 2 CO 3 HCO 3 - 1 10 : = 7.4 H 2 CO 3 HCO 3 - 1 20 : = 7.4

2. Causas primarias ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Exceso de pérdidas de HCO 3 - ,[object Object],[object Object],[object Object],[object Object]

Exceso de producción de ácidos no volátiles ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Exceso de ingesta de ácidos no volátiles ,[object Object],[object Object],[object Object]

Alteración en la excreción renal de ácidos ,[object Object],[object Object],[object Object],Cl - +HPO 4 2- H 2 PO 4 - filter

3. Clasificación de la acidosis metabólica ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

4. Compensación ,[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object],↑ [HCO 3 - ] y [HCO 3 - ] /[H 2 CO 3 ] cerca de 20/1 pH cerca a lo normal

(Ⅱ). Acidosis Respiratoria ,[object Object],H 2 CO 3 HCO 3 - 2 20 : H 2 CO 3 HCO 3 - 1 20 : =7.4 =7.4

2. Causas primarias ,[object Object],[object Object]

(1). Disminución en ventilación alveolar ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

(2). Incremento en la inhalación de CO 2 ,[object Object],[object Object]

3. Clasificación ,[object Object],[object Object],[object Object],[object Object],[object Object]

4. Compensación ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],Carbonic anhydrase ↑ [H 2 CO 3 ] H 2 CO 3 HCO 3 - H 2 O CO 2 Cl - H + H + CO 2 H 2 O H + HCO 3 - + + + + K + HCO 3 - Buffered by intracellular buffer system ICF LEC

(Ⅲ). Alcalosis Metabólica ,[object Object],= 7.4 H 2 CO 3 HCO 3 - 1 20 : = 7.4 HCO 3 - 1 40 : H 2 CO 3

(1). Ganancia excesiva de HCO 3 - ,[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],2. Causas primarias

(2). Pérdida excesiva de H + ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

3. Compensación ,[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],[object Object]

Curva de disociación de Hgb-O2 desviada a la izquierda ,[object Object]

Hipocalcemia ,[object Object],[object Object],[object Object],OH - H + Carpopedal Spasm

(Ⅳ). Alcalosis Respiratoria ,[object Object],= 7.4 0.5 20 : = 7.4 H 2 CO 3 HCO 3 - 1 20 : H 2 CO 3 HCO 3 -

2. Causas Primarias ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

3. Clasificación ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

[object Object],[object Object],H 2 CO 3 H 2 CO 3 [HCO 3 - ] relativo incemento H 2 O CO 2 Cl - H + CO 2 H 2 O H + HCO 3 - + + + + K + HCO 3 - LIC LEC H 2 CO 3 HCO 3 - H + disminución primaria de [H 2 CO 3 ]

[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],Acidosis Metabolica Alcalosis Metabolica Acidosis Respiratoria Alkalosis Respiratoria Acidosis Metabolica Alcalosis Metabolica Acidosis Respiratoria Alkalosis Respiratoria ,[object Object],[object Object]

1. Acidosis metabólica + alcalosis metabólica ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

2. Acidosis metabólica + alcalosis respiratoria ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

3. Acidosis metabólica + acidosis respiratoria ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

4. Alcalosis metabolica + alcalosis respiratoria ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

5. Alcalosis metabólica + acidosis respiratoria ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Sistemática de estudio de los trastornos acido-base

pH ALTO BAJO ACIDOSIS ALCALOSIS METABOLICA RESPIRATORIA METABOLICA RESPIRATORIA HCO3 pCO2 pCO2 HCO3 HCO3 pCO2 pCO2 HCO3 NORMAL TRASTORNO MIXTO TRASTORNO COMPENSADO

Casos clínicos ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Dx ,[object Object],[object Object]

Casos clinicos ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Dx ,[object Object],[object Object],[object Object]

Casos clínicos ,[object Object],[object Object],[object Object],[object Object],[object Object],[object Object],[object Object]

Dx ,[object Object],[object Object],[object Object],[object Object]

Referencias ,[object Object],[object Object]

Equilibrio Acido Base

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Equilibrio Acido Base