Cannot excrete enough h to maintain acid base balance

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Cannot excrete enough H+ to maintain acid-base balance Hypokalemia Causes (FYI) Ca2+, multiple myeloma, SLE, sickle-cell dz, renal transplant rejection, toluene ingestion
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Metabolic Acidosis Normal anion gap/hyperchloremic states Distal (Type IV) RTA Hyporeninemic hypoaldosteronism Impaired ammoniagenesis Hypoaldosteronism  hyperkalemia Causes (FYI): Nephropathy due to HIV, diabetes or sickle cell disease
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Metabolic Acidosis Normal anion gap/hyperchloremic states Proximal (type II) RTA Insufficient proximal bicarbonate reabsorption Bicarbonate is lost in urine Leads to Na+ wasting and secondary hyperaldosteronism Hypokalemia Is chronic and non-progressive Causes (FYI): Defects in proximal tubular bicarabonate reabsorption Amyloidosis, multiple myeloma, exposure to lead, mercury or expired tetracycline antibiotics Carbonic anhydrase inhibitors
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Metabolic Acidosis Clinical presentation Chronic metabolic acidosis Relatively asymptomatic Osteomalacia and osteopenia in adults Severe, acute acidosis (pH < 7.2) N/V, loss of appetitie Kussmaul respirations = deep rapid breaths Occurs as body attempts to compensate Vasodilation Flushing, tachycardia, CO  hypotension, organ blood flow & CO, bradycardia Confusion, lethargy, stupor, coma Hyperkalemia, hyperglycemia
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Metabolic Acidosis Respiratory Compensation Mechanism: Hyperventilation  Increased CO2 excretion Occurs immediately
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PQ is a 45 y/o M with the following ABG: pH 7.5, PaCO2 = 47, HCO3- = 36 Na = 146, Cl = 102, HCO3- = 36 What is his acid-base disorder? 1. Metabolic alkalosis, compensated 2. Metabolic alkalosis, not compensated 3. Respiratory alkalosis, compensated 4. Respiratory alkalosis, not compensated
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Compensation of Metabolic Alkalosis PaCO2 (in mmHg) should increase by 0.4-0.6 times the rise in plasma HCO3- (in mEq/L)
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Was the compensation appropriate? 1. Yes 2. No
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Compensation of Metabolic Alkalosis PaCO2 (in mmHg) should increase by 0.4-0.6 times the rise in plasma HCO3- (in mEq/L) 36 mEq/L – 24 mEq/L = 12 mEq/L 12 mEq/L x 0.5 = 6 PaCO2 = 40 + 6 = 46 mmHg
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Is there an elevated anion gap? 1. Yes 2. No
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Metabolic Alkalosis Is pH high or low? Is the primary disturbance with HCO3- or PaCO2?
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Generation of Metabolic Alkalosis Excessive loss of hydrogen ions Vomiting Nasogastric tube suctioning Diuretic use Administration of bicarbonate-rich fluids Bicarbonate, acetate, lactate, citrate Excess mineralocorticoid activity
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Maintenance of Metabolic Alkalosis Quickly corrected in patients with normal renal function Is maintained in patients with renal dysfunction Due to impaired bicarbonate excretion There are 2 mechanisms of maintaining metabolic alkalosis Volume-mediated (NaCl-responsive) Volume-independent (NaCl-resistant)
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Maintenance of Metabolic Alkalosis Volume-mediated (NaCl-responsive) ↓ intravascular volume ↓ kidney function  ↓ bicarbonate excretion
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