Acid-base metabolism

Prof. MAMUKA CHKHAIDZE Course n°: 3 Sub-category: (3.1.4.) Date: (12-04-2014) Language: Georgian City: Tbilisi Country: Republic of Georgia Weight: kb Related text: no

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mJava-tutovani metabolizmi

prof. mamuka CxaiZe

11-13.04.2014

Tbilisi

III kursi

mJava-tutovani metabolizmi

adamianis mier:

• 15.000 mmol naxSirorJangi gamomuSavdeba yovedRiurad, romelic uerTdeba ra wyals warmoqmnis naxSirmJavas HH2CO3

• metaboluri reaqciebis Sedegad mravali aTasi mmoli organuli mJava gamoiyofa (rZe mJava, limonmJava da a.S), romlebic garadaiqmnebian naxSirwylebad, wylad da CO2.

• daaxloebiT 50 - 100 meq. e.w. metaboluri mJavebi gamomuSavdeba yoveldRiurad (ZiriTadad gogirdis Semcveli aminomJavebisgan, romlebic sakvebiT miiReba)

mJava-tutovani metabolizmi

rogorc xedavT, adamiani yoveldRiurad gamoimuSavebs uamrav mJavas, romelic unda amoisunTqos, gamoyos, daSalos neitralur molekulebamde, an unda gaaneitralos buferebiT, rom ar ganviTardes fataluri acidemia!

adamiani yoveldRe dgas mJavebiT “dabombvis” saSiSroebis winaSe!

magram

organizmi axerxebs mJava-tutovani wonaworobis dacvas: filtvebis mier CO2-is gamodevniT,

organuli mJavebis metaboluri utilizaciiT

da

Tirkmlis mier metaboluri (araxsnadi) mJavebis eqskreciiT

mJava-tutovani metabolizmi

mJava-tutovani metabolizmi

mJava tutovani wonasworoba fasdeba Semdegi

parametrebis gazomviT sisxlSi: gaxsnili CO2 + H2O ↔ H2CO3 ↔ HCO3- + H+ sisxlis airebis analizis dros izomeba: pH da CO2 ,

xolo HCO3- iTvleba …...

mJava-tutovani metabolizmi

Henderson-Hasselbalch pH = 6.10 + log ([HCO3-] ÷ [0.03 x PCO2])

sadac pH tolia (-log [H+]); 6.10 Ka –s uaryofiTi log (-log Ka), disociaciis konstantaa am reaqciaSi; 0.03 CO2-is xsnadobis koeficientia sisxlSi; xolo PCO2naxSirorJangis parcialuri wnevaa sisxlSi.

advili warmodgenisTvis gavamartivoT: HCO3- pH ~ --------- PaCO2

pH ukuproporciul kavSirSia [H+]; pH –is cvlileba 1.00 –iT warmoadgens [H+] -is 10-jer

cvlilebas

pH [H+] nanomol/L 7.80 16 7.70 20 7.60 26 7.50 32 7.40 40 7.30 50 7.20 63 7.10 80 7.00 100 6.90 125 6.80 160

Kassirer-Bleich equation: [H+] = 24 × PCO2 / [HCO3-]

mJava-tutovani metabolizmi

rodesac H2CO3 izomeba venur sisxlSi, is rogorc wesi izomeba pirdapir, rogorc totaluri CO2 (ion sensitiuri eleqtrodebiT),

es venur sisxlSi pirdapir gazomili “totaluri CO2” zogadad 2 meq/l –iT metia vidre imavdroulad aRebuli arteriuli sisxlis HCO3 _

normebi

arteriuli:

pH – 7.36 – 7.44 (SeiZleba SegxvdeT 7.35-7.45)

HCO3¯ 22-27 (26) meq/l PaCO2 – 36-44 mmHg c.venuri: pH – 7.31-7.39 HCO3¯ 22-27 (26) meq/l PaCO2 – 41- 49 mmHg perif. venuri ar gamoxatavs organizmis

homeostazis mdgomareobas zustad da araakuratulia!

terminologia

acidemia pH < 7.36 alkalemia pH > 7.44 acidozi, procesi romelic amcirebs eqstracelularuli siTxis pH-s(H+ ) (Tu kompensirebuli ar iqneba).

alkalozi, procesi romelic zrdis eqstracelularuli siTxis pH-s(H+ ) (Tu kompensirebuli ar iqneba).

terminologia acidozi:

metaboluri - HCO3- respiratoruli - PaCO2

alkalozi:

metaboluri - HCO3- respiratoruli - PaCO2

alkalozi -mizezebi

• respiratoruli alkalozis mizezebi: zogadad nebismieri etiologiis hiperventilacia (hipoqsemia, stresze pasuxi,agzneba, cxeleba, sefsisi, da a.S.)

• metaboluri alkalozis mizezebi: wyalbadis ionebis gasrtointestinuri kargva (Rebineba, ng-zondidan “evakuacia”), Tirkmlis mier wyalbadis ionebis kargva (mineralokortikoidebis pirveladi siWarbe, maryuJovani da Tiaziduri diruetikebi – “kontraqciuli” alkalozi, posthiperkapniuri alkalozi, Tandayolili Bartter Gitelman sindromi, da sxva), hipokalemia, tuteebis miReba da a.S

acidozi - mizezebi

• respiratoruli acidozis mizezebi:

VCO2 x 0.863 PaCO2 = -------------------

VA sadac VCO2 = CO2 produqcia

VA = VE – VD – alveoluri anu aqtualuri wuTventilacia

VE = wuT(totaluri)ventilacia (= resp. rate x tidal volume) VD = mkvdari sivrcis ventilacia (= resp. rate x mkv.siv. moculoba)

0.863 koeficienti romelsac gadahyavs VCO2 da VA mm Hg -Si

maSasadame, resp. acidozis erTaderTi globaluri mizezia: alveoluri ventilaciis

araadeqvaturoba!!!!!

• respiratoruli acidozis mizezebi (gagrZeleba):

am globaluri mizezis gamomwvevi ori mizezi SeiZleba iyos (cal-calke an orive erTad), xolo am ori mizezis gamowvevi - uamravi qvemizezebi:

VA = VE – VD araadeqvaturi VE - cns daavadebiT gamowveuli, an

iatrogenuli (sedativebi, opiatebi da a.S) centraluri hipoventilacia, periferiuli nervuli, nerv-kunTovani an kunTovani daavadebebiT (myasthenia gravis, polyneuropathy, Guillen Barre, polyneuritis) gamowveuli sasunTqi kunTebis da diafragmis sisuste. (es yvelaferi amcirebs sasunTqQ moculobas an/da sunTqvis sixSires)

araadeqvaturi VD – filtvebis mZime restriqciuli (pnevmonia, plevriti, ateleqtazi, pnevmoToraqsi da a.S.), an obstruqciuli (qofd, asTma, emfizema, da a.S)

acidozi - mizezebi

metaboluri acidozis mizezebi

met. acidozis mizezi SeiZleba iyos: mJavis koncentraciis gazrda, bikarbonatebis ionebis kargva, Tirkmlis mier met. mJavebis (nonvolatile metabolic acid) eqskreciis Semcireba, diluciuri acidozi.

mJavis koncentraciis gazrda, wyalbadis ionebis koncentracia imatebs, -laqtat acidozi, ketoacidozi (diabeturi, alkoholuri da sxva), intoqsikaciebi (aspirini, acetaminofeni, meTanoli da sxva)

metaboluri acidozis mizezebi

- bikarbonatebis ionebis kargva (diarea, Tirkmlis ukmarisoba – 2 tipis tubularuli acidozi, ureTris implantacia sigmoidur nawlavSi.

- Tirkmlis mier met. mJavebis (nonvolatile metabolic acid) eqskreciis Semcireba (glomeluruli filtraciis xarisxis Semcirebis dros, I tipis, distaluri tublaruli acidozi)

- diluciuri acidozi- i.v. didi raodenobiT xsnarebis gadasxma, romlebic arc bikarbonats da arc laqtats (romelic Semdeg metabolizdeba bikarbonatad) ar Seicaven.

M

metaboluri acidozi

yovelTvis rodesac arteriuli sisxlis analizSi aRmoaCen met. acidozs

dif. diagnostikisTvis

daTvale anionuri sxvaoba!

Anion Gap metaboluri acidozi SeiZleba

iyos normaluri AG-iT,

an gazrdili AG-iT!!!!

Anion Gap anionuri sxvaoba (a.s.)

norma: zogadad iTvleba, rom

a.s. normaSi aris 8-16 meq/l,

magram

sxvadasxva analizatorebs (SMA -6, SMA -12, ASTRA, etc) sxvadasxva normebi aqvT, ase rom rodesac amowmebT a.s. aucileblad miaqcieT yuradReba Tqveni laboratoriis normebs!

misi daTvla Tqvenc SegiZliaT:

AG = Na+ - (Cl- + HCO3-) zogierT qveyanaSi (ara aSS-Si)kaliumsac

iTvaliswineben:

A AG = (Na+ + K + ) - (Cl- + HCO3-) am SemTxvevaSi a.s. –is norma mcirdeba 4 meq/l-iT

anionuri sxvaoba (a.s.)

as gvexmareba metaboluri acidozis diferencialur diagnostikaSi!

ramdenadac rutinuli lab. testiT Cven vigebT natriumis, (kaliumis), bikarbonatebis da qloris raodenobas, as warmoadgens e.w. “gauzomavi” anionebis (Unmeasured anions) 23 meq/l- Semcvelobas. normaSi aseTi anionebi aris: ZiriTadad albumini (sisxlSi is uaryofiTad damuxtulia), aseve organuli mJavebi, fosfatebi da sulfatebi. aseve aris e.w. mcire kaTionebi kalciumi, magniumi – 6-7 meq/l, Sesabamisad a.s. daaxloebiT unda iyos 23-7=16, (zog litertauraSi SeiZleba mcired gansxvavebuli normebi

SegxvdeT)

gazrdili anionuri sxvaoba (a.s.)

AG = Na+ - (Cl- + HCO3-) rodesac metaboluri acidozi warmodgenilia

gazrdili as-iT es niSnavs rom HCl-ze da HCO3-- ze ufro Zlieri mJavis koncentacia izrdeba sisxlSi! romelic gamodevnis qlorsac da bikarbonatsac.

es SeiZleba sicocxlisTvis saSiSi mdgomareobebis niSani iyos!

laqtat acidozi – qsovilovani hipoperfuzia (Soki)! diabeturi (an alkoholuri) ketoacidozi, salicilatebiT intoqsikacia!

metaboluri acidozi

• laqtat da ketoacidozis dros rodesac gamomwvev mizezs vumkurnalebT (gavaumjobesebT qsovilovan perfuzias, gavakontrolebT glukozis dones da a.S) isini metabolizdebian bikarbonatad da acidozi TavisiT swordeba (swored amitom am mdgomareobebis dros ar SeiZleba natriumis bikarbonatis gamoyeneba Tu sicocxlisTvis saSiSi acidemia ar ganviTarda - pH < 7.15)

• damatebiTi kvlevebi dif. diagnostikisTvis – laqtatis done sisxlSi, glukozis done sisxlSi, ketonebi SardSi…..

• umkurnale gamomwvev mizezs!

metaboluri acidozi

normaluri as-iT

• ZiriTadi mizezia: hiperqloremiuli met acidozi.

(xSirad iatrogenuli, Tirkmlis ukmarisobiT, diareiT an sxva gziT bikarbonatebis kargviT gamowveuli)

metaboluri acidozi dif. diagnostika

met. acidozi

Cl- da a.s laqtati , glukoza, ketosxeulebi

mizezi

umkurnale mizezs da ara met. acidozs per se SeiZleba iyos Sereuli hiperqloremiuli / gazrdil a.s.-

iani

mag.: mZime diarea, didi raodenobiT wylis danakargebiT: pacientma dakarga bikarbonatebic da hipovolemiis gamo ganviTarda g.d.w –is sindromi laqtat acidoziT.

a.s. –is alternatiulia e.w. “Zlieri ionebis sxvaobis” meTodi

STRONG ION DIFFERENCE - Stewart’s equation amaze mogvianebiT

mJava tutovani wonsaworoba damatebiTi parametrebi

• BE (base excess) - normaSi – 2 dan +2 mde • is iTvleba da ara izomeba- warmoadgens tutis naSTs,

romelic sisxlSia (H+) da aris tutis is raodenoba romelic saWiroa erT litr sisxls rom daematos raTa pH gaxdes 7.4 (normaluri oqsigenaciis, 37 C temp-is, sisxli sadac PCO2 – 40 mm.vwy.sv-ia)

• bikarbonatebTan erTad BE gvexmareba mJava tutovani balansis metaboluri komponentis gansazRvraSi. unda aRiniSnos, rom bikarbonatis da BE-s aranormaluri cifrebi jer kidev ar niSnavs, rom pirveladi metaboluri darRvevebia!

• Tu BE > +2 (3) met. alkalozia da piriqiT.

• BE bikarboantTan SedarebiT ufro yovlismomcveli parametria, moicavs yvela metabolur process.

mJava tutovani wonasworoba

kompensacia da pirveladi fiz. darRvevis gansazRvra

-pirveladi met. acidozi- respiratoruli kompensacia iwyeba daaxloebiT 30 wT-Si, HCO3- -is yoveli 1 meq/l-iT Semcireba iwvevs PaCO2 -is 1,2 mmHg-iT Semcirebas.

PaCO2 = Serum HCO3 + 15 PaCO2 arteriuli pH -is meaTedis toli (25 mmHg arterial pH 7.25- ia.

am dros HCO3 daaxloebiT 11 meq/L) -pirveladi met. alkalozi - HCO3- -is yoveli 1 meq/l-iT

gazrda gazrdis PaCO2 -is 0,7 mmHg-iT, magram is arasadros gaxdeba 55 mmHg-ze meti!

am formulebis garda mniSvnelovania klinikuri Sefaseba, laboratoria da anamnezi

mJava tutovani wonasworoba

kompensacia da pirveladi fiz. darRvevis gansazRvra

respiratoruli darRvevebisas dauyovneblivi pasuxi

Tirkmlis mxridan ver asworebs pH-s srulad, amas sWirdeba 3-5 dRe (mw. vs qr. resp. darRvevebi)!

-pirveladi resp. acidozi – mw. fazaSi- PaCO2 -is 10 mmHg-iT gazrdas mohyveba HCO3- -is 1 meq/l-iT momateba, qr. fazaSi ukve HCO3- imatebs 3-5 da SeiZleba meti meq/l-iT. mag: PaCO2 - 70 mmHg HCO3- iqneba 29 meq/l rac Seesabameba H+ -s 58 nnmol/l-s anu pH- 7,23 mw. fazaSi da 7,34 qr. fazaSi.

-pirveladi resp. alkalozi - mw. fazaSi- PaCO2 -is 10 mmHg-iT klebas mohyveba HCO3- -is 2 meq/l-iT kleba, qr. fazaSi ukve HCO3- iklebs 4-5 da SeiZleba meti meq/l-iT.

mJava tutovani wonasworobis diagnozi

• gansazRvre pirveladi darRveva (garda qr. resp. akalozis an msubuqi-saSualo met. acidozisa, kompensatoruli meqanizmi, rogorc wesi ver uzrunvelyofs normalur pH!

• Seafase kompensaciis xarisxi – Zalian dabali an maRali xarisxi komlensaciisa Sereul mJava tutovan darRvevebze miuTiTebs

• gansazRvre anionuri sxvaoba – Tu met. acidozia

• dasvi klinikuri diagnozi

• umkurnale mJAva tutovani darRvevebis mizezs !

mJava tutovani wonasworoba alterantiuli midgoma

Cveni kolgebis umetesoba yoveldRiur praqtikaSi iyenebs zemoT xsenebul meTods mJava tutovani

wonasworobis interpretciisa,

Tumca

Cveni bevri kolega emxroba e.w. Zlieri ionebis sxvaobis anu stiuartis princips

"strong ion difference" (SID) or the Stewart approach

SID

• stiuartis mixedviT mJava tutovan wonaswirobas ganapirobebs ara bikarbonatebis koncentracia sisxlSi (ramdenadac is susti ionia), aramed

1. e.w. Zlieri ionebisa rogorbicaa: kaTionebi: Na, K, Ca, Mg da anionebisa - Cl da laqtati.

2. met. mJavebis (albumini da fosfatebi) rogorc buferebis

3. da arteriuli PCO2.

SIDapp (realuri)= [Na+] + [K+] + [Ca++] + [Mg++] - [Cl-] - [lactate-]

normaSi is 40 meq/l-ia. misi zrda zrdis sisxlis pH s da piriqiT.

• SID SeiZleba daviTvaloT albumnis da fosfatis saSualebiTac da mas efeqturi SID ewodeba

• Effective SID (SIDeff)SIDeff = (12.2 × Pco2/10-pH) + 10 ×

[Albumin × (0.123 × pH – 0.631)] + [PO4 × (0.309 × pH – 0.469)]

• SIDapp is da SIDeff sxvaobas “strong ion gap” anu SIG ewodeba:

• SIG = SIDapp - SIDeff normaSi is nulis tolia!

• misi dadebiTi cifrebi miuTiTebs, SesaZlo organul acidozze (endogenuri mJavebis produqciaze an eqzogenuri mJabevis miRebaze).

SID vs AG • ufro sofistikuria da kalkulacia garTulebulia

(dros moiTxovs)

• aucilebelia laboratoriaSi fosfatebis da albuminis analizi, rac Cvens realobaSi sirTuleebs gviqmnis.

• ramdenadac am or midgomas Soris mTavari gansxvaveba albumnis gazomvaa, Tu albuminis koncentraciis cvilebebi gaTvaliswinebuli iqneba AG –is dros, SID ar gvTAvazobs raime upiratesobas AG –is winaaRmdeg. (yoveli 1g/dl-iT albuminis cvlileba, cvlis gauzomav anionebs 2,3-2,5 meq/l-iT)

• SID moiTxovs sxvadsxva parametrebis seriul gadazomvebs, rac zrdis teqnikuri Secdomebis da araswori interpretaciebis risks.

SID vs AG

• amdenad eqspertebi upiratesobas aniWeben AG-s Strong ions and the analysis of acid-base disturbances (Stewart approach) Author Richard H Sterns, MD, Section Editor Michael Emmett, MD, Deputy Editor John P Forman, MD, MSc

Disclosures All topics are updated as new evidence becomes available and our peer review process is complete. Literature review current through: Mar 2014. | This topic last updated: Feb 22, 2014.

kiTxvebi?

gmadlobT!