Pleno.scenario 3 urogenital

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    PLENARY DISCUSSION

    ASIHS PATIENT

    GROUP 2

    ANATHARAO A/L SUBRAMANIAM

    DIAN PRATIWI BURNAMA FAJAR SATRIA PRATAMA

    KHALIDAH

    KEVIN MAULANDA

    MEIVITA WULANDARI

    SONYA VIESKA TIARA RAHMA ZAIN

    VEGGY PRATAMA ANANDA PUTRA

    WIDYATUL AINA

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    Scenario 3 ;Asihs Patient

    Asih is a medical school student who are undergoing their

    clinical pediatrics section. One day, he gets a patient, a boy

    aged 5 years who were admitted to hospital because of a

    loss of consciousness. Typical symptoms in children are

    kussmaul respiratory and growth retardation. Blood gas

    analysis showed a significant decrease in the levels of

    bicarbonate and anion gap within normal limits. laboratory

    results of urine showed the pH of the urines is alkaline.

    Doctors suspect the child is suffering kidney disease. basedon this, Asih try to analyze what happened to the child.

    How do you explain what happened to the child?

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    Learning objective1. Regulation of acid-base balance

    2. Factors affecting the acid-base balance as well as water

    and electrolyte

    3. Buffer mechanism in maintaining acid-base balance

    4. Regulation of fluid-electrolyte

    5. Acid-base balance disorders as well as water andelectrolytes

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    1. BODY REGULATION OF ACID-BASE BALANCE

    Refers to precise regulation of free H+ concentration in bodyfluids

    Acids

    Group of H+ containing substances that dissociate in

    solution to release free H

    +

    and anions(H2CO3)Bases

    Substance that can combine with free H+ and remove it fromsolution(HCO3)

    pH

    Designation used to express the concentration of H+ pH 7 neutral

    pH less than 7 acidic

    pH greater than 7 basic

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    BUFFER SYSTEM

    The fastest performer, works in seconds

    Bicarbonate ions combine with excess hydrogenions to form carbonic acid in a dynamic

    relationship HCO3 + H+ H2CO3

    For every molecule of carbonic acid, there are 20molecules of bicarbonate

    Any change in the this 20:1 ratio is immediatelycorrected to maintain pH

    An increase H+ causes an increase in H2CO3

    A decrease in H+ causes a decrease in H2CO3

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    BUFFER SYSTEM

    Carbonic acid is a weak, volatile acid which must be eliminated The enzyme carbonic anhydrase causes the carbonic acid to

    convert to carbon dioxide and water

    The CO2 and the H2O are easily eliminated by the lungs andkidneys

    Buffers system in the bodyBicarbonate: most important ECF buffer

    Phosphate: important ICF and renal tubular buffer

    HPO4-- + H+ H2PO4

    -

    Ammonia: important renal tubular bufferNH3 + H

    + NH4+

    Proteins: important ICF and ECF buffers

    Largest buffer store in the body

    Albumins and globulins, such as Hb

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    The respiratory system can activate changes in pHwithin 1 to 3 minutes and can eliminate or conserve Co2. As

    discussed, when a strong acid is present in the body, thebicarbonate, carbonic acid buffer pair is activated to buffer theacid. This results in a net increase of carbonic acid, whichdissociates into Co2 and H2O. Carbon dioxide is theneliminated by the lungs. An increase in H+ concentration inthe blood stimulates the breathing center in the medulla to

    increase the respiratory rate, which facilitates CO2elimination. If, on the other hand, pH is elevated secondary toan increase in HCO3-, the respiratory center is inhibited, andthe respiratory rate decreases.

    This results in CO2 retention, which then becomesavailable to form carbonic acid, which buffers the excess

    bicarbonate. The respiratory system is thus able tocompensate for changes in pH related to metabolic disordersby regulating Pc02, which alters the bicarbonatecarbonic acidratio. The respiratory system cannot, however, produce anyloss or gain of hydrogen ions. Respiratory compensation isactivated within minutes and is usually fully functional within I

    to 2 days.

    Respiratory System

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    9

    RENAL SYSTEM

    Can take hours to days to workKidneys can retain bicarbonate ion, causing

    a decrease in H+ and an increase in pH

    Kidneys can excrete bicarbonate ion,

    causing an increase in H+ and a decreasein pH

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    Renal compensation is a slower process, requiring Ito 2 days for complete activation. The kidneys react tochanges in pH by regulating the excretion orconservation of HC03-

    A low pH stimulates excretion of H+ into the urine.

    As H+ enters the urine, it displaces another positive ion,usually Na+. At the same time, HC03- is reabsorbed inexchange for the H+. The Na+ is then reabsorbed intothe tubule cell, where it combines with HC03- to formNaHC03 which is then available to buffer other H+ in theblood. The rale of H+ excretion, and therefore the rate ofHC03- reabsorption, is proportionate to arterial Pc02.This reaction is reversed for increases in pH.

    Renal System

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    The transport of H+ in the renal tubules is facilitated by thebuffer's phosphate and ammonia, which is classified as a base.

    Most ammonia is converted to urea by the liver and is eliminatedfrom the body in urine. The remaining ammonia combines with H+to form the ammonium ion (NH4+) in the renal tubules. NH4+ alsodisplaces Na+ and is eliminated in the urine. The Na+ is thenreabsorbed into the tubule cells, where it combines with HC03- toform NaHC03, which is absorbed into the blood to buffer excessH+.

    The amount of H+ excreted in the urine can be measuredby determining the amount of alkali required to neutralize theurine and is called titratable acidity. As a result of H+ and NH4+excretion, urine usually has an acidic pH of 6. In the clinicalsetting, checking urine pH can be a useful indicator of the

    degree of renal compensation when assessing acid-basestatus. For example, a low or acidic blood pH will beaccompanied a few days later by a low or acidic urine pH whenrenal compensatory mechanisms are active. The reverse is truein alkalotic states.

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    2. FACTORS THAT AFFECT THEEQUILIBRIUM LIQUID ELECTROLYTE

    AND ACID BASE

    1.age

    fluid composition in adult women in about 50% of the body weight

    fluid composition in adult men 60% of body weight

    on children's body fluid composition 75% of body weight

    in the elderly komposis 40-50% of body fluid loss dsri Berst2. Climate

    the colder the climate, the less caitan that ekskresikan by the body,and vice versa.

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    3.diet

    diet affect fluid and electrolyte intake, when nutrient intake is not strong,

    the body will burn fat prtotein and, thus serum albumin and protein

    reserves will decline.

    4.stress

    stress will lead to increased cell metabolism, thereby increasing the

    levels of sodium and water retention in the body

    5. ill

    sunburnthis will lead to a lot of liquid which is excreted in the body surface.

    cardiovascular-renal disease

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    FACTORS THAT AFFECT ACID-BASE BALANCE

    1. Hydrogen ion concentration in the body

    2.konsentrasi bicarbonate ions in the body3.Partial pressure carbon dioxide in the body

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    1. Bicarbonate Buffer SystemConsist of a weak acid H2CO3 and bicarbonate salt NaHCO3.

    When a strong acid such as HCl is added to a solution of

    bicarbonate buffer, an increase in H ions released by the HCl will

    be supported by HCO3.

    H + HCO3 H2CO3 CO2 + H2O

    When strong bases such as NaOH is added to a solution of

    bicarbonate buffer, ion OH from NaOH joined H2CO3 to form

    HCO3 extra.

    NaOH + H2CO3 NaHCO3 + H2O

    3. Buffer System on Acid-Base Balance

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    Henderson-Hasselbalch equation

    Increasing the concentration of bicarbonate ions causes the pH to

    rise, shifting the acid-base balance toward alkalosis.Increasing the concentration of H2CO3 cause decreased pH, acid-

    base balance shifts toward acidosis.

    pH= pKa + log [HCO3] / [H2CO3]

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    2. Phosphate buffer system

    Plays an important role in supporting the renal tubular fluid andintracellular fluid. The main elements of phosphate buffer system is

    H2PO4 and HPO4.

    When a strong acid such as HCl is added to the phosphate buffersolution, hydrogen accepted by HPO4 converted to H2PO4.

    When strong bases such as NaOH is added to the phosphate

    buffer system, OH supported by H2PO4 to form a number of

    additions HPO4 + H2O

    HCl + Na2HPO4 NaH2PO4 + NaCl

    NaOH + NaH2PO4 Na2HPO4 + H2O

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    3. Protein

    Is an important intracellular buffer.

    Diffusion elements of bicarbonate buffer system causing pH in

    intracellular fluid change when there is a change of extracellularfluid pH.

    60-70% of total chemical buffering fluid inside the cells and

    mostly produced by the intracellular protein.

    The slow movement of hydrogen ions and bicarbonate ions

    through the cell membrane often slow intracellular protein

    maximum capacity up to several hours to buffer acid-base

    disturbances.

    4. The Ammonia Buffer System

    This ammonia buffer system occurs in 3 steps:1) synthesis ofNH4

    + from glutamine, an amino acid in the proximal tubule,

    thick ascending loop of Henle & distal tubules

    2) recycling & reabsorption ofNH3 in the kidneys medulla, &

    3) buffering of H+ ions by NH3 in the collecting tubules

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    4. Fluid Electrolyte Balance

    Distribution of Body FluidsIntracellular = inside the cell; 42% of body weight

    Extracellular = outside the cell, 17% of body weight Interstitial = contains lymph; fluid between cells and outside blood

    vessels

    Intravascular = blood plasma found inside blood vessels

    Transcellular = fluid that is separated by cellular barrier,

    Body fluids contain ElectrolytesAnions negative charge

    Cl, HCO3, SO4

    Cations positive charge

    Na, K, Ca Electrolytes are measured in mEq

    Minerals are ingested as compounds and are constituents ofall body tissues and fluids

    Minerals act as catalysts

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    Electrolytes in Body Fluids

    Normal Values Sodium (Na+) 35 145 mEq/L

    Potassium (K+) 3.5 5.0 mEq/L

    Ionized Calcium (Ca++) 4.5 5.5 mg/dL

    Calcium (Ca++) 8.5 10.5 mg/dL

    Bicarbonate (HCO3) 24 30 mEq/L

    Chloride (Cl--) 95 105 mEq/L

    Magnesium (Mg++) 1.5 2.5 mEq/L

    Phosphate (PO4---

    ) 2.8 4.5 mg/dL

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    Regulation of Body Fluids

    Homeostasis is maintained through Fluid intake Hormonal regulation

    Fluid output regulation

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    Fluid Intake Thirst control center located in the hypothalamus

    Osmoreceptors monitor the serum osmotic pressureWhen osmolarity increases (blood becomes more

    concentrated), the hypothalamus is stimulated resulting inthirst sensation Salt increases serum osmolarity

    Hypovolemia occurs when excess fluid is lostAverage adult intake 2200 2700 mL per day Oral intake accounts for 1100 1400 mL per day

    Solid foods about 800 1000 mL per day

    Oxidative metabolism 300 mL per day

    Those unable to respond to the thirst mechanism areat risk for dehydration Infants, patients with neuro or psych problems, and older

    adults

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    Hormonal Regulation

    ADH (Antidiuretic hormone)Stored in the posterior pituitary and released in response to

    serum osmolarity

    Pain, stress, circulating blood volume effect the release ofADH Increase in ADH = Decrease in urine output = Body saves water

    Makes renal tubules and ducts more permeable to water

    Renin-angiotensin-aldosterone mechanismChanges in renal perfusion initiates this mechanismRenin responds to decrease in renal perfusion secondary to

    decrease in extracellular volumeRenin acts to produce angiotensin I which converts to

    angiotensin II which causes vasoconstriction, increasingrenal perfusionAngiotensin II stimulates the release of aldosterone when

    sodium concentration is low

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    Hormonal Regulation

    AldosteroneReleased in response to increased plasma potassium levels

    or as part of the renin-angiotensin-aldosterone mechanism tocounteract hypovolemia

    Acts on the distal portion of the renal tubules to increase the

    reabsorption of sodium and the secretion and excretion ofpotassium and hydrogen

    Water is retained because sodium is retained

    Volume regulator resulting in restoration of blood volume

    Atrial Natriuretic Peptide (ANP) ANP is a hormone secreted from atrial cells of the heart in response to atrial

    stretching and an increase in circulating blood volume

    ANP acts like a diuretic that causes sodium loss and inhibits the thirstmechanism

    Monitored in CHF

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    Fluid Output Regulation

    Organs of water loss Kidneys Lungs

    Skin

    GI tract

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    Fluid Output RegulationKidneys are major regulatory organ of fluid balance Receive about 180 liters of plasma to filter daily

    1200 1500 mL of urine produced daily

    Urine volume changes related to variation in the amount and typeof fluid ingested

    Skin Insensible Water Loss

    Continuous and occurs through the skin and lungs

    Can significantly increase with fever or burns

    Sensible Water Loss occurs through excess perspiration

    Can be sensible or insensible via diffusion or perspiration

    500 600 mL of insensible and sensible fluid lost through skineach day

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    Fluid Output RegulationLungs

    Expire approx 500 mL of water daily

    Insensible water loss increases in response to changes in

    resp rate and depth and oxygen administration

    GI Tract

    3 6 liters of isotonic fluid moves into the GI tract and thenreturns to the ECF

    200 mL of fluid is lost in the feces each day Diarrhea can increase this loss significantly

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    Regulation of Electrolytes Major Cations in body fluids

    Sodium (Na+)

    Potassium (K+)

    Calcium (Ca++)

    Magnesium (Mg++)

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    Sodium RegulationMost abundant cation in the extracellular fluid

    Major contributor to maintaining water balance Nerve transmission Regulation of acid-base balance

    Contributes to cellular chemical reactions

    Sodium is taken in via food and balance is

    maintained through aldosterone

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    Potassium Regulation

    Major electrolyte and principle cation in the

    extracellular fluid

    Regulates metabolic activities

    Required for glycogen deposits in the liver andskeletal muscle

    Required for transmission of nerve impulses, normal

    cardiac conduction and normal smooth and skeletal

    muscle contractionRegulated by dietary intake and renal excretion

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    Calcium Regulation Stored in the bone, plasma and body cells

    99% of calcium is in the bones and teeth

    1% is in ECF

    50% of calcium in the ECF is bound to protein (albumin) 40% is free ionized calcium

    Is necessary for Bone and teeth formation

    Blood clotting

    Hormone secretion

    Cell membrane integrity

    Cardiac conduction

    Transmission of nerve impulses

    Muscle contraction

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    Magnesium RegulationEssential for enzyme activities

    Neurochemical activities

    Cardiac and skeletal muscle excitability

    RegulationDietary

    Renal mechanisms

    Parathyroid hormone action

    50 60% of magnesium contained in bones 1% in ECF

    Minimal amount in cell

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    5. Acid-base balance disorders as well as water

    and electrolytes

    Acid-Base Imbalance

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    PaCO2 & pHA primary disorder where the first change is an elevation ofPaCO2,resulting in decreased pH.

    Compensation (bringing pH back up toward normal) is a secondary

    retention ofHCO3 by the kidneys; this elevation of HCO3- is notmetabolic alkalosis since it is not a primary process.

    Primary Event Compensatory Event

    HCO3- HCO3- pH ~ --------- pH ~ ---------

    PaCO2 PaCO2

    RESPIRATORY ACIDOSIS

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    A primary acid-base disorder where the first change isa lowering ofHCO3-, resulting in decreased pH.

    Compensation (bringing pH back up toward normal) isa secondary hyperventilation; this lowering ofPaCO2,

    Renal excretion of hydrogen ions & K+ exchangesPrimary Event Compensatory Event

    HCO3- HCO3-

    pH ~ ------------ pH ~ ------------PaCO2 PaCO2

    Metabolic acidosis

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    Metabolic Alkalosis

    A primary acid-base disorder where the first change is anelevation ofHCO3-, resulting in increased pH.

    Compensation is a secondary hypoventilation (increasedPaCO2), Compensation for metabolic alkalosis is less predictablethan for the other three acid-base disorders.

    Primary Event Compensatory Event

    HCO3- HCO3- pH ~ ------------ pH ~ ---------

    PaCO2 PaCO2

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    Respiratory Alkalosis

    A primary disorder where the first change is a lowering ofPaCO2, resulting in an elevated pH.

    Compensation is a secondary lowering(excreting)HCO3 by

    the kidneys.

    Primary Event Compensatory Event

    HCO3- HCO3- pH ~ ------- pH ~ --------

    PaCO2 PaCO2

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    Water Electrolyte Disorders

    Hipovolemia is a diminution of the circulating volume of Blooddue to multiple factors like Hemorrhage, dehydration, burns,

    among others.

    Dehydrationis the loss of water and salts essential for normal bodyfunction. Dehydration occurs when the body loses more fluid than

    it takes in.

    Hyponatremiais a medical term which refers to a dangerously lowlevel of sodium in the body.

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    Edemais swelling that is caused by fluid trapped inyour bodys tissues. Edema happens most often in the

    feet, ankles, and legs, but can affect other parts of the

    body, such as the face, hands, and abdomen. It can

    also involve the entire body.

    Hyperkalemia is defined as a condition in which the

    serum potassium level is greater than 5.3 mEq/L. Any

    of 3 pathogenetic mechanisms can cause

    hyperkalemia: excessive intake, decreased excretion,

    d hif f i ll l ll l

    Water Electrolyte Disorders