Bi ging
cn bng acid-base
TS. Phan Hi
Nam
i cng
I. Khi nim cn bng acid-base
II. Cc c ch n nh cn bng acidbase
2.1. Hot ng ca cc h m :
+ H huyt tng
+ H ca hng cu
2.2. Hot ng sinh l ca phi
2.3. Hot ng sinh l ca thn.
III. Mt s thng s chnh nh gi trng
thi CBAB
IV. Mt s ri lon CBAB
* Mt s lu v XN CBAB
Khi nim cn bng acid-base
CBAB - S n nh nng ion hydro (pH)
dch th/ l trng thi m H + thch hp
nht cho cc CH/ c th.
Nc (60-70%) phn ly:
H2 O
H+
+ OH trng thi cn bng phn ly (L tc dng khi):
[H+] [OH-] = k = 10-14 (k- hng s
phn ly)
H2O
V [H+ ]= [OH-] =>[H+]x[OH-] = [H+]2 = 10-14
Log [H+]2 = Log 10 -14 =>2 Log [ H+] = - 14 -> Log
[ H+] = -7
Qui c: pH l gi tri m ca Log nng H +,
tnh:
pH = - Log [ H+]
nh hng ca pH ti cc phn t sinh
hc
+pH thay i:
-> thay i cc lin kt hydro, LK disulfua (S-S-)=> thay i cu trc, CN ca protein
c bit protein l enzym -> ri lon hng,
tc v cng cc f/ m E xc tc.
+ pH nh hng:
- Receptor/ mng Tb (nhn bit v v.c cht qua
mng TB)
- Hb & i lc gn O2 ca Hb
- Acid nucleic (AND, ARN)- Di truyn.
- Khng th- bo v c th
- Hormon ( HCH)
Cc nguy c gy ri lon CBAB
S to thnh CO2, H2CO3:
- CO2: Krebs & kh carboxyl ca amino acid (~ 200
ml/min).
- CO2 kt hp vi nc, phn ly to H + & HCO3-:CB ng
CO2 + H2O
H2CO3
H+ + HCO3Nu CO2 ko o thi -> nhim acid (cn bng ->
phi).
S to thnh acid HC, VC:
+ Chuyn ho G, L, P -> SPTG a s l acid 1,3-DPG,
a.pyruvic
RL:--> acid pyruvic, lactic, -Hydroxybutyric ,->
nhim acid
, RL cc CH -> xu hng nhim acid: acidose
Bnh l:
+ Bnh lm acid mu: - Tiu ng: acid cetonic/M
Nguy c gy ri lon CBAB
+ Bnh lm kim mu:
- Nn/ tc mn v, ht dch v DD: mt H+
Dng qu nhiu thuc li niu.
- Tim, truyn qu nhiu Nabicarbonat (sai .
+ :
pH mu M: 7,38 7,42 duy tr c do H+ = H+
o thi.
=> CBAB thc cht l duy tr s n inh
ion H+/ c th.
Cc c ch n nh CBAB:
1- H m (Ht, HCu).
2- H sinh l phi
3- H sinh l ca thn.
Cc h m ca mu
H m mu= H huyt tng + H
Hng
H cu
Bicarbona
Protein
PPhosphat
m
t
(45%)
(1-2%)
(53%)
Huyt t H2CO3/NaHC Protein/Proteina
t natri
O3
ng
Hng
cu
(35%)
(10%)
H2CO3/KHCO
HHb/KHb,
HbO2/KHbO2
(18%)
( 35%)
NaH2PO4/Na2H
PO4
KH2PO4/K2HPO4
Vai tr ca cc h m/ iu ho
CBAB
H huyt tng:
* H m bicarbonat: H2CO3/ NaHCO3
+ Quan trng: 35% DT/ c th, iu ho: nhanh, mnh.
+ Cn bng ng: CO2 + H2O
H2CO3 H+ + HCO3+ Pt Handerson-Haselbalch:
[HCO3pH = pK H2CO3 + log ]
[ H CO
2
[HCO3= 6,1 + log
]
0.03.
pCO
+ C ch H: KM => Kim yu; Acid mnh => acid
yu-> T
- Kim (OH-) / M => Kim yu,
XOH + H2CO3
XHCO3 + H2O, VD:
NaOH + H2CO3
NaHCO3 + H2O.
- Acid (H+) / M: RH + NaHCO3
RNa +H2CO3 (phn
ly)
VD: HCl + NaHCO3
NaCl +H2CO3
H2OCO2
Phi ->
thi
H m huyt tng
* H m protein:
+ Cu to t cc A.A (COOH, NH2), c tnh lng
tnh:
- COOH
COO- + H+ ( + base) - chng li
kim ho
- NH2 + H+
NH3+ - chng li acid ho.
+ Chng li acid = a.a kim (Arg, Lys)/ NH2 + H+
NH3+.
+ Chng li kim = a.a acid (Glu, Asp)/ H+ + base
(OH-).
Vai tr m: ng k (60 80 g/l)
* H m phosphat (NaH2PO4/ Na2HPO4 )
- Tt v c pK = 6,8 (~ 7,40).
- Vai tr m: yu v c nng thp/ M (1
2 mmol/l)
H m hng cu
+ HC c H bicarbonat, phosphat nhng VT m ch yu do Hb
+ Hb c 2 H: HHb/ KHb & HHbO2/ KHbO2, m = 2 cch:
1- To DX carbamin: NH2/ Hb + CO2 -> dx carbamin (5% CO2).
2- Nh hot ng ca nhn Imidazon/His:
Hb + O2 -> HbO2 + H+, H+ -> pH/ phi (*)
HbO2 + H+ -> HHb + O2 => H+ -> pH/ TC (*)
Vai tr m ca Hb l o thi CO2 cho c th -> chng acid
ho (S
T )
Mu
Phi
chc
TM K+HCO +
K HCO3K+HCO33
K+
CA
HCO3- HHb
O2
H+
H2CO3 KHbO2
H2O
HHb
M
KHbO2
O2
HCO3H+
KHbO2
H2CO3
CA
CA
CO2
CO2
Ch.ho
HHb
K+
Bt: CO2/TC = CO2 /
H2O
Th ra
Phi iu ho CBAB
CO2 + H2O
HCO3CO2 th
ra
BT: CO2/TC = CO2/ phi
Nhim
acid
+
(H
/M):
. TK
phi (TS, B
th)
-> o thi
CO2
H2 O
CO2
H2CO3
H2CO3
. CO2 phi > CO2/ TC
Nhim
base (OH-
Ph
i
HCO3
(chng acid)
CO2
H+ +
H+
Mu
T
chc
/M):
. TK phi ( TS, B
th) ->
o thi CO2
. CO2 TC > CO2/
Phi
Tt: Phi o thi CO2, bn
b, lin tc => iu ho
CBAB c hiu qu
Phi
CO2
HCO3
-
CO2
OH
Mu
Thn iu ho CBAB
* c im: chm, hiu qu mnh, duy tr HCO3-/ H.t &
DGB
* Ti hp Lng
thu gn
gn, 10%
.T hon ton
Mao
TBHCO
ng3 l:n90%/ TB L
L xa. (NTB)
qun
gn
NaHCO3
Na
+
HCO3
E1
H2CO3
CA
K+
Na
H+
HCO3-
H2CO3
H 2O
E2
K+
Na
+
HCO3(90%)
E1HCO3-.ATPase
E2- Na+,K+CO2
ATPase
H2O CO2
CO2
+
THT HCO3- : + PCO2 (CC b tr ca thn khi c th nhim base,
acid h hp)
+ THT Na+/ TB ng thn.
Thi H+, ti hp thu HCO3- ng ln xa
Lng T (NT
u)
Na+
K
HPO4--
H+
R
H2
PO4-
R
H
TB ng ln
xa
E2
Mao qun
Na+
K
E1
H+
HCO3H2CO3
H2 O
NH3
Glutaminase
CO2
Na+
K+
HCO3(~10
%)
CO2
Glu
NH4+
Gln
+ o thi H+: Acid (RH), mui amoni, mui
+
Ti hp thu HCO3- : ~ 10%
phosphat
+ Tn to HCO3-: : n bt-> 50- 100 mmol H+/ 24h/: H2SO4
(SPCH a.a S);
H3PO4 (SPTH ca P0-Lipid, acid nucleic); A.uric-
Cc thng s nh gi trng thi cn bng acid- base
1. pH mu
2. PaCO2
3. Bicarbonat
4. Bicarbonat thc ( Actual Bicarbonat = AB)
5. Bicarbonat chun (Standard bicarbonat = SB)
6. CO2 ton phn ( Total CO2 = t.CO2)
7. Base m (Bufer base = BB)
8. Base d (Base excess = BE)
pH mu
pH mu/ M = 7,38 7,42.
pH < 7,38 nhim acid
pH > 7,42 - nhim base
pH mu/TM < M 0,02
pH -> nh gi mc b tr ca c th:
- Acidose:
pH 7,38 7,42: b ton phn
(nhim acid)
7,37 7,25: b 1 phn
< 7,25: mt b.
- Alcalose:
pH 7,38 7,42 : b ton phn
(nhim base)
7,43 7,55: b 1 phn
> 7,55: mt b.
+ pH < 7,30: Nhim toan h hp: ph qun ph
vim
Nhim toan CH nng: T.
+ pH > 7,55: Nhim kim h hp: CTSN
Nhim kim chuyn ho nng: a
chy ko di..
PaCO2, CO2 ton phn
: PaCO2 = 40 mmHg
- Thng s cho bit cc ri lon CBAB do NN h hp
- Ph thuc thng kh ph nang: khi TKPN v ng
c li.
BL: - nhim toan HH do o thi CO2 phi,
gp:
. Thng kh PN, tc nghn ph qun
. Bnh phi: PQPV, vim phi, hen
. Ht phi CO2, ht li Ko kh th
t.CO2 = CO2 ha tan + CO2 carbaminat + CO2/bicarbonat
B c ch TK: thuc ng, bi lit, nhim
c,
PaCO2-5%
(+Hb)- 5%
HCO 3-- 90%
CTSN, u no
.
. : t.CO2 = 25 - 30 (mmol/l).
t.CO2 : Nhim toan h hp, nhim kim CH
Bicarbonat ( HCO3-)
+ L lng HCO3- c trong H.T 37OC, gm B thc v B chun.
- Bicarbonat thc (actual bicarbonat = AB):
. L nng thc t HCO3- ca mu mu M ly K ko tip
xc vi ko kh, n tng ng vi pH v PaCO2 thc ca mu
mu.
. : AB = 25 mmol/l.
- Bicarbonat chun (standard bicarbonat= SB):
. SB: l lng HCO3- (mmol/l) ca h.t c qui v K chun
nh PaCO2= 40 mmHg, To= 37oC, pH = 7,40.
. : SB = 24 2 (mmol/l).
+ L TS cho bit RLCBAB lin quan ti NN chuyn ho.
BL: HCO3-: NT h hp, NKCH: nn nhiu, ht dch DD, a chy
: Nhim toan CH, gp:
. T do ng cc th cetonic
. Ph phi cp, ng kinh: RLCH glucid-> ng acid
lactic.
. Vim thn cp; mn: ko thi c acid
. a chy cp lm mt HCO3-
Base m (Buffer base = BB), Base d (Base
exess = BE)
Base m: L tng cc anion m trong mu (mmol/l).
BB = [HCO3-] + Protein- + Hb- + Phosphat: 46 - 48 (mmol/l)
Base d : L s chnh lch gia BB ca BN v BB ca ngi bnh th
ng.
: BE = 0 (pH = 7,40; PaCO2= 40 mmHg; Hb TP = 150 g/l, 37 OC).
BE cng vi Bicarbonat l 2 TS c ngha xc nh nguyn nhn
RLCBAB do chuyn ho.
BE dng () gp: Nhim kim CH (nn nhiu, a chy ko di..)
BE m () gp : Nhim toan CH (T..)
Ch : + Cc TS: pH, PaCO2 - o = CCL
Cc TS khc: HCO3- (AB), t.CO2, BB, BE- tnh ton
+ Kt qu CBAB chnh xc khi:
- Ly mu:
. M (tr, quay,cnh tay), MM ho - u ngn tay, di tai
. Dng c chuyn bit-> Mu ko tip xc vi ko kh.
- My c chy chun, o ngay.
Cc ri lon cn bng acid- base
3 nhm RL: - Do N.N h hp, N.N chuyn ho & Do N.N
hn hp.
( PaCO2)
(HCO3-, BE)
PaCO
2
4
0
Nhim toan h hp
Ri lon khi pht l pCO2 do thi tr CO2
phi, gp:
* Bnh phi: - P. Qun, ph vim
- Vim phi
- Hen
- Kh thng phi
* HCTK: - Thuc ng
- Bi lit
- CTSN, u no
- Ri lon tun hon no
* Ht phi CO2/ k.kh th
* XN: pH (< 7,38)
pCO2 (> 40mmHg)
HCO3- mu (> 25 mmol/l)
t CO2 , cc TS khc t thay i
Nhim kim chuyn ho
L trng thi tha Base hoc mt acid (k o phi l
H2CO3)
* Nguyn nhn:
+ Qu tha base:
- qu nhiu bicarbonat (T)
- n ung: qu nhiu cht
t/c kim
+ Do mt acid: - Nn nhiu (HCL , K+ )
- Ht D.dy (Cl- ), a
chy(H+ )
- Thuc li niu nhiu -> K +
* KQXN cc thng s:
- pH mu (> 7,5, mt b)
- pCO2 (> 40mmHg do thng kh )
- HCO3- (> 25mmol/l) v tCO2, BB , BE
Nhim kim h hp
Ri lon khi pht l pCO2
Gp: + Thng kh phi : - Giai on u
vim phi
- St cao
- H hp nhn to
qu mc
- CTSN
+ Th trong kh quyn c pCO2 thp (ln
cao)
KQXN: - pH mu (> 7,42) (khi mt b)
- pCO2 mu
- t.CO2
- BB
- BE (-)
Nhim toan chuyn ho
L s mt anion m- ch yu l HCO 3- mu&D
ngbo; Tch
lu cc acid C/ thc t l acid mnh m anion ca
chng ko
th bi xut qua thn
*KQXN - pH mu (< 7,24- mt b)
- pCO2 (f/ b tr ca phi)
- t.CO2 Hoc bnh thng
- SB
- BB , BE (-)
- HCO3-
* Gp: - tiu ng ( acid cetonic)
- RLCH Glucid: ng a.pyruvic, a.lactic
- Tn thng thn: THT HCO3- RL => HCO3-
- T nhiu thuc li niu -> thi HCO3- =>
HCO3-
Nhim toan hn hp
L s kt hp nhim toan CH v h hp =>
pH mu
* XN: - pH mu mnh
- p CO2
- HCO3-
- SB va
- BB
- BE(-)
Nhim kim hn hp
L kt hp ca nhim kim h hp v nhim
kim chuyn ho => pH mu rt nhiu
* XN: - pH mu
- pCO2 t
- HCO3-
- SB : 34-36 mmol/l (bt 24mmol/l)
