Acidobazická rovnováha

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Brönstedova teorie=

lKyselina je donorem protonu

nHA = ; H+ + A-

lBáze je akceptorem protonu

nB + H+ = ; BH+

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Koncentrace H+

lpH =3D -log [H+]

lFyziologické hodnoty

npH =3D 7.40

n[H+] =3D 40 nmol/L

lSrovnání s ostatními soluty

n[Na+] =3D 140 mmol/L

n[K+] =3D 4 mmol/L =

n[HCO3-] =3D 24 mmol/L

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= Henderson-Hasselbalchova rovnice

lKa

llog Ka =3D log [H+] + log

l-log [H+] =3D - log Ka + log

l pH =3D pK= a + log

[HA]

[A-]

=3D

[HA]

[H+][A-]

[HA]

[A-]

[HA]

[A-]

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Nárazníkové systémy (pufry)

lRoztoky slabé kyseliny a silné zás= ady (nebo opačně) mají schopnost vyrovnávat výkyvy pH <= /span>

lFyziologické pufrační systémy

nhemoglobin

nplasmatické proteiny

nfosfáty

nkosti

nbikarbonát/kyselina uhličitá

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Titrační křivky acidobazických párů

8

6

4

2

10

pH

NH= 4+

pK= a=3D9.4

H<= /b>2PO4-

pK= a=3D6.8

NH= 3

HP= O4=3D

HC= O3-

H<= /b>2CO3

pK= a=3D6.1

La= ctic Acid

La= ctate

pK= a=3D3.9

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Principy izohydrie

lPoměr mezi disociovanou a nedisociovanou formou kteréhokoliv pufru je závislý pouze na pH a pKa pro dan&y= acute; pár

l= Všechny pufrační systé= ;my v těle jsou v rovnováze

l= Změna v poměru koncentrací jednoho páru změní koncentrační poměr i u ostatních pufrů

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36%<= /b>

15%<= /b>

6%

42%<= /b>

1%

Na+        = ;      H+

H+, Cl- co-uptake

57%&= #13;

Intracellular

Buffering

43%&= #13;

Extracellular

Buffering

Pr- += H+       HPr=

HCO3- + H+

H2CO3

H20 + CO2

K+        = ;        H+

Pufrování kysel&eacut= e; nálože

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<= ![endif]>

2%

26%<= /b>

4%

67%<= /b>

1%

Cl-        = ;            &n= bsp;    HCO3-

32%&= #13;

Intracellular

Buffering

68%&= #13;

Extracellular

Buffering

HCO<= /b>3-

Retained in

ECF

HPr<= span style=3D'mso-spacerun:yes'>        = ;   Pr- += H+

H+        = ;        Na +

Orga= nic Acids

Pufrování alkalick&ea= cute; nálože

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<= ![endif]>

lH2O + CO2        H2CO3         H+ + HCO3-

l

lKa =3D

l

lpH =3D pKa + log

l

lpH =3D 6.1 + log

CA<= /span>

[CO2]

[H+][HCO3- ]

[CO2]

[HCO3- ]

0,225 x PCO2

[HCO3- ]

Systém kyseliny uhlič= ité/bikarbonátu

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<= ![endif]>
Systém kyseliny uhlič= ité/bikarbonátu

lOtevřený pufrovací systém

nPCO2 určen alveolární ventilací (v rovnováze s alveolárním vzduchem), respirační slož= ka

n[HCO3-] regulován ledvinami, metabolická složka

= lEfektivita tohoto systému je tedy mnohem větší, než by vyplývalo z jeho pKa =3D 6.1

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Denní exkrece kyselin

lTěkavé kyseliny: 15 mol/den

n Z oxidati= vního metabolismu cukrů, tuků a proteinů na CO2

lNetěkavé kyseliny: 1 mmol/kg/den

noxidace sulfhydrylových skupina na H2SO4

nHydrolýza fosfoproteinů, fosfolipidů a nukleových kyselin na H3PO4

nInkompletní metabolismus cukrů, tuků a proteinů na organické kyseliny

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Renální acidobazická homeostáza

lReabsorpce bikarbonátu z primární moče

n4 500 mmol HCO3 je přefiltrováno glomerulem = ;

nReabsorpce v proximálníkm tubulu

lRegenerace bikarbonátu ztraceného = pufrováním metabolismem vzniklých netěkavých kyselin

nDistální sekrece protonů

nSyntéza amoniaku

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3 HCO= 3-

Na+

Acidobazická homeostáza:
Proximání tubulus

Apica= l

Basol= ateral

Na+

HCO3-

CA=

<= b>CO2

+

H2O

CO2 + H2O

H2CO3

CA=

H+

HCO3-

H+

H2CO3

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R0lGODlh0gACAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAADS AAIAgQAAAADMzADKygECAwIijI+py+0Po5y02nsBELvz74XgKJbkaaboqrbs68bwLMdAAQA7 ------=_NextPart_01CA5E65.B7F62470 Content-Location: file:///C:/B13410B2/abr_soubory/slide0015.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Acidobazická rovnováha
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Tubulární reabsorpce bikarbonátu
<= ![endif]> = = = = =

10

15

20

25

35

30

40

Serum Bicarbonate (mmol/L)

Excreted

Reabsorbed

Filtered

= =

10

20

30

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file:///C:/B13410B2/abr_soubory/slide0015_image097.gif Content-Transfer-Encoding: base64 Content-Type: image/gif R0lGODlhGwAYAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAAAAAAB AAEAgAAAAAECAwICRAEAOw== ------=_NextPart_01CA5E65.B7F62470 Content-Location: file:///C:/B13410B2/abr_soubory/slide0016.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Acidobazická rovnováha
<= ![endif]>
Reabsorpce HCO3- v proximálním tubulu

lPozitivní stimuly

ndeplece cirkulujícího volumu

ndeplece chloridů <= /span>

nacidémie

nhypokalémie

nhyperkapnie

lNegativní stimuly

nvolumová expanze

nalkalémie

nhyperkalémie

nhypokapnie

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<= ![endif]>

HCO3-

Acidobazická homeostáza:
sběrný kanálek

Apica= l

Basol= ateral

H+

CO2 + H2O

CA=

HCO3-

H+

Cl-

2 K+

3 Na<= span style=3D'font-family:"Times New Roman";mso-ascii-font-family:"Times New Ro= man"; font-size:67%;color:#993300;position:relative;top:-.75em;mso-text-raise:50= %'>+

Na+

K+

K+

Princ= ipal Cell

Inter= calated Cell

Buffer-

H-Buffer

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R0lGODlhWgBaAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALCEAGgAl ACIAhAAAAJkzAJk1AJkxAJo0AJozAJM3AJs3AJkyAJ0zAJk0AJgxAJgyAJY0AJYzAJo1AJgzAKJE AAECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwECAwWnIAAEYmmeaGqSIhEU aiyLwUvXyKyvdaAAix5sN2P0CCVjDUlUKYSnXq2JakhTiN6PKjr0cirptjmAylw1B7XQ20kFxOyU aJ6xawvqNyG7ckc1QyloPn83AUxRfoZPbSaNAWCGh4Uli5MicixBgZgoV3ueKJqdoigDdzUDpile EAEHrCp3srNztSe0uCIPUlq7vo61pLe1kMK4pLs8xbtyy4/Ny4nQmCEAOy== ------=_NextPart_01CA5E65.B7F62470 Content-Location: file:///C:/B13410B2/abr_soubory/slide0018.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Acidobazická rovnováha
<= ![endif]>
Distální sekrece H+

lStimulace

npřebytek sodí= ku intralumin&= aacute;lně

npřebytek mineralokortikoidů

lInhibice

nnedostatek sodíku intraluminálně

nhypoaldosteronismus

ndeficit pufrů intralumin&= aacute;lně

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<= ![endif]>
Pufry moče

lTitrovatelné kyseliny

nfosfáty

nsulfáty

norganické kyseliny

lAmoniak

lBikarbonát

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<= ![endif]>
Exkrece amoniaku

lSyntéza v proximálním tubulu <= /span>

nstimulace

–acidémie=

–hypokalé= mie

ninhibice

–alkalémi= e

–hyperkalé= ;mie

lRecyklace ve dřeni

lZachycení ve sběrném kanálku

nZávislá na sekreci H+ a luminálním pH

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Acidobazická homeostáza:
Amoniogeneze

Apica= l

Basol= ateral

Glutamine

2 HCO= 3-

2 NH<= span style=3D'font-family:"Times New Roman";mso-ascii-font-family:"Times New Ro= man"; font-size:67%;color:#990066;position:relative;top:.37em;mso-text-raise:-25= %'>4+

KG=3D

2 CO<= span style=3D'font-family:"Times New Roman";mso-ascii-font-family:"Times New Ro= man"; font-size:67%;color:#990066;position:relative;top:.37em;mso-text-raise:-25= %'>2 + 2 H<= /span>2O

2 H+

2 HCO= 3-

<= b>Glucose

or

CO2

2 NH<= span style=3D'font-family:"Times New Roman";mso-ascii-font-family:"Times New Ro= man"; font-size:67%;color:#990066;position:relative;top:.37em;mso-text-raise:-25= %'>3

2 H+

+

2 NH<= span style=3D'font-family:"Times New Roman";mso-ascii-font-family:"Times New Ro= man"; font-size:67%;color:#990066;position:relative;top:.37em;mso-text-raise:-25= %'>4+

Proxi= mal Tubule

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Záchyt amoniaku ve dřeni ledvin

Loop of

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+

NH= 3

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Záchyt amoniaku ve dřeni ledvin

lNH4+ je zachycen ve dř= eni ve sběrném kanálku pH gradientem mezi sb<= /span>ě= rným kanálkem a intersticiem dřeně= ledvin

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charset="us-ascii" Acidobazická rovnováha
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Vztah exkrece NH4+ a pH moče=

5

6

7

8

pH

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Ac= idosis

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Čistá sekrece H+ ledvinami<= /span>

lUH+ =3D UTA + UNH4+ - UHCO3-

nTitrovatelná kyselina: 30-50 mmol/den

nNH4+: 30-50 mmol/den

nHCO3-: zanedbatelný =

nFree H+: zanedbatelný

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Analytika ABR

lVzorek heparinizované plné krve

–arteriální, kapilární, venózní smíšená&= #13;

lMěří se: pH, pCO2 (potenciometrie)

lPočítá se (van Slykeovy rovnice):

l cHCO3- (mmol/l)=3D0,23pCO2 x 10 (pH-6,1)

l         BEect=3D (c HCO3- -24,2) + 14,8 (pH-7,4)

= 211;

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Analytika ABR

lStewart-Fenclův přístup nezávislých proměnných

lpCO2

lSID =3D Na + +K + +Ca 2+ +Mg 2+ -Cl –

lAtot =3D albumin + fosfát=

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Poruchy acidobazické rovnováhy: = Terminologie

lAcidóza

nProces, který směřuje ke snížení pH krve

lAlkalóza

nProces, který směřuje ke zvýšení= pH krve

lAcidémie

narteriální krev pH < 7.36 <= /span>

lAlkalémie

narteriální krev pH > 7.44

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Poruchy acidobazické rovnováhy: = Terminologie

lKompenzace

nFyziologická snaha respiračního nebo renálního systému o návrat k fyziologickému pH

n

lKorekce

nLéčebné zásahy smě= 45;ující k odstranění poruchy ABR

n

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Poruchy acidobazické rovnováhy: = Terminologie

lJednoduchá porucha

nJe přítomna pouze jedna výchylka ABR a její kompenza= ční proces

lSmíšená porucha
nPřítomny dvě a více odchylek ABR a jejich kompenzace. Výsledn pH zá= ;visí na směru jednotlivých odchylek a je= jich síle.

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Jednoduché poruchy ABR

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image/gif R0lGODlhGwBuAHcAMSH+GlNvZnR3YXJlOiBNaWNyb3NvZnQgT2ZmaWNlACH5BAEAAAAALAEAAAAY AG0AgAAAAP///wKnhI8Qy5yPmoRUNgqtw0kv3nlgJI6GF5hnaaKtIqYYanH0Zt8tvbOgq4JNgisc UXgMJSPLpvMJjUqn1Kr1is1qt9yu9wtWyZzjpZE4RNeCwJ7G/R7dypl5bk7vCGupfCgOdyHm80N4 txZ4dpgmZzjjWAEZNklZaXmJmam5OUimCJcEOIjYKPlnWtQWabfKWrE30VfKWCg6K5j4wWa7iJu7 y9urO0oLUQAAOw== ------=_NextPart_01CA5E65.B7F62470 Content-Location: file:///C:/B13410B2/abr_soubory/slide0032.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Acidobazická rovnováha
<= ![endif]>
Metabolická acidóza =

lHyperchloremická (normalní anion gap) = ;

nSnížená exkrece kyselin

nZvýšená ztrá= ta bikarbon&aa= cute;tů

nPřísun protonů

lAnion gap

------=_NextPart_01CA5E65.B7F62470 Content-Location: file:///C:/B13410B2/abr_soubory/slide0033.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; charset="us-ascii" Acidobazická rovnováha
<= ![endif]>
Anion Gap

lAG =3D [Na+] - [Cl-] - [HCO3-]

lFyziologická hodnota: 10 ±<= /span> 2 mmol/l

lHlavní nemě= 45;ené anionty

nalbumin

nfosfáty

nsulfáty

norganické anionty

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Anion Gap

Na+

Cl-

HCO3-

AG

Na+

Cl-

HCO3-

AG

Na+

Cl-

HCO3-

AG

<= u>FYZIOLOGICKY

H= yperchloremická

Z= výšený A G

<= u>METABOLICKÁ ACIDÓZA

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<= ![endif]>
Příčiny metabolick&eacu= te; acidózy se zvýšen&= yacute;m Anion Gapem

lTyp

ldiabetická ketoacidóza
lalkoholická acidóza

llaktátová acidóza
lselhání ledvin

ljedy

nmethanol

nethylenglykol

nsalicylát

nparaldehyd

lZvýšený aniont

lhydroxybutyrá= ;t, acetoacetát

lhydroxybutyrá= ;t, acetoacetát, laktát

llaktát

lfosfát, sulfát, organické anionty =

l

lformát, laktát

loxalát, glycolát

lketokyseliny, laktát, salicylát
lorganické anionty

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Příčiny hyperchloremické metabolické acidózy

lSnížení rená= lní exkrece chloridů

nSelhání ledvin

nDistální RTA

lRenální ztráty bikarbonátu&= #13;

nProximální RTA

nInhibitory karboanhydrázy

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<= ![endif]>
Příčiny hyperchloremické metabolické acidózy

lZtráty bikarbon&aa= cute;tů GIT

nprůjem

nDerivace pankreatických nebo střevních tekutin

l

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Proximální renální tubulární acidóza

10

15

20

25

35

30

40

Bikarbonát v séru (mmol/l)

10

20

30

Pr= oximal RTA

Normal

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HCO3-

Distální renální tubulární acidóza

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Na+

K+

K+

Princ= ipal Cell

Inter= calated Cell

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Metabolická acidóza při renálním selhán&iacut= e;

lČasná (hyperchloremická)

nDeficit pufrů v moči pro poruchu amoniogeneze
nAcidifikační děje bývají zachovány

nMůže být doprovázena hyperkalémií

lPozdní (zvýšený anion gap)= 3;

nRetence fosfátů, sulfá= ;tů a organických aniontů

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Metabolická alkal&oacut= e;za: Příčiny

lZtráta kyselin

nLedvinami

–diuretika <= /span>

–předávkování mineralokortikoidy

–Cushing<= span style=3D'font-family:"Lucida Sans Unicode";mso-ascii-font-family:"Times Ne= w Roman"; mso-fareast-font-family:"Lucida Sans Unicode"'>ův sy

–těžký deficit kalia

–

l

nGIT

–Ztráta žaludeční kyselny

–Průjem se ztrátami chloridů

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Metabolická alkal&oacut= e;za: Příčiny

lPřísun bazí&= #13;

nPodání bikarbonátu

nInfuze organických aniontů

–citrát&#= 13;

–acetát&#= 13;

–laktát&#= 13;

nRychlá korekce chronické hyperkapnie

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Respirační acidóza

lPostižení výměny plynů v plicích

lObstrukce dýchacích cest

lPostižení dýchacch svalů

lPostižení centra pro dýchání v CNS

l

lHyperkapnie - pCO2 nad 5,8 kPa

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Respirační alkalóza

lHypoxémie s hyperventilací

lPatologická stimulace dýchacího centra

lUmělá ventilace pacienta

l

lHypokapnie - pCO2 pod 4,8 kPa

l

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Diagnostika poruch ABR

lAnamnéza

lFyzikální vyšetření

lElektrolyty, krevní plyny
lKomplexní pohled na stav pacienta, klinick&eacut= e; a laboratorn&= iacute; vyšetření

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Mapa ABR

8.5<= /b>

6

9

12

15

18

21

24

27

30

33

39

45

51

57

66

75

1.3<= /b>

2.6<= /b>

3.9<= /b>

5.3<= /b>

6.3<= /b>

10.6=

8.9<= /b>

7.6<= /b>

11.9=

PCO2 (kPa)

7.0<= /b>

7.1<= /b>

7.2<= /b>

7.3<= /b>

7.4<= /b>

7.5<= /b>

7.7<= /b>

8.0<= /b>

pH

[HCO= 3-]

(mmo= l/L)

Norm= al

Acidosis
Metabolic

Acute Resp

Chronic Resp

Alkalosis <= /div>
Metabolic

Acute Resp

Chronic Resp

Gold= berg MS et al: JAMA 1973; 223:269=

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text/html; charset="us-ascii" Acidobazická rovnováha
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Transport kyslíku

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Regulace dýchán&iacu= te;

lnervové mechanismy mozkového kmene

lchemické detekční mechanismy - chemoreceptory

lreflexní mechanismy

= lsuprapontinní mechanismy (v= livy z mozkové kůry, hypothalamu)

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= Fyziologie zásobování tkání kyslíkem

lStav alveoloarteriální bariéry (plicní funkce, lung oxygen uptake)

= lTransport kyslíku krv&iacut= e; - kapacita arteriální krve pro transport kyslíku
= lSchopnost krve (hemoglobinu) uvolnit kyslík ve tkáních (poloha disociační křivky hemoglobinu)

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Parciální tlak kyslíku

lPa= rciální tlak kyslíku v arteriální krvi (PaO2) je z&= aacute;kladním ukazatelem kapacity plic pro výměnu plynů.

l

lNei= nformuje o obsahu kyslíku v krvi!!

l

lLépe o plicníc= h funkcích informuje alveolo-arteriální diference tenze kyslíku (případně= poměr tě= chto hodnot).

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Stanovení PaO2, sO2

lStanovuje se z plné krve modifikovanou Clarkovou elektrodou (amperometrie).

lKoncentrace totHb, oxyHb, deoxyHb, COHb, = MetHb se mě= 45;í spektrofotometricky.

lPočítá se:

lsO2 =3D oxyHb / (oxyHb + deoxyHb)

l

lcO2 (ml/l)=3D1,39 cHbO2 (g/l) + 0,225pO2 (kPa)

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Transport kyslíku

lPro hodnocen&iac= ute; transportu kyslíku krví je nutné znát:

= lKoncentraci celkového hemoglobinu v krvi (tHb)

lSaturaci hemoglo= binu kyslíkem (SaO2)

lFrakci oxyhemoglobinu (O2Hb)

l

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Dodávka kyslíku (oxy= gen delivery =3D DO2)

lDO2 =3D Q x cO2

l =3D Q x (1.34 x Hb x SaO2) + (0.0225 x PaO2)

l k= de Q je srdeční výdej vzta<= /span>ž= ený na povrch těla

lUdává, kolik kyslíku je periferním tkáním skutečně dodáváno. Při normálních = hodnotách srdečního indexu (2.5 - 3.5 l min/m2) je dodávka kyslíku tkáním 520 - = 720 ml/min/m2

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Spotřeba kyslíku (oxygen uptake - VO2)

<= nobr>lVO2 =3D Q x (CaO2 - CvO2)

l       =3D= Q x (1.34 x Hb) x (SaO2 - SvO2)

–=3D   135 ml/min/m2

–Představuje množství kyslíku využitého tkáněmi v daném časovém okamžiku, tedy rozdíl mezi množstvím kyslíku dodaného tkán= ím a množstvím kyslíku, který se vrac= í z venosního řečiště zpět do pravého srdce.

l&#= 13;

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Poměr kyslíkové extrakce (oxygen extraction ratio)=

lO2ER =3D VO2/DO2 x 100

l        = ; =3D 135/552 x 100 = ;

l        = ; =3D   24 %

lZa normálních okolností dodávka kyslíku významně přesahuje jeho spot= 45;ebu, tedy jen malá část dostupného kyslíku je využ= ívána pro metabolické potřeby tkání (22 - 32 %).

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Schopnost krve (hemoglobinu) uvolňovat kyslík ve tkáních

ldisociační křivka - graficky vyjádřený vztah mezi parciálním tlakem kyslíku a saturací hemoglobinu kyslíkem.

l<= /span>   pozic<= span style=3D'font-family:"Times New Roman";mso-ascii-font-family:"Times New Ro= man"; font-size:88%'>e disociační křivky hemoglobinu („halfsaturation&nb= sp; tension“) - p50. Hodnota informuje o posunu disociační křivky doprava nebo doleva. Pokles hodnot p50 signalizuje vzestup afinity hemoglobinu ke kysl<= /span>íku a následně tedy jeho zt= ížené uvolňování = do tkání a naopak.

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Schopnost krve (hemoglobinu) uvolňovat kyslík ve tkáních

<= span style=3D'font-size:88%'>lvzestup afinity Hb ke kyslíku (posun disociačn&= iacute; křivky doleva) způsobují: vzest= up pH, pokles pCO2, pokles teploty, po= kles 2,3-DPG, přítomnost COHb, fetální hemoglobin
lpokles afinity Hb ke kysl&= iacute;ku (posun disociační křivky doprava) způsobují: pokles pH, vzestup pCO2, vzestup teploty, vzestup 2,3-DPG

l&#= 13;

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Hypoxie

lHypoxick&aacu= te; hypoxie - nedostatek kyslíku v tkáních je spojený se sn<= span style=3D'font-family:"Times New Roman";mso-bidi-font-family:"Times New Rom= an"; mso-hansi-font-family:"Times New Roman"'>ížením parciální= ;ho tlaku O2 v krvi (nižší obsah kyslí= ku v krvi)

= lAnemická (transportní) hypoxie - PaO2 je normální, ale transportní schopnost Hb pro kyslík je snížená

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Hypoxie

lStagnační hypoxie - PaO2 a koncentrace <= span style=3D'position:absolute;top:34.75%;left:11.42%;width:94.56%;height:9.25= %'>hemoglobinu jsou normální, ale př<= /span>ívod krve je nedostatečný.

= lHistotoxická hypoxie= - dodávka O2 do tkání je dostateč= ;ná, ale různé toxické látky = znemožňují jeho využití v buňkách

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Kasuistika I

lPacient 50 let, bolesti na hrudi, res= uscitován, kardiomarkery pozitivní

= 68;as od příjmu

0 h

2 h

4 h

12 h

24 h

B_pH

7.= 091

7.= 126

7.= 199

7.= 408

7.= 337

B_pCO2 kPa

7.= 58

9.= 21

7.= 54

5.57

8.= 31

B_pO2 kPa

7.= 33

10= .70

25= .00

14.20

10= .90

B_ABE mmol/l

-1= 3.9

-9= .4

-7= .7

1.= 5

5.= 6

B_SBC mmol/l

13= .6

17= .0

18= .4

25= .7

29= .4

B_sO2 %       = 3;

72= .4

90= .5

98= .8

97= .6

94= .2

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Kasuistika II

lPacient 14 let, v bezvědomí, hluboké dýchání

l

Čas od pří= ;jmu

0 h

2 h

24 h

B_K     mmol/l

8.5

5.9

B_Glu mmol/l

21.9

12.0

B_pH

7.194

7.272

7.404

B_pCO2 kPa

2.16

2.26

3.78

B_pO2     kPa

7.71

10.05

12.44

B_ABEmmol/l&nb= sp;

-21.4

-15.9

-4.8

B_SBCmmol/l&nb= sp;

10.0

12.7

20.5

B_sO2 %       = 3;

86.9

95.8

98.5

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Kasuistika III

lPacientka 57 let, septick&yacut= e; stav, příznaky náhlé příhody břišní (perforace žal. vředu)

l

Čas od pří= ;jmu

0 h

6 h <= /span>

24 h

B_pH

7.26 =

7.31 =

7.38 =

B_pCO2 kPa

5.08= 3;

4.= 7

3.81 =

B_pO2     kPa

7.4 <= /span>

17.= 4

8.= 76

B_ABEmmol/l&nb= sp;

-9.= 2

-7.= 6

-6.= 0

B_SBCmmol/l&nb= sp;

16.= 9

18.= 3

19.= 4

B_sO2 %       = 3;

86.8 <= /span>

99.= 1

92.= 6

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' + ENDSHOW_MESG + '
') doc.close() } function SetSldVisited(){ GetSldList().mList[gCurSld-1].mVisited=3Dtrue } function IsSldVisited(){ return GetSldList().mList[gCurSld-1].mVisited } function hrefList( sldHref, visible, advDelay, advClk ) { this.mSldHref=3D this.mNtsHref =3D sldHref this.mOrigVis=3D this.mVis =3D visible this.mVisited=3D false this.mAdvDelay=3D advDelay this.mAdvOnClk=3D advClk } function SldList(arr,curSld,fEnd) { this.mCurSld =3D curSld; this.mList =3D new Array(); var idx =3D 1; for(ii=3D0;ii 0) { PushSldList(sldList,fEnd); gCurSld =3D 1; } else if( PPTSld.event ) PPTSld.event.cancelBubble=3Dtrue } function PushSldList(arr,fEnd) { var ii =3D gSldStack.length; gSldStack[ii] =3D new SldList(arr,gCurSld,fEnd); GoToSld( gSldStack[ii].mList[0].mSldHref ); } function PopSldList() { if (gSldStack[gSldStack.length-1].fEndShow) EndShow() else { gCurSld =3D gSldStack[gSldStack.length-1].mCurSld; gSldStack[gSldStack.length-1] =3D null; gSldStack.length--; var sldList =3D gSldStack[gSldStack.length-1]; GoToSld( sldList.mList[gCurSld - 1].mSldHref ); } } var custShowList=3Dnew Array(); function ImgBtn( oId,bId,w,action ) { var t=3Dthis t.Perform =3D _IBP t.SetActive =3D _IBSetA t.SetInactive=3D _IBSetI t.SetPressed =3D _IBSetP t.SetDisabled=3D _IBSetD t.Enabled =3D _IBSetE t.ChangeIcon =3D null t.UserAction =3D action t.ChgState =3D _IBUI t.mObjId =3D oId t.mBorderId=3D bId t.mWidth =3D w t.mIsOn =3D t.mCurState =3D 0 } function _IBSetA() { if( this.mIsOn ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _IBSetI() { if( this.mIsOn ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } function _IBSetP() { if( this.mIsOn ) { obj=3Dthis.ChgState( gShadowClr,gHiliteClr,2 ) obj.style.posLeft+=3D1; obj.style.posTop+=3D1 } } function _IBSetD() { obj=3Dthis.ChgState( gFaceClr,gFaceClr,0 ) obj.style.posTop=3D0 } function _IBSetE( state ) { var t=3Dthis GetObj( t.mBorderId ).style.visibility=3D"visible" if( state !=3D t.mIsOn ) { t.mIsOn=3Dstate if( state ) t.SetInactive() else t.SetDisabled() } } function _IBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( t.ChangeIcon ) { obj=3DGetObj(t.mObjId) if( t.ChangeIcon() ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-4)*t.mWidth else obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-0)*t.mWidth } t.SetActive() } } function _IBUI( clr1,clr2,nextState ) { var t=3Dthis SetBorder( GetObj( t.mBorderId ),clr1,clr2 ) obj=3DGetObj( t.mObjId ) obj.style.posLeft=3Dobj.style.posLeft+(t.mCurState-nextState)*t.mWidth-obj= .style.posTop t.mCurState=3DnextState return obj } function TxtBtn( oId,oeId,action,chkState ) { var t=3Dthis t.Perform =3D _TBP t.SetActive =3D _TBSetA t.SetInactive=3D _TBSetI t.SetPressed =3D _TBSetP t.SetDisabled=3D _TBSetD t.SetEnabled =3D _TBSetE t.GetState =3D chkState t.UserAction =3D action t.ChgState =3D _TBUI t.mObjId =3D oId t.m_elementsId=3D oeId t.mIsOn =3D 1 } function _TBSetA() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gHiliteClr,gShadowClr,0,0 ) } function _TBSetI() { var t=3Dthis if( t.mIsOn && !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) } function _TBSetP() { if( this.mIsOn ) this.ChgState( gShadowClr,gHiliteClr,1,1 ) } function _TBSetD() { this.ChgState( gFaceClr,gFaceClr,0,0 ) this.mIsOn =3D 0 } function _TBSetE() { var t=3Dthis if( !t.GetState() ) t.ChgState( gFaceClr,gFaceClr,0,0 ) else t.ChgState( gShadowClr,gHiliteClr,1,1 ) t.mIsOn =3D 1 } function _TBP() { var t=3Dthis if( t.mIsOn ) { if( t.UserAction !=3D null ) t.UserAction() if( !t.GetState ) return if( t.GetState() ) t.SetPressed() else t.SetActive() } } function _TBUI( clr1,clr2,lOffset,tOffset ) { SetBorder( GetObj( this.mObjId ),clr1,clr2 ) Offset( GetObj( this.m_elementsId ),lOffset,tOffset ) } function Offset( obj, top, left ){ obj.style.top=3Dtop; obj.style.left=3Dle= ft } function SetBorder( obj, upperLeft, lowerRight ) { s=3Dobj.style; s.borderStyle =3D "solid" s.borderWidth =3D 1 s.borderLeftColor =3D s.borderTopColor =3D upperLeft s.borderBottomColor=3D s.borderRightColor =3D lowerRight } function GetBtnObj(){ return gBtnArr[window.event.srcElement.id] } function BtnOnOver(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetActive() } function BtnOnDown(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetPressed() } function BtnOnOut(){ b=3DGetBtnObj(); if( b !=3D null ) b.SetInactive() } function BtnOnUp() { b=3DGetBtnObj() if( b !=3D null ) b.Perform() else Upd() } function GetNtsState(){ return parent.gNtsOpen } function GetOtlState(){ return parent.gOtlOpen } function GetOtlTxtState(){ return parent.gOtlTxtExp } function NtsBtnSetFlag( fVal ) { s=3Ddocument.all.item( this.m_flagId ).style s.display=3D"none" if( fVal ) s.display=3D"" else s.display=3D"none" } function _BSetA_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etActive() } function _BSetI_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etInactive() } function _BSetP_Border(){ b =3D gBtnArr[this.mObjId]; if( b !=3D null ) b.S= etPressed() } function _BSetA_BorderImg() { b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gHiliteClr,gShadowClr,2 ) obj.style.posTop=3D0 } } function _BSetI_BorderImg() { b =3D gBtnArr[this.mBorderId] if( b !=3D null && this.mIsOn && !b.GetState() ) { obj=3Dthis.ChgState( gFaceClr,gFaceClr,1 ) obj.style.posTop=3D0 } } var gHiliteClr=3D"THREEDHIGHLIGHT",gShadowClr=3D"THREEDSHADOW",gFaceClr=3D"= THREEDFACE" var gBtnArr =3D new Array() gBtnArr["nb_otl"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOtlPan= e,GetOtlState ) gBtnArr["nb_otlElem"] =3D new TxtBtn( "nb_otl","nb_otlElem",parent.ToggleOt= lPane,GetOtlState ) gBtnArr["nb_nts"] =3D new ImgBtn( "nb_nts","nb_ntsBorder",10,parent.ToggleN= tsPane ) gBtnArr["nb_nts"].SetActive =3D _BSetA_BorderImg; gBtnArr["nb_nts"].SetInactive =3D _BSetI_BorderImg; gBtnArr["nb_ntsBorder"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.= ToggleNtsPane,GetNtsState ) gBtnArr["nb_ntsElem"] =3D new TxtBtn( "nb_ntsBorder","nb_ntsElem",parent.To= ggleNtsPane,GetNtsState ) gBtnArr["nb_prevBorder"] =3D gBtnArr["nb_prev"]=3D new ImgBtn( "nb_prev","n= b_prevBorder",30,parent.GoToPrevSld ) gBtnArr["nb_nextBorder"] =3D gBtnArr["nb_next"]=3D new ImgBtn( "nb_next","n= b_nextBorder",30,parent.GoToNextSld ) gBtnArr["nb_sldshw"]=3D new ImgBtn( "nb_sldshw","nb_sldshwBorder",18,parent= .FullScreen ) gBtnArr["nb_sldshwBorder"] =3D new TxtBtn( "nb_sldshw","nb_sldshwBorder",pa= rent.FullScreen,null ) gBtnArr["nb_sldshwBorder"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwBorder"].SetInactive =3D _BSetI_Border; gBtnArr["nb_sldshwText"] =3D new TxtBtn( "nb_sldshw","nb_sldshwText",parent= .FullScreen,null ) gBtnArr["nb_sldshwText"].SetActive =3D _BSetA_Border; gBtnArr["nb_sldshwText"].SetInactive =3D _BSetI_Border; gBtnArr["nb_voice"] =3D gBtnArr["nb_voiceBorder"] =3D new ImgBtn( "nb_voice= ","nb_voiceBorder",18,parent.ToggleVNarration ) gBtnArr["nb_otlTxtBorder"] =3D gBtnArr["nb_otlTxt"]=3D new ImgBtn( "nb_otlT= xt","nb_otlTxtBorder",23,parent.ToggleOtlText ) gBtnArr["nb_ntsBorder"].m_flagId=3D "nb_nts" gBtnArr["nb_ntsBorder"].SetFlag =3D NtsBtnSetFlag gBtnArr["nb_otlTxt"].ChangeIcon=3D GetOtlTxtState var sNext=3D"Další",sPrev=3D"Předchozí",sEnd=3D"Kon= ec prezentace",sFont=3D"Arial",sArrow=3D"Šipka",sFreeform=3D"Voln&yacu= te; tvar",sRect=3D"Obdélník",sOval=3D"Ovál" function ShowMenu() { BuildMenu(); var doc=3DPPTSld.document.body,x=3DPPTSld.event.clientX+doc.scrollLeft,y= =3DPPTSld.event.clientY+doc.scrollTop m =3D PPTSld.document.all.item("ctxtmenu") m.style.pixelLeft=3Dx if( (x+m.scrollWidth > doc.clientWidth)&&(x-m.scrollWidth > 0) ) m.style.pixelLeft=3Dx-m.scrollWidth m.style.pixelTop=3Dy if( (y+m.scrollHeight > doc.clientHeight)&&(y-m.scrollHeight > 0) ) m.style.pixelTop=3Dy-m.scrollHeight m.style.display=3D"" } function _CM() { if( !parent.IsFullScrMode() ) return; if(!PPTSld.event.ctrlKey) { ShowMenu() return false } else HideMenu() } function BuildMenu() { if( PPTSld.document.all.item("ctxtmenu") ) return var mObj=3DCreateItem( PPTSld.document.body ) mObj.id=3D"ctxtmenu" mObj.style.visibility=3D"hidden" var s=3DmObj.style s.position=3D"absolute" s.cursor=3D"default" s.width=3D"120px" SetCMBorder(mObj,"menu","black") var iObj=3DCreateItem( mObj ) SetCMBorder( iObj, "threedhighlight","threedshadow" ) iObj.style.padding=3D2 CreateMenuItem( iObj,sNext,M_GoNextSld,M_True ) CreateMenuItem( iObj,sPrev,M_GoPrevSld,M_HasPrevSld ) CreateSeparator( iObj ) CreateMenuItem( iObj,sEnd,M_End,M_True ) mObj.style.visibility=3D"visible" } function Cancel() { window.event.cancelBubble=3Dtrue; window.event.returnVa= lue=3Dfalse } function Highlight() { ChangeClr("activecaption","threedhighlight") } function Deselect() { ChangeClr("threedface","menutext") } function Perform() { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) e.Action() else PPTSld.event.cancelBubble=3Dtrue } function ChangeClr( bg,clr ) { e=3DPPTSld.event.srcElement if( e.type=3D=3D"menuitem" && e.IsActive() ) { e.style.backgroundColor=3Dbg e.style.color=3Dclr } } function M_HasPrevSld() { return( parent.HasPrevSld() ) } function M_GoNextSld() { if( gIsEndShow ) M_End(); else GoToNextSld() } function M_GoPrevSld() { if( gIsEndShow ) { gIsEndShow=3D0; history.back();= PPTSld.event.cancelBubble=3Dtrue; } else GoToPrevSld() } function M_True() { return true } function M_End() { window.close( self ) } function CreateMenuItem( node,text,action,eval ) { var e=3DCreateItem( node ) e.type=3D"menuitem" e.Action=3Daction e.IsActive=3Deval e.innerHTML=3Dtext if( !e.IsActive() ) e.style.color=3D"threedshadow" e.onclick=3DPerform e.onmouseover=3DHighlight e.onmouseout=3DDeselect s=3De.style; s.fontFamily=3DsFont s.fontSize=3D"9pt" s.paddingLeft=3D2 } function CreateSeparator( node ) { var sObj=3DCreateItem( node ) SetCMBorder(sObj,"menu","menu") var s=3DsObj.style s.borderTopColor=3D"threedshadow" s.borderBottomColor=3D"threedhighlight" s.height=3D1 s.fontSize=3D"0px" } function CreateItem( node ) { var elem=3DPPTSld.document.createElement("DIV") node.insertBefore( elem ) return elem } function SetCMBorder( o,ltClr,rbClr ) { var s=3Do.style s.backgroundColor=3D"menu" s.borderStyle=3D"solid" s.borderWidth=3D1 s.borderColor=3DltClr+" "+rbClr+" "+rbClr+" "+ltClr } ------=_NextPart_01CA5E65.B7F62470 Content-Location: file:///C:/B13410B2/abr_soubory/fullscreen.htm Content-Transfer-Encoding: quoted-printable Content-Type: text/html; 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Po= známky

Prezentac= e

Osnova

1

Acidobazick&aacu= te; rovnováha

2

Brönstedova= teorie

Kyselina je donorem protonu

HA      &nbs= p;        H⁺ + A^-

Báze je akceptorem protonu

B + H⁺      &nbs= p;      BH⁺

3

Koncentrace H+

pH =3D -log [H⁺]

Fyziologické hodnoty

pH =3D 7.40

[H⁺] =3D 40 nmol/L

Srovnání s ostatními soluty

[Na⁺] =3D 140 mmol/L

[K⁺] =3D 4 mmol/L

[HCO₃^-] =3D 24 mmol/L

4

Henderson-Hassel= balchova rovnice

K_a

log K_a =3D log [H⁺] + log

-log [H⁺] =3D - log K_a + log

pH =3D pK_a = + log

5

Nárazn&ia= cute;kové systémy (pufry)

Roztoky slabé kyseliny a silné zásady (nebo opa= čně) mají schopnost vyrovnávat výkyvy pH

Fyziologické pufrační systémy

hemoglobin

plasmatické proteiny

fosfáty

kosti

bikarbonát/kyselina uhličitá

6

Titračn&iac= ute; křivky acidobazických párů

7

Principy izohydr= ie

Poměr mezi disociovanou a nedisociovanou formou kteréhok= oliv pufru je závislý pouze na pH a pK_a pro daný pár

Všechny pufrační systémy v těle jsou v rovnováze

Změna v poměru koncentrací jednoho páru zm&#= 283;ní koncentrační poměr i u ostatních pufrů<= /li>

8

Pufrován&= iacute; kyselé nálože

9

Pufrován&= iacute; alkalické nálože

10

Systém k= yseliny uhličité/bikarbonátu

H₂O + CO₂       = ;H₂CO₃       = ; H⁺ + HCO₃^-

K_a =3D

pH =3D pK_a + log

pH =3D 6.1 + log

11

Systém k= yseliny uhličité/bikarbonátu

Otevřený pufrovací systém

PCO₂ určen alveolární ventilací= ; (v rovnováze s alveolárním vzduchem), respira= 9;ní složka

[HCO₃^-] regulován ledvinami, metabolic= ká složka

Efektivita tohoto systému je tedy mnohem větš&iacut= e;, než by vyplývalo z jeho pK_a =3D 6.1

12

Denní ex= krece kyselin

Těkavé kyseliny: 15 mol/den

Z oxidativního metabolismu cukrů= ;, tuků a proteinů na CO₂

Netěkavé kyseliny: 1 mmol/kg/den

oxidace sulfhydrylových skupina na H₂SO₄

Hydrolýza fosfoproteinů, fosfolipidů a nukleových kyselin na H₃PO₄

Inkompletní metabolismus cukrů, tuků a protein$= 7; na organické kyseliny

13

Renáln&i= acute; acidobazická homeostáza

Reabsorpce bikarbonátu z primární moče

4 500 mmol HCO₃ je přefiltrováno glomerulem<= /li>
Reabsorpce v proximálníkm tubulu

Regenerace bikarbonátu ztraceného pufrován&iacu= te;m metabolismem vzniklých netěkavých kyselin

Distální sekrece protonů

Syntéza amoniaku

14

Acidobazick&aac= ute; homeostáza:
Proximání tubulus

15

Tubulárn= í reabsorpce bikarbonátu

16

Reabsorpce HCO<= sub>3^- v proximálním tubul= u

Negativní stimuly

volumová expanze

alkalémie

hyperkalémie

hypokapnie

Pozitivní stimuly

deplece cirkulujícího volumu

deplece chloridů

acidémie

hypokalémie

hyperkapnie

17

Acidobazick&aac= ute; homeostáza:
sběrný kanálek

18

Distáln&= iacute; sekrece H⁺

Stimulace

přebytek sodíku intraluminálně

přebytek mineralokortikoidů

Inhibice

nedostatek sodíku intraluminálně

hypoaldosteronismus

deficit pufrů intraluminálně

19

Pufry moče=

Titrovatelné kyseliny

fosfáty

sulfáty

organické kyseliny

Amoniak

Bikarbonát

20

Exkrece amoniak= u

Syntéza v proximálním tubulu

stimulace

acidémie

hypokalémie

inhibice

alkalémie

hyperkalémie

Recyklace ve dřeni

Zachycení ve sběrném kanálku

Závislá na sekreci H+ a luminálním pH

21

Acidobazick&aac= ute; homeostáza:
Amoniogeneze

22

Záchyt a= moniaku ve dřeni ledvin

23

Záchyt a= moniaku ve dřeni ledvin

NH₄⁺ je zachycen ve dřeni ve sběrn&e= acute;m kanálku pH gradientem mezi sběrným kanálke= m a intersticiem dřeně ledvin

24

Vztah exkrece N= H₄⁺ a pH moče

25

Čist&aacut= e; sekrece H⁺ ledvinami

U_H₊ =3D U_TA + U_NH_{4<=
/sub>₊
- U_HCO₃_-}

Titrovatelná kyselina: 30-50 mmol/den

NH₄⁺: 30-50 mmol/den

HCO₃^-: zanedbatelný

Free H⁺: zanedbatelný

26

Analytika ABR

Vzorek heparinizované plné krve

arteriální, kapilární, venózní smíšená

Měří se: pH, pCO₂ (potenciometrie)

Počítá se (van Slykeovy rovnice):

cHCO₃^- (mmol/l)=3D0,23pCO₂ x 10= ^(pH-6,1)

       = ; BE_ect=3D (c HCO₃^- -24,2) + 1= 4,8 (pH-7,4)

27

Analytika ABR

Stewart-Fenclův přístup nezávislých p= roměnných

pCO₂

SID =3D Na ⁺ +K ⁺ +Ca ²⁺ +Mg ^2=
+ -Cl ^–

A_tot =3D albumin + fosfát

28

Poruchy acidobazické rovnováhy: Terminologie

Acidóza

Proces, který směřuje ke snížení= ; pH krve

Alkalóza

Proces, který směřuje ke zvýšení= ; pH krve

Acidémie

arteriální krev pH < 7.36

Alkalémie

arteriální krev pH > 7.44

29

Poruchy acidobazické rovnováhy: Terminologie

Kompenzace

Fyziologická snaha respiračního nebo renálního systému o návrat k fyziologickému pH

Korekce

Léčebné zásahy směřujíc&= iacute; k odstranění poruchy ABR

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Poruchy acidobazické rovnováhy: Terminologie

Jednoduchá porucha

Je přítomna pouze jedna výchylka ABR a jej&iacut= e; kompenzační proces

Smíšená porucha

Přítomny dvě a více odchylek ABR a jejich kompenzace. Výsledné pH závisí na sm= 83;ru jednotlivých odchylek a jejich síle.

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Jednoduch&eacut= e; poruchy ABR

32

Metabolick&aacu= te; acidóza

Hyperchloremická (normalní anion gap)

Snížená exkrece kyselin

Zvýšená ztráta bikarbonátů
Přísun protonů

Anion gap

33

Anion Gap

AG =3D [Na⁺] - [Cl^-] - [HCO3^-]

Fyziologická hodnota: 10 ± 2 mmol/l

Hlavní neměřené anionty

albumin

fosfáty

sulfáty

organické anionty

34

Anion Gap

35

Pří= činy metabolické acidózy se zvýšeným Anion Ga= pem

Zvýšený aniont

b-hydroxybutyrát, acetoacetát

b-hydroxybutyrát, acetoacetát, laktát

laktát

fosfát, sulfát, organické anionty

formát, laktát

oxalát, glycolát

ketokyseliny, laktát, salicylát

organické anionty

Typ

diabetická ketoacidóza

alkoholická acidóza

laktátová acidóza

selhání ledvin

jedy

methanol

ethylenglykol

salicylát

paraldehyd

36

Pří= činy hyperchloremické metabolické acidózy

Snížení renální exkrece chlorid$= 7;

Selhání ledvin

Distální RTA

Renální ztráty bikarbonátu

Proximální RTA

Inhibitory karboanhydrázy

37

Pří= činy hyperchloremické metabolické acidózy

Ztráty bikarbonátů GIT

průjem

Derivace pankreatických nebo střevních tekutin

38

Proximál= ní renální tubulární acidóza

39

Distáln&= iacute; renální tubulární acidóza

40

Metabolick&aacu= te; acidóza při renálním selhání

Časná (hyperchloremická)

Deficit pufrů v moči pro poruchu amoniogeneze

Acidifikační děje bývají zachovány

Může být doprovázena hyperkalémi&iac= ute;

Pozdní (zvýšený anion gap)

Retence fosfátů, sulfátů a organický= ch aniontů

41

Metabolick&aacu= te; alkalóza: Příčiny

GIT

Ztráta žaludeční kyselny

Průjem se ztrátami chloridů

Ztráta kyselin

Ledvinami

diuretika

předávkování mineralokortikoidy

Cushingův sy

těžký deficit kalia

42

Metabolick&aacu= te; alkalóza: Příčiny

Přísun bazí

Podání bikarbonátu

Infuze organických aniontů

citrát

acetát

laktát

Rychlá korekce chronické hyperkapnie

43

Respiračn&= iacute; acidóza

Postižení výměny plynů v plicích=

Obstrukce dýchacích cest

Postižení dýchacích svalů

Postižení centra pro dýchání v CNS<= /li>

Hyperkapnie - pCO_=
2nad 5,8 kPa

44

Respiračn&= iacute; alkalóza

Hypoxémie s hyperventilací

Patologická stimulace dýchacího centra

Umělá ventilace pacienta

Hypokapnie - pCO₂₌pod 4,8 kPa

45

Diagnostika por= uch ABR

Anamnéza

Fyzikální vyšetření

Elektrolyty, krevní plyny

Komplexní pohled na stav pacienta, klinické a laborato= rní vyšetření

46

Mapa ABR

47

Transport kyslíku

48

Regulace dýchání

nervové mechanismy mozkového kmene

chemické detekční mechanismy - chemoreceptory

reflexní mechanismy

suprapontinní mechanismy (vlivy z mozkové ků= ry, hypothalamu)

49

Fyziologie zásobování tkání kyslíkem

Stav alveoloarteriální bariéry (plicní funkce, lung oxygen uptake)

Transport kyslíku krví - kapacita arteriáln&iac= ute; krve pro transport kyslíku

Schopnost krve (hemoglobinu) uvolnit kyslík ve tkáních (poloha disociační k"= 5;ivky hemoglobinu)

50

Parciáln= í tlak kyslíku

Parciální tlak kyslíku v arteriální krvi (PaO₂) je zák= ladním ukazatelem kapacity plic pro výměnu plynů.

Neinformuje o obsahu kyslíku v krvi!!

Lépe o plicních funkcích informuje alveolo-arteriální diference tenze kyslíku (p&#= 345;ípadně poměr těchto hodnot).

51

Stanovení= ; PaO₂, sO₂

Stanovuje se z plné krve modifikovanou Clarkovou elektrodou (amperometrie).

Koncentrace totHb, oxyHb, deoxyHb, COHb, MetHb se měř&iacu= te; spektrofotometricky.

Počítá se:

sO₂=3D oxyHb / (oxyHb + deoxyHb)

cO₂(ml/l)=3D1,39 cHbO₂(g/l) + 0,225pO_{2 =}(kPa)

52

Transport kyslíku

Pro hodnocení transportu kyslíku krví je nutné znát:

Koncentraci celkového hemoglobinu v krvi (tHb)

Saturaci hemoglobinu kyslíkem (SaO₂)

Frakci oxyhemoglobinu (O₂Hb)

53

Dodávka kyslíku (oxygen delivery =3D DO₂)

DO₂ =3D Q x cO₂

=3D Qx (1= .34 x Hb x SaO₂) +(0.0225 x PaO2)

kde Q je srdeční výdej vztažený na povrch těla

Udává, kolik kyslíku je periferním tk&aa= cute;ním skutečně dodáváno. Při normáln&i= acute;ch hodnotách srdečního indexu (2.5 - 3.5 l min/= m²) je dodávka kyslíku tkáním 520 - 720 ml/m= in/m²

54

Spotřeba kyslíku (oxygen uptake - VO₂)

VO₂=3D Q x (CaO₂-CvO_=
2)

       =3D Q x (1= .34 x Hb) x (SaO_=
2- SvO₂)

=3D   135 ml/min= /m²

Představuje množství kyslíku využit&e= acute;ho tkáněmi v daném časovém okam&#= 382;iku, tedy rozdíl mezi množstvím kyslíku dodan= ého tkáním a množstvím kyslíku, který se vrací z venosního řeč= iště zpět do pravého srdce.

55

Poměr kyslíkové extrakce (oxygen extraction ratio)

O₂ER =3D VO₂/DO₂x 100

       = ;   =3D 135/552 x 1= 00

       = ;   =3D   24 %<= /li>
Za normálních okolností dodávka kysl&iac= ute;ku významně přesahuje jeho spotřebu, tedy jen mal= á část dostupného kyslíku je využ&iacut= e;vána pro metabolické potřeby tkání (22 - 32 %).=

56

Schopnost krve (hemoglobinu) uvolňovat kyslík ve tkáních

disociační křivka - graficky vyjádř= ený vztah mezi parciálním tlakem kyslíku a saturací hemoglobinu kyslíkem.

n   pozice disociační křivky hemoglobinu („halfsaturation tension“) - p50. Hodnota informuje o posunu disoci= ační křivky doprava nebo doleva. Pokles hodnot p50 signalizuje vzest= up afinity hemoglobinu ke kyslíku a následně te= dy jeho ztížené uvolňování do tkání a naopak.

57

Schopnost krve (hemoglobinu) uvolňovat kyslík ve tkáních

vzestup afinity Hb ke kyslíku (posun disociační k= řivky doleva) způsobují: vzestup pH, pokles pCO₂, pokles teploty, pokles 2,3-DPG, přítomnost COHb, fetální hemoglobin

pokles afinity Hb ke kyslíku (posun disociační k&= #345;ivky doprava) způsobují:&nbs= p; pokles pH, vzestup pCO₂, vzestup teploty, vzestup 2,3-DPG

58

Hypoxie

Hypoxická hypoxie - nedostatek kyslíku v tk&aa= cute;ních je spojený se snížením parciálního tlaku O₂v krvi (niž&= #353;í obsah kyslíku v krvi)

Anemická (transportní) hypoxie - PaO₂ je normální, a= le transportní schopnost Hb pro kyslík je sníž= ;ená

59

Hypoxie

Stagnační hypoxie - PaO₂ a koncentrace hemoglobinu jsou normální, ale přívod krve= je nedostatečný.

Histotoxická hypoxie - dodávka O₂do tk&aac= ute;ní je dostatečná, ale různé toxické l&aa= cute;tky znemožňují= jeho využití v buňkách

60

Kasuistika I

Pacient 50 let, bolesti na hrudi, resuscitován, kardiomarkery pozitivní

61

Kasuistika II

Pacient 14 let, v bezvědomí, hluboké dýchání

62

Kasuistika III<= /a>

Pacientka 57 let, septický stav, příznaky n&aacut= e;hlé příhody břišní (perforace žal. v&#= 345;edu)

<= /a>= = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = = =
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1	Acidobazick&aacu= te; rovnováha
2	Brönstedova= teorie Kyselina je donorem protonu HA &nbs= p; H⁺ + A^- Báze je akceptorem protonu B + H⁺ &nbs= p; BH⁺
3	Koncentrace H+ pH =3D -log [H⁺] Fyziologické hodnoty pH =3D 7.40 [H⁺] =3D 40 nmol/L Srovnání s ostatními soluty [Na⁺] =3D 140 mmol/L [K⁺] =3D 4 mmol/L [HCO₃^-] =3D 24 mmol/L
4	Henderson-Hassel= balchova rovnice K_a log K_a =3D log [H⁺] + log -log [H⁺] =3D - log K_a + log pH =3D pK_a = + log
5	Nárazn&ia= cute;kové systémy (pufry) Roztoky slabé kyseliny a silné zásady (nebo opa= čně) mají schopnost vyrovnávat výkyvy pH Fyziologické pufrační systémy hemoglobin plasmatické proteiny fosfáty kosti bikarbonát/kyselina uhličitá
6	Titračn&iac= ute; křivky acidobazických párů
7	Principy izohydr= ie Poměr mezi disociovanou a nedisociovanou formou kteréhok= oliv pufru je závislý pouze na pH a pK_a pro daný pár Všechny pufrační systémy v těle jsou v rovnováze Změna v poměru koncentrací jednoho páru zm&#= 283;ní koncentrační poměr i u ostatních pufrů<= /li>
8	Pufrován&= iacute; kyselé nálože
9	Pufrován&= iacute; alkalické nálože
10	Systém k= yseliny uhličité/bikarbonátu H₂O + CO₂ = ;H₂CO₃ = ; H⁺ + HCO₃^- K_a =3D pH =3D pK_a + log pH =3D 6.1 + log
11	Systém k= yseliny uhličité/bikarbonátu Otevřený pufrovací systém PCO₂ určen alveolární ventilací= ; (v rovnováze s alveolárním vzduchem), respira= 9;ní složka [HCO₃^-] regulován ledvinami, metabolic= ká složka Efektivita tohoto systému je tedy mnohem větš&iacut= e;, než by vyplývalo z jeho pK_a =3D 6.1
12	Denní ex= krece kyselin Těkavé kyseliny: 15 mol/den Z oxidativního metabolismu cukrů= ;, tuků a proteinů na CO₂ Netěkavé kyseliny: 1 mmol/kg/den oxidace sulfhydrylových skupina na H₂SO₄ Hydrolýza fosfoproteinů, fosfolipidů a nukleových kyselin na H₃PO₄ Inkompletní metabolismus cukrů, tuků a protein$= 7; na organické kyseliny
13	Renáln&i= acute; acidobazická homeostáza Reabsorpce bikarbonátu z primární moče 4 500 mmol HCO₃ je přefiltrováno glomerulem<= /li> Reabsorpce v proximálníkm tubulu Regenerace bikarbonátu ztraceného pufrován&iacu= te;m metabolismem vzniklých netěkavých kyselin Distální sekrece protonů Syntéza amoniaku
14	Acidobazick&aac= ute; homeostáza: Proximání tubulus
15	Tubulárn= í reabsorpce bikarbonátu
16	Reabsorpce HCO<= sub>3^- v proximálním tubul= u Negativní stimuly volumová expanze alkalémie hyperkalémie hypokapnie Pozitivní stimuly deplece cirkulujícího volumu deplece chloridů acidémie hypokalémie hyperkapnie
17	Acidobazick&aac= ute; homeostáza: sběrný kanálek
18	Distáln&= iacute; sekrece H⁺ Stimulace přebytek sodíku intraluminálně přebytek mineralokortikoidů Inhibice nedostatek sodíku intraluminálně hypoaldosteronismus deficit pufrů intraluminálně
19	Pufry moče= Titrovatelné kyseliny fosfáty sulfáty organické kyseliny Amoniak Bikarbonát
20	Exkrece amoniak= u Syntéza v proximálním tubulu stimulace acidémie hypokalémie inhibice alkalémie hyperkalémie Recyklace ve dřeni Zachycení ve sběrném kanálku Závislá na sekreci H+ a luminálním pH
21	Acidobazick&aac= ute; homeostáza: Amoniogeneze
22	Záchyt a= moniaku ve dřeni ledvin
23	Záchyt a= moniaku ve dřeni ledvin NH₄⁺ je zachycen ve dřeni ve sběrn&e= acute;m kanálku pH gradientem mezi sběrným kanálke= m a intersticiem dřeně ledvin
24	Vztah exkrece N= H₄⁺ a pH moče
25	Čist&aacut= e; sekrece H⁺ ledvinami U_H₊ =3D U_TA + U_NH_{4<= /sub>₊ - U_HCO₃_-} Titrovatelná kyselina: 30-50 mmol/den NH₄⁺: 30-50 mmol/den HCO₃^-: zanedbatelný Free H⁺: zanedbatelný
26	Analytika ABR Vzorek heparinizované plné krve arteriální, kapilární, venózní smíšená Měří se: pH, pCO₂ (potenciometrie) Počítá se (van Slykeovy rovnice): cHCO₃^- (mmol/l)=3D0,23pCO₂ x 10= ^(pH-6,1) = ; BE_ect=3D (c HCO₃^- -24,2) + 1= 4,8 (pH-7,4)
27	Analytika ABR Stewart-Fenclův přístup nezávislých p= roměnných pCO₂ SID =3D Na ⁺ +K ⁺ +Ca ²⁺ +Mg ^2= + -Cl ^– A_tot =3D albumin + fosfát
28	Poruchy acidobazické rovnováhy: Terminologie Acidóza Proces, který směřuje ke snížení= ; pH krve Alkalóza Proces, který směřuje ke zvýšení= ; pH krve Acidémie arteriální krev pH < 7.36 Alkalémie arteriální krev pH > 7.44
29	Poruchy acidobazické rovnováhy: Terminologie Kompenzace Fyziologická snaha respiračního nebo renálního systému o návrat k fyziologickému pH Korekce Léčebné zásahy směřujíc&= iacute; k odstranění poruchy ABR
30	Poruchy acidobazické rovnováhy: Terminologie Jednoduchá porucha Je přítomna pouze jedna výchylka ABR a jej&iacut= e; kompenzační proces Smíšená porucha Přítomny dvě a více odchylek ABR a jejich kompenzace. Výsledné pH závisí na sm= 83;ru jednotlivých odchylek a jejich síle.
31	Jednoduch&eacut= e; poruchy ABR
32	Metabolick&aacu= te; acidóza Hyperchloremická (normalní anion gap) Snížená exkrece kyselin Zvýšená ztráta bikarbonátů Přísun protonů Anion gap
33	Anion Gap AG =3D [Na⁺] - [Cl^-] - [HCO3^-] Fyziologická hodnota: 10 ± 2 mmol/l Hlavní neměřené anionty albumin fosfáty sulfáty organické anionty
34	Anion Gap
35	Pří= činy metabolické acidózy se zvýšeným Anion Ga= pem Zvýšený aniont b-hydroxybutyrát, acetoacetát b-hydroxybutyrát, acetoacetát, laktát laktát fosfát, sulfát, organické anionty formát, laktát oxalát, glycolát ketokyseliny, laktát, salicylát organické anionty Typ diabetická ketoacidóza alkoholická acidóza laktátová acidóza selhání ledvin jedy methanol ethylenglykol salicylát paraldehyd
36	Pří= činy hyperchloremické metabolické acidózy Snížení renální exkrece chlorid$= 7; Selhání ledvin Distální RTA Renální ztráty bikarbonátu Proximální RTA Inhibitory karboanhydrázy
37	Pří= činy hyperchloremické metabolické acidózy Ztráty bikarbonátů GIT průjem Derivace pankreatických nebo střevních tekutin
38	Proximál= ní renální tubulární acidóza
39	Distáln&= iacute; renální tubulární acidóza
40	Metabolick&aacu= te; acidóza při renálním selhání Časná (hyperchloremická) Deficit pufrů v moči pro poruchu amoniogeneze Acidifikační děje bývají zachovány Může být doprovázena hyperkalémi&iac= ute; Pozdní (zvýšený anion gap) Retence fosfátů, sulfátů a organický= ch aniontů
41	Metabolick&aacu= te; alkalóza: Příčiny GIT Ztráta žaludeční kyselny Průjem se ztrátami chloridů Ztráta kyselin Ledvinami diuretika předávkování mineralokortikoidy Cushingův sy těžký deficit kalia
42	Metabolick&aacu= te; alkalóza: Příčiny Přísun bazí Podání bikarbonátu Infuze organických aniontů citrát acetát laktát Rychlá korekce chronické hyperkapnie
43	Respiračn&= iacute; acidóza Postižení výměny plynů v plicích= Obstrukce dýchacích cest Postižení dýchacích svalů Postižení centra pro dýchání v CNS<= /li> Hyperkapnie - pCO_= 2nad 5,8 kPa
44	Respiračn&= iacute; alkalóza Hypoxémie s hyperventilací Patologická stimulace dýchacího centra Umělá ventilace pacienta Hypokapnie - pCO₂₌pod 4,8 kPa
45	Diagnostika por= uch ABR Anamnéza Fyzikální vyšetření Elektrolyty, krevní plyny Komplexní pohled na stav pacienta, klinické a laborato= rní vyšetření
46	Mapa ABR
47	Transport kyslíku
48	Regulace dýchání nervové mechanismy mozkového kmene chemické detekční mechanismy - chemoreceptory reflexní mechanismy suprapontinní mechanismy (vlivy z mozkové ků= ry, hypothalamu)
49	Fyziologie zásobování tkání kyslíkem Stav alveoloarteriální bariéry (plicní funkce, lung oxygen uptake) Transport kyslíku krví - kapacita arteriáln&iac= ute; krve pro transport kyslíku Schopnost krve (hemoglobinu) uvolnit kyslík ve tkáních (poloha disociační k"= 5;ivky hemoglobinu)
50	Parciáln= í tlak kyslíku Parciální tlak kyslíku v arteriální krvi (PaO₂) je zák= ladním ukazatelem kapacity plic pro výměnu plynů. Neinformuje o obsahu kyslíku v krvi!! Lépe o plicních funkcích informuje alveolo-arteriální diference tenze kyslíku (p&#= 345;ípadně poměr těchto hodnot).
51	Stanovení= ; PaO₂, sO₂ Stanovuje se z plné krve modifikovanou Clarkovou elektrodou (amperometrie). Koncentrace totHb, oxyHb, deoxyHb, COHb, MetHb se měř&iacu= te; spektrofotometricky. Počítá se: sO₂=3D oxyHb / (oxyHb + deoxyHb) cO₂(ml/l)=3D1,39 cHbO₂(g/l) + 0,225pO_{2 =}(kPa)
52	Transport kyslíku Pro hodnocení transportu kyslíku krví je nutné znát: Koncentraci celkového hemoglobinu v krvi (tHb) Saturaci hemoglobinu kyslíkem (SaO₂) Frakci oxyhemoglobinu (O₂Hb)
53	Dodávka kyslíku (oxygen delivery =3D DO₂) DO₂ =3D Q x cO₂ =3D Qx (1= .34 x Hb x SaO₂) +(0.0225 x PaO2) kde Q je srdeční výdej vztažený na povrch těla Udává, kolik kyslíku je periferním tk&aa= cute;ním skutečně dodáváno. Při normáln&i= acute;ch hodnotách srdečního indexu (2.5 - 3.5 l min/= m²) je dodávka kyslíku tkáním 520 - 720 ml/m= in/m²
54	Spotřeba kyslíku (oxygen uptake - VO₂) VO₂=3D Q x (CaO₂-CvO_= 2) =3D Q x (1= .34 x Hb) x (SaO_= 2- SvO₂) =3D 135 ml/min= /m² Představuje množství kyslíku využit&e= acute;ho tkáněmi v daném časovém okam&#= 382;iku, tedy rozdíl mezi množstvím kyslíku dodan= ého tkáním a množstvím kyslíku, který se vrací z venosního řeč= iště zpět do pravého srdce.
55	Poměr kyslíkové extrakce (oxygen extraction ratio) O₂ER =3D VO₂/DO₂x 100 = ; =3D 135/552 x 1= 00 = ; =3D 24 %<= /li> Za normálních okolností dodávka kysl&iac= ute;ku významně přesahuje jeho spotřebu, tedy jen mal= á část dostupného kyslíku je využ&iacut= e;vána pro metabolické potřeby tkání (22 - 32 %).=
56	Schopnost krve (hemoglobinu) uvolňovat kyslík ve tkáních disociační křivka - graficky vyjádř= ený vztah mezi parciálním tlakem kyslíku a saturací hemoglobinu kyslíkem. n pozice disociační křivky hemoglobinu („halfsaturation tension“) - p50. Hodnota informuje o posunu disoci= ační křivky doprava nebo doleva. Pokles hodnot p50 signalizuje vzest= up afinity hemoglobinu ke kyslíku a následně te= dy jeho ztížené uvolňování do tkání a naopak.
57	Schopnost krve (hemoglobinu) uvolňovat kyslík ve tkáních vzestup afinity Hb ke kyslíku (posun disociační k= řivky doleva) způsobují: vzestup pH, pokles pCO₂, pokles teploty, pokles 2,3-DPG, přítomnost COHb, fetální hemoglobin pokles afinity Hb ke kyslíku (posun disociační k&= #345;ivky doprava) způsobují:&nbs= p; pokles pH, vzestup pCO₂, vzestup teploty, vzestup 2,3-DPG
58	Hypoxie Hypoxická hypoxie - nedostatek kyslíku v tk&aa= cute;ních je spojený se snížením parciálního tlaku O₂v krvi (niž&= #353;í obsah kyslíku v krvi) Anemická (transportní) hypoxie - PaO₂ je normální, a= le transportní schopnost Hb pro kyslík je sníž= ;ená
59	Hypoxie Stagnační hypoxie - PaO₂ a koncentrace hemoglobinu jsou normální, ale přívod krve= je nedostatečný. Histotoxická hypoxie - dodávka O₂do tk&aac= ute;ní je dostatečná, ale různé toxické l&aa= cute;tky znemožňují= jeho využití v buňkách
60	Kasuistika I Pacient 50 let, bolesti na hrudi, resuscitován, kardiomarkery pozitivní
61	Kasuistika II Pacient 14 let, v bezvědomí, hluboké dýchání
62	Kasuistika III<= /a> Pacientka 57 let, septický stav, příznaky n&aacut= e;hlé příhody břišní (perforace žal. v&#= 345;edu)