01:58,15,Jan,2009 | (1080/0/0) | Original

combined metabolic and respiratory acidosis


[Favorite] [Set Home] metabolic acidosis of clinical manifestations Copyright www.wfwcyy.com on this article do not understand [the Advisory online expert] multiple metabolic acidosis, or primary disease have a clear incentive, therefore, mostly that focus on the primary disease. Metabolic acidosis is a major impact on the body caused by the cardiovascular system and central nervous system dysfunction. In contrast, metabolic acidosis compared the performance characteristic is the breath to deepen, accelerate, known as Kussmaul breathing.
1. Acidosis on the cardiovascular system, cardiovascular system, including: â‘  decreased myocardial contractility. In addition to hydrogen ion concentration in cardiac metabolism, but also through the reduction of myocardial calcium influx, reduced sarcoplasmic reticulum calcium release and competitive inhibition of binding calcium and troponin, the myocardial contractility decreased. â‘¡ arrhythmia. Acidosis so that the relocation of intracellular potassium ions, coupled with increased renal tubular cells secrete hydrogen ions and potassium ions to reduce emission, so the elevated serum potassium. Hyperkalemia can cause cardiac arrhythmia, severe heart block can occur, or ventricular fibrillation. â‘¢ reduced vascular sensitivity to catecholamines. Reduction of hydrogen ions increased capillary and arteriolar smooth muscle before the sphincter response to the catecholamines, leading to peripheral vasodilatation, blood pressure, slightly reduced.
2. Metabolic acidosis, central nervous system showed inhibition of the central nervous system function, such as unresponsiveness, lethargy, severe cases coma. The occurrence of the following factors: â‘  inhibiting biological oxidation of hydrogen ions increased the activity of enzymes that weaken the process of oxidative phosphorylation, ATP generated less brain energy supply. â‘¡ acidosis increased brain glutamate decarboxylase activity, the inhibitory neurotransmitter GABA generates an increase.
3. Metabolic acidosis, respiratory system respiratory center to stimulate chemoreceptors, respiratory rate accelerated rate of deepening, known as Kussmaul breathing, normal lung function, can Pac0, down; but in a very severe metabolic acidosis or hypokalemia combined , due to the decline in respiratory muscle contraction, breathing weakened.
4. Digestive system is often a lack of appetite, nausea, vomiting, sometimes diarrhea, abdominal pain.
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combined metabolic and respiratory acidosis

VIII chronic pulmonary heart disease
I. Overview
Chronic pulmonary heart disease (chronic pulmonary heart disease) is due to lung tissue, lung
or thoracic vascular changes caused by chronic lung structure and / or pulmonary dysfunction, resulting in increased pulmonary vascular resistance, pulmonary hypertension, thereby causing the right ventricle hypertrophy, enlargement, right heart failure or even heart disease.
Second, the cause of
(A) chronic bronchitis complicated by emphysema most common, accounting for about 80-90%.
(B) of the thorax movement disorders
(C) pulmonary vascular disease
Third, the pathogenesis
Hypoxia: the most important factor of pulmonary hypertension ↘
Hypercapnic pulmonary vasoconstriction, spasm
Respiratory acidosis ↗ ↓
↓
Function of the increase in pulmonary vascular resistance factors
Anatomy of the increase in pulmonary vascular resistance factors
Increased blood volume and blood viscosity increased
↓
Pulmonary hypertension compensatory right ventricular hypertrophy →
↓
→ decompensated right heart right heart failure
Example: pulmonary heart disease pulmonary hypertension, the most important reason is
A, pulmonary artery occlusion
B, reduced pulmonary capillary bed
C, increased blood volume
D, increased blood viscosity
E, pulmonary artery spasm
Q 【ID: 21030601】
The correct answer: E
Fourth, clinical manifestations
(A) of the lung, decompensated cardiac function (including remission)
1, the symptoms: the performance of the primary disease that is chronic bronchitis, emphysema symptoms.
2, the signs:
(1) cyanosis
(2) signs of emphysema
(3) right ventricular hypertrophy: P2 hyperthyroidism prompted pulmonary hypertension, significant systolic xiphoid heart beating under the prompt right ventricular hypertrophy.
(B) of the lung, decompensated cardiac function (including acute exacerbation): decompensated chronic pulmonary heart disease caused by the most common causes are acute respiratory infections. Mainly as
1, respiratory failure:
(1) symptoms: disturbance of consciousness.
(2) signs: obvious cyanosis; conjunctival hyperemia, edema.
2, heart failure: the main performance of right heart failure.
Fifth, complications
(A) of the pulmonary encephalopathy: the respiratory failure due to lack of oxygen, carbon dioxide retention, which leads to mental disorders, neurological symptoms of a syndrome. Chronic pulmonary heart disease mortality.
(B) of the acid-base imbalance and electrolyte disturbance; the most common respiratory acidosis.
(C) of the arrhythmia, atrial arrhythmia, disorders of which the most characteristic of atrial tachycardia.
(D) Other: gastrointestinal bleeding; septic shock; disseminated intravascular coagulation; multiple organ failure (MOF) and so on.
Example: chronic pulmonary heart disease the most common cause of arrhythmia is
A, atrial premature beats and atrial tachycardia
B, atrial fibrillation
C, premature ventricular contractions
D, ventricular tachycardia
E, atrioventricular block
【Q & A ID: 21030602】
The correct answer: A
VI, auxiliary examination
(A) X-ray examination:
1, X-ray features of primary disease: underlying disease and signs of acute lung infection.
2, pulmonary hypertension syndrome: expansion of the right lower pulmonary artery, diameter ≥ 15mm; its diameter and the ratio of tracheal diameter ≥ l.07; prominent pulmonary artery segment was the height> 3mm.
3, increase the right ventricle: apex convex.
(B) ECG: P waves are mainly pulmonary and right ventricular hypertrophy performance.
(C) echocardiography
1, the right ventricular outflow tract diameter ≥ 30mm; right ventricular diameter ≥ 20mm.
2, left ventricular diameter ratio <2.
(D) blood gas analysis:
1, when the Pa02 <60mmHg, PaC02> 50mmHg can be diagnosed as respiratory failure.
2, acid-base balance: the most common respiratory acidosis, pH decline, PaC02 increased. Followed by respiratory acidosis metabolic acidosis.
VI, diagnosis
(A) of the primary disease, the respiratory system: such as chronic bronchitis, obstructive emphysema.
(B) to determine the pulmonary hypertension and right ventricular hypertrophy (signs, X ray, ECG, etc.) or signs of right heart failure.
Example: pulmonary heart disease and chronic bronchitis, emphysema, there are many similarities of clinical signs, but the difference is with pulmonary heart disease
A, difficulty breathing, symptoms of cyanosis
B, signs of severe emphysema
C, pulmonary hypertension and signs of increased right ventricular
D, blood gas analysis: Pa02 <60mmHg, PaC02> 50mmHg
E, X-ray examination showed an increase in double-lung markings, increased lung field through the brightness
【Q & A ID: 21030603】
The correct answer: C
Seven, treatment
Treatment of acute exacerbation of the key is: positive control of infection; smooth respiratory tract; improve the respiratory function; correct hypoxia and carbon dioxide retention, correct respiratory failure; correct heart failure.
(A) infection control: acute respiratory infection is pulmonary heart disease induced decompensation and an important factor in exacerbations. The first choice of antibiotics based on the specific situation, and then sputum culture and drug sensitivity test adjustment.
(B) oxygen therapy, airway patency: improve ventilation, correct the oxygen and carbon dioxide retention, treatment of respiratory failure.
(C) control of heart failure: the treatment of chronic pulmonary heart disease and other heart failure treatment heart failure has its differences, which effectively control the infection, improve respiratory function, heart failure can often be corrected. Following the above treatment fails or recurrent disease, severe heart failure still need to use diuretics, digitalis preparations and vasodilators.
1, diuretics: the role of a small amount of light using diuretics.
2, digitalis preparations: for infection has control, respiratory failure has improved, poor efficacy of diuretics, heart failure who can not be corrected. Patients with pulmonary heart disease, poor tolerance of digitalis drugs, can lead to poisoning. Therefore, the dose should be small (1/2-2/3 of the volume), should use rapid onset, rapid excretion of drugs, such as intravenous drug lanatoside or lanatoside C K. It should be noted: not to the efficacy of heart rate as indicators of digitalis.
(D) control arrhythmias: arrhythmias in patients with pulmonary heart disease usually caused by hypoxia, infection, acid-base imbalance, electrolyte disorders and side effects of digitalis due to excessive and aminophylline. In the above-mentioned factors are controlled or eliminated, the majority of patients with arrhythmia may disappear.
(E) to correct acid-base imbalance and electrolyte disturbance
Example: Female, 58 years old, repeated coughing, sputum for 15 years, shortness of breath 5 years, almost 1 week of fever, shortness of breath, lower extremity edema hospitalized. Examination: BP140/90mmHg, lip cyanosis, jugular vein engorgement, barrel chest, lungs hyperresonance percussion can be heard and dry, moist rales, P2 hyperthyroidism, heart rate 110 beats / min, and premature beats can be heard (3 times / min), see the heart beating under the xiphoid, hepatomegaly (Youlei under 4.5cm), soft, tenderness (), liver neck reflux symptoms (), lower extremity pitting edema. The preferred treatment of patients
A, effective infection control
B, rapid bolus cardiac drugs
C, rapid strong diuretic injection
D, Rapid correction of arrhythmia
E, rapid intravenous vasodilators
【Q & A ID: 21030604】
The correct answer: A
IX respiratory failure
I. Overview
Respiratory failure is due to a variety of causes lung ventilation and (or) ventilation with severe dysfunction, leading to hypoxemia with / or without hypercapnia, in turn raises a number of pathophysiological changes and clinical manifestations of the syndrome. Diagnosis depends on arterial blood gas analysis. At sea level, resting breathing air, Pa02 less than 60mmHg or accompanied PaC02 than 50mmHg, and to rule out heart anatomy and primary shunt reduction in cardiac output caused by hypoxia and other factors, to confirm the diagnosis.
Second, classification
(A) in accordance with the classification of arterial blood gas analysis
I-respiratory failure: hypoxic respiratory failure, Pa02 less than 60mmHg, PaC02 reduced or normal, mainly seen in severe lung infections.
Type II respiratory failure: hypercapnic respiratory failure, Pa02 less than 60mmHg, PaC02 higher than 50mmHg, mainly seen in patients with chronic obstructive pulmonary disease (COPD).
(B) the classification of disease Jihuan
1, acute respiratory failure:
2, chronic respiratory failure: The most common is chronic obstructive pulmonary disease (COPD), as the damage gradually increased respiratory function
After a long time to develop from.
Third, the cause of
(A) obstructive airway diseases: chronic obstructive pulmonary disease (COPD), severe bronchial asthma.
(B) lung disease: pneumonia, severe tuberculosis.
(C) pulmonary vascular disease: pulmonary embolism.
(D) of the thorax and pleural disease: thoracic deformity, extensive pleural thickening.
(E) neuromuscular diseases: cerebrovascular disease, brain trauma.
In particular, the various causes of chronic obstructive pulmonary disease (including chronic bronchitis, emphysema) is the most common.
Fourth, clinical manifestations (chronic respiratory failure)
Acute respiratory infections cause acute exacerbations of chronic respiratory failure and decompensation of the most common causes. The clinical manifestations of respiratory failure than the performance of the primary disease, but mainly by the oxygen and carbon dioxide retention caused by the performance.
(A) difficulty in breathing
Or in combination with respiratory dysfunction and increased respiratory infections.
(B) cyanosis
Is a typical expression of hypoxia, when arterial oxygen saturation of less than 90% can occur when the lips, nail bed cyanosis phenomenon.
(C) of the spirit of the neurological symptoms
Can be expressed as PaC02 increased inhibition after the first excitement. Excitement symptoms include: insomnia, irritability, etc.; and suppression of pulmonary encephalopathy occurred as follows: conscious indifference, intermittent seizures, lethargy, and even coma.
(D) circulatory system
Oxygen and carbon dioxide retention, the heart rate; high blood pressure; may arise from lack of oxygen before the contraction of, atrial fibrillation; severe cases, there may be ventricular fibrillation, cardiac arrest.
(E) digestive system
Severe hypoxia and carbon dioxide retention can cause extensive gastric mucosal congestion, edema, erosion, and stress ulcer bleeding, causing upper gastrointestinal bleeding; some cases there may be alanine aminotransferase (ALT) increased.
(VI) urinary system
Some patients had renal dysfunction, manifested as oliguria, hematuria, proteinuria, tubular urine, plasma urea nitrogen increased.
(G) acid-base balance and electrolyte disorders
Chronic respiratory failure during respiratory acidosis in the most common, followed by respiratory acidosis with metabolic alkalosis. Acidosis, increased serum potassium, alkali poisoning reduced. No certain rule changes in serum sodium.
V. Blood gas analysis
(A) arterial oxygen partial pressure (Pa02)
Normal: 80 ~ 100mmHg, <60mmHg suggest respiratory failure.
(B) arterial carbon dioxide partial pressure (PaC02)
Normal: 35 ~ 45mmHg; respiratory acidosis PaCO2 increased, decreased when respiratory alkalosis; if PaC02> 50mmHg suggest respiratory failure.
(C) of the blood pH (pH)
Normal is 7.35 ~ 7.45; pH alkalosis prompted increased, pH decreased prompted acidosis; but the pH difference is not unusual respiratory or a metabolic factors, be combined with PaC02, HCO3-changes and the clinical comprehensive analysis of other information.
(D) bicarbonate (HCO3-)
Normal is 22 ~ 27mmol / L; it is the body's metabolic acid-base balance of quantitative indicators; HC03-increased metabolic alkalosis prompted to reduce the prompt metabolic acidosis.
(E) base excess (BE)
Normal value ± 2.3mmol / L; the blood samples were titrated to pH 7.4, the consumption amount of acid or alkali, acid is positive, negative and alkali.
Six treatment
Treatment principle: under the conditions of maintaining the airway, improve and correct the oxygen metabolism of carbon dioxide retention and orderly
Chaos, control complications, thus predisposing factor based on the treatment of diseases and to gain time and create the conditions.
(A) clear the airway, increasing ventilation: hypoxic and corrected to improve the basic conditions for carbon dioxide retention.
1, a bronchodilator.
2, expectorant therapy: use of expectorant drugs or inhalation.
3, respiratory stimulants: a serious lack of ventilation, especially for those associated with disturbance of consciousness; application of respiratory stimulants on the premise that we must keep the airway open. The use of respiratory stimulants had no significant effect of l2 hours, the patient did not recover consciousness, consider endotracheal intubation or tracheostomy for mechanical ventilation.
4, endotracheal intubation or tracheostomy for severe cases (PaO2 ≤ 45mmHg, PaCO2 ≥ 70mmHg), or unconsciousness or even coma, and respiratory secretions of a large number of patients should be considered for endotracheal intubation or incision, establishment of artificial airway, mechanical ventilation.
(B) to correct hypoxia
For the oxygen with carbon dioxide retention in patients with type Ⅱ respiratory failure, should adopt the continuous low concentration of low-flow oxygen (inspired oxygen flow rate 1 ~ 3L/min, the concentration of 25 ~ 33%); inspired oxygen concentration (%) = 21 4 × oxygen flow (L / min). Because patients with chronic hypercapnic respiratory center of the chemical receptors on the CO2 response is poor, mainly by hypoxemia on breathing of carotid body, aortic body chemoreceptor stimulation to maintain. If the high oxygen concentration, so that oxygen rapidly rising, lifting the hypoxic peripheral chemoreceptor stimulation, patients will suppress respiration, causing further deterioration of ventilation, CO2 increase.
(C) infection control
Is an important measure for treatment of respiratory failure. When signs of respiratory tract infection should be based on sputum culture and drug susceptibility testing, selection of effective antimicrobial agents.
(D) water, electrolyte and acid-base imbalance treatment of chronic respiratory failure is often accompanied by respiratory acidosis, the treatment of major initiatives is to improve the ventilation, excessive discharge of carbon dioxide; concurrent metabolic acidosis, the discretion to use a small amount of 5 % sodium bicarbonate infusion, but to pay attention to maintaining airway patency; respiratory failure in a large number of diuretics, and corticosteroids after the often complicated by low potassium, low chloride acidosis, metabolic alkalosis produced, should be promptly added potassium, chloride, and intravenous infusion of arginine hydrochloride available.
(E) symptomatic treatment
Example: The male, admitted to hospital with respiratory failure due to pulmonary heart disease. Mind clear admission physical examination, blood gas analysis: Pa030mmHg, PaC0260mmHg. After getting oxygen unclear consciousness, coma, blood gas analysis: Pa0270mmHg, PaC0280mmHg. In this case the most likely cause of deterioration is ()
A, increased infection
B, increase of heart failure
C, increased airway resistance
D, oxygen inappropriate
E, peripheral circulatory failure
【Q & A ID: 21030701】
The correct answer: D
Example: Male, 71 years of age, smoking patients. Recurrent cough, sputum, asthma for 40 years, nearly 1 week to cough yellow sputum, and difficult to cough up thick, daytime sleepiness, sleepless night, wake up this morning and found the emergency call. Physical examination: BP148/90mmHg Pa02 <60mmHg, PaC02> 50mmHg, sleeping like, pupils and other large, conjunctival edema, neck soft, barrel chest, lungs could be heard and more dry, moist rales, heart rate 120 beats / min , could be heard and premature beats, pitting edema of both lower extremities, pathological reflex was not elicited.
1, the patient most likely reason is sleeping
A, cerebral hemorrhage
B, cerebral thrombosis
C, cerebral infarction
D, pulmonary encephalopathy
E, metabolic alkalosis
【Q & A ID: 21030702】
The correct answer: D
2 May due to further determine the drowsiness, the most meaningful is the first choice
A, cardiac ultrasound
B, chest X-ray film
C, blood gas analysis
D, brain CT
E, ECG
【Answer ID: 21030703】
The correct answer: C
3, assuming that the reasons identified above, the preferred treatment is
A, use of diuretics
B, use of expectorant drugs
C, continuous low concentration of oxygen
D, use of bronchodilators
E, endotracheal intubation or tracheostomy
【Q & A ID: 21030704】
The correct answer: E
Complications:
1. Acidosis http://www.huoguan.com acid poisoning is the primary substance of any alkaline or acidic substances essential to reduce the pH value can increase in abnormal (not compensated or not compensated adequately) or normal (full compensation or complex disorder); the contrary is Bian Bian net alkalosis is any net increase in primary alkaline or acid substances to reduce Mai primary, while the pH value can be abnormal (not compensated by or on behalf compensation is not sufficient) or normal (fully compensated or complex disorders) Que network. Acid-base disorders can lead to complex changes in pH value is more significant (such as respiratory acidosis metabolic acidosis), also can return to normal pH value (such as respiratory acidosis with metabolic alkalosis) in the pH value of the normal health search acidosis or alkalosis do not need to add basic drugs in patients with Mai or acid treatment of drug Mai only the primary disease or predisposing factor to Mai
2. Hyperlipidemia acidosis is the acid pH value of less than normal http://www.huoguan.com, hyperlipidemia is a means of alkali pH value is greater than normal health search in patients with severe acidosis need
to add alkali drugs, and hyperlipidemia in patients with severe alkali acidic drugs need to add a healthy acidosis acidosis search is simple, it can be acidosis alkalosis (eg, severe respiratory acidosis combined with mild metabolic alkalosis) http:/ / www.huoguan.com, and hyperlipidemia can put forth a single alkaline soda poisoning, can also be combined Que network is alkalosis acidosis (such as severe respiratory alkalosis combined with mild metabolic acidosis)
Therefore, both acid and alkali poisoning and acid-base hyperlipidemia hyperlipidemia different but related http://www.huoguan.com acid pH must merge poisoning, acid poisoning is not http://www.huoguan.com Mai combined hyperlipidemia certain clinical acid-base or acid with alkaline pH hyperlipidemia drug therapy is not healthy acid-base search is generally http://www.huoguan.com poisoning http://www.huoguan.com.
3. Alkalosis the heart and brain blood vessels, reducing blood supply to further increase the tissue hypoxia
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