Metabolic – the change of acid-base balance of the internal environment connected with accumulation of hydroxyl OH-and "alkalization" anions of blood. It is shown in the form of heavy respiratory and sosudodvigatelny violations. At shift of pH (a hydrogen indicator) more than on 0,2-0,3 there is a coma, on 0,4 – the patient perishes. The state is diagnosed on the basis of results of the analysis on KShchS. Specific treatment – hydrochloric acid before normalization of a ratio of ions of OH-and H+, restoration of balance of electrolytes, correction of the diseases which became the reason of metabolic failure.
Metabolic (not gas) – the frustration arising at loss of ions of hydrogen, chlorine, potassium against the background of the safe or increased quantity of hydroxyl molecules in blood. Meets at various pathological states. Comes to light at the patients of a resuscitation profile who underwent the procedure of the forced diuresis with violation of the technology of manipulation more often. Can proceed in the compensated and dekompensirovanny forms, character of a current is determined by the pH level. Dekompensirovanny versions are observed at insufficiency of compensatory and adaptive mechanisms. Pathology demands correction at compensation stage, otherwise chances of success of treatment decrease.
Reasons of a metabolic alkaloz
Change of concentration of the ions which are taking part in regulation of KShchS arises under the influence of external or internal etiofaktor. Loss of H+ as a result of their mechanical removal from an organism leads to formation of a chlorosensitive form of a disease. Chlororesistant versions become result of internal pathological processes. Are the most common causes:
- External factors. MA develops at the gipovolemiya created owing to the wrong use of diuretics, blood loss when losing gastric contents against the background of vomiting, washing of a stomach via the probe, existence of a gastrostoma. The states arising in attempts of medicamentous correction of acidosis and a compensatory metabolic kind of frustration also enter into this group.
- Internal factors. MA is one of symptoms of such diseases as a stenosis of a renal artery, reninprodutsiruyushchy tumors, malignant arterial hypertension. Pathology comes to light at hormonal violations – increase in production of an adrenokortikotropin, glucocorticosteroids. In certain cases metabolic becomes result of hyper correction of ketoacidosis and lactateacidosis.
At a deviation of a hydrogen indicator in the alkaline party in an organism there is a number of negative changes. Redistribution of electrolytes between a cage and intercellular liquid is observed that breaks processes of polarization and depolarization. Oppression of fermental systems, hypoventilation of compensatory type is noted. Ability of hemoglobin to contact oxygen increases, ability of blood to delete carbon dioxide at the same time decreases, the oxyhemoglobin dissociation curve moves.
The described process leads to accumulation of CO2 in fabrics, respiratory violations, a fabric hypoxia. Against the background of deterioration in oxygenation of cages damage of a brain, including its sosudodvigatelny center is formed. It becomes the reason of change of a vascular tone, fluctuations of arterial pressure. Initially level HELL increases, later decreases to the shock or not defined figures. At final stages activity of bark of a brain is oppressed, the coma develops.
Metabolic it is classified by the level of a hydrogen indicator and sensitivity to therapy by the chlorocontaining medicines. At a safe hydrogen indicator pathology is considered compensated, is not followed by heavy violations. If the shift of pondus Hydrogenii makes more than 0,1, there is a violation of the vital functions of an organism. Alkalemiya proceeds in a chlorosensitive or chlororesistant form:
- Chlorosensitive. Arises at loss by an organism of a large number of ions of chlorine. It is rather easily corrected by introduction of physiological solution of sodium of chloride. It is usually provoked by the external reasons. At a long current is followed by a compensatory delay of sodium and chlorides which release with urine decreases to 10 mmol/litre.
- Chlororesistant. Meets at somatic diseases increase in concentration of kortikosteroidny hormones. There is a strengthened removal to urine of the chlorides connected with potassium and sodium. The gipokaliyemiya develops. Distinctive feature of chlororesistant versions is lack of effect of introduction of NaCl of 0,9%.
Symptoms of a metabolic alkaloz
The compensated kinds of an alkalemiya at patients with Burnett's syndrome, gastric pathology can is long to proceed without noticeable manifestations. Over time patients have hypostases, turgor of skin decreases, appetite worsens, there is a generalized itch. Disgust for milk and dairy products is possible. Due to adjournment of salts of calcium in kidney tubules secretory ability of kidneys worsens. The clinical picture is formed in several months or years after the beginning of a disease.
Alkaloza of easy degree are followed by a headache, drowsiness and fatigue, strengthening of neuromuscular excitability. At some patients convulsive reductions of separate muscle fibers come to light, arterial pressure decreases. Partial blockade of intracardial conductivity, premature ventricular contraction is possible. At medium-weight and severe forms the takhiaritmiya is noted. Patients complain of heartbeat, breast pains. Kloniko-tonic spasms, nonsense, consciousness violations are observed.
Heavy alkaloza break work of pulmonary system. Short wind with increase in frequency of respiratory movements, , inclusion of auxiliary muscles is found in patients. There is a hypoxia which leads to defeat of the muscular device and development of a rabdomioliz. The myoglobin which is formed at the same time is allocated with urine, giving it dark color. There is an obstruction of kidney tubules. In an organism nitrogenous slags collect, extent of violation of acid-base balance increases.
Refer renal and respiratory failure, fibrillation of ventricles of heart to number of complications of an alkalemiya. ODN proceeds on secondary type, is more characterized by a giperkapniya. OPN arises owing to obstruction of tubules deposits of calcium and a myoglobin, is shown by an anury or an oliguriya. Fibrillation of ventricles actually represents cardiac arrest, demands holding resuscitation actions. All specified processes can come to light during the first hours from an onset of the illness if the expressed metabolic violations take place. The compensated MA forms do not lead to development of similar complications.
The diagnosis metabolic is in most cases exposed by the doctor the intensivist or the therapist. Can define a state also other experts with the higher medical education, familiar with the KShchS normal values. Differential diagnostics is carried out with metabolic acidosis, a gas alkaloz. In the first case in serum increase in ions of H+, decrease pH less than 7,35, in the second is found – the recent alveolar hyperventilation is defined. MA is diagnosed with use of the following methods:
- Anamnesis, fizikalny inspection. The clinical signs characteristic of this or that extent of alkalization of the internal environment come to light. At the anamnesis there is repeated vomiting, washings of a stomach, the diseases of adrenal glands which are followed by the strengthened production of kortikotropny hormones. Signs are not specific therefore to make the diagnosis only on their basis inadmissibly.
- Laboratory analyses. The main way of definition of metabolic failures – the analysis of arterial blood on KShchS and electrolytes. At MA the indicator of pH exceeds 7,4, the partial pressure of carbon dioxide makes more than 40 mm of mercury., standard bicarbonate is higher than 25 mmol/litre, surplus of the bases more than 5 mmol/litre. Decrease in concentration of potassium, magnesium, serum chlorides is noted. At the compensated current laboratory indicators are in limits of referensny values.
- Hardware researches. Directly metabolic it is not diagnosed by hardware methods therefore similar techniques have auxiliary value. The depression of a segment of ST and a negative tooth of T on the ECG, decrease in a saturation by results of a pulsoksimetriya is an indirect sign. At a radiographic research of kidneys in them congestions of kalitsifikat are found. During gastroscopy symptoms of chronic gastritis, stomach ulcer quite often come to light.
Treatment of a metabolic alkaloz
Elimination of primary process which led to development of metabolic violations is the cornerstone of therapy. Patients are directed to consultation to the gastroenterologist, with ulcer defects appoint the medicines promoting scarring of an ulcer. It is recommended to refuse the soaking-up antatsid. Treatment of hormonal violations is performed by the endocrinologist. At frequent vomiting apply the means reducing excitability of the emetic center, medicine of the choice is tserukat or . For direct treatment of an alkalemiya and its consequences use the next ways:
- Medicamentous. To the patient appoint chloride sodium infusions. At deficiency of ions of K+ enter glyukozo-potassium mix to which at a lack of magnesium add magnesium sulfate. At a hyperactivity of hormones of adrenal glands it is recommended . The hydrogen indicator at the level of 7,7 and demands introduction of weak solutions of hydrochloric acid to the central vein above. As an alternative HCL can be applied ammonium chloride, however it is contraindicated at a renal failure.
- Equipment rooms. Are used as a way of maintenance of activity in cases when metabolic leads to heavy frustration. The patients suffering from respiratory insufficiency need performing oxygenotherapy or IVL. At violation of kidney function the hemodialysis for removal of nitrogenous connections is appointed. At fibrillation of ventricles electropulse therapy is shown.
At Burnett's syndrome caused by consumption in food of a large amount of milk or baking soda, medicamentous correction is not required. The condition of patients is normalized within several days after removal from a diet of alkaline products. An exception – the started cases at which chronic insufficiency of function of kidneys develops. In need of carrying out a hemodialysis of the patient hospitalize, carry out a filtration of blood and medicamentous correction of water-salt balance.
Forecast and prevention
The forecast of MA depends on the course of the main disease. The versions provoked by frequent vomiting, washing of a stomach, gastritis usually easily give in to correction. Medicinal change of pondus Hydrogenii without treatment of primary process at a giperaldosteronizm is irrational as pathology will constantly recur. The severe forms of an alkaloz which are followed by complications have the adverse forecast. The risk of death of the patient against the background of violations of a warm rhythm, intoxication products of own metabolism, a gipoksemiya is high.
Prevention consists in timely treatment of the diseases capable to lead to metabolic changes. Digestive tract pathology, frequent causeless vomiting demand consultation of the gastroenterologist. When finding the patient in ORIT the task of prevention of an alkalemiya lays down on the doctor on duty. Daily tests on concentration of electrolytes in serum, studying of gases of blood and pH are shown to patients with high risk of alkalization. It allows to reveal changes at an initial stage and to carry out necessary correction.