Clinical Note

Examples of Metabolic Alkalosis

It is difficult to induce alkalosis in a normal individual by administering large quantities of alkali because of the ease of increasing the renal excretion of HCO—. Ordinarily, the factor responsible for the generation of the elevated plasma HCO— is easily identified. With vomiting or gastric aspiration, the loss of hydrochloric acid together with NaCl, K+, and volume results in a rise in the HCO— concentration, as in the first equilibrium reaction above. Loop diuretics and thiazide diuretics increase H+ excretion. Augmented renal excretion of H+ also accounts for the generation of HCO— in conditions in which there is an excess of adrenal steroids, which directly stimulate H+ secretion in the distal tubule and collecting duct.

When alkalosis occurs because of gastric volume losses, excessive HCO— reabsorption often continues even when renal function is normal. This excessive reabsorption can be corrected only when the ECF volume and Cl— deficit is replaced, and thus this condition is referred to as contraction alkalosis. The explanation for the increased reabsorption of HCO— after such volume losses may involve many factors including Cl— and K+ depletion. Loss of Na+ and the associated contraction of extracellular volume restrict HCO— excretion by increasing the avidity with which the proximal tubule reabsorbs Na+. The increased Na+-H+ antiport in the proximal tubule also increases HCO— reabsorption, but Cl— depletion also plays an important role. For reasons that are not clear, volume replacement must include Cl— for the alkalosis to be corrected.

Step 1

Mixed Acid-Base Disorder there is an underlying mixture of alkalosis and acidosis; both the Pqo2 and HC03" values must be abnormal t t pH < 7.37 pH > 7.43

Acidemia Alkalemia

FIGURE 6 Step 1 in a systematic analysis of acid-base status. When examining the values obtained from an arterial blood gas analysis, the first step is to determine if the plasma pH is normal. A plasma pH below 7.37 is called acidemia and it suggests the presence of an acidosis as the primary disorder. A plasma pH above 7.43 is called alkalemia and it suggests the presence of an alkalosis as the primary disorder. However, the plasma pH may also be in the normal range if there are offsetting primary acid-base disorders.

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