Acid Base Balance-dina

7/24/2019 Acid Base Balance-dina

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ACID-BASE BALANCE

Dina Nilasari


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Defnition

Bronsted and Lowry's defnition :

An acid is a substance that donates a proton in a

reaction, while a base is a substance that accepts aproton in a reaction.

Arrhenius's defnition :

An acid is a substance that increases the

concentration o hydrogen ion (H+ when dissol!edin water and a base is a substance that increasesthe concentration o hydro"yl ion (#H$ whendissol!ed in water.


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Defnition

Acidemia: PH < 7,3

Al!alemia: PH" 7,## Acidosis: Proses $an% menai!!an &H'(

Al!alosis: Proses $an% men)r)n!an&H'(


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Why a normal pH is

very important ?


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*a+or Aderse conse)ences o.seere al!alemia

Cardiovascular

Arteriolar constriction Reduction of coronary blood flowRespiratory Hypoventilation Hypercarbia and hypoksemiaMetabolic stimulation of anaerobic glycolysis

production of organic acid hypokalemia hypomagnesemia and hypophosphatemiaCerebral reduction of cerebral blood flow tetany, seizure, stupor


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Kondisi [H+] nmol/L pH Klinik

Asidemi > 100 < 7,0 Letal

Asidemi 50 80 7,1 7,3 e!"atian

#o!mal $0 % 7,$ 0,0% #o!mal

Alkalemi %0 3& 7,$$ 7,&' e!"atian

Alkalemi < %0 > 7,70 Letal

Dikuti dari kuliah dr!arlindun an " " !D#$%H dalam kuliah mimbar &$'( tentan asam#basa


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Hende!son(Hassel)al*"

H% + -% H++ H-3(

)*aw mass action+ kC-. / k.0H12HC-3#4

k5k. / $a / H12 HC-3#5C-.

6H17 / $a 2 pC-.5HC-3#

pH / # log H1

pH / # log $a 1 log 0HC-3#5pC-.4

pH . &,10 + lo [H-3(] [0,03 p-%]2

Ata

[H+] . %$ p-% / [H-3]


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Normal Blood Gas Value

Measurement Arterial blood Mixed venous Venous

pH (range)

7.40(7.7!7.44)

7."(7.#!7.4#)

7."(7.#!7.4#)

p$%(mmHg)

(de&reases 'ith age)

0!#00 !40 0!0

p*$%(mmHg) "!44 4#!# 40!%

$%saturation

(de&reases 'ith age)

+, "0!0 "0!

H*$!

(m-/) 123 mmol/5

%%!%" %%!%" %%!%

Base di66eren&e (de6i&it/e&ess)

!% to 8% !% to 8% !% to 8%

Clinicians pocket reference, 10thedition


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9rimary disorders

Primary disorder Problem pH HCO3 pCO2

:eta;oli& a&idosis Gain o6 H8 or loss o6 H*$

:eta;oli& al


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>ompensasi

=enal&ompensation

:eta;oli&

al


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Com/ensation

0om/ensasi: %espirasi:Hi/er ata) 1i/oentilasi

mem/en%ar)1i C2 )nt)! !om/ensasi /rosesmeta4oli! $an% /rimer, ter+adi dalam 1it)n%anmenit

%enal:5etensi ata) e!s!resi H( ata) HC23ole1 %in+al )nt)! !om/ensasi /roses res/irasi

/rimer, dalam 1it)n%an +am sam/ai 1ari *e!anisme !om/ensasi tida! /erna1

men%!ore!si PH sam/ai normal Bila PHnormal mi6ed disorder


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&id!;ase nomogram

Harrisons Principles of Internal Medicine, 16thedition


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Lan%!a1 /en%1it)n%an

Conto1:

PH 7, PC2 #8 HC23 9

LAN0AH I

H(; # 6 PC2

HC23

H(

;7,8-/H= 6 >?? @ #6 #8

9

; @ #?

Am4il sam/le dara1 )lan%


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PH 7, PC2 #8HC23 9

LAN0AH II

Acidemia: /H < 7,3

Al!alemia: /H " 7,##

LAN0AH III

0enali %an%%)an P5I*E5NA

Conto1: Cari $an% ara1n$a sama

Asidemia (=0enai!an C2 ata) Pen)r)nan HC23

PC2 ; #8 ;

HC23 ; 9; tida! coco!


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*a!a /rimern$a asidosis res/iratori!

Bila &e $nya searah

HC23 ; /C2 ; ?

Primern$a adala1 $an% /alin% 4esar/er4edaan$a Asidosis meta4oli!


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LAN0AH I

Per%)na!an ta4el di 4aa1 ini )nt)! men%1it)n%!om/ensasi

Bila 4er4eda

mi6ed disorder


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9redi&tion o6 &ompensatory responses on simple a&id!;ase

distur;an&es

Harrisons Principles of Internal Medicine, 17th edition


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PH 7, PC2 #8HC23 9

Asidosis res/iratori!

!roni!

HC23 menin%!at # tia/ /enin%!atan PaC2 >? mmH%

PaC2 menin%!at 8 8>? 6 #

HC23 # ( 3, ; 7,

)i*ple asidosis respiratori&


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nion Gap

Anion gap = Na - Cl ! HCO3"

Normal value # $-%2 m&'()

*e+ers to t,e relations,ip among t,e bodys .ations

Na"/ and anions Cl and HCO3"

0,e gap represents t,e anions not routinelymeasured sul+ates/ p,osp,ates/ proteins/ and

organi. a.ids/ su., as la.ti. a.id and 1etone a.ids"


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LAN0AH

Hit)n% anion %a/

Na- FCl( HC23G

Normal : 8-> mmol

Bila menin%!at lan+)t!an !e LAN0AH I


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A; 9 HC23 ;

Lan%!a1 I

Hit)n% delta A dan EPECEDHC23

BANDIN0ANJJ

Delta A 9->? ; >9

HC23 $an% di1ara/!an ; #->9 ;

meta4olic acidosis


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Conto1 soal

Pasien > ta1)n den%an D*, na)sea, omitin%, a4dominal/ainK

Anion %a/ ; 3 HC23 ; >8

Delta A: >3

E6/ected HC23 #->3 ; >>

Berarti ada $an% HC23 n$a asidosis meta4oli! mi6edal!alosis meta4oli! dari m)nta1n$aK


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ASID2SIS *EAB2LI0

4 6#4#KAA# 9:;K4 AA=

44 K6H4LA#A# 4KA9#A

444 966#4 AA= ?ion(H@


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DIE5ENSIASI EI2L2IASID2SIS *EAB2LI0

. -/0A1A %#230) A)A4

A/ 4-/0A1 (Asid.la&tat, &etoasid.

. 0-HLA/A B0A%B#A1

A/ #%4AL (2iare, %1A, nhibitor

5arbonic Anhidrase

. %-1-) A)A4 (ion$H

A/ 4-/0A1 (502 )tage 6$6

A/ #%4AL (%1A7, %1A8

Dikutip dari kuliah dr!arlindungan ", "p!D#$%H dalam kuliah mimbar &$'( tentang asam#basa


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Metabolic acidosis

Anion gap

normal

%ut

Diarrhea

&istule(leal loop

Renal

R8A

Carbonicanhydrase

inhibitor

92ogenous

"alicylates

Methanol!araldehyde

9ndogenous

*actic acidosis

$etoacidosis

# diabetic

#starvation

'remia


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@i66erential diagnosis

Causes o+ ,ig,-anion-gap metaboli. a.idosis

Aoins

-thylene gli&ol

:ethanol

2ali&ylates

=enal 6ailure

(a&ute and &hroni&)

a&ti& a&idosis

>etoa&idosis@ia;eti&

l&oholi&

2tarvation

Harrisons Principles of Internal Medicine, 16th edition


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@i66erential diagnosis

Gastrointestinal ;i&ar;onate loss @iarrhea

-ternal pan&reati& or small!;o'el drainage

reterosigmoidostomyC DeDunal loopC ileal loop

@rugs *al&ium &hloride (a&idi6ying agent)

:agnesium sul6ate (diarrhea)

*holestyramine (;ile a&id diarrhea)

=enal a&idosis Hypo


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ANI2N-AP M5IN

A da!a", no!mal

A(!in . [?#a + K@ -l] !in

A(!in mennkkan "asil mins pada ente!itis

6ksk! Amonia dan -l tini dalam !in

A(!in mennkkan "asil positip

9A(1,9A($,K )distal tak mamp

eksk! Amonia, -l dan

ion(H


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*ana%ement

5orrect the underlying disorder

1reat*ent with bicarbonate should bereser!ed or se!ere *etabolic acidosis(pH9.;

H5#< needed = ;,8 " B> " ?H5#illous adenoma

92cess

mineralocorticoid

# Cushing syndrome

# Conn+s syndrome# 92ogenous steroid

# ?artter+s syndrome

; me


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@i66erential

diagnosisHarrisons Principles of

Internal Medicine, 17th edition


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*ana%ement

Correct t1e )nderl$in% ca)se

C1loride-res/onsie

5e/lace ol)me it1 NaCl i. de/leted

Correct 1$/o!alemia i. /resent

NH#Cl and HCl s1o)ld 4e resered .or e6tremecases

C1loride-resistant

reat )nderl$in% /ro4lem


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Primar$ /C2

/H , &HC23-'

Aleolar 1$/oentilation

5es/irator$ Acidosis


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Dierential Dia%nosis

Central Dr)%s anest1etics,

mor/1ine, sedatie= Stro!e In.ection

Aira$ 24str)ction Ast1ma

Parenc1$mal Em/1$sema

Pne)moconiosis Bronc1itis Ad)lt res/irator$

distress s$ndrome Barotra)ma

Ne)rom)sc)lar Poliomielitis

0$/1oscoliosis

*$ast1enia

*)sc)lard$stro/1ies

*iscellaneo)s

24esit$ H$/oentilation

Permissie1$/erca/nia

O1at 1a//ens in res/irator$


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O1at 1a//ens in res/irator$acidosis

entilation

C-.

H.- H.C-3H

HC-3

Respiratory

center

Respiratory

rate

>asodilatation of

cerebral vessel

Cerebral edema,

depress C="

Conserve

bicarbonate,

sodium ions

92crete

hydrogen

ions

=aHC-3

$


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Si%ns and s$m/toms

Headac1e

Altered L2C: restlessness coma

ine Qa//in% tremor, de/resses reQe6es

Na)sea, omitin%

ac1$cardia, entric)lar arr1$t1mias

Cardiac arrest


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*ana%ement

Int)4ation, mec1anical entilation

Increase entilator rate, loerin% /C2

reat )nderl$in% ca)se

*onitor ital si%ns, ne)rolo%ic stat)s, assess

cardiac r1$t1m


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5es/irator$ Al!alosis

Primar$ /C2

/H

, &HC23-

'

Aleolar 1$/erentilation R1$/oca/nia

Di ti l Di i


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Dierential Dia%nosis Central stim)lation

An6iet$,

1$/erentilations$ndrome, /ain,/s$c1osis

Head tra)ma or CAit1 central ne)ro%enic1$/erentilation

*enin%itis, ence/1alitis )mors eer, earl$ se/sis

Dr)%s or 1ormones Pre%nanc$,

/ro%esterone Catec1olamines Nicotine Salic$lates ant1ines s)c1 as

amino/1$line

Stim)lation o. c1estrece/tors

lail c1est Cardiac .ail)re P)lmonar$ em4olism

H$/o6emia or iss)e

1$/o6ia Hi%1 altit)de Pne)monia,

/)lmonar$ edema As/iration Seere anemia

*iscellaneo)s He/atic .ail)re H$/ert1$roidism Iatro%enic mec1anical

oerentilation

O1 t 1 i i t


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O1at 1a//ens in res/irator$al!alosis

respiratory rate

or depth

C-.

elimination

!C-.

pH

A*$A*-

"("


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Si%ns and s$m/toms

An increase in t1e rate and de/t1 o. res/irations

ac1$cardia

An6io)s, restless, m)scle ea!ness, dic)lt$4reat1in%

Con.)sion or s$nco/e

Alternatin% /eriods o. a/nea and 1$/erentilation


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Si%ns and s$m/toms

H$/erreQe6ia, car/o/edal s/asm, tetan$,arr1$t1mias, seiT)res, coma

EC c1an%es:

/rolon%ed P5 interal, a Qattened ae, a/rominent M ae, a de/ressed S se%ment


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*ana%ement

*onitor ital si%ns

*onitor inta!e and o)t/)t

IKK t1era/$

*onitor AB and ser)m electrol$te leels

26$%en t1era/$, 4reat1 into a /a/er 4a%,mec1anical entilator i. needed

reat )nderl$in% ca)se


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Thank You


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