Keseimbangan Asam Basa

Edward Kusuma, Bambang Pujo Semedi

ARTERIAL BLOOD GAS NORMAL

SATUAN

pH

NORMAL
RANGE
7.35
- 7.45

PaCO

35 - 45

mmHg

PaO

75 - 98

mmHg

Bicarbonate

22-26

mmol/L

Anion gap

10 - 14

mmol/L

PARAMETER

EVALUASI OKSIGENASI
Cek PaO2
Berapa angka normal?
Menentukan angka normal berdasarkan ratio PaO2 / FiO2
Normal P/F ratio = 400 - 500
Jadi PaO2 = 100
adalah NORMAL bila FiO2 21% (P/F ratio = 476)
adalah TIDAK NORMAL bila FiO2 100% (P/F ratio = 100)

ARTERIAL BLOOD GASES

Give information about :
- Oxygenation
- Ventilation
- Acid - base status

Interpretation of arterial
blood gases
Oxygenation

pH
PaCO2

Ventilation

PaO2

Acid base status

Base excess

HCO3-

Saturation

Acid-base

H20

CO2

H2CO3

HCO3-

H+

H20

CO2

H2CO3

HCO3-

H+

Normal [H+] = 40 nmol/l

pH = - log [H+] = 7.4

H20

H2CO3

CO2

Normal PaCO2 = 5.3 kPa

= 40 mmHg

10

HCO3-

H+

ALVEOLAR VENTILATION

H20

H2CO3

CO2

Normal PaCO2 = 5.3 kPa

= 40 mmHg

11

HCO3-

H+

Normal HCO3- = 22-26 mmol/l

H20

CO2

H2CO3

12

HCO3-

H+

ALVEOLAR VENTILATION

Normal HCO3- = 22-26 mmol/l

H20

CO2

H2CO3

HCO3-

RENAL HCO3- HANDLING

13

H+

Interpretation of arterial
blood gases

Oxygenation
Ventilation
Acid base status

pH
PaCO2
PaO2

HCO3-

Base excess
Saturation

OXYGENATION
What is the PaO2?
Is this is adequate for the

pH

Does the ABG result agree

HCO3-

amount of inspired oxygen?

with the saturation probe?

PaCO2

PaO2

Base excess

Saturation

OXYGENATION
Normal PaO2 breathing air (FiO2 = 21%) is 90 -100 mmHg; small
reduction with age

Lower values constitute hypoxemia

PaO2 < 60 mmHg on room air = respiratory failure
PaO2 should go up with increasing FiO2
A PaO2 of 100 mmHg breathing 60% O2 is not normal
You need to know the FiO2 to interpret the ABG

OXYGENATION
- Correlate the ABG result with the saturation probe
result
- If there is a discrepancy:
- Is there a problem with the probe (poor perfusion? etc)
- Is there a problem with the blood gas (is it a venous sample?)

OXYGENATION
Is the PO2 is lower than expected?
Calculate the A-a gradient to assess if the low PO2 is due to:
Low alveolar PO2
Structural lung problems causing failure of oxygen transfer
!

In clinical setting........
SpO2 can represent SaO2 if there is not source error
Pulse oxymeter :
Source error

Poor peripheral perfusion

Dark skin
False nails or nail varnish
Lipaemia
Bright ambient light
Poorly adherent probe
Excessive motion
Carboxy-haemoglobin or

A
I
M
E
X
O
YP

methaemoglobin

19

OXYGENATION

(A-a) PO2 gradient = {[FiO2 x (760-47)] - (PCO2/RQ)} - PaO2

Normal value : A-a gradient = (Age/4) + 4

Young person at sea level :

A-a increases 5 to 7 mmHg for every 10 % increase FiO2

Room Air : 10 to 20 mmHg

100% oxygen : 60 to 70 mmH

Increased age affects A-a gradient (at sea level)

Age 20 years: 4 to 17 mmHg

Age 40 years: 10 to 24 mmHg

Age 60 years: 17 to 31 mmHg

Age 80 years: 25 to 38 mmHg

OXYGEN CASCADE
Transport oxygen to the cells can be divided into SIX simple steps :

3. Chemical bonds with the Hgb that is reversible

O2 UPTAKE
HAEMOGLOBIN

4. Convective transport of O2 to the tissues

CARDIAC OUTPUT

5. Diffusion into the cells and organelles

DIFFUSION DISTANCE

METABOLISM

VO2

6. Reduction and oxidation in mitochondria

DO2

2. Diffusion of oxygen into the blood

VENTILATION

CaO2
SaO2

1. Convection of O2 from ambient air into the body

21

EXTERNAL RESPIRATION PROCESS

PIO2= 159

PAO2 : 102
PACO2 : 40

Pulmonary Ventilation
PAO2 : 40
PACO2 : 46

PAO2 : 102
PACO2 : 40

PAO2 : 100
PACO2 : 40

Pulmonary Gas Exchange

22

Acid Base Analysis

Stepswise Conventional Analysis

23

Metode Analisa Gas Darah

Hendersson Hasselbach Klasik

Stewart

Stepwise Conventional Analysis
24

Stepswise Conventional Analysis

Berdasar pada pengukuran dan kalkulasi:

pH

PaCO

bicarbonat

anion gap
2

25

Komponen utama pada pendekatan ini

adalah penghitungan:

adekwasi kompensasi yang terjadi

kesesuaian anion gap dengan
perubahan konsentrasi serum
bikarbonat

26

Metabolic and Respiratory Compensation

in Acid-Base Disorder
Metabolic acidosis

Expected PaCO2 = (1.5 x [HCO3]) +8 +/-2

!

Metabolic alkalosis

Expected PaCO2 = (0.7 x [HCO3]) + 21 +/- 1.5

!

Acute respiratory acidosis

Expected HCO3 = 24 + (PaCO2 - 40) / 10

!

Chronic Respiratory Acidosis

Expected HCO3 = 24 + (PaCO2 - 40) / 3

!

Acute Respiratory Alkalosis

Expected HCO3 = 24 - (40 - PaCO2) / 5

!

Chronic respiratory alkalosis

Expected HCO3 = 24 - (40 - PaCO2) / 2

27

Metabolic and Respiratory Compensation

in Acid-Base Disorder
Metabolic acidosis ( HCO3 )

Expected PaCO2 = (1.5 x [HCO3]) +8 +/-2

!
Metabolic alkalosis (

HCO3 )

Expected PaCO2 = (0.7 x [HCO3]) + 21 +/- 1.5

!
!
Acute respiratory acidosis (

lower exp. pCO2

superimposed
respiratory alkalosis.

higher exp. pCO2
superimposed
respiratory acidosis

PaCO2 )

Expected HCO3 = 24 + (PaCO2 - 40) / 10

!
Chronic Respiratory Acidosis (

PaCO2 )

Expected HCO3 = 24 + (PaCO2 - 40) / 3

!
Acute Respiratory Alkalosis (PaCO2)

Lower exp HCO3

superimposed metabolik
acidosis

!

Expected HCO3 = 24 - (40 - PaCO2) / 5

!
Chronic respiratory alkalosis ( PaCO2 )

Expected HCO3 = 24 - (40 - PaCO2) / 2
28

Higher exp. HCO3

superimposed metabolik
alkalosis

Compensatory changes in acid base imbalances

29

Internal Consistency

step 1
Apakah data internally
consistent

H+= 24 x [ PaCO2/HCO3-]

30

pH

Approximate

H+ mmol / L

100

7.1

80

7.2

60

7.25

55

7.3

50

7.35

45

7.4

40

7.45

35

7.5

35

7.55

28

7.6

25

step 2
Apa gangguan primernya: acidosis atau
alkalosis

apakah pCO , bicarbonate, anion gap dalam

2

batas normal ?

31

step 3
apakah penyebabnya : respiratorik atau
metabolik ?

lihat pCO

dan HCO3

32

step 4
Bila kelainan metabolik yang ditemukan, apakah
kompensasi respiratorik adekuat?

Bila kelainan respiratorik yang ditemukan,

apakah kompensasi metabolik adekuat?

33

Metabolic and Respiratory Compensation

in Acid-Base Disorder
lower exp. pCO2

superimposed
respiratory alkalosis.

Metabolic acidosis ( HCO3 )

Expected PaCO2 = (1.5 x [HCO3]) +8 +/-2

!
Metabolic alkalosis (

HCO3 )

higher exp. pCO2

superimposed
respiratory acidosis

Expected PaCO2 = (0.7 x [HCO3]) + 21 +/- 1.5

!
!
Acute respiratory acidosis (

PaCO2 )

Expected HCO3 = 24 + (PaCO2 - 40) / 10

!
Chronic Respiratory Acidosis (

PaCO2 )

Expected HCO3 = 24 + (PaCO2 - 40) / 3

!
Acute Respiratory Alkalosis (PaCO2)

Lower exp HCO3

superimposed metabolik
acidosis

!

Expected HCO3 = 24 - (40 - PaCO2) / 5

!
Chronic respiratory alkalosis ( PaCO2 )

Expected HCO3 = 24 - (40 - PaCO2) / 2
34

Higher exp. HCO3

superimposed metabolik
alkalosis

pH and HCO3 changes

-

Acute respiratory

pH

[HCO 3-]

Falls 0.06

Rises 0.8 mmol

for every 1 kPa rise

(up to 30 mmol/l)

in PaCO 2

Falls 1.5 mmol

for every 1 kPa fall in

(down to 18 mmol/l)

PaCO 2

Rises 3.0 mmol

for every 1 kPa rise

(up to 36 mmol/l)

in PaCO 2

Falls 3.8 mmol

for every 1 kPa fall in

acidosis
Acute respiratory

Rises 0.06

alkalosis
Chronic respiratory

Falls 0.02

acidosis
Chronic respiratory
alkalosis

Rises 0.02

(down to 18 mmol/l)

35

PaCO 2

For acute respiratory

conditions

Acute respiratory

pH

[HCO 3-]

Falls 0.06

Rises 0.8 mmol

for every 1 kPa rise

(up to 30 mmol/l)

in PaCO 2

Falls 1.5 mmol

for every 1 kPa fall in

(down to 18 mmol/l)

PaCO 2

Rises 3.0 mmol

for every 1 kPa rise

(up to 36 mmol/l)

in PaCO 2

Falls 3.8 mmol

for every 1 kPa fall in

acidosis
Acute respiratory

Rises 0.06

alkalosis
Chronic respiratory

Falls 0.02

acidosis
Chronic respiratory
alkalosis

Rises 0.02

(down to 18 mmol/l)

36

PaCO 2

1 kPa = 7.5 mmHg

Early renal compensation

for respiratory conditions

Acute respiratory

pH

[HCO 3-]

Falls 0.06

Rises 0.8 mmol

for every 1 kPa rise

(up to 30 mmol/l)

in PaCO 2

Falls 1.5 mmol

for every 1 kPa fall in

(down to 18 mmol/l)

PaCO 2

Rises 3.0 mmol

for every 1 kPa rise

(up to 36 mmol/l)

in PaCO 2

Falls 3.8 mmol

for every 1 kPa fall in

acidosis
Acute respiratory

Rises 0.06

alkalosis
Chronic respiratory

Falls 0.02

acidosis
Chronic respiratory
alkalosis

Rises 0.02

(down to 18 mmol/l)

37

PaCO 2

1 kPa = 7.5 mmHg

Acute respiratory

pH

[HCO 3-]

Falls 0.06

Rises 0.8 mmol

for every 1 kPa rise

(up to 30 mmol/l)

in PaCO 2

Falls 1.5 mmol

for every 1 kPa fall in

(down to 18 mmol/l)

PaCO 2

Rises 3.0 mmol

for every 1 kPa rise

(up to 36 mmol/l)

in PaCO 2

Falls 3.8 mmol

for every 1 kPa fall in

acidosis
Acute respiratory

Rises 0.06

alkalosis
Chronic respiratory

Falls 0.02

acidosis
Chronic respiratory
alkalosis

Rises 0.02

(down to 18 mmol/l)

Late renal compensation

for respiratory conditions
38

PaCO 2

1 kPa = 7.5 mmHg

step 5
Apakah ada kenaikan anion gap?

Anion gap = [Na ] - [Cl ] - [HCO ]

Normal = 12 (+2) mEq/L

apakah perubahan anion gap sebanding
+

dengan perubahan bicarbonat

39

Anion Gap

Anion Gap = [Na+] [Cl-] - [HCO3-]

The anion gap is an artificial

difference between the commonly
measured anions and cations.
In reality there is electrochemical
neutrality
[Na+] + [unmeasured cations] = [Cl-] + [HCO3-] + [unmeasured anions]
[unmeasured anions] - [unmeasured cations] = [Na+] - ([Cl-] + [HCO3-])
40

Untuk menentukan apakah px sudah

mengalami acidosis/alkalosis metabolik
sebelumnya (kronis), hitung initial HCO3Initial HCO3- = anion gap measured - anion gap normal + HCO3- measured

hasil < 20 :

px sudah mempunyai asidosis metabolik kronik (faktor
di luar anion gap)

!

hasil > 30 :

px sudah mempunyai alkalosis metabolik kronik
41

Normal Anion Gap

Asidosis Metabolik
HCO3 loss and replaced with Cl > anion gap
normal
If hyponatraemia is present the plasma [Cl-] may
be normal despite the presence of a normal
anion gap acidosis > this could be considered
a relative hyperchloraemia

42

step 6

Evaluasi ulang apakah analisa sesuai

dengan situasi klinik pasien

43

contoh kasus
36 tahun, laki - laki, Riwayat DM type 2,

perokok kronis, alkoholik, ditemukan dalam

kondisi agitasi

1 jam kemudian px masuk ICU dalam

kondisi penurunan kesadaran

BGA: pH 7.18 PaCO 23

Na 132 K 5.2 Cl 97
Glucose 235
2

44

PaO2 78

HCO3 21

step 1 - internal
consistency
24 x [ PaCO /HCO
= 24 x 23 / 21

= 26.3
+
H=

-]

Perkiraan H+ utk pH 7.18 adalah

sekitar 60 mmol/L
DATA TIDAK
KONSISTEN
45

pH

Approximate

H+ mmol / L

100

7.1

80

7.2

60

7.25

55

7.3

50

7.35

45

7.4

40

7.45

35

7.5

35

7.55

28

7.6

25

BGA diulang
Data baru:

pH 7.18

PaCO2 23

Na 132 K 5.2

PaO2 78

Cl 97

HCO3- 9

Glucose 235

46

ulangi step 1
internal consistency
= 24 x (21/9)

= 64

sesuai dengan

perkiraan H+ utk
pH 7.18

DATA KONSISTEN
47

pH

Approximate

H+ mmol / L

100

7.1

80

7.2

60

7.25

55

7.3

50

7.35

45

7.4

40

7.45

35

7.5

35

7.55

28

7.6

25

step 2
alkalosis atau acidosis?
pH 7.18 PaCO
Na 132 K 5.2
HCO 9

Glucose 235
3

23

Cl 97

ACIDOSIS
48

PaO2 78

step 3
respiratorik atau metabolik?

pH 7.18

PaCO2 23

Na 132 K 5.2

PaO2 78

Cl 97

HCO3- 9

Glucose 235

acidosis metabolik
49

step 4
apakah kompensasi
adekuat ?

pH 7.18

PaCO2 23

Na 132 K 5.2

PaO2 78

Cl 97

HCO3- 9

Glucose 235

Metabolic acidosis

Expected PaCO2 = (1.5 x [HCO3]) +8 +/-2

Metabolic alkalosis

Expected PaCO2 = (0.7 x [HCO3]) + 21 +/- 1.5

expected PaCO2 =
1.5 x 9 + 8 + 2 =
21.5 + 2

Acute respiratory acidosis

Expected HCO3 = 24 + (PaCO2 - 40) / 10

Chronic Respiratory Acidosis

Expected HCO3 = 24 + (PaCO2 - 40) / 3

Acute Respiratory Alkalosis

Expected HCO3 = 24 - (40 - PaCO2) / 5

Chronic respiratory alkalosis

Kesimpulan :

Expected HCO = 24 - (40 - PaCO ) / 2

metabolik acidosis dengan
kompensasi respiratorik adekuat
3

50

step 5
anion gap

pH 7.18

PaCO2 23

Na 132 K 5.2
HCO3- 9

Glucose 235

- [HCO
Anion gap =
132 - 97 - 9 = 26

(Normal = 12 (+2) mEq/L)
+
[Na ]

[Cl ]

-]

kesimpulan: Ada kenaikan anion gap

51

PaO2 78

Cl 97

apakah ada faktor

asidosis / alkalosis
kronis?

pH 7.18

PaCO2 23

Na 132 K 5.2

PaO2 78

Cl 97

HCO3- 9

Glucose 235

ukur initial HCO3-

Initial HCO3- = anion gap measured - anion gap normal

+ HCO3 measured

= 26 - 12 + 9 = 23
Kes: tak ada bukti kronis acidosis / alkalosis

52

kesimpulan step 5
anion gap meningkat

tak ada bukti kronis acidosis / alkalosis
metabolik

53

kesimpulan kasus
asidosis metabolik, kompensasi respiratorik
adekuat, ada peningkatan anion gap,

klinis DM, penurunan kesadaran

what next?

adakah kemungkinan toxic ingestion?

cek keton

cek asam lactat
54

Metabolic Acidosis
Increased Anion Gap
Lactic Acidosis

Ketoacidosis

diabetic

Alcoholic

Renal Failure (late stage)

Poisoning:

salicylate

methanol

ethylene glycol

paraldehyde

toluene

Normal Anion Gap

GI bicarbonate loss

diarrhoea

pancreatic/billiary drain

urinary diversion

Renal bicarbonate loss

type 2 renal tubular acidosis

ketoacidosis

post chronic hypocapnia

Impaired renal excretion

renal hypoperfusion

!
55

Metabolic Alkalosis
Mechanism

Examples

Volume (chloride depletion)

Vomiting / gastric drainage

Diuretic therapy

Post hypercapneic alkalosis

Hyperadrenocorticoidism

Cushing syndrome

Conns syndrome

Bartters syndrome

Secondary hyperaldosteronism

steroid tx

Severe Potassium Depletion

Acute milk alkali syndrome

Excessive alkali intake

56

Respiratory Acidosis
Pasien dengan acute hypercapnia selalu
mengalami acidosis

Pasien dengan chronic hypercania juga

mengalami acidosis. Bila terdapat

peningkatan pH yang signifikan, cari faktor
sebelumnya mis: diuretic, low sodium diet,
atau post hypercapnic alkalosis

57

Respiratory Alkalosis
Non Hypoxic respiratory
Hypoxia
center stimulation
Acute (pneumonia, asma, Anxiety

pulm edema)

Fever

Chronic (pulmonary
Sepsis

fibrosis, cyanotic heart
Salicylate intoxication

dissease, high altitude,
Cerebral diseases
anemia)
(tumor, encephalitis)

hepatic cirrhosis

pregnancy

after correction of
metab acidosis

excessive mech vent.

58

Take home message

!

Evaluasi asam basa stepwise harus

memperhitungkan semua parameter yang ada
dalam AGD (PaO2, PCO2, HCO3, SaO2, Anion Gap)

Tiap perubahan keasaman akan menimbulkan

kompensasi

Cari apakah kompensasi adekuat / tidak

Jika kompesasi tidak adekuat / berlebihan: mungkin
terdapat kombinasi penyebab
59

AIR

ARD

BPS

60

61

from the top of62 SEOUL tower

Gyeongbok
Palace
63

Komapsumnida !
Thank You !

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