GANGGUAN KESEIMBANGAN

ASAM BASA PADA ANAK

Dr. WAN NEDRA, Sp. A
BAGIAN ANAK FK. YARSI
2015

Acid/base
Respiratory
Acidosis

Metabolic
Alkalosis

Metabolic
Acidosis

Respiratory
Alkalosis

BE = 0
HCO3 = 24

7.4

ABG Rules
Rule 1: An increase or decrease in PaCO2 of
10 mm Hg, respectively, is associated with a
reciprocal decrease or increase of 0.08 pH
units.
Rule 2: An increase or decrease in [HCO3-]
or 10 mEq/L respectively is associated with
a directly related increase or decrease of
0.15 pH units.

Acidosis
pH < 7.2
decreased responsiveness to catecholamines
cardiac dysfunction
arrhythmias
increased potassium serum levels

RESPIRATORY ACIDOSIS
Increased pCO2 and pH below 7.35 due to
hypoventilation, emphysema etc.
Compensation occurs in the kidney through
increased H+ excretion and HCO3reabsorption. Bicarbonate/carbonic acid ratio
is 10-15:1.

RESPIRATORY ALKALOSIS
Hyperventilation due to O2 deficiency, CVA, or
anxiety are causes of respiratory
alkalosis. Renal compensation occurs by
decreasing H+ excretion and HCO3reabsorption.
H+ is reabsorbed. Bicarbonate/carbonic acid
ratio is 30-40:1.

METABOLIC ACIDOSIS
Due to loss of HCO3- by diarrhea,
ketoacidosis, keto acids from a high protein
diet,
high stomach acidity, anaerobic fermentation,
and renal disease. Compensation
occurs by an increase in respiration rate.
Bicarbonate/carbonic acid ratio is 10-15:1.

METABOLIC ALKALOSIS
Increased intake of antacids, low protein/high
vegetable diet, and vomiting/loss of
HCl are common causes. Compensation is by
hypoventilation. Bicarbonate/carbonic
acid ratio is 35:1.

Case Studies

KASUS
Anak 2 tahun, didiagnosis sebagai Meteorismus
akibat komplikasi dari Diare Akut dengan gangguan
elektrolit darah. Dasar diagnosis dari anamnesis
muntah, mencret dan kembung. Pada pemeriksaan
fisik tampak abdomen membuncit, tidak terdengar
bising usus. Gambaran soal berikut ini adalah hasil
laboratorium penunjang yang diambil dari darah
pasien. Yang mana hasil pemeriksaan dibawah ini
yang sesuai dengan kondisi diatas:

Hasil Laboratorium
pH
Serum

Na
K+
ClHCO3(meq/L) (meq/L) (meq/L) (meq/L)

(A) 7,25
(B) 7,35
(C) 7,50
(D) 7,45
(E) 7,32

128
130
130
140
140

5,8
2,8
3,6
4,0
3,0

88
90
88
100
112

16
21
34
22
18

Lanjutan kasus 1
Follow up 4 jam setelah di Rumah Sakit:
Pasien lelah (fatigue), sesak nafas (pernafasan
Kussmaull), Cuping Hidung, muntah.
Hasil AGD:
pH: 7,1 Asidosis, HCO3: - 25 Metabolik
Penanganan: Koreksi dg Bicnat

Apa yang terjadi pada pasien tsb?

Manifestasi sangat tergantung pd penyebab &
kecepatan perkembangan proses penyakit
Asidosis Alkalosis Metabolik akan:
Depresi miokardial disertai menurunnya Cardiac
output (Curah Jantung), dpt terjadi aritmia dan
fibrilasi ventrikular
Penurunan tekanan darah
Penurunan aliran ke sirkulasi hepatik dan renal
Metabolisme otak menurun

Alkalosis Metabolik
Overventilation pada kasus gagal nafas
Alkalosis
Klinis sama dg asidosis metabolik
Curah jantung menurun, depresi ventilasi
sentral

Tatalaksana Asidosis Metabolik

Tentukan pH: Letal bila kurang dari 7, Perlu
perhatian bila 7,1-7,3
Anion gap untuk menentukan etiologi

Tatalaksana penyebab menjadi penting

Treatment of Metabolic Acidosis

The total replacement dose of [HCO3 -] can be calculated as
follows:
Replace with one-half the total amount of bicarbonate over 8-12
h and reevaluate.
Be aware of sodium and volume overload during replacement.
Normal or isotonic bicarbonate drip is made with 3 ampules
NaHCO3 (50 mmol NaHCO3/ampule) in 1 L D5W.

METABOLIC ALKALOSIS:
Metabolic alkalosis represents an increase in
[HCO3 -] with a compensatory rise in pCO2.

Differential Diagnosis
In two basic categories of diseases the kidneys
retain [HCO3 -]
They can be differentiated in terms of
response to treatment with sodium chloride
and also by the level of urinary [Cl-] as
determined by ordering a Spot,or random
urinalysis for chloride (UCl).

Chloride-Sensitive (Responsive) Metabolic

Alkalosis:
The initial problem is a sustained loss of chloride out of
proportion to the loss of sodium (either by renal or GI )
This chloride depletion results in renal sodium
conservation leading to a corresponding reabsorption of
[HCO3 -] by the kidney.
In this category of metabolic alkalosis, the urinary [Cl-]
is <10 mEq/L,
and the disorders respond to treatment with
intravenous NaCl.

Chloride-Insensitive (Resistant) Metabolic

Alkalosis:
The pathogenesis in this category is direct
stimulation of the kidneys to retain
bicarbonate irrespective of electrolyte intake
and losses.
The urinary [Cl-] >10 mEq/L, and these
disorders do not respond to NaCl
administration.

Treatment of Metabolic Alkalosis

Correct the underlying disorder.
1. Chloride-responsive
a. Replace volume with NaCl if depleted.
b. Correct hypokalemia if present.
c. NH4Cl and HCl should be reserved for extreme
cases.
2. Chloride-resistant
a. Treat underlying problem, such as stopping
exogenous steroids.

RESPIRATORY ACIDOSIS: DIAGNOSIS

AND TREATMENT
Respiratory acidosis is a primary rise in pCO2
with a compensatory rise in plasma [HCO3 -].
Increased pCO2 occurs in clinical situations in
which decreased alveolar ventilation occurs.

Differential Diagnosis
1. Neuromuscular Abnormalities with Ventilatory Failure
2. Central Nervous System Drugs, Sedative,,Central sleep apnea
3. Airway Obstruction
a. Chronic (COPD)
b. Acute (asthma)
c. Upper airway obstruction
d. Obstructive sleep apnea
4. Thoracic/Pulmonary Disorders
a. Bony thoracic cage: Flail chest, kyphoscoliosis
b. Parenchymal lesions: Pneumothorax, pulmonary edema,
c. Large pleural effusions
d. Scleroderma
e. Marked obesity (Pickwickian syndrome)

Treatment of Respiratory Acidosis

Improve Ventilation:
Intubate patient and place on ventilator,
increase ventilator rate, reverse narcotic
sedation with naloxone (Narcan), etc

RESPIRATORY ALKALOSIS:
Respiratory alkalosis is a primary fall in pCO2
with a compensatory decrease in plasma
[HCO3 -].
Respiratory alkalosis occurs with increased
alveolar ventilation.

Differential Diagnosis
1. Central stimulation
a. Anxiety, hyperventilation syndrome, pain
b. Head trauma or CVA with central neurogenic hyperventilation
c. Tumors
d. Salicylate overdose
e. Fever, early sepsis
2. Peripheral stimulation
a. PE
b. CHF (mild)
c. Interstitial lung disease
d. Pneumonia
e. Altitude
f. Hypoxemia:
3. Miscellaneous
a. Hepatic insufficiency
b. Pregnancy
c. Progesterone
d. Hyperthyroidism
e. Iatrogenic mechanical overventilation

Treatment of Respiratory Alkalosis

Correct the underlying disorder.
Hyperventilation Syndrome: Best treated by
having the patient rebreathe into a paper bag
to increase pCO2, decrease ventilator rate

Anak 2 tahun, didiagnosis sebagai Meteorismus akibat komplikasi dari Diare Akut dengan gangguan elektrolit darah. Dasar diagnosis d

Disturbance of acid based balance

Disturbance

Respiratory
Acidosis
Respiratory
Alkalosis
Metabolic
Acidosis
Metabolic
Alkalosis

Plasma PH

Plasma PCO2

Plasma HCO3

Questions?