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Dina Nilasari
Definition
Bronsted and Lowry's definition :
An acid is a substance that donates a proton in a
reaction, while a base is a substance that accepts a
proton in a reaction.
Arrhenius's definition :
An acid is a substance that increases the
concentration of hydrogen ion (H+) when dissolved
in water and a base is a substance that increases
the concentration of hydroxyl ion (OH-) when
dissolved in water.
Definition
Why a normal pH is
very important ?
Kondisi
[H+] nmol/L pH
Asidemi
> 100
< 7,0
Asidemi
50 80
7,1 7,3
Normal
40 2
7,4 0,02
Alkalemi
20 36
7,44 7,69
Alkalemi
< 20
> 7,70
Klinik
Letal
Perhatian
Normal
Perhatian
Letal
Dikutip dari kuliah dr.Parlindungan S, SpPD-KGH dalam kuliah mimbar FKUI tentang asam-basa
Henderson-Hasselbalch :
H2O + CO2
H+ + HCO3-
Arterial blood
Mixed venous
Venous
7.40
(7.37-7.44)
7.36
(7.31-7.41)
7.36
(7.31-7.41)
pO2 (mmHg)
(decreases with age)
80-100
35-40
30-50
pCO2 (mmHg)
36-44
41-51
40-52
>95
60-80
60-85
22-26
22-26
22-28
-2 to +2
-2 to +2
-2 to +2
pH
(range)
O2 saturation
(decreases with age)
HCO3- (mEq/L)
[SI: mmol/L]
Base difference
(deficit/excess)
Primary disorders
Primary disorder
Problem
Metabolic acidosis
Metabolic alkalosis
Respiratory acidosis
Hypoventilation
Respiratory alkalosis
Hyperventilation
pH
HCO3 pCO2
Kompensasi
Acidosis
Metabolic
acidosis
Respiratory
acidosis
Respiratory
compensation
VS
Alkalosis
Metabolic
alkalosis
Respiratory
alkalosis
Renal
compensation
Compensation
Kompensasi:
Acid-base nomogram
Langkah penghitungan
Contoh:
PH 7,25 PCO2 48 HCO3 29
LANGKAH I
H+ = 24 x PCO2
HCO3
H+ =(7,8-pH) x 100 ~ 24x 48
29
= 55
~ 40
LANGKAH II
Acidemia: pH < 7,36
Alkalemia: pH > 7,44
LANGKAH III
Kenali gangguan PRIMERNYA
Contoh: Cari yang arahnya sama
Asidemia (+) Kenaikan CO2 atau Penurunan HCO3
PCO2 =
48
HCO3 =
LANGKAH IV
Asidosis respiratorik
kronik
Anion Gap
Anion gap = Na - (Cl + HCO3)
LANGKAH V
AG= 29 HCO3 = 6
Langkah VI
BANDINGKAN!!
Delta AG 29-10 = 19
Contoh soal 2
Pasien 21 tahun dengan DM, nausea, vomiting, abdominal
pain.
Anion gap = 23
HCO3 = 18
Delta AG: 13
Expected HCO3 24-13 = 11
Berarti ada yang HCO3 nya asidosis metabolik mixed
alkalosis metabolik dari muntahnya.
ASIDOSIS METABOLIK
I.
DIFERENSIASI ETIOLOGI
ASIDOSIS METABOLIK
I.
II.
KEHILANGAN BIKARBONAT
AG NORMAL (Diare, RTA, Inhibitor
Carbonic Anhidrase)
Metabolic acidosis
Anion gap
normal
Gut
Renal
Exogenous
Endogenous
Diarrhea
RTA
Salicylates
Lactic acidosis
Fistule
Carbonic
anhydrase
inhibitor
Methanol
Ketoacidosis
Ileal loop
Paraldehyde
- diabetic
-starvation
Uremia
Differential diagnosis
Causes of high-anion-gap metabolic acidosis
Lactic acidosis
Ketoacidosis
Diabetic
Alcoholic
Starvation
Toxins
Ethylene glicol
Methanol
Salicylates
Renal failure
(acute and chronic)
Differential diagnosis
Causes of non-anion-gap metabolic acidosis
Diarrhea
External pancreatic or small-bowel drainage
Ureterosigmoidostomy, jejunal loop, ileal loop
Drugs
Renal acidosis
Hypokalemia
Mineralocorticoid deficiency
Mineralocorticoid resistance
Na delivery to distal nephron
Tubulointerstitial disease
Ammonium excretion defect
Other
Hiperkalemia
ANION-GAP URIN
AG darah, normal :
AG-urin = [(Na + K) Cl] urin
AG-urin menunjukkan hasil minus pada enteritis.
Ekskr. Amonia dan Cl tinggi dalam urin.
AG-urin menunjukkan hasil positip RTA-1,RTA-4,GGK
Tub.distal tak mampu
ekskr. Amonia, Cl dan
ion-H.
Management
ALKALOSIS METABOLIK
I.
Dikutip dari kuliah dr.Parlindungan S, SpPD-KGH dalam kuliah mimbar FKUI tentang asam-basa
Aldosteron
di tub.distal
Volume sirkulasi
efektif turun
Renin Ang.II
dilepas meningkat
Aktif. Na3HCO3stimulasi
NaH-ATPase
& NaH-antiporter
dan ClHCO3exchanger
eks.ion-H
Reabsorbsi HCO3
Cl
pH
ion-K
keluar
dari sel
ion-H
masuk ke
dalam sel
KOMPENSASI RESPIRATORIK
PENINGKATAN pCO2
[HCO3] NAIK 1 meq/l pCO2 NAIK 0,75 mmHg
GEJALA KLINIK
1. SUSUNAN SARAF PUSAT
LEMAS, BINGUNG, TETANI, PARESTESIA,
KRAMP OTOT, KEJANG.
2. JANTUNG : ARITMI, HIPOKSEMI
3. ELEKTROLIT
HIPOKALEMI, HIPOFOSFATEMI.
Dikutip dari kuliah dr.Parlindungan S, SpPD-KGH dalam kuliah mimbar FKUI tentang asam-basa
Metabolic alkalosis
Urine chloride (UCl )
< 10 meq/l
10 meq/l
Chloride responsive
Chloride resistant
Excess
mineralocorticoid
Renal loss of
chloride
GI loss of H , Cl
-NG suction
- Diuretics
- Cushing syndrome
- Vomiting
- Cystic fibrosis
- Conns syndrome
- Villous adenoma
- Exogenous steroid
- Bartters syndrome
Differential
diagnosis
Harrisons Principles of
Internal Medicine, 17th edition
Management
Chloride-responsive
Chloride-resistant
Respiratory Acidosis
Primary pCO2
pH , [HCO3-]
Alveolar hypoventilation
Differential Diagnosis
Central
Drugs (anesthetics,
morphine, sedative)
Stroke
Infection
Airway
Obstruction
Asthma
Parenchymal
Emphysema
Pneumoconiosis
Bronchitis
Adult respiratory
distress syndrome
Barotrauma
Neuromuscular
Poliomielitis
Kyphoscoliosis
Myasthenia
Muscular
dystrophies
Miscellaneous
Obesity
Hypoventilation
Permissive
hypercapnia
CO2
H2CO3
HCO3
H
Vasodilatation of
cerebral vessel
Excrete
Conserve
bicarbonate, hydrogen
ions
sodium ions
NaHCO3
Cerebral edema,
depress CNS
Respiratory
center
Respiratory
rate
Headache
Nausea, vomiting
Cardiac arrest
Management
Respiratory Alkalosis
Primary pCO2
pH , [HCO3-]
Differential Diagnosis
Central stimulation
Anxiety,
hyperventilation
syndrome, pain,
psychosis
Head trauma or CVA
with central neurogenic
hyperventilation
Meningitis, encephalitis
Tumors
Fever, early sepsis
Drugs or hormones
Pregnancy,
progesterone
Catecholamines
Nicotine
Salicylates
Xanthines such as
aminophyline
Stimulation of chest
receptors
Flail chest
Cardiac failure
Pulmonary embolism
Hypoxemia or Tissue
hypoxia
High altitude
Pneumonia,
pulmonary edema
Aspiration
Severe anemia
Miscellaneous
Hepatic failure
Hyperthyroidism
Iatrogenic mechanical
overventilation
PCO2
pH
ALKALO
SIS
Tachycardia
Confusion or syncope
ECG changes:
prolonged PR interval, a flattened T wave, a
prominent U wave, a depressed ST segment
Management
I.V. therapy
Thank You