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Asyer

Asyer
pH PCO2 HCO3 Intepretasi

N N N NORMAL

Asidosis
↓ N ↓
Metabolik
Asidosis
↓ ↑ N
Respiratoar
Alkalosis
↑ N ↑
Metabolik
Alkalosis
↑ ↓ N
Respiratoar
CO2 + H2O H2CO3 H+ + HCO3-

CO2 + H2O H+ + HCO3-


AGD Henderson-Hasselbach
Respiratory Asidosis Penurunan pH
akut = 0.8 ( PaCO2 - 40 )
kronik = 0.3 ( PaCO2 - 40 )
Respiratory Alkalosis Peningkatan pH
akut = 0.8 ( 40 - PaCO2 )
kronik = 0.3 ( 40 - PaCO2 )

Kelainan primer Kompensasi yang


diharapkan
Asidosis metabolic pCO2 = 1.25 x ∆HCO3
Alkalosis metabolic pCO2 = 0.75 x ∆HCO3 Hitung
Anion Gap
Asidosis respiratorik akut HCO3= 0.1 x ∆ pCO2
Asidosis respiratorik kronik HCO3= 0.4 x ∆ pCO2
Alkalosis respiratorik akut HCO3= 0.2 x ∆ pCO2
Alkalosis respiratorik kronik HCO3= 0.4 x ∆ pCO2
Asidosis respiratorik akut

kompensasi diharapkan:
HCO3 = 0.1 x ∆ pCO2 = 0.1 x ∆ (56-40) = 1.6
Seharusnya perubahan HCO3- = 24 + 1.6 = 25.6
HCO3 18  kompensasi tidak sesuai

ASIDOSIS RESPIRATORIK AKUT


dengan campuran ASIDOSIS METABOLIC
CO2

Independent SID

Atot
pH
H+

Dependent HCO3

dll
STRONG ION DIFFERENCE (SID)
SID = [KATION KUAT] – [ANION KUAT]

= ([Na+] + [K+] + [Ca++] + [Mg++]) - ([Cl-] + [lactate-])

 Normal = 40 - 42 mEq/l.
H+

HCO3-
Na+ OH- CO32-
ATot SID
Alb -
Posfat - Unmeasured Anion
XA -
K+
Mg++
Ca++

Cl-

KATION ANION
SID↓
SID
SID↑

Na Na Na
Cl
Cl
Cl
Plasma

1 Litre 140/2 = 70 mEq/L


Na+ = 140 mEq/L
H2O 102/2 = 51 mEq/L
Cl- = 102 mEq/L SID = 19 mEq/L
SID = 38 mEq/L 1 liter 2 liter

SID : 38  19 = Acidosis

DILUTIONAL ACIDOSIS
Diuretic
DI
Plasma Evaporasi Plasma

Na+ = 140 mEq/L


Cl- = 102 mEq/L
SID = 38 mEq/L 140/1/2 = 280 mEq/L
102/1/2 = 204 mEq/L
1 liter SID = 76 mEq/L ½ litre

SID : 38  76 = alkalosis
CONTRACTION ALKALOSIS
Plasma 0.9% NaCl

Na+ = 140 mEq/L Na+ = 154 mEq/L


Cl- = 102 mEq/L Cl- = 154 mEq/L
SID = 38 mEq/L 1 litre SID = 0 mEq/L 1 litre

SID : 38 
Plasma

= Na+ = (140+154)/2 mEq/L= 147 mEq/L


Cl- = (102+ 154)/2 mEq/L= 128 mEq/L

SID = 19 mEq/L 2 litre

SID : 19  Acidosis
Plasma lactate Ringer

Cation+ = 137 mEq/L


Na+ = 140 mEq/L Cl- = 109 mEq/L
Cl- = 102 mEq/L Laktat- = 28 mEq/L
SID= 38 mEq/L 1 litre SID = 0 mEq/L 1 litre

SID : 38
Plasma

= Na+ = (140+137)/2 mEq/L= 139 mEq/L


Cl- = (102+ 109)/2 mEq/L = 105 mEq/L
Laktat- (termetabolisme) = 0 mEq/L
2 litre
SID = 34 mEq/L

SID : 34
Plasma;
Plasma + NaHCO3
hyperchloremic
acidosis

25 mEq
NaHCO3
Na+ = 140 mEq/L Na+ = 165 mEq/L
Cl- = 130 mEq/L Cl- = 130 mEq/L
SID =10 mEq/L 1.025 SID = 35 mEq/L
1 litre
litre

SID  : 10  35 :  Alkalosis, pH normal


Total konsentrasi asam lemah
dalam larutan
(Albumin, Fosfat)
K K HCO3 K
HCO3 SID HCO3

Alb
Alb Alb 

Na Na Na

Cl Cl Cl

Normal Acidosis Alkalosis


K K HCO3- SID 
HCO3- SID
Lact

A- A-

Na+ Na+

Cl- Cl-

Normal Asidosis Laktat


AG = [Na] – [Cl+ HCO3]
= A- + UA

UA

K AG
A-

HCO3-
A- = weak acid
Na
(albumin, fosfat)
UA = unmeasured anion
Cl
(laktat, keton, dll)
Normal
 
AG AG = 12-16

Na HCO-3 24

140
K Cl 102

Metabolic acidosis
HCO3- 
Normal anion gap acidosis Increased anion gap acidosis
AG = 15 (normal) AG/
HCO-3 15 Other = 25 
Na Na anion
HCO-3 15
145 145
K Cl K
115  105
Cl (normal)

HCO3- decreases and replaced by Cl- so HCO3- decreases and replaced by anions
there is a Cl- shift :Eg. Diarrhea or simple other than Cl- so no Cl- shift: Eg.renal failure
gain of H+ and diabetic keto-acidosis
Calculated AG + 0,25 (42 – Albumin)

Faktor dependen  HCO3

Underestimated pada keadaan gangguan metabolik


STRONG ION GAP
Kellum JA, Kramer DJ, Pinsky MR: Strong ion gap: A methodology for exploring
unexplained anions. J Crit Care 1995,10:51--55.
SIG
Mg++
Ca++

K+ 4
SIDa HCO3-
A-
SIDe
Lactate

= [Na+] + [K+] + [Mg++] + [Ca++] - [Cl-] – [Lactate-]

+ Cl-
Na
= 12.2×pCO2/(10-pH )+10×[alb]×(0.123×pH–0.631) +[PO4–]×(0.309×pH–0.

SIG = SIDa – SIDe  Normal value = zero


Jika SIG >  terdapat UA
KATION ANION
Perbedaan dgn AG  pd SIG, nilai albumin ikut dalam kalkulasi
MODIFIED FENCL - STEWART

BE = BE dari AGD
NaCl effect = [ Na – Cl ] - 38
Albumin effect = 0,25 X ( 42 - Albumin (g/dl)

UA = BE – SID effect – Albumin effect


CASE 1 :
 Kesadaran: GCS 15
BP 110/60 HR : 75
RR 25 SpO2 99% NRM 10 lpm

 Lab:
 pH 7.25/PCO2 30/ HCO3 14 / BE-10
 Na 140/ Cl 112/ Alb 4.0
 Lab:
CASE 1  pH 7.25 / PCO2 30 / HCO3 14 / BE-10
 Na 138 / K 4.0 / Cl 112/ Ca 5 / Mg 2
 Alb 4.0

SID = ([Na+] + [K+] + [Ca++] + [Mg++]) - ([Cl-] + [lactate-])


= (138 + 4 + 5 + 2) – (112 )
= 37  ASIDOSIS

AG = [Na+K] – [Cl+ HCO3]


= (138) – (112+14)
= 16  ASIDOSIS - NORMAL anion gap
 Lab:
CASE 1  pH 7.25/PCO2 30/ HCO3 14 / BE-10
 Na 138 / K 4.0 / Cl 112/ Ca 5 / Mg 2
 Alb 4.0

NaCl effect = [ Na – Cl ] - 38 = 138 - 112 - 38 = -12

Albumin effect = 0,25 X ( 42 - Albumin (g/dl)


= 0.25 (42-40)
= 0.5

UA = BE – NaCl effect – Albumin effect


= -10 - (-12) - 0.5
= 1.5
150 7.25 / 30 / -10 / 14

140
HCO3-
Alb
112
BE akibat pe Cl-  -10
Alb
102

Asidosis metabolik ec. hiperkloremia


Th/: Batasi NaCl
- Terapi diuretik

Na+ Cl-
CASE 2 :

 Kesadaran : Somnolen
 BP 90/45 HR 112
 RR 30 SpO2 96% dengan simple mask 6
L/mnt

 Lab
 Na 140 / K 4.0 / Cl 102/ Ca 5/ Mg 2
 pH 7.42/ PCO2 35/ HCO3 21 / BE -2
 Lab:
CASE 2  Na 140 / K 4.0 / Cl 102/ Ca 5/ Mg 2
 pH 7.42/ PCO2 35/ HCO3 23 / BE -2
 Alb 1.8

SID = ([Na+] + [K+] + [Ca++] + [Mg++]) - ([Cl-] + [lactate-])


= (140 + 4 + 5 + 2) – (102 + *)
= 49  ALKALOSIS

AG = [Na+K] – [Cl+ HCO3]


= (140) – (102+23)
= 15  ASIDOSIS - NORMAL anion gap
CASE 2  Lab:
 Na 140 / K 4.0 / Cl 102/ Ca 5/ Mg 2
 pH 7.42/ PCO2 35/ HCO3 23 / BE -2
 Alb 1.8

NaCl effect = [ Na – Cl ] - 38 = 140 - 102 - 38 = 0

Albumin effect = 0,25 X ( 42 - Albumin (g/dl)


= 0.25 (42-18)
=6

UA = BE – NaCl effect – Albumin effect


= -2 - (0) - 6
=- 8

Laktat : 7.8
7.42 / 35 / 100 / -2 / 21

140
HCO 3
-
HCO3- SID  normal
24 22 -
BE astrup = - 8 + 6 = - 2 HCO3
30.7
UA = - 8 BE akibat lact  - 8
BE akibat hipoalb  + 6 Alb
hipoalbumin
102

Lactic Asidosis metabolik “masking” oleh hipoalbumin

Na+ Cl-