Download - Workshop Asam-Basa Stewart
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PENDEKATAN “STEWART” PENDEKATAN “STEWART” DALAM FISIOLOGI DALAM FISIOLOGI
KESEIMBANGAN ASAM BASAKESEIMBANGAN ASAM BASA“A Stewart Approach”“A Stewart Approach”
Anang Achmadi, SpAn
Yohanes WH George, SpAn.,KIC
Iqbal Mustafa, SpAn.,KIC., FCCM
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A physical-chemical A physical-chemical analysisanalysis
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ASAM BASA..ASAM BASA..
pHpH
[H[H++]]
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Acid Base
Notasi pH diciptakan oleh seorang ahli kimia dari Denmark yaitu Notasi pH diciptakan oleh seorang ahli kimia dari Denmark yaitu Soren Peter Sorensen pada thn 1909, yang berarti log negatif dari Soren Peter Sorensen pada thn 1909, yang berarti log negatif dari konsentrasi ion hidrogen. Dalam bahasa Jerman konsentrasi ion hidrogen. Dalam bahasa Jerman disebutdisebutWasserstoffionenexponent Wasserstoffionenexponent (eksponen ion hidrogen) dan (eksponen ion hidrogen) dan diberi simbol pH yang berarti: ‘diberi simbol pH yang berarti: ‘ppotenz’ (power) of otenz’ (power) of HHydrogen. ydrogen.
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Normal = 7.40 (7.35-7.45)Normal = 7.40 (7.35-7.45)
Viable range = 6.80 - 7.80Viable range = 6.80 - 7.80
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MENGAPA PENGATURAN MENGAPA PENGATURAN pHpH SANGAT PENTING ? SANGAT PENTING ?
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RespirasiRespirasiHiperventilasiHiperventilasiPenurunan kekuatan otot nafas dan Penurunan kekuatan otot nafas dan
menyebabkan kelelahan menyebabkan kelelahan ototototSesakSesak
MetabolikMetabolikPeningkatan kebutuhan Peningkatan kebutuhan metabolismemetabolismeResistensi insulinResistensi insulinMenghambat glikolisis anaerobMenghambat glikolisis anaerobPenurunan sintesis ATPPenurunan sintesis ATPHiperkalemiaHiperkalemiaPeningkatan degradasi proteinPeningkatan degradasi protein
OtakOtakPenghambatan metabolisme dan Penghambatan metabolisme dan
regulasi volume sel otakregulasi volume sel otakKomaKoma
KardiovaskularKardiovaskularGangguan kontraksi otot jantungGangguan kontraksi otot jantung
Dilatasi Arteri,konstriksi vena, dan Dilatasi Arteri,konstriksi vena, dan sentralisasi volume darahsentralisasi volume darah
Peningkatan tahanan vaskular paruPeningkatan tahanan vaskular paru
Penurunan curah jantung, tekanan Penurunan curah jantung, tekanan darah arteri, dan aliran darah darah arteri, dan aliran darah hati dan ginjalhati dan ginjal
Sensitif thd Sensitif thd reentrant arrhythmiareentrant arrhythmia dan penurunan ambang fibrilasi dan penurunan ambang fibrilasi ventrikelventrikel
Menghambat respon kardiovaskular Menghambat respon kardiovaskular terhadap katekolaminterhadap katekolamin
Management of life-threatening Acid-Base Disorders, Horacio J. Adrogue, And Nicolaos EM: Review Article;The New England Journal of Medicine;1998
AKIBAT DARI ASIDOSIS BERATAKIBAT DARI ASIDOSIS BERAT
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KardiovaskularKardiovaskularKonstriksi arteriKonstriksi arteriPenurunan aliran darah koronerPenurunan aliran darah koronerPenurunan ambang anginaPenurunan ambang anginaPredisposisi terjadinya supraventrikel dan ventrikel Predisposisi terjadinya supraventrikel dan ventrikel aritmia yg refrakteraritmia yg refrakter
RespirasiRespirasiHipoventilasi yang akan menjadi hiperkarbi dan Hipoventilasi yang akan menjadi hiperkarbi dan hipoksemiahipoksemia
MetabolicMetabolicStimulasi glikolisis anaerob dan produksi asam organikStimulasi glikolisis anaerob dan produksi asam organikHipokalemiaHipokalemiaPenurunan konsentrasi Ca terionisasi plasmaPenurunan konsentrasi Ca terionisasi plasmaHipomagnesemia and hipophosphatemiaHipomagnesemia and hipophosphatemia
OtakOtakPenurunan aliran darah otakPenurunan aliran darah otakTetani, kejang, lemah delirium dan stuporTetani, kejang, lemah delirium dan stupor
AKIBAT DARI ALKALOSIS BERATAKIBAT DARI ALKALOSIS BERAT
Management of life-threatening Acid-Base Disorders, Horacio J. Adrogue, And Nicolaos EM: Review Article;The New England Journal of Medicine;1998
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PENILAIAN STATUS PENILAIAN STATUS ASAM BASAASAM BASA
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The disadvantage of men not knowing the past is that they do not know the present.
G. K. Chesterton
CARA TRADISIONALCARA TRADISIONAL
Hendersen-Hendersen-Hasselbalch Hasselbalch
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pH pH = 6.1 + log= 6.1 + log[HCO[HCO33
--]]
pCOpCO22
GINJALGINJAL
PARUPARU
BASA BASA
ASAMASAM CO2
HCO3HCO3
CO2
KompensasiKompensasi
NormalNormal
NormalNormal
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DISORDER pH PRIMER RESPON KOMPENSASI
ASIDOSIS ASIDOSIS METABOLIKMETABOLIK
HCO3- pCO2
ALKALOSIS ALKALOSIS METABOLIKMETABOLIK
HCO3- pCO2
ASIDOSIS ASIDOSIS RESPIRATORRESPIRATOR
II
pCO2 HCO3-
ALKALOSIS ALKALOSIS RESPIRATORRESPIRATOR
II
pCO2 HCO3-
RANGKUMAN GANGGUAN RANGKUMAN GANGGUAN KESEIMBANGAN ASAM BASA KESEIMBANGAN ASAM BASA
TRADISIONALTRADISIONAL
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HOW TO UNDERSTAND ACID-HOW TO UNDERSTAND ACID-BASEBASE
A quantitative Acid-Base Primer For Biology and Medicine
Peter A. Stewart
Edward Arnold, London 1981
Now for something new…
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DUA VARIABELDUA VARIABEL
pH atau [HpH atau [H++] DALAM PLASMA ] DALAM PLASMA DITENTUKAN OLEHDITENTUKAN OLEH
VARIABELVARIABELINDEPENDENINDEPENDEN
Stewart PA. Can J Physiol Pharmacol 61:1444-1461, 1983.
DEPENDENDEPENDENT T
VARIABLESVARIABLES
Menurut Stewart ;Menurut Stewart ;
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VARIABEL INDEPENDENVARIABEL INDEPENDEN
COCO22 STRONG ION STRONG ION DIFFERENCEDIFFERENCE
WEAK ACIDWEAK ACID
pCOpCO22 SIDSID AAtoto
tt
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COCO22 Didalam plasma berada Didalam plasma berada
dalam 4 bentukdalam 4 bentuk– sCOsCO22 (terlarut) (terlarut)
– HH22COCO33 asam karbonat asam karbonat
– HCOHCO33-- ion bikarbonat ion bikarbonat
– COCO332-2- ion karbonat ion karbonat
• Rx dominan dari CORx dominan dari CO22 adalah rx adalah rx
absorpsi OHabsorpsi OH-- hasil disosiasi air hasil disosiasi air dengan melepas Hdengan melepas H++..
• Semakin tinggi pCOSemakin tinggi pCO22 semakin semakin
banyak Hbanyak H++ yang terbentuk. yang terbentuk.
• Ini yg menjadi dasar dari Ini yg menjadi dasar dari terminologi “respiratory acidosis,” terminologi “respiratory acidosis,” yaitu pelepasan ion hidrogen yaitu pelepasan ion hidrogen akibat akibat pCO pCO22
COCO22
OHOH-- + CO + CO22 HCO HCO33-- + H + H++
CACA
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STRONG ION DIFFERENCESTRONG ION DIFFERENCE
Definisi:Definisi:Strong ion difference adalah ketidakseimbangan Strong ion difference adalah ketidakseimbangan muatanmuatan dari ion-ion kuat. Lebih rinci lagi, SID adalah jumlah dari ion-ion kuat. Lebih rinci lagi, SID adalah jumlah
konsentrasi basa kation kuat dikurangi jumlah dari konsentrasi basa kation kuat dikurangi jumlah dari konsentrasi asam anion kuat. Untuk definisi ini semua konsentrasi asam anion kuat. Untuk definisi ini semua konsentrasi ion-ion diekspresikan dalam ekuivalensi konsentrasi ion-ion diekspresikan dalam ekuivalensi (mEq/L).(mEq/L).
Semua ion kuat akan terdisosiasi sempurna jika berada didalam Semua ion kuat akan terdisosiasi sempurna jika berada didalam larutan, misalnya ion natrium (Nalarutan, misalnya ion natrium (Na++), atau klorida (Cl), atau klorida (Cl--). Karena ). Karena selalu berdisosiasi ini maka ion-ion kuat tersebut tidak selalu berdisosiasi ini maka ion-ion kuat tersebut tidak berpartisipasi dalam reaksi-reaksi kimia. Perannya dalam kimia berpartisipasi dalam reaksi-reaksi kimia. Perannya dalam kimia asam basa hanya pada hubungan elektronetraliti.asam basa hanya pada hubungan elektronetraliti.
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Gamblegram
NaNa++
140140
KK+ + 44CaCa++++
MgMg++++
ClCl--
102102
KATION ANION
SIDSID
STRONG ION STRONG ION DIFFERENCEDIFFERENCE
[Na+] + [K+] + [kation divalen] - [Cl-] - [asam organik kuat-]
[Na+] + [K+] - [Cl-] = [SID]
140 mEq/L + 4 mEq/L - 102 mEq/L = 34 mEq/L
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SKETSA HUBUNGAN ANTARA SID,HSKETSA HUBUNGAN ANTARA SID,H++ DAN DAN OHOH--
SIDSID(–) ((++))
[H[H++]] [OH[OH--]]
Dalam cairan biologis (plasma) dgn suhu 370C, SID hampir selalu positif, biasanya berkisar 30-40 mEq/Liter
AsidosisAsidosis AlkalosiAlkalosiss
Konsentrasi [H+]
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Kombinasi protein dan posfat disebut asam lemah total (total weak acid) [Atot]. Reaksi disosiasinya adalah:
[A[Atottot] (KA) = [A] (KA) = [A--].[H].[H++]]
[Protein H] [Protein-] + [H+]
WEAK ACIDWEAK ACID
disosiasi
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Gamblegram
NaNa++
140140
KK+ + 44CaCa++++
MgMg++++
ClCl--
102102
HCOHCO33--
2424
KATION ANION
SIDSID
Weak acidWeak acid(Alb-,P-)(Alb-,P-)
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DEPENDENT VARIABLESDEPENDENT VARIABLES
HH++
OHOH--
CO3CO3-- AA--
AHAH
HCO3-HCO3-
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Strong IonsStrong IonsDifferenceDifference
pCOpCO22
ProteinProteinConcentrationConcentration
pHpH
INDEPENDENT VARIABLESINDEPENDENT VARIABLES DEPENDENT VARIABLESDEPENDENT VARIABLES
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PRINSIP-PRINSIP DASAR PRINSIP-PRINSIP DASAR TEORI TEORI STEWARTSTEWART
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• Hukum kekekalan massa (Law of Mass):Hukum kekekalan massa (Law of Mass):– Jumlah dari suatu zat/substansi akan selalu konstan
kecuali ditambahkan atau dikurangi dari luar, atau dibuat/dirusak oleh suatu reaksi kimia.
• Netralitas elektrik (Electroneutrality):Netralitas elektrik (Electroneutrality):– Semua larutan sejati mempunyai muatan listrik yang
netral, dimana konsentrasi total kation harus sama dengan konsentrasi anion
iones (+) = iones (-)
Stewart PA. Modern quantitative acid-base chemistry. Can J Physiol Pharmacol 61:1444-1461, 1983.
PRINSIP UMUMPRINSIP UMUM
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Konsep larutan encer Konsep larutan encer (Aqueous solution)(Aqueous solution)
• Semua cairan dalam tubuh manusia Semua cairan dalam tubuh manusia mengandung air, dan air merupakan sumber mengandung air, dan air merupakan sumber [H[H++]] yang tidak habis-habisnya yang tidak habis-habisnya
• [H[H++]] ditentukan oleh ditentukan oleh disosiasi air disosiasi air (K(Kww), dimana ), dimana
molekul Hmolekul H22O akan berdisosiasi menjadi ion-ion O akan berdisosiasi menjadi ion-ion
HH33OO++ dan OH dan OH--
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MOLEKUL AIR DAN PRODUK DISOSIASINYAMOLEKUL AIR DAN PRODUK DISOSIASINYA(auto-ionisasi air)(auto-ionisasi air)
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H H
H
O
O
O
O
H
H
H H
H H
+-
+
+
+
++
+
+ +
-
-
Sebenarnya, H+ di dalam larutan berada dalam bentuk H3O+
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OH-
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Elektrolit = Ion-ion Elektrolit = Ion-ion
Substansi yang Substansi yang terdisosiasi terdisosiasi sempurnasempurna di dalam suatu larutan : di dalam suatu larutan :
Kation;Kation; Na Na++,K,K++,Mg,Mg++,Ca,Ca++++
Anion;Anion; Cl Cl--,SO,SO44--,PO,PO44
==, ,
laktat laktat--, keto, keto--..
Substansi yang hanya sebagian terdisosiasi dalam suatu larutan :
Albumin-, Posfat-, H2CO3
Ion-ion kuat Ion-ion kuat (Strong ions) (Strong ions) ::
Ion-ion lemah Ion-ion lemah (Weak ions) :(Weak ions) :
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2 3 4 5 6 7 8 9
100
80
70
60
50
40
30
20
10
% ter-ionisasi
pH
pK
CO
2
HC
O3
-
Alb
umin
Lact
ate,
ace
toac
etat
e
MENGAPA DISEBUT ION KUAT DAN LEMAH ?MENGAPA DISEBUT ION KUAT DAN LEMAH ?
Suatu ion dikatakan kuat atau lemah tergantung dari pKnya (pH, dimana 50% dari substansi tsb terdisosiasi). Mis; pK Lactate 3.9 (berarti, pada pH normal, hampir 100% laktat terdisosiasi ). H2CO3 dan Alb disebut asam lemah karena pada pH normal hanya 50% substansinya terdisosiasi.
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BAGAIMANA JIKA ION-ION KUAT BAGAIMANA JIKA ION-ION KUAT BERADA DI DALAM AIR……BERADA DI DALAM AIR……
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Reaksi hidrasi ion-ion Na dan ClReaksi hidrasi ion-ion Na dan Cl
Na+
Cl-O-
H+
O-
O-O-
H+
H+
H+
H+
H+
H+
H+
OH-
OH-
OH-
O-O-
O-
O-
H+
H+
H+
H+H+
H+
H+
H+
H+
H+
H+
H+O-
H+
OHOH--
HH33OO++
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DI DALAM PLASMA TERDAPAT:DI DALAM PLASMA TERDAPAT:
OHOH-- + CO + CO22 H H22COCO33 HCO HCO33-- CO CO33
= = + H+ H++CA
[A[Atottot] (KA) = [A] (KA) = [A--].[H].[H++]]
[Na+] + [K+] - [Cl-] = [SID]
[2H[2H22O] Kw . [HO] Kw . [H++][OH][OH--]]
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NaNa140140
KKMgMgCaCa
ClCl102102
PPAlbAlb
HCOHCO33 = 24 = 24
ClCl115115
PPAlbAlb
HCOHCO33--
Asidosis hiperklore
mi
SID nSID
ClCl102102
Laktat/keto=UA
Keto/laktat
asidosisCLCL9595
PPAlbAlb
SID
Alkalosis hipoklore
mi
KATIONKATION ANIONANION
APLIKASIAPLIKASI
H3O+ = H+ = 40 nEq/LHCOHCO33
--
HCO3-
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PATOFISIOLOGI PATOFISIOLOGI GANGGUAN GANGGUAN
KESEIMBANGAN ASAM KESEIMBANGAN ASAM BASABASA
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Cl-Na
ClH+
Na+
Cl-Cl-
Cl-
Cl-Cl-
Cl-
Cl- Cl-
SID cairan lambung < / () ; asam
PancreasPancreasNa+ Na+
EmpeduEmpeduNa+ Na+
Na+
Na+
Na+Na+
SID plasma Alkalosis
SID plasma -
Asidosis
SID plasma normal
Jejunum
Cl-
Cl- Cl-
Cl-
Colon
Na+
Na+
SID cairan intestinal normal
Na+ Na+
Na+
Diare: Na
Pembuluh darah
Cl
Na
Cl
Na
H+
ClNa
Muntah, Muntah, penyedotanLambung, sekresi EF >> sekresi EF >>
Cl
Magder S. Magder S. Pathophysiology of Pathophysiology of metabolic acid-base disturbances in metabolic acid-base disturbances in patients with critical illnesspatients with critical illness.In: Critical .In: Critical
Care Nephrology. Kluwer Academic Care Nephrology. Kluwer Academic Publishers, Dordrecht, The Netherlands, Publishers, Dordrecht, The Netherlands, 1998. pp 279-296.Ronco C, Bellomo R 1998. pp 279-296.Ronco C, Bellomo R
(eds). (eds).
Made by : George
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Volume dan komposisi elektrolit cairan gastrointestinal From Miller, Anesthesia, 5th ed,2000.
-4040306060-ColonColon
27.592.592.551151151000-2000IleumIleum
22.51151157.51301302000-4000JejunumJejunum
37.51101107.5140140300-600BileBile
67.580807.5140140300-800PancreasPancreas
-20-20115115151580801000-1000-20002000
StomachStomach
1813132566500-2000SalivaSaliva
HCO3-
SID
ClCl-- (mEq/L)(mEq/L)
K+ (mEq/L)NaNa++ (mEq/L)(mEq/L)
24 h vol. (mL)
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Perbandingan komposisi elektrolit urin dan plasma Perbandingan komposisi elektrolit urin dan plasma From
27271.91.9HCOHCO33--
106106153.3153.3ClCl--
4.44.447.547.5KK++
138.4138.4147.5147.5NaNa++
PlasmaPlasmaUrineUrineIon-ion (mEq/l)Ion-ion (mEq/l)
MARTINI, Fundamentals of Anatomy and Physiology; 5 th ed,2001
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Effects of diuretics on urine Effects of diuretics on urine compositioncomposition
6060
1010
1515
2525
2525
1515
PotassiumPotassium
(mEq/l)(mEq/l)
120120151570708.28.233Carbonic anhydrase Carbonic anhydrase inhibitorsinhibitors
15151201201301307.27.233Potassium-sparing Potassium-sparing diurticsdiurtics
4411011090906.56.51010Osmotic diureticsOsmotic diuretics
111551551401406.06.088Loop diureticsLoop diuretics
25251501501501507.47.41313Thiazide diureticsThiazide diuretics
11606050506.46.411No drugNo drug
BicarbonateBicarbonate
(mEq/l)(mEq/l)
ChlorideChloride
(mEq/l)(mEq/l)
SodiumSodium
(mEq/l)(mEq/l)
pHpHVolumeVolume
(ml/min)(ml/min)
Source: adapted from Tonnesen AS, Clincal pharmacology and use of diuretics. In: Hershey SG, Bamforth BJ, Zauder H, eds, Review courses in anesthesiology. Philadelphia: Lippincott, 1983; 217-226
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KLASIFIKASI GANGGUAN KLASIFIKASI GANGGUAN KESEIMBANGAN ASAM BASA KESEIMBANGAN ASAM BASA
BERDASARKAN PRINSIP BERDASARKAN PRINSIP STEWARTSTEWART
Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic acid-base disturbances in critically ill patients. Am J Respir Crit Care Med 2000 Dec;162(6):2246-51
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KLASIFIKASI
ASIDOSIS ALKALOSIS
I. Respiratori PCO2 PCO2
II. Nonrespiratori (metabolik)
1. Gangguan pd SID
a. Kelebihan / kekurangan air [Na+], SID [Na+], SID b. Ketidakseimbangan anion
kuat:
i. Kelebihan / kekurangan Cl- [Cl-], SID [Cl-], SID ii. Ada anion tak terukur [UA-], SID
2. Gangguan pd asam lemah
i. Kadar albumin [Alb] [Alb]
ii. Kadar posphate [Pi] [Pi]
Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic acid-base disturbances in critically ill patients. Am J Respir Crit Care Med 2000 Dec;162(6):2246-51
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RESPIRASIRESPIRASI M E T A B O L I KM E T A B O L I K
Abnormal Abnormal pCO2pCO2
AbnormalAbnormalSIDSID
AbnormalAbnormalWeak acidWeak acid
AlbAlb PO4-PO4-
AlkalosisAlkalosis
AsidosisAsidosis
TurunTurun
MeningkatMeningkat
TurunTurun
kelebihankelebihan
kekurangankekurangan
PositifPositif meningkatmeningkat
Fencl V, Am J Respir Crit Care Med 2000 Dec;162(6):2246-51
AIRAIR Anion kuatAnion kuat
Cl-Cl- UA-UA-
HipoHipo
HiperHiper
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pCO2 berbanding terbalik terhadap pH
pCO2 pH
40-45 mmHg 7.35-7.45
pH
pCO2 pH
pCO2
AlkalosisAcidosis
HOMEOSTASIS
RESPIRASIRESPIRASI
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RESPIRASIRESPIRASI M E T A B O L I KM E T A B O L I K
Abnormal Abnormal pCO2pCO2
AbnormalAbnormalSIDSID
AbnormalAbnormalWeak acidWeak acid
AlbAlb PO4-PO4-
AlkalosisAlkalosis
AcidosisAcidosis
TurunTurun
meningkatmeningkat
turunturun
kelebihankelebihan
kekurangankekurangan
PositifPositif meningkatmeningkat
AIRAIR Anion kuatAnion kuat
Cl-Cl- UA-UA-
HipoHipo
HiperHiper
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Na+ = 140 mEq/LCl- = 102 mEq/LSID = 38 mEq/L
140/1/2 = 280 mEq/L102/1/2 = 204 mEq/L SID = 76 mEq/L1 liter ½ liter
KEKURANGAN AIR - WATER DEFICITKEKURANGAN AIR - WATER DEFICITDiuretic
Diabetes Insipidus
Evaporasi
SID : 38 SID : 38 76 = 76 = alkalosisalkalosis
ALKALOSIS KONTRAKSIALKALOSIS KONTRAKSI
Plasma Plasma
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Na+ = 140 mEq/LCl- = 102 mEq/L SID = 38 mEq/L
140/2 = 70 mEq/L102/2 = 51 mEq/L SID = 19 mEq/L
1 liter 2 liter
KELEBIHAN AIR - WATER EXCESSKELEBIHAN AIR - WATER EXCESS
1 Liter H2O
SID : 38 SID : 38 19 = 19 = AcidosisAcidosis
ASIDOSIS DILUSIASIDOSIS DILUSI
Plasma
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RESPIRASIRESPIRASI M E T A B O L I KM E T A B O L I K
Abnormal Abnormal pCO2pCO2
AbnormalAbnormalSIDSID
AbnormalAbnormalWeak acidWeak acid
AlbAlb PO4-PO4-
AlkalosisAlkalosis
AcidosisAcidosis
turunturun
meningkatmeningkat
turunturun
kelebihankelebihan
kekurangankekurangan
PositifPositif meningkatmeningkat
AIRAIR Anion kuatAnion kuat
Cl-Cl- UA-UA-
HipoHipo
HiperHiper
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Na+ = 140 mEq/L Cl- = 95 mEq/L
SID = 45 mEq/L 2 liter
ALKALOSIS HIPOKLOREMIKALKALOSIS HIPOKLOREMIK
SID ALKALOSIS
GANGGUAN PD SID:GANGGUAN PD SID:Pengurangan ClPengurangan Cl--
Plasma
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Na+ = 140 mEq/L Cl- = 120 mEq/LSID = 20 mEq/L 2 liter
ASIDOSIS HIPERKLOREMIKASIDOSIS HIPERKLOREMIK
SID ASIDOSIS
GANGGUAN PD SID:GANGGUAN PD SID:Penambahan/akumulasi Penambahan/akumulasi
ClCl--
Plasma
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Na+ = 140 mEq/LCl- = 102 mEq/LSID = 38 mEq/L
Na+ = 154 mEq/LCl- = 154 mEq/LSID = 0 mEq/L1 liter 1 liter
PLASMA + NaCl 0.9%PLASMA + NaCl 0.9%
SID : 38
Plasma NaCl 0.9%
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2 liter
ASIDOSIS HIPERKLOREMIK AKIBAT ASIDOSIS HIPERKLOREMIK AKIBAT PEMBERIAN LARUTAN Na Cl 0.9% PEMBERIAN LARUTAN Na Cl 0.9%
=
SID : 19 SID : 19 AsidosisAsidosis
Na+ = (140+154)/2 mEq/L= 147 mEq/L
Cl- = (102+ 154)/2 mEq/L= 128 mEq/L
SID = 19 mEq/L
Plasma
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Na+ = 140 mEq/L Cl- = 102 mEq/L SID= 38 mEq/L
Cation+ = 137 mEq/L Cl- = 109 mEq/L
Laktat- = 28 mEq/L SID = 0 mEq/L
1 liter 1 liter
PLASMA + Larutan RINGER PLASMA + Larutan RINGER LACTATELACTATE
SID : 38 SID : 38
Plasma Ringer laktatLaktat cepat
dimetabolisme
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2 liter
=
Normal pH setelah pemberian Normal pH setelah pemberian RINGER LACTATE RINGER LACTATE
SID : 34 SID : 34 lebih alkalosis dibanding jika lebih alkalosis dibanding jika diberikan NaCl 0.9% diberikan NaCl 0.9%
Na+ = (140+137)/2 mEq/L= 139 mEq/L
Cl- = (102+ 109)/2 mEq/L = 105 mEq/L Laktat- (termetabolisme) = 0 mEq/L SID = 34 mEq/L
Plasma
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Na+ = 140 mEq/LCl- = 130 mEq/LSID =10 mEq/L
Na+ = 165 mEq/LCl- = 130 mEq/LSID = 35 mEq/L1 liter 1.025
liter
25 mEq NaHCO3
SID SID : 10 : 10 35 : 35 : Alkalosis, pH kembali normal Alkalosis, pH kembali normal namun namun mekanismenya bukan karena pemberian HCOmekanismenya bukan karena pemberian HCO33
-- melainkan karena melainkan karena pemberian Napemberian Na++ tanpa anion kuat yg tidak dimetabolisme seperti Cl tanpa anion kuat yg tidak dimetabolisme seperti Cl --
sehingga SID sehingga SID alkalosis alkalosis
Plasma; asidosis
hiperkloremik
MEKANISME PEMBERIAN NA-BIKARBONAT PADA ASIDOSIS
Plasma + NaHCO3
HCO3 cepat dimetabolis
me
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Pada asidosis kronik; Pada asidosis kronik; [CO[CO33
2-2-]] pembentukan CaCO pembentukan CaCO33 << << integritas integritas
tulang terganggu tulang terganggu osteoporosis osteoporosis
COCO22 + H + H22O O HCO HCO33-- + H + H++
[HCO[HCO33
- - ]] [CO[CO33
2-2-]] + [H + [H++]] Reaksi pembentukan karbonat
Alkalosis [H[H++]] reaksi ke kanan [CO[CO332-2-]]
Efek pemberian bikarbonat:Efek pemberian bikarbonat:
• Jika [CO[CO33
2-2-]] maka calcium yang terionisasi akan diikat oleh [CO[CO33
2-2-]]
hipokalsemia akut; sensitifitas membran sel tetany, tetany, hyperexcitability of hyperexcitability of musclesmuscles, , sustained contractionsustained contraction, dan gangguan kontraksi otot jantung., dan gangguan kontraksi otot jantung.
• Pe natrium secara cepat SID secara cepat alkalosis berat kompensasi paru dengan cara menahan CO2 hipoventilasi COCO22
narkosis narkosis apneu apneu
Asidosis [H[H++]] reaksi ke kiri [CO[CO332-2-]]
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NaNa++ NaNa++
KK
HCO3-
ClCl-- ClCl--
HCO3-
SID
Normal Ketosis
UA = Unmeasured Anion:UA = Unmeasured Anion:Laktat, acetoacetate, salisilat, Laktat, acetoacetate, salisilat,
metanol dll.metanol dll.
A-A-AA--
Keto-
SID KK
Lactic/Keto asidosis
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RESPIRASIRESPIRASI M E T A B O L I KM E T A B O L I K
Abnormal Abnormal pCO2pCO2
AbnormalAbnormalSIDSID
AbnormalAbnormalWeak acidWeak acid
AlbAlb PO4-PO4-
AlkalosisAlkalosis
AsidosisAsidosis
turunturun
meningkatmeningkat
turunturun
kelebihankelebihan
kekurangankekurangan
PositifPositif meningkatmeningkat
AIRAIR Anion kuatAnion kuat
Cl-Cl- UA-UA-
HipoHipo
HiperHiper
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NaNa NaNa NaNa
K K KHCO3
ClCl ClCl ClCl
HCO3HCO3SID
Normal Acidosis Alkalosis
GANGGUAN PD ASAM LEMAH:GANGGUAN PD ASAM LEMAH:Hipo/HiperalbuminHipo/Hiperalbumin-- atau P atau P--
Alb/P Alb/P
AlbAlb--/P/P--
AlbAlb--/P/P--
SIDSID
Alkalosis Alkalosis hipoalbuminhipoalbumin/hipoposfate/hipoposfate
mimi
Asidosis Asidosis hiperprotein/ hiperprotein/
hiperposfatemihiperposfatemi
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Regulasi Ph dan mekanisme Regulasi Ph dan mekanisme kompensasikompensasi
Chronic control Chronic control (long-term)(long-term)
Rapid regulation Rapid regulation (short-term)(short-term)
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Regulasi pH pasien PPOK ?Regulasi pH pasien PPOK ?
PCO2
PPOK
pH
NHNH44Cl Cl
HipoalbuminHipoalbumin
Sintesis Alb <<Sintesis Alb <<
HipokloremiHipokloremi
Absorpsi Cl Absorpsi Cl
Amoniagenesis
Amoniagenesis
SIDSID
pH npH n
ClCl
NHNH44
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PaCO2
pH
NHNH44Cl Cl HipoalbuminHipoalbumin
Laktat- / keto-
SID SID
Sintesis Alb <<Sintesis Alb <<
HipokloremiHipokloremi
Amoniagenesis
COCO22SIDSID
Kompensasi akutKompensasi akut hiperventilasihiperventilasi
Anaerobik metAnaerobik met(syok, MODS), DM(syok, MODS), DM
NHNH44
ClCl
pH npH n
Regulasi pH pada asidosis akut non-Regulasi pH pada asidosis akut non-ginjal?ginjal?
ClNa
Kompensasi kronikKompensasi kronik
ClClSOSO44
POPO44
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PENILAIAN ANALISA GAS DARAH PENILAIAN ANALISA GAS DARAH MENGGUNAKAN KOMBINASI BASE MENGGUNAKAN KOMBINASI BASE
EXCESS DAN STEWARTEXCESS DAN STEWART
Nilai2 yg diperlukan:Nilai2 yg diperlukan:1.1. AGD (BE)AGD (BE)2.2. NatriumNatrium3.3. KloridaKlorida4.4. AlbuminAlbumin
Story DA, Bellomo R. Story DA, Bellomo R. Hendersen-Hasselbach vs Stewart: Another Acid-Base Hendersen-Hasselbach vs Stewart: Another Acid-Base ControversyControversy; Review Article, Crit Care & Shock (2002)2:59-63; Review Article, Crit Care & Shock (2002)2:59-63
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[HC
O3- ]
PCO2 = 80 40
20
pH7.0 7.2 7.4 7.6 7.8
10
20
30
40
50
AsidosisAsidosis MetabolikMetabolik
Base Defisit
AlkalosisAlkalosis MetabolikMetabolik
Base Excess
Base Base Excess/ Excess/
Base DeficitBase Deficit
BE = (1 - 0.014Hgb) (HCOBE = (1 - 0.014Hgb) (HCO33 – 24 + (1.43Hgb + 7.7) (pH - – 24 + (1.43Hgb + 7.7) (pH - 7.4)`7.4)`
Normal
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UAUA = BE – [(efek Na + efek Cl) + efek Alb] = BE – [(efek Na + efek Cl) + efek Alb]
UNMEASURED ANION (UNMEASURED ANION (UAUA))PADA ASIDOSIS METABOLIKPADA ASIDOSIS METABOLIK
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BASE EXCESS DAN STEWARTBASE EXCESS DAN STEWART(a) Free water (a) Free water
0.3 x (Na-140) 0.3 x (Na-140)
(b) Chloride effect (b) Chloride effect
102-(Cl x 140/Na) 102-(Cl x 140/Na)
(c) Albumin effect (c) Albumin effect
(0.148 x pH - 0.818) (42-[alb]) (0.148 x pH - 0.818) (42-[alb])
UA = BE/BD – [(a) + (b) + (c)] mEq/LUA = BE/BD – [(a) + (b) + (c)] mEq/L
Magder S. Pathophysiology of metabolic acid-base disturbances in patients with critical illness.In: Critical Care Nephrology.Kluwer Academic Publishers, Dordrecht, The Netherlands, 1998. pp 279-296.Ronco C, Bellomo R (eds).
Jika + efek alkalinisasi Jika - efek asidifikasi
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Strong ions, weak acids and base excess: a simplified Fencl–Stewart approach to
clinical acid–base disorders
D. A. Story, H. Morimatsu and R. Bellomo . British Journal of Anaesthesia, 2004, Vol. 92,
Clinical Investigations
• SBE(mmol/l=meq/l);SBE(mmol/l=meq/l);– from a blood gas machine from a blood gas machine
• Na–Cl effect (meq/l)=Na–Cl effect (meq/l)=– [Na[Na++]–[Cl]–[Cl––]–38]–38
• Albumin effect (meq/l)=Albumin effect (meq/l)=– 0.25x[42–alb(g/l)] 0.25x[42–alb(g/l)]
• Unmeasured ion effect (meq/l)=Unmeasured ion effect (meq/l)=
– SBE–(Na–Cl) effect–alb effectSBE–(Na–Cl) effect–alb effect
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Alb
BASE EXCESS DAN STEWARTBASE EXCESS DAN STEWART
140
150
102
112Efek asidifikasi Cl- -10 BD -10
HCO3-
Efek alkalinisasi SID(Na & Cl) +10 BE +10
Na+ HCO3- Cl-
Alb
HCO3-
Alb
Kasus 1:Kasus 1: 7.25 / 30 / -10 / 147.25 / 30 / -10 / 14
Na 140; Cl 112; Alb 4Na 140; Cl 112; Alb 4
(a) Free water effect: (a) Free water effect:
0.3 x (140-140) = 00.3 x (140-140) = 0
(b) Chloride effect (b) Chloride effect
102-(112) x 140/140) = - 10 102-(112) x 140/140) = - 10
(c) Albumin effect (c) Albumin effect
(0.148 x 7.25 - 0.818) (42-[40]) = 0.5(0.148 x 7.25 - 0.818) (42-[40]) = 0.5
UA = - 10 – [(0) + (-10) + (0.5)] mEq/L = - 0.5UA = - 10 – [(0) + (-10) + (0.5)] mEq/L = - 0.5
Kasus 1:Kasus 1: 7.48 / 45 / +10 / 347.48 / 45 / +10 / 34
Na 150; Cl 102; Alb 4Na 150; Cl 102; Alb 4
(a) Free water effect: (a) Free water effect:
0.3 x (150-140) = 30.3 x (150-140) = 3
(b) Chloride effect (b) Chloride effect
102-(102 x 140/150) = 6.8 102-(102 x 140/150) = 6.8
(c) Albumin effect (c) Albumin effect
(0.148 x 7.25 - 0.818) (42-[40]) = 0.5(0.148 x 7.25 - 0.818) (42-[40]) = 0.5
UA = 10 – [(3) + (6.8) + (0.5)] mEq/L = - 0.3UA = 10 – [(3) + (6.8) + (0.5)] mEq/L = - 0.3
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BASE EXCESS DAN STEWARTBASE EXCESS DAN STEWART
140
102Efek alkalinisasi dari
hipoalb + 6.7 Alb
Na+ HCO3- Cl-
hipoalb
HCO3-UA =- 8.7
SID
BD = -8.7 + 6.7 = - 2
HCO3-
Efek asidifikasi laktat - 8.7
Kasus 2:Kasus 2: 7.42 / 35 / 100 / -2 / 217.42 / 35 / 100 / -2 / 21
Na 140; Cl 102; Alb 1.8; Na 140; Cl 102; Alb 1.8; Menurut H-H normal
(a) Free water (a) Free water
0.3 x (140-140) = 00.3 x (140-140) = 0
(b) Chloride effect (b) Chloride effect
102-(102 x 140/140) = 0102-(102 x 140/140) = 0
(c) Albumin effect (c) Albumin effect
(0.148 x 7.42 - 0.818) (42-[18]) = 6.7(0.148 x 7.42 - 0.818) (42-[18]) = 6.7
UA = - 2 – [(0) + (0) + (6.7)] mEq/L = - 8.7UA = - 2 – [(0) + (0) + (6.7)] mEq/L = - 8.7
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Latihan soalLatihan soal
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• Pria 50 th, riwayat DM dgn th/ OAD,
– Ditemukan tidak sadar di tempat tidur.
– Empat hari sebelumnya os menderita infeksi
paru disertai mual muntah.
– Di UGD S; 330C, Leukosit; 20.000, GD;
400.
– AGD 6.8 / 12 / 1.8 / -33.1
– Na 140, Cl 103, Alb 4.2
Soal :Soal :
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6.8 / 12/ 1.8 / -33.1. 6.8 / 12/ 1.8 / -33.1. Na 140; Cl 103; Alb 4.2Na 140; Cl 103; Alb 4.2
Analisa menggunakan Base Excess dan StewartAnalisa menggunakan Base Excess dan Stewart
(a) Free water effect: (a) Free water effect:
0.3 x (140-140) = 00.3 x (140-140) = 0
(b) Chloride effect: (b) Chloride effect:
102-(103 x 140/140) = -1102-(103 x 140/140) = -1
(c) Albumin effect:(c) Albumin effect:
(0.148 x 6.8 - 0.818) (42-[42]) = 0(0.148 x 6.8 - 0.818) (42-[42]) = 0
UA = - 33.1 – [(0) + (-1) + (0)] = - 32 mEq/LUA = - 33.1 – [(0) + (-1) + (0)] = - 32 mEq/L
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140
103
HCO3
Alb 4.2
Na+ HCO3- Cl-
UA
SID -
Efek asidifikasiketo – 32
H+
Alb 4.2
102Efek asidifikasi
Cl = -1
BD = 0 + (- 32) + (- 1) = - 33.1
Efek Alb dan Na = 0Efek Alb dan Na = 0
GamblegramGamblegramElectroneutrality disosiasi air
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Dua puluh empat jam setelah th/ insulin, pasien mulai sadar dan responDua puluh empat jam setelah th/ insulin, pasien mulai sadar dan respon
7.23 / 28 / 11.7 / -13.4.7.23 / 28 / 11.7 / -13.4.
Na 152, Cl 130. Alb 40.Na 152, Cl 130. Alb 40.
(a) Free water (a) Free water
0.3 x (152-140) = 3.60.3 x (152-140) = 3.6
(b) Chloride effect (b) Chloride effect
102-(130 x 140/152) = -17.7102-(130 x 140/152) = -17.7
(c) Albumin effect (c) Albumin effect
(0.148 x 7.23 - 0.818) (42-[42]) = 0(0.148 x 7.23 - 0.818) (42-[42]) = 0
UA = -13.4 – [(3.6) + (-17.7) + (0)] mEq/L = -0.7UA = -13.4 – [(3.6) + (-17.7) + (0)] mEq/L = -0.7
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BASE EXCESS DAN STEWARTBASE EXCESS DAN STEWART
140
103
Na+ HCO3- Cl-
Alb normalAlb normal
SID tetap
keto
Efek asidifikasi Cl = –17.7 mEq/L
152HCO3
-
130
Efek alkalinisasi Na = +3.6 mEq/l
Ketosis 24 jam7.23 / 28 / 11.7 / -13.4. 7.23 / 28 / 11.7 / -13.4.
Na 150; Cl 130; Alb 4.0;
Efek asidifikasi ClEfek asidifikasi Cl-- merupakan efek terbesar merupakan efek terbesar yang berkontribusi thd BEyang berkontribusi thd BEastrupastrup – 13.4 – 13.4
Asidosis hiperkloremia pasca ketosis akut Asidosis hiperkloremia pasca ketosis akut akibat pemberian larutan NaCl 0.9% akibat pemberian larutan NaCl 0.9%
(protokol cairan pada ketosis)(protokol cairan pada ketosis)
UA = -13.4 – [ (3.6) + (-17.7) + (0) ] = - 0.7
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• Pria 55 th, Decomp Cordis, riwayat HHD.
– ICU, HP 2, paska edema paru
– MASALAH: sulit weaning
– PF; Apatis-CM, ekst dingin, HR 120, RR 10 (SIMV 10,
PS 10, PEEP 5, FiO2 50%), BP 110/55, S 37.8. Ronki
-/-, kardiomegali
– Lab; 11,6/11.000/36/239. GD; 180, U/C 95/2.3
– Th/ lasik drip 5 mg/jam (2 hari), NTG, lanoxin
– Oliguri (0.2 cc/kg/BB)
– AGD 7.48/46/81/+9.1/96% dgn 40% O2.
– Na 133, K 2.9 Cl 90, Alb 3.5
Soal 2:
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7.48/46/+9.1/96 Na 133; Cl 90; Alb 3.5
Analisa menggunakan Base Excess dan Stewart
(a) Free water effect:
0.3 x (133-140) = -0.3
(b) Chloride effect:
102-(90 x 140/133) = 7.2
(c) Albumin effect:
(0.148 x 7.48 - 0.818) (42-[35]) = 2.0
UA = 9.1 – [(-0.3) + (7.2) + (2.0)] = 0.2 mEq/L
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• Th/; CVC Th/; CVC +2, Stop lasix, loading +2, Stop lasix, loading NaCl 500/2 jam + 500 NaCl 0.9/24 jam.NaCl 500/2 jam + 500 NaCl 0.9/24 jam.
• Lab 24 jam; 7.37/38/91/+2/97%. Na 138 K Lab 24 jam; 7.37/38/91/+2/97%. Na 138 K 3.7 Cl 99 Alb 3.3 3.7 Cl 99 Alb 3.3
• Inotropik Dob 5 Inotropik Dob 5 g/kg/mnt + bolus lasix g/kg/mnt + bolus lasix 20 mg 20 mg T-piece T-piece
• T-Piece 6 jam T-Piece 6 jam ekstubasi. Evaluasi ekstubasi. Evaluasi paska ekstubasi 6 jam paska ekstubasi 6 jam hasil baik hasil baik
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• Wanita 65 th, Post CABG of pump on pump.– HP 3 2 hari pasca ekstubasi
– PF; ekst dingin, HR 120, RR 20, BP 160/55, S 38.8.
Ronki +/+, RO ; edema paru + pneumonia lobaris ka
– Lab; 10,6/9.000/32/200. GD; 176, U/C 56/2.6
– Th/ lasik drip 2 mg/jam (hari ke 2),
– Urin (0.5 cc/kg/BB)
– AGD 7.31/22/81/-1.7/96% dgn NRM 12 L/m O2.
– SvO2 56%. CI 2.8
– Na 133, Cl 93, Alb 3.5
Soal 3:
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7.31/22/81/-1.7/96 Na 133; Cl 93; Alb 3.5
Analisa menggunakan Base Excess dan Stewart
(a) Free water effect:
0.3 x (133-140) = -0.3
(b) Chloride effect:
102-(93 x 140/133) = 4.1
(c) Albumin effect:
(0.148 x 7.31 - 0.818)(42-[35]) = 1.8
UA = -1.7 – [(-0.3) + (4.1) + (1.8)] = -7.3 mEq/L
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• Laktat 4.6• Th/; CPAP mask 5 cmH2O. FiO2 50%• Lasix stop, ganti oral 2x1 tab. Antibiotik ganti Cefepime 3x1
• Evaluasi 2 jam; sesak berkurang, HR 95. BP 127/60. CI 2.9 SvO2 71%. Laktat 1.7
• Lab; 7.34/37/119/-0.8/99%.• 24 jam kemudian CPAP ganti nasal 4 liter/mnt, HD dan Resp stabil normal
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Hendersen-Hendersen-Hasselbalch Hasselbalch Matur SuksmeMatur Suksme
Anang & George