16. gangguan keseimbangan asam basa anak
TRANSCRIPT
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
1/38
GANGGUAN KESEIMBANGAN
ASAM BASA PADA ANAK
Dr. WAN NEDRA, Sp. A
BAGIAN ANAK FK. YARSI
2015
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
2/38
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
3/38
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
4/38
Acid/base
7.4
BE = 0
HCO3 = 24
Respiratory
Acidosis
Metabolic
Acidosis
Metabolic
Alkalosis
Respiratory
Alkalosis
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
5/38
ABG Rules
Rule 1:An increase or decrease in PaCO2of10 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 witha directly related increase or decrease of
0.15 pH units.
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
6/38
Acidosis
pH < 7.2
decreased responsiveness to catecholamines
cardiac dysfunction
arrhythmias
increased potassium serum levels
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
7/38
RESPIRATORY ACIDOSIS
Increased pCO2 and pH below 7.35 due to
hypoventilation, emphysema etc.
Compensation occurs in the kidney through
increased H+ excretion and HCO3-
reabsorption. Bicarbonate/carbonic acid ratio
is 10-15:1.
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
8/38
RESPIRATORY ALKALOSIS
Hyperventilation due to O2 deficiency, CVA, or
anxiety are causes of respiratory
alkalosis. Renal compensation occurs by
decreasing H+ excretion and HCO3-
reabsorption.
H+ is reabsorbed. Bicarbonate/carbonic acid
ratio is 30-40:1.
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
9/38
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.
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
10/38
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.
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
11/38
Case Studies
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
12/38
KASUS
Anak 2 tahun, didiagnosis sebagai Meteorismusakibat komplikasi dari Diare Akut dengan gangguanelektrolit darah. Dasar diagnosis dari anamnesismuntah, mencret dan kembung. Pada pemeriksaanfisik tampak abdomen membuncit, tidak terdengarbising usus. Gambaran soal berikut ini adalah hasillaboratorium penunjang yang diambil dari darahpasien. Yang mana hasil pemeriksaan dibawah ini
yang sesuai dengan kondisi diatas:
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
13/38
Hasil Laboratorium
pH
Serum
Na
(meq/L)
K+
(meq/L)
Cl-
(meq/L)
HCO3-
(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
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
14/38
Lanjutan kasus 1
Follow up 4 jam setelah di Rumah Sakit:
Pasien lelah (fatigue), sesak nafas (pernafasan
Kussmaull), Cuping Hidung, muntah.
Hasil AGD:
pH: 7,1Asidosis, HCO3: - 25Metabolik
Penanganan: Koreksi dg Bicnat
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
15/38
Apa yang terjadi pada pasien tsb?
Manifestasi sangat tergantung pd penyebab &
kecepatan perkembangan proses penyakit
AsidosisAlkalosis 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
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
16/38
Alkalosis Metabolik
Overventilation pada kasus gagal nafas
Alkalosis
Klinis sama dg asidosis metabolik
Curah jantung menurun, depresi ventilasi
sentral
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
17/38
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
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
18/38
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
19/38
Treatment of Metabolic AcidosisThe total replacement dose of [HCO3 -] can be calculated as
follows:
Replace with one-half the total amount of bicarbonate over 8-12h and reevaluate.
Be aware of sodium and volume overload during replacement.
Normal or isotonic bicarbonate drip is made with 3 ampulesNaHCO3 (50 mmol NaHCO3/ampule) in 1 L D5W.
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
20/38
METABOLIC ALKALOSIS:
Metabolic alkalosis represents an increase in
[HCO3 -] with a compensatory rise in pCO2.
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
21/38
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).
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
22/38
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
23/38
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
24/38
Chloride-Sensitive (Responsive) Metabolic
Alkalosis:
The initial problem is a sustained loss of chloride out ofproportion to the loss of sodium (either by renal or GI )
This chloride depletion results in renal sodiumconservation leading to a corresponding reabsorption of[HCO3 -] by the kidney.
In this category of metabolic alkalosis, the urinary [Cl-]is
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
25/38
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.
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
26/38
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 extremecases.
2. Chloride-resistant
a. Treat underlying problem, such as stoppingexogenous steroids.
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
27/38
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.
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
28/38
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.Sclerodermae. Marked obesity (Pickwickian syndrome)
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
29/38
Treatment of Respiratory Acidosis
Improve Ventilation:
Intubate patient and place on ventilator,increase ventilator rate, reverse narcotic
sedation with naloxone (Narcan), etc
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
30/38
RESPIRATORY ALKALOSIS:
Respiratory alkalosis is a primary fall in pCO2
with a compensatory decrease in plasma
[HCO3 -].
Respiratory alkalosis occurs with increased
alveolar ventilation.
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
31/38
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. PEb. 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
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
32/38
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
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
33/38
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
34/38
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
35/38
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
36/38
na a un, agnos s se aga e eor smus a a omp as ar are u engan gangguan e e ro ara . asar agnos s
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
37/38
Disturbance of acid based balance
Disturbance Plasma PH Plasma PCO2 Plasma HCO3
Respiratory
Acidosis
Respiratory
Alkalosis
Metabolic
Acidosis
Metabolic
Alkalosis
-
7/25/2019 16. Gangguan Keseimbangan Asam Basa Anak
38/38
Questions?