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Asam-Basa Darah dan Keseimbangan

Cairan Elektrolit

Dr. Isngadi, M.Kes., SpAn.

Lab. Anestesiologi & Reanimasi


FK. UB / RS. Dr. Saiful Anwar
Malang
Analisa gas darah
Apa yang dibaca ?

pH, PaCO2, BE
HCO3, PaO2
Acidosis
pH < 7.35

Decrease
d HCO3

Increase
d paCO2
Alkalosis
pH > 7.45

Increase
d HC03
Decreased
CO2
1. pH Classification
2. PaCO2 Classification
3. Metabolic Classification
4. Compensation Evaluation
5. Complete Acid-Base Classification
Classification pH
Normal 7.35-7.45
Acidosis < 7.35
Alkalosis >7.45
Classification of Laboratory
Respiratory Acid-Base Component

Classification PaCO2 (mmHg)


Normal Resp.Component 35-45
Respiratory Acidosis >45
Respiratory Alkalosis <35
Classification of Laboratory
Metabolic Acid-Base Component

Classification BE HCO3
Normal Metab.Component 02 242
Metabolic Acidosis < -2 <22
Metabolic Alkalosis > +2 >26
Nilai normal BGA

7,35 pH 7,45
45 PaCO2 35
-2 BE +2
22 HCO3 26
Langkah Langkah
Baca pH normal, acidosis, alkalosis
Lihat PaCO2 atau BE, mana yg searah dengan
pH
Bila PaCO2 yang searah respiratorik sebagai
proses primer
Bila BE yang searah metabolik sebagai proses
primer
Bila proses primer sudah diketahui, lihat dimana
posisi komponen yg lain :
Bila berlawanan proses kompensasi
Bila searah proses ganda
Bila posisi normal belum atau tidak ada proses
kompensasi
Menganalisa BGA

ACIDOSIS Normal ALKALOSIS


7,35 pH 7,45
45 PaCO2 35
-2 BE +2
22 HCO3 26
pH : 7.28, PaCO2 : 40, BE : -10

ACIDOSIS Normal ALKALOSIS


7.28 7,35 pH 7,45
45 40 2
PaCO 35
-10 -2 BE +2
22 HCO3 26

Acidosis metabolik tanpa kompensasi


pH : 7.32, PaCO2 : 55, BE : +1

ACIDOSIS ALKALOSIS
7.32 7,35 pH 7,45
55 45 PaCO2 35
-2 +1
BE +2
22 HCO3 26

Acidosis respiratorik tanpa kompensasi


pH : 7,50 ; PaCO2 : 30 ; BE : -2 ;

ACIDOSIS ALKALOSIS
7,35 pH 7,45 7,50
45 PaCO2 35 30
-2 BE +2
22 HCO3 26
Alkalosis respiratorik tanpa kompensasi
pH : 7,48 ; PaCO2 : 30 ; BE : -6 ;

ACIDOSIS ALKALOSIS
7,35 pH 7,45 7,48
45 PaCO2 35 30
-6 -2 BE +2
22 HCO3 26
Alkalosis respiratorik dgn kompensasi metabolik
pH : 7,55 ; PaCO2 : 30 ; BE : +5 ;
ACIDOSIS ALKALOSIS
7,35 pH 7,45 7,55
45 PaCO2 35 30
-2 BE +2 +5
22 HCO3 26

Alkalosis respiratorik dan metabolik


(proses ganda)
pH : 7.32, PaCO2 : 30, BE : -10

ACIDOSIS ALKALOSIS
7.32 7,35 pH 7,45
45 PaCO2 35 30
-10 -2 BE +2
22 HCO3 26

Acidosis metabolik dgn kompensasi respiratorik


CLASSIFICATION of PaO2
PaO2 (mmHg)
CLASSIFICATION Adult Newborn
Hyperoxemia >100 >90
Normoxemia 80-100 60-90
Mild hypoxemia 60-79 50-59
Moderate hypoxemia 45-59 40-49
Severe hypoxemia <45 <40
Severity of Generalized Acid-Base
disturbances
pH Degree of Impairment
<7,20 Severe Acidosis
7,20-7,29 Moderate Acidosis
7,30-7,34 Mild Acidosis
7,35-7,45 Normal pH
7,46-7,50 Mild Alkalosis
7,51-7,55 Moderate Alkalosis
>7,55 Severe Alkalosis
BAHAYA GANGGUAN ASAM BASA
Acidosis menyebabkan kadar Kalium darah naik,
fungsi sel & ensim tubuh terganggu.
Alkalosis menurunkan kadar Kalium di dalam
darah.
alkalosis juga mendorong kurve disosiasi oksigen
ke kiri.
pC02 yang tinggi (80 - 100 mmHg)
menyebabkan coma, aritmia ventrikuler serta
vasodilatasi pembuluh darah otak.
pC02 yang rendah [ < 25 mm-Hg]
menyebabkan vasokonstriksi pembuluh darah
otak
Cause of Respiratory Acidosis

Hypoventilation for any reason


COPD
Paralysis of respiratory muscles
Cardiac Arrest Code
Cause of Metabolic Acidosis
Starvation
DKA
Renal Failure
Lactic Acidosis from heavy exercise
Drugs EtOH, ASA
Diarrhea
Cause of Respiratory Alkalosis

Hyperventilation from any cause


Pneumonia

Too high ventilator settings


Metabolic Alkalosis

Excessive vomiting
Gastric suctioning
Hypokalemia OR Hypercalcemia
Excess aldosterone
Drugs Steroids, diuretics, NaHCO3
Asidosis Metabolik

Koreksi Nabic [ mEq ]= 0,3 X BB X BE,


berikan 50% bolus, tunggu 30-60 mnt,
50% sisanya diberikan dgn kecepatan
1 mEq/menit
Fluid & Electrolyte
Normal Water Balance

I. Intake:
Fluid ingestion 60%
Foods 30%
Metabolism 10%
II. Output:
Urine 60%
Sweat 8%
Feces 4%
"Insensible" loss 28%
(skin, lungs)
Fluid Compartments
Extracellular

Intracellular

Intracellular

Interstitial
of ECF

of ECF

Fluid is in both compartments 50-60% of body weight


Body Fluid Compartments: Composition
Intracellular Extracellular
Intravascular Interstitial
Sodium (mEq/l) 10 145 142
Potassium (mEq/l) 140 4 4
Calcium (mEq/l) <1 3 3
Magnesium (mEq/l) 50 2 2
Chloride (mEq/l) 4 105 110
Bicarbonate (mEq/l) 10 24 28
Phosphorus (mEq/l) 75 2 2
Protein (g/dl) 16 7 2
Body Fluid Compartments: Composition
Electrolyte Plasma Plasma water Interstitial Intracell. fluid
(mEq/L) (mEq/L) fluid (mEq/L) (mEq/kg H2O)
CATIONS
Sodium 142 152 145 10
Potassium 4 4 4 156
Calcium 5 5 3 3
Magnesium 3 3 1 26
Total 154 164 153 195
ANIONS
Chloride 103 109 114 2
Bicarbonate 27 29 30 10
Phosphate 2 2 2 108
Sulfate 1 1 1 20
Organic acids 5 6 5
Protein 16 17 1 55
Total 154 164 153 195
Volume and composition of gastrointestinal
fluids
24 h vol. Na+ K+ Cl- HCO3-
(mL) (mEq/L) (mEq/L) (mEq/L) (mEq/L)
Saliva 500-2000 2-10 20-30 8-18 30

Stomach 1000-2000 60-100 10-20 100-130 0

Pancreas 300-800 135-145 5-10 70-90 95-120

Bile 300-600 135-145 5-10 90-130 30-40

Jejunum 2000-4000 120-140 5-10 90-140 30-40

Ileum 1000-2000 80-150 2-8 45-140 30

Colon - 60 30 40 -

From Miller, Anesthesia, 5th ed.


Serum Electrolytes

Symbo Normal
Name Function Hypo Causes Hyper Causes
l Value

Maintains GI Losses High fever, heatstroke


Sodium Na 135-145 concentration of Diuretics, burns, wound due to insensible water
ECF drainage loss, diabetes insipidus

Major ICF cation;


Acidosis
cellular and GI Losses diarrhea,
Renal disease
Potassium K 3.5-5.0 metabolic functions vomiting, duretics,
K containing drugs
including cardiac diaphoresis
K salt substitute
rhythms

Transmission of Chronic renal failure, Vit


nerve impulses, D deficiency, Mult. Myeloma,
Calcium Ca 4.5-5.5 cardiac pancreatiti,s, loop thiazide diuretics,
contractions, bone, diuretics, diarrhea malignancies,
blood clotting hyporparathyroidism

Diarrhea, vomiting, NG Maalox and Milk of


Muscle, RBCs and
Magnesium Mg 1.5-2.5 Suction, hyper Magnesia in patients
CNS, metabolism
aldosteronism with renal failure

Muscle, RBCs, CNs, Malnourished, alcohol Renal failure,


Phosphate Phos 1.7-4.6 w/ Calcium in withdrawal, phosphate- chemoTx, enemas
bones and teeth binding antacids containing
Kebutuhan sehari
BB : 50 Kg
Volume : 2000 ml (40-50 cc/Kg)
Natrium : 100-200 mEq (2-4mEq/Kg)
Kalium : 50-150 mEq (1-3 mEq/Kg)
Kalori : 1500 kcal (30kcal/Kg)

mEq/Kg
Pilihan infus yang ada :
RD 1000 + D5 1000 KaEnMg 2000
ml Natrium 147 ml Natrium 100
Kalium 4 Kalium 40
Kalori 400 Kalori 800
Pedoman terapi cairan

cairan keluar = cairan masuk

1.Apa yang keluar : jumlah dan komposisi


2. Diganti semua / dikurangi / dilebihi
3. Evaluasi volume : tanda-tanda klinis
4. Evaluasi elektrolit : periksa lab & tanda
klinis
Gangguan keseimbangan

Excess & Deficit

Hypernatremia Hyponatremia
Hyperkalemia Hypokalemia

Saline excess Saline deficit

Water excess Water deficit


ISOTONIC LOSS :
peritonitis, ileus, muntaber, edema trauma

harus diganti RL / NaCl 0.9% / RA


jangan diganti NaCl 0.45% - D5%
berlaku untuk semua usia, bayi - manula
replacement yang mengabaikan Natrium
isotonis akan menyebabkan water excess
(hiponatremia, edema otak)
SALINE EXCESS

SALINE DEFICIT
Na 145

Na 145

Infus
RL/NaCl

1. Restriksi cairan
2. Diuresis Lasix

normal Na 145
WATER DEFICIT

Na 165 Infus
Dextrose 5%

Na 145

normal
WATER
EXCESS
Na 125
NORMO-volemia Na 125

HYPER-volemia
BAHAYA : Edema Otak, TIK naik
TANDA :1. Nadi lambat, tekanan darah naik
2. Hyper-reflexia, kejang
3. C o m a
WATER
EXCESS
Na 125
NORMO-volemia Na 125

HYPER-volemia
Terapi : 1. Restriksi air
2. Semua infus NaCl 0.9%
3. Lasix 1-3 mg/kg/iv
4. HANYA BILA ADA KEJANG :
NaCl 3% 200 ml dalam 1-3 jam,
kejang di terapi Valium i.v.
HYPER-K vs HYPO-K

Ca-gluconat KCl drip terbagi


100 - 200 mg, i.v. rata 24 jam
Na-bicarbonate Maksimum
50 - 100 mEq 20 mEq per jam
Dextrose 10-20% atau 200 mEq per
PLUS insulin 10 -20 hari.
unit per botol 500
cc
Strategi terapi cairan
Koreksi Volume
hipovolemia lebih sering dijumpai
Koreksi Natrium
water excess (hiponatremia) lebih sering
dijumpai
Koreksi Kalium
hypokalemia lebih sering dijumpai
GANGGUAN KESEIMBANGAN
CAIRAN & ELEKTROLIT

SALINE DEFICIT / SALINE EXCESS


air dan Natrium proporsional (isotonik)
WATER DEFICIT / WATER EXCESS
air dan Natrium tidak proporsional (hipotonik)

KALIUM DEFICIT / KALIUM EXCESS


hanya Kalium, tidak menyangkut air
Gangguan elektrolit Kalium

Tubuh memiliki banyak cadangan Kalium


Hipokalemia mudah ditolerir

Hiperkalemia lebih berbahaya


destruksi jaringan karena trauma, sepsis,
nekrosis, luka bakar > 30%
gagal ginjal akut
hemolisis
kejang otot berkepanjangan
Bahaya
Hiper K > 4.5 Hipo K < 3.0
Aritmia ventrikuler
PVC Aritmia
PVC multiple supraventrikuler dan
VT / VF bila K > 6 bisa ventrikuler
Diperburuk asidosis VT/VF bila K < 2.5
Kelemahan otot
bergaris dan juga otot
nafas
Ileus paralitik
Diperburuk alkalosis
Intoksikasi digitalis
HYPER-K vs HYPO-K

Ca-gluconat
100 - 200 mg, i.v.
Na-bicarbonate
KCl drip rata 24 jam
50 - 100 mEq Maksimum

Dextrose 10-20%
20 mEq per jam atau
PLUS insulin 10 -20 200 mEq per hari.
1 cc = 1 mEq,
unit per botol 500 cc
larutkan dalam Dext
5%, bagi rata
Management of hyponatremia

the rate of rise in plasma sodium should


not exceed 0.5 mEq/L/hour
the final plasma sodium concentration
should not exceed 130 mEq/L

Sodium deficit (mEq) = Normal TBW x (130 - Current PNa)

3% sodium chloride contains 513 mEq of sodium per liter


60 kg woman with a plasma sodium of 120 mEq/L,
the sodium deficit = 0.5 X 60 X (130 - 120) = 300 mEq.

Because 3% sodium chloride contains 513 mEq of


sodium per liter, the volume of hypertonic saline
needed to correct a sodium deficit of 300 mEq will be
300/513 = 585 mL. Using a maximum rate of rise of
0.5 mEq/L/hour for the plasma sodium (to limit the risk
of a demyelinating encephalopathy), the sodium
concentration deficit of 10 mEq/L in the previous
example should be corrected over at least 20 hours.
Thus, the maximum rate of hypertonic fluid
administration will be 585/20 = 29 mL/hour