Asam-Basa Darah dan Keseimbangan

Cairan Elektrolit

Lab. Anestesiologi & Reanimasi

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

pH, PaCO2, BE
HCO3, PaO2
 Acidosis
pH < 7.4

Decrease
d HCO3

Increase
d paCO2
 Alkalosis
pH > 7.4

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 0±2 24±2
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
 ¾ of ECF

¼ 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, RBC’s and
Magnesium Mg 1.5-2.5 Suction, hyper Magnesia in patients
CNS, metabolism
aldosteronism with renal failure

Muscle, RBC’s, 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
Kalium 4 100 Kalium
Kalori 400 40 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%
PLUS insulin 10 -20
unit per botol 500 cc
20 mEq per jam atau
200 mEq per hari.
 1 cc = 1 mEq,
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