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 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 PaCO
40 2 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 BE
+1 +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 +5
+2
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

l ar
sc u
av a
Intracellular
I ntr

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 fluid Intracell. fluid
(mEq/L) (mEq/L) (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+ (mEq/L) Cl- (mEq/L) HCO3-

(mL) (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

Normal
Name Symbol Function Hypo Causes Hyper Causes
Value

GI Losses High fever, heatstroke

Maintains
Sodium Na 135-145 Diuretics, burns, wound due to insensible water
concentration of 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

Chronic renal failure, Vit

Transmission of
D deficiency,
nerve impulses, Mult. Myeloma, thiazide
Calcium Ca 4.5-5.5 pancreatiti,s, loop
cardiac contractions, diuretics, malignancies,
diuretics, diarrhea
bone, 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, chemoTx,
Phosphate Phos 1.7-4.6 w/ Calcium in bones withdrawal, phosphate-
enemas containing
and teeth binding antacids
 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 ml • KaEnMg 2000 ml
Natrium 147 Kalium Natrium 100
4 Kalori 400 • Kalium 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 100 - • KCl drip terbagi rata 24

200 mg, i.v. jam
• Na-bicarbonate 50 - • Maksimum 20
100 mEq mEq per jam atau 200
• Dextrose 10-20% PLUS mEq per hari.
insulin 10 -20 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 • Aritmia supraventrikuler

– PVC dan bisa ventrikuler
– PVC multiple – VT/VF bila K < 2.5
– VT / VF bila K > 6 • Kelemahan otot bergaris
• Diperburuk asidosis dan juga otot nafas
• Ileus paralitik
• Diperburuk alkalosis
• Intoksikasi digitalis
 HYPER-K vs HYPO-K

• Ca-gluconat 100 -
200 mg, i.v.
• KCl drip rata 24 jam
• Na-bicarbonate 50 -
• Maksimum 20
100 mEq mEq per jam atau 200 mEq
• Dextrose 10-20% PLUS per hari.
insulin 10 -20 unit per – 1 cc = 1 mEq, larutkan
dalam Dext 5%, bagi rata
botol 500 cc
 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