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16. Gangguan Keseimbangan Asam Basa Anak

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    GANGGUAN KESEIMBANGAN

    ASAM BASA PADA ANAK

    Dr. WAN NEDRA, Sp. A

    BAGIAN ANAK FK. YARSI

    2015

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    Acid/base

    7.4

    BE = 0

    HCO3 = 24

    Respiratory

    Acidosis

    Metabolic

    Acidosis

    Metabolic

    Alkalosis

    Respiratory

    Alkalosis

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    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.

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    Acidosis

    pH < 7.2

    decreased responsiveness to catecholamines

    cardiac dysfunction

    arrhythmias

    increased potassium serum levels

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    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.

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    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.

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    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.

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    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.

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    Case Studies

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    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:

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    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

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    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

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    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

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    Alkalosis Metabolik

    Overventilation pada kasus gagal nafas

    Alkalosis

    Klinis sama dg asidosis metabolik

    Curah jantung menurun, depresi ventilasi

    sentral

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    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

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    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.

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    METABOLIC ALKALOSIS:

    Metabolic alkalosis represents an increase in

    [HCO3 -] with a compensatory rise in pCO2.

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    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).

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    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

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    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.

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    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.

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    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.

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    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)

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    Treatment of Respiratory Acidosis

    Improve Ventilation:

    Intubate patient and place on ventilator,increase ventilator rate, reverse narcotic

    sedation with naloxone (Narcan), etc

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    RESPIRATORY ALKALOSIS:

    Respiratory alkalosis is a primary fall in pCO2

    with a compensatory decrease in plasma

    [HCO3 -].

    Respiratory alkalosis occurs with increased

    alveolar ventilation.

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    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.

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