16. Gangguan Keseimbangan Asam Basa Anak

7/25/2019 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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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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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


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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


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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


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Disturbance of acid based balance

Disturbance Plasma PH Plasma PCO2 Plasma HCO3

Respiratory

Acidosis

Respiratory

Alkalosis

Metabolic

Acidosis

Metabolic

Alkalosis


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16. Gangguan Keseimbangan Asam Basa Anak

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16. Gangguan Keseimbangan Asam Basa Anak