Post on 30-May-2015
description
CAZ CLINIC
SUUB
SINDROMUL DE INTESTIN SCURT
Cazul la prima vedere…
Barbat de 63 ani
Infarct entero-mezenteric in 2006 si 2009
Enterectomie larga – gastroduodenojejunotransversoanastomoza (fara D3,D4,prima ansa jejunala)
Casectic (∆M = 45-50kg/3 ani)
Sindrom diareic persistent si impresionant
Tetrapareza recent instalata (motiv de reinternare in prezent)
Tegumente uscate, mucoase uscate, tendinta la hTA, tahicardic
Edeme generalizate si pufoase
Relativ poliuric in absenta stimularii diurezei
Tendinta la hiperpnee
T
Teoretic…
Sindrom de malabsorbtie sever si complex
Dezechilibre hidroelectrolitice complexe
Dezechilibre acidobazice complexe
Iminenta de instabilitate hemodinamica
“Suferinta” renala in cadrul dezechilibrului electrolitic
SIBO( small intestinal bacterial overgrowth)
Acum ori altadata simptomatologie neurologica
“centrala” in preajma unor pranzuri bogate
Modificari sau simptomatologie compatibila cu boli
reumatologice
Antecedente de fractura
Antecedente de colica renala
SID? Ser ringer Ser fiziologic Na-Cl 1 molar Na-HCO3 1 molar K-Cl 1 molar
Glu 5%, 10% Apa distilata
MULTIBIC SID=38
STEWART
HENDERSON-HASSELBALCH
Strong Ions
HCO3--H+
f(x)=y
Descrierea EAB
Focus H+ sau HCO3
Focus Strong Ion
Boston Copenhaga
H-H EQ
Singer
Hastings BB
Stewart IND vs DEP
Border flux Kofranek
C O N S T A B L E
f(x)=y
Bicarbonat
Weak anions
apa
Compusi
nutritivi
Strong cations Sodiu
Potasiu
Magneziu
Calciu
Pierderi relative
Dilutional Ac. Sau Concentrational Alk.
AGMA sau Ac. Cu SID ↓ Si SIG↑
Componenta de alk. met.prin hALB si hP
HCMA sau Ac. Cu SID↓
Tulburari AB primare
Strong cations
PMSA↓
GFR↓=>NH4↓ ACM
Instrumente pentru D-lactat
SIG sau AG Corectat sau
BE gap
UAG vs UOSM GAP
UOSM GAP vs UAG
Direct
D-lactatul este filtrat Si nereabsorbit renal
Acidoza este mai curand hiperclo- remica decat acidoza cu gaura anionica crescuta.
HipoK
K,Mg↓ Pmsa↓
ECG NM
RENAL
hipoK induced Renal dysfunction
Defect de concentrare(DI nefrogen) Cresterea formarii de NH4
Cresterea reabsorbtiei de HCO3 Cresterea reabsorbtiei de Na
Nefropatie hipokaliemica
TTKG-ul, teoretic, este “conservator” renal in stadiul de hipokalemie “franca”
Defect de concentrare
AQP 2 ↓
Na-K-2Cl ↓=> ↓Mecanismul de
contracurent
NH4↑
pHi↓
HipoK
↑Reabs. HCO3
HipoK pHi↓ ↑NHE proximal
↑NAE
Hiperplazie de celule tubulare Eventual fibroza tubulointerstitiala Atrofie de celule tubulare Formare de chisti in medulara
Insuficienta renala cronica(RIFLE cu E)
Un lucru-i cert: pacientul trebuie umplut
CAT?
CU CE?
Si eventual, simultan sau mai incolo, golit
Cu SID-ul potrivit ?
Furosemidul cladeste SID-ul
Cum adica furosemidul cladeste SID-ul?
Cum adica furosemidul cladeste SID-ul?
Furosemidul e “antidotul” acetazolamidei in termeni de SID
Furosemidul va creste NAE cu costul unei pierderi de potasiu. Veti fi injectat potasiu in momentul adm. de furosemid.
Si tot el “strica” Osm.med.
Indici HD L,MAP,CO,SVO2, ∆PCO2,∆PCO2/
∆CO2
Mereu raportat la “ce a fost”
Estimare MSFP NAVIGATOR
Responsivitate la fluid-indici dinamici
Estimare TBW si comparare cu TBWe
PROBLEMATIC
CAT?
In continuare tot despre “cat”…
Weber E. The law of pulsatile flow and its application to the circulation. Primitive model of the circulation. (German) In: Berichte ueber die Verhandlungen der Konigl Sachsischer Cesellschaften der Wissen-Schaften zu Leipzig, Weidmanische Buchhandlung, 1850
MSFP MCFP
Sa fie indeajuns de plin
“The peripheral circulation controls cardiac output in many clinical conditions. Manipulation of the peripheral circulation is as important to the successful treatment of shock and other altered circulatory states, as is the manipulation of cardiac output.”
MSFP
“Under normal circumstances, cardiac output is controlled by the peripheral vasculature, which is as energetic at returning blood to the heart as the heart is at pumping blood to the periphery.”
Pana astazi…
“The Navigator systematizes cardiovascular management to simplify cognitive tasks, reduce side effects and to ensure better achievement
of therapeutic targets.”
Pmsa = 0.96•RAP+0.04•MAP+0.96•1/26•SVRnBW•CO
EH=(Pmsa-RAP)/Pmsa
Totul a inceput cu CVVHDF
MSFP pe ventilator
Pmsf-RAP=CO•RVR ∆V/∆Pmsf=C
MSFP este f(MAP,RAP)
Pao=MSFP•(1+Rsu/Rsd)-Rsu/Rsd•RAP
Pao=c-d•Pcv
MSFP=c/(d+1)
Rven MSFP
EH
DOBUTREX
MFSP↑
Nu-l vrem prea “plin” din respect pentru px
Px
“The extraction tension is the single most important quantity of the arterial oxygen status. If the arterial blood is unable to supply 2,3 mmol/L, without a fall in oxygen tension below 4,5 kPa, then there is a disturbance in the oxygen status of the arterial blood.”
PO2(a)
ceHb
P50
Px determ.
Calcule in EAB
AG = Na+K-Cl-HCO3; 7-17 mEq/l
Alb-=albg/l•(0.123•ph-0.631)
Pphate-=Pmmol/l•(0.309•pH-0.469)
SIDa=Na+K+Ca+Mg-Cl-L
SIDe=2.46•10-8•pCO2mmHg/10-pH
+Alb-+Pphate-
SIG=SIDa-SIDe; <5mEq/L
AGcorr=AG-Alb--Pphate--L; <5mEq/L
AGcorr=AG-2•Albg/dl-0.5•Pmg/dl-L
A avut pacientul D-lactat?
Ph=7.279
pCO2=18.3
Na=147
K=2
Cl=121
Lactat=1
HCO3=8.3
Albumina=1.9g/dl
Fosfor seric=0.5mg/dl
A avut pacientul D-lactat?
Acidemie Context
Hipoalbuminemic
AG=19.7
SIGAARD-ANDERSEN
Dam spirono in hK ?
OSMuKp
OSMpKuTTKG
Uosm >300 and UNa >25
Supliment…
CRISTALOID
2PCΟS
ΚapΗ
10
ΑτοτΚaSID
log1pΚpΗ
2PCΟS
ΚapΗ
10
ΑτοτΚaSID
log1pΚpΗ
2PCΟS
SID
log1pΚpΗ
2PCΟS
SID
log1pΚpΗ
2PCOS
3HCO
log1pKpH
2PCOS
SID
log1pKpH
D I L U T I E
Ideal inseamna…
24
Pentru ca 35 nu e 24
2011
Na,K si apa-cam cat?
Deci…