Crregullimet acido bazike
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Nje qasje algoritmike
Hysni Dida
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Marrja e gjakut arterial
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Radial Artery
Ulnar Artery
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HyrjeAstrupometri mat pH, pCO2 dhe pO2
[HCO3-] dhe diferenca bazike llogaritenduke perdorur ekuacionin Henderson-Hasselbalch
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Parametrat normaleCrregullimet acidobazike mund te verehen edhe nqs
kemi vetem 3 parametra pH, pCO2 dhe HCO3
Vlerat normale
• pH = 7.36 – 7.44
• PCO2 = 36-44 mmhg
• HCO3 = 22-26 mEq/L
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Marredhenia midis [H+] & pHpH [H
+] pH [H
+]
7.80
7.75
16
18
7.30
7.25
50
56
7.70
7.65
20
22
7.20
7.15
63
71
7.60
7.55
25
28
7.10
7.00
79
89
7.50
7.45
32
35
6.95
6.90
100
112
7.40
7.35
40
45
6.85
6.80
141
159
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Baze deficiti dhe Baze eksesiNje ndryshim me 0.15 ne pH eshte ekuivalent
me nje ndryshim ne baze me 10 mEq/L.
Nje renie ne baza psh HCO3 quhetbaze deficit dhe nje rritje ne bazaquhet baze ekses
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Ndryshime Metabolike vsRespiratore
Kur ndryshimi primar eshte pCO2 atehere crregullimieshte respirator
Kur ndryshimi primar eshte HCO3- => crregullimmetabolik
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Acidemia vs Alkalemia
Kur pH I gjakut eshte <7.35 kemi te bejme me
acidemi
Kur pH I gjakut eshte >7.45 kemi te
bejme me Alkalemi
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Crregullimet primare dhe pergjigjet kompesatore
3
2
24HCO
PaCOH
Crregullimi Ndryshimi primar Ndryshimi kompesator
Respiratory acidosis PCO2 HCO3
Respiratory alkalosis PCO2 HCO3
Metabolic acidosis HCO3 PCO2
Metabolic alkalosis HCO3 PCO2
• Ndryshimet kompesatore ndodhin qe te mbajne te pandryshuarraportin PCO2/HCO3
• Ndryshimet kompesatore jane ne te njejtin drejtim me ndryshiminprimar
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Kompesimi Crregullimet respiratore kompesohen me ane te
veshkave
Crregullimet metabolike kompesohen me ane teveshkave (kur veshkat nuk jane shkaku) dhe me ane tepulmoneve
Crregullimi me I pa kompesuar eshte alkalozametabolike sepse kompesimi respirator eshtehypoventilimi I cili nuk mund te zgjaze per nje kohe tegjate sepse nxiten kemoreceptoret qendrore
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Kompesimi respirator I acidozes metabolike
Pergjigja ventilatore pas nje acidoze metabolike eshte te krijoje njealkaloze respiratore gje qe do te coje ne nje HIPERVENTILIM duke ulur paCO2 I cili matet me formulen e Winter
PaCO2 I pritur = (1.5×HCO3) + (8±2)
Nese paCO2 I matur eshte ekuivalent me paCO2 e pritur atehere kompesimi
respirator eshte adekuat dhe kjo gjendje quhet Acidoze metabolike e kompesuar
Nese paCO2 I matur eshte me I madh se paCO2 I pritur atehere pergjigja respiratore
nuk eshte adekuate dhe kemi nje acidoze respiratore shtese acidozes metabolike. Ky
crregullim quhet Acidoze metabolike primare me mbivendosje te nje acidoze
respiratore
Nese paCO2 I matur eshte me I vogel se ai I pritur atehere eshte nje alkaloze
respiratore mbivendosur nje acidoze metabolike primare
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Kompesimi I alkalozes metabolike Formula e meposhtme vlen ne rastet kur HCO3 >40
PaCO2 I pritur = (0.7×HCO3) + (21±2)
Nese paCO2 I matur eshte I barabarte me paCO2 e pritur atehere kemite bejme me kompesim adekuat respirator= Alkaloze metabolkie e kompesuar
Nese paCO2 I matur eshte me I madh se ai I pritur kompesimirespirator nuk eshte adekuat dhe kemi nje acidoze respiratorembivendosur alkalozes metabolike primare
Nese paCO2 I matur eshte me I ulet se ai I pritur atehere kemi njealkaloze respiratore te mbivendosur =Alkaloze metabolike primareme mbivendosje nje alkaloze respiratore
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Kompesimi metabolik Ndodh ne veshka
Ndryshimi I perqendrimit te CO2 con ne ndryshim te perthithjes se HCO3- ne tubulat renale
Ne acidoze respiratore kemi rritje te paCO2 dhe rritje te perthithjes se HCO3-ne veshka
Ne alkaloze respiratore kemi ulje te paCO2 dhe ulje te perthithjes se HCO3-
Eshte me I ngadalte , fillon 6-12 ore pasi eshte vendosur crregullimi primar ndajnje crregullim quhet akut para fillimit te kompesimt renal dhe kronik pas fillimit te kompesimit renal
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Kompesimi metabolik Alkaloza respiratore
Ulet paCO2 ulet HCO3-
Acidoza respiratore
Rritet pa CO2 rritet HCO3-
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Crregullimet Akute respiratore Perpara se te filloje kompesimi renal nje ndryshim I
paCO2 me 1mmHg do te sjelle nje ndryshim me 0.008 ne pH ∆pH = 0.008 × ∆PaCO2
Nga ky ekuacion del pH I pritur per nje acidoze respiratore akute
pH I pritur = 7.40 – [0.008 × (PaCO2 – 40)]
Ndersa pH I pritur per nje alkaloze respiratoreakute llogaritet
pH I pritur= 7.40 + [0.008 × (40 - PaCO2)]
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Kompesimi renal ne crregullime kronike respiratore
Kur vendoset kompesimi renal I plote cdo ndryshimme 1mmHg paCO2 e ndryshon pH me vetem O.OO3 njesi ∆pH = 0.003 × ∆PaCO2
pH I pritur per nje acidoze respiratore te kompesuar
pH pritur= 7.40 – [0.003 × (PaCO2 – 40)]
Ndersa per alkalozen respiratore te kompesuar(kronike)
pH pritur = 7.40 + [0.003 × (40 - PaCO2)]
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Crregullimet dhe kompesimi
Type of Disorder pH PaCO2 [HCO3]
Metabolic Acidosis
Metabolic Alkalosis
Acute Respiratory Acidosis
Chronic Respiratory Acidosis
Acute Respiratory Alkalosis
Chronic Respiratory Alkalosis
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Algoritmi I interpretimit tecrregullimeve AB Stadi O percakto nese te dhenat jane te vlefshme
duke perdorur ek Haselbach
Stadi 1 percakto ndryshimin primar
Stadi 2 shiko pergjigjet kompesatore
Stadi 3 perdor Gap per te percaktuar ac.metabolike
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Stadi 1 Rregulla 1 mund te kemi nje crregullim acidobazik
dhe kur vlera e pH ose paCO2 eshte normale
Rregulla 2 nese pH dhe paCO2 jane te dy jonormalshiko kahet
++=> nese jane me te njejtin kah =crreg.metabolik
++=> nese jane me kahe te kunderta = crreg.respirator
psh nese pH=7.23 dhe paCO2=23mmHg
Acidoze metabolike
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Stadi 1 Rregulla 3 nese pH ose paCO2 jane normal kemi nje
crregullim miks respirator dhe metabolik
Nese pH eshte normal kahu I paCO2 tregoncrregullimin respirator
Nese paCO2 eshte normal kahu I pH tregoncrregullimin metabolik
Psh: pH=7.37 paCO2=55mmHg
acidoze respiratore me alkaloze metabolike
Ska crregullim primar sepse pH eshte normal
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Stadi 2 I vlefshem kur nga stadi 1 del nje crregullim primar
Qellimi I ketij stadi eshte te percaktojme nesekompesimi eshte adekuat ose jo.
Rregulla 4 nese ka nje crregullim primar metabolikperdor HCO3 e matur dhe gjej paCO2 e pritur
Nese paCO2 pritur =paCO2 matur kompesim I plote
Nese paCO2 pritur >paCO2 matur mbivendosje e alkalozes respiratore
Nese paCO2 pritur <paCO2 matur mbivendosje e acidozes respiratore
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Stadi 2 Shembull : paCO2=23mmHg pH=7.32 HCO3=15 mEq/L
Zbatojme rregullin 2 kemi ACIDOZE Metabolike primare
paCO2 pritur=(1.5*15) +8± 2= 30.5±2 mmHg
paCO2 pritur >paCO2 matur acidoze metabolike primare me mbivendosje alkaloze respiratore
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Stadi 2 Rregulla 5 nese ka crregullim respirator=perdor
paCO2 per te llogaritur pH pritur
pH matur >pH pritur ne acidoz/alkaloz resp akutekemi mbivendosje ACIDOZE metabolike
pH matur <pH pritur ne acidoz/alkaloz resp.kronikekemi mbivendosje ALKALOZ metabolike
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Stadi 2 Shembull : paCO2=23mmHg pH=7.54
alkaloz respiratore
pH pritur akute=7.4 +[0.008*(40-23)]=7.54
pHpritur akut=pHmaturgjendje akute pa kompesuar
pra kemi alkaloz respiratore akute
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Stadi 3 Perdorim Gap per te llogaritur /percaktuar acidozen
metabolike
Anion gap=diferenca midis anioneve te pamatshmeme kationet e pamatshme
AG=Na -(HCO3 +Cl)=12
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Stadi 3 Acidoze metabolike me GA te rritur normokloremike
Ketoacidoza
Acidoza laktike
Acidoza uremike
Acidoza metabolike me GA normal hiperkloremike
Acidoza renale tubulare
Acidoza uremike e hershme
Acidoza posthypokapnike
Acidoza e diluimit’
Diarrea
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Stadi 3 Influenca e albumines
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Stadi 3Urinary anion gap perdoret per te kuptuar shkaqet
renale/jorenale te Acidozes metabolike me AG normal
E pavlefshme ne Hypovolemi, oliguri, hyponatriuri, acidoze me AG
UAG=(uNa+uK)-uCl =±10
Kur UAG <-10 shkaku eshte jorenal
Kur UAG >+10 shkaku eshte renal psh
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Metabolic
Acidosis
Anion Gap
“MUDPILERS
”
Metabolic Acidosis
Non-Gap
“HARDUPS”
Acute Resp.
Acidosis
“anything
causing
hypoventilation”
Metabolic
Alkalosis
“CLEVERPD”
Respiratory
Alkalosis
“CHAMPS”
•Methanol
•Uremia
•DKA/Alcoho
lic ketoacidosis
•Paraldehyde
•Isoniazid
•Lactic acidosis
•Ethylene
Glycol
•Renal
failure(End-
Stage)/Rhabd
o
•Salicylates
•Hyperalimentation
•Acetazolamide
•Renal Tubular
Acidosis
•Diarrhea
•Ureterosigmoidosto
my
•Post-hypocapnia
•Spironolactone
•Early Renal Failure
Negative AG
•Multiple Myeloma
•CNS
depression
•Airway
obstruction
•Pulmonary
edema
•Pneumonia
•Hemo/Pneumo
thorax
•Neuromuscular
•Contraction
•Licorice
•Endocrine
(Conn/Cushing
/Bartters)
•Vomiting
•Excess alkali
•Refeeding
•Post-
hypercapnia
•Diuretics
•CNS disease
•Hypocapnia
•Anxiety
•Mech.
Ventilation
•Progesteron
e
•Salicylates
•Sepsis
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Mixed Acid-Base Disorders
Mixed respiratory alkalosis & metabolic acidosis
ASA overdose
Sepsis
Liver failure
Mixed respiratory acidosis & metabolic alkalosis
COPD with excessive use of diuretics
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Mixed Acid-Base DisordersMixed respiratory acidosis &
metabolic acidosis
Cardiopulmonary arrest
Severe pulmonary edema
Mixed high gap metabolic acidosis & metabolic alkalosis
Renal failure with vomiting
DKA with severe vomiting
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Mixed Acid-Base DisordersNormal pH + ↓PCO2 + ↓HCO3 - Respiraory Alkalosis +
Metabolic Acidosis
Normal pH + ↑PCO2 + ↑ HCO3 - Respiratory Acidosis + Metabolic Alkalosis
Normal pH + Normal PCO2 + Normal HCO3 -Metabolic Acidosis + Metabolic Alkalosis
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Some Aids to Interpretation of Acid-Base Disorders
"Clue" Significance
High anion gap Always strongly suggests a metabolic acidosis.
Hyperglycaemia If ketones present also diabetic ketoacidosis
Hypokalemia and/or hypochloremia Suggests metabolic alkalosis
Hyperchloremia Common with normal anion gap acidosis
Elevated creatinine and urea Suggests uremic acidosis or hypovolemia (prerenal renal failure)
Elevated creatinine Consider ketoacidosis: ketones interfere in the laboratory method (Jaffe reaction) used for creatinine measurement & give a falsely elevated result; typically urea will be normal.
Elevated glucose Consider ketoacidosis or hyperosmolar non-ketotic syndrome
Urine dipstick tests for glucose and ketones Glucose detected if hyperglycaemia; ketones detected if ketoacidosis
http://www.anaesthesiamcq.com/AcidBaseBook/ab9_2.php
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FormulasMetabolic Acidosis: (Winter’s formula) Expected PaCO2 = (1.5×HCO3) + (8±2) Metabolic Alkalosis: Expected PaCO2 = (0.7×HCO3) + (21±2) Acute Respiratory Acidosis: Expected pH = 7.40 – [0.008 × (PaCO2 – 40)] 10mmhg ↑ in PaCO2 will ↑ HCO3 by 1mmol/L Acute Respiratory Alkalosis: Expected pH = 7.40 + [0.008 × (40 - PaCO2)] 10mmhg ↓in PaCO2 will ↑ HCO3 by 2mmol/L Chronic Respiratory Acidosis: Expected pH = 7.40 – [0.003 × (PaCO2 – 40)] 10mmhg ↑ in PaCO2 will ↑ HCO3 by 4mmol/L Chronic Respiratory Alkalosis: Expected pH = 7.40 + [0.003 × (40 - PaCO2)] 10mmhg ↓ in PaCO2 will ↑ HCO3 by 4mmol/L
3
2
24HCO
PaCOH
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Formulas ..Cont’d AG = Na - (CL + HCO3) AG Correction for Albumin Expected AG(mEq/L)=[2×Albumin(g/dL)]+[0.5×PO4(mg/dL) Adjusted AG = Obserbed AG + 2.5 × [4.5 - Measured Albumin (g/dL)] Urinary AG = (UNa + UK)-UCl Plasma Osmolality = 2×Na + Glucose/18 + BUN/2.8 Na/Cl > 1.4 = metabolic alkalosis (hypochloremia) Na/Cl < 1.27 = non anion gap acidosis (hyperchloremia)
AG Excess/HCO3 Deficit = (Measured AG - 12) /(24- Measured HCO3)
HCO3 deficit(mEq)=0.6×Wt(kg) (15-Measured HCO3) mEq of NaHCO3 = Apparent Volume of distribution × Target change in
HCO3 TBW(kg) × [0.4 +(2.4/HCO3)] = Apparent Volume of distribution Cl Deficit (mEq) = 0.2 × Wt(kg) × (Normal Cl- Actual Cl) volume of isotonic saline needed to correct the deficit is the ratio: Cl
deficit/154
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http://www.medcalc.com/acidbase.html
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