asam basa steward

1. Acid Base Management in
Emergency Unit
Stewart Approach
Rudyanto Sedono
ICU Department of Anesthesiology and Intensive Care
Faculty of Medicine University of Indonesia
Cipto Mangunkusumo Hospital
Jakarta

2. ASAM BASA..
pH
[H+]

3. Acid Base
Notasi pH diciptakan oleh seorang ahli kimia dari Denmark yaitu Soren Peter Sorensen
pada thn 1909, yang berarti log negatif dari konsentrasi ion hidrogen. Dalam bahasa
Jerman disebutWasserstoffionenexponent (eksponen ion hidrogen) dan diberi simbol pH
yang berarti: ‘potenz’ (power) of Hydrogen.

4. Regulasi asam basa diatur melalui proses di:
1. Ginjal dengan cara mempertahankan [HCO3
-]
sebesar 24 mM dan
2. Mekanisme respirasi dengan cara mempertahankan
tekanan parsial CO2 arteri (PaCO2) sebesar 40
mmHg.
Hendersen-Hasselbalch

5. pH = 6.1 + log
[HCO3
-]
 pCO2
GINJAL
PARU
BASA
ASAM CO2
HCO3
HCO3
CO2
Kompensasi
Normal
Normal

6. DISORDER pH PRIMER RESPON
KOMPENSASI
ASIDOSIS
METABOLIK
 HCO3-  pCO2 
ALKALOSIS
METABOLIK
 HCO3-  pCO2 
ASIDOSIS
RESPIRATORI
 pCO2  HCO3- 
ALKALOSIS
RESPIRATORI
 pCO2  HCO3- 
RANGKUMAN GANGGUAN KESEIMBANGAN
ASAM BASA TRADISIONAL

7. Now for something new…

9. So..what’s the differences?
Stewart’s Approach
Henderson-Hasselbalch

10. DUA VARIABEL
pH atau [H+] DALAM PLASMA
DITENTUKAN OLEH
VARIABEL
INDEPENDEN
VARIABEL
DEPENDEN
Menurut Stewart ;
Menentukan
Stewart PA. Can J Physiol Pharmacol 61:1444-1461, 1983.
Primer (cause) Sekunder (effect)

11. VARIABEL INDEPENDEN
CO2 STRONG ION
DIFFERENCE
WEAK ACID
pCO2
SID
Atot
Controlled by
the respiratory
system The electrolyte
composition of the
blood (controlled
by the kidney)
The protein
concentration
(controlled by the
liver and metabolic
state)

12. DEPENDENT VARIABLES
H+
OH-
CO3
= A-
AH
HCO3
-

13. Gamblegram
Na+
K+ 4
Ca++
Mg++
Cl-
HCO3
-
KATION ANION
SID
STRONG ION DIFFERENCE &
WEAK ACID
= {[Na+] + [K+] + [kation divalen]} - {[Cl-] + [As.organik kuat-]}
As. Organik kuat
Weak acid
(Alb-,P-)
 SID

14. Strong Ions
Difference
pCO2
Protein
Concentration
pH
INDEPENDENT VARIABLES DEPENDENT VARIABLES

15. Hubungan antara SID, H+ & OH-
SID
(–) (+)
[H+] [OH-]
Dalam cairan biologis (plasma) dgn suhu 370C, SID hampir
selalu positif, biasanya berkisar 30-40 mEq/Liter
Asidosis Alkalosis
Konsentrasi [H+]

16. KLASIFIKASI GANGGUAN KESEIMBANGAN ASAM
BASA BERDASARKAN PRINSIP STEWART
Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic acid-base disturbances in critically ill
patients. Am J Respir Crit Care Med 2000 Dec;162(6):2246-51

17. RESPIRATORY M E T A B O L I C
 in pCO2  in SID  in Weak acid
Alb PO4
-
Alkalosis
Acidosis
Decrease
Increase
Decrease
Excess
Deficit
Positive Increase
Fencl V, Am J Respir Crit Care Med 2000 Dec;162(6):2246-51
WATER  STRONG
ANION
Cl UA
Hypo
Hyper

18. Na+ = 140 mEq/L
Cl- = 102 mEq/L
SID = 38 mEq/L 140/1/2 = 280 mEq/L
102/1/2 = 204 mEq/L
SID = 76 mEq/L
1 liter ½ liter
WATER DEFICIT
Diuretic
Diabetes Insipidus
Evaporasi
SID : 38  76 = alkalosis
ALKALOSIS KONTRAKSI
Plasma Plasma

19. Na+ = 140 mEq/L
Cl- = 102 mEq/L
SID = 38 mEq/L
140/2 = 70 mEq/L
102/2 = 51 mEq/L
SID = 19 mEq/L
1 liter 2 liter
WATER EXCESS
1 Liter
H2O
SID : 38  19 = Acidosis
ASIDOSIS DILUSI
Plasma

20. Na+ = 140 mEq/L
Cl- = 102 mEq/L
SID = 38 mEq/L
Na+ = 154 mEq/L
Cl- = 154 mEq/L
SID = 0 mEq/L
1 liter 1 liter
PLASMA + NaCl 0.9%
SID : 38  pH normal
Plasma NaCl 0.9%

21. 2 liter
ASIDOSIS HIPERKLOREMIK AKIBAT
PEMBERIAN LARUTAN Na Cl 0.9%
=
SID : 19  pH   lebih asidosis
Na+ = (140+154)/2 mEq/L= 147 mEq/L
Cl- = (102+ 154)/2 mEq/L= 128 mEq/L
SID = 19 mEq/L
Plasma

22. Na+ = 140 mEq/L
Cl- = 102 mEq/L
SID= 38 mEq/L
Cation+ = 137 mEq/L
Cl- = 109 mEq/L
Laktat- = 28 mEq/L
SID = 0 mEq/L
1 liter 1 liter
PLASMA + Larutan RINGER LACTATE
SID : 38
Plasma Ringer laktat
Laktat cepat
dimetabolisme

23. 2 liter
=
Normal pH setelah pemberian
RINGER LACTATE
SID : 34  lebih alkalosis dibanding jika diberikan NaCl 0.9%
Na+ = (140+137)/2 mEq/L= 139 mEq/L
Cl- = (102+ 109)/2 mEq/L = 105 mEq/L
Laktat- (termetabolisme) = 0 mEq/L
SID = 34 mEq/L
Plasma

24. Na+ = 140 mEq/L
Cl- = 130 mEq/L
SID =10 mEq/L
Na+ = 165 mEq/L
Cl- = 130 mEq/L
SID = 35 mEq/L
1 liter 1.025
liter
25 mEq
NaHCO3
SID  : 10  35 :  Alkalosis, pH kembali normal  namun mekanismenya bukan
karena pemberian HCO3
- melainkan karena pemberian Na+ tanpa anion kuat yg
tidak dimetabolisme seperti Cl- sehingga SID   alkalosis
Plasma;
asidosis
hiperkloremik
MEKANISME PEMBERIAN NA-
BIKARBONAT PADA ASIDOSIS
Plasma + NaHCO3
HCO3 cepat
dimetabolisme

25. Strong ions, weak acids and base excess:
a simplified Fencl–Stewart approach to
clinical acid–base disorders
Story, Morimatsu, Bellomo (2004), British Journal of Anaesthesia. Vol. 92,
• SBE = from a blood gas machine =…
• Na–Cl effect = [Na+]–[Cl–]–38 =...
• Albumin effect = 0.25 x [42–Alb(g/l)] =…
• UA = SBE –(Na–Cl)effect – Albumin effect =…

27. • SBE = -10
• Na–Cl effect = [Na+]–[Cl–]–38 = 140–112–38 = -10
• Albumin effect = 0.25 x [42–40(g/l)] = 0.5
• UA = -10 – (-10) – 0.5 = -0.5
Kasus 1:
7.25 / 30 / -10 / 14
Na 140; Cl 112; Alb 4.0
• SBE = from a blood gas machine =…
• Na–Cl effect = [Na+]–[Cl–]–38 =...
• Albumin effect = 0.25 x [42–Alb(g/l)] =…
• UA = SBE –(Na–Cl)effect – Albumin effect =…

28. Alb
BASE EXCESS DAN STEWART
140
150
102
112
BE akibat pe Cl-  -10
HCO3
-
Na+
Cl-
Alb
7.25 / 30 / -10 / 14
WD/: Asidosis metabolik karena hiperkloremia
Causal: - Pemberian Lar NaCl berlebihan
- Gagal ginjal akut
Th/: Batasi NaCl
HD/CRRT

29. Kasus 2 :
7.42 / 35 / 100 / -2 / 21 ;
Na 140; Cl 102; Alb 1.8
Menurut H-H  normal
• SBE = from a blood gas machine =…
• Na–Cl effect = [Na+]–[Cl–]–38 =...
• Albumin effect = 0.25 x [42–Alb(g/l)] =…
• UA = SBE –(Na–Cl)effect – Albumin effect =…
• SBE = -2
• Na–Cl effect = [Na+]–[Cl–]–38 = 140–102–38 = 0
• Albumin effect = 0.25 x [42–18(g/l)] = 6
• UA = -2 – 0 – 6 = -8

30. BASE EXCESS DAN STEWART
140
102
HCO3
-
24
Alb
Na+ Cl-
hipoalbumin
HCO3
-
30.7
SID  normal
BE astrup = - 8 + 6 = - 2
HCO3-
22
BE akibat lact  - 8
UA = - 8
BE akibat hipoalb  + 6
7.42 / 35 / 100 / -2 / 21
Lactic Asidosis metabolik “masking” oleh hipoalbumin

31. Perempuan , 25 th
Dx/ Perdarahan Post Partum ( HPP )
PF : Apatis , TD 80/50 HR 140 S 37
Lab :
AGD : 7,18/20,9/165/9,8/-19,3/98,9
Na 137 K 3,89 Cl 104
Hb 6,4 Tr 24.000 Alb 0,5 Laktat 11,7
SGOT/PT 2.758/657 GDS 200
Ur Cr 39/1,8
Pertanyaan :
Apa diagnosis gangguan keseimbangan asam basanya ?
Gunakan rumus Fencl – Stewart untuk menjelaskan mekanismenya
Apa penyebabnya ?
Apa rencana terapinya ?

39. Di UGD diberikan loading NaCl 0,9 % 2000 cc, insulin, Bicnat 100
meq bolus, lanjut 100 meq drip
Dari pemerikasaan ulang laboratorium didapatkan hasil :
AGD : 7,51/27,5/166/24/-0,7/99,3
Na 135 K 3,0 Cl 113
Pertanyaan :
Apa diagnosis gangguan keseimbangan asam basanya ?
Gunakan rumus Fencl – Stewart untuk menjelaskan
mekanismenya
Apa penyebabnya ?
Apa rencana terapinya ?

41. SID
PCO2
Weak acid
pH
Renal Failure
Lactic acidosis
Keto-acidosis
Vomiting
Diare
Heart Failure
Lung disease
Hyperventilation
Hypoventilation
Nephrotic Syndrome
Dehydration
Malnutrition
Charge Balance
Dissociation of:
Water
Protein
Carbonic acid
CONCLUSION

42. If you are not
confused, you
are not
conscious
Thank you