The patient is a 63-year-old man with a history of extensive small bowel resection who now presents with severe diarrhea, dehydration, and new onset tetraparesis. He has signs of electrolyte imbalances and complex acid-base disturbances related to short bowel syndrome and malabsorption. The document discusses evaluating the patient's acid-base status and developing a treatment plan to address fluid and electrolyte abnormalities using intravenous solutions tailored to his strong ion difference.
2. 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 (ΔM = 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
3. Teoretic…
Sindrom de malabsorbtie sever si complex
Dezechilibre hidroelectrolitice complexe
Dezechilibre acidobazice complexe
Iminenta de instabilitate T
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
6. Descrierea EAB
Focus H+ sau
HCO3
Focus Strong Ion
H-H EQ
Copenhaga Boston
Singer
Hastings
BB
Stewart
IND vs DEP
Border flux Kofranek
C
O
N
S
T
A
B
L
E
f(x)=y
9. 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
11. Instrumente pentru D-lactat
SIG sau AG
Corectat sau
BE gap
D-lactatul este filtrat
Si nereabsorbit renal
UAG vs
UOSM GAP
Direct
UOSM GAP
vs UAG
Acidoza este mai curand hiperclo-remica
decat acidoza cu gaura
anionica crescuta.
12.
13.
14. K,Mg↓ Pmsa↓
HipoK
RENAL
ECG NM
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”
16. Hiperplazie de celule tubulare
Eventual fibroza tubulointerstitiala
Atrofie de celule tubulare
Formare de chisti in medulara
Insuficienta renala cronica(RIFLE cu E)
17. Un lucru-i cert: pacientul trebuie umplut
CAT?
Furosemidul cladeste SID-ul
CU CE?
? Cu SID-ul potrivit
Si eventual, simultan sau mai incolo,
golit
20. 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.
21. Indici HD
L,MAP,CO,SVO2,
ΔPCO2,ΔPCO2/
ΔCO2
Mereu raportat la
“ce a fost”
Responsivitate la
fluid-indici dinamici
Estimare MSFP
NAVIGATOR
Estimare TBW si
comparare cu TBWe
PROBLEMATIC
CAT?
22. 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
23. 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.”
25. “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.”
26. 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
32. Nu-l vrem prea “plin” din respect pentru px
Px
Px determ.
PO2(a)
ceHb
P50
“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.”
33. Calcule in EAB
AG = Na+K-Cl-HCO3; 7-17 mEq/l
SIDa=Na+K+Ca+Mg-Cl-L
SIDe=2.46•10-8•pCO2mmHg/10-pH
+Alb-+Pphate-
Alb-=albg/l•(0.123•ph-0.631)
Pphate-=Pmmol/l•(0.309•pH-0.469)
SIG=SIDa-SIDe; <5mEq/L
AGcorr=AG-2•Albg/dl-0.5•Pmg/dl-L
AGcorr=AG-Alb--Pphate--L; <5mEq/L
34. 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
35. A avut pacientul D-lactat?
Hipoalbuminemic
AG=19.7
Acidemie Context