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.

1. CAZ CLINIC
SINDROMUL DE INTESTIN SCURT
SUUB

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

4. 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

5. Strong Ions
STEWART
f(x)=y
--H+
HCO3
HENDERSON-HASSELBALCH

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

8. Bicarbonat
Weak anions
apa
Compusi
nutritivi
Sodiu Strong cations
Magneziu
Potasiu
Calciu
Pierderi
relative

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

10. Strong cations
PMSA↓
ACM GFR↓=>NH4↓

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.

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”

15. Defect de
concentrare
AQP 2 ↓
Na-K-2Cl ↓=>
↓Mecanismul de
contracurent
HipoK
pHi↓
NH4↑
↑Reabs. HCO3
HipoK pHi↓ ↑NHE proximal
↑NAE

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

18. Cum adica furosemidul cladeste SID-ul?

19. Cum adica furosemidul cladeste SID-ul?

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.”

24. MSFP

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

27. Totul a inceput cu CVVHDF

28. MSFP pe ventilator
Pmsf-RAP=CO•RVR ΔV/ΔPmsf=C

29. MSFP este f(MAP,RAP)
Pao=MSFP•(1+Rsu/Rsd)-Rsu/Rsd•RAP
Pao=c-d•Pcv
MSFP=c/(d+1)

30. EH
DOBUTREX
Rven MSFP

31. MFSP↑

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

38. SIGAARD-ANDERSEN

42. Dam spirono in hK ?

Ku OSMp
Kp OSMu
TTKG


Uosm >300 and UNa >25

43. Supliment…
CRISTALOID

44. Κa Ατοτ
S PCΟ2
Κa
pΗ
10
SID
pΗ pΚ1 log





 
Κa Ατοτ
S PCΟ2
Κa
pΗ
10
SID
pΗ pΚ1 log





 
SID
S PCΟ2
pΗ pΚ1 log

 
SID
SID
S PCΟ2
pΗ pΚ1 log

HCO3
S PCO2
pH pK1 log

 
S PCO2
pH pK1 log

 
D
I
L
U
T
I
E

45. Ideal inseamna…
24

46. Pentru ca 35 nu e 24

47. 2011

50. Na,K si apa-cam cat?

51. Deci…