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Anion (mEq/L)
Na+
140
Cl
103
K+
HCO 3
25
Ca + +
Protein
16
Mg + +
Organic
H+
0.000040
Other
(40 nmol/L) Inorganic
{H:(H2O)n}+
H+ + HCO3CO2
PEMBENTUKAN H +
DAN PEMBUANGANNYA
Nutrient
Produk
H+ (mmol/hari)
H+
70
H+
140
H+ +HPO42 -
30
Glutamat, aspartat
HCO3-
110
HCO3-
60
H2PO4-
30
40
Protein
HCO3-
Glutamine
CO2 + H2O
ATP
H+ (secreted)
URINE
LIVER
FILTERED
HPO42-
2 H2PO42(to urine)
UREA
2H+
2HCO 3 -
Blood
4500
mmol/day
b. pCO2 = 40 mm Hg
c. [HCO3 ] = 25 mmol/L
d. Anion gap plasma Na-Cl-[HCO3 ] = 12 mEq/L jika kadar
albumin normal yaitu 4 gr% . Setiap penurunan albumin 1
gram % dari harga normal maka kadar AG dikurangi 4
Acidemia :
Respiratory Acidemia jika pCO2 lebih dari 44
Metabolic Acidemia jika [HCO3 ] kurang 25
(140)
A-
Other
Anion
HCO3(25)
Cl(103)
Metabolic Alkalemia :
Setiap kenaikan
Respiratory Acidemia :
Akut :
Setiap pCO2 naik 10 mmHg = [HCO3 ] naik 1 mEq/L
Kronik :
Setiap pCO2 naik 10 mmHg = [HCO3 ] naik 4 mEq/L
Respiratory Alkalemia :
Akut :
Setiap pCO2 turun 10 mmHg = [HCO3 ] turun 2 mEq/L
Kronik :
Setiap pCO2 turun 10 mmHg = [HCO3 ] turun 5 mEq/L
Langkah Ketujuh :
Determine Delta ratio (Delta gap) =
(Increase in anion gap / Decrease in bicarbonate)
Assessment Guideline
< 0.4
0.4 - 0.8
1 to 2
>2
Osmolar Gap
Osmolar gap = (Measured osmolality) (Calculated osmolarity)
2 [Na+] + Glucose ( mmol/L) + Urea N (mmol/L)
0R
2 [Na+] + Glucose( mg% /18) + Urea N(mg% /2.8)
The osmolar gap can be very useful in assisting
diagnosis in metabolic acidosis due to toxic
alcohols & glycols (eg ethylene glycol, methanol).
[H+]
HIGH
NORMAL
LOW
Acidemia
Mixed Disorder if :
pCO2 & HCO3 both low
pCO2 &HCO3 both high
Plasma AG wide
Alkalemia
HCO3
LOW
METABOLIC
ACIDOSIS
pCO2
High
RESPIRATORY
ACIDOSIS
HCO3
HIGH
PCO2
LOW
METABOLIC
ALKALOSIS
RESPIRATORY
ALKALOSIS
Metabolic Acidosis
Definition
High [H+] / Low pH and Low [HCO3] in plasma. Metabolic
acidosis may also be detected by finding a wide plasma AG
(>15 meq/L) even without a pH or [HCO3] change
Expected physiological response :
Lung : Lower pCO2 to minimize fall in pH.Quantitatively the
fall in pCO2 from 40 mmHg should equal the fall in plasma
[HCO3] from 25 mmol/L
Kidney : Excrete NH4+ to make new [HCO3] .Normally the
kidney excrete 40 mmol NH4+ /day .During metabolic acidosis
should be at least 1 mmol/KgBW/day .Ideally as high as 300
mmol/day
Metabolic Acidosis
Clinical Classification :
Acid gain
Is recognized by finding anions that have
accumulated in plasma
Loss of [HCO3]
The plasma Anion |Gap normal
Other
Cation
Na+
(140)
Other
Anion
HCO3(25)
Cl-
Other
Cation
A-
Other
Anion
L-
(140)
(103)
Normal
A-
Added
Anion
HCO3-
Na+
Other
Cation
Cl
Other
Anion
HCO3-
Na+
(140)
Cl-
Metabolic Acidosis
Metabolic Acidosis
With increased
With normal
Anion Gap
Anion Gap
Acid Gain
Metabolic Acidosis With increased Anion Gap
Other
Cation
AL-
Na+
(140)
Other
Anion
Added
Anion
HCO3-
Cl-
Other
Cation
AL-
Na+
(140)
Other
Anion
Added
Anion
HCO3-
Cl-
Loss
Other
Cation
A-
Other
Anion
HCO3-
Na+
(140)
Cl
HCO3
=
pCO2
NO
YES
Plasma AG
=
HCO3
Respiratory
Acidosis
or Alkalosis
YES
No Rise AG
Loss Na HCO3
GI
GU
Indirect
AG >
Met Alkalosis
Chr Resp
Acidosis
Plasma
Keton
4 + undiluted
YES
NO
Ketoacidosis
Hypoxia
NO
YES
HCO3
Lactic Acidosis
NO
Plasma Osmolal Gap
> 20 mOsm
YES
Methanol
Ethanol
Ethylene Glycol
NO
Type B Lactic Acidosis
D Lactic Acidosis
Other acids
EMERGENCY MEASURES
Before the biochemical results are
available , measure to ensure a proper
airway , adequate circulation and O2
delivery must be pursued vigorously.
Treatment of Ketoacidosis
In ketoacidosis the rate of H+ production is slow
NaHCO3 may provoke severe hypokalemia
NaHCO3 should be avoided in most cases except :
When hyperkalemia is severe despite insulin theraphy
In very severe acidemia [HCO3] < 5 mmol/L to raise the
plasma [HCO3] close to twofold
When acidemia worsens despite insulin theraphy
( perhaps insulin resistance )
Give Na HCO3
What are the benefits and
What are the risks ?
Benefits
Risks
Metabolic
benefit
Glycolysis is faster
so more ATP is
made in vital
organ
HYPOKALEMIA
CAN CAUSE
RESPIRATORY FAILURE
NO
ACUTE
PULMONA
RY EDEMA
YES
RAPID
PRODUCTION
OF CO2
PRECIPITATE
CaCO3
ACUTE HYPOCALCEMIA