Teori Dasar Pendekatan Kuantitatif I Dan II Copy
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Transcript of Teori Dasar Pendekatan Kuantitatif I Dan II Copy
WORKSHOP ACIDBASE STEWART PERDICI 2006
Teori Dasar Pendekatan Kuantitatif I
Stewart approachStewart approach
ASAM BASA..ASAM BASA..
pHpH[H[H++]]
Acid Base
Notasi pH diciptakan oleh seorang ahli kimia dari Notasi pH diciptakan oleh seorang ahli kimia dari Denmark yaitu Soren Peter Sorensen pada thn 1909, yang Denmark yaitu Soren Peter Sorensen pada thn 1909, yang berarti log negatif dari konsentrasi ion hidrogen. Dalam berarti log negatif dari konsentrasi ion hidrogen. Dalam bahasa Jerman disebutbahasa Jerman disebutWasserstoffionenexponent Wasserstoffionenexponent (eksponen ion hidrogen) dan diberi simbol pH yang (eksponen ion hidrogen) dan diberi simbol pH yang berarti: berarti: ‘‘ppotenzotenz’’ (power) of (power) of HHydrogen. ydrogen.
pH = -log[H+]defined by Sorensen
Normal = 7.40 (7.35-7.45)Normal = 7.40 (7.35-7.45)Viable range = 6.80 - 7.80Viable range = 6.80 - 7.80
Keseimbangan Keseimbangan asam basaasam basa
Saya punya hasil astrup, artinya apa nich..? Who cares Who cares
about acid about acid base base
balance…?balance…?
MENGAPA MENGAPA PENGATURAN pH PENGATURAN pH
SANGAT PENTING ?SANGAT PENTING ?
RespirasiRespirasiHiperventilasiHiperventilasiPenurunan kekuatan otot nafas dan Penurunan kekuatan otot nafas dan
menyebabkan kelelahan menyebabkan kelelahan ototototSesakSesak
MetabolikMetabolikPeningkatan kebutuhan Peningkatan kebutuhan metabolismemetabolismeResistensi insulinResistensi insulinMenghambat glikolisis anaerobMenghambat glikolisis anaerobPenurunan sintesis ATPPenurunan sintesis ATPHiperkalemiaHiperkalemiaPeningkatan degradasi proteinPeningkatan degradasi protein
OtakOtakPenghambatan metabolisme dan Penghambatan metabolisme dan
regulasi volume sel otakregulasi volume sel otakKomaKoma
KardiovaskularKardiovaskularGangguan kontraksi otot jantungGangguan kontraksi otot jantung
Dilatasi Arteri,konstriksi vena, dan Dilatasi Arteri,konstriksi vena, dan sentralisasi volume darahsentralisasi volume darah
Peningkatan tahanan vaskular paruPeningkatan tahanan vaskular paru
Penurunan curah jantung, tekanan Penurunan curah jantung, tekanan darah arteri, dan aliran darah darah arteri, dan aliran darah hati dan ginjalhati dan ginjal
Sensitif thd Sensitif thd reentrant arrhythmiareentrant arrhythmia dan penurunan ambang fibrilasi dan penurunan ambang fibrilasi ventrikelventrikel
Menghambat respon kardiovaskular Menghambat respon kardiovaskular terhadap katekolaminterhadap katekolamin
Management of life-threatening Acid-Base Disorders, Horacio J. Adrogue, And Nicolaos EM: Review Article;The New England Journal of Medicine;1998
AKIBAT DARI ASIDOSIS BERATAKIBAT DARI ASIDOSIS BERAT
KardiovaskularKardiovaskularKonstriksi arteriKonstriksi arteriPenurunan aliran darah koronerPenurunan aliran darah koronerPenurunan ambang anginaPenurunan ambang anginaPredisposisi terjadinya supraventrikel dan ventrikel Predisposisi terjadinya supraventrikel dan ventrikel aritmia yg refrakteraritmia yg refrakter
RespirasiRespirasiHipoventilasi yang akan menjadi hiperkarbi dan Hipoventilasi yang akan menjadi hiperkarbi dan hipoksemiahipoksemia
MetabolicMetabolicStimulasi glikolisis anaerob dan produksi asam organikStimulasi glikolisis anaerob dan produksi asam organikHipokalemiaHipokalemiaPenurunan konsentrasi Ca terionisasi plasmaPenurunan konsentrasi Ca terionisasi plasmaHipomagnesemia and hipophosphatemiaHipomagnesemia and hipophosphatemia
OtakOtakPenurunan aliran darah otakPenurunan aliran darah otakTetani, kejang, lemah delirium dan stuporTetani, kejang, lemah delirium dan stupor
AKIBAT DARI ALKALOSIS BERATAKIBAT DARI ALKALOSIS BERAT
Management of life-threatening Acid-Base Disorders, Horacio J. Adrogue, And Nicolaos EM: Review Article;The New England Journal of Medicine;1998
Efek pH dan COEfek pH dan CO22 terhadap oksigenasi terhadap oksigenasi jaringanjaringan
BetterBetterUnloadingUnloading
InhibitedInhibitedUnloadingUnloading
P50
Tn A;pH 7.5
Sat O2 99%
Tn B;pH 6.9
Sat O2 89%
PENILAIAN STATUS PENILAIAN STATUS ASAM BASAASAM BASA
Analytic tools used in acid base chemistry
• CO2-bicarbonate (Boston) approach– Schwartz, Brackett et al– H-H equation
• The Base deficit/excess (Copenhagen) approach– 1948 Singer-Hasting, Buffer Base (BB)– 1958 Siggaard-Andersen. Base Deficit/Excess
(BDE)• 1960, Hb into calculation, modified Standard Base
Deficit/Excess (SBE)• 1977 Van Slyke equation to computed SBE• Has been validated by Schlitic and Morgan
Analytic tools used in acid base chemistry
• 1977, Anion Gap approach– Emmet and Narins– To address the limitation of Boston and Copenhagen
• 1978, Stewart introduced the physical-chemical approach– 3 independent variable;
• PCO2, SID and weak acid
• 1983, Stewart-Fencl approach• 1998, Anion Gap Corrected
– Fencl and Figge
• 2004, simplified Stewart-Fencl approach– Story DA, Morimatsu et al
The disadvantage of men not knowing the past is that they do not know the present.
G. K. Chesterton
CARA TRADISIONALCARA TRADISIONAL
Hendersen-Hendersen-Hasselbalch Hasselbalch
Regulasi asam basa diatur melalui proses di:Regulasi asam basa diatur melalui proses di:1.1. Ginjal dengan cara mempertahankan [HCOGinjal dengan cara mempertahankan [HCO33
--] ] sebesar 24 mM dan sebesar 24 mM dan
2.2. Mekanisme respirasi dengan cara Mekanisme respirasi dengan cara mempertahankan mempertahankan tekanan parsial COtekanan parsial CO2 2 arteri arteri
(PaCO(PaCO22) sebesar 40 mmHg.) sebesar 40 mmHg.
Hendersen-Hasselbalch
pH pH = 6.1 + log= 6.1 + log[HCO[HCO33
--]]
pCOpCO22
GINJALGINJAL
PARUPARU
BASA BASA
ASAMASAM CO2
HCO3HCO3
CO2
KompensasiKompensasi
NormalNormal
NormalNormal
pH = 6.1 + logpH = 6.1 + log [ HCO[ HCO33--]]
0.03 0.03 xx
1. Change in1. Change inMetabolic disturbanceMetabolic disturbance
2. Change after2. Change afterRenal compensation forRenal compensation forRespiratory disturbanceRespiratory disturbance
1. Change in1. Change inRespiratory disturbanceRespiratory disturbance
2. Change after2. Change afterRespiratory compensation forRespiratory compensation for
Renal disturbanceRenal disturbance
pCO2pCO2
Diagram Davenport[ H
CO
3- ]PCO2 = 80 40
20
pH7.0 7.2 7.4 7.6 7.8
10
20
30
40
50
pH = 6.1 + Ginjal Paru
BB
AA
CC
7.4 / 40 / 247.4 / 40 / 24
7.2 / 80 / 307.2 / 80 / 30
7.6 / 20 / 187.6 / 20 / 18NormalNormal
Low
pH
Alkalosis Metabolik
PCO2
HCO3 -
normal
High
Low
pH
Alkalosis Respiratori
PCO2
HCO3 -
normal
HighHigh
pH
PCO2
HCO3-
Asidosis Respiratori
normal
Low
High
pH
PCO2
HCO3-
Asidosis Metabolik
normal
Low
Gangguan asam-basa primerGangguan asam-basa primer
Diagnosis menggunakan nilai asam basa serum:
Davenport Diagram
[ HC
O3- ]
PCO2 = 80 40
20
pH7.0 7.2 7.4 7.6 7.8
10
20
30
40
50
Henderson- Hasselbalch:
pH = pK + log [HCO3-]
s PCO2AsidosisAsidosis RespiratoriRespiratori AlkalosisAlkalosis
MetabolikMetabolik
AlkalosisAlkalosis RespiratoriRespiratori
Asidosis Asidosis MetabolikMetabolik
pH = 6.1 + Ginjal Paru
atau,
Normal
RESPON KOMPENSASIRESPON KOMPENSASI
Alkalosis Respiratori[ H
CO
3- ]
PCO2 = 80 40
20
pH7.0 7.2 7.4 7.6 7.8
10
20
30
40
50
AlkalosisAlkalosis Respiratori Respiratori
terkompensasiterkompensasi
Penyebab: 1) Nyeri 2) Histerik 3) Hipoksia
AlkalosisAlkalosis RespiratoriRespiratori
Normal
kompensasi = [HCO3-]
Asidosis Respiratori[H
CO
3- ]
PCO2 = 80 40
20
pH7.0 7.2 7.4 7.6 7.8
10
20
30
40
50
AsidosisAsidosis RespiratoriRespiratori
kompensasi = [HCO3-]
Penyebab:1) PPOK, Gagal jantung
kronik, bbrp pnyktparu
2) Obat anestesi
AsidosisAsidosis Respiratori Respiratori
terkompensasiterkompensasi
Metabolic Alkalosis[ H
CO
3- ]
PCO2 = 80 40
20
pH7.0 7.2 7.4 7.6 7.8
10
20
30
40
50
AlkalosisAlkalosis MetabolikMetabolik
kompensasi = PCO2Penyebab:1) Intake basa >>2) Kehilangan asam
(Muntah,penyedotan lambung)
AlkalosisAlkalosis Metabolik Metabolik
terkompensasiterkompensasi
Metabolic Asidosis[ H
CO
3- ]
PCO2 = 80 40
20
pH7.0 7.2 7.4 7.6 7.8
10
20
30
40
50
AsidosisAsidosis MetabolikMetabolik
kompensasi = PCO2
Penyebab:1) Kehilangan basa
(eg. diare)2) Akumulasi asam
(diabetes, gagal ginjal)3) Asidosis Tubular Ginjal
AsidosisAsidosis Metabolik Metabolik
terkompensasiterkompensasi
Kompensasi ginjal terhadap asidosis resp. kronik
Kompensasi ginjal & paru terhadap asidosis non ginjal
PPOK
Keto/Laktat asidosis
ASIDOSIS METABOLIKASIDOSIS METABOLIK
ANION GAPANION GAP
Metabolic acidosis
NaK Cl
AGHCO-
3
AG = 10-15AG = 10-15
2525
105105145145
NormalNormal
NaK Cl
HCO-3
AG1515
115 115 145145
= 15 (normal)= 15 (normal)
NaK Cl
HCO-3
AG = 25 (incl A-)= 25 (incl A-)1515
105105145145
Normal AG Normal AG ASIDOSIS ASIDOSIS HIPERKLOREMIKHIPERKLOREMIK
Peningkatan AG Peningkatan AG ASIDOSIS ASIDOSIS LAKTAT/KETO/SALISILAT DLLLAKTAT/KETO/SALISILAT DLL
Penambahan HPenambahan H++ Cl Cl-- Kehilangan HCOKehilangan HCO33
--Penambahan HPenambahan H++ A A--
ElectroneutralityElectroneutrality
[HC
O3- ]
PCO2 = 80 40
20
pH7.0 7.2 7.4 7.6 7.8
10
20
30
40
50
AsidosisAsidosis MetabolikMetabolik
Base Defisit
AlkalosisAlkalosis MetabolikMetabolik
Base Excess
Base Base Excess/ Excess/
Base DeficitBase Deficit
BE = (1 - 0.014Hgb) (HCOBE = (1 - 0.014Hgb) (HCO33 – 24 + (1.43Hgb + 7.7) (pH - – 24 + (1.43Hgb + 7.7) (pH - 7.4)`7.4)`
Normal
DISORDER pH PRIMER RESPON KOMPENSASI
ASIDOSIS ASIDOSIS METABOLIKMETABOLIK
HCO3- pCO2
ALKALOSIS ALKALOSIS METABOLIKMETABOLIK
HCO3- pCO2
ASIDOSIS ASIDOSIS RESPIRATORRESPIRATOR
II
pCO2 HCO3-
ALKALOSIS ALKALOSIS RESPIRATORRESPIRATOR
II
pCO2 HCO3-
RANGKUMAN GANGGUAN RANGKUMAN GANGGUAN KESEIMBANGAN ASAM BASA KESEIMBANGAN ASAM BASA
TRADISIONALTRADISIONAL
HOW TO UNDERSTAND ACID-HOW TO UNDERSTAND ACID-BASEBASE
A quantitative Acid-Base Primer For Biology and Medicine
Peter A. Stewart
Edward Arnold, London 1981
Now for something new…
WORKSHOP ACIDBASE STEWART PERDICI 2006
Goals, definitions and Goals, definitions and basic principles of basic principles of
Stewart theoryStewart theory
WORKSHOP ACIDBASE STEWART PERDICI 2006
• ElectroneutralityElectroneutrality. . In aqueous solutions in any In aqueous solutions in any compartment, the sum of all the positively charged ions compartment, the sum of all the positively charged ions must equal the sum of all the negatively charged ions.must equal the sum of all the negatively charged ions.
• Conservation of mass,Conservation of mass, the amount of a substance remains the amount of a substance remains constant unless it is added, removed, generated or constant unless it is added, removed, generated or destroyed. The relevance is that the total concentration of destroyed. The relevance is that the total concentration of an incompletely dissociated substance is the sum of an incompletely dissociated substance is the sum of concentrations of its dissociated and undissociated forms.concentrations of its dissociated and undissociated forms.
PRINSIP UMUMPRINSIP UMUM
Stewart PA. Modern quantitative acid-base chemistry. Can J Physiol Pharmacol 61:1444-1461, 1983.
WORKSHOP ACIDBASE STEWART PERDICI 2006
Konsep larutan encer Konsep larutan encer (Aqueous solution)(Aqueous solution)
• Semua cairan dalam tubuh manusia Semua cairan dalam tubuh manusia mengandung air, dan air merupakan sumber mengandung air, dan air merupakan sumber [H[H++]] yang tidak habis-habisnya yang tidak habis-habisnya
• [H[H++]] ditentukan oleh ditentukan oleh disosiasi air disosiasi air (K(Kww), ), dimana molekul Hdimana molekul H22O akan berdisosiasi O akan berdisosiasi menjadi ion-ion Hmenjadi ion-ion H33OO++ dan OH dan OH--
Hydrogen ion• Hidrogen ion concentration in body fluids is
extremely low, on the order of one ten-millionth of an equivalent perliter.
• Changes in hidrogen ion concentration may have important effects on biochemical reaction rates simply because hydrogen ions are involved in so many biochemical reactions.
• Clinically, hidrogen ion concentration, ([H+]), in body fluids is important as a useful indicators of several different kinds of pathology
Hydrogen ion• [H+] is most easily meassured in blood, via
small venipuncture sample and a pH meter. The [H+] of mixed venous blood sample is usually near 4.5x10-8 Eq/litre (pH 7.35), while arterial blood [H+] is near 4.0x10-8 Eq/litre )pH 7.40).
• Value about 1.2x10-7 E/litre (pH 6.9) or below about 1.6 x10-8 Eq/litre (pH 7.8) indicate life threatening situation and demand immediate intervention.
The Goals
• In any given solution, under specified conditions, we want to establish the
quantitative relationships between hydrogen ion hydrogen ion concentration in that solution and all the other variables in the solution that determine that hydrogen ion concentration.
WORKSHOP ACIDBASE STEWART PERDICI 2006
Definitions of “solution”• Definition:
– A solution is said to be acid-base neutral if its hydrogen ion concentration (H+) is equal to its hydroxyl ion concentration (OH-)
• Acid-base neutrality is a very special, rarely achieved condition. It must be carefully distinguished from electrical neutrality, a very different.
– A solution is said to be acidic, or acid, if its (H+) is greater than its (OH-)
– A solution is said to be alkaline, or basic, if its (H+) is less than its (OH-)
WORKSHOP ACIDBASE STEWART PERDICI 2006
[H+][H+][OH-][OH-]
[H+] >[OH-][H+] >[OH-][H+] = [OH-][H+] = [OH-] [H+] < [OH-][H+] < [OH-]
NeutralNeutral AcidicAcidic BasicBasic
Asam: adalah zat yang ketika ditambahkan ke dalam larutan, Asam: adalah zat yang ketika ditambahkan ke dalam larutan, akan menyebabkan peningkatan konsentrasi [H+] akan menyebabkan peningkatan konsentrasi [H+]
Basa: adalah zat yang ketika ditambahkan ke dalam larutan akan Basa: adalah zat yang ketika ditambahkan ke dalam larutan akan menurunkan konsentrasi [H+]menurunkan konsentrasi [H+]
Definitions of “substance”
[H+] and temperature• (H+), by its self, is clearly nor reliable meassure
of acidity, alkalinity or neutrlity, nor its negative log, pH. In pure water, for example, (H+) and (OH-) are always equal, so pure water is always acid-base neutral, but its (H+) varies significantly with teamperature, from 3.4x10-8 Eq/litre at 00C to 8.8x10-7 Eq/litre at 1000C.
• The common text book statement that neutrality is at pH 7.0, corresponding to (H+) of 1.0x10-7 Eq/litre, is only true in pure water at 250C. In particular, it is not true at body temperature, 370C, for which the pH of pure water is 6.8
WORKSHOP ACIDBASE STEWART PERDICI 2006
What is the pH of water?What is the pH of water?
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MOLEKUL AIR DAN PRODUK DISOSIASINYAMOLEKUL AIR DAN PRODUK DISOSIASINYA(auto-ionisasi air)(auto-ionisasi air)
disosiasi
+
WORKSHOP ACIDBASE STEWART PERDICI 2006
H H
H
O
O
O
O
H
H
H H
H H
+-
+
+
+
++
+
+ +
-
-
Sebenarnya, H+ di dalam larutan berada dalam bentuk H3O+
WORKSHOP ACIDBASE STEWART PERDICI 2006
OH-
Air / HAir / H22O O • Sangat reaktif:Sangat reaktif:
– dis-asosiasi airdis-asosiasi air• Karena massa dari H sangat kecil = maka Karena massa dari H sangat kecil = maka
di dalam suatu di dalam suatu larutanlarutan selalu akan terjadi selalu akan terjadi ““proton jumpingproton jumping””
O-HH++
O-HH++
HH++
OHOH-- ++HH33OO++H+
Auto-ionisasi
Proton jumpingProton jumping
Water does not Water does not spontaneously spontaneously
disassociate……………strong disassociate……………strong ions must be present!ions must be present!
WORKSHOP ACIDBASE STEWART PERDICI 2006
Peranan elektrolit dalam Peranan elektrolit dalam teori stewart teori stewart
Elektrolit = Ion-ion Elektrolit = Ion-ion
Ion-ion kuat Ion-ion kuat (Strong ions) (Strong ions)
Ion-ion lemah Ion-ion lemah (Weak ions) (Weak ions)
• Semua ion kuat akan terdisosiasi sempurna jika berada Semua ion kuat akan terdisosiasi sempurna jika berada didalam larutan. Karena selalu berdisosiasi ini maka ion-ion didalam larutan. Karena selalu berdisosiasi ini maka ion-ion kuat tersebut tidak berpartisipasi dalam reaksi-reaksi kimia, kuat tersebut tidak berpartisipasi dalam reaksi-reaksi kimia, perannya dalam kimia asam basa hanya pada hubungan perannya dalam kimia asam basa hanya pada hubungan elektronetraliti.elektronetraliti.
WORKSHOP ACIDBASE STEWART PERDICI 2006
Strong IonsStrong IonsCompletely dissociate in aqueous solutionCompletely dissociate in aqueous solution
• CationsCations– NaNa++
– KK++
– CaCa++++
– MgMg++++
• Anions Anions – ClCl--
– SOSO44--
– Lactate-Lactate-– Acetoacetate-Acetoacetate-
UnmetabolizablUnmetabolizabl
e Strong e Strong KationKation
UnmetabolizablUnmetabolizable Strong Anione Strong Anion Metabolizable Metabolizable Strong AnionStrong Anion
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2 3 4 5 6 7 8 9
100
80
70
60
50
40
30
20
10
% ter-ionisasi
pH
pK
CO2
HCO
3-
Albu
min
Lact
ate,
ace
toac
etat
e
MENGAPA LAKTAT DAN KETON DISEBUT ION MENGAPA LAKTAT DAN KETON DISEBUT ION KUAT?KUAT?
Suatu ion dikatakan kuat atau lemah tergantung dari pKnya (pH, dimana 50% dari substansi tsb terdisosiasi). Mis; pK Lactate 3.9 (berarti, pada pH normal, hampir 100% laktat terdisosiasi ). H2CO3 dan Alb disebut asam lemah karena pada pH normal hanya 50% substansinya terdisosiasi.
WORKSHOP ACIDBASE STEWART PERDICI 2006
• Strong ions/electrolyte:Strong ions/electrolyte:
MgMg++CaCa++++
ClCl--
LactateLactate--
SO4SO4-2-2
Substance that exist as essentiallySubstance that exist as essentially completely dissociatedcompletely dissociated in aqueous solution,in aqueous solution,
KK++
NaNa++
KKAA > 10 > 10–4–4 Eq/L Eq/L
HH33OO++
OHOH--
HH33OO++ HH33OO++HH33OO++
OHOH--
OHOH--
OHOH--
Old paradigm
• NaOH + HCl NaCl + H2O
• NaOH + HCl Na+ + Cl- + OH- + H+
• The Na+ and Cl- have not taken part in any reaction and no NaCl is formed
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WORKSHOP ACIDBASE STEWART PERDICI 2006
• Weak ions/electrolyte:Weak ions/electrolyte:
Substance that are onlySubstance that are only partially dissociatedpartially dissociated in in aqueous solution,aqueous solution,
COCO22
AlbuminAlbumin--PhosphatePhosphate--
KKA A between 10between 10–4–4 and 10 and 10-12-12 Eq/L Eq/L
OHOH--HH33OO++
Elektrolit jika berada dalam air
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WORKSHOP ACIDBASE STEWART PERDICI 2006
BAGAIMANA JIKA ION-ION KUAT BAGAIMANA JIKA ION-ION KUAT BERADA DI DALAM AIR……BERADA DI DALAM AIR……
WORKSHOP ACIDBASE STEWART PERDICI 2006
Na+
Ion-ion kuat akan berdisosiasi di dalam air (plasma)
Cl- --
- --
+
++
+++
+
+
+
+
++
++
+++
+
++
+ +--
--
-
Garam solid
WORKSHOP ACIDBASE STEWART PERDICI 2006
WORKSHOP ACIDBASE STEWART PERDICI 2006
WORKSHOP ACIDBASE STEWART PERDICI 2006
Na+Cl-
Reaksi hidrasi ion-ion kuat
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Strong Ions and WaterStrong Ions and Water
NaNa++ ClCl--
WaterWater
SaltSalt
O-HH++
HH++
““Proton Proton JumpingJumping””
Jika larutan mengandung ClJika larutan mengandung Cl--(anion) >> (anion) >> (SID (SID) ) H H33OO++ >> >>
HH33OO++
OHOH--
Jika larutan mengandung NaJika larutan mengandung Na++ (kation) >> (kation) >> (SID (SID ) ) OH OH-- >> >>
NaNa
Strong ions disassociate in waterStrong ions disassociate in water
SID nSID n
ClClClCl
SID SID
NaNa
SID SID AcidAcidBaseBase
OO--HH++
HH++PlasmaPlasma
WORKSHOP ACIDBASE STEWART PERDICI 2006
Perubahan yang terjadi pada pH atau [HPerubahan yang terjadi pada pH atau [H++] ] bukan sebagai akibat dari penambahan atau bukan sebagai akibat dari penambahan atau
pengurangan Hpengurangan H++, namun semata-mata , namun semata-mata akibat dari akibat dari disosiasi dari air…akibat adanya disosiasi dari air…akibat adanya perubahan dari strong ion difference dalam perubahan dari strong ion difference dalam
air tersebutair tersebut
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DI DALAM PLASMA :DI DALAM PLASMA :
4.4. OHOH-- + CO + CO22 H H22COCO33 HCO HCO33-- CO CO33
= = + H+ H++CA
2.2. [A[Atottot] (KA) = [A] (KA) = [A--].[H].[H++]]
1. [Na+] + [K+] - [Cl-] = [SID]
3.3. [2H[2H22O] Kw . [HO] Kw . [H++][OH][OH--]]
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PERSAMAAN ATAU FORMULA2 DALAM
STEWART APPROACH
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1. PURE WATER
Characteristic of water;• Strongly ionic substances dissociate when placed in water• Water it self dissociates, but only a little• Water containts a lot of water
Molecular weight are small (18) but…Molar concentration is >> (55.3 mol/l at 370C)
WORKSHOP ACIDBASE STEWART PERDICI 2006
Water dissociates as follow;
H2O H+ + OH-
Very rapid reaction, equilibrium is reached instantaneously in biological solution
At equilibrium
[H+].[OH-] = Kw.[H2O]Kw is very small, 4.3 x 10-16 Eq/l at 370C and temperature dependent, e.g at 250C is 1.8 x 10-16Eq/l
WORKSHOP ACIDBASE STEWART PERDICI 2006
A new constant
Kw’ = Kw x [H2O]
Kw’ is product of the two constant; - Kw and - The molar concentration of water
Let’s find the pH of pure water…
WORKSHOP ACIDBASE STEWART PERDICI 2006
[H+] x [OH-] = Kw’If we know the Kw’, we still need to find one of the other variables, [OH-]
Electroneutrality;[H+] – [OH-] = 0[H+] = [OH-]
[H+] = Kw’if [H+] = Kw’ (neutral)if [H+] > Kw’ (acidic)if [H+] < Kw’ (basic)
WORKSHOP ACIDBASE STEWART PERDICI 2006
2. STRONG ELECTROLYTES IN PURE WATER
Water dissociation;
[H+] x [OH-] = Kw’ …equation 0
Electroneutrality;[H+] - [OH-] + [Na+] - [Cl-] = 0 …equation #1
Substitute Kw’/[H+] for [OH-]
[H+] – Kw’/[H+] + [Na+] – [Cl-] = 0
[H+]2 + [H+]( [Na+] – [Cl-]) – Kw’ = 0Quadratic equation a.x2 + b.x + c = 0
[H+] = - ( [Na+] – [Cl-] )/2 + {( [Na+] – [Cl-] )2/4 + Kw’}
SID = STRONG IONS DIFFERENCE
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• And solving for [H+]
[H+] = Kw’ + SID2/4 – SID/2 …equation #2
[OH-] = Kw’ + SID2/4 + SID/2 …equation #3
In these solution it is clear that if the hydrogen ion concentration changes
the SID must have changed
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SKETCH; RELATIONSHIP BETWEEN SID,H+ AND OH-
SID
(–) (+)
[H+] [OH+]
In biological solutions at 370C, the SID nearly always positive, usually around 40 mEq/Liter
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• A more complex setup – Adding a weak electrolyte• A weak electrolyte, [Atot]:
– One that partially dissociated in the pH range– The most important in plasma is albumin– Represents the total amount of weak electrolytes produced
by biochemical reactions within the body, or represents the total amount of available “buffer” in body.
3. ADDING A WEAK ELECTROLYTE
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• Weak Acids:– HA (such as albumin) dissociates to form H+ and A-, as
follow:HA H+ + A-
Combined with two equation and the term of electroneutrality
[H+] x [OH-] = Kw’ … eq#0
[H+] + [OH-] + [SID] + [A-] = 0 … eq#1A
Dissociation of acids and conservation of mass;[H+] x [A-] = KA x [HA] …eq #4
[HA] + [A-] = [ATot] …eq #5
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• Identify the independent variables (Kw’,[SID],[ATot] and KA) and dependent one ([H+],[OH-],[HA] and [A-]
• Eliminate all dependent variables apart from [H+] from the equation by substitution:
[OH-] = Kw’/[H+] …from eq #0
[HA] = [ATot] – [A-] …from eq #5
And substituting eq#5 into eq#4
[A-] = Ka x [ATot] /([H+] + KA)
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Substitute these values into equation #1A, and get;
[SID] +[H+]-Kw’/[H+]–KA [ATot] /(KA+[H+]) =0… eq #6
Use a computer programe to find the [H+]
IT’S EASY AND QUICK !!!
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• Take a mixture of strong ions and water, and expose it to CO2
• What happen to CO2 gas when exposed to water– Dissolved– React with water to form carbonic acid– Bicarbonate or – Carbonate ions
4. STRONG IONS WITH CO2
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a. CO2 can dissolved:
CO2 (gas) CO2 (dissolved)
Equilibrium:
[CO2 dissolved] = SCO2 x PCO2 …equation #7A
SCO2 = Solubility of CO2, 3.0 x 10–5 Eq/l/mmHg at 370C
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b. Can react with water;
CO2 + H2O H2CO3
Equilibrium;[CO2 dissolved] x [H2O] = K x [H2CO3]…equation #7B
If [H2O] constant;
[H2CO3] = KH x PCO2
KH at 370C is 9 x 10–8 Eq/l
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c. H2CO3 dissociate; H2CO3 H+ + HCO3
-
• Equilibrium;
[H+] x [HCO3-] = K x [H2CO3]
[H+] x [HCO3-] = KC x PCO2 …equation #8
KC is 2.6 x 10–11 Eq/l2/mmHg
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d. HCO3- rapidly dissociate:
HCO3- H+ + CO3
–2
• Equilibrium;
[H+] x [CO3–2] = K3 x [HCO3
-] …equation #9
K3 is 6 x 10–11 Eq/l
K3 is 6 x 10 –11 Eq/l
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THE SIX SIMULTANEOUS EQUATIONS USED BY STEWART
Water Dissociation EqulibriumWater Dissociation Equlibrium
[H[H++] x [OH] x [OH--] = Kw’] = Kw’
Electrical Neutrality EquationElectrical Neutrality Equation
[SID] + [H[SID] + [H++] = [HCO] = [HCO33--] + [A] + [A--] + [CO3 ] + [CO3 –2–2] + [OH] + [OH--]]
Weak acid Dissociation EquilibriumWeak acid Dissociation Equilibrium
[H[H++] x [A] x [A--] = KA x [HA]] = KA x [HA]Conservation of Mass for “A” Conservation of Mass for “A”
[A[ATotTot] = [HA] + [A] = [HA] + [A--]]
Bicarbonate Ion Formation EquilibriumBicarbonate Ion Formation Equilibrium
[H[H++] x [HCO] x [HCO33] = Kc x pCO] = Kc x pCO22
Carbonat Ion Formation EquilibriumCarbonat Ion Formation Equilibrium
[H[H++] x [CO] x [CO33–2–2] = K3 x [HCO] = K3 x [HCO33
--]]
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A 4th polynomial order
ax4 + bx3 + cx2 + dx + e = 0Substitute;
a.[H+]4 + b.[H+]3 + c.[H+]2 + d.[H+] + e = 0Where,
a = 1b = [SID] + KA
c = { KA ([SID] – [ATot]) – Kw’ – Kc.pCO2}d = - {KA (Kw’ + Kc.pCO2) – K3.Kc.CO2}e = - (KA.K3.Kc.pCO2)
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[SID]+[H+]-KC.pCO2/[H+]-KA.[ATot]/(KA+[H+])-K3.KC.pCO2/[H+]2-Kw’/[H+]=0
[H+] dan [HCO3-] = ([SID], pCO2, [ATot])
In these solution it is clear that if the hydrogen or
bicarbonate ion concentration changes
the SID,ATot and pCO2 must have changed
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BLOOD PLASMA
NaNa++
KK++
MgMg++++
CaCa++++
ClCl--
XAXA --
PosfatPosfat --AlbAlb --
HCOHCO33--
OHOH- - COCO332-2-
SIDSIDHH++
AATotTot
Unmeasured AnionUnmeasured Anion
CATIONCATION ANIONANION
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The practical significance of all this maths If we want to calculate the pH, we must:
1. Know the concentrations of the strong ions, and
2. Plug these value into equations;
Note:If you add basic or acidic substance, you cannot just say” We added so much hydroxide so the pH will change by so much.”
You have to work things out using the equations.
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ACIDBASIC II
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The difference;
• The Stewart approach emphasizes mathematically independent and dependent variables.
• Actually, HCO3- and H+ ions represent the effects
rather than the causes of acid-base derangements.
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Teori Dasar Pendekatan Kuantitatif II
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Henderson-HasselbalchHenderson-Hasselbalch StewartStewart’’s Approachs Approach
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DUA VARIABELDUA VARIABEL
pH atau [HpH atau [H++] DALAM PLASMA ] DALAM PLASMA DITENTUKAN OLEHDITENTUKAN OLEH
VARIABELVARIABELINDEPENDENINDEPENDEN
VARIABELVARIABEL DEPENDENDEPENDEN
Menurut Stewart ;Menurut Stewart ;
MenentukanMenentukan
Stewart PA. Can J Physiol Pharmacol 61:1444-1461, 1983. Stewart PA. Can J Physiol Pharmacol 61:1444-1461, 1983.
Primer (cause)Primer (cause) Sekunder (effect)Sekunder (effect)
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VARIABEL INDEPENDENVARIABEL INDEPENDEN
COCO22 STRONG ION STRONG ION DIFFERENCEDIFFERENCE
WEAK ACIDWEAK ACID
pCOpCO22 SIDSID AAtottotControlled by Controlled by
the respiratory the respiratory systemsystem The electrolyte The electrolyte
composition of the composition of the blood (controlled blood (controlled
by the kidney)by the kidney)
The protein The protein concentration concentration
(controlled by the (controlled by the liver and metabolic liver and metabolic
state)state)
• Rx dominan dari CORx dominan dari CO22 adalah rx absorpsi OH adalah rx absorpsi OH-- hasil disosiasi air dengan melepas Hhasil disosiasi air dengan melepas H++..
• Semakin tinggi pCOSemakin tinggi pCO22 semakin banyak H semakin banyak H++ yang yang terbentuk.terbentuk.
• Ini yg menjadi dasar dari terminologi Ini yg menjadi dasar dari terminologi “respiratory acidosis,” yaitu pelepasan ion “respiratory acidosis,” yaitu pelepasan ion hidrogen akibat hidrogen akibat pCO pCO22
COCO22
OHOH-- + CO + CO22 HCO HCO33-- + H + H++
CACA
STRONG ION DIFFERENCESTRONG ION DIFFERENCE
Definisi: Strong ion difference adalah ketidakseimbangan Definisi: Strong ion difference adalah ketidakseimbangan muatanmuatan dari ion-ion kuat. dari ion-ion kuat.
SID adalah jumlah konsentrasi basa kation kuat dikurangi SID adalah jumlah konsentrasi basa kation kuat dikurangi jumlah dari konsentrasi asam anion kuat.jumlah dari konsentrasi asam anion kuat.
Untuk definisi ini semua konsentrasi ion-ion diekspresikan Untuk definisi ini semua konsentrasi ion-ion diekspresikan dalam ekuivalensi (mEq/L).dalam ekuivalensi (mEq/L).
Gamblegram
NaNa++
140140
KK+ + 44CaCa++++MgMg++++
ClCl--102102
KATION ANION
SIDSID
STRONG ION STRONG ION DIFFERENCEDIFFERENCE
[Na+] + [K+] + [kation divalen] - [Cl-] - [asam organik kuat-]
[Na+] + [K+] - [Cl-] = [SID] 140 mEq/L + 4 mEq/L - 102 mEq/L = 34 mEq/L
ClClNaNa
Hubungan SID dgn pH/HHubungan SID dgn pH/H++
SIDSID(–)(–) (+)(+)
[H[H++] ] ↑↑↑↑ [OH[OH--] ↑↑] ↑↑
Dalam cairan biologis (plasma) dgn suhu 37Dalam cairan biologis (plasma) dgn suhu 3700C, SID selalu positif, C, SID selalu positif, nilainya berkisar 30-40 mEq/Liternilainya berkisar 30-40 mEq/Liter
AsidosisAsidosis AlkalosisAlkalosis
Konsentrasi HKonsentrasi H++
NaNa
SID↓SID↓
ClCl NaNaClCl
SID↑SID↑SIDSID
SID vs pH & [H+]
1
2
3
4
56
7
8
9
10
-10 0 10 20 30 40 50 60 70 80
[SID] mEq/L
10
20
30
40
5060
70
80
90
100
pH [H+] nmol/L
Kellum JA. Kidney Int 53: S81-S86, 1998
Kombinasi protein dan posfat disebut asam lemah total (total weak acid) [Atot]. Reaksi disosiasinya adalah:
[A[Atottot] (KA) = [A] (KA) = [A--].[H].[H++]]
[Protein H] [Protein-] + [H+]
WEAK ACIDWEAK ACID
disosiasi
Gamblegram
NaNa++
140140
KK+ + 44CaCa++++MgMg++++
ClCl--102102
HCOHCO33--
2424
KATION ANION
SIDSIDWeak acidWeak acid(Alb-,P-)(Alb-,P-)
WEAK WEAK ACIDACID
NaNa++
KK+ + 44CaCa++++MgMg++++
ClCl--
HCOHCO33--
KATIONKATION ANIONANION
SIDSID
STRONG ION DIFFERENCE & STRONG ION DIFFERENCE & WEAK ACID IN PLASMAWEAK ACID IN PLASMA
= {[Na= {[Na++] + [K] + [K++] + [kation divalen]} - {[Cl] + [kation divalen]} - {[Cl--] + [As.organik kuat] + [As.organik kuat--]}]}
As. Organik kuat
Weak acidWeak acid(Alb-,P-)(Alb-,P-)
SID
Conclusion
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Strong IonsStrong IonsDifferenceDifference
pCOpCO22
ProteinProteinConcentrationConcentration
pHpH
INDEPENDENT VARIABLESINDEPENDENT VARIABLES DEPENDENT VARIABLESDEPENDENT VARIABLES
DEPENDENT VARIABLESDEPENDENT VARIABLES
HH++
OHOH--
COCO33== AA--
AHAH
HCOHCO33--
HH33OO++
++ OHOH
Perubahan SIDPerubahan SID Perubahan AtotPerubahan Atot
Perubahan CO2Perubahan CO2
HH2200
DISSOCIATION & DISSOCIATION & ASSOCIATION OF PURE ASSOCIATION OF PURE
WATERWATER
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KLASIFIKASI GANGGUAN KLASIFIKASI GANGGUAN KESEIMBANGAN ASAM BASA KESEIMBANGAN ASAM BASA
BERDASARKAN PRINSIP STEWARTBERDASARKAN PRINSIP STEWART
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KLASIFIKASI GANGGUAN KESEIMBANGAN ASAM KLASIFIKASI GANGGUAN KESEIMBANGAN ASAM BASA BERDASARKAN PRINSIP STEWARTBASA 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
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RESPIRATORYRESPIRATORY M E T A B O L I CM E T A B O L I C
in pCOin pCO22 in SIDin SID in Weak in Weak acidacid
Alb PO4-
AlkalosisAlkalosis
AcidosisAcidosis
DecreaseDecrease
IncreaseIncrease
DecreaseDecrease
ExcessExcess
DeficitDeficit
PositivePositive IncreaseIncreaseFencl V, Am J Respir Crit Care Med 2000 Dec;162(6):2246-51
WATER STRONG ANION
ClCl UAUA
HypoHypo
HyperHyper
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Na+ = 140 mEq/LCl- = 102 mEq/LSID = 38 mEq/L 140/1/2 = 280 mEq/L
102/1/2 = 204 mEq/L SID = 76 mEq/L1
liter½ liter
WATER DEFICITWATER DEFICIT
DiureticDiabetes Insipidus
Evaporasi
SID : 38 SID : 38 76 = 76 = alkalosisalkalosisALKALOSIS KONTRAKSIALKALOSIS KONTRAKSI
Plasma Plasma
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Na+ = 140 mEq/LCl- = 102 mEq/L SID = 38 mEq/L
140/2 = 70 mEq/L102/2 = 51 mEq/L SID = 19 mEq/L
1 liter
2 liter
WATER EXCESSWATER EXCESS
1 Liter H2O
SID : 38 SID : 38 19 = 19 = AcidosisAcidosisASIDOSIS DILUSIASIDOSIS DILUSI
Plasma
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NaNa140140
KKMgMgCaCa
ClCl102102
POPO44
AlbAlb
SID = 34SID = 34
Cl Cl 115115
AlbAlbPOPO44
SID SID
Asidosis Asidosis hiperklorhiperklor
ClCl102102
Laktat/keto
Asidosis Asidosis Keto/laktatKeto/laktat
CL CL 9595
AlbAlbPOPO44
Alkalosis Alkalosis hipoklorhipoklor
SID SID SIDSID
in SID and Weak Acidin SID and Weak Acid
POPO44
AlbAlb
Normal Normal
ClCl102102
SIDSID
Alkalosis Alkalosis hipoalb/ hipoalb/ fosfatfosfat
ClCl102102
SIDSIDAlb/Alb/POPO44
Asidosis Asidosis hiperalb/ hiperalb/
fosfatfosfat
George, 2003
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Efek terapi cairan terhadap Efek terapi cairan terhadap keseimbangan asam basakeseimbangan asam basa
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Na+ = 140 mEq/LCl- = 102 mEq/LSID = 38 mEq/L
Na+ = 154 mEq/LCl- = 154 mEq/LSID = 0 mEq/L1 liter 1 liter
PLASMA + NaCl 0.9%PLASMA + NaCl 0.9%
SID : 38 pH normal
Plasma NaCl 0.9%
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2 liter
ASIDOSIS HIPERKLOREMIK AKIBAT ASIDOSIS HIPERKLOREMIK AKIBAT PEMBERIAN LARUTAN Na Cl 0.9% PEMBERIAN LARUTAN Na Cl 0.9%
=
SID : 19 SID : 19 pH pH lebih asidosislebih asidosis
Na+ = (140+154)/2 mEq/L= 147 mEq/LCl- = (102+ 154)/2 mEq/L= 128 mEq/L
SID = 19 mEq/L
Plasma
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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 LACTATEPLASMA + Larutan RINGER LACTATE
SID : 38 SID : 38
Plasma Ringer laktatLaktat cepat
dimetabolisme
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2 liter
=
Normal pH setelah pemberian Normal pH setelah pemberian RINGER LACTATE RINGER LACTATE
SID : 34 SID : 34 lebih alkalosis dibanding jika lebih alkalosis dibanding jika diberikan NaCl 0.9% 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
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Rapid Saline Infusion Produces Hyperchloremic Acidosis in Rapid Saline Infusion Produces Hyperchloremic Acidosis in Patients Undergoing Gynecological SurgeryPatients Undergoing Gynecological Surgery
(Scheingraber et al.: Anesthesiology 1999, 90)(Scheingraber et al.: Anesthesiology 1999, 90)
NaCl 0.9%NaCl 0.9%(n = 12)(n = 12)
Lact. Ringer’s Lact. Ringer’s (n = 12)(n = 12)
Time of infusion (min) 135 135 ±± 23 23 138 138 ±± 20 20
Volume after 120 min (ml/kg)
71 71 ±± 14 14 67 67 ±± 18 18
Estimated blood loss (ml) 962 962 ±± 332 332 704 704 ±± 447 447
Urine output (ml) 717 717 ±± 459 459 1 075 1 075 ±± 799 799
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Scheingraber et al., Anesthesiology 90 (1999)
Lactated Ringer’sLactated Ringer’s NaCl 0.9%NaCl 0.9%
7.507.50
7.457.45
7.407.40
7.357.35
7.307.30
7.257.25
7.207.200 30 60 90 120 min 0 30 60 90 120 min
0 30 60 90 120 min0 30 60 90 120 min
50
46
42
38
34
30
26
44
00
-4-4
-8-8
-12-12
3.0
2.5
2.0
1.5
1.0
0.5
0.0
mm
Hg
mm
ol/l
mm
ol/l
pH CO2
BE Lactate
# # #
### #*
#*
#* #*
*
*
* * *
** *
* P<0.05 intragroup# P<0.05 intergroup
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Scheingraber et al., Anesthesiology 90 (1999)
[Na+] [Cl-]
SID Prot-
0 30 60 90 120 min 0 30 60 90 120 min
0 30 60 90 120 min0 30 60 90 120 min
148
144
140
136
120
115
110
105
100
17.5
15
12.5
10
7.5
45
40
35
30
25
mm
ol/l
mm
ol/l
mm
ol/l
mm
ol/l
#*#* #* #*
#*#*#*
#*
#*#*
* ***
***
**
* *
****
**
**
**
* P<0.05 intragroup# P<0.05 intergroup
Lactated Ringer’sLactated Ringer’s NaCl 0.9%NaCl 0.9%
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Na+ = 140 mEq/LCl- = 130 mEq/LSID =10 mEq/L
Na+ = 165 mEq/LCl- = 130 mEq/LSID = 35 mEq/L1 liter 1.025
liter
25 mEq NaHCO3
SID SID : 10 : 10 35 : 35 : Alkalosis, pH kembali normal Alkalosis, pH kembali normal namun namun mekanismenya bukan karena pemberian HCOmekanismenya bukan karena pemberian HCO33
-- melainkan karena melainkan karena pemberian Napemberian Na++ tanpa anion kuat yg tidak dimetabolisme seperti Cl tanpa anion kuat yg tidak dimetabolisme seperti Cl--
sehingga SID sehingga SID alkalosis alkalosis
Plasma; asidosis
hiperkloremik
MEKANISME PEMBERIAN NA-BIKARBONAT PADA ASIDOSIS
Plasma + NaHCO3
HCO3 cepat dimetabolis
me
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Strong Ion Difference in Strong Ion Difference in Gastrointestinal TractGastrointestinal Tract(interaction between membrane)(interaction between membrane)
1.1. Magder S. Pathophysiology of metabolic acid-base disturbances in patients with critical illness.Magder S. Pathophysiology of metabolic acid-base disturbances in patients with critical illness. In:Critical In:Critical Care Nephrology. Kluwer Academic Publishers, Dordrecht, The Netherlands, 1998. pp 279-296.Ronco C, Care Nephrology. Kluwer Academic Publishers, Dordrecht, The Netherlands, 1998. pp 279-296.Ronco C, Bellomo R (eds).Bellomo R (eds).
2.2. Sirker AA et al.Acid base physiology: the Sirker AA et al.Acid base physiology: the ‘‘traditionaltraditional’’ and the and the ‘‘modernmodern’’ approaches. Anaesthesia, 2002, approaches. Anaesthesia, 2002, 57; 348-35657; 348-356
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SekresiSekresi gastergaster
NaNa
ClClHH++ Cl-Cl-
Cl-Cl-
Cl-Cl-
SID cairan lambung < / (SID cairan lambung < / () ; asam) ; asamAntasida: Antasida: MgOH, CaOH MgOH, CaOH SID SID
PancreasNa+Na+
Empedu
Na+Na+
Na+Na+
SID plasma SID plasma AlkalosisAlkalosis
SID plasma -SID plasma -AsidosisAsidosis
SID plasma SID plasma normalnormal
SID cairan SID cairan intestinal normalintestinal normal
Na+Na+
Na+Na+
Na+Na+
Diare: Diare: Na loss Na loss
Plasma sitePlasma site
ClCl
NaNa
ClCl
NaNa
HH++
ClClNaNa
Muntah, penyedotanMuntah, penyedotanLambung, sekresi EF >> Lambung, sekresi EF >>
Cl loss Cl loss Alkalosis karena muntah
Alkalosis karena muntah
Cl-Cl-
Na+Na+
Absorbsi Absorbsi JejunumJejunum
Absorbsi Absorbsi ColonColon
Na+Na+
NaNaClCl
SID plasma SID plasma normalnormal
Cl-Cl-
Na+Na+
George, 2003George, 2003
Cl-Cl- Na+Na+Na+Na+
Cl-Cl-Cl-Cl-
Na+Na+
Asidosis karena diare
Asidosis karena diare
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Volume dan komposisi elektrolit cairan gastrointestinal24 h vol.
(mL)NaNa++
(mEq/L)(mEq/L)K+ (mEq/L) ClCl-- (mEq/L) (mEq/L) HCO3
-
SIDSalivaSaliva 500-2000 66 25 1313 18
StomachStomach 1000-1000-20002000
8080 1515 115115 -20-20
PancreasPancreas 300-800 140140 7.5 8080 67.5BileBile 300-600 140140 7.5 110110 37.5
JejunumJejunum 2000-4000 130130 7.5 115115 22.5
IleumIleum 1000-2000 115115 5 92.592.5 27.5
ColonColon - 6060 30 4040 -
Miller, 5th ed,2000.
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24 h 24 h vol. vol. (mL)(mL)
NaNa++ (mEq(mEq/L)/L)
KK++ (mEq(mEq/L)/L)
ClCl-- (mEq(mEq/L)/L)
HCOHCO33- -
SIDSID
SalivaSaliva 500-500-20002000
66 2525 1313 1818
StomachStomach 1000-1000-20002000
8080 1515 115115 -20-20
PancreaPancreass
300-800300-800 140140 7.57.5 8080 67.567.5
BileBile 300-600300-600 140140 7.57.5 110110 37.537.5
JejunumJejunum 2000-2000-40004000
130130 7.57.5 115115 22.522.5
IleumIleum 1000-1000-20002000
115115 55 92.592.5 27.527.5
ColonColon -- 6060 3030 4040 --
From Miller, Anesthesia, 5th ed,2000.From Miller, Anesthesia, 5th ed,2000.
Boron & Boulpaep, Medical Boron & Boulpaep, Medical Physiology,ch 27, 2003.Physiology,ch 27, 2003.
pH of Body fluidspH of Body fluidsVolume dan komposisi Volume dan komposisi elektrolit cairan elektrolit cairan gastrointestinalgastrointestinal
WORKSHOP ACIDBASE STEWART PERDICI 2006
Strong Ion Difference Strong Ion Difference in Kidneyin Kidney
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The kidneys are the most important regulators The kidneys are the most important regulators of SID for acid-base purposes.of SID for acid-base purposes.
Sirker AA et al.Acid base physiology: the ‘traditional’ and the ‘modern’ approaches. Anaesthesia, 2002, 57;
348-356
NaNa+ +
148148ClCl- -
153153
NaNa+ +
138138ClCl- -
106106
Plasma Plasma
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Perbandingan komposisi elektrolit urin dan Perbandingan komposisi elektrolit urin dan plasmaplasma
Ion-ion (mEq/l)Ion-ion (mEq/l) UrineUrine PlasmaPlasma
NaNa++ 147.5147.5 138.4138.4
KK++ 47.547.5 4.44.4
ClCl-- 153.3153.3 106106
HCOHCO33-- 1.91.9 2727
MARTINI, Fundamentals of Anatomy and Physiology; 5 th ed,2001
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Effects of diuretics on urine Effects of diuretics on urine compositioncomposition
VolumeVolume(ml/min)(ml/min)
pHpH SodiumSodium(mEq/l)(mEq/l)
PotassiumPotassium(mEq/l)(mEq/l)
ChlorideChloride(mEq/l)(mEq/l)
BicarbonateBicarbonate(mEq/l)(mEq/l)
No drugNo drug 11 6.46.4 5050 1515 6060 11
Thiazide diureticsThiazide diuretics 1313 7.47.4 150150 2525 150150 2525
Loop diureticsLoop diuretics 88 6.06.0 140140 2525 155155 11
Osmotic diureticsOsmotic diuretics 1010 6.56.5 9090 1515 110110 44
Potassium-sparing Potassium-sparing diurticsdiurtics
33 7.27.2 130130 1010 120120 1515
Carbonic anhydrase Carbonic anhydrase inhibitorsinhibitors
33 8.28.2 7070 6060 1515 120120
Source: adapted from Tonnesen AS, Clincal pharmacology and use of diuretics. In: Hershey SG, Bamforth BJ, Zauder H, eds, Review courses in anesthesiology. Philadelphia: Lippincott, 1983; 217-226
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Regulasi pH dan mekanisme Regulasi pH dan mekanisme kompensasikompensasi
Chronic control Chronic control (long-term)(long-term)
Rapid regulation Rapid regulation (short-term)(short-term)
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PCO2
PPOK
pH
NHNH44Cl Cl HipokloremiHipokloremi
Absorpsi Cl Absorpsi Cl
Amoniagenesis
Amoniagenesis
SIDSID
pH normalpH normal
ClClNHNH44
Kompensasi kronikKompensasi kronik
Kompensasi terhadap kronik hiperkarbi (PPOK) Kompensasi terhadap kronik hiperkarbi (PPOK)
George, 2003
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Group 1 Group 2 Group 3
paCOpaCO22 < 40 < 40 paCOpaCO22 40-50 40-50 paCOpaCO22 > 50 > 50
pH
SID
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pCO2pH
SID
HCO3-
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Respon kompensasiRespon kompensasi
Cl-Na+
K+ Lactate
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KESIMPULANKESIMPULAN
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Hendersen-Hendersen-Hasselbalch Hasselbalch
TERIMA KASIHTERIMA KASIH