Nje qasje algoritmike

Hysni Dida

Marrja e gjakut arterial

Radial Artery

Ulnar Artery

HyrjeAstrupometri mat pH, pCO2 dhe pO2

[HCO3-] dhe diferenca bazike llogaritenduke perdorur ekuacionin Henderson-Hasselbalch

Parametrat normaleCrregullimet acidobazike mund te verehen edhe nqs

kemi vetem 3 parametra pH, pCO2 dhe HCO3

Vlerat normale

• pH = 7.36 – 7.44

• PCO2 = 36-44 mmhg

• HCO3 = 22-26 mEq/L

Marredhenia midis [H+] & pHpH [H

+] pH [H

+]

7.80

7.75

16

18

7.30

7.25

50

56

7.70

7.65

20

22

7.20

7.15

63

71

7.60

7.55

25

28

7.10

7.00

79

89

7.50

7.45

32

35

6.95

6.90

100

112

7.40

7.35

40

45

6.85

6.80

141

159

Baze deficiti dhe Baze eksesiNje ndryshim me 0.15 ne pH eshte ekuivalent

me nje ndryshim ne baze me 10 mEq/L.

Nje renie ne baza psh HCO3 quhetbaze deficit dhe nje rritje ne bazaquhet baze ekses

Ndryshime Metabolike vsRespiratore

Kur ndryshimi primar eshte pCO2 atehere crregullimieshte respirator

Kur ndryshimi primar eshte HCO3- => crregullimmetabolik

Acidemia vs Alkalemia

Kur pH I gjakut eshte <7.35 kemi te bejme me

acidemi

Kur pH I gjakut eshte >7.45 kemi te

bejme me Alkalemi

Crregullimet primare dhe pergjigjet kompesatore

3

2

24HCO

PaCOH

Crregullimi Ndryshimi primar Ndryshimi kompesator

Respiratory acidosis PCO2 HCO3

Respiratory alkalosis PCO2 HCO3

Metabolic acidosis HCO3 PCO2

Metabolic alkalosis HCO3 PCO2

• Ndryshimet kompesatore ndodhin qe te mbajne te pandryshuarraportin PCO2/HCO3

• Ndryshimet kompesatore jane ne te njejtin drejtim me ndryshiminprimar

Kompesimi Crregullimet respiratore kompesohen me ane te

veshkave

Crregullimet metabolike kompesohen me ane teveshkave (kur veshkat nuk jane shkaku) dhe me ane tepulmoneve

Crregullimi me I pa kompesuar eshte alkalozametabolike sepse kompesimi respirator eshtehypoventilimi I cili nuk mund te zgjaze per nje kohe tegjate sepse nxiten kemoreceptoret qendrore

Kompesimi respirator I acidozes metabolike

Pergjigja ventilatore pas nje acidoze metabolike eshte te krijoje njealkaloze respiratore gje qe do te coje ne nje HIPERVENTILIM duke ulur paCO2 I cili matet me formulen e Winter

PaCO2 I pritur = (1.5×HCO3) + (8±2)

Nese paCO2 I matur eshte ekuivalent me paCO2 e pritur atehere kompesimi

respirator eshte adekuat dhe kjo gjendje quhet Acidoze metabolike e kompesuar

Nese paCO2 I matur eshte me I madh se paCO2 I pritur atehere pergjigja respiratore

nuk eshte adekuate dhe kemi nje acidoze respiratore shtese acidozes metabolike. Ky

crregullim quhet Acidoze metabolike primare me mbivendosje te nje acidoze

respiratore

Nese paCO2 I matur eshte me I vogel se ai I pritur atehere eshte nje alkaloze

respiratore mbivendosur nje acidoze metabolike primare

Kompesimi I alkalozes metabolike Formula e meposhtme vlen ne rastet kur HCO3 >40

PaCO2 I pritur = (0.7×HCO3) + (21±2)

Nese paCO2 I matur eshte I barabarte me paCO2 e pritur atehere kemite bejme me kompesim adekuat respirator= Alkaloze metabolkie e kompesuar

Nese paCO2 I matur eshte me I madh se ai I pritur kompesimirespirator nuk eshte adekuat dhe kemi nje acidoze respiratorembivendosur alkalozes metabolike primare

Nese paCO2 I matur eshte me I ulet se ai I pritur atehere kemi njealkaloze respiratore te mbivendosur =Alkaloze metabolike primareme mbivendosje nje alkaloze respiratore

Kompesimi metabolik Ndodh ne veshka

Ndryshimi I perqendrimit te CO2 con ne ndryshim te perthithjes se HCO3- ne tubulat renale

Ne acidoze respiratore kemi rritje te paCO2 dhe rritje te perthithjes se HCO3-ne veshka

Ne alkaloze respiratore kemi ulje te paCO2 dhe ulje te perthithjes se HCO3-

Eshte me I ngadalte , fillon 6-12 ore pasi eshte vendosur crregullimi primar ndajnje crregullim quhet akut para fillimit te kompesimt renal dhe kronik pas fillimit te kompesimit renal

Kompesimi metabolik Alkaloza respiratore

Ulet paCO2 ulet HCO3-

Acidoza respiratore

Rritet pa CO2 rritet HCO3-

Crregullimet Akute respiratore Perpara se te filloje kompesimi renal nje ndryshim I

paCO2 me 1mmHg do te sjelle nje ndryshim me 0.008 ne pH ∆pH = 0.008 × ∆PaCO2

Nga ky ekuacion del pH I pritur per nje acidoze respiratore akute

pH I pritur = 7.40 – [0.008 × (PaCO2 – 40)]

Ndersa pH I pritur per nje alkaloze respiratoreakute llogaritet

pH I pritur= 7.40 + [0.008 × (40 - PaCO2)]

Kompesimi renal ne crregullime kronike respiratore

Kur vendoset kompesimi renal I plote cdo ndryshimme 1mmHg paCO2 e ndryshon pH me vetem O.OO3 njesi ∆pH = 0.003 × ∆PaCO2

pH I pritur per nje acidoze respiratore te kompesuar

pH pritur= 7.40 – [0.003 × (PaCO2 – 40)]

Ndersa per alkalozen respiratore te kompesuar(kronike)

pH pritur = 7.40 + [0.003 × (40 - PaCO2)]

Crregullimet dhe kompesimi

Type of Disorder pH PaCO2 [HCO3]

Metabolic Acidosis

Metabolic Alkalosis

Acute Respiratory Acidosis

Chronic Respiratory Acidosis

Acute Respiratory Alkalosis

Chronic Respiratory Alkalosis

Algoritmi I interpretimit tecrregullimeve AB Stadi O percakto nese te dhenat jane te vlefshme

duke perdorur ek Haselbach

Stadi 1 percakto ndryshimin primar

Stadi 2 shiko pergjigjet kompesatore

Stadi 3 perdor Gap per te percaktuar ac.metabolike

Stadi 1 Rregulla 1 mund te kemi nje crregullim acidobazik

dhe kur vlera e pH ose paCO2 eshte normale

Rregulla 2 nese pH dhe paCO2 jane te dy jonormalshiko kahet

++=> nese jane me te njejtin kah =crreg.metabolik

++=> nese jane me kahe te kunderta = crreg.respirator

psh nese pH=7.23 dhe paCO2=23mmHg

Acidoze metabolike

Stadi 1 Rregulla 3 nese pH ose paCO2 jane normal kemi nje

crregullim miks respirator dhe metabolik

Nese pH eshte normal kahu I paCO2 tregoncrregullimin respirator

Nese paCO2 eshte normal kahu I pH tregoncrregullimin metabolik

Psh: pH=7.37 paCO2=55mmHg

acidoze respiratore me alkaloze metabolike

Ska crregullim primar sepse pH eshte normal

Stadi 2 I vlefshem kur nga stadi 1 del nje crregullim primar

Qellimi I ketij stadi eshte te percaktojme nesekompesimi eshte adekuat ose jo.

Rregulla 4 nese ka nje crregullim primar metabolikperdor HCO3 e matur dhe gjej paCO2 e pritur

Nese paCO2 pritur =paCO2 matur kompesim I plote

Nese paCO2 pritur >paCO2 matur mbivendosje e alkalozes respiratore

Nese paCO2 pritur <paCO2 matur mbivendosje e acidozes respiratore

Stadi 2 Shembull : paCO2=23mmHg pH=7.32 HCO3=15 mEq/L

Zbatojme rregullin 2 kemi ACIDOZE Metabolike primare

paCO2 pritur=(1.5*15) +8± 2= 30.5±2 mmHg

paCO2 pritur >paCO2 matur acidoze metabolike primare me mbivendosje alkaloze respiratore

Stadi 2 Rregulla 5 nese ka crregullim respirator=perdor

paCO2 per te llogaritur pH pritur

pH matur >pH pritur ne acidoz/alkaloz resp akutekemi mbivendosje ACIDOZE metabolike

pH matur <pH pritur ne acidoz/alkaloz resp.kronikekemi mbivendosje ALKALOZ metabolike

Stadi 2 Shembull : paCO2=23mmHg pH=7.54

alkaloz respiratore

pH pritur akute=7.4 +[0.008*(40-23)]=7.54

pHpritur akut=pHmaturgjendje akute pa kompesuar

pra kemi alkaloz respiratore akute

Stadi 3 Perdorim Gap per te llogaritur /percaktuar acidozen

metabolike

Anion gap=diferenca midis anioneve te pamatshmeme kationet e pamatshme

AG=Na -(HCO3 +Cl)=12

Stadi 3 Acidoze metabolike me GA te rritur normokloremike

Ketoacidoza

Acidoza laktike

Acidoza uremike

Acidoza metabolike me GA normal hiperkloremike

Acidoza renale tubulare

Acidoza uremike e hershme

Acidoza posthypokapnike

Acidoza e diluimit’

Diarrea

Stadi 3 Influenca e albumines

Stadi 3Urinary anion gap perdoret per te kuptuar shkaqet

renale/jorenale te Acidozes metabolike me AG normal

E pavlefshme ne Hypovolemi, oliguri, hyponatriuri, acidoze me AG

UAG=(uNa+uK)-uCl =±10

Kur UAG <-10 shkaku eshte jorenal

Kur UAG >+10 shkaku eshte renal psh

Metabolic

Acidosis

Anion Gap

“MUDPILERS

”

Metabolic Acidosis

Non-Gap

“HARDUPS”

Acute Resp.

Acidosis

“anything

causing

hypoventilation”

Metabolic

Alkalosis

“CLEVERPD”

Respiratory

Alkalosis

“CHAMPS”

•Methanol

•Uremia

•DKA/Alcoho

lic ketoacidosis

•Paraldehyde

•Isoniazid

•Lactic acidosis

•Ethylene

Glycol

•Renal

failure(End-

Stage)/Rhabd

o

•Salicylates

•Hyperalimentation

•Acetazolamide

•Renal Tubular

Acidosis

•Diarrhea

•Ureterosigmoidosto

my

•Post-hypocapnia

•Spironolactone

•Early Renal Failure

Negative AG

•Multiple Myeloma

•CNS

depression

•Airway

obstruction

•Pulmonary

edema

•Pneumonia

•Hemo/Pneumo

thorax

•Neuromuscular

•Contraction

•Licorice

•Endocrine

(Conn/Cushing

/Bartters)

•Vomiting

•Excess alkali

•Refeeding

•Post-

hypercapnia

•Diuretics

•CNS disease

•Hypocapnia

•Anxiety

•Mech.

Ventilation

•Progesteron

e

•Salicylates

•Sepsis

Mixed Acid-Base Disorders

Mixed respiratory alkalosis & metabolic acidosis

ASA overdose

Sepsis

Liver failure

Mixed respiratory acidosis & metabolic alkalosis

COPD with excessive use of diuretics

Mixed Acid-Base DisordersMixed respiratory acidosis &

metabolic acidosis

Cardiopulmonary arrest

Severe pulmonary edema

Mixed high gap metabolic acidosis & metabolic alkalosis

Renal failure with vomiting

DKA with severe vomiting

Mixed Acid-Base DisordersNormal pH + ↓PCO2 + ↓HCO3 - Respiraory Alkalosis +

Metabolic Acidosis

Normal pH + ↑PCO2 + ↑ HCO3 - Respiratory Acidosis + Metabolic Alkalosis

Normal pH + Normal PCO2 + Normal HCO3 -Metabolic Acidosis + Metabolic Alkalosis

Some Aids to Interpretation of Acid-Base Disorders

"Clue" Significance

High anion gap Always strongly suggests a metabolic acidosis.

Hyperglycaemia If ketones present also diabetic ketoacidosis

Hypokalemia and/or hypochloremia Suggests metabolic alkalosis

Hyperchloremia Common with normal anion gap acidosis

Elevated creatinine and urea Suggests uremic acidosis or hypovolemia (prerenal renal failure)

Elevated creatinine Consider ketoacidosis: ketones interfere in the laboratory method (Jaffe reaction) used for creatinine measurement & give a falsely elevated result; typically urea will be normal.

Elevated glucose Consider ketoacidosis or hyperosmolar non-ketotic syndrome

Urine dipstick tests for glucose and ketones Glucose detected if hyperglycaemia; ketones detected if ketoacidosis

http://www.anaesthesiamcq.com/AcidBaseBook/ab9_2.php

FormulasMetabolic Acidosis: (Winter’s formula) Expected PaCO2 = (1.5×HCO3) + (8±2) Metabolic Alkalosis: Expected PaCO2 = (0.7×HCO3) + (21±2) Acute Respiratory Acidosis: Expected pH = 7.40 – [0.008 × (PaCO2 – 40)] 10mmhg ↑ in PaCO2 will ↑ HCO3 by 1mmol/L Acute Respiratory Alkalosis: Expected pH = 7.40 + [0.008 × (40 - PaCO2)] 10mmhg ↓in PaCO2 will ↑ HCO3 by 2mmol/L Chronic Respiratory Acidosis: Expected pH = 7.40 – [0.003 × (PaCO2 – 40)] 10mmhg ↑ in PaCO2 will ↑ HCO3 by 4mmol/L Chronic Respiratory Alkalosis: Expected pH = 7.40 + [0.003 × (40 - PaCO2)] 10mmhg ↓ in PaCO2 will ↑ HCO3 by 4mmol/L

3

2

24HCO

PaCOH

Formulas ..Cont’d AG = Na - (CL + HCO3) AG Correction for Albumin Expected AG(mEq/L)=[2×Albumin(g/dL)]+[0.5×PO4(mg/dL) Adjusted AG = Obserbed AG + 2.5 × [4.5 - Measured Albumin (g/dL)] Urinary AG = (UNa + UK)-UCl Plasma Osmolality = 2×Na + Glucose/18 + BUN/2.8 Na/Cl > 1.4 = metabolic alkalosis (hypochloremia) Na/Cl < 1.27 = non anion gap acidosis (hyperchloremia)

AG Excess/HCO3 Deficit = (Measured AG - 12) /(24- Measured HCO3)

HCO3 deficit(mEq)=0.6×Wt(kg) (15-Measured HCO3) mEq of NaHCO3 = Apparent Volume of distribution × Target change in

HCO3 TBW(kg) × [0.4 +(2.4/HCO3)] = Apparent Volume of distribution Cl Deficit (mEq) = 0.2 × Wt(kg) × (Normal Cl- Actual Cl) volume of isotonic saline needed to correct the deficit is the ratio: Cl

deficit/154

http://www.medcalc.com/acidbase.html