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


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


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


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…


Goals, definitions and Goals, definitions and basic principles of basic principles of

Stewart theoryStewart theory


• 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.


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.


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-)


[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


What is the pH of water?What is the pH of water?


MOLEKUL AIR DAN PRODUK DISOSIASINYAMOLEKUL AIR DAN PRODUK DISOSIASINYA(auto-ionisasi air)(auto-ionisasi air)

disosiasi

+


H H

H

O

O

O

O

H

H

H H

H H

+-

+

+

+

++

+

+ +

-

-

Sebenarnya, H+ di dalam larutan berada dalam bentuk H3O+


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!


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.


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


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.


• 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



• 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



BAGAIMANA JIKA ION-ION KUAT BAGAIMANA JIKA ION-ION KUAT BERADA DI DALAM AIR……BERADA DI DALAM AIR……


Na+

Ion-ion kuat akan berdisosiasi di dalam air (plasma)

Cl- --

- --

+

++

+++

+

+

+

+

++

++

+++

+

++

+ +--

--

-

Garam solid


Na+Cl-

Reaksi hidrasi ion-ion kuat


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


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


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--]]


PERSAMAAN ATAU FORMULA2 DALAM

STEWART APPROACH


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)


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


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…


[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)


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


• 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


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


• 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


• 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


• 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)


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 !!!


• 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


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


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


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


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


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

--]]


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)


[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


BLOOD PLASMA

NaNa++

KK++

MgMg++++

CaCa++++

ClCl--

XAXA --

PosfatPosfat --AlbAlb --

HCOHCO33--

OHOH- - COCO332-2-

SIDSIDHH++

AATotTot

Unmeasured AnionUnmeasured Anion

CATIONCATION ANIONANION


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.


ACIDBASIC II


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.


Teori Dasar Pendekatan Kuantitatif II


Henderson-HasselbalchHenderson-Hasselbalch StewartStewart’’s Approachs Approach


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)


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


ClCl--102102

HCOHCO33--

2424

KATION ANION

SIDSIDWeak acidWeak acid(Alb-,P-)(Alb-,P-)

WEAK WEAK ACIDACID

NaNa++


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


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


KLASIFIKASI GANGGUAN KLASIFIKASI GANGGUAN KESEIMBANGAN ASAM BASA KESEIMBANGAN ASAM BASA

BERDASARKAN PRINSIP STEWARTBERDASARKAN PRINSIP STEWART


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


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


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


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


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


Efek terapi cairan terhadap Efek terapi cairan terhadap keseimbangan asam basakeseimbangan asam basa


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%


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


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


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


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


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


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%


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


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


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


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.


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


Strong Ion Difference Strong Ion Difference in Kidneyin Kidney


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


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


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


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)


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


Group 1 Group 2 Group 3

paCOpaCO22 < 40 < 40 paCOpaCO22 40-50 40-50 paCOpaCO22 > 50 > 50

pH

SID


pCO2pH

SID

HCO3-


Respon kompensasiRespon kompensasi

Cl-Na+

K+ Lactate


KESIMPULANKESIMPULAN


Hendersen-Hendersen-Hasselbalch Hasselbalch

TERIMA KASIHTERIMA KASIH

teori dasar pendekatan kuantitatif i dan ii copy

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