Keseimbangan Asam Basa

ARTERIAL BLOOD GAS NORMAL

PARAMETER NORMAL SATUAN
pH 7.35 - 7.45
PaCO 35 - 45 mmHg
PaO 75 - 98 mmHg
Bicarbonate 22-26 mmol/L
Anion gap 10 - 14 mmol/L
 EVALUASI OKSIGENASI
Cek PaO2
Berapa angka normal?
Menentukan angka normal berdasarkan ratio PaO2 /
FiO2 Normal P/F ratio = 400 - 500
Jadi PaO2 = 100
adalah NORMAL bila FiO2 21% (P/F ratio = 476)
adalah TIDAK NORMAL bila FiO2 100% (P/F ratio =
100)
 ANALISA GAS DARAH

Give information
about :
- Oxygenation
- Ventilation
- Acid - base status
INTEPRETASI ANALISA GAS DARAH

pH
• Oxygenation PaCO2

• Ventilation PaO2
HCO 3 -
• Acid base status Base excess

Saturation
Acid-base

H2 0 + CO2 H2 CO3 HCO 3 - + H+

8
H2 0 + CO2 H2CO3 HCO 3 - + H+

Normal [H + ] = 40 n m o l / l
pH = - log [H + ] = 7.4

9
H2 0 + CO2 H2 CO3 HCO 3 - + H+

Normal PaCO2 = 5.3 kPa

= 40
mmHg
 ALVEOLAR VENTILATION

H2 0 + CO2 H2CO3 HCO 3 - + H+

Normal PaCO2 = 5.3 kPa

= 40
mmHg
11
 Normal HCO 3 - = 2 2 - 2 6 m m o l / l

H2 0 + CO2 H2CO3 HCO 3 - + H+

 ALVEOLAR
VENTILATION

Normal HCO 3 - = 2 2 - 2 6 m m o l / l

H2 0 + CO2 H2 CO3 HCO 3 - + H+

RENAL HCO 3 - HANDLING

 Interpretation o f arterial b l o o d gases

pH
• Oxygenation
PaCO2
• Ventilation PaO2

HCO 3
• Acid base status -

Base
exces
s
Saturati
on
 OXYGENATION

•What is the PaO2? pH

• Is this is adequate for the PaCO2

amount of inspired oxygen?
PaO2
• Does the ABG result
HCO 3 -
agree with the saturation
probe? Base excess

Saturation
 OXYGENATION
• Normal Pa O 2 breathing air (FiO2 = 21%) is 90 -100 mmHg; small
reduction with age
• Lower values constitute hypoxemia
• P a O 2 < 60 mmHg on room air = respiratory failure
• P a O 2 should go up with increasing FiO2
• A P a O 2 of 100 mmHg breathing 60% O 2 is not normal
• You need to know the FiO 2 to interpret the ABG
 OXYGENATION
- Correlate the ABG result with the saturation
probe result
- If there is a discrepancy:
- Is there a problem with the probe (poor perfusion? etc)
- Is there a problem with the blood gas (is it a venous
sample?)
 OXYGENATION
• Is the PO 2 is lower than expected?
• Calculate the A-a gradient to assess if the low PO 2 is due to:
• Low alveolar PO 2
• Structural lung problems causing failure of oxygen transfer
 In clinical setting........
SpO 2 can represent SaO 2 if there is not source error
Pulse oxymeter :
Source error
๏ Poor peripheral perfusion
๏ Dark skin
๏ False nails or nail varnish
๏ Lipaemia
๏ Bright ambient light
A
๏ Poorly adherent probe EM I
O X
๏ Excessive motion
H YP
๏ Carboxy-haemoglobin or
methaemoglobin

19
 OXYGENATION
• (A-a) PO2 gradient = {[FiO2 x (760-47)] - (PCO2/RQ)} - PaO2
• Normal value : A-a gradient = (Age/4) + 4
• Young person at sea level :
• A-a increases 5 to 7 mmHg for every 10 % increase FiO2
• Room Air : 10 to 20 mmHg
• 100% oxygen : 60 to 70 mmH
• Increased age affects A-a gradient (at sea level)
• Age 20 years: 4 to 17 mmHg
• Age 40 years: 10 to 24 mmHg
• Age 60 years: 17 to 31 mmHg
• Age 80 years: 25 to 38 mmHg
 OXYGEN CASCADE
Transport oxygen to the cells can be divided into SIX simple
steps :

1. Convection of O 2 from ambient air into the VENTILATION

SaO 2
body

CaO2
2. Diffusion of oxygen into the O 2 UPTAKE

DO2
blood
3. Chemical bonds with the Hgb that is HAEMOGLOBIN
reversible
4. Convective transport of O 2 to the CARDIAC OUTPUT
tissues
5. Diffusion into the cells and DIFFUSION DISTANCE
organelles

VO2
6. Reduction and oxidation in METABOLISM
mitochondria

21
 Metode Analisa Gas Darah

• Hendersson Hasselbach
Klasik
• Stewart
• Stepwise Conventional
Analysis
 “Stepswise Conventional
Analysis”

Berdasar pada pengukuran dan

kalkulasi:

✓ pH
✓ PaCO 2

✓ bicarbonat
✓ anion gap
Komponen utama pada pendekatan ini
adalah penghitungan:

• adekwasi kompensasi yang

terjadi
• kesesuaian anion gap dengan
perubahan konsentrasi serum
bikarbonat
Metabolic and Respiratory Compensation
in Acid-Base Disorder
Metabolic acidosis
Expected PaCO2 = (1.5 x [HCO3]) +8 +/-2

Metabolic alkalosis
Expected PaCO2 = (0.7 x [HCO3]) + 21 +/- 1.5

Acute respiratory acidosis

Expected HCO3 = 24 + (PaCO2 - 40) / 10

Chronic Respiratory Acidosis

Expected HCO3 = 24 + (PaCO2 - 40) / 3

Acute Respiratory Alkalosis

Expected HCO3 = 24 - (40 - PaCO2) / 5

Chronic respiratory alkalosis

Expected HCO3 = 24 - (40 - PaCO2) / 2
 Metabolicand Respiratory
Compensation in Acid-Base Disorder

�
Metabolic acidosis (⇩ HCO3 ) lower exp. pCO2 ➜
superimposed
Expected PaCO2 = (1.5 x [HCO3]) +8 +/-2 respiratory
Metabolic alkalosis (⇧ HCO3 )
alkalosis.
higher exp. pCO2 ➜
Expected PaCO2 = (0.7 x [HCO3]) + 21 +/- superimposed
1.5 respiratory

�
acidosis
Acute respiratory acidosis (⇧ PaCO2 )
Expected HCO3 = 24 + (PaCO2 - 40) /
10 Lower exp HCO3 ➜
superimposed
Chronic Respiratory Acidosis (⇧ PaCO2 ) acidosi
metabolik
Expected HCO3 = 24 + (PaCO2 - 40) / 3 s
Higher exp. HCO3
Acute Respiratory Alkalosis (⇩PaCO2) superimposed
➜
Expected HCO3 = 24 - (40 - PaCO2) / alkalosi
metabolik
s
5

Chronic respiratory alkalosis (⇩ PaCO2 )

Compensatory changes in acid base imbalances
 Internal
Consistency
step 1 pH Approximate H+
mmol / L
7 100
7.1 80
7.2 60

• Apakah data 7.25

7.3
55
50
consistent”
“internally
7.35 45

• H+= 24 x [ -
7.4 40
PaCO2/HCO3 ] 7.45 35
7.5 35
7.55 28
7.6 25
 step 2

• Apa gangguan primernya: acidosis atau

alkalosis
• apakah pCO , bicarbonate, anion gap
2
dalam batas normal ?
 step 3

• apakah penyebabnya : respiratorik

atau
metabolik ?
• lihat pCO dan HCO
2 3
 step 4

• Bila kelainan metabolik yang ditemukan,

apakah
kompensasi respiratorik adekuat?
• Bila kelainan respiratorik yang
ditemukan, apakah kompensasi metabolik
adekuat?
 Metabolicand Respiratory
Compensation in Acid-Base Disorder

Metabolic acidosis (⇩ HCO3 ) lower exp. pCO2 ➜

�
superimposed
Expected PaCO2 = (1.5 x [HCO3]) +8 +/-2 respiratory
alkalosis.
Metabolic alkalosis (⇧ HCO3 ) higher exp. pCO2 ➜
Expected PaCO2 = (0.7 x [HCO3]) + 21 +/- 1.5 superimposed
respiratory
acidosis
Acute respiratory acidosis (⇧ PaCO2 )

�
Expected HCO3 = 24 + (PaCO2 - 40) / 10
Lower exp HCO3 ➜
Chronic Respiratory Acidosis (⇧ PaCO2 ) superimposed
Expected HCO3 = 24 + (PaCO2 - 40) / 3 acidosi
metabolik
s
Acute Respiratory Alkalosis (⇩PaCO2) Higher exp. HCO3
Expected HCO3 = 24 - (40 - PaCO2) / s➜uperimposed
alkalosi
metabolik
5
s
Chronic respiratory alkalosis (⇩ PaCO2 )
Expected HCO3 = 24 - (40 - PaCO2) /
pH and HCO3 - changes
pH [HCO 3 - ]

Acute respiratory Falls 0.06 Rises 0.8 mmol for every 1 kPa rise
acidosis (up to 30 mmol/l) in PaCO2

Acute respiratory Rises 0.06 Falls 1.5 mmol for every 1 kPa fall in
alkalosis (down to 18 mmol/l) PaCO2

Chronic respiratory Falls 0.02 Rises 3.0 mmol for every 1 kPa rise
acidosis (up to 36 mmol/l) in PaCO2

Chronic respiratory Rises 0.02 Falls 3.8 mmol for every 1 kPa fall in
alkalosis (down to 18 mmol/l) PaCO2

33
 For acute respiratory conditions

pH [HCO 3 - ]

Acute respiratory Falls 0.06 Rises 0.8 mmol for every 1 kPa rise
acidosis (up to 30 mmol/l) in PaCO2

Acute respiratory Rises 0.06 Falls 1.5 mmol for every 1 kPa fall in
alkalosis (down to 18 mmol/l) PaCO2

Chronic respiratory Falls 0.02 Rises 3.0 mmol for every 1 kPa rise
acidosis (up to 36 mmol/l) in PaCO2

Chronic respiratory Rises 0.02 Falls 3.8 mmol for every 1 kPa fall in
alkalosis (down to 18 mmol/l) PaCO2

1 kPa = 7.5 mmHg

 Early renal compensation
for respiratory conditions

pH [HCO 3 - ]

Acute respiratory Falls 0.06 Rises 0.8 mmol for every 1 kPa rise
acidosis (up to 30 mmol/l) in PaCO2

Acute respiratory Rises 0.06 Falls 1.5 mmol for every 1 kPa fall in
alkalosis (down to 18 mmol/l) PaCO2

Chronic respiratory Falls 0.02 Rises 3.0 mmol for every 1 kPa rise
acidosis (up to 36 mmol/l) in PaCO2

Chronic respiratory Rises 0.02 Falls 3.8 mmol for every 1 kPa fall in
alkalosis (down to 18 mmol/l) PaCO2

1 kPa = 7.5 mmHg

 pH [HCO 3 - ]

Acute respiratory Falls 0.06 Rises 0.8 mmol for every 1 kPa rise
acidosis (up to 30 m mo l/ l) in PaCO2

Acute respiratory Rises 0.06 Falls 1.5 mmol for every 1 kPa fall in
alkalosis (down to 18 m m o l/ l) PaCO2

Chronic respiratory Falls 0.02 Rises 3.0 mmol for every 1 kPa rise
acidosis (up to 36 m mo l/ l) in PaCO2

Chronic respiratory Rises 0.02 Falls 3.8 mmol for every 1 kPa fall in
alkalosis (down to 18 m m o l/ l) PaCO2

1 kPa = 7.5 mmHg

Late renal compensation
for respiratory conditions
 step 5

• Apakah ada kenaikan anion gap?

• Anion gap = [Na ] - [Cl ] -
+ - -

• Normal = 12 (+2) mEq/L

[HCO ]3

• apakah perubahan anion gap sebanding

dengan perubahan bicarbonat
 Anion Gap
Anion Gap = [Na+] – [Cl - ] - [HCO3 - ]

• The anion gap is an artificial

difference between the commonly
measured anions and cations.
• In reality there is electrochemical
neutrality
[Na+] + [unmeasured cations] = [Cl - ] + [HCO 3 - ] + [unmeasured
anions]

[unmeasured anions] - [unmeasured cations] = [Na+] - ([Cl - ]

+ [HCO 3 - ])
 Untuk menentukan apakah px sudah
mengalami acidosis/alkalosis metabolik
sebelumnya (kronis), hitung initial HCO3-

- -
Initial HCO3 = anion gap measured - anion gap normal + HCO3
measured

hasil < 20 :
px sudah mempunyai asidosis metabolik kronik (faktor
di luar anion gap)

hasil > 30 :
px sudah mempunyai alkalosis metabolik kronik
 Normal Anion Gap Asidosis
Metabolik

HCO3 loss and replaced with Cl —> anion gap

normal
If hyponatraemia is present the plasma [Cl-] may
be normal despite the presence of a normal
anion gap acidosis —> this could be considered
a ‘relative hyperchloraemia’
 step
6

Evaluasi ulang apakah analisa

sesuai dengan situasi klinik
pasien
 Metabolic Acidosis

Increased Anion Gap Normal Anion Gap

Lactic Acidosis GI bicarbonate loss

Ketoacidosis diarrhoea
diabetic pancreatic/billiary drain
Alcoholic urinary diversion
Renal Failure (late stage) Renal bicarbonate loss
Poisoning: type 2 renal tubular acidosis
salicylate ketoacidosis
methanol post chronic hypocapnia
ethylene glycol Impaired renal excretion
paraldehy renal hypoperfusion
de toluene
 Metabolic Alkalosis
Mechanism
•Volume (chloride depletion)
•Hyperadrenocorticoidism
•Severe Potassium Depletion
•Excessive alkali intake
Examples
•Vomiting / gastric drainage
•Diuretic therapy
•Post hypercapneic alkalosis
•Cushing syndrome
•Conn’s syndrome
•Bartter’s syndrome
•Secondary hyperaldosteronism
•steroid tx
•Acute milk alkali syndrome
 Respiratory Acidosis

• Pasien dengan acute hypercapnia

selalu mengalami acidosis
• Pasien dengan chronic hypercania juga
mengalami acidosis. Bila terdapat
peningkatan pH yang signifikan, cari
faktor sebelumnya mis: diuretic, low
sodium diet, atau post hypercapnic alkalosis
 Respiratory Alkalosis
Hypoxia Non Hypoxic respiratory
center stimulation
• Acute (pneumonia, • Anxiety
asma, pulm edema) • Fever
• Chronic (pulmonary • Sepsis
fibrosis, cyanotic • Salicylate intoxication
heart dissease, high • Cerebral diseases
altitude, anemia) (tumor,
encephalitis)
• hepatic cirrhosis
• pregnancy
• after correction of
metab acidosis
• excessive mech