rối loạn toan kiềm bài giảng chuẩn TS ngọc HSCC a9

Rối loan thăng bằng kiềm toan bài giảng chuẩn của TS Ngọc HSCC A9 Bệnh viện Bạch Mai Rối loan thăng bằng kiềm toan bài giảng chuẩn của TS Ngọc HSCC A9 Bệnh viện Bạch Mai Rối loan thăng bằng kiềm toan bài giảng chuẩn của TS Ngọc HSCC A9 Bệnh viện Bạch Mai Rối loan thăng bằng kiềm toan bài giảng chuẩn của TS Ngọc HSCC A9 Bệnh viện Bạch Mai Rối loan thăng bằng kiềm toan bài giảng chuẩn của TS Ngọc HSCC A9 Bệnh viện Bạch Mai Rối loan thăng bằng kiềm toan bài giảng chuẩn của TS Ngọc HSCC A9 Bệnh viện Bạch Mai

Rối loạn thăng bằngAcid-Base trong

Hồi sức cấp cứu

Ngo Duc Ngoc, MD

Kiến thức cơ bản

 Toan máu: pH < 7.36

 Ki m máu: pH > 7.44 Ki m máu: pH > 7.44 ề ề

 Toan hóa máu: Quá trình d n t i toan máu Toan hóa máu: Quá trình d n t i toan máu ẫ ẫ ớ ớ

 Ki m hóa máu: Quá trình d n t i toan máu Ki m hóa máu: Quá trình d n t i toan máu ề ề ẫ ẫ ớ ớ

 T ư ơ ơ ng quan đ ng quan đ ườ ườ ng th ng ngh ch bi n gi a pH & [ H+]  ng th ng ngh ch bi n gi a pH & [ H+]  ẳ ẳ ị ị ế ế ữ ữ khi pH trong gi i h n 7.10 – 7.50 ớ ạ

khi pH trong gi i h n 7.10 – 7.50 ớ ạ

Tương quan pH và [H+]

7.8 16 7.55 30 7.30 50 7.05 89 7.75 18 7.50 32 7.25 56 7.00 100 7.70 20 7.45 35 7.20 63 6.95 112 7.65 22 7.40 40 7.15 71 6.90 126 7.60 25 7.35 45 7.10 79 6.85 141

Question 1

A patient has arterial CO2 tension of

40 mm Hg, and serum bicarbonate

of 24 mEq/L What is his estimated hydrogen ion concentration?

Question 1

A patient has arterial CO2 tension of

40 mm Hg, and serum bicarbonate

of 24 mEq/L What is his estimated hydrogen ion concentration?

a 40 nEq/L

b 20 nEq/L

c 30 nEq/L

d 50 nEq/L

Question 2

In the same patient with an arterial

carbon dioxide tension of 40 mm Hg, and serum bicarbonate of 24 mEq/L, what is the estimated arterial pH?

a 7.40

b 7.35

c 7.50

d 7.30

Question 3

A patient admitted for hyperglycemic, hyperosmolar, non-ketotic syndrome has the following laboratory values:

Na=160 mEq/L, HCO 3 =25 mEq/L, Cl=101 mEq/L,

Question 3

A patient admitted for hyperglycemic, hyperosmolar, ketotic syndrome has the following laboratory values: Na=160 mEq/L, HCO 3 =25 mEq/L, Cl=101 mEq/L, PaCO 2 =25

Respiratory Acidosis ↑ ↑ pCO2 pCO2 ↑ ↑ HCO3 HCO3

Respiratory Alkalosis ↓ ↓ pCO2 pCO2 ↓ ↓ HCO3 HCO3

Metabolic Acidosis ↓ ↓ HCO3 HCO3 ↓ ↓ pCO2 pCO2

Metabolic Alkalosis ↑ ↑ HCO3 HCO3 ↑ ↑ pCO2 pCO2

In simple acid­base disorders, pCO 2  & HCO 3  move in the same 

direction.

In mixed disorders they move in the opposite directions.

Basics review

 Compensatory responses try to keep the pH constant. They never  overcompensate and almost never normalize.

Mechanisms of compensation

Extracellular (hemoglobin, plasma proteins,

bicarbonates)

Intracellular buffers

Respiratory

Renal base excretion

Renal acid excretion

Normal Anion Gap

Wide Anion Gap

 AG and  HCO3

– Every  in AG   in HCO3

  AG =  HCO3

Rules of  AG and  HCO3 in WAGMA

 If   HCO3 =   AG : Wide AG Metabolic  Acidosis

 If   HCO3 <   AG: Metabolic alkalosis +  WAGMA

Causes of decreased anion gap

 Increased unmeasured cation

High K, Ca, and Mg

Gamma globulin, lithium

Causes of increased anion gap

Normal AG metabolic acidosis

RTA type I and II Posthypercapnea Diarrhea

Ureterosigmoidostomy Ileal loop

Pancreatic fistula Correction phase of DKA

Normal AG metabolic acidosis

Type IV RTA

Interstitial nephritis Hypoaldosteronism Hydronephrosis

HCL infusion Dilutional acidosis

Normal AG metabolic acidosis

Normal Anion Gap Metabolic Acidosis

Question 4

A 55-year-old male with a long standing DM is admitted for severe pancreatitis CT guided tube is placed to drain a suspected pancreatic abscess The following laboratory values are obtained

Question 4

A 55-year-old male with a long standing DM is admitted for severe pancreatitis CT guided tube is placed to drain a suspected pancreatic abscess The following laboratory values are obtained

Question 5

70 y/o man s/p chemotherapy for metastatic stomach cancer is 

transferred to ICU with hypotension, fever and neutropenia. While  being resuscitated with IV fluid, he developed respiratory distress.  Laboratory studies showed: 

Question 5

70 y/o man s/p chemotherapy for metastatic stomach cancer is  transferred to ICU with hypotension, fever and neutropenia. 

While being resuscitated with IV fluid, he developed respiratory  distress. Laboratory studies showed: 

Causes of metabolic alkalosis

Vomiting

NG suction

Cl wasting diarrhea Colonic villous adenoma Remote diuretic ingestion Post hypercapnea

Poorly reabsorbed anions

Causes of metabolic alkalosis

Primary hyper aldosteronism Cushing’s syndrome

Liddle syndrome Barter’s syndrome

K deficiency

Mg deficiency Milk-alkali syndrome

Question 7

A patient is admitted to the ICU for

new onset seizure His serum

bicarbonate is 70 mEq/L His urine Cl

is 50 mEq/L The most likely etiology

of his acid-base abnormality is:

Question 7

A patient is admitted to the ICU for

new onset seizure His serum

bicarbonate is 70 mEq/L His urine Cl

is 50 mEq/L The most likely etiology

of his acid-base abnormality is:

Question 8

A 60 year old female presented with nausea, vomiting and weakness. Her  mental status is intact. Vital signs:

BP 85/55 mm Hg HR 120/min

RR 18/min Temp 36.8˚C

Exam shows dry mucosa and mild diffuse abdominal tenderness with no  rebound. L abs & ABG show:

Question 8

A 60 year old female presented with nausea, vomiting and weakness. Her  mental status is intact. Vital signs:

Exam shows dry mucosa and mild diffuse abdominal tenderness with no  rebound. Labs & ABG show:

2 x Na [or 2 x (Na + K)] + Glu/18 + BUN/2.8

e.g for normal values of Na:140, Glu:90, BUN:14

It would be: 280 + 5 + 5 = 290 (normal: 295)

failure (unidentified toxins)

Question 10

A 30 y male with history of ETOH use presented with nausea & vomiting. He is jaundiced,  agitated and hallucinating. Vital signs

Question 10

A 30 y male with history of ETOH use presented with nausea & vomiting. He is  jaundiced, agitated and hallucinating. Vital signs