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KULIAH

KESEIMBANGAN ASAMBASA

dr Muhammad Zulkarnain B M.Ked(An), SpAn

pH Review

pH = - log [H+]
H+ is really a proton
Range is from 0 - 14
If [H+] is high, the solution is acidic; pH < 7
If [H+] is low, the solution is basic or
alkaline ; pH > 7

ACIDS AND BASES


Svante Arrhenius in 1903 established the foundations of acidbase chemistry.
In an aqueous solution,
an Arrhenius acid is any substance that delivers a hydrogen ion
into the solution. (HCl)
A base is any substance that delivers a hydroxyl ion into the
solution. (NaOH)
Notasi pH diciptakan oleh seorang ahli kimia dari
Denmark yaitu Soren Peter Sorensen pada thn 1909,
yang berarti log negatif dari konsentrasi ion hidrogen.
Dalam bahasa Jerman disebutWasserstoffionenexponent
(eksponen ion hidrogen) dan diberi simbol pH yang
berarti: potenz (power) of Hydrogen.
In 1909, L.J. Henderson coined the term acid-base balance.
Hasselbalch (1916)

The degree of dissociation of substances in water determines


whether they are strong acids or strong bases.
Similarly, ions such as sodium,
sodium potassium,
potassium and chloride,
chloride which
do not easily bind other molecules, are considered
strong ions;
ions they exist free in solution.
Strong cations (Na+ , K+ , Ca2+ , Mg2+ ) act as Arrhenius bases
Strong anions (Cl- , LA- [lactate], ketones, sulfate, formate) act
as Arrhenius acids.
In 1923, Brnsted and Lowry
They defined acids as proton donors and bases as proton
acceptors.

NH3 + H2 O NH4 + + OH
In this situation, water is the proton donor, the Brnsted-Lowry
acid, and ammonia the proton acceptor, the Brnsted-Lowry
base.
HCl + H2 O H3 O+ + Cl
In the previous reaction, hydrogen chloride acts as a
Brnsted-Lowry acid and water as a Brnsted-Lowry base.
CO2 + H2 O H2 CO3 H+ + HCO3
In this reaction, carbon dioxide is hydrated to carbonic acid, a
Brnsted-Lowry acid, which subsequently dissociates to
hydrogen (H+ ) and bicarbonate (HCO3 - ) ions.

Acids are H+ donors.


Bases are H+ acceptors, or give up OH- in
solution.
Acids and bases can be:
Strong dissociate completely in
solution
HCl, NaOH
Weak dissociate only partially in
solution
Lactic acid, carbonic acid
8

The Body and pH

Homeostasis of pH is tightly controlled


Extracellular fluid = 7.4
Blood = 7.35 7.45
< 6.8 or > 8.0 death occurs
Acidosis (acidemia) below 7.35
Alkalosis (alkalemia) above 7.45

10

Normal values for arterial blood gases


Arterial Blood Gases (ABG)

Blood Gas Parameter

Parameter Reported
and Symbol Used

Carbon dioxide
tension*

Normal Value

PCO2

35 45 mm Hg
(average, 40)

Oxygen tension*

PO2

80 100 mm Hg

Oxygen percent
saturation

SO2

97

Hydrogen ion
concentration*

pH

7.35 7.45

Bicarbonate
* Indicates measured parameter

HCO3-

22 26 mmol/L

Normal values may differ slightly in exams

GANGGUAN KESEIMBANGAN ASAMBASA TRADISIONAL


DISORDER

pH

PRIMER

RESPON
KOMPENSASI

ASIDOSIS
METABOLIK

HCO3-

pCO2

ALKALOSIS
METABOLIK

HCO3-

pCO2

ASIDOSIS
RESPIRATORI

pCO2

HCO3-

ALKALOSIS
RESPIRATORI

pCO2

HCO3-

Normal Compensatory Response


Any primary disturbance in acid-base
homeostasis invokes a normal
compensatory response.
A primary metabolic disorder leads to
respiratory compensation, and a primary
respiratory disorder leads to an acute
metabolic response due to the buffering
capacity of body fluids.
A more chronic compensation (1-2 days) due
to alterations in renal function.

Mixed Acid - Base Disorder


Most acid-base disorders result from a single primary
disturbance with the normal physiologic compensatory
response and are called simple acid-base disorders.
In certain cases, however, particularly in seriously ill
patients, two or more different primary disorders may
occur simultaneously, resulting in a mixed acid-base
disorder.
The net effect of mixed disorders may be additive (eg,
metabolic acidosis and respiratory acidosis) and result in
extreme alteration of pH;
or they may be opposite (eg, metabolic acidosis and
respiratory alkalosis) and nullify each others effects on
the pH.

CARA TRADISIONAL

Hendersen-Hasselbalch

The disadvantage of men not knowing the


past is that they do not know the present.
G. K. Chesterton

Normal

pH = 6.1 + log
Normal

[HCO
GINJAL
BASA ]
3

HCO
HCO 3
3

Kompensasi

ASAM
pCO2
PARU

CO
CO22

RANGKUMAN GANGGUAN
KESEIMBANGAN ASAM BASA
TRADISIONAL
DISORDER

pH

PRIMER

ASIDOSIS
METABOLIK

HCO3-

RESPON
KOMPENSASI
pCO2

ALKALOSIS
METABOLIK

HCO3-

pCO2

ASIDOSIS
RESPIRATORI

pCO2

HCO3-

ALKALOSIS
RESPIRATORI

pCO2

HCO3-

KLASIFIKASI GANGGUAN
KESEIMBANGAN ASAM BASA
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

Menurut Stewart ;

pH atau [H+] DALAM PLASMA


DITENTUKAN OLEH
DUA VARIABEL
VARIABEL
INDEPENDEN

DEPENDEN
T
VARIABLES

VARIABEL INDEPENDEN

CO2

STRONG ION
DIFFERENCE

pCO2

SID

WEAK ACID

Ato
t

CO2
CO2 Didalam plasma berada Rx dominan dari CO2 adalah rx
absorpsi OH- hasil disosiasi air
dalam 4 bentuk
dengan melepas H+.

sCO2 (terlarut)
H2CO3 asam karbonat

HCO3- ion bikarbonat


CO32- ion karbonat

Semakin tinggi pCO2 semakin


banyak H+ yang terbentuk.

Ini yg menjadi dasar dari


terminologi respiratory acidosis,
yaitu pelepasan ion hidrogen
akibat pCO2

OH- + CO2 HCO3- + H+


CA

STRONG ION DIFFERENCE


Definisi:
Strong ion difference adalah ketidakseimbangan muatan
dari ion-ion kuat. Lebih rinci lagi, SID adalah jumlah
konsentrasi basa kation kuat dikurangi jumlah dari
konsentrasi asam anion kuat. Untuk definisi ini semua
konsentrasi ion-ion diekspresikan dalam ekuivalensi
(mEq/L).
Semua ion kuat akan terdisosiasi sempurna jika berada didalam
larutan, misalnya ion natrium (Na+), atau klorida (Cl-). Karena
selalu berdisosiasi ini maka ion-ion kuat tersebut tidak
berpartisipasi dalam reaksi-reaksi kimia. Perannya dalam kimia
asam basa hanya pada hubungan elektronetraliti.

STRONG ION
DIFFERENCE

Gamblegram

Mg++
Ca++

K+ 4

SID

[Na+] + [K+] + [kation divalen] - [Cl-] - [asam organik kuat-]

Na+
140

[Na+]
140 mEq/L

[K+]
+

Cl102
-

4 mEq/L -

KATION

[Cl-]
102 mEq/L

ANION

[SID]
=

34 mEq/L

SKETSA HUBUNGAN ANTARA SID,H+ DAN


OH-

Konsentrasi [H+]

[H+]

[OH-]

Asidosis

()

Alkalosis

SID

(+)

Dalam cairan biologis (plasma) dgn suhu 370C, SID hampir


selalu positif, biasanya berkisar 30-40 mEq/Liter

WEAK ACID
[Protein-] + [H+]

[Protein H]
disosiasi

Kombinasi protein dan posfat disebut asam


lemah total (total weak acid) [Atot].
Reaksi disosiasinya adalah:

[Atot] (KA) = [A-].[H+]

Gamblegram
Mg++
Ca++

K+ 4

HCO324
Weak acid
(Alb-,P-)

Na+
140

KATION

Cl102

ANION

SID

DEPENDENT VARIABLES

H+

HCO3OH-

AH
CO3-

A-

INDEPENDENT VARIABLES

DEPENDENT VARIABLES

Strong Ions
Difference

pCO2

Protein
Concentration

pH

KLASIFIKASI
I. Respiratori

ASIDOSIS
PCO2

ALKALOSIS
PCO2

II. Nonrespiratori (metabolik)


1. Gangguan pd SID
a. Kelebihan / kekurangan air
b. Ketidakseimbangan anion
kuat:
i. Kelebihan / kekurangan Clii. Ada anion tak terukur

[Na+], SID

[Cl-], SID

[Na+], SID

[Cl-], SID

[UA-], SID

2. Gangguan pd asam lemah


i. Kadar albumin

[Alb]

[Alb]

ii. Kadar posphate

[Pi]

[Pi]

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

RESPIRASI

METABOLIK

Abnormal
pCO2

Abnormal
SID

AIR

Anion kuat

Cl-

Alkalosis

Turun

kekurangan

Hipo

Asidosis

Meningkat

kelebihan

Hiper

Fencl V, Am J Respir Crit Care Med 2000 Dec;162(6):2246-51

Abnormal
Weak acid

Alb

PO4-

UA-

Turun
Positif

meningkat

KEKURANGAN AIR - WATER DEFICIT


Diuretic
Diabetes Insipidus
Evaporasi

Plasma

Plasma

Na+ = 140 mEq/L


Cl- = 102 mEq/L
SID = 38 mEq/L

1 liter

140/1/2 = 280 mEq/L


102/1/2 = 204 mEq/L
SID = 76 mEq/L

SID : 38 76 = alkalosis
ALKALOSIS KONTRAKSI

liter

KELEBIHAN AIR - WATER EXCESS

Plasma

Na+ = 140 mEq/L


Cl- = 102 mEq/L
SID = 38 mEq/L

1 Liter
H2O

1 liter

140/2 = 70 mEq/L
102/2 = 51 mEq/L
SID = 19 mEq/L

2 liter

SID : 38 19 = Acidosis
ASIDOSIS DILUSI

GANGGUAN PD SID:
Pengurangan ClPlasma

Na+ = 140 mEq/L


Cl- = 95 mEq/L
SID = 45 mEq/L

SID

2 liter

ALKALOSIS

ALKALOSIS HIPOKLOREMIK

GANGGUAN PD SID:
Penambahan/akumulasi
ClPlasma

Na+ = 140 mEq/L


Cl- = 120 mEq/L
SID = 20 mEq/L

SID

2 liter

ASIDOSIS

ASIDOSIS HIPERKLOREMIK

PLASMA + NaCl 0.9%

Plasma

NaCl 0.9%

Na+ = 140 mEq/L


Cl- = 102 mEq/L
SID = 38 mEq/L

Na+ = 154 mEq/L


Cl- = 154 mEq/L
SID = 0 mEq/L

1 liter

SID : 38

1 liter

ASIDOSIS HIPERKLOREMIK AKIBAT


PEMBERIAN LARUTAN Na Cl 0.9%
Plasma

Na+ = (140+154)/2 mEq/L= 147 mEq/L


Cl- = (102+ 154)/2 mEq/L= 128 mEq/L
SID = 19 mEq/L

2 liter

SID : 19 Asidosis

PLASMA + Larutan RINGER LACTATE

Plasma

Ringer laktat
Laktat cepat
dimetabolisme

Na = 140 mEq/L
Cl- = 102 mEq/L
SID= 38 mEq/L
+

1 liter

SID : 38

Cation+ = 137 mEq/L


Cl- = 109 mEq/L
Laktat- = 28 mEq/L
SID = 0 mEq/L

1 liter

Normal pH setelah pemberian


RINGER LACTATE
Plasma

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

2 liter

SID : 34 lebih alkalosis dibanding jika


diberikan NaCl 0.9%

MEKANISME PEMBERIAN NABIKARBONAT PADA ASIDOSIS

Plasma;

Plasma + NaHCO3

asidosis
hiperkloremik

Na+ = 140 mEq/L


Cl- = 130 mEq/L
SID =10 mEq/L

25 mEq
NaHCO3

1 liter

1.025
liter

HCO3 cepat
Na = 165 mEq/L dimetabolisme
+

Cl- = 130 mEq/L


SID = 35 mEq/L

SID : 10 35 : Alkalosis, pH kembali normal namun mekanismenya


bukan karena pemberian HCO3- melainkan karena pemberian Na+ tanpa anion kuat
yg tidak dimetabolisme seperti Cl- sehingga SID alkalosis

UA = Unmeasured Anion:
Laktat, acetoacetate, salisilat,
metanol dll.
K

HCO3-

SID

SID

KetoA-

A
-

Na+

HCO3-

Na+
Cl-

ClLactic/Keto asidosis

Normal

Ketosis

GANGGUAN PD ASAM LEMAH:


Hipo/Hiperalbumin- atau PK

HCO3

SID

Na
Cl

Normal

SID

Alb-/P

Alb-/P-

Na

HCO3

SID

Alb/P

Asidosis Na
hiperprotein/
hiperposfatemi
Cl

Acidosis

HCO3

Alkalosis
hipoalbumin
Cl/hipoposfate
mi

Alkalosis

Calculate the anion gap.


Anion gap = Na - (Cl + HCO3 ).
Normal anion gap is 8 - 15 mEq/L.

If the anion gap is elevated


Then compare the changes from normal between
the anion gap and [HCO3 ].
If the change in the anion gap is greater than the
change in the [HCO3 ] from normal, then a
metabolic alkalosis is present in addition to a gap
metabolic acidosis.
If the change in the anion gap is less than the
change in the [HCO3 ] from normal, then a non
gap metabolic acidosis is present in addition to a
gap metabolic acidosis.

Anion Gap Acidosis:


Anion gap >12 mEq/L; caused by a
decrease in [HCO3 -]
balanced by an increase in an
unmeasured acid ion from either
endogenous production or exogenous
ingestion (normochloremic acidosis).

Non anion Gap Acidosis:


Anion gap = 8-12 mEq/L; caused by a decrease
in [HCO3 -] balanced by an increase in chloride
(hyperchloremic acidosis). Renal tubular
acidosis is a type of non gap acidosis
The anion gap is helpful in identifying metabolic
gap acidosis, non gap acidosis, mixed metabolic
gap and non gap acidosis. If an elevated anion
gap is present, a closer look at the anion gap
and the bicarbonate helps differentiate among
(a) a pure metabolic gap acidosis
(b) a metabolic non gap acidosis
(c) mixed metabolic gap and non gap acidosis, and
(d) a metabolic gap acidosis and metabolic
alkalosis.

Increased Anion Gap


Normal = 8-15
May differ institutionally

Accumulation of organic acids (ketones,


lactate)
Toxic Ingestions
methanol, ethylene glycol, salicylates
Reduced inorganic acid excretion
phosphates, sulfates
Decrease in unmeasured cations
(unusual)

Increased AG Metabolic Acidosis:


Methanol
Uremia/Renal
Failure
INH, Iron--lactate
Paraldehyde

Lactic Acidosis
Has many etiologies
Cyanide, CO, Toluene,
HS
Poor perfusion

Ethylene glycol
Salicylates
Methyl salicylate
(Oil of wintergreen)

Mg salicylate
Levraut J et al. Int Care Med
23:417, 1997

Decreased or Negative Anion Gap


Clin J Am Soc Nephrol 2: 162-174, 2007

Low protein most important


Albumin has many unmeasured negative charges
Normal anion gap (12) in cachectic person
Indicates anion gap metabolic acidosis
2-2.5 mEq/liter drop in AG for every 1 g drop in albumin

Other etiologies of low AG:


Low K, Mg, Ca, increased globulins (Mult. Myeloma), Li, Br
(bromism), I intoxication

Negative AG
more unmeasured cations than unmeasured anions
Bromide, Iodide, Multiple Myeloma