Fencle versus Kellum Please install office XP to enable animation.

Presentasi berjudul: "Fencle versus Kellum Please install office XP to enable animation."— Transcript presentasi:

1 Fencle versus Kellum Please install office XP to enable animation

2 PENDAHULUAN Diagnosis (& prognosis) of acid-base disorders guide fluid therapy Explain the role of strong ions on pH Elaborate the influences of metabolic component of acid-base disorders (masking effect of hypoalbuminemia, phosphate in ARF) Detect and calculate UA (unmeasured anion) Perform synergistically with ventilatory & hemodynamic support

3 HH vs Stewart Determinant pH: pCO2 & HCO3 SBE (standard base excess)
corrected AG AG + [0.25 x (44 - albumin)] Determinant pH:pCO2, SID, ATOT UA effect (Fencle-Stewart) SIG = AG – A- SIG = SIDa –SIDe (menghitung UA) Lain-lain: Tidak dikenal istilah asidosis hiperkloremik, asidosis dilutional,alkalosis kontraksi, alkalosis hipoalbuminemik Lain-lain: Dikenal istilah asidosis hiperkloremik, asidosis dilutional,alkalosis kontraksi, alkalosis hipoalbuminemik

4 Peter Stewart ( ) JA Kellum Vladimir Fencl ( )

5 Fencle & Kellum Fencle-Stewart JA Kellum
Directly measures the amount of UA Measure the effect of UA on base excess Values more negative than -6 mEq/L suspect the presence of UA

6 BASE EXCESS DAN STEWART
BE =The amount of acid or alkali to add to a blood sample (whole blood) in vitro to reverse the pH to 7.40, while pCO2 being maintained at 40 mmHg. Fencl - Stewart Approach measures the effect of UA on base excess also called BEUA

7 BASE EXCESS & STEWART BE measured by machine (or HCO *(pH - 7.4) ) SID effect, mEq/l = A + B A. Free Water effect on Na+ = 0.3 x ([Na+] – 140) B. Corrected Cl- effect = 102 – ([Cl-] x 140/[Na+]) ATOT effect, mEq/l = x pH x (42 - [Albumin]) UA effect = BE ef – SID ef – ATot ef Story DA, Bellomo R. Strong ions, weak acids and base excess: a simplified Fencl–Stewart approach to clinical acid–base disorders British Journal of Anaesthesia, 2004, Vol. 92, No

8 Case 1 BE -4 SID effect, mEq/l = A + B A. Free Water effect on Na+
Fencle-Stewart Case 1 pH 7.2/ pCO2 25/ BE -4/ HCO3- 10 Na+160 ;Cl- 102 ;K+ 5 ;Alb 3.7 BE -4 SID effect, mEq/l = A + B A. Free Water effect on Na+ = 0.3 x ([160] – 140)=6 B. Corrected Cl- effect = 102 – ([C102-] x 140/[160])=12.75 ATOT effect, mEq/l = x x (42 - [37])=1.273 UA effect = BE ef – SID ef – ATot ef= -4 -( )=

9 SID effect (free water effect + chloride effect 19.75)
BASE EXCESS & STEWART Fencle-Stewart SID effect (free water effect + chloride effect 19.75) 160 Na HCO3- SID i SID effect 19.75 (alkalinisasi) 142 UA Na UA effect Albumin effect 1.273 (alkalinisasi) Alb Alb Primary metabolic acidosis, with increased anion gap, mixed with a metabolic alkalosis, with full respiratory compensation Na+ Cl-

10 UA effect = 10 – [(3) + (6.8) + (0.5)] mEq/L = - 0.3
Fencle-Stewart Case 2: 7.48 / 45 / +10 / 34 Na 150; Cl 102; Alb 4 (a) Free water effect: 0.3 x ( ) = 3 (b) Chloride effect 102-(102 x 140/150) = 6.8 (c) Albumin effect (0.123 x ) (42-[40]) = 0.578 UA effect = 10 – [(3) + (6.8) + (0.5)] mEq/L = - 0.3

11 BASE EXCESS & STEWART 150 140 Primary metabolic alkalosis,
Fencle-Stewart BASE EXCESS & STEWART Alkalizing effect of HyperNa+ +10  BE +9.8 150 HCO3- 140 Alb Alb Primary metabolic alkalosis, with full respiratory compensation Na+ Cl-

12 UA effect = 9 – [(0) + (9) + (0)] mEq/L = 0
Fencle-Stewart Case 3: 7.48 / 45 / + 9 / 34 Na 140; Cl 93; Alb 4.2 (a) Free water effect: 0.3 x ( ) = 0 (b) Chloride effect 102-(93 x 140/140) = 9 (c) Albumin effect (0.123 x ) (42-[42]) = 0 UA effect = 9 – [(0) + (9) + (0)] mEq/L = 0

13 Alkalizing effect of Hypochloremia
Fencle-Stewart BASE EXCESS & STEWART Alkalizing effect of Hypochloremia +9  BE +9 140 HCO3- 102 Alb Alb 93 Na+ Cl-

14 UA effect = -4 – [(0) + (0) + (6.3)] mEq/L = -10.3
Fencle-Stewart Case 4: 7.35 / 35 / -4 / 15 Na 140; Cl 102; Alb 2.0 (a) Free water effect: 0.3 x ( ) = 0 (b) Chloride effect 102-(102 x 140/140) = 0 (c) Albumin effect (0.123 x ) (42-[20]) = UA effect = -4 – [(0) + (0) + (6.3)] mEq/L = -10.3

15 BASE EXCESS DAN STEWART
Fencle-Stewart BASE EXCESS DAN STEWART BE due to  Alb  140 SID BE due to hypoalbuminemia UA- (10.3) Alb Hipoalb Na+ Cl-

16 Hipoalbuminemia SIDe =31.5 HCO3- 26 Na+ 137 Cl- 112 KATION ANION
pH 7.36/pCO2 46/ BE 0.96/HCO3 26 Na+ 137; Cl- 112, Alb 20 g/L; Hb 8 g /dl Mg++ 1 HCO3- 26 Ca++ 2.2 K+ 3.5 SIDe =31.5 25 3.5 3.2 Na+ 137 Weak acid (Alb- 20,P- 1) Cl- 112 When these patients have a normal pH and a normal SBE and HCO3- concentration, it would seem most appropriate to consider this to be physiologic compensation for a decreased ATOT rather than classifying this condition as a complex acid–base disorder with a mixed metabolic acidosis/ hypoalbuminemic alkalosis Stewart's designation of a 'normal' SID of approximately 40 mmol/l was based on a 'normal' CO2 and ATOT The 'normal' SID for a patient with an albumin of 2g/dl would be much lower (eg approximately 32 mmol/l). John A Kellum Determinants of blood pH in health and disease Critical Care 2000, 4:6-14  KATION ANION SIDa = ( ) – 112 = 31.7 SIDe= x[20] x [1]

17 7.42 / 35 / -1.86 / 22 ; Interpreted by H-H  normal
Fencle-Stewart Case 5 (severe sepsis): 7.42 / 35 / / 22 ; Interpreted by H-H  normal (a) Free water 0.3 x ( ) = 0 (b) Chloride effect 102-(102 x 140/140) = 0 (c) Albumin effect (0.123 x ) (42-[18]) = 6.7 UA effect = – [(0) + (0) + (6.7)] mEq/L = Catatan: Nilai K, Ca & Mg tidak ditampilkan Na+ 140; K+ 3.5 Cl- 102; Alb 1.8

18 BASE EXCESS DAN STEWART
140 SIDe  30.84 Acidifying effect of lactate  UA = Alkalizing effect of hypoalb  + 6.7 Alb 102 hipoalbumin Na+ Cl-

19 J.A. KELLUM Directly measures the amount o f UA

20 Kasus 6. Pasien cardiac arrest,CPR, hypoxic encephalopathy pH 7
Kasus 6. Pasien cardiac arrest,CPR, hypoxic encephalopathy pH 7.55; Na+ 159 mEql/L ;K mEql/L; Cl- 121 mEq/L ;Ca mEq/L;Mg mEq/L; PO mg/dl; Alb 9 g/L; PCO2 29 mmHg; HCO mEq/L; BE 3 Apakah jenis kelainan asam-basa pasien ini? Langkah: 1. Untuk menghitung ATOT,harus dicari nilai Pi (dalam mEq/L) dari PO4 dan albumin Dikonversi menjadi mEq/L dg rumus. Pi = (PO4 x10/30.97)x(0.309xpH-0.469) = (0.85 x 10/30.97) x x ) = ~ 0.5 mEq/L Albumin = Alb x(0.123 x pH-0.631) = 9 x(0.123 x 7.55 – 0.631) = mEq/L 2. Hitung SIDa = Na+ + K+ Ca++ + Mg++ - Cl = 48 mEq/L 3. Hitung SIDe = HCO3- + Pi + Albumin = mEq/L 4 UA (unmeasured anion) = SIDa- SIDe = 19.31

21 Kasus 6. Pasien cardiac arrest,CPR, hypoxic encephalopathy pH 7
Kasus 6. Pasien cardiac arrest,CPR, hypoxic encephalopathy pH 7.55; Na+ 159 mEql/L ;K mEql/L; Cl- 121 mEq/L ;Ca mEq/L;Mg mEq/L; PO mg/dl; Alb 9 g/L; PCO2 29 mmHg; HCO mEq/L; BE 3 Ca HCO Mg K Penurunan SID ~10 dikacaukan oleh efek dari UA yang tinggi(menurunkan SID). Defisit air plasma (Na 159 mEq/L) meningkatkan SID. Low SID acidosis diselubungi oleh hipoalbuminemia. BE luput mendeteksi asidosis dg UA tinggi dan menginterpretasi status asam basa hanya sebagai alkalosis metabolik ringan.HCO3 high normal. SIDe (28.67) Na SIDa (50.6) ATOT Alb Pi SIG =(UA) = SIDa –SIDe = 19.31 121

22 JA Kellum Case 7. Patient with multiple trauma, followed by ARDS and sepsis pH 7.32; Na+ 131 mEql/L ;K mEql/L; Cl- 86 mEq/L ;Ca mEq/L;Mg mEq/L; PO4 4 mg/dl; Alb 8 g/L; PCO2 41 mmHg; HCO3 21 mEq/L; BE -4.2 What is the acid-base profile of this patient? Approach: 1. To calculate ATOT,you have to determine Pi (in mEq/L) from PO4 and albumin converted to mEq/L by the following formulas. Pi = (PO4 x10/30.97)x(0.309xpH-0.469) = (4 x 10/30.97) x x ) = ~ 2.3 mEq/L Albumin = Alb x(0.123 x pH-0.631) = 8 x(0.123 x 7.32 – 0.631) = mEq/L 2. Calculate SIDa = Na+ + K+ Ca++ + Mg++ - Cl = 55 mEq/L 3. Calculate SIDe = HCO3- + Pi + Albumin = mEq/L 4 UA (unmeasured anion) = SIDa- SIDe = 29.55

23 JA Kellum Case 7. Patient with multiple trauma, followed by ARDS and sepsis pH 7.32; Na+ 131 mEql/L ;K mEql/L; Cl- 86 mEq/L ;Ca mEq/L;Mg mEq/L; PO4 4 mg/dl; Alb 8 g/L; PCO2 41 mmHg; HCO3 21 mEq/L; BE -4.2 Ca HCO Mg SIDe (25,454) K SIDa (55) Na ATOT Alb Pi SIG =(UA) = SIDa –SIDe = 29.55 86 SID decreased by ~ 12 mEq/L (owing to water excess and high UA and Pi. This acidosis was masked by alkalosis due to Cl deficit and hypoalbuminemia; HCO3 onlu slightly decreased. Base deficit was only - 4 mEq/L Here, the severity of acidosis had been underestimated.

24 Thank YOU