EAB-sp
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Transcript of EAB-sp
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Imp in compensarea Ac resp
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Mecanisme compensatoriiBicarbonat - 15 min
Hiperventilatie-1-2 ore cu max la 12-24 ore
Tamponare intracelulara si osoasa 2 ore
Excretie renala si reabsorbtie de bicarbonat
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Compensarea in Ac respiratorie
Rapida (min-ore) intracelular
Lenta (renala in debuta la 6-12 ore cu un max la 3-5 zile) prin cresterea elimin de ac carbonic, cresterea secretiei de amoniac:-ac la niv cel TCP:1 cresterea prod de bicarbonat2 cresterea reabs de Na3 cresterea prod de NH3
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AG = (Na+ + K+) [(Cl-) + (HCO3-)]; v.n. = 16 2 mmol/l.AG = (Na+) [(Cl+) + (HCO3-)]; v.n. = 12 4 mmol/l.
AG trebuie corectata n caz de hipoalbuminemie, utiliznd urmtoarea formul:AG corectata = AG + 0,25(Albumina normala Albumina masurata)N.B. Formula este valabil pentru albumina exprimat n g/l, dac este exprimat n g/dl, factorul de corecie va fi 2,5.
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Acidoze cu AG mareAceste acidoze sunt determinate de creterea concentraiei de ioni de hidrogen (H+)AG = (Na+) [(Cl-) + (HCO3-)]
Acidoze cu AG normal (hipercloremice)Acidozele cu AG normal sunt datorate pierderii de bicarbonat HCO3-, AG normala = (Na+) [(Cl-) + (HCO3-)]
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Acidoze AG mareAcidoza lactica (L/D) N.B. Bicarbonat la pH< 7,1 sau HCO3< 5CetoacidozeRabdomiolizaIntoxicatii: metanol, formaldehida, etilenglicol, toluen(hipurat), salicilati, paraldehida, L-5 oxoprolinuria
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Propilenglicol ac piruvic si lactic(excipient la lorazepam si diazepam)
Salicilati cresc productia de cetoacizi si ac lactic
Methanol formaldehida ac formic
Etilen glicol ac glicolic si oxalic
L 5 oxoprolina def GLT sintetaza, acetaminofen
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ATRTip 1 disf tubul distalaSjogren, SLE, Artr Reum, hipercalciuria, amfotericina
ASKARAN
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ATRTip 2 proximalaMM, inhib de AC, metale grele(ex. mercur), hipocalcemia, deficit de vit D, amiloidoza
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ATRTip 4 hiporeninemica, hipoaldosteronicaDZ, IEC, NSAID, heparina, nefrita tubulointerstitiala, insuf adrenala, uropatie obstructiva
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Tratament
In primul rand se trateaza cauza.La pH < 7,10 ! se da bicarbonat sau la pH < 7,20 daca ap oboseala mm respHCO3 dupa formula clasica
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Alcaloza metabolicaClor responsive:-pierdere de suc gastric-diuretice-diaree acida(pierdere de CL)-fibroza chistica-posthipercapnica
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Alcaloza metabolicaClor neresponsiva:Exces de MC (mineralocorticoizi)Sdr CushingSteroiziSdr Liddle, Gitelman, BarterLicoriceIng de alkali (bicarbonat, antiacide, citrat)Hipokalemie severa
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Alcaloza metabolica - Tratament
Adm de NaClAdm de KCl: 10 meq/h iv sau 40 meq la 4-6 ore poAcetazolamida 375-500mg poHCL 0,1 N
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BOSTON AproachPaCO2HCO3
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Copenhagen AproachSinger + Hastings 1948Siggard Andersen 1948Base Deficit/Excess
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Anion Gap Aproach - 1977
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Delta AG/Delta bicarbonat
Delta ratio = AG/ [HCO-3] = (AG 12)(24 HCO-3)
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In ac lactica initial normal apoi cresteIn cetoacidoza rap 1:1!D lactat si hipurat nu se reabsorb !
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SID AproachStewart 1983
SID ap = Na+K+Mg+Ca-ClSID ef = HCO3 + albumina + PiSIG = SID ap- SID ef --- AG
Fencle 1993
Cl corr = Cl obs Na norm/Na obs
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Variabile independenteSIDAtotpaCO2
Variabile dependente- pH- HCO3- H
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albumin charge = [albumin]*(pH*0.123 - 0.631) (albumin in g/l) phosphate charge = [PO4]*(pH*0.309 - 0.469) (phosphate in mmol/l)
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Gilfix Aproach 1993