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Rối loạn thăng bằngAcid-Base Hồi sức cấp cứu Ngo Duc Ngoc, MD Kiến thức Phương trình Henderson – Hasselbach: pH = pK + log HCO3/H2CO3 H2CO3 = 0.03 x PaCO2 pH được đảm bảo bởi tỷ lệ: HCO3/PaCO2 Cần nhớ: [ H+] (nEq/L) = 24 x (PaCO2/HCO3) PaCO2 bình thường = 40 (36-44) HCO3 bình thường = 24 (22-26) [ H+] bt = 40 nEq/L pH bt = 7.40 (7.36-7.44) Kiến thức Toan máu: pH 7.44 Toan hóa máu: Q trình dẫn tới toan máu Kiềm hóa máu: Q trình dẫn tới toan máu Tương quan đường thẳng nghịch biến giữa pH & [ H+] khi pH trong giới hạn 7.10 – 7.50 Tương quan pH [H+] PH [H] PH [H] PH [H] PH [H] 7.8 7.75 7.70 7.65 7.60 16 18 20 22 25 7.55 7.50 7.45 7.40 7.35 30 32 35 40 45 7.30 7.25 7.20 7.15 7.10 50 56 63 71 79 7.05 7.00 6.95 6.90 6.85 89 100 112 126 141 Question 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 b c d 40 nEq/L 20 nEq/L 30 nEq/L 50 nEq/L Question 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 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 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 c d 7.35 7.50 7.30 Question A patient admitted for hyperglycemic, hyperosmolar, non-ketotic syndrome has the following laboratory values: Na=160 mEq/L, HCO3=25 mEq/L, Cl=101 mEq/L, PaCO2=25 mm Hg and pH=7.38 Which of the following best describes the patient’s acidbase abnormality? a Alkalemia b Acidemia c Metabolic acidosis d Respiratory alkalosis Question A patient admitted for hyperglycemic, hyperosmolar, nonketotic syndrome has the following laboratory values: Na=160 mEq/L, HCO3=25 mEq/L, Cl=101 mEq/L, PaCO 2=25 mm Hg and pH=7.38 Which of the following best describes the patient’s acidbase abnormality? a Alkalemia b Acidemia c Metabolic acidosis d Respiratory alkalosis Question 78 y/o female with connective tissue disease s/p kidney transplant & recent leg amputation for ischemic limbs is admitted for fever and leukocytosis. Wound site looks erythematous. Twelve h after admission, she develops tachypnea and is transferred to ICU for impending respiratory failure. You initiate the work up including labs & ABG which show: pH 7.07 PaCO2 42 mm Hg pO2 85 mm Hg Na 137 mEq/L K 4 mEq/L Cl 108 mEq/L Bicarb 12 mEq/L Cr 2 mg/dL Which of the following best explains the acidbase disorder? a. Non AG metabolic acidosis b. High AG metabolic acidosis c. Respiratory acidosis & Non AG metabolic acidosis d. Wide AG & Non AG metabolic acidosis & Respiratory acidosis Question 78 y/o female with connective tissue disease s/p kidney transplant & recent leg amputation for ischemic limbs is admitted for fever and leukocytosis. Wound site looks erythematous. Twelve h after admission, she develops tachypnea and is transferred to ICU for impending respiratory failure. You initiate the work up including labs & ABG which show: pH 7.07 PaCO2 42 mm Hg pO2 85 mm Hg Na 137 mEq/L K 4 mEq/L Cl 108 mEq/L Bicarb 12 mEq/L Cr 2 mg/dL Which of the following best explains the acidbase disorder? a. Non AG metabolic acidosis b. High AG metabolic acidosis c. Respiratory acidosis & Non AG metabolic acidosis d. Wide AG & Non AG metabolic acidosis & Respiratory acidosis Metabolic alkalosis Due to bicarbonate Administration Formation Renal reabsorption Stimuli for renal reabsorption: High PaCO2 Extracellular volume contraction Chloride depletion Steroid excess K depletion Causes of metabolic alkalosis Saline responsive (urine Cl 30) Primary hyper aldosteronism Cushing’s syndrome Liddle syndrome Barter’s syndrome K deficiency Mg deficiency Milk-alkali syndrome Question 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: a Vomiting b Colonic villous adenoma c Milk-alkali syndrome d Diuretic ingestion Question 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: a Vomiting b Colonic villous adenoma c Milk-alkali syndrome d Diuretic ingestion Question 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. Labs & ABG show: pH 7.48 PaCO2 46 mm Hg Na 144 mEq/L K 3.5 mEq/L Cl 100 mEq/L Bicarb 34 mEq/L Which of the following best explains the acidbase disorder? a. Metabolic alkalosis b. Respiratory acidosis with metabolic compensation c. Metabolic alkalosis/ respiratory alkalosis d. Metabolic alkalosis/respiratory acidosis e. None of the above, this is a lab error Question 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. Labs & ABG show: pH 7.48 PaCO2 46 mm Hg Na 144 mEq/L K 3.5 mEq/L Cl 100 mEq/L Bicarb 34 mEq/L Which of the following best explains the acidbase disorder? a. metabolic alkalosis (2nd to vomiting and volume & chloride loss with partial respiratory compensation) b. respiratory acidosis with metabolic compensation c. metabolic alkalosis/ respiratory alkalosis d. metabolic alkalosis/respiratory acidosis e. none of the above, this is a lab error Question 36 y male found unresponsive. No PMH reported. Vital signs: BP 100/50 mm Hg RR 12/min HR 104/min Temp 37° C. Neurologic exam is nonfocal and rest of the exam reveals no major abnormality except fruity smell. Labs & ABG show: pH 7.35 PaCO2 44 mm Hg Na 136 mEq/L K 4.0 mEq/L Cl 100 mEq/L Bicarb 25 mEq/L BUN 14 mg/dL Cr 1.8 mg/dl Glucose 90 mg/dL Measured Serum osmolality is 345 and serum is positive for ketones What ist the most likely cause of the acid base abnormality? a. DKA b. Alcoholic ketoacidosis c. Isopropanol ingestion d. Methanol ingestion e. Ethylene glycol ingestion Question 36 y male found unresponsive. No PMH reported. Vital signs: BP 100/50 mm Hg RR 12/min HR 104/min Temp 37° C. Neurologic exam is nonfocal and rest of the exam reveals no major abnormality except fruity smell. Labs & ABG show: pH 7.35 PaCO2 44 mm Hg Na 136 mEq/L K 4.0 mEq/L Cl 100 mEq/L Bicarb 25 mEq/L BUN 14 mg/dL Cr 1.8 mg/dl Glucose 90 mg/dL Measured Serum osmolality is 345 and serum is positive for ketones What ist the most likely cause of the acid base abnormality? a. DKA b. Alcoholic ketoacidosis c. Isopropanol ingestion d. Methanol ingestion e. Ethylene glycol ingestion Osmolality Measured in serum and; Calculated by formula: x Na [or x (Na + K)] + Glu/18 + BUN/2.8 e.g for normal values of Na:140, Glu:90, BUN:14 It would be: 280 + + = 290 (normal: 280295) Measured Osm – calculated Osm