Nje qasje algoritmike

Hysni Dida
Marrja e
gjakut arterial
Ulnar Artery

Radial Artery
Hyrje
 Astrupometri mat pH, pCO2 dhe pO2
 [HCO3-] dhe diferenca bazike llogariten
duke perdorur ekuacionin Henderson-
Hasselbalch
 Parametrat normale
 Crregullimet acidobazike mund te verehen edhe nqs
kemi vetem 3 parametra pH, pCO2 dhe HCO3

 Vlerat normale
• pH = 7.36 – 7.44
• PCO2 = 36-44 mmhg
• HCO3 = 22-26 mEq/L
Marredhenia midis +
[H ] & pH
pH [H+] pH [H+]
7.80 16 7.30 50
7.75 18 7.25 56
7.70 20 7.20 63
7.65 22 7.15 71
7.60 25 7.10 79
7.55 28 7.00 89
7.50 32 6.95 100
7.45 35 6.90 112
7.40 40 6.85 141
7.35 45 6.80 159
Baze deficiti dhe Baze eksesi
 Nje ndryshim me 0.15 ne pH eshte ekuivalent
me nje ndryshim ne baze me 10 mEq/L.

 Nje renie ne baza psh HCO3 quhet

baze deficit dhe nje rritje ne baza
quhet baze ekses
Ndryshime Metabolike vs
Respiratore
 Kur ndryshimi primar eshte pCO2 atehere crregullimi
eshte respirator

 Kur ndryshimi primar eshte HCO3- => crregullim

metabolik
Acidemia vs Alkalemia
 Kur pH I gjakut eshte <7.35 kemi te bejme me
acidemi

Kur pH I gjakut eshte >7.45 kemi te

bejme me Alkalemi
Crregullimet primare dhe pergjigjet kompesatore

H   24  PaCO


HCO 
2

Crregullimi Ndryshimi primar Ndryshimi kompesator

Respiratory acidosis PCO2 HCO3
Respiratory alkalosis PCO2 HCO3
Metabolic acidosis HCO3 PCO2
Metabolic alkalosis HCO3 PCO2

• Ndryshimet kompesatore ndodhin qe te mbajne te pandryshuar

raportin PCO2/HCO3

• Ndryshimet kompesatore jane ne te njejtin drejtim me ndryshimin

primar
Kompesimi
 Crregullimet respiratore kompesohen me ane te
veshkave
 Crregullimet metabolike kompesohen me ane te
veshkave (kur veshkat nuk jane shkaku) dhe me ane te
pulmoneve
 Crregullimi me I pa kompesuar eshte alkaloza
metabolike sepse kompesimi respirator eshte
hypoventilimi I cili nuk mund te zgjaze per nje kohe te
gjate sepse nxiten kemoreceptoret qendrore
Kompesimi respirator I acidozes metabolike
 Pergjigja ventilatore pas nje acidoze metabolike eshte te krijoje nje
alkaloze respiratore gje qe do te coje ne nje HIPERVENTILIM duke
ulur paCO2 I cili matet me formulen e Winter

 PaCO2 I pritur = (1.5×HCO3) + (8±2)

 Nese paCO2 I matur eshte ekuivalent me paCO2 e pritur atehere kompesimi

respirator eshte adekuat dhe kjo gjendje quhet Acidoze metabolike e kompesuar
 Nese paCO2 I matur eshte me I madh se paCO2 I pritur atehere pergjigja respiratore
nuk eshte adekuate dhe kemi nje acidoze respiratore shtese acidozes metabolike. Ky
crregullim quhet Acidoze metabolike primare me mbivendosje te nje acidoze
respiratore
 Nese paCO2 I matur eshte me I vogel se ai I pritur atehere eshte nje alkaloze
respiratore mbivendosur nje acidoze metabolike primare
Kompesimi I alkalozes metabolike
 Formula e meposhtme vlen ne rastet kur HCO3 >40
 PaCO2 I pritur = (0.7×HCO3) + (21±2)

 Nese paCO2 I matur eshte I barabarte me paCO2 e pritur atehere kemi

te bejme me kompesim adekuat respirator= Alkaloze metabolkie e
kompesuar

 Nese paCO2 I matur eshte me I madh se ai I pritur kompesimi

respirator nuk eshte adekuat dhe kemi nje acidoze respiratore
mbivendosur alkalozes metabolike primare

 Nese paCO2 I matur eshte me I ulet se ai I pritur atehere kemi nje

alkaloze respiratore te mbivendosur =Alkaloze metabolike primare
me mbivendosje nje alkaloze respiratore
Kompesimi metabolik
 Ndodh ne veshka

 Ndryshimi I perqendrimit te CO2 con ne ndryshim te perthithjes se HCO3- ne

tubulat renale

 Ne acidoze respiratore kemi rritje te paCO2 dhe rritje te perthithjes se HCO3-

ne veshka

 Ne alkaloze respiratore kemi ulje te paCO2 dhe ulje te perthithjes se HCO3-

 Eshte me I ngadalte , fillon 6-12 ore pasi eshte vendosur crregullimi primar ndaj
nje crregullim quhet akut para fillimit te kompesimt renal dhe kronik pas
fillimit te kompesimit renal
Kompesimi metabolik
 Alkaloza respiratore
 Ulet paCO2  ulet HCO3-

 Acidoza respiratore
 Rritet pa CO2  rritet HCO3-
Crregullimet Akute respiratore
 Perpara se te filloje kompesimi renal nje ndryshim I
paCO2 me 1mmHg do te sjelle nje ndryshim me 0.008
ne pH  ∆pH = 0.008 × ∆PaCO2
 Nga ky ekuacion del pH I pritur per nje acidoze respiratore akute

pH I pritur = 7.40 – [0.008 × (PaCO2 – 40)]

Ndersa pH I pritur per nje alkaloze respiratore
akute llogaritet
pH I pritur= 7.40 + [0.008 × (40 - PaCO2)]
Kompesimi renal ne crregullime kronike respiratore
 Kur vendoset kompesimi renal I plote cdo ndryshim
me 1mmHg paCO2 e ndryshon pH me vetem O.OO3
njesi ∆pH = 0.003 × ∆PaCO2
 pH I pritur per nje acidoze respiratore te kompesuar
pH pritur= 7.40 – [0.003 × (PaCO2 – 40)]

 Ndersa per alkalozen respiratore te kompesuar

(kronike)
 pH pritur = 7.40 + [0.003 × (40 - PaCO2)]
Crregullimet dhe kompesimi
Type of Disorder pH PaCO2 [HCO3]
Metabolic Acidosis   
Metabolic Alkalosis   
Acute Respiratory Acidosis   
Chronic Respiratory Acidosis   
Acute Respiratory Alkalosis   
Chronic Respiratory Alkalosis   
Algoritmi I interpretimit te
crregullimeve AB
 Stadi O  percakto nese te dhenat jane te vlefshme
duke perdorur ek Haselbach

 Stadi 1  percakto ndryshimin primar

 Stadi 2  shiko pergjigjet kompesatore

 Stadi 3  perdor Gap per te percaktuar ac.metabolike

Stadi 1
 Rregulla 1  mund te kemi nje crregullim acidobazik
dhe kur vlera e pH ose paCO2 eshte normale
 Rregulla 2  nese pH dhe paCO2 jane te dy jonormal
shiko kahet
 ++=> nese jane me te njejtin kah =crreg.metabolik
++=> nese jane me kahe te kunderta = crreg.respirator
psh nese pH=7.23 dhe paCO2=23mmHg
Acidoze metabolike
Stadi 1
 Rregulla 3  nese pH ose paCO2 jane normal kemi nje
crregullim miks respirator dhe metabolik
 Nese pH eshte normal kahu I paCO2 tregon
crregullimin respirator
 Nese paCO2 eshte normal kahu I pH tregon
crregullimin metabolik
 Psh: pH=7.37 paCO2=55mmHg
 acidoze respiratore me alkaloze metabolike

 Ska crregullim primar sepse pH eshte normal

Stadi 2
 I vlefshem kur nga stadi 1 del nje crregullim primar
 Qellimi I ketij stadi eshte te percaktojme nese
kompesimi eshte adekuat ose jo.
 Rregulla 4 nese ka nje crregullim primar metabolik
perdor HCO3 e matur dhe gjej paCO2 e pritur

 Nese paCO2 pritur =paCO2 matur kompesim I plote

 Nese paCO2 pritur >paCO2 matur mbivendosje e alkalozes respiratore
 Nese paCO2 pritur <paCO2 matur mbivendosje e acidozes respiratore
Stadi 2
 Shembull : paCO2=23mmHg pH=7.32 HCO3=15 mEq/L

 Zbatojme rregullin 2  kemi ACIDOZE Metabolike primare

 paCO2 pritur=(1.5*15) +8± 2= 30.5±2 mmHg

 paCO2 pritur >paCO2 matur  acidoze metabolike primare me

mbivendosje alkaloze respiratore
Stadi 2
 Rregulla 5 nese ka crregullim respirator=perdor
paCO2 per te llogaritur pH pritur

 pH matur >pH pritur ne acidoz/alkaloz resp akute

kemi mbivendosje ACIDOZE metabolike
 pH matur <pH pritur ne acidoz/alkaloz resp.kronike
kemi mbivendosje ALKALOZ metabolike
Stadi 2
 Shembull : paCO2=23mmHg pH=7.54
 alkaloz respiratore

 pH pritur akute=7.4 +[0.008*(40-23)]=7.54

 pHpritur akut=pHmatur gjendje akute pa
kompesuar

 pra kemi alkaloz respiratore akute

Stadi 3
 Perdorim Gap per te llogaritur /percaktuar acidozen
metabolike
 Anion gap=diferenca midis anioneve te pamatshme
me kationet e pamatshme

 AG=Na -(HCO3 +Cl)=12

Stadi 3
 Acidoze metabolike me GA te rritur normokloremike
 Ketoacidoza
 Acidoza laktike
 Acidoza uremike
 Acidoza metabolike me GA normal hiperkloremike
 Acidoza renale tubulare
 Acidoza uremike e hershme
 Acidoza posthypokapnike
 Acidoza e diluimit’
 Diarrea
Stadi 3
 Influenca e albumines
Stadi 3
Urinary anion gap perdoret per te kuptuar shkaqet
renale/jorenale te Acidozes metabolike me AG normal
E pavlefshme ne Hypovolemi, oliguri, hyponatriuri,
acidoze me AG
UAG=(uNa+uK)-uCl =±10
Kur UAG <-10 shkaku eshte jorenal
Kur UAG >+10 shkaku eshte renal psh
Metabolic Metabolic Acidosis Acute Resp. Metabolic Respiratory
Acidosis Non-Gap Acidosis Alkalosis Alkalosis
Anion Gap “HARDUPS” “anything “CLEVERPD” “CHAMPS”
“MUDPILERS causing
” hypoventilation”
•Methanol •Hyperalimentation •CNS •Contraction •CNS
disease
•Uremia •Acetazolamide depression •Licorice •Hypocapnia

•DKA/Alcoho •Renal Tubular •Airway •Endocrine •Anxiety

lic ketoacidosis Acidosis obstruction (Conn/Cushing •Mech.
•Paraldehyde •Diarrhea •Pulmonary /Bartters) Ventilation
•Isoniazid •Ureterosigmoidosto
edema •Vomiting •Progesteron
•Pneumonia
•Lactic acidosis my •Excess alkali e
•Post-hypocapnia •Hemo/Pneumo •Refeeding •Salicylates
•Ethylene
Glycol •Spironolactone
thorax •Post- •Sepsis
•Neuromuscular hypercapnia
•Renal •Early Renal Failure
failure(End- Negative AG •Diuretics
Stage)/Rhabd •Multiple Myeloma
o
•Salicylates
Mixed Acid-Base Disorders
Mixed respiratory alkalosis & metabolic
acidosis
ASA overdose
Sepsis
Liver failure
Mixed respiratory acidosis & metabolic
alkalosis
COPD with excessive use of diuretics
Mixed Acid-Base Disorders
Mixed respiratory acidosis &
metabolic acidosis
Cardiopulmonary arrest
Severe pulmonary edema
Mixed high gap metabolic acidosis
& metabolic alkalosis
Renal failure with vomiting
DKA with severe vomiting
Mixed Acid-Base Disorders
 Normal pH + ↓PCO2 + ↓HCO3 - Respiraory Alkalosis +
Metabolic Acidosis
 Normal pH + ↑PCO2 + ↑ HCO3 - Respiratory Acidosis
+ Metabolic Alkalosis
 Normal pH + Normal PCO2 + Normal HCO3 -
Metabolic Acidosis + Metabolic Alkalosis
Some Aids to Interpretation of Acid-Base Disorders

"Clue" Significance

High anion gap Always strongly suggests a metabolic

acidosis.
Hyperglycaemia If ketones present also diabetic
ketoacidosis
Hypokalemia and/or hypochloremia Suggests metabolic alkalosis

Hyperchloremia Common with normal anion gap acidosis

Elevated creatinine and urea Suggests uremic acidosis or hypovolemia

(prerenal renal failure)
Elevated creatinine Consider ketoacidosis: ketones interfere
in the laboratory method (Jaffe reaction)
used for creatinine measurement & give
a falsely elevated result; typically urea
will be normal.

Elevated glucose Consider ketoacidosis or hyperosmolar

non-ketotic syndrome
Urine dipstick tests for glucose and ketones Glucose detected if hyperglycaemia;
ketones detected if ketoacidosis

http://www.anaesthesiamcq.com/AcidBaseBook/ab9_2.php
 Formulas
 Metabolic Acidosis: (Winter’s formula)
 Expected PaCO2 = (1.5×HCO3) + (8±2)
 Metabolic Alkalosis:
 Expected PaCO2 = (0.7×HCO3) + (21±2)
 Acute Respiratory Acidosis:
 Expected pH = 7.40 – [0.008 × (PaCO2 – 40)]
 10mmhg ↑ in PaCO2 will ↑ HCO3 by 1mmol/L


Acute Respiratory Alkalosis:
Expected pH = 7.40 + [0.008 × (40 - PaCO2)] H   24  HCO
 PaCO2

 10mmhg ↓in PaCO2 will ↑ HCO3 by 2mmol/L 3

 Chronic Respiratory Acidosis:

 Expected pH = 7.40 – [0.003 × (PaCO2 – 40)]
 10mmhg ↑ in PaCO2 will ↑ HCO3 by 4mmol/L
 Chronic Respiratory Alkalosis:
 Expected pH = 7.40 + [0.003 × (40 - PaCO2)]
 10mmhg ↓ in PaCO2 will ↑ HCO3 by 4mmol/L
Formulas
 AG = Na - (CL + HCO3)
..Cont’d
 AG Correction for Albumin
 Expected AG(mEq/L)=[2×Albumin(g/dL)]+[0.5×PO4(mg/dL)
 Adjusted AG = Obserbed AG + 2.5 × [4.5 - Measured Albumin (g/dL)]
 Urinary AG = (UNa + UK)-UCl
 Plasma Osmolality = 2×Na + Glucose/18 + BUN/2.8
 Na/Cl > 1.4 = metabolic alkalosis (hypochloremia)
 Na/Cl < 1.27 = non anion gap acidosis (hyperchloremia)
 AG Excess/HCO3 Deficit = (Measured AG - 12) /(24- Measured
HCO3)
 HCO3 deficit(mEq)=0.6×Wt(kg) (15-Measured HCO3)
 mEq of NaHCO3 = Apparent Volume of distribution × Target change in
HCO3
 TBW(kg) × [0.4 +(2.4/HCO3)] = Apparent Volume of distribution
 Cl Deficit (mEq) = 0.2 × Wt(kg) × (Normal Cl- Actual Cl)
 volume of isotonic saline needed to correct the deficit is the ratio: Cl
deficit/154
http://www.medcalc.com/acidbase.html