telci asid baz 2016 yb kongresito apply approach to the diagnosis and treatment af acid-base, fluid, and elec- trolytc problems. RA(Preston(:(AcidJBase,(Fluids,(and(Electrolytes(Made(Ridiculously(Simple(

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ASİT -‐ BAZ DENGESİ

Dr.Lü1i TELCİ İstanbul Tıp Fakültesi Yoğun Bakım Bilim Dalı,

Anesteziyoloji Anabilim Dalı

18. Ulusal Yoğun Bakım Kongresi, 6-‐10 Nisan Belek Antalya-‐ 2016

Asit-‐Baz kompleksi

•  Karmaşa •  Karar verme yeNsini, sağduyuyu etkileyen, baskı alPnda tutan, ruhsal dengesizliklere neden olabilen karmaşıklıkların tamamı

•  ChrisNan Bohr (1855-‐1911) -‐ Kopenhag

–  “kan-‐gaz pompası” Haemataerometer •  August Krogh (1874-‐1949) -‐ Kopenhag

–  microtonameter •  John Sco] Haldane (1860-‐1936) -‐ Oxford

–  Gaz analizörü •  Yandell Henderson (1873-‐1944) -‐ Yale •  K.A.Hasselbalch (1874-‐1962) -‐ Kopenhag •  J.W. Severinghaus (1922-‐ ) -‐ San Francisco •  P. Astrup (1915-‐2000) -‐ Kopenhag •  Ole Siggaard-‐Andersen (1932-‐ ) -‐ Kopenhag

The History of Blood Gases, Acids and Bases P Astrup, JW Severinghaus, Munksgarard-‐ 1986

•  SA Arrhenius (1859-‐1927) Stockholm •  N Bjerrum (1879-‐1958) Kopenhag •  JN Bronsted (1879-‐1947) Kopenhag •  LJ Henderson (1878-‐1942) Harvard •  DD Van Slyke (1883-‐1971) New York

– Kan gaz analizörü 1917

The History of Blood Gases, Acids and Bases P Astrup, JW Severinghaus, Munksgarard-‐ 1986

nüfus hasta vefat 1711 veba 70.000 23.000 1853 Kolera 150.000 8.000 5.000 1913 İspanyol gribi 600.000 100.000 3.500 1952 polio salgını “ “ 2.241 27

345 solunum kasları tutulumu 31 hasta solunum yetmezliği

“40 years ago” P Astrup Acta Anesthesiol Scand. Sup 105,11-‐12, 1995

•  Acil ToplanP •  Güçlü öneri •  Çelik ciğerden elle venNlasyona geçiş


Björn Ibsen

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ToplanPda hekimler,

“çok yüksek serum bikarbonat değeri” = metabolik alkaloz Ibsen, “uzun süredir aPlamamış CO2’nin sonucu” = solunumsal asidoz


Polio salgını iyi ki Danimarka’da çıkmış!

DD Van Slyke Ölçümlerin praNğe yansıması-‐ 1917

1930 1940 1950 Ole Siggard Andersen (problem çözücü) Asit -‐ baz verilerinden data Anlaşılabilir! nomogramlar / diagramlar

P Astrup, Ole-‐Siggaard Andersen-‐ 60 year Scand J. Clin Lab Invest 53, Sup 214,22-‐26, 1993

Ole-‐Siggaard Andersen: The Acid-‐Base Status of the Blood. 4th eds, Munksgaard Copenhagen, 1976


P Astrup, Ole-‐Siggaard Andersen-‐ 60 year Scand J. Clin Lab Invest 53, Sup 214,22-‐26, 1993

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Gamble 1947 •  1920-‐ 1930 Pediatrist •  JL Gamble 1895-‐1965) Harvard


BA Shapiro :Clinical ApplicaNon of Blood Gases. Year Book Medical Publishers Inc Chicago 1973,1974,1975

BA Shapiro :Clinical ApplicaNon of Blood Gases. Year Book Medical Publishers Inc Chicago 1973,1974,1975

Prof.Dr. Nuran Gökhan: İnsan vücudunda asid-‐baz dengesinin düzenlenmesi. İstanbul Üniversitesi Tıp Fakültesi Yayınları Sermet Matbaası İstanbul-‐ 1970

Prof.Dr. Nuran Gökhan: İnsan vücudunda asid-‐baz dengesinin düzenlenmesi. İstanbul Üniversitesi Tıp Fakültesi Yayınları Sermet Matbaası İstanbul-‐1970

Prof.Dr. İlhan Vidinel: Asit-‐Baz Dengesi. Fizyopatolojik prensipler. Ege Üniversitesi Tıp Fakültesi Yayınları N.85, E.Ü. Matbaası Bornova,1971

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Yerli Kaynaktan

Kompensasyon: a kompensasyon yok b kısmi kompensasyon var c maksimal kompensasyon var d tam kompensasyon var


NJ Weldy: Body Fluids and Electrolytes 5th ed, The CV Mosby Company, St Louis, Washington DC, Toronto-‐ 1988

Death Death

RA Preston : Acid-‐Base, Fluids, and Electrolytes Made Ridiculously Simple Med master INC.Miami – 1997

I did not have a consistent, simple, and easy to apply approach to the diagnosis and treatment af acid-base, fluid, and elec- trolytc problems.



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RA Preston : Acid-‐Base, Fluids, and Electrolytes Made Ridiculously Simple Med master INC.Miami – 1997 JA Kellum, PWG Elbers: Stewart’ s textbook of acid-‐base-‐ 2009

pH =7,36 – 7,44 H+ = 36 – 43 nmol/L

pH 7.4

6.8

7.8

[H+] (nmol/L)

7.8

6.8

Stewart yaklaşımı

Kan plazması à pH à H+

PCO2

SID

ATOT

Depo H2O

pH 7.4

6.8

7.8

[H+] (nmol/L)

6,8 7,8 Görmeyen var mı?

S Tugrul et al: Case report of severe metabolic alkolosis: life compaNble new level The Journal of Trauma, injury, infecNon and criNcal care 68(3) 2010

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CO2 (15.000mmol/gün)

a)  CO2 + Hb = HbCO2 ~ %70

b)  CO2 + H2O D H2CO3 D H+ + HCO-‐3

H+

H+

CO2 + H2O D H2CO3 D H+ + HCO3-‐

pH = pK1 + log10 [ HCO3

-‐ ] 0.03 x PCO2

Henderson – Hasselbach

H+

Solunumsal asidoz

Eylem

Solunumsal asidoz

Akut ? Kronik ?

Solunumsal asidoz

Eylem

Solunumsal asidoz

Akut ? Kronik ?

anamnez

Formül

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Solunumsal alkaloz / kese kağıdı


Therapy: The spontaneous hyperventilation syndrome is treated by rebreathing in a paper or plastic bag. This causes an increase in pCO2 and a fall ln plasma pH. The cerebral vasoconstriction is thereby relieved and this may be the reason why the patient regains his voluntary control of respiration and stops hyperventilating.

Metabolik asidoz / Anyon Gap

JA Kellum, PWG Elbers: Stewarts’ Textbook of Acid Base. 2nd eds, Tulu com-‐USA-‐2009


Metabolik alkaloz / tedavisi

•  NH+4 à (1969)

•  HCL à (1936) Hydrocloric acid has been used intra- venously in concentration as high as 500 mmol/l (Cullen 1936). Due to the low pH, it is strongly irritating and tends to produce phlebitis.

When given intra- venously, some of the ammonia can be utilized by the tissues for protein synthesis (Fürst, Josephson, Maschio & Vinnars 1969). Eighty percent ot the administered ammonium ions will be metabolize within 30 min in a normal liver. NH+

4 is toxic and should be administered slowly (for example 1 mmol/h per kg body mass). It is contra indicated in liver insufficiency, where it may precipitate coma.

Hydrocloric acid infusion, as a 0.1 to 0.25 N solution, has been used with success in patients with severe metabolic alkalosis (pH > 7.55 and sys- temic instability such as encephalopathy or cardiac arrhyth- mia (24) refractory to conventional measures. 25,31

JE Parillo, RP Delinger. CriNcal Care Medicine Principle of diagnosis and management in the adult. 4th eds. -‐ 2014

Kompensasyon

•  Akciğer-‐Böbrek Karaciğer-‐ Sindirim sistemi

•  KriNk hasta tanımı – Yoğun bakım hastası – Acil hasta

•  Kompensasyon beklenmemeli !

Çoğul organ yetersizliği / adayı

Telci L: Asit-‐Baz Dengesi, 2.Baskı ,Nobel, İstanbul, 2011

Documents

telci asid baz 2016 yb kongresito apply approach to the diagnosis and treatment af acid-base, fluid, and elec- trolytc problems. RA(Preston(:(AcidJBase,(Fluids,(and(Electrolytes(Made(Ridiculously(Simple(