Tulburari Ale Echilibrului Hidroelectrolitic Si Acidobazic Cu

8/18/2019 Tulburari Ale Echilibrului Hidroelectrolitic Si Acidobazic Cu

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Obiectivele cursului

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Notiuni de fiziologie.Compozitia compartimentelor lichidiene (1)

1. Apa - principalul constituient al organismului

apa extracelulara(1/3 din apa totala,20% din cantittotala)

apa intracelulara(2/3 din apa totala,40% din cantit totala)


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Notiuni de fiziologie.Compozitia compartimentelor lichidiene (2)

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Rolul apei si electrolitilor in organism

APA

#

Rol esential in supravietuireacelulelor intervin in reactiilechimice si metabolice

#

Rol in absorbtia si transportulnutrientilor

#

Rol in reglarea temperaturii

corporale

#

In eliminarea produsilor demetabolism in urina

ELECTROLITII

#

rol vital in mentinereahomeostaziei organelor

# contribuie la asigurareaactivit cardiace ,cerebrale,musculare (potentialul derepaus si de actiune si decontractilitate)

# balanta lichidiana

# livrarea de oxigen

#

balanta acidobazica


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BALANTA APEI IN ORGANISM

SETEOSMO-RECEPTORI

DESHIDRATARE

CELULARA

BARO-RECEPTORI HIPOVOLEMIE

APORT H2O

ADH

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H2O

SOLUTIE HIPERTONA SOLUTIE HIPOTONA

CONDITII CU HIPERTONICITATE

A COMPARTIMENTULUI

EXTRACELULAR :

1 . HIPERNATREMIA

2 . HIPERGLICEMIA

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MODIFICARILE DE VOLUM SI COMPOZITIE alecompartimentelor organismului

! Hiper-osmolaritatea!

HIPERSODEMIA

! HIPERGLICEMIA

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Osm plasm = 2Na++uree 2,8+glicemie/18

VN: Na+ seric = 135-145 mEq/l (VN


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- DEPLETIE VOLEMICA

• TAHICARDIE

• HIPOTENSIUNE

• SINCOPA

• SOC

- EDEME (PERIFERICE / PULMONARE ) – exces Na

• POLIURIE

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• INSUFICIENTA RENALA

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ABORDARE DIAGNOSTICA A HIPERSODEMIEI

HIPERSODEMIE+

Eval nivelul volemiei

+

osmolaritatea plasmatica

+

osmolaritatea urinara

+

val Na urinar


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REDISTRIBUTIE intracelulara

• Catecolamine (%-agoni"ti )•

Insulina

• alcaloza metabolica / respiratorie

• paralizia periodica familiala hK

• hipotermia

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7D@EB@>CA;E?DA : k M 9 M *E] 6WFALS CRESCUT : - HEMOLIZA

- LEUCOCITOZA

- TROMBOCITOZA

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• SUPLIMENT K

• TRANSFUZII

• PENICILINA

• TNP

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• DEFICIT MINERALOCORTICOID

• ANTAGONISTI ALDOSTERON

• INTOXICATIE DIGITALA

• SUCCINILCOLINA


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7D@EB@>CA;E?DA O ?A5D_E;CABD =WD5D=E• TULBURARI DE RITM / CONDUCERE

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• INSUFICIENTA RESPIRATORIE

•

PARALIZIE FLASCA• CONFUZIE MENTALA

K

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;>WVCDD =BD;CAW>D!E DY>C>5E

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48/118

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Solutions Na +

K +

Ca 2+

Mg 2+

Cl - HCO

3

- Dextrose mOsm/L

Lactated

Ringer’s130 4 3 109 28 273

7ABC?A5G

;>WVCDD =BD;CAW>D!E


49/118

;>WVCDD =BD;CAW>D!E7D@>C>5E

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50/118

D5!D=ACDD8

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;>WVCDD =BD;CAW>D!E 7D@EBC>5E

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;>WVCDD =BD;CAW>D!E 7D@EBC>5E


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D-0&$',&&." #).2,&&.)% $%,'.)&0"

SOLUTIILE CRISTALOIDE SALINE


55/118

SOLUTIILE CRISTALOIDE SALINE

1. SOLUTII DE RESUSCITARE VOLEMICA (princip sol)

1.

SOLUTII DE INLOCUIRE A PIERDERILOR FIZIOLOGICE SI

PATOLOGICE

Utilizare in:

! /"*)%'1&"

! +&"%0"%& 0&1"#,&R"8 R'%#',2%&60&'%"" #"R"%"9 '#+&%',&" 1'#,%&$' $%"#$2,'9


56/118

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Ld B"U'$"%"' 0"


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TERAPIA LICHIDIANA

! ;>WVCDD =BD;CAW>D!E

! ;>WVCDD =>W>D!AWE

! @B>!V;E !E ;A5`E

SOLUTII COLOIDALE


58/118

SOLUTII COLOIDALE

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ALBUMINA (5% 20%)


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ALBUMINA (5%,20%)

! @%)02# #'-12&-9 "H,' %$ 0" %"'$,&& 0" ,&+

'-'


61/118

Solutii coloide pe baza de amidon (HES)

$)-,&- 5'9 =.

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64/118

Modalitati de administrare alichidelor

! catetere periferice

!

catetere venoase centrale

!

PICC (catetere centrale cuinsertie periferica)

!

Catetere de tip Hickman


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TULBURARILE ECHILIBRULUI

ACIDO-BAZIC


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Obiectivele cursului

&

Definirea unor notiuni de baza pentru

intelegerea EAB

& Definirea principalelor tulburari ale EAB

& Acidoza: descriere tipuri, efecte clinice,

principii de tratament

&

Alcaloza: descriere tipuri, efecte clinice,

principii de tratament

Concepte de baza in analiza EAB


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Concepte de baza in analiza EAB Concentratia ionilor de hidrogen si notiunea de pH

H2O H+ +OH-

&

H+ asigura activit sist enzimatice celulare&

H+ = 35-45nEq/l (16-160nEq/l-limite de supravietuire)&

cel mai precis ion reglat in organism

&

pH= -log [H+]= log 1/[H+],&

pH = pKa +log HCO3-/pCO2#

0,23 (ec HendersonHasselbach)

& H+ (nEq/L) = 24#PCO2/HCO3 (conform

ecua#ie Henderson-Hasselbach modificat! "i simplificat!)

Orice modificare a conc H+ este rezultatul modificariloracizilor volatili (CO2) "i nevolatili (ex HCl, sulfuric, lactic)iar clinic se exprim! ca modific!ri respiratorii "i respectivmetabolice.


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Valori normale:& pH=7,35-7,45,& bicarbonat = 22-24 mEq/L& pCO2 = 40 mEq/L (VN 38-43 mmHg (art), 45-48mmHg (ven)

@%&-$&+'."." ,&+2%& 0" ,2.42%'%& '." EAX


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@%&-$&+'."." ,&+2%& 0" ,2.42%'%& '." EAX

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BE_WE=Cx A=V?VWABEA z5 >B`A5D;? !E A=DYD ;AV XAYEd

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&

?DjCA F*",'4).&$' #& %"#+&%',)%&"G

TULBURARI ale echilibrului ACIDOBAZIC


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H+ , HCO3

CHEMORECEPTORI

VENTILATIA , PCO2

H+ , HCO3VENTILATIA , PCO2

PCO2

PCO2

S . RENAL

REABSORBTIA HCO3 , HCO3 - S

REABSORBTIA HCO3 , HCO3 - S

Tulburare MODIFICARE PRIMARA RASPUNS COMPENSATOR

RESPIRATORIE

Acidoz! Alcaloz!

METABOLICA

Acidoz!

Alcaloz!

PaCO2

PaCO2

HCO3-

HCO3-

HCO3-

HCO3-

PaCO2

PaCO2

C2.42%'%& '." EAX


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C2.42%'%& '." EAXB'#+2-#2. $)*+"-#',)% .' ) ,2.42%'%" +%&*'%' "#," 0" '

.&*&,' *)0&@VW =>?@E5;ABDD \ %'+)%, @=>I 6 7=>Q =>5;CA5C

=>?@E5;ABE \ =>BE=CDE

MECANISME COMPENSATORII


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1. Sisteme tampon' bicarbonat, hemoglobina, fosfat, amoniac, proteine intracelulare

2. Mecanisme respiratorii:'

Intervin promt, modificare pCO2'

Raspuns compensator la o tulburare primara metabolica'

Estimarea compensarii in conditii de acidoza metabolica:'

PaCO2 = 1,5#

HCO3- +( 8±

2)'

PaCO2 scade cu 1-1,5 mmHg sub valoarea de 40 pentru fiecare sc!dere cu1mEq/L a bicarbonatului plasmatic.

'

Estimarea compensarii in conditii de alcaloza metabolica:

'

PaCO2 = 0,7 # HCO3-

+( 8±2)'

PaCO2 cre"te cu 0,25 – 1 mmHg peste valoarea de 40 pentru fiecare'

cre"tere cu 1mEq/L a bicarbonatului plasmatic.

3. Mecanisme renale

' Raspuns mai tardiv (6-12 ore)

' secretia de H+ , reabsorbtia/excretia bicarbonatului filtrat glomerular

' eliminarea exces de acizi ca aciditate titrabila si ioni de amoniu cuproducere de bicarbonat nou

' Raspuns compensator important in tulburarile primare respiratorii

' modificare a PCO2 cu 1mmHg fa#! de valoarea normal! (40 mmHg) va modifica pH-ul fa#!

de cel normal de 7,40 cu 0,008 unit!#i în direc#ie opus! în condi#iile unei tulbur!ri acute

sau cu 0,003 în tulbur!rile cronice


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Cum interpretam o tulburare acido-bazica?

1.

Identificarea tulbur!rii majore utilizând pH-ul,PCO2, HCO3-

2. Evaluarea r!spunsului compensator

3. Aprecierea EAB la pacientul critic

Identificarea tulbur!rii majore utilizând


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jpH-ul, PCO2, HCO3-

pH modificat '

identificare modificari PCO2, HCO3- '

Modificarea acestora in aceeasi directie-tulburareprimara acido-bazica cu raspuns compensator

'

Modificarea acestora in directie opusa-tulburareacido-bazica mixta de tip acidoza sau alcaloza

' pH si pCO2 modificate in aceeasi directie –tulburare

primara metabolica

'

pH si pCO2 modificate in directie opusa- tulburareprimara respiratorie

' PCO2 normal- modificarea pH va indica tulburarea

metabolic!

Identificarea tulbur!rii majore utilizând pH-ul,


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j p ,PCO2, HCOZ[

N\]^>SS> N0-S]SZPP\?> \0-Z[ ]WV P3_`A

1:*'"a9 P(;97"%*:9 N8*P989

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1:*'"a9 P*c;9 8()N*89;"8*( )* P(;97"%*:9

Identificarea tulbur!rii majore utilizând


77/118

jpH-ul, PCO2, HCO3-

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dj1 3F63 10!.-5f !12 031A1A6f 1A01A-5f

! N\ #"8P9% [ P"'*k:98(9 40-S J9 *#'*:9 ";$%7$898( '(


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Interpretare echilibru acido bazic lapacientul critic

1. MODELUL CONVENTIONAL - ABORDAREA CLASICA

2.

METODA STEWART

1. MODELUL CONVENTIONAL - ABORDAREA CLASICA


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Concentratia de H+ din lichidul extracelular depinde de balanta întrepresiunea par#ial! a CO2 (PCO2) "i concentra#ia de bicarbonat (HCO3

-)din lichid "i se exprim! astfel:

H+ (nEq/L) = 24#pCO2/HCO3-

Limite:& cuantifica tulburarile EAB doar ca respiratorii sau nonrespiratorii

&

nu cuantifica tulb metabolice& nu considera acizii nevolatili (organici)& explica doar participarea pulmonara si renala la reglarea concentratiei

ionilor de hidrogen fara a explica si rolul altor organe.

Pentru cuantificarea componentei metabolice au fost propusi indicatoriindependenti de pCO2 ai tulb EAB' Definire 1948 Singer si Hasting – concept de baze tampon' 1960 Astrup – bicarbonat standard (paCO2 =40 mmHg-

standardizat)' 1960 - Siggard Andersen - baze exces (BE)

Indicatori independenti de PaCO2 ce contribuie la


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mentinerea constanta a concentratiei ionilor de hidrogen

BAZE TAMPON (BB=buffer base) (VN = 40-50mmol/L)

& Cantitatea totala a sistemelor tampon (bicarbonat , albumina,fosfati, Hb)

& Scazute in acidoze, crescute in alcaloze

Probleme: capacitatea tampon este alterata in conditiile modificariiconcentratiei hemoglobinei !!!!!

BB= contrabalanseaza diferenta intre ionii puternici (cationi/anioni)

BAZE EXCES (BE) (VN = -2 si +2mmol/L)'

Deviatia BB fata de normal' Se refera in primul rand la consumul de bicarbonat

NU POT SEPARA DIFERITELE FORME DE ACIDOZA METABOLICA !!

DIFERENTIEREA TIPULUI DE ACIDOZA METABOLICA


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Conceptul de “gaura anionica”

GA = totalitatea anionilor (puternici si slabi) prezenti in plasmacare nu se determina de rutina :

& ALBUMINA

& FOSFATI ANORGANICI, SULFATI,

&

ACIZI ORGANICI (LACTIC , ACETOACETIC,

$- HIDROXIBUTIRIC, etc )

& permite identificarea tipului de acidoza metabolica:

cu GA CRESCUTA (cantit crescuta de acizi organici )cu GA NORMALA (hipercloremica)

B1d21 1j!-j!01[Na+ +K +] =[Cl- +HCO3-] +GA VN: -10-12 mEq/l


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j-2,1A1:*'"a9 P(;97"%*:9

:$B1 023F0d61

N8*# 9:$P$%98( '( 9:*a*

[ a ] [C CO3 ] G 0 q/

1:*'"a9 P(;97"%*:9 :$B1 j-2,1A1[

g\!4320A-23,!01i

N8*# N*(8'(8( '( 7*:987"#9;

• 1A@d,!j1• A10616• l")l9)$%l9<•

9%< 9#*"#* g (c9:*a* "8?9#*:*i

Metoda Steward de apreciere a EAB


83/118

&

Permite cuantificarea mai precisa a tulburarilor metabolice de tipacidoza si alcaloza.

& Acest model clarific! rolul rinichiului, ficatului, intestinului încontrolul echilibrului acido-bazic

&

Statusul acidobazic respectiv concentratia ionilor de hidrogendin sange depinde de nu doar de elementele prezente dar si de :incarcatura electrica (cationi/anioni), cantitatea si gradul dedisociere al acestora (ioni puternici, slabi, gaze sangvine, etc)

& In conditii normale, diferenta intre cationii si anionii puternicinumita SID –diferenta ionilor puternici trebuie sa fie egala cuvaloarea ionilor slabi (pentru mentinerea electroneutralitatii).Orice modificare a acestei diferente explica diferitele tipuri deacidoza si alcaloza.

SID = (Na + + K + + Ca++ + Mg++ ) – (Cl- + lactat- + anioni puternici)F!. % % CT Cb 3 `%


84/118

09


85/118

ACIDOZA METABOLICA SIRESPIRATORIE

E_E=CE ;D;CE?D=E AWE A=D!>YED


86/118

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ACIDOZA METAB cu GA NORMALA (HIPERCLOREMICA) La pacien#ii din terapie intensiv! cele mai comune cauze de acidoz!

metabolic! hipercloremic! sunt:

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ALCALOZA METABOLICA SIRESPIRATORIE

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pH , p CO2

Stimulare central!

• Durere, anxietate(psihogen!), febr!

• Infec#ii, tumori, ischemie

cerebral! (AVC)• Indus! medicamentos

(salicila#i, analepticerespiratorii

• Sarcina•

Iatrogen!-Indus! deventilator

• Seps! • Encefalopatie metabolic!

Stimulare periferic!

• Hipoxemia de diferitetipuri: – altitudine

–

afec#iuni respiratorii:pneumonie, astm , emboliepulmonar! ,

• Afec#iuni cardiace:insuficien#a cardiac! ,edem pulmonar

• Anemia sever!

ALCALOZA RESPIRATORIE10 H CO2 b 40 H d t i bi b t l i


117/118

cu 10 mm Hg a pCO2 sub 40 mm Hg determina bicarbonatului cu2-5 mEq/L

Consecinte:&

vasoconstrictie cerebrala& vasodilatatie pulmonara&

vasoconstrictie sistemica&

coronaroconstrictie –spasm coronarian

Principii de tratament

& stabilirea "i tratarea cauzei declan"atoare

&

la pacien#i în stare critic! unde hiperventila#ia nu poate fi

corectat! este indicat! intubarea "i controlul ventila#iei&

în condi#iile alcalozei severe (pH 7,60) se recomand! solu#iiacide de tipul de acid clorhidric, clorur! de amoniu, arginin! hidroclorid!

@*7%*"?89k(


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Tulburari Ale Echilibrului Hidroelectrolitic Si Acidobazic Cu

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