telci asid baz 2016 yb kongresi.pptx

27/04/16 Asit-­‐Baz kompleksi •  Karmaşa •  Karar verme yeNsini, sağduyuyu etkileyen, baskı alPnda tutan, ruhsal dengesizliklere neden olabilen karmaşıklıkların tamamı 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 •  ChrisNan Bohr (1855-­‐1911) -­‐ Kopenhag –  “kan-­‐gaz pompası” Haemataerometer •  August Krogh (1874-­‐1949) -­‐ Kopenhag –  microtonameter •  John Sco] Haldane (1860-­‐1936) -­‐ Oxford • 
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–  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 • 
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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 The History of Blood Gases, Acids and Bases P Astrup, JW Severinghaus, Munksgarard-­‐ 1986 nüfus 1711 veba 70.000 1853 Kolera 150.000 1913 İspanyol gribi 600.000 1952 polio salgını “ “ hasta 8.000 100.000 2.241 vefat 23.000 5.000 3.500 27 345 solunum kasları tutulumu 31 hasta solunum yetmezliği “40 years ago” P Astrup Acta Anesthesiol Scand. Sup 105,11-­‐12, 1995 P Astrup, JW Severinghaus, Munksgarard-­‐ 1986 Björn Ibsen •  Acil ToplanP •  Güçlü öneri •  Çelik ciğerden elle venNlasyona geçiş “40 years ago” P Astrup Acta Anesthesiol Scand. Sup 105,11-­‐12, 1995 1 27/04/16 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! “40 years ago” P Astrup Acta Anesthesiol Scand. Sup 105,11-­‐12, 1995 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 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 2 27/04/16 Gamble 1947 •  1920-­‐ 1930 Pediatrist •  JL Gamble 1895-­‐1965) Harvard Ole-­‐Siggaard Andersen: The Acid-­‐Base Status of the Blood. 4th eds, Munksgaard Copenhagen, 1976 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 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. İlhan Vidinel: Asit-­‐Baz Dengesi. Fizyopatolojik prensipler. Ege Üniversitesi Tıp Fakültesi Yayınları N.85, E.Ü. Matbaası Bornova,1971 3 27/04/16 Yerli Kaynaktan Kompensasyon: a kompensasyon yok b kısmi kompensasyon var c maksimal kompensasyon var d tam kompensasyon var Prof.Dr. İlhan Vidinel: Asit-­‐Baz Dengesi. Fizyopatolojik prensipler. Ege Üniversitesi Tıp Fakültesi Yayınları N.85, E.Ü. Matbaası Bornova,1971 Death
Death
Prof.Dr. İlhan Vidinel: Asit-­‐Baz Dengesi. Fizyopatolojik prensipler. Ege Üniversitesi Tıp Fakültesi Yayınları N.85, E.Ü. Matbaası Bornova,1971 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.
NJ Weldy: Body Fluids and Electrolytes 5th ed, The CV Mosby Company, St Louis, Washington DC, Toronto-­‐ 1988 RA Preston : Acid-­‐Base, Fluids, and Electrolytes Made Ridiculously Simple Med master INC.Miami – 1997 RA Preston : Acid-­‐Base, Fluids, and Electrolytes Made Ridiculously Simple Med master INC.Miami – 1997 RA Preston : Acid-­‐Base, Fluids, and Electrolytes Made Ridiculously Simple Med master INC.Miami – 1997 4 27/04/16 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 7.8
7.8 pH 7.4 6.8
6.8 [H+] (nmol/L) Stewart yaklaşımı 7.8 pH 7.4 Kan plazması à pH à H+ 6.8 PCO2 Depo H2O SID ATOT [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 5 27/04/16 CO2 (15.000mmol/gün) H+ H+ CO2 + H2O D H2CO3 D H+ + HCO3-­‐ pH = pK1 + log10 [ HCO3-­‐ ] 0.03 x PCO2 a)  CO2 + Hb = HbCO2 ~ %70 b)  CO2 + H2O D H2CO3 D H+ + HCO-­‐3 Henderson – Hasselbach H+ Solunumsal asidoz Eylem Solunumsal asidoz Akut ? Kronik ? Solunumsal asidoz Eylem Solunumsal asidoz Akut ? Kronik ? a namnez Formül 6 27/04/16 Solunumsal alkaloz / kese kağıdı Metabolik asidoz / Anyon Gap 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.
Ole-­‐Siggaard Andersen: The Acid-­‐Base Status of the Blood. 4th eds, Munksgaard Copenhagen, 1976 JA Kellum, PWG Elbers: Stewarts’ Textbook of Acid Base. 2nd eds, Tulu com-­‐USA-­‐2009 Metabolik alkaloz / tedavisi • 
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When given intravenously, 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
NH+4 is toxic and should be administered
+ à liver.
Hydrocloric
acid Ithas
NHslowly
(1969) (for
example 1 mmol/h per kg
body mass).
is
4
been
used
intravenously
in concentration
as ithigh
as
contra indicated in
liver insufficiency,
where
may
500
mmol/l
(Cullen 1936). Due to the low pH, it is strongly
HCL à
(1936) precipitate
coma.
irritating and tends to produce phlebitis.
Ole-­‐Siggaard Andersen: The Acid-­‐Base Status of the Blood. 4th eds, Munksgaard Copenhagen, 1976 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
systemic instability such as encephalopathy or cardiac
arrhythmia (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 Çoğul organ yetersizliği / adayı •  Kompensasyon beklenmemeli ! Telci L: Asit-­‐Baz Dengesi, 2.Baskı ,Nobel, İstanbul, 2011 7