telci asid baz 2016 yb kongresito apply approach to the diagnosis and treatment af acid-base, fluid,...
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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
“40 years ago” P Astrup Acta Anesthesiol Scand. Sup 105,11-‐12, 1995
Björn Ibsen
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ToplanPda hekimler,
“çok yüksek serum bikarbonat değeri” = metabolik alkaloz Ibsen, “uzun süredir aPlamamış CO2’nin sonucu” = solunumsal asidoz
“40 years ago” P Astrup Acta Anesthesiol Scand. Sup 105,11-‐12, 1995
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
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
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
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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Prof.Dr. İlhan Vidinel: Asit-‐Baz Dengesi. Fizyopatolojik prensipler. Ege Üniversitesi Tıp Fakültesi Yayınları N.85, E.Ü. Matbaası Bornova,1971
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
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.
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
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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
Ole-‐Siggaard Andersen: The Acid-‐Base Status of the Blood. 4th eds, Munksgaard Copenhagen, 1976
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
Ole-‐Siggaard Andersen: The Acid-‐Base Status of the Blood. 4th eds, Munksgaard Copenhagen, 1976
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
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