distúrbio acido básico
TRANSCRIPT
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Distúrbio ácido-básico
Antonio [email protected]
Médico coordenadorUnidade de Medicina Intensiva PediátricaUnidade de Medicina Intensiva Neonatal
Hospital Padre Albino
Professor de Pediatria nível II Faculdades Integradas Padre Albino
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Porque pedir gasometria
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Prá ver como o paciente tá!
Prá ver os eletrólitos!
Prá ver o pH!
Para definir o estado ácio-básico do paciente!
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� Processos bioquímicos e enzimáticos do metabolismo celular
�Osmolaridade�Eletrólitos�Nutrientes�Temperatura�Oxigênio�Dióxido de carbono
�Íon hidrogênio
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[H+]
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Potencial Hidrogeniônico
A [H+] é quantificada em unidades de pH
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� pH = - log [H+]
� Solução aquosa neutra 25º C� [H+] = 1 x 10-7
� [H+] = 0,000.000.1 M�pH = 7 (neutro)
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Arrhenius :Ácido é toda substância que
em solução aquosa libera o íon hidrogênio (H+)
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Anion gap
medida de ânions não mensurados no plasma
valores normais 12 ± 2 mEq/L
Valores > 16 mEq/Lpresença de ânions não mensuráveis
A fórmula usada para seu cálculo é:
AG = [(Na+ + K+) – (Cl- + Bicarbonato)]
anion
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Sistemas Reguladores do pH
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Bicarbonato -Ácido Carbonico
1 20
pH = 7.4H2CO3 ……………… HCO3
24 mEq/L1.2 mEq/L
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Regula ção
� Anidrase Carbônica
CO2 +H2O H2CO3 H+ + HCO3Carbon Carbonic Bicarbonate
Dioxide Acid
(ACID) (BASE)
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MÉTODO DE HENDERSON-HASSELBALCH
•utilizada para descrever os distúrbios do equilíbrio ácido-básico no sangue
parâmetros: pH, PaCO2, bicarbonato, excesso de base (BE = Base Excess) e anion gap (AG) ou intervalo aniônico
BE = 0,9287 x [( BIC – 24,4)] + (14,83 x pH – 7,4)]
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SANGUE COMO UMA SOLU ÇÃO-TAMPÃO
pulmões e rins
pH do sistema tampão ácido carbônico-bicarbonato
receptores no cérebro
H+ e CO2 nos fluídos corpóreos
concentração de CO2 aumenta
equilíbrios deslocam-se para a direita
formação de mais H+
CO2 +H2O H2CO3 H+ + HCO3
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SANGUE COMO UMA SOLU ÇÃO-TAMPÃO
formação de mais H+
reflexo para hiperventilar
eliminação de CO2
deslocando o equilíbrio para a direita
CO2 +H2O H2CO3 H+ + HCO3
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SANGUE COMO UMA SOLU ÇÃO-TAMPÃO
Os rins absorvem ou liberam H+ e HCO3-; muito do
excesso de ácido deixa o corpo na urina, que normalmente tem pH de 5,0 a 7,0.
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Valores normais
� pH 7.35-7.45� Compatibilidade 6.8 - 8.0� ___/______/___/______/___
6.8 7.35 7.45 8.0ácido alcalino
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Qual a primeira informação para interpretar a gasometria
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Ver o pH!
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PaCO 2 = 60 mmHg
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Ver o pH!
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Interpreta ção do pH
� pH 7.35-7.45
� Compatibilidade 6.8 - 8.0
___/______/___/______/___ 6.8 7.35 7.45 8.0
ácido alcalino
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___/______/___/______/___ 6.8 7.35 7.45 8.0
ácido alcalino
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Alcalemia
Acidemia
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PaCO2/HCO3
CO2 +H2O H2CO3 H+ + HCO3Carbon Carbonic Bicarbonate
Dioxide Acid
PaCO2 = [(1,5 x Bic) + 8] +/- 2
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Interpreta ção do pH
� Aumento de Ânion -gap
� pH > 7�Tratar a doen ça de base
� pH < 7�Tratar o pH
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Anion gap
� Anion Gap > 12 ± 2 mEq/L
� M - Metanol� U - Uremia� D – Cetoacidose� P - Paraldeído� L - Lática� E – Etileno glicol� S - Salicilato
� Anion Gap < 12 ± 2 mEq/L
� Hiperalimentação� Acetazolamida� Acidose tubular renal� Diarréia� Fístula pancreática� Enteroestomias� Sondas enterais
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Is there a role for sodium bicarbonate in treating lacticacidosis from shock?John H. Boyd and Keith R. WalleyCurrent Opinion in Critical Care 2008, 14:379–383
Recent findings
The most recent 2008 Surviving Sepsis guidelines strongly recommend
against the use of bicarbonate in patients with pH at least 7.15 , while deferring judgment in more severe acidemia.
There is little rationale or evidence for the use of bicarbonate therapy for lactic acidosis due to shock.
Effective therapy of lactic acidosis due to shock is to reverse the cause.
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Acidemia Alcalemia
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Qual é o distúrbio primário
CO2 +H2O H2CO3 H+ + HCO3Carbon Carbonic Bicarbonate
Dioxide Acid
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Interpreta ção do pH
___/______/___/______/___ 6.8 7.35 7.45 8.0
ácido alcalino
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PH= 7,15
PaCO2= 45
PaO2= 95 mmHg
BE= -12
HCO3= 22
Sat= 98%
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PH= 7,15
PaCO2= 45
PaO2= 95 mmHg
BE= -12
HCO3= 22
Sat= 98%
Acidose mista
CO2 +H2O H2CO3 H+ + HCO3
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PH= 7,15
PaCO2= 50
PaO2= 95 mmHg
BE= -12
HCO3= 22
Sat= 98%
Acidose mista
CO2 +H2O H2CO3 H+ + HCO3
Pneumonia
Choque séptico
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PH= 7,32
PaCO2= 24 (24 – 28)
PaO2= 95 mmHg
BE= -12
HCO3= 12
Sat= 98%
Acidose mista
CO2 +H2O H2CO3 H+ + HCO3
Pneumonia
Choque séptico