PENDEKATAN

ASAM BASA
METODA STEWART

Anang Achmadi
Department of Anesthesiology & Intensive Care
Santosa Hospital Bandung Central
 BGA/ AGD

pH : 7.42

?
pCO2 : 35
pO2 : 100
BE : -2
HCO3 : 21
GANGGUAN KESEIMBANGAN ASAM BASA
TRADISIONAL

DISORDER pH PRIMER RESPON

KOMPENSASI
ASIDOSIS HCO3- pCO2
METABOLIK
ALKALOSIS HCO3- pCO2
METABOLIK
ASIDOSIS pCO2 HCO3-
RESPIRATORI
ALKALOSIS pCO2 HCO3-
RESPIRATORI
7.42 / 35 / 100 / -2 / 21
Menurut H-H normal

Na 140; Cl 102; Alb 1.8

(a) Free water
n 0.3 x (140-140) = 0
(b) Chloride effect
n 102-(102 x 140/140) = 0
(c) Albumin effect
n (0.148 x 7.42 - 0.818) (42-[18]) = 6.7
n UA = - 2 [(0) + (0) + (6.7)] mEq/L = - 8.7

HIDDEN
METABOLIC ACIDOSIS
Am J Respir Crit Care Med Vol 162. pp 22462251,2000
 Traditional view
Problems:
1. Which one is the independent variable?
2. What is the source of hydrogen ions?
3. Does not provide quantitative assessment
4. Does not explain dilutional acidosis or
contraction alkalosis
5. Does not explain hypoalbuminemic alkalosis
 Subversive New Concepts
in Acid-base Physiology
New paradigms are emerging (Current Opinion
Crit Care 1999; 5: 427- 477) in acid base physiology

Based on the work of the late Peter

Stewart (Can J Physiol Pharmacol 1983; 61: 1444-1461)
They are subversive because they
challenge traditional teaching
 Stewarts Approach
The Henderson-Hesselbach equation
describes the relationship of 3 linked
variables but does not say which is
dependent and which independent
The solvent (H2O) not the solutes is the
largest source of hydrogen ions
Menurut Stewart

pH atau [H+] DALAM PLASMA

DITENTUKAN OLEH

DUA VARIABEL

VARIABEL DEPENDENT
INDEPENDEN VARIABLES

Stewart PA. Can J Physiol Pharmacol 61:1444-1461, 1983.

 VARIABEL INDEPENDEN

CO2 STRONG ION DIFFERENCE WEAK ACID

pCO2
SID Atot
Controlled by the
The protein
respiratory system
The electrolyte concentration
composition of the (controlled by the liver
blood and metabolic state)
(controlled by the
kidney)
 CO2

CO2 Didalam plasma berada Rx dominan dari CO2 adalah rx

dalam 4 bentuk absorpsi OH- hasil disosiasi air
sCO2 (terlarut) dengan melepas H+.
H2CO3 asam karbonat Semakin tinggi pCO2 semakin
HCO3- ion bikarbonat banyak H+ yang terbentuk.
CO32- ion karbonat Ini yg menjadi dasar dari
terminologi respiratory acidosis,
yaitu pelepasan ion hidrogen
akibat pCO2

OH- + CO2 HCO3- + H+

CA
 STRONG ION DIFFERENCE

Definisi:
Strong ion difference adalah ketidakseimbangan muatan
dari ion-ion kuat. Lebih rinci lagi, SID adalah jumlah
konsentrasi basa kation kuat dikurangi jumlah dari
konsentrasi asam anion kuat. Untuk definisi ini semua
konsentrasi ion-ion diekspresikan dalam ekuivalensi
(mEq/L).

Semua ion kuat akan terdisosiasi sempurna jika berada didalam

larutan, misalnya ion natrium (Na+), atau klorida (Cl-). Karena
selalu berdisosiasi ini maka ion-ion kuat tersebut tidak
berpartisipasi dalam reaksi-reaksi kimia. Perannya dalam kimia
asam basa hanya pada hubungan elektronetraliti.
 STRONG ION DIFFERENCE

Mg++
Ca++
K+ 4
SID

[Na+] + [K+] + [kation divalen] - [Cl-] - [asam organik kuat-]

Na+
140 Cl-
102

[Na+] + [K+] - [Cl-] = [SID]

140 mEq/L + 4 mEq/L - 102 mEq/L = 34 mEq/L

KATION ANION
 MENGAPA DISEBUT ION KUAT DAN LEMAH ?

100
80
70
60
% ter-ionisasi 50 pK
40
30
20
10

2 3 4 5 6 7 8 9

pH
Suatu ion dikatakan kuat atau lemah tergantung dari pKnya (pH, dimana 50%
dari substansi tsb terdisosiasi). Mis; pK Lactate 3.9 (berarti, pada pH normal,
hampir 100% laktat terdisosiasi ). H2CO3 dan Alb disebut asam lemah karena
pada pH normal hanya 50% substansinya terdisosiasi.
 Elektrolit = Ion-ion
Ion-ion kuat
(Strong ions) :
Substansi yang terdisosiasi
sempurna di dalam suatu larutan :
Kation; Na+,K+,Mg+,Ca++
Anion; Cl-,SO4-,PO4=,
laktat-, keto-.
Ion-ion lemah
(Weak ions) :
Substansi yang hanya
sebagian terdisosiasi dalam
suatu larutan :
Albumin-, Posfat-, H2CO3
 Hubungan SID dgn pH/H+

Konsentrasi H+ [H+] [OH-]

SID SID
SID
Na Na Na
Cl Asidosis Cl Alkalosis Cl

() SID (+)

Dalam cairan biologis (plasma) dgn suhu 370C, SID selalu positif,
nilainya berkisar 30-40 mEq/Liter
 DEPENDENT VARIABLES

H+ HCO3-

OH- AH
CO3- A-
 PRINSIP UMUM
Hukum kekekalan massa (Law of Mass):
Jumlah dari suatu zat/substansi akan selalu konstan
kecuali ditambahkan atau dikurangi dari luar, atau
dibuat/dirusak oleh suatu reaksi kimia.
Netralitas elektrik (Electroneutrality):
Semua larutan sejati mempunyai muatan listrik yang
netral, dimana konsentrasi total kation harus sama
dengan konsentrasi anion
iones (+) = iones (-)

Stewart PA. Modern quantitative acid-base chemistry. Can J Physiol Pharmacol 61:1444-1461, 1983.
 Konsep larutan encer
(Aqueous solution)

Semua cairan dalam tubuh manusia

mengandung air, dan air merupakan sumber [H
+] yang tidak habis-habisnya

[H+] ditentukan oleh disosiasi air (Kw), dimana

molekul H2O akan berdisosiasi menjadi ion-ion
H3O+ dan OH-
 WEAK ACID

[Protein H] [Protein-] + [H+]

disosiasi
Kombinasi protein dan posfat disebut asam
lemah total (total weak acid) [Atot].
Reaksi disosiasinya adalah:

[Atot] (KA) = [A-].[H+]

INDEPENDENT VARIABLES DEPENDENT VARIABLES

Strong Ions
Difference
H+
PHYSICOCHEMICAL Rx HCO3-
CONSERVATION of MASS OH-
pCO2
ELECTRONEUTRALITY tCO2
A-
CO3=

Protein
Concentration
BLOOD PLASMA

H+

HCO3- SID
Na+ OH- CO32-
ATot
Alb -
Posfat - Unmeasured Anion
XA -
K+
Mg++
Ca++

Cl-

CATION ANION
 Clasification (Fencl et al)

ACIDOSIS ALKALOSIS

I. Respiratory PCO2 PCO2

II. Nonrespiratory (metabolic)

1. Abnormal SID

a. Water excess/deficit SID, [Na+] SID, [Na+]

b. Imbalance of strong anions

i. Chloride excess/deficit SID, [Cl-] SID, [Cl-]

ii. Unidentified anion excess SID, [XA-]

2. Non-volatile acids

i. Serum albumin [Alb] [Alb]

ii. Inorganic phosphate [Pi] [Pi]

WORKSHOP ACIDBASE STEWART PERDICI
2006
Advantages of Stewarts Method
The effect of chloride is explicitly recognized
The effect of plasma proteins and phosphate in
appreciated and quantified
The pathogenesis of the acid-base disorder is
better understood
More logical therapies can be implemented
Misdiagnoses are decreased, especially if
lactate is not immediately available
 STOMACH

Alkaline tide

Cl-
Na: 20-80
SID (+)
Cl: 150-180
pH
SID (-) Alkalosis
pH

Kellum JA. Diagnosis and Treatment of Acid-Base Disorders. In: Textbook of Critical Care,
W.B. Saunders Co, Philadelphia, PA , 1999. Grenvik A, Shoemaker PK, Ayers
S, Holbrook (eds). pp839-853

Magder S. Pathophysiology of metabolic acid-base disturbances in patients with

critical illness.In: Critical Care Nephrology. Kluwer Academic Publishers, Dordrecht,
The Netherlands, 1998. pp 279-296.Ronco C, Bellomo R (eds).
 SMALL INTESTINE INTESTINE

GALL
BLADDER
pH > 7.5 Cl- Cl-
PANCREAS
pH > 7.7 SID ()
CATION
pH

Kellum JA. Diagnosis and Treatment of Acid-Base Disorders. In: Textbook of Critical Care,
W.B. Saunders Co, Philadelphia, PA , 1999. Grenvik A, Shoemaker PK, Ayers
S, Holbrook (eds). pp839-853
Magder S. Pathophysiology of metabolic acid-base disturbances in patients with critical
illness.In: Critical Care Nephrology. Kluwer Academic Publishers, Dordrecht, The
Netherlands, 1998. pp 279-296.Ronco C, Bellomo R (eds).
 Volume dan komposisi elektrolit cairan gastrointestinal
From Miller, Anesthesia, 5th ed,2000.

24 h vol. Na+ K+ (mEq/L) Cl- (mEq/ HCO3-

(mL) (mEq/L) L) SID

Saliva 500-2000 6 25 13 18

Stomach 1000-2000 80 15 115 -20

Pancreas 300-800 140 7.5 80 67.5

Bile 300-600 140 7.5 110 37.5

Jejunum 2000-4000 130 7.5 115 22.5

Ileum 1000-2000 115 5 92.5 27.5

Colon - 60 30 40 -
 DILUTIONAL ACIDOSIS
NaCl + H2O Na+ + Cl- + H+ + OH- + H2O

1 L H2O
2 liter
Na+ = 70 mEq/L
Na+ = 140 mEq/L Cl- = 55 mEq/L
Cl- = 110 mEq/L SID = 15 mEq/L
SID = 30 mEq/L 1 liter
 CONTRACTION ALKALOSIS

1 Liter

Na+ = 140 mEq/L

Cl- = 110 mEq/L 1 liter Na+ = 280 mEq/L
liter
SID = 30 mEq/L Cl- = 220 mEq/L
SID = 60 mEq/L
 Ringer Laktat
Na Cl K Ca Osms bicnat

Ringer Laktat 131 111 5 4 276 29

Plasma 135 105 4 5 290 +10 24

33
 NaCl
Na Cl Osm

NaCl 0,9% 154 154 308

NaCl 0,45% 77 77
NaCl 3% 513 513 1026

Plasma 135 108 290 +10

34
PLASMA + NaCl 0.9%

Plasma NaCl 0.9%

Na+ = 140 mEq/L Na+ = 154 mEq/L

Cl- = 102 mEq/L Cl- = 154 mEq/L
SID = 38 mEq/L 1 liter SID = 0 mEq/L 1 liter

SID : 38
35
 ASIDOSIS HIPERKLOREMIK AKIBAT
PEMBERIAN LARUTAN Na Cl 0.9%

Plasma

= Na+ = (140+154)/2 mEq/L= 147 mEq/L

Cl- = (102+ 154)/2 mEq/L= 128 mEq/L

SID = 19 mEq/L 2 liter

SID : 19 Asidosis
36
PLASMA + Larutan RINGER LACTATE

Plasma Ringer laktat

Laktat cepat
dimetabolisme
Cation+ = 137 mEq/L
Na+ = 140 mEq/L Cl- = 109 mEq/L
Cl- = 102 mEq/L Laktat- = 28 mEq/L
SID= 38 mEq/L 1 liter SID = 0 mEq/L 1 liter

SID : 38
37
Normal pH setelah pemberian
RINGER LACTATE

Plasma

= Na+ = (140+137)/2 mEq/L= 139 mEq/L

Cl- = (102+ 109)/2 mEq/L = 105 mEq/L
Laktat- (termetabolisme) = 0 mEq/L
2 liter
SID = 34 mEq/L

SID : 34 lebih kecil perubahan SID dibanding jika

diberikan NaCl 0.9%
38
 Kesimpulan

0.9% saline = (Ab)normal Saline

Reid et al, Clin Sci, 2003

39
 MEKANISME PEMBERIAN NA-BIKARBONAT
PADA ASIDOSIS

Plasma; Plasma + NaHCO3

asidosis
hiperkloremik

25 mEq
NaHCO3 HCO3 cepat
Na+ = 140 mEq/L Na+ = 165 mEq/L dimetabolisme
Cl- = 130 mEq/L Cl- = 130 mEq/L
1.025 SID = 35 mEq/L
SID =10 mEq/L 1 liter
liter

SID : 10 35 : Alkalosis, pH kembali normal namun mekanismenya bukan

karena pemberian HCO3- melainkan karena pemberian Na+ tanpa anion kuat yg
tidak dimetabolisme seperti Cl- sehingga SID alkalosis
 Efek pemberian bikarbonat:

CO2 + H2O HCO3- + H+

[HCO3- ] [CO32-] + [H+] Reaksi pembentukan karbonat

Alkalosis [H+] reaksi ke kanan [CO32-]

Jika [CO32-] maka calcium yang terionisasi akan diikat oleh [CO32-]
hipokalsemia akut; sensitifitas membran sel tetany, hyperexcitability of
muscles, sustained contraction, dan gangguan kontraksi otot jantung.

Pe natrium secara cepat SID secara cepat alkalosis berat

kompensasi paru dengan cara menahan CO2 hipoventilasi CO2
narkosis apneu

Asidosis [H+] reaksi ke kiri [CO32-]

Pada asidosis kronik; [CO32-] pembentukan CaCO3 << integritas

tulang terganggu osteoporosis
OTHER FINDINGS :
1. HCO3 doesn t improve hemodynamic in
critically ill patients who have lactic acidosis
(Cooper; Ann Inter Med. 1990)
2. HCO3 therapy in the treatment of lactic acidosis :
Medicine or toxin?
(Sing Et Al, J Ann. Osteopath. Assoc. 1995)
3. The Routine use of sodium
bicarbonate is no longer recommended.
(In 1992, the American National Conference on
Cardiopulmonary Resuscitation established current
guidelines)
4. CONSENSUS CONFERENCE in FRANCE (June 2000)
organized by The French Reanimation Society
recommend not to give sodium bicarbonate in any
acidosis except in HCO3 loss.
 PENILAIAN ANALISA GAS DARAH
MENGGUNAKAN KOMBINASI BASE EXCESS
DAN STEWART
Nilai2 yg diperlukan:
1. AGD (BE)
2. Natrium
3. Klorida
4. Albumin

Story DA, Bellomo R. Hendersen-Hasselbach vs Stewart: Another Acid-Base

Controversy; Review Article, Crit Care & Shock (2002)2:59-63
 BE = (1 - 0.014Hgb) (HCO3 24 + (1.43Hgb + 7.7) (pH - 7.4)`

50
PCO2 = 80 40

40
Base Excess/
[HCO3-]

Alkalosis
"20 Base Deficit
30 Metabolik

Base Excess"

Normal "
20 Base Defisit"
Asidosis
Metabolik "
10
7.0 7.2 7.4 7.6 7.8
pH
 UNMEASURED ANION (UA)
PADA ASIDOSIS METABOLIK

UA = BE [(efek Na + efek Cl) + efek Alb]

 BASE EXCESS DAN STEWART
(a) Free water
n 0.3 x (Na-140)
Jika + efek alkalinisasi
(b) Chloride effect Jika - efek asidifikasi
n 102-(Cl x 140/Na)
(c) Albumin effect
n (0.148 x pH - 0.818) (42-[alb])
n UA = BE/BD [(a) + (b) + (c)] mEq/L
Magder S. Pathophysiology of metabolic acid-base disturbances in patients with critical illness.
In: Critical Care Nephrology.Kluwer Academic Publishers, Dordrecht, The Netherlands, 1998. pp 279-296.
Ronco C, Bellomo R (eds).
Clinical Investigations

Strong ions, weak acids and base excess:

a simplified FenclStewart approach to
clinical acidbase disorders
D. A. Story, H. Morimatsu and R. Bellomo . British Journal of Anaesthesia, 2004, Vol. 92,

SBE(mmol/l=meq/l);
from a blood gas machine
NaCl effect (meq/l)=
[Na+][Cl]38
Albumin effect (meq/l)=
0.25x[42alb(g/l)]
Unmeasured ion effect (meq/l)=
SBE(NaCl) effectalb effect
Hatur nuhun