URGENTE
ACIDO-BAZICE
ACIDOZA METABOLICA
|
pH < 7,35; HCO3- < 21 mmol/l; mecanism compensator scaderea PaCO2. |
ETIOLOGIE
|
Gaura anionica normala (acidoza hipercloremica) |
digestiv: diaree, fistula intestinala, enterostomie, ureterosigmoidostomie renal: acidoza tubulara renala tip I / II, IRA (stadiu precoce) hiperalimentatie parenterala medicamente: Acetazolamida, Amfotericina, NH4Cl |
|
Gaura anionica crescuta (acidoza normocloremica) |
acidoza lactica1: hipoxie, sepsis, congenitala acidoza cetozica: diabet zaharat, foame intoxicatii exogene2 medicamente: ß-adrenergice, Teofilina, Izoniazida febra, hipotermie insuficienta renala |
pH < 7,35 + lactat seric > 5 mmol/l.
Salicilati, alcooli (etanol, metanol, etilenglicol), paraldehida, monoxid de carbon, cianuri.
|
CLINIC |
Respiratorii |
polipnee tahipnee respiratie acidotica Küssmaul |
|
Cardiace |
tahicardie tulburari de ritm cardiac vasodilatatie, scaderea TA diastolice |
|
Digestive |
greata varsaturi diaree dureri abdominale difuze ileus paralitic |
|
Nervoase |
astenie cefalee dezorientare stupor coma (pH < 7) deces (pH< 6,80) |
|
Alte semne |
febra inexplicabila |
|
PARACLINIC |
Sange |
Urina |
Alte investigatii |
|
ionograma (hiperpotasemie) ASTRUP glicemie uree, creatinina acid lactic ± piruvic |
sumar: - cetonurie - glicozurie - proteinurie - pH ionograma |
gaura anionica gaura osmolara diferenta arterio-venoasa de O2 |
|
TRATAMENT |
La sugar < 3 luni se administreaza solutie semimolara 4,2%.
ACIDOZA RESPIRATORIE |
pH < 7,35 cauzat de PaCO2 crescuta, compensat prin cresterea HCO3-
ETIOLOGIE
Afectiuni respiratorii |
laringita, aspiratie de corp strain atelectazie, pneumonie, bronhopneumonie, bronsiolita, astm bronsic, emfizem, fibroza chistica |
|
Boli neuro-musculare |
miastenie, poliradiculonevrita (sindrom Guillane- Bare), poliomielita forma bulbara, difterie decurarizare ineficienta, supradozare anticolinergica, traumatism toracic, hemotorace, pneumotorace |
|
Depresia centrului respirator |
intoxicatii (sedative, narcotice, Morfina) coma leziuni SNC ventilatie mecanica inadecvata |
CLINIC |
|
tahicardie HTA transpiratii, hipersecretie bronsica, vasodilatatie periferica, agitatie tremuraturi, halucinatii, somnolenta, coma, convulsii, stop respirator edem cerebral |
PARACLINIC |
Sange |
Urina |
|
ionograma (hiperpotasemie, hipocloremie) ASTRUP |
ionogramapH |
TRATAMENT |
ALCALOZA RESPIRATORIE |
|
pH > 7,44 cauzat de PaCO2 scazut, compensat prin scaderea HCO3- |
ETIOLOGIE
|
extrapulmonara: soc, anemii, afectiuni cardiace pulmonara: EPA, embolie pulmonara, astm, bronhopneumonie centrala: meningita, encefalita, hemoragii, tumori cerebrale, accident vascular cerebral intoxicatii: Aspirina (stadiu precoce), analeptice, cocaina, amfetamine altele: hipertiroidism, graviditate, insuficienta hepatica |
CLINIC
|
tahicardie palpitatii dureri precordiale parestezii convulsii tetanie |
PARACLINIC |
ionograma (hipopotasemie, hipercloremie, hipocalcemie)ASTRUP |
TRATAMENT |
ALCALOZA METABOLICA |
|
pH > 7,44, HCO3- > 28 mmol/l; mecanism compensator cresterea PaCO2 |
ETIOLOGIE
|
Aport crescut de alcaline |
NaHCO3 citrat de sodiu (transfuzii masive) saruri de acizi organici |
|
Pierderi mari de acizi |
digestive: varsaturi, stenoza pilorica, aspiratie gastrica, diaree congenitala cu pierdere excesiva de clor renale: abuz de diuretice saluretice (tiazidice si de ansa), exces de mineralocorticoizi (sindrom Cushing), hiperaldosteronism primar (sindrom Conn) si secundar (sindrom Bartter), corticoterapie depletie severa de potasiu, doze mari de Penicilina, Carbenicilina |
CLINIC |
|
ileus paralitic, spasme, convulsii, tetanie, aritmii cardiace astenie, confuzie, somnolenta, coma, reflexe exacerbate hipoventilatie formele grave: insuficienta circulatorie progresiva, puls slab perceptibil, hipotensiune ortostatica |
PARACLINIC |
Sange |
Urina |
|
ionograma (hipopotasemie, hipocloremie, calcemie normala / scazuta) ASTRUP |
ionogramapH 6,8-7,8 (mai acid in pierderi extrarenale de K+) |
TRATAMENT |
Etiologic
Alte
masuri
tratamentul hipopotasemiei
corectie volemica cu NaCl 0,9%
Acetazolamida 5-7,5 mg/kg/zi po la 8h (forma severǎ) maxim 1 g/zi
la pH > 7,70: 0,1-0,2 N HCl1 0,3 mEq/kg/h administrat pe vena centrala
deficit H+(mEq) = K x G x (HCO-3 initial - HCO-3 final), K=0,5
initial se compenseaza 1/2 din cantitatea calculata
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2. Cronan KM, Norman ME. Renal and electrolyte emergencies. În: Synopsis of pediatric emergency medicine. Fleisher GR, Ludwig S. (IVth edition, Lippincott Williams & Wilkins, Philadelphia, 2002: 332-339.
3. Foulkes D. Fluids and Electrolytes. În: The Harriet Lane Handbook. A Manual for pediatric House Officers. Gun VL, Nechyba C. (XVIth edition), Mosby, St Louis, 2002: 233-251.
4. Ledwith CA. Fluids & Electrolytes. În: Handbook of pediatrics. Appleton & Lange. USA Merenstein GB. si colab. 1994: 94-104.
5. Nanulescu M. Perturbari acido-bazice. Perturbari electrolitice. În: Urgente in pediatrie. Nanulescu M. Editura Dacia, Cluj Napoca, 1994: 91-101
6. Nichols DG, Yaster M. Electrolyte, metabolic and endocrine disorders. În: Golden Hour. The Handbook of Advanced Pediatric Life Support. Nichols DG. si colab. (IIthedition), Mosby, St Louis, 1996: 197-208.
7. Pearson GA. Fluids, electrolytes and blood. În: Handbook of Paediatric Intensive Care. Pearson GA. W.B. Saunders, Philadelphia, 2002: 83-91.
8. Pearson G.A. Metabolic intensive care. În: Handbook of pediatric Intensive Care. Pearson GA. W.B. Saunders, Philadelphia, 2002: 123-128.
9. Popescu V. Tauberg L. Boli metabolice si endocrine. În: Algoritm diagnostic si terapeutic in pediatrie. Popescu V. Editura Medicala. Amaltea, Bucuresti, 1999: 591-632.
10. Salomon B. Apa si electrolitii. În: Ghid clinic de pediatrie. Illing S. Spranger S. Editura. BIC ALL, Bucuresti,
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