Teori Dasar Pendekatan Kuantitatif I Dan II

Teori Dasar Pendekatan
Kuantitatif I
Stewart approach
WORKSHOP ACIDBASE
STEWART PERDICI 2006
ASAM BASA..
[H ]
+
pH
Acid
Base
Notasi pH diciptakan oleh seorang ahli kimia dari

Denmark yaitu Soren Peter Sorensen pada thn 1909, yang
berarti log negatif dari konsentrasi ion hidrogen. Dalam
bahasa Jerman disebutWasserstoffionenexponent
(eksponen ion hidrogen) dan diberi simbol pH yang
berarti: potenz (power) of Hydrogen.
defined by Sorensen
pH = -log[H ]
+
[H ]
-6
1 x 10
-7
1 x 10
8 x 10-8
4 x 10-8
2 x 10-8
1 x 10-8
pH
6.0
7.0
7.1
7.4
7.7
8.0
Normal = 7.40 (7.35-7.45)

Viable range = 6.80 - 7.80
Keseimbangan
asam basa
Who cares
about acid
base
balance?
Saya punya hasil

astrup, artinya
apa nich..?
MENGAPA
PENGATURAN pH
SANGAT PENTING ?
AKIBAT DARI ASIDOSIS BERAT

Kardiovaskular
Gangguan kontraksi otot jantung
Dilatasi Arteri,konstriksi vena, dan
sentralisasi volume darah
Peningkatan tahanan vaskular paru
Penurunan curah jantung, tekanan
darah arteri, dan aliran darah
hati dan ginjal
Sensitif thd reentrant arrhythmia dan
penurunan ambang fibrilasi
ventrikel
Menghambat respon kardiovaskular
terhadap katekolamin
Respirasi
Hiperventilasi
Penurunan kekuatan otot nafas dan
menyebabkan kelelahan otot
Sesak
Metabolik
Peningkatan kebutuhan
metabolisme
Resistensi insulin
Menghambat glikolisis anaerob
Penurunan sintesis ATP
Hiperkalemia
Peningkatan degradasi protein
Otak
Penghambatan metabolisme dan
regulasi volume sel otak
Koma
Management of life-threatening Acid-Base Disorders, Horacio J. Adrogue, And

Nicolaos EM: Review Article;The New England Journal of Medicine;1998
AKIBAT DARI ALKALOSIS BERAT

Kardiovaskular
Konstriksi arteri
Penurunan aliran darah koroner
Penurunan ambang angina
Predisposisi terjadinya supraventrikel dan ventrikel
aritmia yg refrakter
Respirasi
Hipoventilasi yang akan menjadi hiperkarbi dan
hipoksemia
Metabolic
Stimulasi glikolisis anaerob dan produksi asam organik
Hipokalemia
Penurunan konsentrasi Ca terionisasi plasma
Hipomagnesemia and hipophosphatemia
Otak
Penurunan aliran darah otak
Tetani, kejang, lemah delirium dan stupor
Management of life-threatening Acid-Base Disorders, Horacio J. Adrogue, And
Nicolaos EM: Review Article;The New England Journal of Medicine;1998
Efek pH dan CO2 terhadap oksigenasi

jaringan
Tn A;
pH 7.5
Sat O2 99%
Inhibited
Unloading
P50
Better
Unloading
Tn B;
pH 6.9
Sat O2 89%
PENILAIAN STATUS
ASAM BASA
Analytic tools used in acid

base chemistry
CO2-bicarbonate (Boston) approach
Schwartz, Brackett et al
H-H equation
The Base deficit/excess (Copenhagen) approach
1948 Singer-Hasting, Buffer Base (BB)
1958 Siggaard-Andersen. Base Deficit/Excess
(BDE)
1960, Hb into calculation, modified Standard Base
Deficit/Excess (SBE)
1977 Van Slyke equation to computed SBE
Has been validated by Schlitic and Morgan
Analytic tools used in acid

base chemistry
1977, Anion Gap approach
Emmet and Narins
To address the limitation of Boston and Copenhagen
1978, Stewart introduced the physical-chemical approach

3 independent variable;
PCO2, SID and weak acid
1983, Stewart-Fencl approach

1998, Anion Gap Corrected
Fencl and Figge
2004, simplified Stewart-Fencl approach

Story DA, Morimatsu et al
CARA TRADISIONAL
Hendersen-Hasselbalch
The disadvantage of men not knowing the

past is that they do not know the present.
G. K. Chesterton
Regulasi asam basa diatur melalui proses di:
1. Ginjal dengan cara mempertahankan [HCO3-]
sebesar 24 mM dan
2. Mekanisme respirasi dengan cara
mempertahankan
tekanan parsial CO2 arteri
(PaCO2) sebesar 40 mmHg.
Normal
pH = 6.1 + log
Normal
[HCO
GINJAL
BASA ]
3
HCO
HCO 3
3
Kompensasi
ASAM
pCO2
PARU
CO
CO22
pH = 6.1 + log
1. Change in
Metabolic disturbance
2. Change after
Renal compensation for
Respiratory disturbance
[ HCO3-]
0.03 pCO2
x
1. Change in
Respiratory disturbance
2. Change after
Respiratory compensation for
Renal disturbance
Diagram Davenport
50
PCO2 = 80
40
[ HCO3- ]
40
pH = 6.1 + Ginjal
Paru
B 7.2 / 80 / 30
30
20
A 7.4 / 40 / 24
C 7.6 / 20 / 18
Normal
20
10
7.0
7.2
7.4
pH
7.6
7.8
Gangguan asam-basa primer

ma
r
o
n
no
rm
a
P CO
Lo
w
CO 3
ig
h
HC
ma
nor
pH
Lo
w
H
ig
CO 3
CO 2
Asidosis Metabolik
Alkalosis Respiratori
Asidosis Respiratori
CO 2
no
pH
rm
al
P CO
Lo
w
H
ig
pH
Lo
w
pH
H
ig
HC
Alkalosis Metabolik
Diagnosis menggunakan nilai asam basa serum:

50
Davenport Diagram
PCO = 80
40
Henderson- Hasselbalch:
[ HCO3- ]
40
pH = pK + log [HCO3-]
s PCO2
Asidosis
Respiratori
Alkalosis
Metabolik
30
20
pH = 6.1 + Ginjal
Paru
Normal
20
Asidosis
Metabolik
Alkalosis
Respiratori
10
7.0
7.2
7.4
pH
atau,
7.6
7.8
RESPON KOMPENSASI
Alkalosis Respiratori
50
PCO = 80
2
40
[ HCO3- ]
40
20
30
Normal
Alkalosis
Respiratori
20
kompensasi = [HCO3-]
10
7.0
7.2
Alkalosis
Respiratori
terkompensasi
7.4
pH
7.6
7.8
Penyebab:
1) Nyeri
2) Histerik
3) Hipoksia
Asidosis Respiratori
50
PCO = 80
40
[HCO3-]
kompensasi
= [HCO3-]
40
Asidosis
Respiratori
terkompensasi
Penyebab:
1) PPOK, Gagal jantung
kronik, bbrp pnykt
paru
2) Obat anestesi
20
30
Asidosis
Respiratori
20
10
7.0
7.2
7.4
pH
7.6
7.8
Metabolic Alkalosis
50
PCO = 80
40
[ HCO3- ]
40
kompensasi
= PCO2
Alkalosis
Metabolik
terkompensasi
Alkalosis
Metabolik
30
20
20
10
7.0
7.2
7.4
pH
7.6
7.8
Penyebab:
1) Intake basa >>
2) Kehilangan asam
(Muntah,
penyedotan lambung)
Metabolic Asidosis
50
PCO = 80
2
40
[ HCO3- ]
40
20
30
20
Asidosis
Metabolik
Asidosis
Metabolik
terkompensasi
kompensasi = PCO2
10
7.0
7.2
7.4
pH
7.6
7.8
Penyebab:
1) Kehilangan basa
(eg. diare)
2) Akumulasi asam
(diabetes, gagal ginjal)
3) Asidosis Tubular Ginjal
Kompensasi ginjal terhadap asidosis resp. kronik
PPOK
Kompensasi ginjal & paru terhadap asidosis non ginjal
Keto/Laktat
asidosis
ASIDOSIS METABOLIK
Normal
ANION GAP
Electroneutrality
145
AG = 10-15
AG
Na
HCO-3
Cl
25
105
Penambahan H+ ClKehilangan HCO3-
Metabolic acidosis
AG
Na
145
HCO-3
Cl
Penambahan H+ A-
= 15 (normal)
AG
15
145
115
Normal AG ASIDOSIS
HIPERKLOREMIK
Na
HCO-3
Cl
= 25 (incl A-)
15
105
Peningkatan AG ASIDOSIS
LAKTAT/KETO/SALISILAT
DLL
BE = (1 - 0.014Hgb) (HCO3 24 + (1.43Hgb + 7.7) (pH 7.4)`
50
PCO = 80
40
[HCO3-]
40
Alkalosis
Metabolik
30
Base Excess
20
Base
Excess/
Base Deficit
Normal
20
Base Defisit
10
7.0
Asidosis
Metabolik
7.2
7.4
pH
7.6
7.8
RANGKUMAN GANGGUAN
KESEIMBANGAN ASAM BASA
TRADISIONAL
DISORDER
pH
PRIMER
ASIDOSIS
METABOLIK
HCO3-
RESPON
KOMPENSASI
pCO2
ALKALOSIS
METABOLIK
HCO3-
pCO2
ASIDOSIS
RESPIRATORI
pCO2
HCO3-
ALKALOSIS
RESPIRATORI
pCO2
HCO3-
Now for something new

HOW TO UNDERSTAND ACIDBASE
A quantitative Acid-Base Primer
For Biology and Medicine
Peter A. Stewart
Edward Arnold, London 1981
Goals, definitions and

basic principles of
Stewart theory
WORKSHOP ACIDBASE
PRINSIP UMUM
Electroneutrality. In aqueous solutions in any
compartment, the sum of all the positively charged ions
must equal the sum of all the negatively charged ions.
Conservation of mass, the amount of a substance remains
constant unless it is added, removed, generated or
destroyed. The relevance is that the total concentration of
an incompletely dissociated substance is the sum of
concentrations of its dissociated and undissociated forms.
Stewart PA. Modern quantitative acid-base

chemistry.
Can J Physiol Pharmacol 61:1444-1461, 1983.
WORKSHOP
ACIDBASE
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-
WORKSHOP ACIDBASE
Hydrogen ion
Hidrogen ion concentration in body fluids is
extremely low, on the order of one tenmillionth of an equivalent perliter.
Changes in hidrogen ion concentration may
have important effects on biochemical reaction
rates simply because hydrogen ions are
involved in so many biochemical reactions.
Clinically, hidrogen ion concentration, ([H+]), in
body fluids is important as a useful indicators
of several different kinds of pathology
Hydrogen ion
[H+] is most easily meassured in blood, via
small venipuncture sample and a pH meter. The
[H+] of mixed venous blood sample is usually
near 4.5x10-8 Eq/litre (pH 7.35), while arterial
blood [H+] is near 4.0x10-8 Eq/litre )pH 7.40).
Value about 1.2x10-7 E/litre (pH 6.9) or below
about 1.6 x10-8 Eq/litre (pH 7.8) indicate life
threatening situation and demand immediate
intervention.
The Goals
In any given solution, under specified
conditions, we want to establish the
quantitative relationships between hydrogen
ion hydrogen ion concentration in that solution
and all the other variables in the solution that
determine that hydrogen ion concentration.
WORKSHOP ACIDBASE
Definitions of solution
Definition:
A solution is said to be acid-base neutral if
its hydrogen ion concentration (H+) is equal
to its hydroxyl ion concentration (OH-)
Acid-base neutrality is a very special, rarely
achieved condition. It must be carefully
distinguished from electrical neutrality, a very
different.
A solution is said to be acidic, or acid, if its

(H+) is greater than its (OH-)
A solution is said to be alkaline, or basic, if
its (H+) is less than its (OH-)
Definitions of substance
[H+]
[OH-]
Neutral
[H+] = [OH-]
Acidic
Basic
[H+] >[OH-]
[H+] < [OH-]
Asam:
Basa:adalah
adalah zat
zat yang
yangketika
ketika
ditambahkan
ditambahkan
ke dalam
ke dalam
larutan
larutan,
akan
akan menyebabkan
menurunkan
peningkatan
konsentrasi
konsentrasi
[H+]
[H+]
WORKSHOP ACIDBASE
[H+] and temperature

(H+), by its self, is clearly nor reliable meassure
of acidity, alkalinity or neutrlity, nor its
negative log, pH. In pure water, for example,
(H+) and (OH-) are always equal, so pure water
is always acid-base neutral, but its (H +) varies
significantly with teamperature, from 3.4x10-8
Eq/litre at 00C to 8.8x10-7 Eq/litre at 1000C.
The common text book statement that
neutrality is at pH 7.0, corresponding to (H +) of
1.0x10-7 Eq/litre, is only true in pure water at
250C. In particular, it is not true at body
temperature, 370C, for which the pH of pure
water is 6.8
WORKSHOP ACIDBASE
What is the pH of water?
MOLEKUL AIR DAN PRODUK DISOSIASINYA

(auto-ionisasi air)
disosiasi
WORKSHOP ACIDBASE
Sebenarnya, H+ di dalam larutan berada dalam bentuk H3O+

+
H
+ H
O
-
O
+ H
+H
O
H
+
O
H
H
WORKSHOP
ACIDBASE
+
+
H+
OH-
WORKSHOP ACIDBASE
Air / H2O
Sangat reaktif:
dis-asosiasi air
Karena massa dari H sangat kecil = maka
di dalam suatu larutan selalu akan terjadi
proton jumping
Auto-ionisasi
H
O- OH
H+
- +
HO
O
3
+
Proton jumping
Water does not

spontaneously
disassociatestrong
ions must be present!
Peranan elektrolit dalam

teori stewart
WORKSHOP ACIDBASE
Elektrolit = Ion-ion
Ion-ion kuat
(Strong ions)
Ion-ion lemah
(Weak ions)
Semua ion kuat akan terdisosiasi sempurna jika berada

didalam larutan. 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 Ions
Completely dissociate in aqueous solution
Cations
Anions
Na+
K+
Ca++
Mg++
Cl SO4 Lactate Acetoacetate-
Unmetabolizabl
e Strong
Kation
Unmetabolizabl
e Strong Anion
Metabolizable
Strong Anion
WORKSHOP ACIDBASE
MENGAPA LAKTAT DAN KETON DISEBUT ION

KUAT?
40
30
Alb
um
in
50
HC
O
% ter-ionisasi
60
70
pK
CO
Lac
tat
e, a
cet
oac
e
80
tat
e
100
20
10
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.
WORKSHOP ACIDBASE
Strong ions/electrolyte:
Substance that exist as essentially
completely dissociated in aqueous solution,
H3O+
K+
H3O+
Ca
++
OH Mg
-
OH-
Lactate-
Na+
OH
H3O+
SO4-2
H3O+
OH-
KA > 104 Eq/L

WORKSHOP ACIDBASE
Cl-
Old paradigm
NaOH + HCl NaCl + H2O
NaOH + HCl Na+ + Cl- + OH- + H+
The Na+ and Cl- have not taken part in
any reaction and no NaCl is formed
WORKSHOP ACIDBASE
Weak ions/electrolyte:
Substance that are only partially dissociated in
aqueous solution,
Phosphate-
Albumin-
H3O+ OH-
CO2
KA between 104 and 10-12 Eq/L
WORKSHOP ACIDBASE
Elektrolit jika berada

dalam air
WORKSHOP ACIDBASE
BAGAIMANA JIKA ION-ION KUAT

BERADA DI DALAM AIR
WORKSHOP ACIDBASE
Garam solid
+ +
Na+
Cl
+
+
+
+ +
+
+
- ++
+ +
Ion-ion kuat akan berdisosiasi

di dalam air (plasma)
WORKSHOP ACIDBASE
-+
+
+
+
+-
WORKSHOP ACIDBASE
WORKSHOP ACIDBASE
Cl-
Na+
Reaksi hidrasi ion-ion kuat

WORKSHOP ACIDBASE
Strong Ions and Water

Jika larutan mengandung Cl-(anion) >> (SID) H3O+ >>
Jika larutan mengandung Na+ (kation) >> (SID ) OH- >>
Water
O- H OH+
H+
Strong ions disassociate in water
Base
Acid
Na+ ClSalt
SID
SID
SID n
H3O+
Na
Na
O
PlasmaH
Cl
Cl
WORKSHOP ACIDBASE
Proton
Jumping
Perubahan yang terjadi pada pH atau [H +]

bukan sebagai akibat dari penambahan atau
pengurangan H+, namun semata-mata
akibat dari disosiasi dari airakibat adanya
perubahan dari strong ion difference dalam
air tersebut
WORKSHOP ACIDBASE
DI DALAM PLASMA :
1. [Na+] + [K+] - [Cl-] = [SID]
2. [Atot] (KA) = [A-].[H+]

3. [2H2O] Kw . [H+][OH-]
CA
4. OH + CO2 H2CO3 HCO3- CO3= + H+

-
WORKSHOP ACIDBASE
PERSAMAAN ATAU
FORMULA2 DALAM
STEWART APPROACH
WORKSHOP ACIDBASE
1. PURE WATER
Characteristic of water;
Strongly ionic substances dissociate when placed in water
Water it self dissociates, but only a little
Water containts a lot of water
Molecular weight are small (18) but
Molar concentration is >> (55.3 mol/l at 370C)
WORKSHOP ACIDBASE
Water dissociates as follow;

H2O H+ + OHVery rapid reaction, equilibrium is reached instantaneously in biological
solution
At equilibrium
[H+].[OH-] = Kw.[H2O]
Kw is very small, 4.3 x 10-16 Eq/l at 370C and temperature dependent,
e.g at 250C is 1.8 x 10-16Eq/l
WORKSHOP ACIDBASE
A new constant
Kw = Kw x [H2O]
Kw is product of the two constant;
- Kw and
- The molar concentration of water
Lets find the pH of pure water
WORKSHOP ACIDBASE
[H+] x [OH-] = Kw
If we know the Kw, we still need to find one of the other variables, [OH -]
Electroneutrality;
[H+] [OH-] = 0
[H+] = [OH-]
[H+] = Kw
if [H+] = Kw (neutral)
if [H+] > Kw (acidic)
if [H+] < Kw (basic)
WORKSHOP ACIDBASE
2. STRONG ELECTROLYTES IN
PURE
WATER
Water dissociation;
[H+] x [OH-] = Kw equation 0
SID = STRONG IONS DIFFERENCE
Electroneutrality;
[H+] - [OH-] + [Na+] - [Cl-] = 0 equation #1

Substitute Kw/[H+] for [OH-]
[H+] Kw/[H+] + [Na+] [Cl-] = 0

[H+]2 + [H+]( [Na+] [Cl-]) Kw = 0
Quadratic equation a.x2 + b.x + c = 0
[H+] = - ( [Na+] [Cl-] )/2 + {( [Na+] [Cl-] )2/4 + Kw}

WORKSHOP ACIDBASE
And solving for [H+]

[H+] = Kw + SID2/4 SID/2
equation #2
[OH-] = Kw + SID2/4 + SID/2 equation #3

In these solution it is clear that if the hydrogen ion concentration
changes
the SID must have changed
WORKSHOP ACIDBASE
SKETCH; RELATIONSHIP BETWEEN SID,H+ AND

OH-
[H+]
[OH+]
()
SI
D
(+)
In biological solutions at 370C, the SID nearly

always positive, usually around 40 mEq/Liter
WORKSHOP ACIDBASE
3. ADDING A WEAK
ELECTROLYTE
A more complex setup Adding a weak electrolyte
A weak electrolyte, [Atot]:
One that partially dissociated in the pH range
The most important in plasma is albumin
Represents the total amount of weak electrolytes produced
by biochemical reactions within the body, or represents the
total amount of available buffer in body.
WORKSHOP ACIDBASE
Weak Acids:
HA (such as albumin) dissociates to form H+ and A-, as
follow:
HA H+ + ACombined with two equation and the term of
electroneutrality
[H+] x [OH-] = Kw eq#0
[H+] + [OH-] + [SID] + [A-] = 0 eq#1A
Dissociation of acids and conservation of mass;
[H+] x [A-] = KA x [HA] eq #4
[HA] + [A-] = [ATot] eq #5
WORKSHOP ACIDBASE
Identify the independent variables (Kw,[SID],[ATot] and KA)

and dependent one ([H+],[OH-],[HA] and [A-]
Eliminate all dependent variables apart from [H+] from the
equation by substitution:
[OH-] = Kw/[H+] from eq #0
[HA] = [ATot] [A-] from eq #5
And substituting eq#5 into eq#4
[A-] = Ka x [ATot] /([H+] + KA)
WORKSHOP ACIDBASE
Substitute these values into equation #1A, and get;

[SID] +[H+]-Kw/[H+]KA [ATot] /(KA+[H+]) =0 eq #6
Use a computer programe to find the [H+]
ITS EASY AND QUICK !!!
WORKSHOP ACIDBASE
4. STRONG IONS WITH CO2

Take a mixture of strong ions and water, and expose it to CO 2
What happen to CO2 gas when exposed to water
Dissolved
React with water to form carbonic acid
Bicarbonate or
Carbonate ions
WORKSHOP ACIDBASE
a. CO2 can dissolved:

CO2 (gas) CO2 (dissolved)
Equilibrium:
[CO2 dissolved] = SCO2 x PCO2 equation #7A
SCO2 = Solubility of CO2, 3.0 x 105 Eq/l/mmHg at 370C
WORKSHOP ACIDBASE
b. Can react with water;

CO2 + H2O H2CO3
Equilibrium;
[CO2 dissolved] x [H2O] = K x [H2CO3]equation #7B
If [H2O] constant;
[H2CO3] = KH x PCO2
KH at 370C is 9 x 108 Eq/l
WORKSHOP ACIDBASE
c. H2CO3 dissociate;
H2CO3 H+ + HCO3 Equilibrium;
[H+] x [HCO3-] = K x [H2CO3]
[H+] x [HCO3-] = KC x PCO2 equation #8
KC is 2.6 x 1011 Eq/l2/mmHg
WORKSHOP ACIDBASE
d. HCO3- rapidly dissociate:

HCO3- H+ + CO32
Equilibrium;
[H+] x [CO32] = K3 x [HCO3-] equation #9
K3 is 6 x 1011 Eq/l
K3 is 6 x 10 11 Eq/l
WORKSHOP ACIDBASE
THE SIX SIMULTANEOUS

EQUATIONS USED BY STEWART
Water Dissociation Equlibrium
[H+] x [OH-] = Kw
Electrical Neutrality Equation
[SID] + [H+] = [HCO3-] + [A-] + [CO3 2] + [OH-]

Weak acid Dissociation Equilibrium
Conservation of Mass for A
[H+] x [A-] = KA x [HA]
[ATot] = [HA] + [A-]
Bicarbonate Ion Formation Equilibrium
[H+] x [HCO3] = Kc x pCO2

Carbonat Ion Formation Equilibrium
[H+] x [CO32] = K3 x [HCO3-]

WORKSHOP ACIDBASE
A 4th polynomial order
ax4 + bx3 + cx2 + dx + e = 0

Substitute;
a.[H+]4 + b.[H+]3 + c.[H+]2 + d.[H+] + e = 0

Where,
a = 1
b = [SID] + KA
c = { KA ([SID] [ATot]) Kw Kc.pCO2}
d = - {KA (Kw + Kc.pCO2) K3.Kc.CO2}
e = - (KA.K3.Kc.pCO2)
WORKSHOP ACIDBASE
[SID]+[H+]-KC.pCO2/[H+]-KA.[ATot]/(KA+[H+])-K3.KC.pCO2/[H+]2-Kw/[H+]=0
[H+] dan [HCO3-] = ([SID], pCO2, [ATot])

In these solution it is clear that if the hydrogen or
bicarbonate ion concentration changes
the SID,ATot and pCO2 must have changed

WORKSHOP ACIDBASE
BLOOD PLASMA
H+
HCO3-
Na
OH-
CO32-
Alb
Posfat
K
Mg++
Ca++
+
XA
Cl-
CATION
ANION
WORKSHOP ACIDBASE
SID
ATot
Unmeasured Anion
The practical significance of all this maths

If we want to calculate the pH, we must:
1. Know the concentrations of the
strong ions, and
2. Plug these value into equations;
Note:
If you add basic or acidic substance, you cannot just
say We added so much hydroxide so the pH will
change by so much.
You have to work things out using the equations.
WORKSHOP ACIDBASE
ACIDBASIC II
WORKSHOP ACIDBASE
WORKSHOP ACIDBASE
The difference;
The Stewart approach emphasizes mathematically
independent and dependent variables.
Actually, HCO3- and H+ ions represent the effects
rather than the causes of acid-base derangements.
WORKSHOP ACIDBASE
Teori Dasar Pendekatan

Kuantitatif II
WORKSHOP ACIDBASE
Henderson-Hasselbalch
Stewarts Approach
WORKSHOP ACIDBASE
Menurut Stewart ;
pH atau [H+] DALAM PLASMA

DITENTUKAN OLEH
DUA VARIABEL
VARIABEL
INDEPENDEN
Primer (cause)
Menentukan
VARIABEL
DEPENDEN
Sekunder (effect)
Stewart PA. Can J Physiol Pharmacol 61:1444-1461, 1983.

WORKSHOP ACIDBASE
VARIABEL INDEPENDEN
CO2
pCO2
Controlled by
the respiratory
system
STRONG ION
DIFFERENCE
SID
The electrolyte
composition of the
blood (controlled
by the kidney)
WORKSHOP ACIDBASE
WEAK ACID
Atot
The protein
concentration
(controlled by the
liver and metabolic
state)
CO2
OH- + CO2 HCO3- + H+
CA
Rx dominan dari CO2 adalah rx absorpsi OHhasil disosiasi air dengan melepas H+.
Semakin tinggi pCO2 semakin banyak H+ yang
terbentuk.
Ini yg menjadi dasar dari terminologi
respiratory acidosis, yaitu pelepasan ion
hidrogen akibat pCO2
STRONG ION DIFFERENCE
Definisi: Strong ion difference adalah ketidakseimbangan

muatan dari ion-ion kuat.
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).
STRONG ION
DIFFERENCE
Gamblegram
Mg++
Ca++
K+ 4
SID
[Na+] + [K+] + [kation divalen] - [Cl-] - [asam organik kuat-]
Na+
140
[Na+]
140 mEq/L
[K+]
+
Cl102
-
4 mEq/L -
KATION
[Cl-]
102 mEq/L
ANION
[SID]
=
34 mEq/L
Hubungan SID dgn pH/H+

Konsentrasi H+
[H+] [OH-]
SID
Na
Cl
SID
Asidosis
()
Na
Cl
SID
SID
Alkalosis
Na
Cl
(+)
Dalam cairan biologis (plasma) dgn suhu 370C, SID selalu positif,
nilainya berkisar 30-40 mEq/Liter
SID vs pH & [H+]
pH
10
100
90
80
70
60
50
40
30
20
1
-10
10
20
30
40
50
60
70
10
80
[SID] mEq/L
Kellum JA. Kidney Int 53: S81-S86, 1998
[H+]
nmol/L
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+]
Gamblegram
WEAK
ACID
Mg++
Ca++
K+ 4
HCO324
Weak acid
(Alb-,P-)
Na+
140
KATION
Cl102
ANION
SID
STRONG ION DIFFERENCE &

WEAK ACID IN PLASMA
Mg++
Ca++
K+ 4
HCO
SID
SID
Weak acid
(Alb-,P-)
As. Organik kuat
= {[Na+] + [K+] + [kation divalen]} - {[Cl-] + [As.organik kuat-]}
Na+
KATION
Cl-
ANION
Conclusion
WORKSHOP ACIDBASE
INDEPENDENT VARIABLES
DEPENDENT VARIABLES
Strong Ions
Difference
pCO2
Protein
Concentration
pH
DEPENDENT VARIABLES
H+
HCO3OH-
AH
CO3=
A-
DISSOCIATION &
ASSOCIATION OF PURE
WATER
Perubahan CO2
H2 0
Perubahan SID
H 3 O+
Perubahan Atot
OH
KLASIFIKASI GANGGUAN
KESEIMBANGAN ASAM BASA
BERDASARKAN PRINSIP STEWART
WORKSHOP ACIDBASE
KLASIFIKASI GANGGUAN KESEIMBANGAN ASAM

BASA BERDASARKAN PRINSIP STEWART
Fencl V, Jabor A, Kazda A, Figge J. Diagnosis of metabolic acid-base disturbances in critically ill
WORKSHOP
patients. Am J Respir
Crit CareACIDBASE
Med 2000 Dec;162(6):2246-51
METABOLIC
RESPIRATORY
in pCO2
in Weak
acid
in SID
WATER
STRONG
ANION
Cl
Alkalosis
Decrease
Deficit
Hypo
Acidosis
Increase
Excess
Hyper
Alb
PO4-
UA
Decrease
Positive
Increase
WORKSHOP ACIDBASE
Fencl V, Am
STEWART PERDICI
2006J Respir Crit Care Med 2000 Dec;162(6):2246-51
WATER DEFICIT
Diuretic
Diabetes Insipidus
Plasma
Evaporasi
Na+ = 140 mEq/L

Cl- = 102 mEq/L
SID = 38 mEq/L
1
liter
Plasma
140/1/2 = 280 mEq/L

102/1/2 = 204 mEq/L
SID = 76 mEq/L
SID : 38 76 = alkalosis
ALKALOSIS KONTRAKSI
WORKSHOP ACIDBASE
liter
WATER EXCESS
Plasma
Na+ = 140 mEq/L

Cl= 102 mEq/L
SID = 38 mEq/L
1 Liter
H 2O
1
liter
140/2 = 70 mEq/L
102/2 = 51 mEq/L
SID = 19 mEq/L
2
liter
SID : 38 19 = Acidosis
ASIDOSIS DILUSI
WORKSHOP ACIDBASE
in SID and Weak Acid

K
Mg
Ca
Na
140
George, 2003
SID = 34
Alb
PO4
SID
Alb
PO4
SID
SID
Laktat/keto
Alb
PO4
Alb
PO4
Cl
102
Cl
115
Normal
Asidosis
hiperklor
CL
95
Alkalosis
hipoklor
SID
Cl
102
Asidosis
Keto/laktat
WORKSHOP ACIDBASE
Cl
102
Alkalosis
hipoalb/
fosfat
SID
Alb/
PO4
Cl
102
Asidosis
hiperalb/
fosfat
Efek terapi cairan terhadap

keseimbangan asam basa
WORKSHOP ACIDBASE
PLASMA + NaCl 0.9%
Plasma
Na+ = 140 mEq/L
Cl- = 102 mEq/L
SID = 38 mEq/L
NaCl 0.9%
1 liter
Na+ = 154 mEq/L

Cl- = 154 mEq/L
SID =
0 mEq/L
SID : 38 pH normal
WORKSHOP ACIDBASE
1 liter
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 pH lebih asidosis

WORKSHOP ACIDBASE
WORKSHOP ACIDBASE
WORKSHOP ACIDBASE
PLASMA + Larutan RINGER LACTATE
Plasma
Ringer laktat
Laktat cepat
dimetabolisme
Na = 140 mEq/L
Cl- = 102 mEq/L
SID= 38 mEq/L
+
1
liter
Cation+ = 137 mEq/L

Cl- = 109 mEq/L
Laktat- = 28 mEq/L
SID = 0 mEq/L
SID : 38
WORKSHOP ACIDBASE
1
liter
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
SID = 34 mEq/L
2
liter
SID : 34 lebih alkalosis dibanding jika

diberikan
NaCl 0.9%
WORKSHOP ACIDBASE
Rapid Saline Infusion Produces Hyperchloremic Acidosis in

Patients Undergoing Gynecological Surgery
(Scheingraber et al.: Anesthesiology 1999, 90)
NaCl 0.9%
(n = 12)
Lact. Ringers
(n = 12)
Time of infusion (min)
135 23
138 20
Volume after 120 min

(ml/kg)
71 14
67 18
Estimated blood loss (ml)
962 332
704 447
Urine output (ml)
717 459
1 075 799
WORKSHOP ACIDBASE
Lactated Ringers
NaCl 0.9%
pH
7.50
7.45
7.35
30
60
#
-4
90
26
120 min
2.5
30
60
* P<0.05 intragroup
# P<0.05 intergroup
90
120 min
60
90
#*
#*
60
90
120 min
#*
#*
2.0
1.5
1.0
0.5
0.0
30
Lactate
3.0
-8
38
30
mmol/l
mmol/l
-12
BE
42
34
7.25
7.20
46
mmHg
7.40
7.30
CO2
50
30
120 min
Scheingraber et al., Anesthesiology 90 (1999)

WORKSHOP ACIDBASE
Lactated Ringers
NaCl 0.9%
[Na+]
144
mmol/l
#*
#*
#*
#*
140
30
mmol/l
45
60
*
90
120 min
35
#*
#*
30
15
60
*
90
* P<0.05 intragroup
# P<0.05 intergroup
*
120 min
*
60
*
90
*
120 min
Prot*
12.5
*
*
10
30
30
17.5
25
SID
40
100
#*
#*
110
105
#*
#*
115
mmol/l
136
[Cl-]
120
mmol/l
148
7.5
30
60
90
120 min
et al., Anesthesiology 90 (1999)

WORKSHOP Scheingraber
ACIDBASE
WORKSHOP ACIDBASE
MEKANISME PEMBERIAN NABIKARBONAT PADA ASIDOSIS
Plasma;
Plasma + NaHCO3
asidosis
hiperkloremik
Na+ = 140 mEq/L

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

SID = 35 mEq/L
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
WORKSHOP ACIDBASE
Strong Ion Difference in

Gastrointestinal Tract
(interaction between membrane)
1.
2.
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).
Sirker AA et al.Acid base physiology: the traditional and the modern approaches. Anaesthesia, 2002,
57; 348-356
WORKSHOP ACIDBASE
Muntah, penyedotan
Lambung, sekresi EF >>
Cl loss
Antasida: MgOH, CaOH SID
Na
Plasma site
Sekresi
gaster
SID cairan lambung < / ( ) ; asam

H+
SID plasma
normal
Na
AlkaNa+
lo s i s
kare
Cl-na m
Na+
u n ta
h
Cl
Na+
Cl-
Na+
Cl-
Na+
Cl-
Cl
SID plasma
Alkalosis
Na
Cl
Cl-
Empedu
Na+
Na+
Pancreas
Na+
Cl-
SID cairan
intestinal normal
Na+
ClNa+
H+
Na+
Cl-
Absorbsi
Jejunum
Cl
SID plasma Asidosis
Na
Na+
re
a
i
Abso
d
rbsi
a
n
Colo
are
n
k
sis
o
Diare: Na loss Asid
WORKSHOP ACIDBASE
Na
SID plasma
normal
Cl
George, 2003
Volume dan komposisi elektrolit cairan gastrointestinal

24 h vol.
(mL)
Na+
(mEq/L)
K+ (mEq/L) Cl- (mEq/L)
HCO3-
Saliva
500-2000
25
13
18
Stomach
10002000
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
92.5
27.5
Colon
60
30
40
SID
WORKSHOP ACIDBASE
Miller, 5th ed,2000.
Volume dan komposisi

elektrolit cairan
gastrointestinal
24 h
Na
K
Cl
HCO
+
pH of Body fluids
vol.
(mL)
(mEq
/L)
(mEq
/L)
(mEq
/L)
SID
Saliva
5002000
25
13
18
Stomach
10002000
80
15
115
-20
Pancrea
s
300-800
140
7.5
80
67.5
Bile
300-600
140
7.5
110
37.5
Jejunum
20004000
130
7.5
115
22.5
Ileum
10002000
115
92.5
27.5
Colon
60
30
40
From Miller, Anesthesia, 5th ed,2000.

Boron & Boulpaep, Medical Physiology,ch 27,
WORKSHOP ACIDBASE
2003.
Strong Ion Difference

in Kidney
WORKSHOP ACIDBASE
The kidneys are the most important regulators

of SID for acid-base purposes.
Plasma
Na+
Cl138
106
Na+
148
Cl153
Sirker AA et al.Acid
base physiology:
WORKSHOP
ACIDBASEthe traditional
and the modern STEWART
approaches.
Anaesthesia,
2002, 57;
PERDICI
2006
348-356
Perbandingan komposisi elektrolit urin dan

plasma
Ion-ion (mEq/l)
Urine
Plasma
Na+
147.5
K+
47.5
Cl-
153.3
HCO3-
1.9
138.4
4.4
106
27
MARTINI, Fundamentals of Anatomy and Physiology; 5 th ed,2001

WORKSHOP ACIDBASE
Effects of diuretics on urine

composition
Volume
(ml/min)
pH
Sodium
(mEq/l)
Potassium
(mEq/l)
Chloride
(mEq/l)
Bicarbonate
(mEq/l)
No drug
6.4
50
15
60
Thiazide diuretics
13
7.4
150
25
150
25
Loop diuretics
6.0
140
25
155
Osmotic diuretics
10
6.5
90
15
110
Potassium-sparing
diurtics
7.2
130
10
120
15
Carbonic anhydrase
inhibitors
8.2
70
60
15
120
Source: adapted from Tonnesen AS, Clincal pharmacology and use of diuretics. In: Hershey SG,
Bamforth BJ, Zauder H, eds, Review courses in anesthesiology. Philadelphia: Lippincott, 1983; 217-226
WORKSHOP ACIDBASE
Regulasi pH dan mekanisme

kompensasi
Rapid regulation
(short-term)
Chronic control
(long-term)
WORKSHOP ACIDBASE
Kompensasi terhadap kronik hiperkarbi (PPOK)

pH normal
PCO2
pH
Kompensasi kronik
SID
PPOK
sis
e
n
ge
nia
o
Am
NH4
Cl
NH4Cl
Absorpsi Cl
Hipokloremi
George, 2003
WORKSHOP ACIDBASE
paCO2 < 40
paCO2 40-50
paCO2 > 50
pH
SID
Group 1
Group 2
WORKSHOP ACIDBASE
Group
3
pH
pCO2
SID
HCO3-
WORKSHOP ACIDBASE
Na+
Cl-
K+
Lactate
espon kompensasi
WORKSHOP ACIDBASE
KESIMPULAN
WORKSHOP ACIDBASE
TERIMA KASIH
WORKSHOP ACIDBASE

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Teori Dasar Pendekatan

Notasi pH diciptakan oleh seorang ahli kimia dari

Normal = 7.40 (7.35-7.45)

Saya punya hasil

AKIBAT DARI ASIDOSIS BERAT

Management of life-threatening Acid-Base Disorders, Horacio J. Adrogue, And

AKIBAT DARI ALKALOSIS BERAT

Efek pH dan CO2 terhadap oksigenasi

Analytic tools used in acid

Analytic tools used in acid

1978, Stewart introduced the physical-chemical approach

1983, Stewart-Fencl approach

2004, simplified Stewart-Fencl approach

The disadvantage of men not knowing the

Gangguan asam-basa primer

Diagnosis menggunakan nilai asam basa serum:

Kompensasi ginjal terhadap asidosis resp. kronik

Kompensasi ginjal & paru terhadap asidosis non ginjal

Penambahan H+ ClKehilangan HCO3-

BE = (1 - 0.014Hgb) (HCO3 24 + (1.43Hgb + 7.7) (pH 7.4)`

Now for something new

Goals, definitions and

Stewart PA. Modern quantitative acid-base

Konsep larutan encer

A solution is said to be acidic, or acid, if its

[H+] < [OH-]

[H+] and temperature

What is the pH of water?

MOLEKUL AIR DAN PRODUK DISOSIASINYA

Sebenarnya, H+ di dalam larutan berada dalam bentuk H3O+

Water does not

Peranan elektrolit dalam

Semua ion kuat akan terdisosiasi sempurna jika berada

Completely dissociate in aqueous solution

Cl SO4 Lactate Acetoacetate-

MENGAPA LAKTAT DAN KETON DISEBUT ION

KA > 104 Eq/L

Elektrolit jika berada

BAGAIMANA JIKA ION-ION KUAT

Ion-ion kuat akan berdisosiasi

Reaksi hidrasi ion-ion kuat

Strong Ions and Water

Strong ions disassociate in water

Perubahan yang terjadi pada pH atau [H +]

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

4. OH + CO2 H2CO3 HCO3- CO3= + H+

Water dissociates as follow;

Lets find the pH of pure water

[H+] - [OH-] + [Na+] - [Cl-] = 0 equation #1

[H+] Kw/[H+] + [Na+] [Cl-] = 0

[H+] = - ( [Na+] [Cl-] )/2 + {( [Na+] [Cl-] )2/4 + Kw}

And solving for [H+]

[OH-] = Kw + SID2/4 + SID/2 equation #3

the SID must have changed

SKETCH; RELATIONSHIP BETWEEN SID,H+ AND

In biological solutions at 370C, the SID nearly

Identify the independent variables (Kw,[SID],[ATot] and KA)

Substitute these values into equation #1A, and get;

4. STRONG IONS WITH CO2

a. CO2 can dissolved:

b. Can react with water;

d. HCO3- rapidly dissociate:

THE SIX SIMULTANEOUS