CAZ CLINIC

SUUB

SINDROMUL DE INTESTIN SCURT

Cazul la prima vedere…

Barbat de 63 ani

Infarct entero-mezenteric in 2006 si 2009

Enterectomie larga – gastroduodenojejunotransversoanastomoza (fara D3,D4,prima ansa jejunala)

Casectic (∆M = 45-50kg/3 ani)

Sindrom diareic persistent si impresionant

Tetrapareza recent instalata (motiv de reinternare in prezent)

Tegumente uscate, mucoase uscate, tendinta la hTA, tahicardic

Edeme generalizate si pufoase

Relativ poliuric in absenta stimularii diurezei

Tendinta la hiperpnee

T

Teoretic…

Sindrom de malabsorbtie sever si complex

Dezechilibre hidroelectrolitice complexe

Dezechilibre acidobazice complexe

Iminenta de instabilitate hemodinamica

“Suferinta” renala in cadrul dezechilibrului electrolitic

SIBO( small intestinal bacterial overgrowth)

Acum ori altadata simptomatologie neurologica

“centrala” in preajma unor pranzuri bogate

Modificari sau simptomatologie compatibila cu boli

reumatologice

Antecedente de fractura

Antecedente de colica renala

SID? Ser ringer Ser fiziologic Na-Cl 1 molar Na-HCO3 1 molar K-Cl 1 molar

Glu 5%, 10% Apa distilata

MULTIBIC SID=38

STEWART

HENDERSON-HASSELBALCH

Strong Ions

HCO3--H+

f(x)=y

Descrierea EAB

Focus H+ sau HCO3

Focus Strong Ion

Boston Copenhaga

H-H EQ

Singer

Hastings BB

Stewart IND vs DEP

Border flux Kofranek

C O N S T A B L E

f(x)=y

Bicarbonat

Weak anions

apa

Compusi

nutritivi

Strong cations Sodiu

Potasiu

Magneziu

Calciu

Pierderi relative

Dilutional Ac. Sau Concentrational Alk.

AGMA sau Ac. Cu SID ↓ Si SIG↑

Componenta de alk. met.prin hALB si hP

HCMA sau Ac. Cu SID↓

Tulburari AB primare

Strong cations

PMSA↓

GFR↓=>NH4↓ ACM

Instrumente pentru D-lactat

SIG sau AG Corectat sau

BE gap

UAG vs UOSM GAP

UOSM GAP vs UAG

Direct

D-lactatul este filtrat Si nereabsorbit renal

Acidoza este mai curand hiperclo- remica decat acidoza cu gaura anionica crescuta.

HipoK

K,Mg↓ Pmsa↓

ECG NM

RENAL

hipoK induced Renal dysfunction

Defect de concentrare(DI nefrogen) Cresterea formarii de NH4

Cresterea reabsorbtiei de HCO3 Cresterea reabsorbtiei de Na

Nefropatie hipokaliemica

TTKG-ul, teoretic, este “conservator” renal in stadiul de hipokalemie “franca”

Defect de concentrare

AQP 2 ↓

Na-K-2Cl ↓=> ↓Mecanismul de

contracurent

NH4↑

pHi↓

HipoK

↑Reabs. HCO3

HipoK pHi↓ ↑NHE proximal

↑NAE

Hiperplazie de celule tubulare Eventual fibroza tubulointerstitiala Atrofie de celule tubulare Formare de chisti in medulara

Insuficienta renala cronica(RIFLE cu E)

Un lucru-i cert: pacientul trebuie umplut

CAT?

CU CE?

Si eventual, simultan sau mai incolo, golit

Cu SID-ul potrivit ?

Furosemidul cladeste SID-ul

Cum adica furosemidul cladeste SID-ul?

Cum adica furosemidul cladeste SID-ul?

Furosemidul e “antidotul” acetazolamidei in termeni de SID

Furosemidul va creste NAE cu costul unei pierderi de potasiu. Veti fi injectat potasiu in momentul adm. de furosemid.

Si tot el “strica” Osm.med.

Indici HD L,MAP,CO,SVO2, ∆PCO2,∆PCO2/

∆CO2

Mereu raportat la “ce a fost”

Estimare MSFP NAVIGATOR

Responsivitate la fluid-indici dinamici

Estimare TBW si comparare cu TBWe

PROBLEMATIC

CAT?

In continuare tot despre “cat”…

Weber E. The law of pulsatile flow and its application to the circulation. Primitive model of the circulation. (German) In: Berichte ueber die Verhandlungen der Konigl Sachsischer Cesellschaften der Wissen-Schaften zu Leipzig, Weidmanische Buchhandlung, 1850

MSFP MCFP

Sa fie indeajuns de plin

“The peripheral circulation controls cardiac output in many clinical conditions. Manipulation of the peripheral circulation is as important to the successful treatment of shock and other altered circulatory states, as is the manipulation of cardiac output.”

MSFP

“Under normal circumstances, cardiac output is controlled by the peripheral vasculature, which is as energetic at returning blood to the heart as the heart is at pumping blood to the periphery.”

Pana astazi…

“The Navigator systematizes cardiovascular management to simplify cognitive tasks, reduce side effects and to ensure better achievement

of therapeutic targets.”

Pmsa = 0.96•RAP+0.04•MAP+0.96•1/26•SVRnBW•CO

EH=(Pmsa-RAP)/Pmsa

Totul a inceput cu CVVHDF

MSFP pe ventilator

Pmsf-RAP=CO•RVR ∆V/∆Pmsf=C

MSFP este f(MAP,RAP)

Pao=MSFP•(1+Rsu/Rsd)-Rsu/Rsd•RAP

Pao=c-d•Pcv

MSFP=c/(d+1)

Rven MSFP

EH

DOBUTREX

MFSP↑

Nu-l vrem prea “plin” din respect pentru px

Px

“The extraction tension is the single most important quantity of the arterial oxygen status. If the arterial blood is unable to supply 2,3 mmol/L, without a fall in oxygen tension below 4,5 kPa, then there is a disturbance in the oxygen status of the arterial blood.”

PO2(a)

ceHb

P50

Px determ.

Calcule in EAB

AG = Na+K-Cl-HCO3; 7-17 mEq/l

Alb-=albg/l•(0.123•ph-0.631)

Pphate-=Pmmol/l•(0.309•pH-0.469)

SIDa=Na+K+Ca+Mg-Cl-L

SIDe=2.46•10-8•pCO2mmHg/10-pH

+Alb-+Pphate-

SIG=SIDa-SIDe; <5mEq/L

AGcorr=AG-Alb--Pphate--L; <5mEq/L

AGcorr=AG-2•Albg/dl-0.5•Pmg/dl-L

A avut pacientul D-lactat?

Ph=7.279

pCO2=18.3

Na=147

K=2

Cl=121

Lactat=1

HCO3=8.3

Albumina=1.9g/dl

Fosfor seric=0.5mg/dl

A avut pacientul D-lactat?

Acidemie Context

Hipoalbuminemic

AG=19.7

SIGAARD-ANDERSEN

Dam spirono in hK ?

OSMuKp

OSMpKuTTKG

Uosm >300 and UNa >25

Supliment…

CRISTALOID

2PCΟS

ΚapΗ

10

ΑτοτΚaSID

log1pΚpΗ

2PCΟS

ΚapΗ

10

ΑτοτΚaSID

log1pΚpΗ

2PCΟS

SID

log1pΚpΗ

2PCΟS

SID

log1pΚpΗ

2PCOS

3HCO

log1pKpH

2PCOS

SID

log1pKpH

D I L U T I E

Ideal inseamna…

24

Pentru ca 35 nu e 24

2011

Na,K si apa-cam cat?

Deci…