1

MOT SO KHAI NIEM C BAN VE THANG BANG TOAN-KIEM

ThS. BS. LE HU THIEN BIEN
I. NONG O H
+
VA pH
1. Y ngha.
- Nong o H
+
trong mau vao khoang 40 nEq/L va c gi sao cho ch giao ong
trong mot khoang ra t nho (<10 nEq/L) e khong anh hng en chc nang te bao.
- Nanoequivalent bang mot phan trieu milliequivalent va [H
+
] trong mau khoang
0,00004 mEq/L. Viec s dung n v qua nho nh vay se lam rac roi trong thc
hanh, do o nong o [H
+
] thng c bieu dien bang pH = -log
10
[H
+
] e de s
dung hn. Nong o [H
+
] 40 nEq/L tng ng vi pH 7,40. Can lu y pH la so
am cua [H
+
] nen pH thay oi ngc chieu vi [H
+
], khi [H
+
] tang th pH giam
va ngc lai.
- Theo phng trnh Handerson, pH = 6,10 + log[HCO
3
]/PaCO
2
0,03. Nh vay
pH se thay oi theo PaCO
2
va HCO
3
.
2. Cac yeu to anh hng PaCO
2
.
- Mot cach n gian, co the xem PaCO
2
VCO
2
/V
E
, trong o VCO
2
la lng
CO
2
do c the san xuat va V
E
la thong kh phut.
- San xuat CO
2
tuy thuoc: nhiet o c the, toc o chuyen hoa va l oa i chuye n
ho a. V du , san xuat CO
2
tang khi tang than nhiet. Khi c the tang toc o
chuyen hoa: tap luyen the thao, phong, nhiem trung huyet th lng CO
2
san
xuat cung tang. Trong cac loai chuyen hoa chat chnh (tinh bot, ng, m) th
tinh bot sinh ra CO
2
nhieu nhat va m sinh ra CO
2
t nhat. Do o oi vi benh
nhan suy ho hap man, nen tranh che o an nhieu tinh bot e han che bien
chng tang CO
2
mau.
- Giam thong kh phut co the do giam the tch kh lu thong hoac giam tan so
th. Ngoai ra tang khoa ng chet cung co the lam tang PaCO
2
.
- Tom lai, cac yeu to anh hng VCO
2
t khi nao lam thay oi PaCO
2
. Ma hau
nh tat ca cac trng h p thay oi PaCO
2
eu do giam/tang thong kh.
3. Cac yeu to anh hng HCO
3
.
- Mac du phoi la c quan ong vai tro chnh trong bai tiet acid, nhng co mot so
acid khong bay hi kho ng the bai tiet qua
phoi c (bang 1). Ca c acid nay ch c
bai tiet qua than. Moi ngay c the san xuat
khoang 50-60 mEq acid khong bay hi va
than co the bai tiet de dang lng acid nay.
Tuy nhien neu lng acid khong bay hi
nay c san xuat qua nhieu (v du: nhiem
acid lactic trong soc nhiem trung) hoac suy
than lam giam kha nang bai tiet acid th
lng acid khong bay hi trong mau se
ang 1. Nguon goc cac loa| ac|d co d[nh
Chat chuyen hoa Ac|d co d(nh
Chuyen hoa dam Su|fur|c ac|d
Phosphor|c ac|d
Chuyen hoa mo Acetoacet|c ac|d
-hydroxybutyr|c
Chuyen hoa Lact|c ac|d
t|nh bot

2
tang gay toan chuyen hoa.
- Khi trong mau xuat hie n mot acid manh th acid nay se c trung hoa bi cac
he em. Lay he em bicarbonate lam v du.
HCl + H
2
CO
3
/NaHCO
3
NaCl + H
2
O + CO
2
Ngoai ra trong mau kho ng ch co he em
bicarbonate ma con co nhieu he em
khac tuy theo v tr hoat ong (bang 2).
Tom lai cac he em ong vai tro rat quan
trong, gi cho pH khong thay oi nhieu
khi mau b nhiem acid.
- Mot lan na than lai ong vai tro quan
trong trong ieu hoa bicarbonate, thong
qua cac c che: (1) tai hap thu HCO
3
-
(2) bai tiet acid va (3) bai tie t NH
4
+
.
Tom lai co hai c quan trong trong ieu hoa thang bang toan kiem: (1) he than
kinh-ho hap: ieu hoa PaCO
2
va (2) than: ieu hoa HCO
3
-
.
II. PHAN LOAI ROI LOAN TOAN KIEM
1. Cac loai roi loan toan kiem chnh.
- Gia tr bnh thng cua cac thong so pH, PaCO
2
va HCO
3
la c s e phan loai cac
roi loan toan kiem (pH 7,36-7,44; PaCO
2
36-44 mmHg, HCO
3
22-26 mEq/L).
- Khi pH < 7,36 th goi la nhiem toan va khi pH > 7,44 th goi la nhiem kie m.
- Theo phng trnh Handerson, pH b thay oi khi PaCO
2
thay oi hoac HCO
3
thay
oi. Nhng thay oi pH gay ra do thay oi PaCO
2
goi la roi loan toan kiem ho hap.
Nhng thay oi pH gay ra do thay oi HCO
3
goi la roi loan toan kiem chuyen hoa.
V du: tang PaCO
2
lam giam pH va c goi la toan ho hap.
2. ap ng bu tr.
- e gi cho pH khong b thay oi qua
nhieu th khi mot trong hai yeu to cua
phng trnh Handerson thay oi, yeu to
con lai phai thay oi theo hng ngc
lai. V du: giam HCO
3
gay toan chuyen
hoa se c bu tr bang giam PaCO
2
.
Cac loai ro i loan toan kiem nguyen phat
va ap ng bu tr c tom tat trong
bang 3.
- ap ng bu tr khong bao gi u manh e a pH ve bnh thng, ma ch han che
s thay oi pH do roi loa n nguyen phat gay ra.
- Roi loan toan kiem chuyen hoa co ap ng bu tr tc th. V du khi nhiem
toan/kiem chuyen hoa th he ho hap se c kch thch/c che tc th lam
tang/giam thong kh dan en giam/tang PaCO
2
. Trong khi o ro i loan toan kiem ho
hap, khi PaCO
2
tang/gia m, than khong the thay oi ngng tai hap thu HCO
3
ngay
tc th. Do o trong toan ho hap cap (va i ngay au) PaCO
2
thay oi t, nhng pH
ang 2. Cac he dem trong mau
Ngoa| bao
- B|carbonate
- Prote|n: a|bum|ne, g|obu||ne
- Phosphatevo co
No| bao
- Hemog|ob|ne
- Phosphate huu co
ang 3. Cac ro| loan toan k|em va dap ung bu tru
Ro| |oan toan k|em Thay do| 0ap ung
nguyen phat bu tru
Toan ho hap tang PaCO
2
tang HCO
8

K|em ho hap g|am PaCO
2
g|am HCO
8

Toan chuyen hoa g|am HCO
8
g|am PaCO
2

K|em chuyen hoa tang HCO
8
tang PaCO
2

3
thay oi nhieu. Con khi a qua giai oan man tnh th PaCO
2
thay oi nhieu nhng
pH thay oi t.
III. TOAN CHUYEN HOA
1. Phan loai nguyen nhan toan chuyen hoa.
Toan chuyen hoa co the do tang acid khong bay hi hoac mat bicarbonate. Khoang
trong anion (AG) co the giup chan oan phan bie t hai nhom nguyen nhan nay.
Toan chuyen hoa co khoang trong anion cao.
- Nhiem acid lactic.
- Nhiem ketone: tieu ng, nghien ru, oi.
- Ngo oc: methanol, salicylate, ethylene glycol.
- Suy than cap/man.
Toan chuyen hoa co khoang trong anion bnh thng.
- Mat bicarbonate qua ng tieu hoa: tieu chay, dan lu/do dch tuy,
dch mat hoac ruot non.
- Mat bicarbonate qua tha n: benh toan hoa ong than, suy thng than.
- Cac thuoc tang kali mau: li tieu gi kali, c che men chuyen, c che
thu the angiotensin, kha ng viem non-steroid, cyclosporin. Cac thuoc nay
ch gay mat bicarbonate khi dung tren benh nhan suy than.
2. Nhiem acid lactic.
Acid lactic la san pham cua chuyen hoa yem kh. Nhiem toan acid lactic xay ra khi
lng acid lactic c san xuat vt qua kha nang trung hoa cua cac he em.
- Nhiem acid lactic type A, khi co giam ti mau va cung cap oxy mo.
Soc.
Suy tim nang, thieu mau nang.
Roi loan s dung oxy te bao: ngo oc cyanide.
- Nhiem acid lactic type B, khi khong co giam cung cap oxy mo.
Suy gan, suy than nang.
Benh ac tnh: ung th mau.
Thuoc: biguanide, izoniazide, zidovudine.
- ieu tr nhiem toan acid lactic nen tap trung vao ieu tr nguyen nhan. Bicarbonate
ch nen s dung trong nhiem acid lactic nang khi pH < 7,1.
3. Nhiem ketone.
Nhiem toan ketone do ai thao ng.
- S tch tu cac ketoacid se lam tang AG. Tuy nhien, neu benh nhan
khong b thieu nc hay suy than th ketoacid se c bai tiet qua than
lam giam AG va ty le AG/HCO
3
khong tang qua nhieu, ch khoang
1:1 (xem them phan VIII).
- ieu tr nen chu yeu la bu dch va insulin. NaHCO
3
ch nen dung khi
nhiem toan nang, pH < 7,1.
Nhiem toan ketone do ru.
4
- Thng xay ra tren ngi nghien ru khi uong ru nhieu kem theo an
uong kem.
- Benh nhan hay co cac roi loan toan kiem phoi hp: kiem ho hap do suy
gan, kiem chuyen hoa do non oi.
- Tng t nh trong nhiem toan ketone do tieu ng, neu chc nang
than bnh thng th ketoacid c bai tiet nhie u qua than lam cho AG
va ty le AG/HCO
3
khong qua cao.
4. Suy than.
- Co s tham gia cua ca hai c che gay nhiem toan chuyen hoa: giam bai tiet
acid co nh va giam tai hap thu HCO
3
. Do o AG t khi nao > 20 mmol/L.
- Ngoai ra, mac du lng acid co nh co the tch tu nhieu nhng HCO
3
t khi nao
giam < 15 mEq/L nh co s ho tr cua cac he em khac.
5. Toan chuyen hoa co khoang trong anion bnh thng.
- Do mat HCO
3
, qua ng tieu hoa hoac qua than. Xet nghiem khoang trong
anion nieu se giup phan biet hai nhom nguyen nhan nay (xem them phan VIII).
IV. KIEM CHUYEN HOA
Mac du t c quan tam nh toan chuyen hoa,
nhng kiem chuyen hoa mi la loai roi loan toan
kiem thng gap nhat. Khong nh toan chuyen
hoa, gay ra do nhiem cac acid co nh, kie m
chuyen hoa t khi nao do nhiem cac chat kiem ma
chu yeu do mat acid hoac giam bai tie t HCO
3
.
Mot so nguyen nhan thng gap cua kiem chuyen
hoa liet ke trong bang 4.
1. Mat acid.
Khi b non oi hoac hut dch v th te bao thanh se san xuat HCl bu vao lng acid b
mat. Qua trnh san xuat acid se sinh ra HCO
3
bai tiet ngc vao mau.
2. Giam bai tiet bicarbonate.
- Giam the tch mau lam tang tai hap thu Na
+
(va ion am i kem la Cl
-
), do o
lng Na
+
va Cl
-
trong loc dch thap se lam giam kha nang bai tiet HCO
3
.
- Cng aldosterone lam tang bai tiet H
+
va tai hap thu Na
+
tai ong than xa gay
ra kiem chuyen hoa ke m tang the tch dch ngoai bao. Trong khi o ha kali mau
(di 2 mEq/L) lam tang bai tiet H
+
thay cho bai tiet K
+
.
X tr kie m chuyen hoa nen tap trung vao ieu tr nguyen nhan gay ma t H
+
hoac giam
bai tiet HCO
3
-
. V du: dung thuoc c che bm proton e giam mat acid dch v, ngng
thuoc li tieu, bu dch, bu kali. Ngoai ra co the tang bai tie t HCO
3
bang: (1)
acetazolamide, neu chc nang than tot hoac (2) loc mau, neu benh nhan b suy than.

V. TOAN HO HAP
- Nguyen nhan toan ho hap phan loai theo v tr to n thng cua he than kinh-ho hap.
Than kinh trung ng: ngo thuoc ngu, chan thng, tai bien mach mau nao.
ang 4. Vot so nguyen nhan k|em
chuyen hoa
Vat ac|d
- Non o|, hut d(ch da day
- Lo| t|eu: th|az|de, |o| t|eu qua|
C|am ba| t|et b|carbonate
- C|am ka|| mau nang
- C|am the tch d(cn ngoa| bao
- Cuong a|dosterone

5
ng th: hen suyen, benh phoi tac nghen man.
Nhu mo phoi: hoi chng nguy kch ho hap ngi ln.
Than kinh-c: hoi chng Guillain-Barre, nhc c.
- X tr toan ho hap tuy thuoc vao mc o va toc o cua toan ho hap. Viec anh gia
toc o cua toan ho hap (cap hay man tnh) giup tranh c viec ieu tr qua mc,
lam PaCO
2
xuong qua nhanh, co the gay ra cac bien chng: ro i loan nhp tim, giam
ti mau nao, co giat.
VI. KIEM HO HAP
- Co rat nhieu tac nhan kch thch lam tang thong kh, tuy nhien thng gap nhat la
tnh trang giam oxy ma u va cac tac nhan kch thch than kinh trung ng (au, lo
lang, viem nao-mang na o).
- X tr kiem ho hap chu yeu la ieu tr nguyen nhan. Tren benh nhan th may co
the han che kiem ho ha p bang: (1) giam the tch kh lu thong, (2) gia m tan so th,
(3) dung thuoc an than-dan c.
VII. TOAN CHUYEN HOA VA S DUNG BICARBONATE
- Toan chuyn hoa la mot ri lon toan kiem co c trng la gim pH ma u do giam
HCO
3
nguyen phat co hoac khong kem ap ng bu tr la giam PaCO
2
.
- Toan chuyen hoa kha thng gap tren benh nhan trong khoa hoi sc va hau het la
di dang roi loan toan kiem phoi hp.
- e chan oan nguyen nhan toan chuyen hoa th ngoai kh mau ong mach th xet
nghiem au tien khac can lam la ion o (hai xet nghiem nen thc hie n cung luc).
Ngoai ra th tuy theo benh canh lam sang ma can lam them cac xe t nghiem nh
lactate mau, ketone mau, ap suat tham thau mau.
1. Anh hng cua toan chuyen hoa vi c the.
Toan chuyen hoa cap.
- Tim mach la he c quan b anh hng nghiem trong nhat: giam co bop c
tim, giam cung lng tim, dan mach, giam tac dung thuoc van mach.
- Ho hap: tang thong kh, chu yeu la tang the tch kh lu thong (kieu th
Kussmaul), giam co bop c hoanh.
- He than kinh: roi loan tri giac.
- Chuyen hoa: e khang insuline, tang ai lc oxy-hemoglobin.
Toan chuyen hoa man.
- Xng la c quan b anh hng nghiem trong nhat: loang xng va lam
nang hn cac benh xng co san.
2. Phan loai toan chuyen hoa (xem III.1)
3. Nhiem toan acid lactic.
nh ngha.
- Nhiem toan acid lactic va nhiem ketone do tieu ng la hai nguyen nhan
thng gap nhat cua toan chuyen hoa nang.
- Nhiem toan acid lactic xay ra khi lactate mau > 5 mmol/L kem theo tnh
trang toan chuyen hoa. Mot so benh nhan co lactate mau 2-5 mmol/L nhng
6
khong kem nhiem toan th ch c xem nh b tang lactate mau ch khong
phai nhiem toan acid lactic.
C che sinh benh.
- Lactate la mot san pham phu cua chuyen hoa glucose. Pyruvate sinh ra t
glucose neu chuyen hoa yem kh th tao ra lactate va 47 kcal (ch bang 7%
so vi chuyen hoa hieu kh). Noi chung, nhiem toan acid lactic co the do:
tang san xuat lactate, giam s dung pyruvate hoac giam s dung lactate.
- Lactate c san xuat chu yeu : c, ruot, hong cau. Ngoai ra trong mot so
trng hp benh ly th phoi, bach cau cung tr thanh mot nguon san xuat
lactate anh ke du khong co thieu oxy mo.
Phan loai.
- Theo quan iem kinh ien th nhiem toan acid lactic la hau qua cua thieu
oxy mo, do o Cohen va Woods phan loai nhie m toan acid lactic thanh 2
nhom chnh: (1) type A: nhiem toan acid lactic do thieu oxy mo va (2) type
B: nhiem toan acid lactic khong do thieu oxy mo. Phan loai nay cung co y
ngha quan trong ve mat ieu tr v trong nhiem toan acid lactic type A th
khoi phuc cung cap oxy mo la bien phap ieu tr triet e nha t,
- Phan loai nay ch e cap en nhiem L-lactic, con D-lactic hiem gap tren
lam sang va co c che sinh benh khac nen khong c e cap en.

Nhm nguyn nhn do thiu
oxy(Hypoxic-Type A)
Nhm nguyn nhn khng do thiu
oxy(Non-Hypoxic-Type B)
Thiu mu: shock, thiu mu nng,
ngng tim
Gim thi tr (ri lon chung- type B1):
suy thn, suy gan
Thiu oxy ton th: Ng c carbon
monoxide
Gim chc nng men Pyruvate
dehydrogenase (type B2-thuc ): sepsis,
thiu thiamin, cn cng catecholamine,
nhim toan ceton do tiu ng, ru
Suy h hp: Hen nng, COPD, ngt Khng c kh nng kt hp oxy trong
qu trnh phosphoryl ha (type B2-cht
c): Ng c cyanide,salicylat,
methanol & ethylene glycol, biguanid,
thuc retroviral, INH
Gim ti mu vng: thiu mu chi,
mc treo
Tng chuyn ha ym kh glucose (type
B3- cc cas khc): tng hot ng th
lc, sepsis, cn ng kinh ton th, cc
bnh l c tnh

4. Suy than.
- Ca suy than cap va suy than man eu co the gay nhiem toan chuyen hoa. Trong
o suy than man la nguyen nhan hang au cua toan chuyen hoa man.
- Trong suy than nhe (GFR 20-50 ml/phut) th mat HCO
3
la c che chnh gay
nhiem toan chuyen hoa (theo kieu co khoang tro ng anion bnh thng). Khi suy
7
than tien trien nang hn (GFR < 20 ml/phut) th kha nang thai cac acid co nh
b giam i ang ke va gay nhiem toan theo kieu co khoang trong anion cao.
Noi chung th toan chuyen hoa do suy than do ca hai c che mat HCO
3
va
nhiem acid co nh do o khoang trong anion (AG) t khi nao tang tren 20
mEq/L.
- Ngoai ra v co s tham gia cua cac he em ngoai bao va xng nen [HCO
3
] t
khi giam d i 15 mEq/L. Neu [HCO
3
] qua tha p th nen tm them nguon mat
HCO
3
khac, v du: tieu chay.
- Tuy nhien tang kali ma u thng ro ret hn cac trng hp nhiem toan do acid
hu c nh nhiem toan acid lactic hay nhiem toan ketone do tieu ng.
5. Nhiem toan ketone.
Nhiem toan ketone do ai thao ng (DKA).
- Ketone la sa n pham chuyen hoa cua acid beo. Khi c the phai s dung acid
beo thay cho ng e sinh nang lng th lam tang ketone mau. Cac the
ketone gom: acetone, acetoacetate va -hydroxybutyrate.
- Xet nghiem ketone mau va nc tieu dung phan ng nitroprusside ch phat
hien c acetoacetate. Neu benh nhan ong thi b nhiem acid lactic th
luc nay lng -hydroxybutyrate c san xua t nhieu hn va gi vai tro
chnh trong gay nhiem ketone. Tuy nhien xet nghiem ketone co the ch tang
rat t hoac am tnh. Trong khi o, nhng thuoc co nhom sulfhydryl (v du:
captopril) co the tng tac vi chat thou nitroprusside lam phan ng ketone
dng tnh gia. V vay neu benh nhan co uo ng captopril th xe t nghiem
ketone mau bang nitroprusside cung khong con chnh xac.
- Ngoai ra xet nghiem ketone mau cung t co gia tr trong theo doi ieu tr v
khi dung insulin th -hydroxybutyrate se giam trc do o ketone mau van
cao trong khi pH mau a cai thien. Luc nay xet nghiem khoang trong anion
se co gia tr hn trong theo doi ket qua ieu tr.
- Neu benh nhan khong b thieu nc hay suy than th ketoacid se c bai
tiet qua than lam giam AG va ty le AG/HCO
3
cung khong tang qua
nhieu (ch khoang 1:1).
- Bicarbonate khong co vai tro quan trong trong ieu tr nhiem toan ketone,
ngoai tr hai trng h p: (1) nhiem toan nang vi pH < 7,10, (2) AG thap
chng to co mat HCO
3
.
Nhiem toan ketone do ru.
Xay ra tren benh nhan nghien ru khi uong nhieu ru ong thi an uong
kem. Tnh trang giam lng carbohydrate nha p va c che tan tao ng do
ru dan en viec s du ng acid beo e cung cap nang lng va sinh ra ketone.
- Thng co roi loan toan kiem phoi hp.
a. Kiem chuyen hoa do non oi lam cho kh mau ong mach gan nh bnh
thng. Trng hp nay, ch phat hien c nhie m toan ketone khi thay AG
cao bat thng.
8
b. Kiem ho hap do suy gan.
- Tng t nh trong DKA, xet nghiem ketone mau cung khong anh gia chnh
xac mc o nang cua nhiem ketone.
6. Ngo oc cap.
Ngo oc salycilate.
- Xay ra do t t hoac uong thuoc qua lieu.
- Co the bieu hien bang kiem ho hap hoac toan chuyen hoa. Trong o kiem
ho hap la do salicylate kch thch trc tiep trung tam ho hap.
- Neu benh canh nhiem toan chuyen hoa noi bat th co the dung bicarbonate
e kiem hoa nc tieu (gi pH nc tieu > 7,5) nham giam tai hap thu
salicylate. Tuy nhien neu benh canh kiem ho hap noi bat th viec dung
bicarbonate co the lam nhiem kiem nghiem tro ng hn.
Ngo oc methanol.
- t gap tren lam sang, bieu hien bang toan chuyen hoa co khoang trong
anion cao. Ngoai ra th methanol la mo t chat hoa tan co ap suat tham thau
nen khi nong o methanol trong mau tang th ap lc tham thau mau o trc
tiep se cao hn ap lc mau tnh toan > 15 mOsm/kg.
- Can ieu tr tch cc bang bicarbonate va loc mau.
7. Toan chuyen hoa do mat bicarbonate.
- Mat bicarbonate co the qua than hoac qua ng tieu hoa.
- Cac nguyen nhan gay mat bicarbonate qua than gom: toan hoa ong than, suy
than, suy thng than, l i tieu gi kali.
- Dch tieu hoa oan di da day noi chung co tnh kiem vi nong o HCO
3

khoang 50-70 mEq/L. Cac nguyen nhan gay mat bicarbonate qua ng tieu
hoa gom: tieu chay, do mat-tuy. Ve nguyen tac th trong nhng trng hp nay
se co AG bnh thng. Tuy nhien neu tnh trang giam the tch qua nang th co
the lam tang AG do suy than, nhiem toan acid lactic.
8. S dung bicarbonate.
Ben canh ieu tr nguyen nhan, s dung bicarbonate cung la mot pha n quan
trong trong ieu tr toan chuyen hoa, nhat la oi vi nhng trng hp toan
chuyen hoa cap tnh va nang.
C s s dung bicarbonate.
Bicarbonate cai thien pH dch ngoai bao do o giam c nhng anh hng
bat li cua toan chuyen hoa. Trong o quan tro ng nhat la giam nhng anh
hng bat li tren huyet ong: cai thien sc co bop c tim, giam bt tnh
trang dan mach, tang hieu qua cua thuoc van mach.
Tac dung bat li cua bicarbonate.
- Qua tai tuan hoan: ac biet kho x tr neu xay ra tren benh nhan suy
than, suy tim, ma ay lai la nhng oi tng de b toan chuyen hoa.
- Tang natri mau, tang ap sua t tham thau mau neu dung dung dch
bicarbonate u trng.
9
- Nhiem toan noi bao. Bicarbonate truyen vao mau phai c van chuyen
chu ong vao noi bao t t. Trong khi o CO
2
sinh ra do phan ng trung
hoa acid lai co the khuyech tan t do vao dch noi bao va lam cho tnh
trang nhiem toan noi ba o nang hn.
- Nhiem kiem do ieu tr. ieu tr qua tch cc la m cho HCO
3
tr ve mc
bnh thng trong khi CO
2
van con thap se lam cho pH mau chuyen t
toan sang kiem. Tnh trang tang thong kh keo dai nay co le do HCO
3

khuyech tan qua hang rao mau-nao cham, v vay tnh trang toan hoa
trong dch nao tuy van con tiep tuc lam kch thch trung tam ho hap.
Ch nh.
- Noi chung vi toan chuyen hoa do mat bicarbonate th viec bu
bicarbonate la hp ly. Con oi v i toan chuye n hoa do nhiem acid co
nh th viec s dung bicarbonate phai than trong hn.
- Trong mot so trng h p toan chuyen hoa do ca hai c che phoi hp th
co the ch nh bicarbonate da vao tnh toan lng bicarbonate tiem
tang. Noi chung khi tham gia trung hoa acid, th bicarbonate van ton
tai trong mau di dang tiem tang. Khi tnh tra ng nhiem toan cai thien
(HX giam) th phan ng se xay ra theo chieu ngc lai va tai sinh
bicarbonate.
HX + NaHCO
3
NaX + H
2
O + CO
2

Nh vay lng bicarbonate tiem tang c tnh theo cong thc.
HCO
3
tiem tang = AG
bn
AG
bt
(12 mEq/L)
Neu bicarbonate tiem ta ng thap th co ch nh dung bicarbonate.
- Trong toan chuyen hoa do nhiem acid co nh th bicarbonate c dung
khi nhiem toan nang (pH < 7,10) v: (1) pH giam di mc nay co the
gay ra cac bien chng nghiem trong, (2) pk cua he em bicarbonate la
6,10 nen khi pH mau giam xuong 7,10 th dung dch bicarbonate mi co
hieu qua tot.
- Ch nen a pH len khoang 7,20 v co a pH len cao hn na cung
khong co li g them ma lai gap nhieu tac dung bat li.
Cach tnh lieu bicarbonate.
- Tai sao khong the s du ng cong thc n gian.
HCO
3
can bu = [HCO3
mong muon
HCO3
benh nhan
] ECF
Trong o ECF la the tch dch ngoai bao v bicarbonate la he em
cua dch ngoai bao.
- Trong thc te, khi nhie m acid khong ch co he em bicarbonate ma con
co cac he em khac tham gia trung hoa acid. Lng HCO
3
truyen vao
mot phan se dung e khoi phuc cac he em khac. Do o neu ch tnh
lng bicarbonate thieu hut trong dch ngoai bao th khong phan anh
c s thieu hut cua d tr kiem toan c the.
10
- Tuy nhien khong the o c s thieu hut cua d tr kiem toan c the
nen ngi ta thay bang khai niem khoa ng bicarbonate.
Khoang HCO
3
= lng HCO
3
truyen/HCO
3
mau
V du: neu truyen 100 mEq HCO
3
lam HCO
3
mau tang len 5mEq/L th
khoang bicarbonate la 20 L. Thong thng khoang bicarbonate chiem
50% trong lng c the. Khi nhiem toan nang (HCO
3
mau 5 mEq/L)
th khoang bicarbonate co the tang len en 90 100% trong lng c
the. Theo quan iem than trong trong s du ng bicabonate, th tnh
khoang bicarbonate bang 50% trong lng c the la hp ly.
- Muc tieu s dung bicarbonate trong toan chuyen hoa la a [HCO
3
]
mau len khoa ng 10 mEq/ L. V du : be nh nha n na ng 60 kg co
[HCO
3
] la 8 mEq/ L, muo n a [HCO
3
] be nh nha n l e n 10
mEq/ L th l ng HCO
3
ca n du ng = (10-8)600, 5= 60 mEq.
- Ngoai ra cung can lu y la trong th i gian bu bicarbonate th benh nhan
van tiep tuc nhiem acid co nh hoac mat bicarbonate cho nen nhng
tnh toan nay ch co gia tr tham khao.
Tom lai, bicarbonate c dung trong toan chuyen hoa do mat HCO
3
. Con trong toan
chuyen hoa do nhiem acid co nh th ch nen dung bicarbonate trong nhng trng
hp nang. Neu co ch nh th ch nen bu bicarbonate t t kem theo kiem tra kh mau
ong mach va theo doi nhng tac dung bat li cu a bicarbonate.
OI CHIEU THUAT NG
- Nhiem kiem do ieu tr: overshoot alkalosis.
- Khoang trong anion (AG): anion gap.
- Roi loan toan kiem phoi hp: mixed acid-base disorder.
- Nhiem toan ketone do ai thao ng (DKA): diabetic ketoacidosis.
- Nhiem toan ketone do ru (AKA): nhiem toan ketone do ru.
- Toan hoa ong than (RTA): renal tubular acidosis.
- Bicarbonate tiem tang: potential bicarbonate.
- Khoang bicarbonate: bicarbonate space.
TAI LIEU THAM KHAO
1. DuBose TD. Acidosis and alkalosis. In: Principles of internal medicine (17
th

edition, 2008). Chap 48: 287-295.
2. Metabolic acidosis. In: Clinical physiology of acid-base and electrolyte disorders,
5
th
edition 2001. Chap 19: 579.
3. BuBose TD. Metabolic acidosis and alkalosis. In: Textbook of critical care 5
th

edition 2005. Chap 127: 1069-1083.
4. Fernandez PC, Cohen RM, Feldman GM. The concept of bicarbonate distribution
space: the crucial role of body buffers. Kidney International 1989; 36: 747-752.4
5. Adrogue HJ, Madias NE. Management of life-threatening acid-base disorders.
New England J Med 1998; 338 (1): 26-34.