1. pendahuluan 3. terapi cairan electrolyte balance
TRANSCRIPT
3. Terapi Cairan Electrolyte Balance
2. Terapi Cairan
1. Pendahuluan
60% dari Berat Badan
adalah H2O
Pasien berat 60 kg
|
36 kg adalah air
(36 liter)
|
jumlah ini harus dipertahankankeseimbangan
volume dan komposisielektrolitnya
Guyton,A.C. Buku Ajar Fisiologi,ed.9. EGC,1997.Hal.376 -377
Cairan Tubuh 60 %
Mem
bra
n S
el
Cairan Ekstraseluler20 %
Cairan Intraseluler40 %
Plasma Darah5%
Cairan Interstitial
15 %
Cairan Tubuh
Kompartemen Cairan Tubuh
Permeabel terhadap H2O saja
Permeabel terhadap H2O & Partikel kecil
Cairan Ekstraselular Cairan intraselular(mEq/L) Intravaskular
(mEq/L)Interstisial(mEq/L)
Natrium 140 148 13
Kalium 4,5 5,0 140
Kalsium 5,0 4,0 1x10-7
Magnesium 1,7 1,5 7,0
Klorida 104 115 3,0
Bikarbonat 24 27 10
Fosfat 2,0 2,3 107
Protein 15 8 40
Kadar Elektrolit
Utama H, Gangguan Keseimbangan Air-elektrolit dan Asam Basa; Fisiologi; patofisiologi, Diagnosis dan Tatalaksana, Edisike-2, Jakarta, Balai Penerbit FKUI,2008
Utama H, Gangguan Keseimbangan Air-elektrolit dan Asam Basa; Fisiologi; patofisiologi, Diagnosis dan Tatalaksana, Edisike-2, Jakarta, Balai Penerbit FKUI,2008
DEWASA ANAK
Air 30-40 ml/kgBB/Hari • 10 kg pertama : 4 ml/kg/jam• 10 -20 kg berikut : tambahkan 2 ml/kg/jam•Untuk setiap kilogram diatas 20 kg : tambahkan 1 ml/kg/jam
Natrium 1- 2 mEq/kGBB/Hari 3-4 mEq/kg/24 jam
Kalium 0,5 – 1 mEq/kgBB/hari 2-3 mEq/kg/24 jam
KEBUTUHAN CAIRAN , ELEKTROLIT
Kristaloid
TERAPI CAIRAN
Mengganti
Kehilangan Akut
1. Kebutuhan normal
2. Dukungan nutrisi
Koloid NutrisiElektrolit
Reff. :
Said. A.Latief,et al. Petunjuk Praktis Anestesiologi Edisi ke2. Bagian Anestesiologi dan Terapi Intensif FKUI.2009.hal 139
RUMATANRESUSITASI
Koreksi
• Kurang minum, untukganti urine, keringat, uap nafas
• Defisit cairan akibatkehilangan abnormal
• Karena usus tidakberfungsi, nutrisidiberikan intravena
• CairanMaintenance
• CairanReplacement/ Resusitasi
• CairanNutrition
Indikasi Terapi Cairan
World Health Organization• World Health Organization guidelines recommend that patients with COVID-19 in
respiratory failure should be treated cautiously with intravenous fluids, especially in settings with limited availability of mechanical ventilation.
• Use a conservative fluid management strategy for ARDS patients without tissue hypoperfusion.
• In resuscitation for septic shock in adults, give 250–500 mL crystalloid fluid as a rapid bolus in the first 15–30 minutes and reassess for signs of fluid overload after each bolus.
• If there is no response to fluid loading or if signs of volume overload appear, reduce or discontinue fluid administration.
• Starches are associated with an increased risk of death and acute kidney injury compared to crystalloids. The effects of gelatins are less clear, but they are more expensive than crystalloids. Hypotonic (vs isotonic) solutions are less effective at increasing intravascular volume. Surviving Sepsis also suggests albumin for resuscitation when patients require substantial amounts of crystalloids, however this conditional recommendation is based on low-quality evidence.
Guidelines Fluid Therapy for Covid 19
Source:: https://www.fluidacademy.org/blog-foam/item/fluids-in-covid19.html
Guidelines Fluid Therapy for Covid 19
UK Joint Anaesthetic and Intensive Care Guidelines
•Conservative fluid management strategy in ARDS.•In cases of significant hypotension or circulatory shock, standard circulatory assessment (fluid responsiveness, cardiac output assessment) and administration of an appropriate fluid and/or pressor (where appropriate) should occur.•Balanced electrolyte solutions are preferred to 0.9% saline and colloids.•While fluid overload should be avoided and more conservative administration may help improve respiratory function, this should be carefully balanced against the risk of inducing acute renal impairment.•Care should be exercised in ‘running patients too dry’ in an effort to spare the lungs, as there are increased insensible fluid losses.
Source:: https://www.fluidacademy.org/blog-foam/item/fluids-in-covid19.html
Tujuan Terapi Cairan
1. Untuk mengganti kehilangan cairan dan elektrolit yang sudah hilang.
2. Untuk memenuhi kebutuhan harian cairan dan elektrolit.
3. Mengganti kehilangan cairan tubuh yang masihberlangsung.
4. Untuk mengatasi syok.
Larutan Maintenance KombinasiLarutan Karbohidrat-WIDA D5 / D10-WIDA D5 ¼ NS
CairanIntraseluler C
aira
nIn
ters
titi
al
Pla
sma
CairanEkstraseluler
Distribusi Cairan Intravena
Terjadi Peningkatan volume padaseluruh kompartemen
Erry Leksana. Terapi Cairan dan Darah. Cermin Dunia Kedokteran edisi 177, hal 304-309
3 liter diinfuskan D5
2000 ml 750 ml 250 ml
Pla
smaCairan
Intraseluler
Cai
ran
Inte
rsti
tial
Larutan Pengganti Cairan Ekstraseluler
Terjadi Peningkatan volume pada kompartemen ekstraselular
Erry Leksana. Terapi Cairan dan Darah. Cermin Dunia Kedokteran edisi 177, hal 304-309
Distribusi Cairan Intravena
1 liter diinfuskan-Ringer Lactate-Sodium Chloride 0,9%-WIDABES-ASERING
750 ml 250 ml
Cairan Ekstraseluler
15
Cairan EkstraselulerTerjadi peningkatan volume hanya pada Intavaskuler
Plasma Expanders :- 6% HES 130 in NaCl 0,9% (WIDAHES 130)-6% HES 130 in electrolyte balanced (WIDAHES BES)
Pla
sma
CairanIntraseluler
Cai
ran
Inte
rsti
tial
Erry Leksana. Terapi Cairan dan Darah. Cermin Dunia Kedokteran edisi 177, hal 304-309
Distribusi Cairan Intravena
1 liter diinfuskan6% HES 130
1000 ml
CRYSTALLOID VS COLLOID
1. https://www.openanesthesia.org/crystalloid-vs-colloid-rx/2. Hahn and Lyons, The half-life of infusion fluids, an educational review, Eur J Anaesthesiol2016;33:475–4823. Lira and Pinsky, Choices in fluid type and volume during resuscitation: impact on patient outcomes, Annals of Intensive Care2014,4:38
BALANCED ELECTROLYTE SOLUTION
Balanced electrolyte solution (BES) adalah cairan yang komposisinya mirip dengan plasma
(sodium, potassium, kalsium, magnesium, chloride) dan menjaga keseimbangan asam-basa
dengan bikarbonat atau buffer basa. pH normal darah : 7,35 – 7,45
R. Zander, Fluid Management, Bibliomed – Medizinische Verlagsgesellschaft mbH, Melsungen, 2009.
Strong Ion Difference (SID)
SID adalah jumlah konsentrasi kation kuat dikurangi jumlah
konsentrasi aniot kuat. SID pada normal plasma adalah 30-40 meq/L.
ACID – BASE CONCEPT
SID = KATION - ANION
PLASMA 1L + NaCl 0.9% 1L
Na+ = 140 mEq/L
Cl- = 102 mEq/L
SID= 38 mEq/L
Cation+ = 154 mEq/L
Cl- = 154 mEq/L
SID = 0 mEq/L
Plasma NaCl 0.9%
.
George Y., Easy Way to Understand Stewart’s Acid Base, Centra Communications, 2015.
PLASMA 1L + NaCl 0.9% 1L
= Na+ = (140+154)/2 mEq/L= 147 mEq/L
Cl- = (102+ 154)/2 mEq/L = 128 mEq/L
SID = 19 mEq/L
SID plasma : 19 acidosis
George Y., Easy Way to Understand Stewart’s Acid Base, Centra Communications, 2015.
ASIDOSIS HIPERKLOREMIK
AKIBAT PEMBERIAN LARUTAN Na Cl 0.9%
BALANCED ELECTROLYTE SOLUTION
In vivo SID = 34 meq/l
In vivo SID = total organic anion
In vitro SID = 0*
*Semua larutan balanced, secara in-vitro, memiliki SID = 0
T. Langer et al., Effects of Intravenous Solutions on acid-base equilibrium: from crystalloids to colloids and blood product, Anesthesiology Intensive Therapy, 2014.
Na+ = 140 mEq/L
Cl- = 102 mEq/L
SID= 38 mEq/L
Cation+ = 156 mEq/L
Cl- = 127 mEq/L
Malate = 10 mEq/L
Acetat- = 24 mEq/L
SID = 29 mEq/L
Plasma WIDABES
BALANCED ELECTROLYTE SOLUTION
Acetat & malate cepatdimetabolisme
PLASMA 1L + BALANCED CRYSTALLOID 1L
= Na+ = (140+156)/2 mEq/L= 148 mEq/L
Cl- = (102+ 127)/2 mEq/L = 114.5 mEq/L
Acetat & malate- (metabolized) = 0 mEq/L
SID = 33.5 mEq/L
SID : 33.5 normal dibanding
jika diberikan unbalanced crystalloid
NORMAL pH SETELAH PEMBERIAN BALANCED CRYSTALLOID
PLASMA 1L + BALANCED CRYSTALLOID 1L
Sediaan : infusKemasan : Botol plastik @500mlStorage : < 30 0CNo Reg : DKL 1730504049A1
Indikasi : Penggantian kehilangan cairanekstraseluler dalam kasus dehidrasiisotonik yang disertai asidosis.
K.I : Hipervolemia, gagal jantungkongestif berat, gagal ginjal denganoliguria/anuria, edema berat, hiper-kalemia, hiperkalsemia, alkalosismetabolik
WIDA BES
BALANCED SOLUTION TO MAINTAIN ACID-BASE STABILITY
WIDA BES
1.Bicarbonate concentration increased as early as 15 minutes after the start of an acetateinfusion 1,2,3
Efek basa asetat beronset cepat, konsentrasinya meningkat 15 menit setelah dimulainya proses infus. 60% - 80% dieliminasisebagai C02 dan keluar via paru-paru.1,2,3
2. Acetate metabolism is unchanged in patients with diabetes.Asetat tidak berpengaruh pada gula darah dan insulin, sehingga aman untuk pasien DM. Sedangkan laktat ketika diinfuskan ke
pasien menaikkan kecepatan pembentukan glukosa 3x lipat.1,2,4
1. R. Zander, Fluid Management, Bibliomed – Medizinische Verlagsgesellschaft mbH, Melsungen, 20092. Reddy et al., Crystalloid Fluid Therapy, Critical Care, 2016:20-593. McCague et et al.,Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2011,19:244. Fernandes et al., Intravenous Acetate Elicits a Greater Free Fatty Acid Rebound in Normal than Hyperinsulinaemic Humans, Eur J Clin Nutr. 20125. Pfortmueller et al., Acetate-buffered crystalloid infusate versus infusion of 0.9% saline and hemodynamic stability in patients undergoing renal transplantation, The Central European
Journal of Medicine, 2017.6. Waack et al, L-Malate’s Plasma and Excretion Profile in the Treatment of Moderate and Severe Hemorrhagic Shock in Rats, BioMed Research International, 2016 .7. Dai et al, Ringer’s Malate Solution Protects Against The Multiple Organ Injury and Dysfunction Caused by Hemorrhagic Shock in Rats, SHOCK, Vol. 38, No. 3, pp. 268Y274, 20128. PI Approved BPOM.
BENEFIT
3. Less than 10% of an acetate dose is eliminated via the kidneys
Kurang dari 10% asetat yang dieliminasi di ginjal, sehingga aman untuk pasien dengan gangguan ginjal. 1,5
4. Acetate does not increase oxygen consumption
Asetat tidak menaikkan konsumsi oksigen, sementara laktat menaikkan konsumsi oksigen dengan cepat hingga 30% danberisiko menyebabkan tissue hypoxia (jaringan kekurangan oksigen) 1
5. For every mole of malate oxidized, two moles of bicarbonate are produced
Malate menghasilkan 2 molekul bikarbonate, lebih banyak dibandingkan anion yang lain. 1
1. R. Zander, Fluid Management, Bibliomed – Medizinische Verlagsgesellschaft mbH, Melsungen, 20092. Reddy et al., Crystalloid Fluid Therapy, Critical Care, 2016:20-593. McCague et et al.,Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2011,19:244. Fernandes et al., Intravenous Acetate Elicits a Greater Free Fatty Acid Rebound in Normal than Hyperinsulinaemic Humans, Eur J Clin Nutr. 20125. Pfortmueller et al., Acetate-buffered crystalloid infusate versus infusion of 0.9% saline and hemodynamic stability in patients undergoing renal transplantation, The Central European
Journal of Medicine, 2017.6. Waack et al, L-Malate’s Plasma and Excretion Profile in the Treatment of Moderate and Severe Hemorrhagic Shock in Rats, BioMed Research International, 2016 .7. Dai et al, Ringer’s Malate Solution Protects Against The Multiple Organ Injury and Dysfunction Caused by Hemorrhagic Shock in Rats, SHOCK, Vol. 38, No. 3, pp. 268Y274, 20128. PI Approved BPOM.
BENEFIT
6. Malate increased the median survival time after severe hemorrhagic shock
Malate meningkatkan median (nilai tengah) survival time pada syok perdarahan 6 Efek ini terjadi karena kejadian luka padaorgan (organ injury) berkurang dengan adanya malate 7
7. Similar to physiological plasma.
Komposisi yang menyerupai plasma akan mengurangi tindakan koreksi
Osmolarity: 309 mOsm/l, osmolality: 291 mosmol/kg H2O Cairan bersifat isotonis, cairannya mendekati plasma
sehingga terus berada di pembuluh darah dan mengurangi trauma pembuluh darah.
8. Suitable for pediatric
Asetat & malat bisa digunakan pada anak-anak. 8
BENEFIT
1. R. Zander, Fluid Management, Bibliomed – Medizinische Verlagsgesellschaft mbH, Melsungen, 20092. Reddy et al., Crystalloid Fluid Therapy, Critical Care, 2016:20-593. McCague et et al.,Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2011,19:244. Fernandes et al., Intravenous Acetate Elicits a Greater Free Fatty Acid Rebound in Normal than Hyperinsulinaemic
Humans, Eur J Clin Nutr. 20125. Pfortmueller et al., Acetate-buffered crystalloid infusate versus infusion of 0.9% saline and hemodynamic stability in
patients undergoing renal transplantation, The Central European Journal of Medicine, 2017.6. Waack et al, L-Malate’s Plasma and Excretion Profile in the Treatment of Moderate and Severe Hemorrhagic Shock in
Rats, BioMed Research International, 2016 .7. Dai et al, Ringer’s Malate Solution Protects Against The Multiple Organ Injury and Dysfunction Caused by Hemorrhagic
Shock in Rats, SHOCK, Vol. 38, No. 3, pp. 268Y274, 20128. PI Approved BPOM.
THANKS
MERCY
TERIMA KASIH
有難う御座います– Arigatou Gozaimasu
잘 잘 잘 잘 잘 잘 (jal meokgessseumnida)
رشك -Syukron
谢谢 -xiexie