terapi cairan

TRIASE

Eko Waskito

TERAPI CAIRAN

Staf RSUD Kota JanthoKabupaten Aceh Besar

Istri: Dr. Ari Gusnita (PPDS Neurologi FK USU)Anak: Aqila Lutfiyah M. Rafif Aditya

Pendidikan Dokter FK USU, selesai Jan 2005Pendidikan Dokter Spesialis Anestesiologi & Terapi IntensifFK USU, masuk Januari 2010

P e r k e n a l a nTempat/ Tgl Lahir: Pematangsiantar10 April 1979

Organisasi: Kabid Litbang HMI FK USUManajer Op. MER-C MedanKoord. Kesehatan PKPA MedanSeksi Ilmiah IDI Aceh BesarMember Of Indonesian Society of Perinatology

Publikasi:Artikel di Media Cetak 35 bh

Pelatihan: ATLS, ACLS, Resusitasi Neonatus, Psikiatri Akut, dll

Niat: Hidup adalah memberi

PHYSIOLOGY

TOTAL BODY FLUID 60% BW

INTRACELLULARFLUID (ICF)

INTRACELLULARFLUID (ICF)

EXTRACELLULARFLUID (ECF) 20% BW

TRANSCELLULAR FLUID

TRANSCELLULAR FLUID

40 % BW

INTRAVASCULARFLUID

INTRAVASCULARFLUID

INTERSTITIIL FLUID

INTERSTITIIL FLUID

5 % BW

15 % BW

1-3 % BW

60% dari berat badan adalah H2O

Pasien berat 50 kg30 kg adalah air

(30 liter)

Intra Vascular Fluid (IVF) 5% BB

Intra Cellular Fluid (ICF) 40% BB

Interstitial Fluid (ISF) 15% BB

ECF

IVF 5% ISF 15% ICF 40%

2500 ml 7500 mlpada pasien 50 kg

ISF merupakan buffer / cadangan yang lebih besar daripada IVF

ECF

IVF 5% ISF 15% ICF 40%

Infusi cairan elektrolit ke IVF akan merembes keluar ke ISFKomposisi IVF dan ISF sama

ECF

Kehilangan cairan yang sering terjadi

· Gastro-intestinal loss– Air– Natrium– Kalium

· Perdarahan– Air– Natrium– Kalium– Albumin– Eritrosit

12

Gastro-intestinal lossDiare, muntaber, peritonitis

1. Interstitial sign : 1. mata cowong, 2. turgor turun, 3. mucosa kering

2. Plasma sign :1. Perfusi lambat2. Nadi naik3. Tekanan darah turun

IVF ISF

12

Terapi Infus untuk Diare, muntaber, peritonitis

1. Infus cepat untuk mengisi kembali IVF2. Infus lambat untuk mengisi kembali ISF3. (memberikan juga cairan maintenance)

1 2

IVF ISF

infus

21

Perdarahan

1. Kehilangan IVF• Perfusi lambat• Nadi naik• Tekanan darah turun

2. Dicoba diisi oleh ISF (transcapillary refill), 100 cc / jam

IVF ISF

21

Terapi infus untuk Perdarahan

1. Infusi cepat mengembalikan IVF

2. Setelah IVF stabil, diteruskan untuk mengembalikan ISF

3. Volume yang diperlukan jadi 2-4x kehilangan IVF

12

IVF ISF

infus

Efek Syok Pada Tingkatan sel

HYPOXIA

LOW-FLOW,POOR PERFUSION

ANAEROBIC METABOLISM

ACIDOSIS

DECREASED CELLULAR ENERGY EFFICIENCY

CELL MEMBRANE FAILURE:

• DIRECT EndotoxinComplement• INDIRECTFailure to maintain normal Na+, K+ or Ca2+ gradientDecreased oxidative phosphorylation

OSMOTIC GRADIEN

T

Water entry into

cell

CELLULAR EDEMA

IMPAIRED INTRACELLULAR

METABOLISM

CELL

DEATH

Na+ entry into cell

Efek syok pada tingkatan sel

PRE-LOAD CONTRACTILITY AFTER-LOAD

STROKE VOLUME HEART-RATE

CARDIAC OUTPUT SYSTEMIC VASCULAR

RESISTANCE

BLOOD PRESSURE

PERDARAHAN

HILANG VOLUME

HILANG ERITROSIT

21

Pasang infusi pada vena besar

1. Vena cubiti, basilica

2. Vena jugularis ext (posisi kepala-leher

tetap in-line)

3. Vena subclavia

4. Vena saphena magna?

FLUID REPLACEMENT

3 : 1 RuleClass I Crystalloid

Class II Crystalloid + Colloid ?

Class III Crystalloid

+Colloid, BloodClass IV Crystalloid

+Colloid, Blood

Pola kerja penanganan shock perdarahanPenderita datang dengan perdarahan

Pasang infus jarum kaliber besar, sample darah

Ukur tekanan darah, hitung nadi, nilai perfusi, produksi urine

Tentukan estimasi jumlah perdarahan, minta darah

Guyur cepat Ringer Laktat atau NaCl 0.9% [hangat, 390C] 3x prakiraan lost-volume [1-2

liter] Evaluasi

• Pulse-Rate [x/min.]• Blood-Pressure• Pulse-Pressure

• Respiratory Rate• Urine out-put [ml/hour]

• Mental status/CNS

normal

evalu

asi

Management selanjutnya

· Rapid response,perdarahan <20%

· Transient response,perdarahan 20-40% BVongoing lossresusitasi tdk adekwatKOLLOID HES

200/0.5transfusi

· Minimal, no responseTindakan bedah segeraTransfusi darah

Hasanul, 2003

Class I Class II Class III Class IV

Blood-Loss[ml] ->750 750-1500 1500-2000 >2000

Blood-loss [%BV] ->15% 15-30% 30-40% >40%

Pulse-Rate [x/min.] <100 >100 >120 >140

Blood-Pressure Normal Normal Decreased Decreased

Pulse-Pressure N or increased

Decreased Decreased Decreased

Respiratory Rate 14-20 20-30 30-35 >35

Urine out-put [ml/hour] >30 20-30 5-15 Negligible

Mental status/CNS Slightly anxious

Midly anxious Anxious and confused

Confused and lethargic

Estimated Fluid and Blood Losses Based on Patient’s Initial Presentation

BV = 70 ml/kg

How to Resuscitate the Circulation ?How to Resuscitate the Circulation ?

CaO2 = (SaO2 x Hb x 1.34) + (PaO2 x 0.0031)

DO2 = CO x CaO2

SV x HR

PRELOAD, CONTRACTILITY

R/ Fluid

Fluids

· “Third space” loss into interstium and tissues–3:1 rule of crystalloid for every ml

of blood loss

· ATLS: 2 liters of crystalloid through large bore IV for early treatment of hemorrhagic shock.

Fluids

· Crystalloid· Colloid· Hypertonic saline· Darah Totilac

Fima RL

Crystalloid Colloid

Advantages - Inexpensive- Promotes urinary flow- Fluid of choice for initial resuscitation of trauma/hemorrhage- Expands intravascular volume- Restores 3rd spaces losses

-More sustained intravascular-Volume increase (1/3 still intravascular at 24 hrs)- Maintain or increase plasma oncotic pressure-Requires smaller volume for equal effects-Less peripheral oedem (more fluids remains intravascular)-May lower intracranial pressure

Disadvantages

- Dilutes colloid osmotic pressure- Promotes peripheral oedem- Higher incidence of pulmpnary oedem- Requires large volume- Effects are transient

-Expensive-May produce coagulopathy (dextrans and hetastarch)-With capillary leaks may potentiate fluid loss to the interstitium-Impairs subsequent crossmatching of blood (dextran)-Dilutes clotting factors and platelet-Decrease platelet adhesiveness (absorption onto platelet membrane reseptor)-Potential blocking of renal tubules and reticuloendothelial cells in the liver-Possible anaphylactoid reaction with dextran

CRYSTALLOID VS COLLOID

Isotonic crystalloids

· Advantages– Cheap– Easy to store and warm– Established safety – Predictable rise in cardiac output

· Disadvantages– Large volumes needed– Dilutional coagulopathy– Increase cytokine activation– No oxygen carrying capacity– May Increase ICP

Na Cl K Ca Buffer pH

Plasma 141

103 4-5 5 Bicarb 7.4

0.9%NS 154

154 ---- ---- ---- 5.7

LR 131

111 2 3 Lactate 6.4

Composition of iv Crystalloid

Fima RL Fima NS Ringer AsetatFima D5

Ringer Laktat vs NaCl 0,9%

· Lowery 1971(Surg Gynecol Obstet)– Vietnam war study LR v NS– Healthy soldiers – No difference in outcome

· Waters 2001 (Aneth Analg)– Patients undergoing aortic aneurysm repair – NS

• More volume (~500-1000ml)• Hyperchloremic acidosis• Dilutional coagulopathy

· Todd (J. Trauma 2007; 62:636-9) – Swine bled via liver injury & resuscitated to MAP

90mmHg– NS

• More volume • Hyperchloremic acidosis• Dilutional coagulopathy

Ringer Laktat vs NaCl 0,9%

• Conclusion– No mortality difference– Ringer Laktat

• Lower overall volume• More buffering capacity

– NaCl 0,9%• Metabolic acidosis• Dilutional coagulopathy

– Preferred fluid outside of US– Probably no difference for prehospital or early fluid

resuscitation.

Ringer Laktat vs NaCl 0,9%

Colloids

· Keuntungan– Volume lebih kecil

• Sedikit udem pulmonum– Bertahan dalam intravascular space

• Cepat mengembalikan hemodinamik normal.

– Kemasan lebih kecil.– Mempunyai efek antioksiden dan

antiinflamasi.

Colloids

· Kerugian – Penularan penyakit. – Peningkatan perdarahan.– Reaksi alergi. – Gagal Ginjal– Dosis maksimal : 20-50mL/kg– Harga lebih mahal.

Jenis cairan yang beredar :

• Kristalloid ( D5W, RL, RA, NaCl )

• Hypertonic Saline

• Kolloid ( Albumin, Fima HES)

• Cairan Nutrisi ( Aminofluid, Intrafusin, Ivelip, Triofusin)

Blood Disadvantages

· Cost· Compatability/error

– Incorrect blood-1:40,000 (death 1:2million)· Immune complications

– 1:40,000· Infection

– Sepsis 1:500,000 (RBCs) 1:50,000 (platelets)– Hep B 1:250,000– Hep C & HIV 1:2million

· Storage requirements· Citrate toxicity· Hypocalcemia· Hyperkalemia ?

Fluid Terapi

VOLUME INTRAVASKULAR

MEKANISME HEMODINAMIK

TOTAL BODY WATER : 60% TOTAL BODY WEIGHT

36 L

ISF

60 kg

9L

ISF IVF ICF

3L 24 L

Physiologic principles of fluid management

ISF

9L

ISF IVF ICF

3L 24 L250 ml

D5W= H2O

750ml

Physiologic principles of fluid management

3L

2 L

Not for resuscitation !!!Not for resuscitation !!!

EDEMA

Intra venous fluid replacement

Fluid Resuscitation

ISF

9L

ISF IVF ICF

3L 24 L750 ml

CRYSTALLOID

RL, RA,

NaCl 0.9%

2250ml

Physiologic principles of fluid management

EDEMA

3L

Require large volume

Cheaper

Fewer adverse side effects

ISF

9L

ISF IVF ICF

3L 24 L1L

Physiologic principles of fluid management

Albumin-5%1 Lexpensiv

eexpensiv

e

ISF

9L

ISF IVF ICF

3L 24 L500 ml

Physiologic principles of fluid management

400

Albumin-20%Cth:Octalbin 20%

100 ml

expensive

expensive

Intra venous fluid replacementFluid Resuscitation

ISF

9L

ISF IVF ICF

3L 24 L1L

Physiologic principles of fluid management

HES-6%, 200/0.5(Fimahes)

1 L

• More rapidly correct hypovolemia

• Maintain intravascular oncotic pressure

• More expensive

Fluid Challenge Protocol

Baseline observations

during infusion

after infusion

after 10-min wait

CVP

< 6

6- 10> 10

> 4

< 22 - 4

> 2< 2

PCWP

<12

12 - 16> 16

> 7

< 33 -7

> 3< 3

Volume challenge(mL/10min)

200

10050Stop

Continue infusionWait 10-min

Stop challengeRepeat challenge

Pressure(mmHg)

Brian T, Andrews, Neuerosurgical Intensive Care, 1993.

How to Resuscitate the Circulation ?How to Resuscitate the Circulation ?

CaO2 = (SaO2 x Hb x 1.34) + (PaO2 x 0.0031)

DO2 = CO x CaO2

R/ Oxyge

n

SaO2 , PaO2

Terapi Oksigen Terapi Oksigen

5-6 L/m

2-4 L/m

Goal terapi oksigen

SaO2, SpO2, 96-98%

PaO2, ≥ 80 mmHg

How to Resuscitate the Circulation ?How to Resuscitate the Circulation ?

CaO2 = (SaO2 x Hb x 1.34) + (PaO2 x 0.0031)

DO2 = CO x CaO2

R/ WholeBlood, PRC

How to Resuscitate the Circulation ?How to Resuscitate the Circulation ?

CaO2 = (SaO2 x Hb x 1.34) + (PaO2 x 0.0031)

DO2 = CO x CaO2

SV x HR

PRELOAD, CONTRACTILITY

R/ Vasoaktive Inotropic

Hasil terapi infusi

• Sirkulasi membaik lalu stabil– good response, normovolemia

• Sirkulasi membaik lalu merosot lagi– transient response, masih hipovolemia, ada perdarahan

berlanjut.– Resusitasi tidak adekuat?– Infus dengan koloid

• Sirkulasi tidak membaik– no response, masih tetap hipovolemia– Tindakan bedah segera kemungkinan ada perdarahan

yang masih berlangsung.

57

soal

• Pasien 32 tahun, datang post partum, lahir diluar rumahsakit. Tidak sadar, nafas 10 x/menit, Nadi tidak teraba, Tensi tidak terukur, muka pucat Apa yang Sdr lakukan ?

soal

• Pasien laki-laki, umur 25 tahun, datang ke rumahsakit akibat KLL, tabrakan motor yg dikendarainya dengan mobil.

• Tidak sadar, nafas 8 x/menit, Nadi tidak teraba, Tensi tidak terukur, muka pucat. Apa yang Sdr lakukan ?

Terima kasih