Download - Fluid Therapy.ppt Nem
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IV FLUID THERAPY
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FisiologiFisiologi
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Pemilihan Cairan Pemilihan Cairan Berdasarkan :Berdasarkan :
Macam Cairan Konsentrasi Zat Terlarut
Status Hidrasi Pasien & Kelainan Metabolik
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Osmolalitas :Jumlah partikel yang osmotik aktif per liter larutanOsmolaritas :Jumlah partikel yang osmotik aktif per kilogram larutanTonisitas :Osmolalitas serum yang efektif ditentukan oleh zat-2 terlarut --> Na & glucosa
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Osmolaritas plasma (mOsmol/L) =2 X [ Na+ ] + Glukosa + BUN
18 2,8Osmolaritas serum normal : 280 - 300 mOsmol/L
Tonisitas (mOsmol/L) =2 X [ Na+ ] + Glukosa ===> N : 275 - 290
18
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Pembagian Cairan Berdasarkan Pembagian Cairan Berdasarkan TonisitasTonisitas
Cairan Isotonis Cairan Hipertonik Cairan Hipotonik
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CAIRAN ISOTONIKCAIRAN ISOTONIK
Konsentrasi partikel dalam larutan = dibandingkan dengan konsentrasi partikel di CIS
Tidak ada pergerakan cairan melalui membran yang semipermeabel
Tidak menyebabkan pembengkakan/ pengerutan sel
Contoh : NaCl 0,9 %
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CAIRAN HIPERTONIKCAIRAN HIPERTONIK Konsentrasi partikel dalam larutan >
dibandingkan di intra sel Menyebabkan air dari intra sel keluar &
sel akan mengkerut Contoh : NaCl 3 %, Dekstrosa 50 %
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CAIRAN HIPOTONIKCAIRAN HIPOTONIK Konsentrasi partikel dalam larutan <
dibandingkan intrasel Menyebabkan cairan dari extrasel
masuk ke intrasel --> pembengkakan sel
Contoh : NaCl 0,45 %
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CAIRANCAIRAN
KRISTALOID KOLOID
CAMPURAN/ KOMBINASI
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BM rendah ( < 8000 dalton ) Tekanan onkotik rendah --> cepat
terdistribusi ke ruang ekstrasel Dengan atau tanpa glukosa Efek mengisi ruang interstitial > koloid Lebih murah & mudah didapat Contoh : RL, NaCl 0,9 %, D5% dll
KRISTALOIDKRISTALOID
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KOLOIDKOLOID BM tinggi ( > 8000 dalton ) Tekanan onkotik tinggi --> sebagian besar
menetap di ruang iv Menetap > lama di ruang iv : kristaloid Mahal, resiko > besar : kristaloid Resiko koloid sintetik : alergi, anafilaksis,
gangguan koagulasi Contoh : - Albumin, produk darah
- sintetik : HES, dextran dll
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The relative distribution of crystalloid & colloid The relative distribution of crystalloid & colloid solutions in the intra-and extravascular fluid space at solutions in the intra-and extravascular fluid space at
equilibrium ( within 30 min to 1 hour of infusion ) equilibrium ( within 30 min to 1 hour of infusion )
FLUID INTRAVASCULAR
EXTRAVASCULAR
Normal capillary permeabilityCrystalloidColloid
20 %70 %
80 %30 %
Increased capillary permeabilityCrystalloidColloid
15 – 20 %60 – 70 %
80 – 85 %30 – 45 %
Increased capillary permeability+ cell membrane dysfunction
CrystalloidColloid
10 – 15 %50 – 60 %
85 – 90 %40 – 50 %
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1. RINGER LAKTAT ( RL ) Paling fisiologis jika diperlukan volume besar Laktat oleh hati --> bikarbonat --> u7 asidosis metabolik ringan Baik u7 defisit CES Kalori ( - )
KRISTALOIDKRISTALOID
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Na+(mEq/L)
K+(Meq/L)
Ca+(Meq/L)
Cl-(Meq/L)
Bikarbonat(Meq/L)
Osmolaritas(mOsmol/L)
RL 131 5 4 111 29* 276Plasma 145 4 3 105 24 290 10* Sebagai laktat
RINGER LAKTAT
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KRISTALOIDKRISTALOID2. RINGER SOLUTION ( RS )
• Komposisi mirip RL
• Na & Cl > RL
• Laktat ( - )
• Kalori ( - )
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3. NaCl 0,9 % Na & Cl tinggi --> baik u7 koreksi awal
defisit CES dengan hiponatremi, hipokloremia & alkalosis metabolik
Pada pemberian volume besar dapat menyebabkan dilutional hyperchloremic acidosis
Kalori ( - )
KRISTALOIDKRISTALOID
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4. DEKSTROSA/ GLUKOSA 5 % (D5%) Cairan pengganti pada kekurangan air
murni Cairan rumatan pada hipernatremi,
hiperkalemia Pemberian jangka lama dapat
menyebabkan hipokalemia, intoksikasi air
KRISTALOIDKRISTALOID
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COLOIDSCOLOIDS
They remain largely within the intravascular space.Therefore, colloids are
most effectivein hypovolemic patiens
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Oncotic pressure --> iv volume --> preload --> Cardiac output ( CO )
iv volume --> hemodilution --> improved rheology --> flow resistance --> DO2
Hemodilution --> Ht --> Arterial oxygen concentration ( CaO2 )
Effect of Synthetic ColloidsEffect of Synthetic Colloids
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TOK volume darah
Sealing effect ( HES 100-300 kD ) Mengembalikan aliran darah regional
pada hipovolemia viscositas, daya adesif leukosit
Efek koloid yang Efek koloid yang menguntungkanmenguntungkan
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HES 200/ 0,5 lebih baik dari pada : Albumin 5 % Ringer laktat HES BM < 50,000 HES BM > 300,000
Sealing effect :Sealing effect :
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Reaksi anafilaktik : Albumin ( 0,003),Dekstran (0,008), Gelatin (0,038) & HES (0,006)
Koagulasi : Dekstran, HES ( tgt dosis ) Keracunan ginjal : HES, Dekstran (dosis
tinggi) Pembatasan penggunaan pd gagal
ginjal : HES
Efek koloid yang merugikanEfek koloid yang merugikan
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Perdarahan tanpa indikasi transfusi --> BM sedang - tinggi ( dekstran 70, HES 100 - 300 kD )
Indikasi transfusi menunggu cocok silang --> BM rendah ( HES 40.000, gelatin, dekstran 40, poligelin )
Reologi & anti trombosis --> dekstran
Pilihan KoloidPilihan Koloid
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Syok berat karena dehidrasi --> poligelin
Perdarahan baru, syok ringan --> isoonkotik
Kebocoran kapiler --> HES 100 - 300 kD
Pilihan KoloidPilihan Koloid
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LOW MW :- Expafusin 6% (40.000/0,5-0,55) in balanced salt solution- Voluven 6% (130.000/0,4) in NaCl 0,9%
MEDIUM MW :- HES steril 6%,10% (200.000/0,5) in NaCl 0,9 %- Hemohes 6% (200.000/0,5) in NaCl 0,9%
HIGH MW :- HES ( 450.000/0,7 )
Hydoxy Ethyl Starch ( HES )Hydoxy Ethyl Starch ( HES )
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EFEK VOLUME INFUS 1 L CAIRAN EFEK VOLUME INFUS 1 L CAIRAN PADA KOMPARTEMEN TUBUH (70 PADA KOMPARTEMEN TUBUH (70
KG)KG)
LARUTAN VOLUMEPLASMA
VOLUMEINTERSTISIAL
VOLUMEINTRASEL
ALBUMIN 5 % 1000 - -HAEMACEL 700 300 -GELAFUNDIN 1000 - -PLASMAFUSIN 1000 - -DEXTRAN 40 1600 -260 -340DEXTRAN 70 1300 -130 -170EXPAFUSIN 1000 - -HES STERIL 6 % 1000 - -HES STERIL 10 % 1450 -450 -
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EFEK VOLUME EFEK VOLUME DARAHDARAH
LARUTAN WAKTU ( JAM )6 %/10 % HES 200/0,5 4 – 86 % HES 200/0,6 8 – 126 % HES 450/0,7 8 – 126 % DEXTRAN 70 6 – 810 % DEXTRAN 40 3,5 – 4,54 % PLASMAFUSIN 4 – 65 % ALBUMIN ( 500 mL ) 3,5 – 4,525 % albumin ( 100 mL ) 3,5 – 4,5GELATIN 1,5 – 2,5
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Koloid pengganti vol darah lebih efisien > kristaloid
Koloid > mahal Rx anafilaktoid koloid > kristaloid Hemodilusi sebelum transfusi dengan
kristaloid atau koloid bermanfaat pada restorasi vol darah
KRISTALOID vs KOLOIDKRISTALOID vs KOLOIDarea persetujuanarea persetujuan
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Resusitasi cairan selain darah secara praktis sangat bermanfaat
Anemia ditoleransi lbih baik dari pada hipovolemia. Perdarahan akut orang sehat anemia ditoleransikan sampai 50 %, sedangkan hipovolemia hanya 30 %
Kelebihan cairan dengan ke2 macam larutan merupakan peristiwa yang tak diinginkan
Koloid lebih efektif dalam mempertahankan tekanan osmotik koloid
KRISTALOID vs KOLOIDKRISTALOID vs KOLOIDarea persetujuanarea persetujuan
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Efek koagulasi Fungsi ginjal Air interstisial paru Lama rawat di ICU & RS Mortalitas Frekwensi ARDS
KRISTALOID vs KOLOIDKRISTALOID vs KOLOIDarea debat ( 1 dekade yl )area debat ( 1 dekade yl )
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Otak --> edema Jantung --> kinerja Paru --> oksigenasi Pencernaan --> translokasi bakteri Perifer --> penyembuhan luka
KRISTALOID >> ----> edema interstisialKRISTALOID >> ----> edema interstisial
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Mahal Makin tidak populer Tidak ada bukti lebih baik daripada
kristaloid dalam menurunkan mortalitas
Kurang efektif dalam mempertahankan TOK daripada koloid
AlbuminAlbumin
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Plasma protein, BM = 69.000 Kadar 4,5 g/dl 80 % penentu tekanan onkotik, 21,8
mmHg 30-40 % di intravaskuler (onkotik), juga
terdapat di interstitial Produksi di Hati 12-25 g/hr --> masuk
sirkulasi darah --> keluar sirkulasi 10 %/ hari
AlbuminAlbumin
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Half life 16 jam Sintesa hanya berjalan baik dalam
kondisi nutrisi, hormon & osmotik yang sesuai
Hati dapat meningkatkan sintesa 2 - 2,7 x normal
AlbuminAlbumin
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Penentu tekanan onkotik plasma Transporter obat, antibiotik, free
radicals & toksin Fungsi lain :
- ada orang dengan analbuminemia- Hipoalbuminemia menyebabkan bio-availabilitas abat naik atau turun
Fungsi AlbuminFungsi Albumin
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Hipoalbumin memperpendek waktu paruh obat ( T1/2 ) :
- Antibiotika ceftriaxone T1/2 normal 9 jam menjadi 5 jam pada kadar albumin 45 %- Artinya, MIC ( minimum inhibitin conc.) normalnya 20 jam akan turun jadi 13 jam --> jadi dosis tunggal 1 x sehari harus naik jadi 2 x sehari
Fungsi AlbuminFungsi Albumin
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PV EXPANSION WITH ADMINISTRATION OF PV EXPANSION WITH ADMINISTRATION OF 250 mL SELECTED FLUIDS250 mL SELECTED FLUIDS
FLUID PV(ML)
IFV(ML)
ICV(ML)
D5W 18 70 162LRS 50 200 05 % ALBUMIN 250 0 025 % ALBUMIN 1000 -750 0
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EFEK INFUS 1 L CAIRAN EFEK INFUS 1 L CAIRAN PADA KOMPONEN TUBUHPADA KOMPONEN TUBUH
CAIRAN ICV ECVTOTAL
ISV IVV
NaCL 0,9 % - 100 1100 825 275D 5 % 660 340 255 85NaCL 5 % - 2950 3950 2690 990Albumin 5 % 0 1000 500 500Darah lengkap 0 1000 0 1000
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Efek albumin pada hasil akhir masih kontroversi
dan menunggupenelitian prospektif multi sentrik & acak
AlbuminAlbumin
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BAHAN PENYELAMAT NYAWANAMUN
DAPAT MENGANCAM NYAWA BILA
DIBERIKAN SECARA SALAH
DARAHDARAH
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PENGAMATAN SUNATRIO : Alasan sayang U7 mencapai Hb 10 g % supaya penyembuhan tidak
terhambat Hb 10 g % minimal Relatif banyak diberikan darah lengkap,seharusnya
dapat digantikan dengan transfusi eritrosit + NS/RL FFP/ albumin sebagai bahan makanan. FFP diberikan
tanpa bukti adanya gangguan koagulasi atau sebagai substitusi plasma
Transfusi kurang rasionalTransfusi kurang rasional
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Transfusi bila :- Hb < 7 mg/dl ( Ht < 21 % )- Jarang bila Hb > 10 mg/ dl ( Ht > 30 % )
Resiko transmisi viral & bakterial Modulasi imun sekunder RCT : Hb 7-9 atau 10-12 mg % tidak berbeda
dalam morbiditas & mortalitas Transfusi ditentukan kasus per kasus
DARAHDARAH
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Arterial blood pressure Urine output Systemic acid-base balance (pH,BE, lactate ) Some clinical assessment of tissue perfusion :
“warm & well perfused” or “cold & shut down” Some measurement of global blood flow &
tissue perfusion : CO/ CI, DO2, SVO2
What do You need to know when You What do You need to know when You resuscitate a Patient in Shock ?resuscitate a Patient in Shock ?
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Bahaya mikrobiologik- Cairan merupakan nutrisi u7 mikroorganisme- Kontaminasi karena : * mikroba udara pada waktu membuka tutup botol * open system tanpa filter * sentuhan * penambahan obat * pirogen
====>
Bahaya yang berhubungan Bahaya yang berhubungan dengan terapi cairan intravenadengan terapi cairan intravena
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Penambahan obat dapat menyebabkan - Kontaminaasi ( 8 % )- Drug incompatibilities- Drug bioavailability :potensi antibiotik hilang, obat terabsorbsi ke botol & selang infus
Bahaya yang berhubungan Bahaya yang berhubungan dengan terapi cairan intravenadengan terapi cairan intravena
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Must to know what the bottle contain
To provide safe & effective To provide safe & effective iv fluid therapy,iv fluid therapy,
clinicians who orders the iv clinicians who orders the iv fluidfluid
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FisiologiFisiologi
BODY FLUID COMPARTMENTS Total BodyTotal Body Water Body Weight (%) Water (%)
Total 60 100Intracellular 40 67Extracellular 20 33Intravascular 5 8Interstitial 15 25
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Prinsip pemilihan Prinsip pemilihan cairan :cairan :
Gantikan kompartemen yg hilang Tujuan I : pemulihan cairan
intravaskuler & perfusi jaringan Perbaiki rongga interstitial Perhatikan kemampuan daya
angkutnya Perbaiki cairan intraseluler
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Pemilihan jenis cairan :Pemilihan jenis cairan :
Colloid :– Lebih baik untuk ekspansi volume
plasma yang segera– Lebih tepat untuk perbaikan Cardiac
Output dan VO2– Mengurangi efek edema paru– Harga mahal
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Pemilihan jenis cairan :Pemilihan jenis cairan :
Criystalloid :– Terbaik untuk dehidrasi (kehilangan
cairan ekstraseluler) atau perdarahan ringan.
– Dapat memberikan efek ekspansi intravaskuler, dengan akibat overekspansi cairan interstitial
– Baik jika tidak terdapat kebocoran kapiler
– Harga murah
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Solution Tonicity Na+ (mEq/L)
Cl- (mEq/L)
K+ (mEq/L)
Ca2+(mEq/L)
Glucose (g/L)
Lactate (mEq/L)
5% Dextrose in water (D5W)
Hypo (253)
50
Normal Saline
Iso (308) 154 154
D5 ¼ NS Iso (330) 38,5 38,5 50
D5 ½ NS Hyper (407)
77 77 50
D5 NS Hyper (561)
154 154 50
RL Isi 273) 130 109 4 3 28
D5 RL Hyper (525)
130 109 4 3 50 28
COMPOSITION OF CRYSTALLOID
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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
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B. COLLOIDS
- NATURAL COLLOIDS:
-PLASMA PROTEIN FRACTION 5%
-HUMAN ALBUMIN 5% AND 2,5%
- SYNTHETIC COLLOIDS
- DEXTRAN 40 AND 70
- HYDROXYETHYL STARCH (HETASTARCH) 6%
AND
10 %
-GELATIN
-MODIFIED FLUID GELATIN
-UREA LINKED GELATIN
-OXYPOLY GELATIN
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Colloids Production Type Molcular Weight(103)
Halflife intravascu
ler
Indication
Plasma protein
Human plasma Serum human albumin
50 4-15 days -Volume substitute- Hypoproteinemia- Hemodilution
Dextran Leuconostoc mesenteroid B 512
D 40, 70 60-70 6 hrs -Hemodilution-Microcirculation disturbance
Gelatine Hydrolisis animal collagen
- Modified gelatine-Urea linked- Oxypolygelatine
35 2-3 hrs -Volume substitute
Starch Acid hydrolisis and ethylene oxide from soybeans and maize
- Hydroxiethylstarch
450 6 hrs -Volume substitute-Hemodilution
Polyvinyl pyrrolidone (PVC)
Polymer synthetic vynil pyrrolidone
- Subtosan--Peristone
5025
-Volume substitute
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Jenis2 cairan untuk mengisi Jenis2 cairan untuk mengisi volume I.vaskulervolume I.vaskuler
Jenis Na Cl K Ca Mg Lact/Acetat lain2
NaCl0.9% 154 154 - - - - -
Ring Lakt 138 112 4 5 - Lakt/28 -
Expafusin 138 125 4 3 Lakt/20 HES/40000
Haes st 6% ,10%
154 154 - - - - HES/200000
Hemacel 145 145 5,1 6,25 - - Polygeline
Gelafundin 142 80 - 1,4 - - Gelatin/35000
Dextran L 130 108 4 2,7 - Lakt/28 Dextran40
NaCl 3% 500 500 - - - - -
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Efek Volume infus 1 l cairan pada kompartemen tubuh (70 kg)
LarutanRLExpafusinAlbumin 5%HaemaccelGelafundinPlasmafusinDextran 40Dextran 70Haes steril 6%Haes steril 10
Vol.plasma20010001000700
100010001600130010001450
Vol. Interstitial800
300
-260-130
-450
Vol. Intrasel
-340-170