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dr. Budhi SantosoMedical Consultan of PT Otsuka Indonesia
Emergency Medicine Lunch SymposiumMakassar, 7th April 2013
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SO!T C"!IC"L"M #IT$E
%.&ame ' Budhi Santoso(.Place)date of *irth ' +akarta, %- Mei %/-0.$ddress ' Mampang Indah II, Blok 1(, 1epok Sa2angan3.Marial status ' Married 2ith 3 children4.$lumny ' Medical 5aculty of Bra2i6aya "ni7, Malang,%0
/.8orking E9perienced ' /.%. Cipete Clinic, +akarta :%0;%3<
/.(. Puskesmas Moro Seneng;=epri, !iau :%3;%-</.0. Schering $> :Med $d7isor' %?;(@@@</.3. Otsuka Indonesia :Med;Consultant' (@@%;(@@-<
-.Training E9perienced ' -.%.>CP ad7ance course, Schering $>;Berlin, %? -.(.Communication on 5amily Planning, S2eden %
-.0.$"CO>S Congress, Philadelphia;"S$, (@@@
-.3.Schering internal leadership course, 1usit, Thailand,-.4.Critical Care $nnual and Pensa Meeting' Bali (@@(-./.$TLS ad7anced, !SCM (@@0-.-. Indonesian >CP, !SCM (@@3-.?.Critically ill in children' Malang, (@@4.-..Critical care 2orkshop, Sura*aya, (@@/, (@@--.%@.$minouid 8orkshop,Tokushima, +apan, (@@?, (@%@
-.%%.Espen Congress, Barcelona Spain, Sept (@%( -.%(.Safety, Ecacy and P# 6oint seminar, +apan;Indonesian 51$,(@%0
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Yang pentingkasih obat,
infus no.12 ?
Cairan Infus
@#$%^&,Wes, e!es,..e!es,bab"as angine......
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Ente harus makanobat seumur hidup !!!
Waduh, lamaamat, dok !!
Enggak, lama,Tergantung berapalama Ente hidup !!!
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Infus Rasional bilapaham 4 hal:
1. Indikasinya2. Fisiologi infus saat masuk tubuh3. Patofisiologinya yang sering
(Resusitasi vs Rumatan)4. Pemilihan infus yang teat
Lobo, et all 2010
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!"(#l! 1$$.$ m%&')
!31R*
!!"2+,-$
!!!2+3R
"!!2+3R
!+!3, /*
LactateRisk ofHyperchloremicacidosis
Intracell
distribution
OsmFluid
CAIRAN RE!I"AI #AN$ %LA&I'( )I*AAI
(#l! 1$4 m%&')
0tsuka /#% internal surveys data 21
5acts'5acts'
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,
Pasien ria 2 th masuk R* dg keluhan utama demamsudah $ hari tidak turun letih insomnia dan dysesia
PF 5 somnolen u6at 7P 1$', 8R 94 RR 12:
bibir e6ah!e6ah lidah kering ; agak kotor faring tidak hieremis. 77 + kg
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iu"asi kasusdemam tifoid, dimana tidak ada asupan oral sama sekali karena pasien dispepsia dan anoreksia
*RO)! AA -./ N*C -./ "otalkalori-kcal/
Na+ -mE0/ + -mEa/
1 *%RI/> ! ! 13 4
1 ?I/0F5I- 3 +$ 42 3$ 2
2 *a6het PR0
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siu"asi kasus demam tifoid, dimana tidak ada asupan oral
sama sekali karena pasien dispepsia dan anoreksia
*RO)! AA -./ N*C -./ "otalkalori-kcal/
Na+ -mE0/ + -mEa/
1 %/ ?>3 ! 1 4 $ 2
1 ?I/0F5I- 3 +$ 42 3$ 2
2 *a6het PR0
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!ES"SIT$SI!ES"SIT$SI !"M$T$&!"M$T$&
1ESI>& TE!$PI C$I!$& I#
Infus Natrium > 100 mEq/L atau koloid 2030 ml/k!/"am #diar$, %&&' 23 L/101( m$nit #p$rdarahan'
Natrium r$ndah #(0100 mEq' )alium s$suai k$*+ arian -am*ahan mikromin$ral, tr El$m$nt dan as+ amino 21 #misal 2( k! 102101 ( (ml/"am
(00 ml/ "am
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Resuscitation Maintenance
Historical Perspective of Infusion Preparation
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4tsuka.ould
o5$r to 6ou
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Hypovolemic shock
StableHemodynamic
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Ringer’s acetate
®
®
Acetate Ringer’s
irst Line
luid Resuscitation Therapy
ASERING
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A First line in replacement fluid forresuscitation: gastroenteritis, burn,
hemorrhagic shock, D ith orhithout hepatic insufficiencyA "ntra operativeA #riming solution for cardiopulmonary
bypass $%#&'A afe replacement fluid for children
Indi6ationBs of AERIN$1
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ASERING®Ringer’s acetate
First Line
Fluid Resuscitation Therapy
( Direkomendasikan oleh W)H)*) untuk
pasien Demam &erdarah Dengue
$D&D')
W.H.O. SEA Dept. of Communicable Disease. Regional Guidelineson Dengue / DHF Pe!ention and Contoll. Regional Publ. "#. $###.
( #ada stroke akut, pemberian +E"-.
sesuai dengan konsep menghindari /+0T+T)
( #encampuran +E"-. dengan 1234g*5 sebanyak 62 cc, akan meningkatkan
tonisitas infus men7adi "*T*-"0)Hadi Panata. Clinical E%peience of Ringe&s acetate 'it( )agnesium sulp(ate adminstation in
Acute *sc(emic Sto+e. Poceeding of P*, PERDOSS*. "--$.
Dama'an *. Paenteal Fluid ,(eap in Sto+e Patients. Poceeding of P*, PERDOSS*. "--$.
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! Loren A et al. Oxidation of lactate and acetate in rat skeletal muscle. Journal of AppliedPhysiology 199 ! "# $ 1 % & p. #' ( #9!
"! )eim*erger +,-.Roland R/. )and*ook of ,linical 0utrition.os*y 199 #. Anderud - Lund . 2ntensi3e ,are of Patients 4ith 5urns. idskr 0or Laegenforen 19"9!
p.#19 ( #199.6. Ringer acetate solution in clinical practice. edimedia.1999
! #omposisi mirip dengan plasma$ tepat untu% mengganti%an
%ehilangan a%ut cairan e%straseluler!$ 1 '
"! #ecepatan metabolisme asetat "&'(4'' m)*+,am $ sedang%anla%tat ''m)*+,am$ asetat lebih cepat meng%ore%si asidosis!
$ 8'
-! .setat memerlu%an sedi%it /" dan melepas%an sedi%it 0/")$ 5 '
4! Metabolisme asetat terutama di otot$ tida% terganggu pada %elainan hati$6'
Aserin. 1 2enefit3
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A Rin.er4s lactate 5678
A AERIN$1 7
A Normal saline 5698
A:era.e pH
General Beneft
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nesthesiology 2 /ov:93($)11+!3iskaser F@ 7ellomo R 8ayhoe ? *tory - Poustie * *mith 7 etis 7ennett ?
Role of um rime in the etiology and athogenesis of6ardioulmonary
byass!asso6iated a6idosis.
Plasmalyte 14, vs Polygeline" Ringer in 22 atients
Cith the 8aema66el!RingerDs rime the metaboli6 a6idosis Eashyer6hloremi6 (∇ #l! "9.$ m%&'l: #I +.!11.$).Cith Plasmalyte the a6idosis Eas indu6ed by an in6rease in unmeasuredanions most robably a6etate and glu6onate.
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In 6on6lusion
atients Eith severe sesis Eho re6eived fluid resus6itation Eith 8%* 13'.42 as6omared Eith those Eho re6eived RingerDs a6etate had a higher risk of death at 9days Eere more likely to re6eive renal!rela6ement theray and had feEer daysalive Eithout renal!rela6ement theray and feEer days alive out of the hosital.
ydro9yethyl Starch %0@)@.3( 7ersus !ingerDs $cetate in Se7ereSepsis
nders Perner ?.-. Ph.-. /i6olai 8aase ?.-. nne 7. >uttormsen ?.-. Ph.-. @yrki udmundurlemenHson ?.-. nders neman ?.-. Ph.-. ristian R. ?adsen ?.-. ?orten 8. ?Jller ?.-. Ph.-. @eanie ?. %lkKLr ?.-.one ?. Poulsen ?.-. sger 7endtsen ?.-. ?.P.8. Robert Cinding ?.-. ?orten *teensen ?.-. PaEel 7ereHoEi6H ?.-. Ph.-.Peter *Je!@ensen ?.-. ?orten 7estle ?.-. Ph.-. ristian *trand ?.-. Ph.-. @Jrgen Ciis ?.-. @onathan 0. Chite ?.-. laus @.
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)2) III = I>02 2!4 'menit
R'R 2 ml'kg bolus dalam 3 menit
yok teratasiyok teratasi yok tidak teratasiyok tidak teratasi
R'R 1 ml'kg'Kam
tabil dalam 9? @amtabil dalam 9? @am
R $ ml'kg'Kam 3 ml'kg'Kam*to N 4, Kam
-etran 4 1!2 ml'kg"eratasi"eratasi
"idak "eratasi"idak "eratasi
8t turun 8t teta'naik
FFP 1 ml'kg -etran 2 ml'kg
ri e'eki, (in)ra Ira!an atari. *ea +er)arah *engue. -I.1///
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Diagram 9. Alur tatalaksana Pemberian cairan Derajat IVProf. Soegeng, Tatalaksana DBD terkini, RSUD Dr Soetomo/FKUnair, 2006
Aserin.
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*%RI/> ; %/ 37
komatibel dengan obat dibaEah ini
A /i6holinA
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JAN’ 2012
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!ES"SIT$SI!ES"SIT$SI !"M$T$&!"M$T$&
&"T!ISI&"T!ISI)ristaloid)ristaloid
M$n!!anti k$hilan!an akut #h$morrha!$,
9I loss, ron!!a k$3'
M$n!!anti k$hilan!an akut #h$morrha!$,
9I loss, ron!!a k$3'
1+ M$n"a!a hom$ostasis hari2+ -$rapi suportif
M$m$p$r.$pat p$n6$m*uha
1+ M$n"a!a hom$ostasis hari2+ -$rapi suportif
M$m$p$r.$pat p$n6$m*uha
TE!$PI C$I!$&
=oloidElektrolitElektrolit
*eri !%/*eri !%/
minofluidminofluid
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are still widely usedfor maintenance therapy *****
RL
!" #e$trose
!" #e$tr% in Rin&ers
8hat are the impacts 8hat are the impacts
5acts'5acts'
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i0a tanpa ekseru a
atau - n0a,kan ?
+isa bisan0a 3tsukaa4a, tuh......sa0a pakai 5 26tts7iaintenane ti)akhipernatrei, ti)akhipoka"ei ??
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#ebutuhan .ir "''' m1 R1 " 1 #.()2 -3 ® " 1
2atrium &' '' m)* "5' m)* '' m)*
#alium 4& 5& m)* 6 m)* 4' m)*
Infus RL 'u(an)ntu( Terapi Rumatan
Ilustrasi 77 -eEasa (0rg Indonesia) O $ kg
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+nak && 9 12 kg
#ebutuhan .ir !& 1 R1 !& 1 #.()2 -3 ® $ !& 1
2atrium 5' '' m)* 7& m)* 8& m)*
#alium "' ( &' m)* 5 m)* -' m)*
Infus RL 'u(an)ntu( Terapi Rumatan
ef) :6) ice H) Fluid Therapy for the #ediatricurgical #atient) Emedicine) 1228 uly))emedicine)com;ped;topic1
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:r$;al$n.$s of6pokal$mia
Chief In:esti.ator Centre No ofpatients
B hypokalemiaon admission
B hypokalemiaon )ischar.e
!ntun. udomo R*A) DD 9 ?8
)@oko idodo RC' D8 996G 896?
Nasronudin R utomo D 565 8D6G
1. *udomo 5ntung. ?arissa Ira. >astroenterogy heatoloy and digestive endos6oy vol.$. %d -e6 24. Page 11$!122. Cidodo - *etiaEan 7 hie #hen.
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Ho< does maintenancefluid therapy e:ol:e,
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-a? @@
-a? =2 0? 12, glu 1@ g
-a? 8= 0? 12
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Pasien RaEat!Ina (di @eang)
-ehydratedPreviously Eell!nourished>ood aetite
-ehydratedPreviously Eell!nourished0r slightly undernourished?etaboli6ally /on!stressed
noreiaFatigue
Previously malnourished0r undernourished or ?etaboli6ally stressed8yoalbuminemia
-ebilitatedIf %/ entirely imossible
Fluid ; basi6ele6trolytemaintenan6e
#omlete%le6trolyte 3 $!1 glu6osemaintenan6e
Parenteral /utrition 1 8igh /P#(glu6ose liid)
AEN2 A'INOFL!I) NEO*AREN'II)
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&y 122AB122@ 8A
lucose
768
Amino acids
B
Electrolytes
-NaJ J ClJ '.J CaJ */
&inc
Aminofluid
A*IN+ L)I#
® ®
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%. 7lomstrand Role for 7ran6hed!#hain mino 6ids in Redu6ing #entral Fatigue @. /utr.
February 1 2=: 13=(2) $44* ! $4+*
"ryptophan
-erotonin/
222
Appetite
Fati.ue
2CAA
-erotonin/
?@F
$OL)EN .;S
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Infe%si+9rauma
Cytokines-"NFJILKJILK5/
InflammationJ fe:erJhyper:entilation
)ehydrationJ
dry ton.ue= mouth
serotonin 'elanocortin
)elayed .astric emptyin.
LO OFA**E"I"E
$OL)EN .;Shy Aminofluid1 is particularly helpful in infectionJtrauma or for post operati:e pts
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7est Re6ommended inFolloEing #onditions
A Febrile illnessesA -ehydrated and anorei6 dyseti6 atientsA >astrointestinal diseases ost resus6itation of
severe diarrhea 6olonos6oy gastroaresis
A 6ute Infe6tious diseasesA %arly ost oerative maintenan6e (straightforEard
surgery)A 8yeremesis gravidarum (after .9 /a#l)
A *troke (after metaboli6 and ele6trolyte 6orre6tion)
*recautions3ARenal Failure associated
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minofluid
Infeksi akut'-emam
Penyakit>astrointestinal
Postoeratif
8ieremesisgravidarum
/eurologi
*esis
-iabetes?ellitus
-7-
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P0- 2
+
/P# = k6al = g
/a" + m%& " 4 m%&
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P0- 3(stress metaboli6 sedang'berat)
+
/P# 3 k6al , g
/a" 3$ m%& " 2 m%&
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Hypovolemic shock
StableHemodynamic
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JAN’ 2012
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6) +gar rasional memberikan infus pahami 5 hal: "ndikasi,Fisiologi, #atofisiologi dehidrasi dan hipovolemi, ediaan infusyang ada dipasaran)
1) +sering $+' pilihan utama infus resusitasi dan memilikikelebihan dibanding / atau -, seperti: maintain suhu utama
perioperatif, D0+, %#&, mencegah asidosis laktat padaneonatus saat %
8) 0aen series di desain memenuhi kebutuhan maintenancedasar, misal: 0+E- 8& $-a? =2 mEC, 0?: 12mEC and glucose1@ gr'
5) +minofluid didesain sebagai infus maintenace terkini yang
sekaligus bisa mengatasi dehidrasi, mencegah anoreia danmengatasi fatigue sehingga mempercepat penyembuhanpasien raat inap
-ak$ om$ M$ssa!$
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Mencegah infus tidak adekuat, tidak
rasional
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a;$ a ni.$da6??