paradigma baru terapi cairan ag gizi
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Paradigma Baru TERAPI CAIRAN
Johan Arifin, Anang Achmadi
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Pendahuluan
• Terapi cairan --> isu sentral sakit kritis• Koreksi, optimasi ( preload )• Dipertimbangkan dengan cermat• Kristaloid atau koloid• Keuntungan & efek samping
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FUNGSI AIR
• Menyerap dan mendistribusikan panas• Perlindungan dan bantalan : cairan
amnion, LCS• Pelumas : kavum serosa, sendi• Media transport
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FISIOLOGI KESEIMBANGAN CAIRAN DAN ELEKTROLIT
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Kandungan Cairan
• Pelarut : air• Bahan terlarut :• Non-elektrolit :glukosa, lemak• Elektrolit : garam • Massa terbanyak : non-elektrolit• Partikel terbanyak : elektrolit paling
berpengaruh pada pergeseran cairan (osmolaritas)
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Perbedaan Komposisi Cairan padaBerbagai Kompartemen
• Terjaditerutamakarenaaktivitasmembran– Keseimbang
an Na / K
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KANDUNGAN ELEKTROLIT CAIRAN TUBUH
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Cairan Berdasarkan Tonisitas
•Cairan Isotonis• Cairan Hipertonik• Cairan Hipotonik
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TERAPI CAIRAN
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Osmolalitas : Jumlah partikel yang osmotik aktif per liter
larutan
Osmolaritas : Jumlah partikel yang osmotik aktif per
kilogram larutan
Tonicity : osmolalitas serum yang effective ditentukan oleh 2 zat terlarut : Na & Glucosa
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Osmolalitas ( 280 - 300 mOsm/L )
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mOsm/L = 2 x ( Na meq/l) + ( Glukosa mg%) / 18
+ (BUN mg%) / 2,8
Tonisitas ( 275 - 290 )90%
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Tonisitas
Osmolality ( 280 - 300 mOsm/L )
mOsm/L = 2 x ( Na meq/l) + ( Glucosa mg%) / 18
+ (BUN mg%) / 2,8
Tonicity ( 275 - 290 )90%
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Isotonic Sol’n
Hypertonic Sol’n
Hypotonic Sol’n
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Cairan Isotonik
- Konsentrasi partilkel dlm larutan =dibandingkan dg konsentrasi partikel di Cairan intraselular
- Tidak menyebabkan pembengkakan / pengerutan sel & tidak ada pergerakan cairan melalui membran yang semipermiabel
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increases ECF
ICF ISF Plasma
Replace acute/abnormal
loss
800 ml 200 ml
• Ringer’s acetate• Ringer’s lactate• Normal saline
Infus Isotonik
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Cairan Hipertonik:
- konsentrasi partikel dlm lar > dibandingkan di intra sel
-Menyebabkan air dari intrasel keluar & sel akan mengkerut-Contoh : NaCl 3 %, Dekstrosa 50 %
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Cairan Hipotonik
- Konsentrasi partikel dalam lar < dibandingkan Intrasel
-Dapat menyebabkan cairan dari extrasel masuk ke intrasel & menyebabkan pembengkakan sel
- Contoh : NaCL 0,45 %
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Infus Hipotonik
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increases ICF > ECF
ICF ISF Plasma
Replace Normal loss (IWL + urine)
• 5% dextrose
85 ml255 ml660 ml
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Cairan Menurut Tekanan Onkotik
• KRISTALOID• KOLOID
• CAMPURAN/ KOMBINASI
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KRISTALOID
1. RINGER LAKTAT ( RL )• Paling fisiologis jika diperlukan volume
besar• Laktat oleh hati --> bikarbonat --> u/ asidosis metabolik ringan• Baik u7 defisit CES• Kalori ( - )
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Ringer Laktat
Na Cl K Ca Osms bicnat
Ringer Laktat 131 111 5 4 276 29
Plasma 135 105 4 5 290 +10 24
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NaCl Na Cl Osm
NaCl 0,9% 154 154 308
NaCl 0,45% 77 77
Plasma 135 108 290 +10
NaCl 3% 513 513 1026
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Na+ = 140 mEq/LCl- = 102 mEq/LSID = 38 mEq/L
Na+ = 154 mEq/LCl- = 154 mEq/LSID = 0 mEq/L1 liter 1 liter
PLASMA + NaCl 0.9%PLASMA + NaCl 0.9%
SID : 38
Plasma NaCl 0.9%
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2 liter
ASIDOSIS HIPERKLOREMIK AKIBAT ASIDOSIS HIPERKLOREMIK AKIBAT PEMBERIAN LARUTAN Na Cl 0.9% PEMBERIAN LARUTAN Na Cl 0.9%
=
SID : 19 SID : 19 Asidosis Asidosis
Na+ = (140+154)/2 mEq/L= 147 mEq/LCl- = (102+ 154)/2 mEq/L= 128 mEq/L
SID = 19 mEq/L
Plasma
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Na+ = 140 mEq/L Cl- = 102 mEq/L SID= 38 mEq/L
Cation+ = 137 mEq/L Cl- = 109 mEq/L
Laktat- = 28 mEq/L SID = 0 mEq/L
1 liter 1 liter
PLASMA + Larutan RINGER PLASMA + Larutan RINGER LACTATELACTATE
SID : 38 SID : 38
Plasma Ringer laktatLaktat cepat
dimetabolisme
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2 liter
=
Normal pH setelah pemberian Normal pH setelah pemberian RINGER LACTATE RINGER LACTATE
SID : 34 SID : 34 lebih alkalosis dibanding jika lebih alkalosis dibanding jika diberikan NaCl 0.9% diberikan NaCl 0.9%
Na+ = (140+137)/2 mEq/L= 139 mEq/L Cl- = (102+ 109)/2 mEq/L = 105 mEq/L Laktat- (termetabolisme) = 0 mEq/L SID = 34 mEq/L
Plasma
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Kesimpulan
0.9% saline 0.9% saline = = (Ab)normal Saline(Ab)normal SalineReid et al, Clin Sci, 2003
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RESUSITASI CAIRAN
TUJUAN : RESTORASI PERFUSI JARINGAN,
TRANSPORT O2
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KURANGI ISKEMIA JARINGAN, KEGAGALAN ORGAN
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Resusitasi Cairan
• Disesuaikan pada individu pasien
• Penilaian kontinyu respons terhadap terapi
• Cairan >> --> morbiditasCairan << --> gagal organ
• Pengawasan intensip dokter & perawat
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Terapi Cairan Rasional
• Perkiraan defisit air tiap kompartemen cairan fisiologis
• Kristaloid/ koloid yang tepat u7 resusitasi kompartemen yang memerlukan
• Pengurangan ruang intravaskuler : laju jantung , TD , TVS , urin .
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Estimated Fluid and Blood Losses
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>20001500 - 2000750 - 1500Up to 750Blood Loss (mL)
Crystalloid and blood
Crystalloid and blood
CrystalloidCrystalloidFluid replacement (3:1 rule)
Confused and lethargic
Anxious and confused
Mildly anxiousSlightly anxious
CNS/Mental status
Neglible5 - 1520 - 30>30Urine output (mL/hr)
>3530 - 4-20 - 3014 - 20Respiratory rate
DecreasedDecreasedDecreasedNormal or decreased
Pulse Pressure (mmHg)
DecreasedDecreasedNormalNormalBlood Pressure
>140>120>100<100Pulse Rate
>40%30% - 40%15% - 30%Up to 15%Blood Loss (%EBV)
Clas IVClass IIIClass IIClass I
ATLS
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ICP AIR OTAKNaCl 0,9 % -RL NaCl HIPERTONIK HES NaCl 0,9 % - -
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Estimasi Volume Darah/ EBV
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AGE BLOOD VOLUMENEONATUSPREMATURFULL-TERM 85 mL/kgBBINFANT 80 mL/kgBBADULT* MALE 75 mL/kgBB* FEMALE 65 mL/kgBB
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Bahaya yang berhubungan dengan terapi cairan intravena
• Bahaya mikrobiologik- Cairan merupakan nutrisi u7 mikroorganisme- Kontaminasi karena : * mikroba udara pada waktu membuka tutup botol * open system tanpa filter * sentuhan * penambahan obat * pirogen
====>
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Bahaya yang berhubungan dengan terapi cairan intravena
• Penambahan obat dapat menyebabkan - Kontaminasi ( 8 % )- Drug incompatibilities- Drug bioavailability :potensi antibiotik hilang, obat terabsorbsi ke botol & selang infus
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Untuk memastikan keamanan dan efektivitas terapi cairan :
Harus tahu isi dan kandungan botol cairan
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Awas & hati-hati !!!
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Anang Achmadi