prinsip terapi cairan1
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terapi cairanTRANSCRIPT
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PRINSIP TERAPI CAIRAN
Dr. Adi Hijaz Yamani
RSUD Teluk Bintuni
Papua Barat
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8/31/2015 2
Terapi cairan rumatan parenteral
Definisi: sejumlah air, elektrolit (Na, K, Cl) sertaglukosa yang dibutuhkan pada pasien yang tidakbisa dimasukkan secara oral.
Cairan rumatan tidak dimaksudkan untukmengganti cairan yang hilang
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Jenis dan jumlahcairan tubuh Tubuh
Padat 40%Cairan tubuh 60%
Cairan ekstraseluler20%
Cairan intraseluler20%Membran sel
Plasmadarah5%
Cairaninterstisial
15%
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Rasio dan komponen tubuh
ANAK Remaja-Dewasa
TUA
70-80%Air
60% 50%
AIR57%
LEMAK
20,8%
Protein
17%
Mineral &
Glikogen 6%
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Contoh KasusDiare akut Dehidrasi
PWL CWL IWL
Rehidrasi (Diperhitungkan PWL + CWL + IWL)
Terehidrasi
Rumatan (Diperhitungkan CWL + IWL)
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Komponen cairan rumatan parenteral
1. IWL
2. Glukosa
3. Urin
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8/31/2015 7
1. Insensible water lossIWL: kulit (2/3) dan paru (1/3)
diperkirakan setiap 100 kcal adalah 50 ml
IWL meningkat : hiperventilasi, panas, terbakar, udara keringIWL menurun : koma, sedasi, hipotiroid, hipotermi, humidity meningkat
contoh : anak 15 kg yang rawat inap akan mempunyai IWL ? 625 ml/24 jam ( 1250 kcal/hari x 50ml/100 kcal) ini terdiri dari200 ml dari paru dan 400 ml dari kulit
Contoh: anak 15 kg dengan respirasi 50/min dan panas 400 C maka ?
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8/31/2015 8
2. Glukosa
• Adalah sumber nutrisi penting untuk otak, jantung dan sel darahmerah
• Pemberian KH pada anak yang puasa akan mengurangi jumlahmetabolisme dan katabolisme protein
• Pada bayi 3 gr/kg/hari glukose dan 1.5 gr/kg/hari mencegahkatabolisme protein
• Larutan dextrose 5% (50 gram atau 255 mOsm/L mencegahglukoneogenesis, katabolisme protein dan ketogenesis
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Bagaimana cara menentukan jumlahcairan Rumatan ?
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8/31/2015 10
Perhitungan kebutuhan kalori
Berdasarkan BB: Holiday & Segar:
0-10 kg: 100 kcal/hari;
11-20kg: 1000 kcal + 50 kcal/kg/hari sampai 10 kg;
>20 kg: 1500 kcal + 20 kcal/kg/hari sampai 20kg.
Contoh: Anak 33 kg 1760 kcal/hari (1000 + 500 + 260)
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8/31/2015 11
Kebutuhan kalori meningkat
• Aktifitas meningkat
• demam: 12% untuk setiap 1 derajat C diatas 380 C
Contoh: seorang anak rawat inap dengan temp 400 C dan BB 10 kg maka dia membutuhkan ?
= 240 kcal/hari (1000x24%) + 1000 kcal/hari= 1240 kcal/hari
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8/31/2015 12
Perhitungan
• Kalori harian : 1250 kcal/hari + (1250 kcal x 24%) 1550 kcal/hari (karena suhu 40oC)
• IWL: 775 ml/hari 520 ml kulit , 260 ml paru
( 1550 kcal/hari x 0.5 cc/kcal)
• Karena respirasi 2x normal maka IWL paru 520 ml
Jadi Total IWL: 1040 ml (520 ml kulit dan 520 ml paru
Contoh: anak 15 kg dengan respirasi 50/min dan panas 400 C maka IWL ?
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8/31/2015 13
3. Urin
• Diperkirakan setiap 100 kcal dikeluarkan urin 65 ml
• Terdapat 15 ml air setiap 100 ml kcal pemakaian energiyang disebut air untuk oksidasi
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8/31/2015 14
Kebutuhan air rumatan
• 65 ml/100 kcal (urin)
• 50 ml/100 kcal (iwl)
• 15 ml/100 kcal (oksidasi)
Maka total ( 65ml + 50 ml – 15 ml) 100 ml setiap 100 kcal atau 1 ml dibutuhkan untuk setiap 1 kcal
Catatan untuk bayi yang minum susu, angka menjadi 1.5 ml
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Table 1. Maintenance fluid requirements for children
Fluid regime/adjustment
Baseline 1 day of age 50 ml kg-1day
-1
2 days of age 75 ml kg-1day
-1
≥ 3 days of age 100 ml kg-1day
-1
< 10 kg 100 ml kg-1day
-1
10-20 kg1000 ml day
-1+ 50 ml kg
-1day
-1
for every kg over 10 kg
> 20 kg1500 ml day
-1+ 20 ml kg
-1day
-1
for every kg over 20 kg
Factors
that
decrease
requireme
nt
Humidified gases X 0.75
Paralyzed X 0.7
High ADH (e.g. IPPV or
coma)X 0.7
Hypothermia -12% per 0C core temp is < 37
0C
High ambient humidity X 0.7
Renal failure X 0.3/free fluids
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Table 1. Maintenance fluid requirements for children (contd’)
Fluid regime/adjustment
Factors
that
increase
requireme
nt
Full activity and oral
feedsX 1.5/free fluids
Fever + 12% per 0C core temp is > 37
Room temp over 31 0C + 30% per
0C
Hyperventilation X 1.2
Preterm neonate (< 1.5
kg)X 1.2
Radiant heater X 1.5
Phototherapy X 1.5
Burns day 1+ 4% per 1% of body surface
area affected
Burns day 2 ++ 2% per 1% of body surface
area affected
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Derajat dehidrasi
Derajat Dehidrasi Menurut Jumlah Cairan yang Hilang
1. Dehidrasi RinganKehilangan cairan 5 % Berat Badan
2. Dehidrasi SedangKehilangan cairan 5- 10 % Berat Badan / 6-8 % BB
3. Dehidrasi BeratKehilangan cairan >10 % Berat Badan
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Dehidrasi
• Beratnya defisit cairan pada dehidrasi persentase penurunan berat badan.
• Dehidrasi ringan: kehilangan BB 3-5% atau sekitar 30-50 mL/kgBB
• Dehidrasi sedang: kehilangan cairan sebanyak 7-10%
• Dehidrasi berat : kehilangan cairan sebanyak 10-15%, atau 100-150 mL/kgBB.
Bayi
• Tanpa tanda dehidrasi kehilangan cairan tubuh 5% dari BB
• Dehidrasi Tak Berat kehilangan cairan tubuh 7% dari BB
• Dehidrasi berat: kehilangan cairan tubuh 10% dari BBanak
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Jenis Dehidrasi Berdasarkan Status Elektrolit
Jenis Dehidrasi Status Elektrolit
Hipotonik / hiponatremik Na serum < 135 mEq/L
Isotonik / isonatremik Na serum 135 - 145 mEq/L
Hipertonik / hipernatremik Na serum > 145 mEq/L
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Tipe Dehidrasi
Dehidrasi isotonik/isonatremik
•Tidak terjadi perubahan osmotik antar kedua dinding sel
•tidak terjadi perubahan volume intraseluler.
Dehidrasi hipotonik/hiponatremik
•Cairan ekstraseluler relatif lebih hipotonik terhadap cairan intraseluler,
•air akan bergerak dari kompartemen ekstraseluler ke intraseluler
Dehidrasi hipertonik/hipernatremik
•Air akan berpindah dari intraseluler ke ekstraseluler untuk mengembalikan keseimbangan osmolalitas
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Algoritme Status Cairan Hiper-NaAssesmen Status Volume
Hipovolemia Euvolemia Hipervolemia
Total Cairan tubuh Total Na
Total Cairan tubuh ↑Total Na ↑
Total Cairan tubuh ↑↑Total Na ↑
U Na >20 U Na <20 U Na Variabel U Na >20
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Renal losses (diuretik, Defisiensi
mineralokortikoid Extrarenal losses
(diare, luka bakar)
Diabetes insipidus
IWL >>
Sindrom chusing, hiperaldosteron
Terapi I Terapi II Terapi III Terapi IV Terapi V
Terapi I , II, III & IV Sirkulasi volum efektif & penyesuaian osm olalitas
Terapi V penggunaan diuretik utk keluarkan Na & diganti air
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Penghitungan Defisit Cairan
Defisit cairan bebas (mL) =
4 mL x Berat Badan kering (kg) x [Perubahan
Na serum mEq/L (mmol/L) yang diinginkan]
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Contoh: Anak 1 tahun, Bb 6 kg dengan diare akut dehidrasi berat. Dengan Elektrolit Na (155) K (3,2)
diagnosis Dehidrasi Hipernatremi
Tentukan kebutuhan cairan & Jenis cairannya ?
Langkah 1: Dehidrasi berat (kehilangan 10% dari BB)
10% x 6000 ( 1 kg=1000 ml) = 600 ml
Langkah 2 : Hipernatremi Free water defisit (FWD)
4 ml air akan menurunkan 1 Meq Natrium
Rumus FWD = Δ Na x Bb x 4 = (155-140) x 6 x 4 = 360 ml
Langkah 3 : Rumatan 6 x 100 ml = 600 ml
Langkah 4 : Tentukan natrium defisit 600 x 140 / 1000 = 84 Meq
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FWD % DEHIDRASI RUMATAN TOTAL
Cairan 360 600 600 1560
Natrium - 84 12 96 Meq
Menentukan Jenis cairan :Dilihat dari kadar Natrium hasil penghitungan : 96 Meq / 1560 ml 61,5 Meq/L Kaen 3B ( Memiliki kadar Natrium 50 Meq/L)
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Fluid Resuscitation in Severe Malnutrition
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Reductive Adaptation
Reducing physical
activity and growth
Reducing basal
metabolism
Reducing inflammatory
and immune responses
Organ dysfunction:• Liver• Kidney• Heart• Muscles• GI tracy
Metabolic dysfunction:
• protein turn over
• functional reserve of
organs
• Na+ K + pumps in cell
membranes &
number
Immune dysfunction:
• abnormal responses
to infection
• iron that is liberated
from red blood cells
infection
Consequences of Reductive Adaptation
Pathophysiology
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Risk of Death
Severely malnourished children are at risk ofdeath from:
• Hypoglycemia
• Hypothermia
• Cardiac failure
• Infection
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General Priciples for Routine Care
There are ten essential steps:1. Treat/prevent hypoglycaemia2. Treat/prevent hypothermia3. Treat/prevent dehydration4. Correct electrolyte imbalance5. Treat/prevent infection6. Correct micronutrient deficiencies7. Start cautious feeding8. Achieve catch-up growth9. Provide sensory stimulation and emotional support10. Prepare for follow-up after recovery
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Treat / prevent dehydration
Treat/prevent dehydration
Note: Low blood volume can coexist with oedema
Do not use the IV route for rehydration except in cases of shock and then do so with care, infusing slowly to avoid flooding the circulation and overloading the heart
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Treat / prevent dehydration
Treatment:
The standard oral rehydration salts solution (90 mmol sodium/l) contains too much sodium and too little potassium for severely malnourished children
Instead give special Rehydration Solution for Malnutrition (ReSoMal)
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Initial assessment:
• weigh the child (or estimate)
• measure temperature, pulse rate, BP and respiratory rate
• give oxygen
• insert intravenous or intraosseous line
• draw blood for investigations where possible
(Blood sugar, FBC, BUSE, Blood culture, BFMP, ABG)
Resuscitation for shock:
• give IV/IO fluid 15ml/kg over 1 hour
• solutions used -1/2NS, Hartmans if 1/2NS not available
• use 1/2NSD5% if hypoglycemic
Monitor and stabilize:
• measure pulse and breathing rate every 5-10 minutes
• start antibiotic IV cefotaxime or ceftriaxone
(if not available ampicillin+ chloramphenicol)
• monitor blood sugar and prevent hypothermia
• IV Quinine only after discussion with Paediatrician
If there are signs of improvements
(pulse and breathing rates are falling):
• repeat IV/IO bolus 15ml/kg over 1 hour
• initiate ORS (or ReSoMal) per oral 10ml/kg/h
• discuss case with Paediatrician and refe
If the child deteriorates (breathing up by 5 breaths/min
or pulse up by 25 beats/min or fails to improve during
IV/IO fluid):
• stop infusion as this can worsen child’s condition
• discuss case with Paediatricianimmediately and refer
Reference: Management of the child with a serious infection or severe malnutrition (IMCI). Unicef WHO 2000
RESUSCITATION PROTOCOL FOR CHILDREN WITH SEVERE MALNUTRITION
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Pemilihan cairan
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RESUSITASI
TERAPI CAIRAN
RUMATANKOREKSI
KRISTALOID KOLOID ELEKTROLIT NUTRISI
RL RANSFundin
DextranHaemacelGelofusin
Kaen 1BKaen 3BKaen 3AKaen 4AKaen 4B
AminofusinKaen Mg3/tridex 100
Menggantikan kehilangan akut cairan tubuh Memelihara keseimbangan cairan tubuh dan nutrisi
Hipo/hiper NaHipo/hiper K
Kaen 1B ( Dx5% : NS = 3 : 1 )Kaen 3A ( Dx + NS + K 10 mq/L + Laktat 20 mEq/L )Kaen 3B (Dx + NS + K 20 mq/L + Laktat 20 mEq/L )Kaen Mg3 ( Dx10% + NS + K 20 mq/L + Laktat 20 mEq/L )Kaen 4A ( Dx 5% : NS ( 4 : 1) + Laktat 10 mEq/L )Kaen 4B (Dx 5% : NS ( 4 : 1) + K 8 mEq/L + Laktat 10 mEq/L )
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Pemilihan cairan berdasarkan tonisitas larutan
3,7004,7001,000RL
9,3003,70014,0001,0005% Dextrose
-7502501,00025% Albumin
1,0001,0005% Albumin
Increased
ICV (ml)
Increased
ISS (ml)
Infused
volume
(ml)
Increased
PV
(ml)
PV plasma volume;ISS interstitial fluid volume;ICV intracellular volume;RL lactated Ringer’s
solution,MFG=modified fluid gelatin
HES 200/0.5 6% 1,000 1,000
MFG 4% 1,000 1,000
Dextran 40 10% 1,000 500-600 -400/-500
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PENGATURAN CURAH JANTUNG DAN TEKANAN DARAH
TEKANAN DARAH
CURAH JANTUNG
TAHANAN VASKULAR SISTEMIK
ISI SEKUNCUP
FREKUENSI JANTUNG
PRELOAD
AFTER LOAD
KONTRAKTILITAS
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KLASIFIKASI SYOK MENURUT ETIOLOGI
SYOK HIPOVOLEMIK SYOK DISTRIBUTIF SYOK KARDIOGENIK SYOK SEPTIK SYOK OBSTRUKTIF
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Syok Hipovolemik
TEKANAN DARAH
CURAH JANTUNG
TAHANAN VASKULAR SISTEMIK
ISI SEKUNCUP
FREKUENSI JANTUNG
PRELOAD
AFTER LOAD
KONTRAKTILITAS
Contoh :Perdarahan masifDehidrasi beratDHF (leakage)
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Syok Kardiogenik
TEKANAN DARAH
CURAH JANTUNG
TAHANAN VASKULAR SISTEMIK
ISI SEKUNCUP
FREKUENSI JANTUNG
PRELOAD
AFTER LOAD
KONTRAKTILITAS
Contoh :KardiomiopatiMiokarditisaritmia
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Syok distributif
TEKANAN DARAH
CURAH JANTUNG
TAHANAN VASKULAR SISTEMIK
ISI SEKUNCUP
FREKUENSI JANTUNG
PRELOAD
AFTER LOAD
KONTRAKTILITAS
Contoh :SepsisAnafilaktikneurogenik
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Cairan
Masuk tubuh :dari saluran cerna ke
CIV
keluar dari tubuhlewat CIV:
kulit,
saluran napas
kemih
saluran cerna
Terdapat keseimbangan
CIV interstitial CIS
Aliran Cairan tubuh:
CIV
CES
CIS
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CES
CIS
MULUT ANUS
Dehidrasi berat : defisit cairan tubuh
10 - 12%, (def. CIV belum sp 30% belum
syok)
CVP turun CIV
DEHIDRASI BERAT
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CES
CIS
MULUT ANUS
Dehidrasi sangat berat : defisit CIV >30% syok hipovolemik
CVP turun CIV
DEHIDRASI SANGAT BERAT & SYOK
Vom diare
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CES
CIS
NORMAL (FISIOLOGIS)
MULUT ANUS
CVP turun
Defisit CIV > 30% syok
hipovolemik
CIV
SYOK ok PERDARAHAN AKUT HEBAT
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CIVCES
CIS
MULUT ANUS
CVP turun
defisit CIV 30% atau
lebih syok hipovolemik
CIV
SYOK ok KEBOCORAN PLASMA
SALURAN MAKANAN
Ruangserosa
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CIVCES
CIS
MULUT ANUS
CVP turun
defisit CIV 30% atau
lebih syok hipovolemik
CIV3rd
space
SYOK ANAFILAKTIK/DISTRIBUTIF
SALURAN MAKANAN
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Syok hipovolemik Syok distributif
Perdarahan Dehidrasi hebat Septik/DHF Anafilaktik
Darah keluar dari tubuh
Cairan keluar tubuh
“Plasma” ke ruang III+inters
”Plasma” ke Ruang III
Vol.total cairan tubuh
Vol.total cairan Tubuh sangat
Vol.total cairan tetap
Vol.total cairan tetap
Terapi : Beri cairan
+ eritrosit
Terapi : Beri cairan
(+elektrolit)
Terapi : Beri cairan Tunggu cairanbalik dari R III
Terapi : Kembalikan cairan dr R III Beri cairan
![Page 48: Prinsip Terapi Cairan1](https://reader031.vdocuments.pub/reader031/viewer/2022012306/563db827550346aa9a910bf2/html5/thumbnails/48.jpg)
![Page 49: Prinsip Terapi Cairan1](https://reader031.vdocuments.pub/reader031/viewer/2022012306/563db827550346aa9a910bf2/html5/thumbnails/49.jpg)