16. ike-the role of crystalloid, colloid and blood[1]

8/13/2019 16. Ike-The Role of Crystalloid, Colloid and Blood[1]

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The Role of Crystalloid, Colloid and Blood in

Fluid Therapy

Ike SR

FK UNPAD/RSHS

Bandung


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Septic Shock

Kombinasi antara

Distributive

Kardiogenik

Hipovolemik Bentuk syok yang sering terjadi di klinis

Merupakan kelanjutan dari proses SIRS dan sepsis


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Terapi cairan

Preload Contractility

Diperlukan volume

intravaskuler yangcukup

Frank Starling

Afterload

Sistim venajantung

Sistim arteri/

kapiler


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Kematian akut pada sindroma syok

30 - 5425 - 35Syok hemoragik

(trauma)

4844

Syok kardiogenik

31 - 63Syok septik

Hospital

death (%)

28 - 30 hari

(%)

dalam

2 - 3 jam (%)

N Eng J Med 2001; 344:699

JAMA 2002; 288: 862

JAMA 2005; 294:448

Circulation 2005; 112: 1992

N Engl J Med 1994; 331:1105

J Trauma 1998; 45:545


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Crystallloid/

colloid

Crystalloid/

colloid

crystalloidcrystalloidFluid

replacement

Confused and

lethargic

Anxious and

confused

Mildly anxiousSlightly

anxiousCNS/

mental status

No UO5-1520-30>30Urine

output

>3530-3520-3014-20Respiratory

rate

DecreaseDecreaseDecreaseNormal or

decrease

Pulse

pressure

DecreaseDecreaseNormalNormalBlood

pressure

>140>120>10040%30-40%15-30%Up to 15%Blood loss

( % EBV)

>20001500-2000750-1500Up to 750Blood loss

Class IVClass IIIClass IIClass I


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Prinsip dasar terapi cairanPrinsip dasar terapi cairan

Resusitasi /

mengganti

defisit cairan

Maintenance

Repair

Kehilangan cairan abnormal GIT

3rd space Ongoing loss

septic

syok Hipovolemik

IWL + urine

Keseimbangan asam basa

keseimbangan elektrolit


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Bbb

Bbbb

C

op

y

rig

ht

BOP

28 mmHg

IFHP

0 mmHg

Venous end Arterial end

BOP

28 mmHg

IFHP

0 mmHg

7 mmHg

8 mmHgBHP 30

mmHg

O2

Waste product

+CO2O2 in

blood

Cells

Interstitial

space

Lymphatic

system

Delivery O2

(DO2)

VO2

Cellular

metabolisme

DO2 = Cardiac Output x CaO2 ( arterial O2 content )

Mikrosirkulasi harus dimonitor oleh karena makrosirkulasi yang baik tidak

menjamin mikrsirkulasi yang baik

MIKROSIRKULASI


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Figure 27.5

The Integration of Fluid Volume Regulation and Sodium

Ion Concentrations in Body Fluids


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Volume Replacement Therapy

with

Volume Replacement Therapy

with

Colloids

Albumin

PPS

Albumin

PPS

Dextran

solutions

Dextran

solutionsHES

Solutions

HES

SolutionsGelatin

solutions

Gelatin

solutions

CrystalloidsCrystalloids

Lactated Ringer's

(Normal) Saline

Lactated Ringer's

(Normal) Saline

Natural -------------Synthetic--------------

+

But not every colloid for every indication!


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Kapan menggunakan kristaloid ?

Di Emergensi mudah didapat dan murah

Dehidrasi

Mengisi volume intravaskuler sementara,interstisial, dan volume intraselular

Rekomendasi ATLS 2000 cc pertama

kristaloid


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> mahalMurahHarga

Dpt dipertahankanmenurunPlasma COP

+-Risiko anafilaksis

> baiktidak sempurnaPerfusi sistim kapilerKurang+Risiko edema jaringan

> sedikit> BanyakKebutuhan cairan

Bertahan lebih lamaTransientStabilisasi hemodinamikBertahan > lamaSingkatIntravascular persistance

KoloidKristaloid

Kristaloid vs Koloid


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Colloids fluid loading leads to greater increase in

preload recruit table LVSWI

due to higher COP

caused by greater plasma volume ( PV ) expansion

Volume effect is >>>


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Colloid loading gives higher CI, PV, and GEDVI


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Kejadian histopatologis iskemik ( pemeriksaan PA)

pada kematian karena syok

436Otak

367Pankreas

16269Intestine

563046Hati

111825Jantung

106555Paru-paru

1001737Jantung

Kardiogenik

n = 197 (%)

Sepsis

n = 93 (%)

Hipovolemik

n = 102 (%)

McGovern VJ, Pathol Annu 1984;19:15


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Saline or colloids do not affect permeability

HES decrease permeability due to endothelial protections

LIS ( lung Injury Score ) may slightly increase in colloid

estimated by respiratory compliance caused by increaseITBV which IV volume was included ( increased volume due

to increased COP )


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ITBV


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Proportion of

patients

without

ARF


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Creatinin concentration over 28 days


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Effects of Colloid solutions on

hemostasis and coagulation

Gelatins HES Dextrans

Factor VIII, vWF

Plateletsadhesionaggregation

Thrombusformation

Blood typing

No effect

No

effect

No clinical

effect

No effectIn emergency situationsblood typing before infusion!


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The patients Hb level, although important, should not be the

sole deciding factor in starting transfusion. The decision totransfuse should be supported by the need to relieve clinical

signs & symptoms & prevent significant morbidity &

mortality

The clinician should be aware of the risks of transfusion-

transmissible infection in the blood components that are

available for the individual pt**

** It should be noted that the rates of non-infective

complications are probably higher than those of infective

complication

WHO principles for the clinical use of blood

components [WHO (1998a)]


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Transfusion should be prescribed only when the

benefits to the pt are likely to outweigh the risks

The clinician should record the reason for

transfusion clearly

A trained person should monitor the transfused pt

& respond immediately if any adverse effects

occur

WHO principles for the clinical use of blood

components [WHO (1998a)]


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FDA guidelines

RBC should not be given for

volume expansion

for improvement of general sense of well being to accelerate wound healing

as hematinic agent

Platelet should not be given for prophylaxis, eitherafter CPB or massive transfusion

FFP should not be used for

volume expansion as nutritional supplement

for prophylaxis, either after CPB or massive

transfusion


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Hb 7-14


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Rekomendasi dari Transfusi Sel Darah MerahIndikasi

Hb


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Rekomendasi transfusi sel darah merah PRC

Indikasi

Bila Hb 7 10 g/dL :

Keuntungan pemberian transfusi PRC

tidak jelas Transfusi PRC dapat dilakukan bila

terdapat hipoksia yang jelas

hypoxemia


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Transfusi Sel Darah Merah PRCIndikasi

Hb 10g/dL tidak perlu transfusi PRC kecuali pasien2 yang memerlukan

kemampuan transport O2 yang lebih

tinggi COPD yang berat

Iskemia jantungPemberian transfusi pada keadaan ini harusdengan alasan yang jelas dan tertulis


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DO2 = Cardiac Output x CaO2 ( arterial O2 content )

(Hb x SpO2 x1,34 )+ ( 0,003 x PaO2)

Stroke Vol x HR

Volume x contractility


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}


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Combine thoracic epidural and general anesthesia

elective colorectal resection ASA I III


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Intra Cellular Space

Cellmembrane

IntravascularSpace

RBC

Capillarymembrane

Kesimpulan

15%

5% 40%

Na = 140 meq/l

K = 4 meq/l

Na=14

0meq/l

K=4m

eq/l

Interstitial

Space

Colloid crystalloids

Glucose solution

Na = 8 meq/l

K = 151 meq/l

Untuk memperbaiki DO2

CurahJantung dan O2 content transfusi


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16. ike-the role of crystalloid, colloid and blood[1]

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