terapi cairan
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TRIASE
Eko Waskito
TERAPI CAIRAN
Staf RSUD Kota JanthoKabupaten Aceh Besar
Istri: Dr. Ari Gusnita (PPDS Neurologi FK USU)Anak: Aqila Lutfiyah M. Rafif Aditya
Pendidikan Dokter FK USU, selesai Jan 2005Pendidikan Dokter Spesialis Anestesiologi & Terapi IntensifFK USU, masuk Januari 2010
P e r k e n a l a nTempat/ Tgl Lahir: Pematangsiantar10 April 1979
Organisasi: Kabid Litbang HMI FK USUManajer Op. MER-C MedanKoord. Kesehatan PKPA MedanSeksi Ilmiah IDI Aceh BesarMember Of Indonesian Society of Perinatology
Publikasi:Artikel di Media Cetak 35 bh
Pelatihan: ATLS, ACLS, Resusitasi Neonatus, Psikiatri Akut, dll
Niat: Hidup adalah memberi
PHYSIOLOGY
TOTAL BODY FLUID 60% BW
INTRACELLULARFLUID (ICF)
INTRACELLULARFLUID (ICF)
EXTRACELLULARFLUID (ECF) 20% BW
TRANSCELLULAR FLUID
TRANSCELLULAR FLUID
40 % BW
INTRAVASCULARFLUID
INTRAVASCULARFLUID
INTERSTITIIL FLUID
INTERSTITIIL FLUID
5 % BW
15 % BW
1-3 % BW
60% dari berat badan adalah H2O
Pasien berat 50 kg30 kg adalah air
(30 liter)
Intra Vascular Fluid (IVF) 5% BB
Intra Cellular Fluid (ICF) 40% BB
Interstitial Fluid (ISF) 15% BB
ECF
IVF 5% ISF 15% ICF 40%
2500 ml 7500 mlpada pasien 50 kg
ISF merupakan buffer / cadangan yang lebih besar daripada IVF
ECF
IVF 5% ISF 15% ICF 40%
Infusi cairan elektrolit ke IVF akan merembes keluar ke ISFKomposisi IVF dan ISF sama
ECF
Kehilangan cairan yang sering terjadi
· Gastro-intestinal loss– Air– Natrium– Kalium
· Perdarahan– Air– Natrium– Kalium– Albumin– Eritrosit
12
Gastro-intestinal lossDiare, muntaber, peritonitis
1. Interstitial sign : 1. mata cowong, 2. turgor turun, 3. mucosa kering
2. Plasma sign :1. Perfusi lambat2. Nadi naik3. Tekanan darah turun
IVF ISF
12
Terapi Infus untuk Diare, muntaber, peritonitis
1. Infus cepat untuk mengisi kembali IVF2. Infus lambat untuk mengisi kembali ISF3. (memberikan juga cairan maintenance)
1 2
IVF ISF
infus
21
Perdarahan
1. Kehilangan IVF• Perfusi lambat• Nadi naik• Tekanan darah turun
2. Dicoba diisi oleh ISF (transcapillary refill), 100 cc / jam
IVF ISF
21
Terapi infus untuk Perdarahan
1. Infusi cepat mengembalikan IVF
2. Setelah IVF stabil, diteruskan untuk mengembalikan ISF
3. Volume yang diperlukan jadi 2-4x kehilangan IVF
12
IVF ISF
infus
Efek Syok Pada Tingkatan sel
HYPOXIA
LOW-FLOW,POOR PERFUSION
ANAEROBIC METABOLISM
ACIDOSIS
DECREASED CELLULAR ENERGY EFFICIENCY
CELL MEMBRANE FAILURE:
• DIRECT EndotoxinComplement• INDIRECTFailure to maintain normal Na+, K+ or Ca2+ gradientDecreased oxidative phosphorylation
OSMOTIC GRADIEN
T
Water entry into
cell
CELLULAR EDEMA
IMPAIRED INTRACELLULAR
METABOLISM
CELL
DEATH
Na+ entry into cell
Efek syok pada tingkatan sel
PRE-LOAD CONTRACTILITY AFTER-LOAD
STROKE VOLUME HEART-RATE
CARDIAC OUTPUT SYSTEMIC VASCULAR
RESISTANCE
BLOOD PRESSURE
PERDARAHAN
HILANG VOLUME
HILANG ERITROSIT
21
Pasang infusi pada vena besar
1. Vena cubiti, basilica
2. Vena jugularis ext (posisi kepala-leher
tetap in-line)
3. Vena subclavia
4. Vena saphena magna?
FLUID REPLACEMENT
3 : 1 RuleClass I Crystalloid
Class II Crystalloid + Colloid ?
Class III Crystalloid
+Colloid, BloodClass IV Crystalloid
+Colloid, Blood
Pola kerja penanganan shock perdarahanPenderita datang dengan perdarahan
Pasang infus jarum kaliber besar, sample darah
Ukur tekanan darah, hitung nadi, nilai perfusi, produksi urine
Tentukan estimasi jumlah perdarahan, minta darah
Guyur cepat Ringer Laktat atau NaCl 0.9% [hangat, 390C] 3x prakiraan lost-volume [1-2
liter] Evaluasi
• Pulse-Rate [x/min.]• Blood-Pressure• Pulse-Pressure
• Respiratory Rate• Urine out-put [ml/hour]
• Mental status/CNS
normal
evalu
asi
Management selanjutnya
· Rapid response,perdarahan <20%
· Transient response,perdarahan 20-40% BVongoing lossresusitasi tdk adekwatKOLLOID HES
200/0.5transfusi
· Minimal, no responseTindakan bedah segeraTransfusi darah
Hasanul, 2003
Class I Class II Class III Class IV
Blood-Loss[ml] ->750 750-1500 1500-2000 >2000
Blood-loss [%BV] ->15% 15-30% 30-40% >40%
Pulse-Rate [x/min.] <100 >100 >120 >140
Blood-Pressure Normal Normal Decreased Decreased
Pulse-Pressure N or increased
Decreased Decreased Decreased
Respiratory Rate 14-20 20-30 30-35 >35
Urine out-put [ml/hour] >30 20-30 5-15 Negligible
Mental status/CNS Slightly anxious
Midly anxious Anxious and confused
Confused and lethargic
Estimated Fluid and Blood Losses Based on Patient’s Initial Presentation
BV = 70 ml/kg
How to Resuscitate the Circulation ?How to Resuscitate the Circulation ?
CaO2 = (SaO2 x Hb x 1.34) + (PaO2 x 0.0031)
DO2 = CO x CaO2
SV x HR
PRELOAD, CONTRACTILITY
R/ Fluid
Fluids
· “Third space” loss into interstium and tissues–3:1 rule of crystalloid for every ml
of blood loss
· ATLS: 2 liters of crystalloid through large bore IV for early treatment of hemorrhagic shock.
Fluids
· Crystalloid· Colloid· Hypertonic saline· Darah Totilac
Fima RL
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
Isotonic crystalloids
· Advantages– Cheap– Easy to store and warm– Established safety – Predictable rise in cardiac output
· Disadvantages– Large volumes needed– Dilutional coagulopathy– Increase cytokine activation– No oxygen carrying capacity– May Increase ICP
Na Cl K Ca Buffer pH
Plasma 141
103 4-5 5 Bicarb 7.4
0.9%NS 154
154 ---- ---- ---- 5.7
LR 131
111 2 3 Lactate 6.4
Composition of iv Crystalloid
Fima RL Fima NS Ringer AsetatFima D5
Ringer Laktat vs NaCl 0,9%
· Lowery 1971(Surg Gynecol Obstet)– Vietnam war study LR v NS– Healthy soldiers – No difference in outcome
· Waters 2001 (Aneth Analg)– Patients undergoing aortic aneurysm repair – NS
• More volume (~500-1000ml)• Hyperchloremic acidosis• Dilutional coagulopathy
· Todd (J. Trauma 2007; 62:636-9) – Swine bled via liver injury & resuscitated to MAP
90mmHg– NS
• More volume • Hyperchloremic acidosis• Dilutional coagulopathy
Ringer Laktat vs NaCl 0,9%
• Conclusion– No mortality difference– Ringer Laktat
• Lower overall volume• More buffering capacity
– NaCl 0,9%• Metabolic acidosis• Dilutional coagulopathy
– Preferred fluid outside of US– Probably no difference for prehospital or early fluid
resuscitation.
Ringer Laktat vs NaCl 0,9%
Colloids
· Keuntungan– Volume lebih kecil
• Sedikit udem pulmonum– Bertahan dalam intravascular space
• Cepat mengembalikan hemodinamik normal.
– Kemasan lebih kecil.– Mempunyai efek antioksiden dan
antiinflamasi.
Colloids
· Kerugian – Penularan penyakit. – Peningkatan perdarahan.– Reaksi alergi. – Gagal Ginjal– Dosis maksimal : 20-50mL/kg– Harga lebih mahal.
Jenis cairan yang beredar :
• Kristalloid ( D5W, RL, RA, NaCl )
• Hypertonic Saline
• Kolloid ( Albumin, Fima HES)
• Cairan Nutrisi ( Aminofluid, Intrafusin, Ivelip, Triofusin)
Blood Disadvantages
· Cost· Compatability/error
– Incorrect blood-1:40,000 (death 1:2million)· Immune complications
– 1:40,000· Infection
– Sepsis 1:500,000 (RBCs) 1:50,000 (platelets)– Hep B 1:250,000– Hep C & HIV 1:2million
· Storage requirements· Citrate toxicity· Hypocalcemia· Hyperkalemia ?
Fluid Terapi
VOLUME INTRAVASKULAR
MEKANISME HEMODINAMIK
TOTAL BODY WATER : 60% TOTAL BODY WEIGHT
36 L
ISF
60 kg
9L
ISF IVF ICF
3L 24 L
Physiologic principles of fluid management
ISF
9L
ISF IVF ICF
3L 24 L250 ml
D5W= H2O
750ml
Physiologic principles of fluid management
3L
2 L
Not for resuscitation !!!Not for resuscitation !!!
EDEMA
Intra venous fluid replacement
Fluid Resuscitation
ISF
9L
ISF IVF ICF
3L 24 L750 ml
CRYSTALLOID
RL, RA,
NaCl 0.9%
2250ml
Physiologic principles of fluid management
EDEMA
3L
Require large volume
Cheaper
Fewer adverse side effects
ISF
9L
ISF IVF ICF
3L 24 L1L
Physiologic principles of fluid management
Albumin-5%1 Lexpensiv
eexpensiv
e
ISF
9L
ISF IVF ICF
3L 24 L500 ml
Physiologic principles of fluid management
400
Albumin-20%Cth:Octalbin 20%
100 ml
expensive
expensive
Intra venous fluid replacementFluid Resuscitation
ISF
9L
ISF IVF ICF
3L 24 L1L
Physiologic principles of fluid management
HES-6%, 200/0.5(Fimahes)
1 L
• More rapidly correct hypovolemia
• Maintain intravascular oncotic pressure
• More expensive
Fluid Challenge Protocol
Baseline observations
during infusion
after infusion
after 10-min wait
CVP
< 6
6- 10> 10
> 4
< 22 - 4
> 2< 2
PCWP
<12
12 - 16> 16
> 7
< 33 -7
> 3< 3
Volume challenge(mL/10min)
200
10050Stop
Continue infusionWait 10-min
Stop challengeRepeat challenge
Pressure(mmHg)
Brian T, Andrews, Neuerosurgical Intensive Care, 1993.
How to Resuscitate the Circulation ?How to Resuscitate the Circulation ?
CaO2 = (SaO2 x Hb x 1.34) + (PaO2 x 0.0031)
DO2 = CO x CaO2
R/ Oxyge
n
SaO2 , PaO2
Terapi Oksigen Terapi Oksigen
5-6 L/m
2-4 L/m
Goal terapi oksigen
SaO2, SpO2, 96-98%
PaO2, ≥ 80 mmHg
How to Resuscitate the Circulation ?How to Resuscitate the Circulation ?
CaO2 = (SaO2 x Hb x 1.34) + (PaO2 x 0.0031)
DO2 = CO x CaO2
R/ WholeBlood, PRC
How to Resuscitate the Circulation ?How to Resuscitate the Circulation ?
CaO2 = (SaO2 x Hb x 1.34) + (PaO2 x 0.0031)
DO2 = CO x CaO2
SV x HR
PRELOAD, CONTRACTILITY
R/ Vasoaktive Inotropic
Hasil terapi infusi
• Sirkulasi membaik lalu stabil– good response, normovolemia
• Sirkulasi membaik lalu merosot lagi– transient response, masih hipovolemia, ada perdarahan
berlanjut.– Resusitasi tidak adekuat?– Infus dengan koloid
• Sirkulasi tidak membaik– no response, masih tetap hipovolemia– Tindakan bedah segera kemungkinan ada perdarahan
yang masih berlangsung.
57
soal
• Pasien 32 tahun, datang post partum, lahir diluar rumahsakit. Tidak sadar, nafas 10 x/menit, Nadi tidak teraba, Tensi tidak terukur, muka pucat Apa yang Sdr lakukan ?
soal
• Pasien laki-laki, umur 25 tahun, datang ke rumahsakit akibat KLL, tabrakan motor yg dikendarainya dengan mobil.
• Tidak sadar, nafas 8 x/menit, Nadi tidak teraba, Tensi tidak terukur, muka pucat. Apa yang Sdr lakukan ?
Terima kasih
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