fluid therapy rsud
DESCRIPTION
anestesiTRANSCRIPT
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04/18/23 1
FLUID THERAPY
Anestesiologi dan ReanimasiRSUD Tasikmalaya
Teguh Santoso
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INDIKASI
Resusitasi cairan. Untuk memenuhi kebutuhan basal air, elektrolit
dan kalori. Mengganti cairan dan elektrolit yang hilang. Mengatasi gangguan keseimbangan asam basa
dan elektrolit.
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• Harus diketahui dengan benar kandungan zat-zat yang terdapat dalam cairan tersebut.
• Tujuan apa yang akan dicapai dengan pemberian cairan tersebut.
PERLU DI INGAT PADA WAKTU MEMBERIKAN CAIRAN INTRAVENA
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PRINSIP TERAPI CAIRAN INFUS
Pemberian cairan intravena untuk mengembalikan volume darah adalah salah satu bentuk terapi medis yang paling efektif dan yang paling baik.
Pada syok, tujuan resusitasi cairan adalah untuk mengembalikan perfusi jaringan dan pengiriman O₂ ke sel, sehingga dapat mengurangi iskemia jaringan dan kegagalan organ.
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DASAR-DASAR UMUM FISIOLOGI CAIRAN TUBUH
a) Cairan Ekstra Seluler (CES) : - PLASMA (5% dari BB)
- CAIRAN INTERSTISIAL (15% dari BB)
b) Cairan Intra Seluler (CIS) : 40% dari BB
c) Cairan Trans – Seluler (CTS) : 1 – 3 % dari BB
Yang penting untuk pemakaian /perhitungan praktis CES dan CIS.
1. Jumlah cairan tubuh
Pada orang dewasa rata-rata 45 – 70 % dari Berat Badan (BB) :
60% PRIA
55% WANITA
Variasi tergantung gemuk-kurusnya.
Pada Kanak : 70 – 80 % dari BB, rata-rata 75%
Cairan tubuh tersebut dibagi dalam :
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Perbandingan CES dan CIS :
( Bayi/Neonatus 1 : 1 )
Pada orang DEWASA CES : CIS = 1 : 2
Pada KANAK CES : CIS = 2 : 3
TRANS SELULER
INTRA SELULER
EKSTRA
SELULER
Plasma
Interstitiel
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Cairan OtakCairan Otak Cairan PencernaanCairan Pencernaan Cairan PleuraCairan Pleura Cairan PerikardiumCairan Perikardium Cairan PeritoniumCairan Peritonium Cairan Persendian Cairan Persendian
CAIRAN TRANSELULER.
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GANGGUAN KESEIMBANGAN CAIRAN & ELEKTROLIT
Mempengaruhi sistem kardiovaskuler.Neurologis.NeuromuskulerGinjal yang paling mempengaruhi atas
keseimbangan cairan dan elektrolit
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Replace
Maintain
Repair
Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock
IWL + urine
Acid base, electrolyte imbalances
BASIC PRINCIPLES
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..
• Correct timing
• Correct indications, dosage• Correct product (composition,concentration)
• Tailored to patient’s fluid and electrolyte status, not diagnosis
• Good monitoring
• Cost-effective
Rational Fluid Regimen
DN Lobo et al. (UK)*
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TERAPI CAIRAN
RESUSITASI
KOLOID NUTRISI
Menggantikankehilangan akut
cairan tubuh
GELATIN, HAES, DEXTRAN
Memelihara keseimbangan cairan tubuh dan nutrisi
RUMATAN
KRISTALOID ELEKTROLIT
RARL NS
RepairKCl, Bicnat
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RESUSITASIRESUSITASI RUMATANRUMATAN
TERAPI CAIRAN IV
Infus Natrium > 100 mEq/L atau koloid 20-30 ml/kg/jam 2-3 L/10-15 menit
Natrium < 100 mEq/LBukan Koloid 4:2:1 (misal 25 kg: 4 x10+2x10+1 x5 65ml/jam 500 ml/6 jam
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• BM rendah ( < 8000 dalton )• Tekanan onkotik rendah --> cepat
terdistribusi ke ruang ekstrasel• Dengan atau tanpa glukosa• Efek mengisi ruang interstitial > koloid• Lebih murah & mudah didapat• Contoh : RL, NaCl 0,9 %, D5% dll
KRISTALOID
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1. RINGER LAKTAT ( RL )• Paling fisiologis jika diperlukan volume besar• Laktat oleh hati --> bikarbonat --> u7 asidosis metabolik ringan• Baik u7 defisit CES• Kalori ( - )
KRISTALOID
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KRISTALOID2. RINGER SOLUTION ( RS )• Komposisi mirip RL • Na & Cl > RL• Laktat ( - )• Kalori ( - )
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3. NaCl 0,9 % • Na & Cl tinggi --> baik u7 koreksi awal defisit
CES dengan hiponatremi, hipokloremia & alkalosis metabolik
• Pada pemberian volume besar dapat menyebabkan dilutional hyperchloremic acidosis
• Kalori ( - )
KRISTALOID
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4. DEKSTROSA/ GLUKOSA 5 % (D5%)• Cairan pengganti pada kekurangan air murni• Cairan rumatan pada hipernatremi, hiperkalemia• Pemberian jangka lama dapat menyebabkan
hipokalemia, intoksikasi air
KRISTALOID
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KOLOID• BM tinggi ( > 8000 dalton )• Tekanan onkotik tinggi --> sebagian besar menetap di
ruang iv• Menetap > lama di ruang iv : kristaloid• Mahal, resiko > besar : kristaloid• Resiko koloid sintetik : alergi, anafilaksis, gangguan
koagulasi• Contoh : - Albumin, produk darah
- sintetik : HES, dextran dll
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• Oncotic pressure --> iv volume --> preload --> Cardiac output ( CO )
• iv volume --> hemodilution --> improved rheology --> flow resistance --> DO2
• Hemodilution --> Ht --> Arterial oxygen concentration ( CaO2 )
Effect of Synthetic Colloids
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TOK volume darah
Sealing effect ( HES 100-300 kD ) Mengembalikan aliran darah regional pada
hipovolemia viscositas, daya adesif leukosit
Efek koloid yang menguntungkan
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• Reaksi anafilaktik : Albumin (0,003),Dekstran (0,008), Gelatin (0,038) & HES (0,006)
• Koagulasi : Dekstran, HES ( tgt dosis )• Keracunan ginjal : HES, Dekstran (dosis tinggi)• Pembatasan penggunaan pd gagal ginjal : HES
Efek koloid yang merugikan
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• Koloid pengganti vol darah lebih efisien > kristaloid
• Koloid > mahal• Rx anafilaktoid koloid > kristaloid• Hemodilusi sebelum transfusi dengan
kristaloid atau koloid bermanfaat pada restorasi vol darah
KRISTALOID vs KOLOIDarea persetujuan
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• Resusitasi cairan selain darah secara praktis sangat bermanfaat• Anemia ditoleransi lbih baik dari pada hipovolemia. Perdarahan akut
orang sehat anemia ditoleransikan sampai 50 %, sedangkan hipovolemia hanya 30 %
• Kelebihan cairan dengan ke2 macam larutan merupakan peristiwa yang tak diinginkan
• Koloid lebih efektif dalam mempertahankan tekanan osmotik koloid
KRISTALOID vs KOLOIDarea persetujuan
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• Efek koagulasi• Fungsi ginjal• Air interstisial paru• Lama rawat di ICU & RS• Mortalitas• Frekwensi ARDS
KRISTALOID vs KOLOIDarea debat ( 1 dekade yl )
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• Otak --> edema• Jantung --> kinerja • Paru --> oksigenasi • Pencernaan --> translokasi bakteri• Perifer --> penyembuhan luka
KRISTALOID >> ----> edema interstisial
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Effects of colloid solutions on haemostasis and coagulation
GelatinsGelatins HES HES DextranDextrans s
Factor VIII, vWF Factor VIII, vWF No effectNo effect
PlateletsPlatelets AdhesionAdhesion AggregationAggregation
No effectNo effect
Thrombus Thrombus formationformation
No clinical No clinical effecteffect
Blood typingBlood typing No effectNo effect In emergency In emergency
situation blood typing situation blood typing
prior to infusion prior to infusion
!
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Effects of colloids on kidney function
Gelatins : No negative effect ! Improved kidney function !Dextrans : Renal insufficiency is possible after Dextran 40HES (High MW) : Acute renal failure after HES is possible
Latentincrease ofurine viscosity
Enhanced flow
resistance
Stop offiltratio
n
Decrease of glomerular filtration
Dextran/HESconcentrationin proximaltubuli
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Efek koloidSintetik Yang Merugikan
• SistemSistem koagulasikoagulasi: Dilusi faktor koagulasi (Penurunan vWF; adesi trombosit ) Dextran , HES BM besar & dosis tinggi/ berulang
• FungsiFungsi ginjalginjal: Dextran, HES BM tinggi dgn DS tinggi (450 kD/ 0.7)
• AkumulasiAkumulasi JaringanJaringan: HES BM tinggi/DS tinggi pd RES, kulit, saraf
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Fluid ChallengeFluid Challenge
Kristaloid atau Kristaloid atau koloidkoloid dengan dengan jumlah dan jumlah dan kecepatan yang kecepatan yang tepat agar tepat agar respon fisiologis respon fisiologis yang terjadi yang terjadi dapat digunakan dapat digunakan untuk menilai untuk menilai kondisi cairan kondisi cairan intravaskularintravaskular
Cairan PengisiCairan Pengisi
Kristaloid atau Kristaloid atau koloidkoloid, diberikan , diberikan untuk mengisi untuk mengisi kehilangan kehilangan cairan cairan intravaskularintravaskular
Cairan Rumatan
Campuran elektrolit dan dekstrosa, diberikan untuk memenuhi kebutuhan fisiologis tubuh
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Choice of Fluid Resuscitationcrystalloid and/or colloid
KRISTALOID:RLRA
NaCl 0.9%
KOLOID:DEXTRAN GELATIN
HESAlbumin
Kurang efektif utk SSD beratPerlu jumlah besarEfek pro-koagulanEfek TVD/ emboli
Efektif utk iv fillingHES: SealingHES: Makro danMikrosirkulasiPlasma tidak dipakai
untuk pengganti
cairan yang hilang !
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TOTAL BODY WATER : 60% TOTAL BODY TOTAL BODY WATER : 60% TOTAL BODY WEIGHTWEIGHT
36 L36 L
ISF
60 kg60 kg
9L9L
ISFISF IVFIVF ICFICF
3L3L 24 L24 L
Physiologic principles Physiologic principles of fluid managementof fluid management
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04/18/23 32
ISF
9L9L
ISFISF IVFIVF ICFICF
3L3L 24 L24 L250 ml250 ml
D5WD5W
750ml750ml
Physiologic Physiologic principles of fluid principles of fluid managementmanagement
3L
2 L2 L
Not for resuscitation !!!
EDEMA EDEMA
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ISF
9L9L
ISFISF IVFIVF ICFICF
3L3L 24 L24 L750 ml750 ml
CRYSTALLOIDCRYSTALLOIDRL, RA, RL, RA,
NaCl 0.9%NaCl 0.9%
2250ml2250ml
Physiologic Physiologic principles of fluid principles of fluid managementmanagement
EDEMAEDEMA
3L
Require large volumeRequire large volumeCheaperCheaper
Fewer adverse side Fewer adverse side effectseffects
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04/18/23 34
ISF
9L9L
ISFISF IVFIVF ICFICF
3L3L 24 L24 L1L1L
Physiologic principles Physiologic principles of fluid managementof fluid management
Albumin-5%Albumin-5%1 L1 Lexpensivexpensiv
eeexpensivexpensiv
ee
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04/18/23 35
ISF
9L9L
ISFISF IVFIVF ICFICF
3L3L 24 L24 L500 ml500 ml
Physiologic principles Physiologic principles of fluid managementof fluid management
404000
Albumin-25%Albumin-25%100 ml100 mlexpensivexpensiv
eeexpensivexpensiv
ee
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04/18/23 36
ISF
9L9L
ISFISF IVFIVF ICFICF
3L3L 24 L24 L1L1L
Physiologic principles Physiologic principles of fluid managementof fluid management
HES-6%, 200/0.5HES-6%, 200/0.51 L1 L
•More rapidly correct More rapidly correct hypovolemiahypovolemia
•Maintain intravascular Maintain intravascular oncotic pressureoncotic pressure•More expensiveMore expensive
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04/18/23 37
ISF
9L9L
ISFISF IVFIVF ICFICF
3L3L24 L24 L
500-500-700 700 mlml
Physiologic principles Physiologic principles of fluid managementof fluid management
•More rapidly correct More rapidly correct hypovolemiahypovolemia
•Maintain intravascular Maintain intravascular oncotic pressureoncotic pressure
• shift to ISFshift to ISF
300 – 300 – 500 ml500 ml
POLYGELINEPOLYGELINE(HAEMACCEL)(HAEMACCEL)
1 Liter1 Liter
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04/18/23 38
ISF
9L9L
ISFISF IVFIVF ICFICF
3L3L 24 L24 L16001600
Physiologic principles Physiologic principles of fluid managementof fluid management
262600
Dextran – 40Dextran – 401 L1 L
340
•More rapidly correct More rapidly correct hypovolemiahypovolemia
•Maintain intravascular Maintain intravascular oncotic pressureoncotic pressure•Volume expandVolume expand•CoagulopathyCoagulopathy
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ISFISFISF IVFIVF ICFICF
3L3L 24 L24 L
Physiologic principles Physiologic principles of fluid managementof fluid management
9L9L
7.5%-Hypertonic 7.5%-Hypertonic Saline + DextranSaline + Dextran
500 ml500 ml
625 ml625 ml
Subjected to recent intensive investigationResuscitate rapidly, reduced volume of fluidReduce cerebral edema
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Kebutuhan harian:
Air : 30-50 mL/kgBBNa+ : 2 meq/kgBBK+ : 1 meq/kgBB
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Potassium Sodium(mEq/kgBW/day) (mEq/kgBW/day)
Adult1 0.9 - 1.3 1.0 - 1.7
For infant to children2 : based on 100 ml of water for each 100 kcal expended.Maintenance elect. requirement : 100 ml and 2-4 mEq of Na and K for every 100 kcal expended.
up to 10 kg11 - 20 kg> 20 kgDaily Body Fluid ± 20 - 30 ± 1.0Homeostasis3 (minimum) (minimum)
100 ml water / kg
1000 ml + 50 ml / kg for each kg above 10 kg
1500 ml + 20 ml /kg for each kg above 20 kg
1. Page C.P., Thomas C.H. and George M. Nutritional Assessment and Support. A primer 2nd Ed. P : 26. 1994.2. Martinez-Bianchi, V., MD, Michelle, RP, MD., Mark A.G., MD. Pediatrics : Vomiting, Diarrhea, and Dehydration in Family Practice Handbook 3rd Ed. USA.3. Kokko and Tannen. Fluid and Electrolyte 3rd Ed. WB Saunders.
Potassium and SodiumHomeostasis and Daily Requirement
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Ilustrasi :
Berat badan anak 25 kg
10 kg 1 X 100 = 100 X 10 = 100010 kg 2 X 50 = 50 X 10 = 50010 kg 3 X 20 = 20 X 5 = 100
= 1600
Kebutuhan Na & Kalium = 32-64 mEq/kgBB
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• Perlu mengetahui berapa kebutuhan air, elektrolit(Na+,K+)
• Perlu mengetahui status Natrium dan kalium serum
• Perlu mengetahui syarat kecepatan K+, dekstrosa
air 30-50 ml/kg; Na+ 2 mEq/kg; K+ 1 mEq/kg
Na+ 135-145 mEq/L; K+ 3,5-5 mEq/L
K+ < 20 mEq/jam*(5-10 mEq/jam); dekstrosa <0,5 g/kg/jam;
Note:•Pada hipokalemia berat (<2 mEq/L) kec bisa 40 mEq/jam•Fungsi ginjal dBN ~ produksi urin sudah 0.5 mL/kgBB/jam
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are still widely used for maintenance therapy
• RL• 5% Dextrose• 5% Dextr. in Ringers
What are the impacts ?What are the impacts ?
Facts: Facts:
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Kebutuhan Air 2000 mL RL 2 L KA-EN 3B® 2 L
Natrium 50 – 100 mEq 260 mEq 100 mEq
Kalium 45 – 63mEq 8 mEq 40 mEq
Infus RL bukanUntuk Terapi Rumatan
Ilustrasi BB Dewasa (Org Indonesia) : ± 50 kg
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Anak BB = 20 kg
Kebutuhan Air 1.5 L RL 1.5 L KA-EN 3B®, 1.5 L
Natrium 60 – 100 mEq 195 mEq 75 mEq
Kalium 20 - 50 mEq 6 mEq 30 mEq
Infus RL bukanUntuk Terapi Rumatan
Ref. :1. Rice H. Fluid Therapy for the Pediatric
Surgical Patient. Emedicine. 2003 July.www.emedicine.com/ped/topic2954.htm
2. Piwko, J.G. and Michael G.C. Neonatology Considerationsfor the Pediatric Surgeon. Emedicine. 2004. www.emedicine.com/ped/topic2982.htm
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Hipokalemia
• Insidens 20% pada pasien rawat-inap (US)*
• Pada diare & malnutrisi • Penyebab bervariasi• Implikasi pada penyakit kardiovaskular: hipertensi,
potensi intoksikasi digitalis, CABG• Pemberian Infus yg mengandung kalium 20 mEq/L
umumnya diperlukan pada pasien rawat-inap
Zwanger M. Hypokalemia. emedicine.com/emerg/topic273.html
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Hypokalemia di Indonesia
• Limitted incidence/prevalence data (3 centers)• Insiden di RSPAD Gatot Soebroto, bagian penyakit
dalam = 26 %• Peningkatan tendency pasien rawat inap dengan
hipokalemia = 17,5 % (saat masuk 27 ps, dan saat keluar menjadi 45 pasien)
1. RSPAD GATOT SOEBROTO-JAKARTA
Sudomo, Untung. Marissa Ira. The Indonesian Journal of: Gastroenterology, Hepatology and Digestive Endoscopy. December 2004. Vol.5, No.3. P.115-120.
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• Prevalens = 24 %• Peningkatan tendency hypokalemia
pasien saat rawat inap (saat masuk 24 pasien, keluar menjadi 39 pasien)
2. SUB.BAG TR0PIK INFEKSI, BAGIAN PENYAKIT DALAM RSCM-JAKARTA
Djoko Widodo, Budi Setiawan, Khie Chen, Leonard Naenggolan, Widayat Djoko Santoso, The Prevalence of Hypokalemia in Hospitalized Pts with Infectious Diseases Problem at Cipto Mangunkusumo Hospital Jakarta, Acta Medica Indonesiana Vol38, No4, October 2006, page 202-204.
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• Prevalens hypokalemia pts = 40 %• Peningkatan tendency hypokalemia pasien
saat rawat inap (saat masuk 40 pasien, keluar menjadi 56 pasien)
3. SUB.BAG TR0PIK INFEKSI BAGIAN PENYAKIT DALAM
RSUD SOETOMO-SURABAYA
Nasronudin, Hamidah, Ida Bagus Krisna, Suharto, Eddy Suwandojo,The prevalence of Hypokalemia in Infectious Diseases Hospitalized Patients, Medika Vol 32, December 2006, page:732-734.
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Mengapa hipokalemia kurang diperhatikan?
Gejala tidak spesifik dan umumnya baru muncul pada kadar K+ < 3 mEq/L
Pada pasien non-kardiak tidak dimonitor ketat
Fasilitas Lab tidak memadaiAwareness << karena tambahan 2 Paradigma lama:
1. Takut hiperkalemi bila diinfus kalium
2. Tidak mungkin hypokalemia bila intake oral cukup
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1. Komposisi infus: KAEN 3B mengandung kalium 10 mEq/500 m
2. Kecepatan infus kalium yg dianjurkan: <20 mEq/jam atau kecepatan lazim: 10 mEq/jam
Kecepatan Rumatan 500 ml/6-8 jam
~ 80 ml/jam; 20 tetes/menit
atau ~ 1,6 mEq K+/jam
Dalam praktek:
Risiko Hiperkalemia minimal!
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Intake kalium dari makanan rata-rataorang Indonesia kurang adequate ??
(ilustrasi 200 mg setara dengan 60 mEq)
1. Sayuran Kentang, buncis 500 gr Kacang 5000 gr
2. Buah Pisang 800 gr Jeruk 1200 gr
3. Daging Sapi atau ayam 600 gr
Halperin & Goldtstein. Fluid, Electrolyte and Acid Base Physiology.WB Saunders Co. 2nd ed.p 358
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•Edema paru bisa terjadi dalam 36 jam pasca bedah bila retensi cairan melebihi 67 ml/kg/d sebaiknya intake air < 2000 ml
•Pemulihan Fungsi saluran cerna lebih cepat pada kelompok pasien reseksi usus yang mendapat cairan postop < 2 L; 77 mEq Na dibandingkan kelompok > 3 L; 154 mEq Na sebaiknya asupan Na+ pasca bedah < 60-100 mEq
1. Arieff Allen L. Fatal Postoperative Pulmonary Edema. Pathogenesis & Literature Review. CHEST 1999;115:1371-13772. Lobo DN et al.Effect of salt and water balance on recovery of gastrointestinal function after elective colonic resection. Lancet
2002 May 25.359(5320):1792-3
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Usus bocor, fistel usus-kulitUsus harus di-istirahatkanNutrisi harus lewat vena (NPE)
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EDEMA ANASARKA + HEPATOMEGALI
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IV Fluid OverloadIV Fluid OverloadIV Fluid OverloadIV Fluid Overload
• Decrease muscular oxygen tension and delay recovery of gastrointestinal function
• Cause general edema• Impede tissue healing and cardiopulmonary
function
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2. PEMAKAIAN INFUS DI UGD
SYOK HIPOVOLEMIKSYOK HIPOVOLEMIK
RA/RL 20-30 ml/kg/jam
Ya TIDAK
< 3 tahun > 3 tahun
KAEN 4A KAEN 1BKecepatan: BB < 10 kg: 4 ml/kg/jam 11-20 kg : 2 ml/kg/jam > 25 kg : 1 ml/kg.jam
Contoh : Anak 5 tahun BB 15 kg- 4 x 10 + 2 x 5 = 50 ml/jam = 12 tetes/menit
Normo/hipoK Normo/hipoK
KAEN 4B KAEN 3B/3A
Observasi/monitor
nadi terabaakral hangaturine output +
kecepatan bisaditurunkan 10 73 ml/kg/jam
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Diagram 9. Alur tatalaksana Pemberian cairan Derajat IVProf. Soegeng, Tatalaksana DBD terkini, RSUD Dr Soetomo/FKUnair, 2006
Asering /
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DBD III & IVO2 2-4 L/menitASERING 20 ml/kg bolus dalam 30 menit
Syok teratasiSyok teratasi Syok tidak teratasiSyok tidak teratasi
RA/RL 10 ml/kg/jam
Stabil dalam 24 jamStabil dalam 24 jam
RA 5 ml/kg/jam 3 ml/kg/jamStop < 48 jam
Dextran 40 10-20 ml/kgTeratasiTeratasi
Tidak TeratasiTidak Teratasi
Ht turun Ht tetap/naik
FFP 10 ml/kg Dextran 20 ml/kg
Sri Rezeki, Hindra Irawan Satari. Demam Berdarah Dengue. FKUI.1999
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Effects of colloids on kidney function
Gelatins : No negative effect ! Improved kidney function !Dextrans : Renal insufficiency is possible after Dextran 40HES (High MW) : Acute renal failure after HES is possible
Latentincrease ofurine viscosity
Enhanced flow
resistance
Stop offiltratio
n
Decrease of glomerular filtration
Dextran/HESconcentrationin proximaltubuli
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Efek koloidSintetik Yang Merugikan
• SistemSistem koagulasikoagulasi: Dilusi faktor koagulasi (Penurunan vWF; adesi trombosit ) Dextran , HES BM besar & dosis tinggi/ berulang
• FungsiFungsi ginjalginjal: Dextran, HES BM tinggi dgn DS tinggi (450 kD/ 0.7)
• AkumulasiAkumulasi JaringanJaringan: HES BM tinggi/DS tinggi pd RES, kulit, saraf
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Fluid ChallengeFluid Challenge
Kristaloid atau Kristaloid atau koloidkoloid dengan dengan jumlah dan jumlah dan kecepatan yang kecepatan yang tepat agar tepat agar respon fisiologis respon fisiologis yang terjadi yang terjadi dapat digunakan dapat digunakan untuk menilai untuk menilai kondisi cairan kondisi cairan intravaskularintravaskular
Cairan PengisiCairan Pengisi
Kristaloid atau Kristaloid atau koloidkoloid, diberikan , diberikan untuk mengisi untuk mengisi kehilangan kehilangan cairan cairan intravaskularintravaskular
Cairan Rumat
Campuran elektrolit dan dekstrosa, diberikan untuk memenuhi kebutuhan fisiologis tubuh
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TATALAKSANA SSD
• End point resusitasi cepat SSD:
Makrosirkulasi: Kesadaran,
Tensi, MAP,
SaO2 >92%SvcO2 >70%, cap.refill <2”,
diuresis
Mikrosirkulasi:Kadar asam laktatSerum < 2mmol/l
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Tatalaksana SSD pada Anak (Depkes, 2005)
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