otsuka cairan.ppt
TRANSCRIPT
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RASIONALE TERAPI CAIRAN
Dr. Budhi Santoso
Medical Consultant PT Otsuka Indonesia
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Replace
Maintain
Repair
Abnormal loss: GIT, 3rdspace,Ongoing loss, septic and
Hypovolemic shock
IWL + urine
Acid base,electrolyte imbalances
BASIC PRINCIPLES
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Rational Fluid Regimen
Correct timing
Correct indications, dosage
Correct product (composition,concentration)
Tailored to patients fluid andelectrolyte status, not diagnosis
Good monitoring Cost-effective
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TERAPI CAIRAN
RESUSITASI
KOLOID NUTRISI
Menggantikan
kehilangan akut
cairan tubuh
OTSUTRAN - L
Memelihara
keseimbangan
cairan tubuh
dan nutrisi
KA-EN 1B
KA-EN 3A
KA-EN 3B
KA-EN 4AKA-EN 4B
AMIPAREN
AMINOVEL- 600
PAN- AMIN G
KA-EN MG 3
MARTOS 10
RUMATAN
KRISTALOID
ELEKTROLIT
ASERING
Otsu- RL
Otsu- NS
Repair
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Pemilihan Cairan
Dehidrasi akut, hipovolemia, syok,hiponatremia
Hiponatremia, hipokloremia (muntah-muntah hebat)
Ringer Laktat/Ringer Asetat
Normal Saline, Ringer Solution
Mengapa ? ? ?
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RL/RA NS RS(Ringer Asetat/Laktat) (NaCl 0,9%) (Ringer solution)
Na+ 130 mEq/L 154 147K+ 4 mEq/L - 4Cl- 109 mEq/L 154 155,5
Cairan Pengganti:
Cairan universal untukResusitasi, intraoperatif
Pada kasus hipokloremia(muntah refrakter)
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Asering, RL & NS
1 L
800 ml
200 ml
Syok hipovolemikDiare dengan dehidrasi beratMuntah-muntah hebatDSSPerdarahan
Luka Bakar
Kedaruratan bedah
Intraoperatif
INDIKASI
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Ringers
acetate
Ringers acetate
First Line
Fluid Resuscitation Therapy
ASERING
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LACTATE: Primarily in the liver, and to lesser degree
the kidney, lactate is metabolized to pyruvate, whichis then converted to CO2and H2O (80%) or glucose(20%), and regeneration of bicarbonate1
ACETATE: metabolized mainly in muscles and to a
lesser extent in tissues such as kidney, heart andliver2
Acetate + H+--------Acetyl-CoA
Coenzyme A
Carbonic acid --------bicarbonate
hydrogen source
Krebs cycle
Ref. 1.Rose BD. Clinical Physiology of Acid-Base and Electrolyte Disorders. McGraw-Hill 4thed 1994 p 554
2. Maxwell MH, Kleeman CR, Narins RG. Clinical Disorders of Fluid and Electrolyte Metabolism.MacGraw-Hill 1987 4thedition p 1063
ASERING& LR
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1. SODIUM LAKTAT ( HATI )
CH3CH(OH)COONa + CO2+H2ONaHCO3 + CH3CH(OH)COOH ( Laktat )
CH3CH(OH)COOH + 3 O2 3 CO2+ 3 H2O : TCA Cycle
2. SODIUM ASETAT ( OTOT )
CH3COONa + CO2+H2O
CH3COOH + 2 O2 2 CO2+ 2 H2O : TCA Cycle
NaHCO3 + CH3COOH ( Asetat )
GLUkOSA
GLIKOGENG - 6 - PL- LAKTAT
PIRUVAT
LDH
Asetil KoA
sintetase
ASETAT Asetil - KoA
2 CO2 TCA Cycle H2O
BIOMOLEKULER ASERING& RL
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Replacement fluid for resuscitationgastroenteritis, burn,hemorrhagic shock, DSS
Intraoperative
Priming solution for cardiopulmonarybypass (CPB)
Replacement fluid for children
Indications of ASERING
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Ringers lactate 6.75
ASERING 7
Normal saline 6.25
Average pH
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J Clin Anesth1998 Feb;10(1):23-7
Kashimoto S, et al
Comparative effects of Ringer's acetate and lactate solutions on
intraoperative central and peripheral temperatures.
PATIENTS: 60 ASA physical status I and II patients undergoing
general surgery.
INTERVENTIONS: Following induction with 5 mg/kg of thiamylaland 0.1 mg/kg of vecuronium, patients were randomly assigned to one
of four groups (15 patients per group).
They received inhalation anesthetics (66% nitrous oxide [N2O] and
1.0% to 2.0% isoflurane or 1.3% to 2.6% sevoflurane) and LR or AR
Effect on Core Temperature
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Comparative Effects of Ringers Acetate (Asering)
and Ringers Lactate on core temperature and thefrequency of shivering in cesarean Section under
Subarachnoid Anesthesia
Susilo Chandra/Eddy Harijanto/Bram
Departement of Anesthesiology and Intensive Therapy
University of Indonesia, School of Medicine,Jakarta
2006
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Study results : Core Temperature
Minutes Ringers lacatate Ringers acetate Significance(p)
(Asering)
Before SAB 36.010 + 0.901 36.325 + 0.809 > 0.05
After SAB 35.858 + 0.778 36.165+ 0.719 > 0.05
5 35.740 + 0.769 36.215 + 0.787 < 0.05
10 35.585 + 0.755 36.120 + 0.773 > 0.05
15 35.475 + 0.747 35.940 + 0.800 > 0.05
20 35.440+ 0.715 35.800 + 0.750 > 0.05
25 35.400 + 0.715 35.675 + 0.665 > 0.05
30 35.363 + 0.501 35.670 + 0.596 > 0.05
35 35.217 + 0.547 35.522 + 0.825 > 0.05
40 35.194 + 0.563 35.576 + 0.699 > 0.05
45 35.018 + 0.615 35.476 + 0.721 > 0.05
50 34.806 + 0.725 35.465 + 0.717 < 0.05
55 34.756 + 0.841 35.481 + 0.717 < 0.05
60 35.010 + 0.829 35.350 + 0.717 > 0.05
65 34.417 + 0.674 35.282 + 0.806 < 0.05
70 34.733 + 0.404 35.225 + 0.850 > 0.05
75 34.733 + 0.379 34.833 + 0.720 > 0.05
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Incidence of shivering
* p
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Degree 0 1 2 3 4 Total
RingersAcetate(n)
15 1 1 3 0 20
Ringer s
Lactate(n)11 1 8 0 0 20
df = 3 p= 0.029
Patient Distribution based on Severity ofShivering after 20 minutes observation
Severity of shivering is less significantly in Asering group in 20 minutes
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Conclusion
Ringers Acetate (Asering) maintains coretemperature better than Ringers lactate in
pregnant women undergoing cesareansection under subarachnoid anesthesia,significantly on 5th, 50th, 55th, 65thminutes
Although there is no significant difference in
the severity of shivering between the twogroups, Ringers lactate is associated withearlier occurrence of shivering thanAsering
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Masui 1999 Sep;48(9):977-80Onizuka S, Kawano T, Takasaki M, Sameshima H, Ikenoue T
Comparison of the effect of rapid infusion of lactated and that of
acetated Ringer's solutions on maternal and fetal metabolism andacid-base balance].
20patients; combined spinal and epidural
25 ml/kg/hrAcetated Ringer's solution is better thanlactated Ringer's solution in rapid infusion
before cesarean section because of the
correction of neonatal lactic acidosis.
Asering in Obstetric Use
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Anaesthesia 1994 Sep;49(9):779-81
McFarlane C, Lee A
A comparison of AR and 0.9% saline for intra-operative fluid
replacement.
The exclusive use of 0.9% saline intra-operatively can produce a
temporary hyperchloraemic acidosiswhich could be givenfalse pathological significance. In addition it may exacerbate an
acidosis resulting from an actual pathological state. The use of abalanced salt solution such as AR may avoid these complications.
AR more suitable as intraoperative fluid vs NS
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Anesthesiology 2000 Nov;93(5):1170-3Liskaser FJ, Bellomo R, Hayhoe M, Story D, Poustie S, Smith B, Letis A, Bennett M
Role of pump prime in the etiology and pathogenesis of cardiopulmonary
bypass-associated acidosis.
Plasmalyte 148 vs Polygeline+ Ringer in 22 patients
With the Haemaccel-Ringer's prime, the metabolic acidosis was
hyperchloremic (Cl-, +9.50 mEq/l; CI, 7.00-11.50).
With Plasmalyte, the acidosis was induced by an increase in unmeasured
anions, most probably acetate and gluconate. The resolution of these two
processes was different because the excretion of chloride was slower
than that of the unmeasured anions (base excess from t1 to t3 = -1.60
for Haemaccel-Ringer's vs. +1.15 for Plasmalyte; P = 0.0062).
AR as priming solution in CPB
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Asering pada Bayi dan Anak
RA bisa digunakan pada anak dan bayi
Diindikasikan untuk resusitasi cairan
Ref: 1. Neonatal Hypernatremic Dehydration Secondary to Lactation Failure
J Am Board Fam Pract 14(2):159-161, 2001. 2001 American Board of Family Practice
2. Darrow DC, ped Clin North Am 1959 & Talbot FB, Am J Dis Child 1938.
3. Guidelines for treatment of DKA, Swedish Pdiatric Association 19964. Dengue haemorrhagic fever: diagnosis, treatment, prevention and control. 2nd edition. Geneva :
World Health Organization. 1997
5. Communicable Disease Epidemiology Office of Epidemiology Washington State Department
of Health.
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2. Asering pada Ketoasidosis Diabetik
Resusitasi cepat NaCl 0,9% 12.5 ml/kg/jam selama 0-2 jam
sampai sirkulasi tepi pulih
Fase rehidrasi lambat selama 48 jam dengan Ringer Asetat
(Rumatan + 5% BB/24 jam)
Rumatan
Ref. Ragnar Hanas. Guidelines for treatment of DKA, Swedish Pdiatric Association 1996
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SECONDARY DENGUE INFECTION
VIRUS REPLICATION ANAMNESTIC ANTIBODY RESPONSE
VIRUS ANTIBODY COMPLEX
COMPLEMENT ACTIVATIONMACROPHAG
CYTOKINES:Anafilatoksin C3a, C5aIl-1, Il-6, Il-12, INF, TNF, LIF
VASCULAR PERMEABILITY
LEAKAGE OF PLASMA
HYPOVOLEMIA
SHOCK
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JENIS CAIRAN (WHO-1998)3.1. Kristaloid:
3.1.1. Ringer Laktat (RL)dekstrose 5% + RL (D5/RL)
3.1.2. Ringer asetat (RA)
dekstrose 5% + RA (D5/RA)3.1.3. NaCL 0,9%
dekstrose 5% + NaCl 0,9%
3.2. Koloid:Dekstran 40 dalam RLPlasma
3. Asering pada DBD dengan Syok
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DBDIII & IVO22-4 L/menit
RA/RL 20 ml/kg bolus dalam 30 menit
Syok teratasi Syok tidak teratasi
RA/RL 10 ml/kg/jam
Stabil dalam 24 jam
RA 5 ml/kg/jam 3 ml/kg/jam
Stop < 48 jam
Dextran 40 10-20 ml/kgTeratasi
Tidak 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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KONKLUSI MANFAAT ASERING
Aman digunakan pada anak & bayi.
Diindikasikanuntuk resusitasi ( misal: kasus dehidrasi berat, Syok DBD,burn, dll)
Indikasi yang lain:3.a. Maintenance DKA pada anak3.b. Mencegah risiko bayi post sectio dari asidosis laktat
3.c. Maintain suhu sentral lebih baik3.d. Dibanding NaClRisiko hiperkloremia asidosis lebih minimized3.e. Dibanding koloid tidak ada risiko perdaraha dan lebih cost effective
References:
1. Anesthesiology 2000 Nov;93(5):1170-3 Liskaser FJ, Bellomo R, Hayhoe M, Story D, Poustie S, Smith B, Letis A, Bennett M.
2. Communicable Disease Epidemiology Office of Epidemiology Washington State Department of Health.3. Darrow DC, ped Clin North Am 1959 & Talbot FB, Am J Dis Child 1938.
4. Dengue haemorrhagic fever: diagnosis, treatment, prevention and control. 2nd edition. Geneva :World Health Organization.1997
5. Guidelines for treatment of DKA, Swedish Pdiatric Association 1996
6. McFarlane C, Lee AA comparison of AR and 0.9% saline for intra-operative fluid replacement.
7. Neonatal Hypernatremic, Dehydration Secondary to Lactation Failure, J Am Board Fam Pract 14(2):159-161, 2001. 2001 American
Board of Family Practice.
8. Onizuka S, Kawano T, Takasaki M, Sameshima H, Ikenoue T[ Comparison of the effect of rapid infusion of lactated and that of acetated
Ringer's solutions on maternal and fetal metabolism and acid-base balance]. Masui 1999 Sep;48(9):977-80
9. Tollofsrud S, et al. Fluid balance and pulmonary functions during and after coronary artery bypass surgery: Ringer's acetate compared
with dextran, polygeline, or albumin. Acta Anaesthesiol Scand 1995 Jul;39(5):671-7
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Situasi Cairan Rumatan di
sebagian RS Penggunaan infus belum customized
Kebanyakan diserahkan ke paramedik Isi dan Pemilihan Cairan tidak jelas
Sering confused antara RLD5 dan RD5
Na+ 130 147Cl- 109 155,5
K+ 4 4
*Otsuka NCE internal data
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RESUSITASI RUMATAN
TERAPI CAIRAN IV
Infus Natrium > 100 mEq/Latau koloid20-30 ml/kg/jam2-3 L/10-15 menit
Natrium rendah4:2:1
(misal 25 kg:4 x10+2x10+1 x5 65ml/jam
500 ml/6 jam
KECEPATAN PEMBERIAN TIDAK SAMA DENGAN
DOSIS HARIAN !!
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Perlu mengetahui berapa kebutuhan air, elektrolit(Na+,K+)
Perlu mengetahui status Natrium dan kalium serum
Perlu mengetahui kecepatan infus K+
, dekstrosa, lipid, AA
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
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Normal Potassium intake recommended by American diet society
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Asupan K+< 10 meq/hari
Defisit Kumulatif 250-300 mEq dalam 7-10 hari
Tannen R.L: Potassium Disorders. In Kokko & Tannen. Fluid and Electrolytes.WB Saunders Company 3rded, pp 123
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Management of Severe Hypokalemia
in hospitalized Patients 866 patients with Serum K+< 3 mmol/L
at admission
55 (6.4%) had no subsequentmesurement of potassium levels
260 (30%) were discharged with
subnormal potassium level
JAMA Vol. 161 No. 8, April 23, 2001
Inadequate clinical management of hypokalemia
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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 20mEq/L umumnya diperlukan pada pasienrawat-inap
Zwanger M. Hypokalemia. emedicine.com/emerg/topic273.html
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Hypokalemia di Indonesia
Limitted incidence/prevalence data
Insiden di RSPAD Gatot Soebroto, bagian
penyakit dalam = 28 % Peningkatan tendency pasien rawat inap
dengan hipokalemia = 17,5 % (saat masuk27 ps, dan saat keluar menjadi 45 pasien)
Sudomo, Untung. Marissa Ira. Gastroenterogy hepatoloy and digestive endoscopy
vol.5. Ed: Dec 2004. Page: 115-120
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Mengapa hipokalemia kurangdiperhatikan?
Gejala tidak spesifik dan umumnya baru
muncul pada kadar K+< 3 mEq/L
Pada pasien non-kardiak tidak dimonitorketat
Fasilitas Lab tidak memadai
Awareness
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Still widely used for maintenance therapy
RL
5 Dextrose
5 Dextr. in Ringers
What are the impacts ?
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KOMPOSISI
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KOMPOSISI
ALTERNATIF PENGGANTI
Product Name Osmolarity Electrolyte (mEq / L ) Glucos
(mOsm/L) Na+ K+ Ca++ CI- Laktat- Asetat - ( g / L
DGAA 296 61 17.5 52 26.5 25
KA - EN 3B 290 50 20 50 20 27
N/2 - D2.5 (2A), 0.45% NaCl & D2.5% + KCl 10 mEq 308 77 10 77 25
KA - EN 3A 290 60 10 50 20 27
N/4 - D5 (4:1) 282 38.5 38.5 50
KA - EN 1B 285 38.5 38.5 37.5
N/4 - D5 (3:1), 0.225% NaCl & D5% 353 38.5 38.5 50
KA - EN 1B 285 38.5 38.5 37.5
N/5 - D4 353 30 30 40
KA - EN 4A 282 30 20 10 40
KA - EN 4B 284 30 8 28 10 37,5
Ringer Laktat (RL) 273 130 4 3 109 28
Ringer asetat (ASERING) 273 130 4 3 109 28
5% Dext in Ringer laktat (RLD5) 551 130 4 3 109 28 50
5% Dext in Ringer asetat (Asering 5) 551 130 4 3 109 28 50
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Takut Hiperkalemia
dengan pemberian KAEN?
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Anjuran: 10 mEq/jam*
KN3B mengandung kalium 10 mEq/500 ml
Kecepatan Rumatan 500 ml/6 jam
~ 80 ml/jam; 20 tetes/menit
atau ~ 1,6 mEq K+/jam
Dalam praktek:
Risiko Hiperkalemia minimal!
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PEMAKAIAN CAIRAN INFUS
DI RUMAH SAKIT
(Aplikasi disesuaikan dengansediaan infus yg ada dipasaran)
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PEMAKAIAN INFUS DI UGD
SYOK HIPOVOLEMIK
ASERING
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/hipoKNormo/
hipoK
KAEN 4B KAEN 3B/MG3
Observasi/
monitor
nadi teraba
akral hangat
urine output +
kecepatan bisaditurunkan 1073 ml/kg/jam
KAEN 3B/3A
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KAEN 3B/3A
Na+50 mEq; K+20 mEq; Glu 27 g/L
INDIKASI:
1. Pneumonia
2. Pleural Effusion
3. Ketoasidosis diabetik (setelah rehidrasi dgNaCl 0,9%)
4. Observasi Tifoid
5. Observasi demam yang belum diketahui penyebabnya
6. Status asthmaticus
7. Fase pemulihan dari DBD
Kasus-kasus baru di mana status gizi tidak terlalu jelek, antara lain:
Kecepatan pemberian: 80 ml/jam (20 tetes/menit)
Catatan : Dosis harian maksimal 50 ml/kgBB, jika tidak dikombinasi infus lain dan
tidak ada asupan cairan per oral
KAEN MG3
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KAEN MG3
Na+50 mEq; K+20 mEq; Glu 100 g/L
INDIKASI:
1. Diare kronik
2. Tbc
4. Tifoid dengan komplikasi
5. Empiema, osteomielitis6. Keganasan
7. Sepsis,
8. Hepatitis akut
9. Ensefalopati hepatik
Kasus-kasus di mana status gizi kurang, antara lain:
Kecepatan pemberian: 80 ml/jam (kira-kira 20 tetes/menit)
Catatan :
Jika gizi jelek bisa dikombinasi dengan PanAminG (2,7% AA + sorbitol 5%) atau
Amiparen (AA 10%)
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Pan Amin G 1000 ml 200 kcal 27 g protein
KNMG3 1000 ml 400 kcal
TOTAL 2000 ml 600 kcal 27 g protein
STRES RINGAN + Gizi BAIK + kurangasupan oral
KAEN MG3 + AA
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Amiparen 1000 ml 100 g protein
KNMG3 1000 ml 400 kcal
TOTAL 2000 ml 400 kcal 100g protein
STRES SEDANG + Gizi Sedang + perlukalori dan protein lebih tinggi
KN MG3 + AMIPAREN
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Pemberian Cairan/Elektrolit
DHF/DSS : Asering, Asering-5 GE : Asering
Muntah-muntah : NaCl 0.9%
Anoreksia : KAEN MG3
Stroke : Asering + MgSO4 20% (awal), setelah 3hari KAEN 3B
Hiperemesis gravidarum: awal NaCl/D5/Asering5
disusul KAEN MG3 + PanAmin G pada hari ke 2 DKA : NaCl 0,9%, disusul KAEN 3B setelah
rehidrasi
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NUTRISI/KALORI
DM : Martos + Aminovel 600
Hati: KAEN MG3 + Aminoleban
Ginjal: D10 + Kidmin
Jantung : KAEN MG3 + Amiparen
Hipoalbuminemia: Amiparen + KAEN MG3
PASIEN BEDAH
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PASIEN BEDAH
Intraoperatif : Asering/Asering-5 Postoperatif : Asering/Asering-5
Setelah di bangsal
Tergantung status nutrisi /stres metabolisme:
Jika kondisi bagus (e.g laparoskopi, kistektomi,
apendektomi dll) infus bisa di-off pada POD1.
Jika kondisi kurang bagus (operasi lama, stresmetabolik
ada dan pasien tidak bisa asupan oral)
bisa KAEN MG3 + PanAmin G/Amiparen + lipid
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PASIEN SYOK
Asering
!!!
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TERAPI CAIRAN
Asering
Ringer Laktat
Normal Saline
RESUSITASI RUMATAN
KRISTALOID KOLOID ELEKTROLIT NUTRISI
Mengganti kehilangan akut
Otsutran- L
Memelihara keseimbangan
SERI KA-EN
AMIPAREN
AMINOVEL- 600
PAN- AMIN G
KA-EN MG 3
MARTOS 10
!!!
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TERIMA KASIH