terapi cairan, hd monitoring, totilac plbg
TRANSCRIPT
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
1/123
Fluid Therapy and
Hemodynamic Monitoring
Cindy E. BoomNational Cardiovascular Center Harapan Kita
Jakarta - Indonesia
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
2/123
Curriculum Vitae
Name:
Dr. Cindy E.Boom.dr.,SpAn.,KAKV.,KAP
DOB : Duri, Riau April 22
Status : Married , 3 children
Education :
MD : Padjadjaran Univ. 1991
Anestesiologist : Padjadjaran Univ.1999
Cardiac Anesthesiologist : National Heart
Center 2001
Pediatric Cardiac Anesthesiologist :
Children Hospital Boston-MA-USA,2005
PhD : Padjadjaran Univ. 2008
Position : SMF National CV Center
Harapan Kita.
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
3/123
Water Function
Universal solvent
Transport nutrients
Removes waste
Lubricates
Shock absorber
Regulates body temperature
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
4/123
Fluid Compartment Physiology
Models for volumes of distribution of fluids
Plasma
3 L
4 - 5%
Blood
cells
2 L
Interstitial
Compartment
10 L
Intracellular
Compartment 30 L
40%
colloid
saline
glucose
20%
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
5/123
Composition of extracellular and intracellularfluids
INTRACELLULAR
EXTRACELLULAR
Na+
K+
Ca++
Mg++
Cl-
PO4-&
organicanions
HCO3-
Protein
Cations Anions150
100
50
0
50
100
150
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
6/123
Six qualitative alterations
1 Hypotonic expansion Ex. Excess water intake
2 Hypotonic contraction Ex. Sodium loss from adrenal insufficiency
3 Isotonic expansion Ex. IV drip of 0,9% NaCl
4 Isotonic contraction Ex. Hemorrhage, burns
5 Hypertonic expansion Ex. Sea water drowning
6 Hypertonic
contraction
Ex. Severe sweating, fever
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
7/123
Fluid Therapy
RESUSCITATION MAINTANANCE
ElectroliteColoidCrystalloid Nutrition
Replacement of an acute
loss (hemoragic, GI loss, 3rd
space)
1. Normal Requirement
2. Nutrition support
Repair
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
8/123
Preload Contractility Afterload
Vasoconstriction
Tissue Perfusion
CO = SV x HR
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
9/123
ADEQUATE OXYGEN TRANSPORT
Rumus Nuun-Freeman untuk Oxygen Delivery - Available O2
CO ( HR x SV) x O2 content ( Hb x SaO2 x 1,34) + ( pO2 x
0,003 )
Bila disederhanakan : CO x Hb x SaO2 x 1,34
Berarti : Bila CO dinaikkan hingga 2 x, maka Hb bisa turun
hingga nya dan tidak mengurangi Oxygen Delivery.
Av. O2 = 15 x 15 x 100% x 1,34 = 301,5
Av. O2 = 30 x 7,5 x 100% x 1,34 = 301,5
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
10/123
Hypovolemic Shock
Blood Pressure
Cardiac Output /
CO
Stroke Volume/ SV
Contractility Afterload
Heart Rate
Systemic Vascular
Resistance (SVR)
Preload
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
11/123
Cardiogenic ShocK
Blood Pressure
Cardiac Output /
CO
Stroke Volume/ SV
Afterload
Heart Rate
Systemic Vascular
Resistance (SVR)
Preload
Contractility
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
12/123
Circulatory Shock
Blood Pressure
Cardiac Output /CO
Stroke Volume/ SV
Contractility Preload Afterload
Heart Rate
Systemic Vascular Resistance / SVR
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
13/123
Treatment Concept of Shock
Enhancing perfusion / Oxygen Delivery
DO2 = CO x CaO2
O2 delivery/ DO2 = HR x SV x Hb x SaO2 x 1.34 + Hb x PaO2
Cardiac
Output Arterial O2content
Inotropik
Contractility
Vasoactive
Fluids
Preload
Afterload
Transfuse Partially dependent
on FIO2& pulmonary
status
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
14/123
O2uptake O2transportO2extraction O2utilisation
Optimize Oxygenation
-
Oxygen Delivery Oxygen Comsumption
ScvO2Cardiac Output Arterial Oxygen
Content
Stroke
VolumeHeart
RateOxgenation
SaO2
Hemoglobin
Hb
Preload-GEDI
- SW
- PPV
After Load- SVRI
Contractiliy- GEF
- CFI
- dPmx
Pulmonary edema
- ELVI
- PVPI
VolumeVasopressors Inotropes
Red Blood Cells+- +
-+ - +
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
15/123
Oxygen Delivery Optimalisation
in Shock
DO2 = CO x Hb x SaO2x1,36
31
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
16/123
Oxygen Delivery Optimalisation
In Shock
DO2 = CO x Hb x SaO2 x 1,36
Oxygenation/
VentilationHR x SV
Preload Afterload
Contractility
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
17/123
DO2 = CO x Hb x SaO2x1,36
Oxygenation/VentilationHR x SV
Preload Afterload
Contractility
1Mech.Vent.
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
18/123
DO2 = CO x Hb x SaO2x1,36
Oxygenation/VentilationHR x SV
Preload Afterload
Contractility
1Mech.
Vent.
1
TerapiCairan
2
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
19/123
DO2 = CO x Hb x SaO2x1,36
Oxygenation/VentilationHR x SV
Preload Afterload
Contractility
1Mech.Vent.
1TerapiCairan
2
3Vasoaktif
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
20/123
DO2 = CO x Hb x SaO2x1,36
Oxygenation/VentilationHR x SV
Preload Afterload
Contractility
1Mech.Vent.
1TerapiCairan
2
3
Vasoaktif
Transfusi
4
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
21/123
Characteristics of DifferentVolume Substitutes
IVVolume Cryst
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
22/123
Volume Replacement Therapy
Crystalloids Colloids
Lactated Ringers
Normal Saline
Hypertonic Sodium
Lactate
Albumin Gelatin Dextran HES
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
23/123
Dextrose (free water)
Vascularspace
water added to intravascular space
Expansions of total body water no volume effect
ECF
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
24/123
Isotonic crystalloids
ECF
Kt= 250 ml.min-1
Svensen et.al, Br.J.Anaesth,
1998
ECF
Vascular
space Kt
Proportional expansion of intra- and extravascular spaces
Crystalloids added to intravascular space
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
25/123
Crystalloids
True solutions
Freely distributed across semipermeablemembrane
Plasma expansion < infused volume
Rapidly excreted
Expansion ECF : Plasma Volume 3:1
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
26/123
Crystalloids
Extracellular space expanders
Limited plasma volume expansion
Maintain urine output
Reduce plasma oncotic pressure
Range of electrolyte content
CHEAP!
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
27/123
Is Normal Saline Normal?
Is 0,9% saline isotonic?
Normal plasma osmolality 280-290 mOsm/L
0,9% saline ~ 308 mOsm/L
Is it physiological?
pH = 6,35
Chloride load can cause acidosis
Abnormal saline?
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
28/123
Who was Ringer?
19th century physician
Worked with frogs heart
Developed his solution to replace frog plasma (Na+= 130 mmol/l)
Original contained 130 mmol NaCl, plus 5 mmol KCl
+ 2,5 mmol CaCl2 (140 mmol Cl-)
Hartmann introduced 28 mmol NaLactate
Still hypotonicbased on frog plasma
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
29/123
Ringers Lactate
Contains 131 mmol Na+, 5.4 mmol K+, 3.5
mmol Ca++, Lactate 28 mmol.
Calcium content may clot blood
Osmolarity = 273 mOsm/l
Lactate metabolised to CO2and H2O and
converted to HCO3
- in kidney
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
30/123
Acetated Ringer
AcetateBicarbonate
Metabolized by muscular, renal and
cardiac tissues Acetate is metabolized quickly even in
hemorrhagic shock
Does not increase the risk of lactateacidosis
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
31/123
Hypertonic Solutions
ECF
ECF
Vascular
space
Expansion of intravascular space
Contraction of ECF
Hypertonic fluid added to intravascular space
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
32/123
Hypertonic Saline (7.5%)
High osmolality (2400 mOsm/L) Small volume resuscitation
Reduces cerebral no-reflow in CPR
Fischer M Resuscitation 1996
Decreases brain water in head injury Shelkh AA Crit.Care Med. 1996
Effective for a limited period only
Favre Schwelz.Med.Wochenschr.1996
Reversed trauma-induced immunosuppresion Colmbra R J.Surg>Res. 1996
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
33/123
Hypertonic Saline Solutions
Immediate improvement in hemodynamics
Increase in survival up to 100%
Low cost
Ready availability
No allergic risk or transmission of infectious agents
Benefits
Uncontrolled internal hemorrhage
Hypernatremia
Hronic heart failure
Decreased platelet aggregation
Prolonged prothrombin/ partial thromboplastin times Hypokalemia
Renal failure
Risks
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
34/123
Hypertonic Na-Lactate
1020 mosm/L, contains 504 mEq Sodium Lactate
Hypertonic solutions of sodium lactate in limited dose (max: 10
ml/kg in 12 hrs) could be used safely for fluid resuscitation
It will not cause hyperchloremic acidosis It will increase cardiac output, limited effect on heart rate, a
slight decreased in MAP, a slight increased in PCWP, and a
decreased in SVR.
Lactate would be a good subtrate for energy metabolism of theheart in the future.
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
35/123
Crystalloids solutions are distributed over theentire
Extracellular space.
And therefore crystalloids are indicated and
most effective when this space is depleted.
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
36/123
COLLOIDS
ll d
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
37/123
Colloids
Advantages:
Good Intra Vascular Volume
Prolonged plasma volume support Moderate volume needed
Minimal risk of tissue edema
Enhances micovascular flow
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
38/123
Colloids
Disadvantages:
Risk of volume overload
Adverse effect on hemostasis
Adverse effect on renal function
Anaphylactic reaction
Expensive
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
39/123
Gelatins
Derived from hydrolyzed bovine collagen
Metabolized by serum collagenase
Histamine release (H1 blockers recommended) Decreases Von Willebrand factor (VWF)
Bovine Spongiform Encephalopathy:
1:1,000.000
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
40/123
Albumins
Heat treated preparation of human serum
5% (50g/l), 25% (250g/l)
Half of infused volume will stay intravascular
COP = 20mmHg = plasma
25%, COP= 70mmHg, it will expand the vascularspace by 4-5 times the volume infused.
should not be used for volume resuscitation
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
41/123
Cochrane studies support mortality following
albumin infusion
Cardiac decompensation after rapid infusion of 20-25% albumin
Ionized Ca++ Aggravate leak syndrome MOFEnhance bleeding
Imparied Na+ & water excretion renal dysfunction
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
42/123
MW DS Max. dose
Plasmasteril
(HETstarch)
240.000 0.7 1.500/day
Pentastarch(HESsteril)
200.000 0.5 2.500/day
Tetrastarch
(Voluven)
130.000 0.4 3.500/day
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
43/123
Characteristics of Colloids
Product Name Conc.% Oncotic
Pressure
Initial
Expansion
%
Stays
(days)
Max.
dose
Hemost.
Albumin 4,5 20 80-100 200-400 0
Dext70 Macrod 6 60-70 120 30-40 1.5g/kg +++
Dext40 Rheom 10 170-190 200 6 1.5g/kg +++
Gelatin Gelfusin 3-4 42 70-90 7 0-+
HES450/0.7 Plasmas6 6 24-30 100 120-182 20ml/kg +++
HES200/0.5 Hesteril 6 30-37 100 3-4 33ml/kg +
HES130/0.4 Voluven 6 36 100-110 50ml/kg 0-+
i d f ll id
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
44/123
Disadvantages of Colloids
Gelatin Starch Dekstran
Anafilactic reaction
Coagulopathy
Renal toxic
Hepatotoxic
Tissue depletion
Restricted use in renal
failure
Not common
No
No
No
No
No
Not common
Yes ( dose
dependent)
Yes
Possibly
Yes
Yes
Common &
severe
Yes
Not common(High dose)
No
No
No
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
45/123
Advantages of Colloids
Refiling IVF faster than crystalloids
Shock time become shorter
Remains in IVF longer than crystalloids
No interstitial edema
Preserves oncotic pressure effect
No interstitial edema
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
46/123
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
47/123
Best strategy to achieve these goals?
Crystalloids or Colloids?
The crystalloid versus colloid controversy
a never ending story?
Is the optimal approach
crystalloid + colloid??
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
48/123
Which Fluids?
Debate is unresolved
Dextrose solutions replace lost water only Crystalloids resuscitate ECF
Colloids remain in the vascular compartment
Choose spesific fluids for spesific purposes!
ll d ll d
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
49/123
Crystalloids vs. Colloids
Follow the physiologic principle
Not depends on the resuscitator
Depends on the patient
Maintain Hb and coagulation
factor value.
Changes in volume of body compartments
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
50/123
Changes in volume of body compartmentsduring fluid infusion
Compartment Glucose 5% NaCl 0.9% Colloids
Intravascular
Interstitial -
Intracellular / - -
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
51/123
Defek primer Pilihan cairan
Dehidrasi IFV RL/RA
Perdarahan baru IV Koloid
Perdarahan lama IV + IFV Koloid + RL
IFV : Interstitial Fluid Volume
IV : Intra Vascular
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
52/123
Immunomodulatory effect offluid resuscitation
RL/NS in > 100mL/KgBW : proinflammatory
HS : antiinflammatory
HES/colloid : antiinflammatory
Menilai kecukupan volume intra-vaskularsuatu
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
53/123
p
penilaian klinis yang sulit
Tanda2 Klinis ?
Menentukan parameter yang tepat
sebagai indikator kecukupan volume
intravaskuler
Fluid Challenge
menilai respons pasien terhadap
intervensi/ pemberian cairan
Intravascular volume evaluation
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
54/123
Intravascular volume evaluation
Static evaluation Dynamic evaluation
Technique proposed to evaluate
hypovolemic
Overt hypovolemic Masking
hypovolemic
Fluid Challenge
A method assessing
responsiveness to fluid infusion
Signs of dehydrationDiminished skin turgor
Thirst
Dry mouth
Dry axillae
Hypernatremia, hyperproteinemia,
elevated hemoglobin/hematocrit
Circulatory signs ofhypovolemiaTachycardia
Arterial hypotension (severe cases)
Increased serum lactate (severe
cases)
Decreased toe temperature
Decreased renal perfusionConcentrated urine (low urine
sodium concentration, high urineosmolarity)
Increased blood urea nitrogen
relative to creatinine concentration
Persistent metabolic alkalosis
P i L Ri i
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
55/123
Passive Leg Rising
Transient hemodynamic effect of passive leg raising (PLR) on leftventricular stroke volume or its surrogates could be an alternativemethod to detect preload responsiveness in all categories of patientsreceiving mechanical ventilation because the effect persists overseveral breaths
PLR induces a translocation of venous blood from the legs to theintra thoracic compartmentresulting in a transient increase in rightventricular and left ventricular preload
PLR as a reversible volume challenge is attractive because it is
easy to perform at the bedside PLR induces a reversible volume challenge that is proportional to
body size, and does not result in volume overload in non preload-responsive subjects
P i L Ri i
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
56/123
Passive Leg Rising
The effects of PLR on cardiac output presumably
depending on the existence of cardiac preload reserve
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
57/123
Pressures and flow is measured during four sequential steps
A first set of measurements was obtained in the semirecumbentposition (45) (designated base 1)
Using an automatic bed elevation technique, the lower limbs were
then raised to a 45 angle while the patients trunk was lowered insupine position
A second set of measurements (designated PLR) were obtainedduring leg elevation, at the moment when aortic blood flow reachedits highest value
The body posture was then returned to the base 1 position and athird set of measurements was recorded (base 2)
Finally, measurements were obtained after a 10-min infusion of 500mL of saline (designated post- VE)
P i L Ri i
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
58/123
Passive Leg Rising
PLR allows for a rapid and reversible preload challenge without
needing to infuse fluid
Parameterpressure and flow
An increase in aortic blood flow 10% by PLR predicted a volume
expansion induced increase in aortic blood flow 15% with a
sensitivity of 97% and specificity of 94%
The effects of PLR on hemodynamics occurred rapidly after starting
the maneuver since in all responders, the highest value of aortic
blood flow and pulse pressure were observed within the first 30 secs
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
59/123
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
60/123
Ultimately, whichever colloid is chosen, they should fulfill therequired principles for hypovolemia
Normalize blood volume
Regulate blood pressure
Stabilize cardiac function
Improve tissue perfusion
Raise oxygen delivery
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
61/123
Significance of Fluid Therapy in Surgery
Fluid therapy
an integral and essential part of major surgery procedure especially in cardiacsurgery.
Physiological andbiochemical
changes
Physiological and biochemical changes in reversibly injured organ /miokardiumoccures
Metabolic shifts, fall in glucose levels, reduction tissue ATP levels, decrease inintracellular pH, onset of oedema and fall in cardiac index and oxigen delivery
Cardiacpreload
Cardiac preload should be maintained for optimal heart function by providingadequate fluid infusion (crystalloidsor colloids)
S l ti C t i i H lf l
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
62/123
Solution Containing Halfmolar
Hypertonic Sodium Lactate
Superior due to
Hemodynamic efficacy and body fluid balance
Efficient energy substrate
Fuel for the myocardium to give an optimum cardiac index
Increase cardiac index
Low vascular resistance
Enhance oxygen delivery
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
63/123
Profiling Lactate
a dead-end waste product of glycolysisdue to hypoxia
primary cause of O2 debt
key factor in acidosis-induced tissue
damage
Traditional View
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
64/123
Profiling Lactate
were on the midst of a lactate shuttle era
an efficient energy substrate
an important intermediary in metabolic processes
mobile fuel for aerobic metabolism
a mediator of redox state among various compartmentsboth within and between cells.
a central player in cellular, regional and whole bodymetabolism.
At Present ( Lactate Revolution since 1970s )
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
65/123
Lactic Acids and Lactate
HC
HO
CH3
CO2H
HC
HO
CH3
CO2-
Lactic Acid Lactate
glucose glycogen
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
66/123
glucose 6-phosphate
pyruvate
NAD
NADH
ADP
ATP
lactate lactate
H+ H+
ATP
ADP
Acidosis
Alcalosis
alanine
1
34
+
-
-
plasmamembrane
mitochondrialmembrane
ADP
ATP
NADH + O2
NAD + H2O
CO2
2
Compartmentation of lactate metabolism(Chatham C J Rosiers C D Forder R J : American Journal of Physiology Endocrinology and Metabolism
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
67/123
(Chatham, C.J., Rosiers, C.D., Forder, R.J.: American Journal of Physiology Endocrinology and Metabolism
Vol. 281, 2001)
Glucose GT G 6 P Glycogen
lactate
lactate
lactate lactate lactate
MCT
MCT
MCT
MCT
MCT
Pyruvate
Pyruvate
Acetyl CoA
Alanine
Alanine
Extracellular Intracellular
Mitochondri
a
S k l i d (SVI) (A) d di l ffi i (B) d
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
68/123
Stroke volume index (SVI) (A) and myocardial efficiency (B) treated
with dichloroacetate (DCA) or saline (CON) at the onset of resuscitation
Barbee et al SHOCK 2000;14:208-214.
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
69/123
HSL: Clinical Evidence
I) Completed/ Published studies
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
70/123
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
71/123
0
5
10
15
-20 0 20 40 60 80 100 120 140
Healthy
Preop
PostopMID-CAB
Lacta
te,mM
time, min
Mustafa I et al Intensive Care
Med 2003;29:1279-85.
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
72/123
Effect of hypertonic sodium lactate versus sodium chloride on
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
73/123
1
2
3
4
5
6
CardiacIndex,
L.m
in-1.m
-2
Afterlactateinfusion
Beforelactateinfusion
Afterlactateinfusion
Beforelactateinfusion
Afterlactateinfusion
Beforelactateinfusion
2.90.1
3.80.2
3.40.2
4.00.24.20.2
3.30.1
p
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
74/123
200
300
400
500
600
700
800
OxygenDelivery,ml.min-1.m
-2
44320
58624
48425
5512756123
45423
Afterlactateinfusion
Beforelactateinfusion
Afterlactateinfusion
Beforelactateinfusion
Afterlactateinfusion
Beforelactateinfusion
p
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
75/123
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
76/123
P=0.0242
P
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
77/123
SVRI and PVRI were lower in HSL group as compared to RL group
Hemodynamic Effects
HSL HSL
p = 0.214p = 0.002
HSL has a lowering effect on vascular resistance which is responsible
for decreasing the cardiac work, and consequently resulting in higher
cardiac index
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
78/123
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
79/123
P l d P t
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
80/123
55
60
65
70
75
80
85
B L-1 R L-2
DenyutJantung,
denyut/menit
68
70
72
74
76
78
80
82
84
86
B L-1 R L-2
TekananArteriRerata,mmHg
6
7
8
9
10
11
12
B L-1 R L-2
TekananVenaSentral,mmHg
21
21.5
22
22.5
23
MPAPTekananArteriP
ulmonalRerata,mmHg
RL
HSL
13
13.5
14
14.5
PCWP
TekananBaji
KapilerParu,mmHg
RL
HSL
= RL
= HSL
*
Preload Parameters
Cardiac Index
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
81/123
Cardiac Index
Cardiac index graphs in (a) both groups and (b) HSL group:
Note: (a) : RL : NLH (b) : 26%-40% : 25%
* : significant; **: very significant; ***: sangat sangat bermakna
0
0.5
1
1.5
2
2.5
3
3.5
4
B L-1 R L-2
CI,L/menit.m
2
0
0.5
1
1.5
2
2.5
3
3.5
4
4.5
5
B L-1 R L-2
CI,L/menit.m
2
(a) (b)
*** * * * *** ***
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
82/123
Tissue Oxygenation (DO )
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
83/123
Tissue Oxygenation (DO2)
Oxygen delivery graphs in (a) both groups and (b) HSL group:
Note: (a) : RL : HSL (b) : 26%-40% : 25%
0
100
200
300
400
500
600
700
800
900
B L-1 R L-2
DO2,mL/menit
0
200
400
600
800
1000
1200
B L-1 R L-2
DO2,mL/menit
(a) (b)
** ** *
Tissue Oxygenation (DO )
Ti O ti (DO )
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
84/123
Delta of Oxygen Delivery inVarious Ejection Fraction
-0.5
-0.3
-0.1
0.1
0.3
0.5
0.7
0.9
1.1
1.3
1.5
21 21 2 5 27 28 2 9 3 2 3 2 32 33 33 33 3 4 3 4 34 3 4 3 4 3 5 3 5 36 36 37 37 37 37 37 38 39 39 39 40 40 40
Ejection Fraction
DeltaofOxygenDelive
ry
1
2
3
4
Tissue Oxygenation (DO2)Tissue Oxygenation (DO2)
4 0m-2
500
RL
HSL
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
85/123
2.0
2.5
3.0
3.5
4.0
cardiacind
ex,
L.m
in-1.m
300
350
400
450
500
Baseline Load-1 Mt Load-2 Baseline Load-1 Mt Load-2
DO2,m
L.m
in-1
A B
C D
1000
1500
2000
2500
3000
SVRI,dyn.s.cm-5
100
150
200
250
300
350
P
VRI,dyn.s.cm-5
Baseline Load-1 Mt Load-2 Baseline Load-1 Mt Load-2
p = 0.0017
p = 0.019 p = 0.0356
p = 0.0130
Boom CE PhD Dissertation
Hyperosmolar sodium-lactate infusion during cardiac surgery
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
86/123
Figure 2.Intra-operative changes inbody fluids, sodiumand potassiumexcretion in patients treated withRLorHL. White columns: patients treated with RL; black columns: patients treated with HL. Panel A: urinary output(L); Panel B: cumulativefluid intakes(L); Panel C: body fluid balance (L); Panel D: sodiumexcretion output(mmol); Panel E: chloride excretion (mmol); E: sodium/chloride ratio. Results are expressed as meanssem,statistical comparisonsbetween RL and HL by unpaired studentst test for: urineoutput (p
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
87/123
Note: : RL : HSL
0
500
1000
1500
2000
2500
3000
B L-1 R L-2
SVRI,dyn
es.detik/cm5.m
2
0
50
100
150
200
250
300
350
B L-1 R L-2
PVRI,dyn
es.detik/cm5.m
2
**
Afterload Parameters
Conclusion
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
88/123
Conclusion
It can be oxidized, recyled, or used as precursor for other energy metabolism
Lactate is a major physiological substrate
Energetic substrate for brain, heart, kidney
Prevention of ischemia-reperfusion injury
It is of major interest in acute conditions
Increase cardiac output
Decrease pulmonary and systemic vascular resistance
Increase oxygen delivery
Increase total urine output
Decrease total fluid balance
Hypertonic Sodium-Lactate possesses several cardiacand hemodynamic properties
Osmolarity
mOsm/LTonicity
mOsm/L
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
89/123
HSL
Lactate-
Na+
K+
Ca++
Cl-
mOsm/L mOsm/L
504.15
6.74
4.02
1.36
1020.42 516.25
0
504.15 504.15
6.74
4.02
1.36
Total
Increases
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
90/123
HSL
Intravascular
volume
Improves
Hemodynamic
Inotropic effect +
vascular resistance
Prevents/Corrects
Cellular edema
Improves
Capillary leakage
Prevents/Corrects
Metabolic Acidosis
Tissue perfusion=
Urine output MAP
Mix Ven O2sat
HSL (Totilac) Acute Toxicology Study
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
91/123
HSL (Totilac ) Acute Toxicology Studyby Prof. Elin Yulinah, ITB (2004)
Objective:
To determine the LD50 (Lethal Dose) of Totilac (up to 5000mg/kg bw)
Methods:
6 groups of mice (male & female) were given different doses of Totilac (from0mg/kgBW to 5000mg/kgBW)
Results: Clinical Symptoms due to intoxication: none found
Death occurrence: administration of 5000mg/KWBW did not cause any death
Body weight: no significance differences between control and test treatmentgroup
Macroscopic observation of pathological organ: none
Defecation: increase of defecation in female (but not abnormal)
Conclusion:
The intravenous LD50 of the test substance in mice is above 5000 mg/kg BW,therefore it is safe and the study can be continued to toxicity sub-chronicstudy.
Experimental/Clinical Proofs
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
92/123
Experimental/Clinical Proofs
Increases
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
93/123
Totilac
Intravascular
volume
Improves
Hemodynamic
Inotropic effect +
vascular resistance
Prevents/Corrects
Cellular edema
Improves
Capillary leakage
Prevents/Corrects
Metabolic Acidosis
Tissue perfusion=
Urine output MAP
Mix Ven O2sat
Effect of acute infusion of sodium lactate or sodium chloride
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
94/123
-0.6
-0.5
-0.4
-0.3
-0.2
-0.1
0.0
Deltahemoglobin,g
1 2
in patients after cardiac surgery
Na-lactate, n = 40Na-chloride, n = 401 = change between 0 and 15 minutes (end of infusion)
2 = change between 0 and 120 minutes
NaCl or Na-lactate was infused during 15 minutes
*p < 0.05 versus 0 (univariate t test)
$ p < 0.05 lactate versus chloride (unpaired student t test)
* **
*
Mustafa,PhD dissertation
Increases
I t l
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
95/123
Totilac
Intravascular
volume
Improves
Hemodynamic
Inotropic effect +
vascular
resistance
Prevents/Corrects
Cellular edema
Improves
Capillary leakage
Prevents/Corrects
Metabolic Acidosis
Tissue perfusion=
Urine output MAP
Mix Ven O2sat
Effect of hypertonic infusion (lactate versusNaCl)
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
96/123
Mustafa & Leverve, Shock, 2002
on hemodynamic
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
97/123
Effect of acute infusion of sodium lactate or sodium chloride
on vascular resistance indexes (SVRI & PVRI)
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
98/123
on vascular resistance indexes (SVRI & PVRI)
in patients after cardiac surgery
Na-lactate, n = 40Na-chloride, n = 401 = change between 0 and 15 minutes (end of infusion)
2 = change between 0 and 120 minutes
NaCl or Na-lactate was infused during 15 minutes
*p < 0.05 versus 0 (univariate t test)
$ p < 0.05 lactate versus chloride (unpaired student t test)
-50
-40
-30
-20
-10
0
10
*
* *
$
Delta,PV
RI,dynes/cm2m2
1 2
-800
-600
-400
-200
0
200
*
*
*
DeltaSVR
I,dynes/cm2m
2
$$
Mustafa,PhD dissertation
Increases
Intravascular
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
99/123
Totilac
Intravascular
volume
Improves
Hemodynamic
Inotropic effect +
vascular resistance
Prevents/Corrects
Cellular edema
Improves
Capillary leakage
Prevents/Corrects
Metabolic Acidosis
Tissue perfusion=
Urine output MAP
Mix Ven O2sat
Effect of hypertonic infusion (lactate versusNaCl)
id b t t
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
100/123
Mustafa & Leverve, Shock2002
on acide base status
Increases
Intravascular
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
101/123
HSL
Intravascular
volume
Improves
Hemodynamic
Inotropic effect +
vascular resistance
Prevents/Corrects
Cellular edema
Improves
Capillary leakage
Prevents/Corrects
Metabolic Acidosis
Tissue perfusion=
Urine output MAP
Mix Ven O2sat
Effect of acute infusion of sodium lactate or sodium chloride
on pH and bicarbonate in patients after cardiac surgery
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
102/123
on pH and bicarbonate in patients after cardiac surgery
Na-lactate, n = 40Na-chloride, n = 401 = change between 0 and 15 minutes (end of infusion)
2 = change between 0 and 120 minutes
NaCl or Na-lactate was infused during 15 minutes
*p < 0.05 versus 0 (univariate t test)
$ p < 0.05 lactate versus chloride (unpaired student t test)
-0.025
0
0.025
0.05
0.075
De
eltapH,units
1 2
*
$
*
*
$
-4
-2
0
2
4
6
8
Bicarbon
ate,mmol/L
1 2
* *
*
$ $
Increases
Intravascular
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
103/123
HSL
Intravascular
volume
Improves
Hemodynamic
Inotropic effect +
vascular resistance
Prevents/Corrects
Cellular edema
Improves
Capillary leakage
Prevents/Corrects
Metabolic Acidosis
Tissue perfusion=
Urine output MAP
Mix Ven O2sat
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
104/123
Effect of acute infusion of sodium lactate or sodium chloride
on plasma sodium and chloride in patients after cardiac surgery
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
105/123
on plasma sodium and chloride in patients after cardiac surgery
Na-lactate, n = 40Na-chloride, n = 401 = change between 0 and 15 minutes (end of infusion)
2 = change between 0 and 120 minutes
NaCl or Na-lactate was infused during 15 minutes
*p < 0.05 versus 0 (univariate t test)
$ p < 0.05 lactate versus chloride (unpaired student t test)
0
2
4
6
8
DeltaplasmaSodium,mmol/L
1 2
**
* *
0
2.5
5
7.5
10
Deltaplasm
aChloride,mmol/L
1 2
*
$
$*
*
*
Mustafa,PhD dissertation
Totilac: Clinical Evidence
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
106/123
Totilac: Clinical Evidence
**
Lactate and brain recovery from ischemia-reperfusion injury
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
107/123
*
****
*
*
20
40
60
80
100
3.0 mM
Glucose
3.0 mMGlucose
+0.2mM
IAA
6.0 mM
Lactate
6.0 mMLactate
+0.2 mM
IAA
1.5 mMGlucose
+3.0 mMLactate
Neuron
allyfunctionalsuccess(%)after
5-minh
ypoxiaand30-minreo
xygenation
Schurr et al, Brain Res., 1997, 744, 105 -11
Slices with lactate showed a significantly higher degree of recovery
Slices with anaerobic lactate production by pre-hypoxia glucose exhibited functional recovery
80% recovery even glucose utilization was blocked during the later part of the hypoxic periodand reoxygenation
Slices in which anaerobic lactate production was blocked during the initial stage of hypoxic didnot recover
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
108/123
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
109/123
Ichai et al, Intensive Care Medicine, 2008
The Use of Hypertonic Sodium Lactate Solutionin Intracranial Tumor Removal Surgery.Is it safe?
An observational studyDoddy Tavianto, Marsudi Rasman, Deddy Koesmayadi
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
110/123
ResultThe benefit of hypertonic sodium lactate in Coronary ArteryBypass Grafting Surgery has been documented for its lactate
and hypertonicity properties leading to improvement of cardiac
performance and hemodynamic status. There are several
evidences from animal and human studies supporting the
clinical benefit of hypertonic solution in improving cerebral
blood flow and reducing intracranial pressure in neurotrauma.
Lactate, previously thought to be a waste product, recently gets
its new paradigm for its role as a fuel for cells containing
mitochondrion especially cardiac and brain cells. Based on
hypothesis that the hypertonicity and lactate properties have
the beneficial effects for the brain, we have conducted an
observational study on the use of hypertonic sodium lactate for
intracranial tumor removal surgery
To observe the safety of hypertonic sodium lactate in
intracranial tumor removal surgery
10 patients underwent intracranial tumor removal surgery,
ASA class 1 and 2, Glasgow Coma Scale = 15
Normal level of blood sodium and lactate
No history of renal and liver disease.
Anesthesia technique:- Induction: propofol 2 mg/kgBW, vecuronium 0.2
mg/kgBW, fentanyl 3 g/kgBW,
O2:N2O=50%:50%, isoflurane 2-3 volume%
- Maintenance: propofol 200 mg - 300 mg/hr,
isoflurane 0.4 volume%, fentanyl 1 g/kgBW,
vecuronium 0.1 mg/kgBW as needed.
EtCO2keep between 25-30 mmHg
Hypertonic lactate solution (Totilac, Innogene Kalbiotech
Pte.Ltd, PT Kalbe Farma, Indonesia) continuously infused at
dose of 1.5 ml/kgBW/hr during the whole surgical periode.
Additional fluid: Ringer Lactate, Hydroxy Ethyl Starch solution
as needed to maintain MAP 65-75 mmHg
Hypertonic sodium lactate solution is safe to be used in intracranial tumor
removal surgery. Good surgical field due to reduced brain tissue edema
were observed in all patient
Great thanks to Prof. Kahdar Wiriadisastra, PhD, Benny Atmadja Wiryomartani MD,
Setyowidhi, MD, MZ Arifin MD and all staffs of Department of Neurosurgery, HasanSadikin General Hospital and St. Borromeus Hospital, Bandung, Indonesia.
Good surgical field due to reduced brain tissue edema
No mannitol needed during surgery
All patients were extubated already in the operating theatre
No significant changes in arterial pH, blood sodium and lactate
level
No adverse events found during the treatment
y , , y yDepartment of Anesthesiology and Reanimation, Faculty of Medicine Padjadjaran University
Hasan Sadikin General Hospital, Bandung, Indonesia
Background
Conclusion
Methods
Objective
Acknowledgment
Result
Pre-Operative and 6 Hours Post-OperativeLaboratory Examination
T til N Cl 0 9% P L di S i l A th i i TURP
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
111/123
111
Totilac
vs NaCl 0.9% Pre-Loading Spinal Anesthesia in TURP(Dandy M, Ike Sri Redjeki, Tatang Bisri)
Site: Hasan Sadikin Hospital, Indonesia
Subject Size and Inclusion Criteria :
22 TURP patients
Methodology (in both Totilac and NS groups):
4 cc/kgBW/20 min before spinal anesthesia Results:
Plasma sodium level, osmolality, arterial pH was maintained better
in Totilac group
None of patients in Totilac group required ephedrine vs. 5
patients in NS (ephedrine is injected if decrease of BP is > 30% afterspinal anesthesia)
TOTILAC vs NaCl 0.9% for TURP
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
112/123
112
Sodium hypetronic lactate (Totilac)
4mL/kgBW in 20 minutesSodium chloride 0.9% (NaCl) 4
mL/kgBW in 20 minutes
Check sodium, osmolarity, pH
Spinal anesthetic : Bupivacaine 2-2.5 mL
TURP operation30 minutes of operation check sodium, osmolality & pH
Sodium Level Osmolality
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
113/123
113
137
138
139
140
141
142
143
Awal Cairan Awal Durante Op Pasca Op
KonsentrasiNatrium(
mEq/L
)
NLH
NaCl 0.9%
Sodium Level
287
288
289
290
291
292
293
294
295
A wal Cairan A wal Durante Op Pas caOp
Osmolalita
s(mOsm/kg)
NLH
NaCl 0.9%
Osmolality
The level of Na serum & osmolality in TOTILAC is higherbus still within normal
boundaryprevents hyponatremia
pHaLactate
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
114/123
114
7.26
7.287.3
7.32
7.34
7.36
7.38
7.47.42
7.44
7.46
Prehidrasi Cai ran Awal Durante Pasca op
pH HSL
NaCl
0
1
2
3
4
5
6
7
8
Prehi dras i C ai ra n Aw al D uran te Pas ca o p
Laktat(mmol/L)
HSL
NaCl
The lactate level in TOTILAC is higherbut then itll decrease; thismeans that lactate is metabolized
In TOTILAC there was no acidosis, while in NaCl 0.9% there was acidosis.
Burn Wound
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
115/123
Burn Wound
Totilac represents 2x the volume required, with
maximum of 4 bags per day For example: the volume required on the first day is
8 liters, when 1 liter of Totilac is used, then it willrepresent around 2 L of fluid.therefore 6 L ofother fluids is infused
Total real infusion will only be 7 Liters (smaller totalvolume) to fulfill the needs of 8 liters of fluid loss
Clinical practice by Dr. Poengky,
plastic surgeon in RSPP, Indonesia:
Totilac vs RL in Dengue Shock in pediatric patients
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
116/123
g p p
Study Procedure
Group I : Hypertonic Sodium Lactate (HSL) 5 mL/kg (15 minute)Group II: Ringer Laktat (RL) 20 mL/kg (15 minutes)If shock persist: repeat once time (x1)
If shock reverse:Group I: continued by HSL 1 mL/kg until 12 hours, then
followed by RL as outlined on DSS SOPGroup II : treated as outlined on DSS SOP
Recurrent shock :
Group I : HSL 5 mL/kg 1xHES 130/0,4RL (DSS SOP)Group II : as outlined on DSS SOP
Blood Pressure
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
117/123
Systole Blood Pressure
0.00
20.00
40.00
60.00
80.00
100.00
120.00
0 0.25 0.5 1 2 3 4 5 6 9 12 18 24
Hour of treatment (H)
Systole(mmHg)
Totilac
RL
Diastole Blood Pressure
0.00
10.00
20.00
30.00
40.00
50.00
60.00
70.00
80.00
0 0.25 0.5 1 2 3 4 5 6 9 12 18 24
Hour of treatment (H)
Diastole(mmHg)
Totilac
RL
p>0.05 (no significant difference) between Totilac and RL group in BP
Cumulative fluid balance in 24H
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
118/123
Cumulative fluid balance in 24H
Note: Fluid balance= fluid intake-urine output
Totilac group show very significant lower fluid balance compare to RL group, even
until 12 H after Totilac was stopped (p value:0.000)
Cumulatif fluid balance
-500.00
0.00
500.00
1000.00
1500.00
2000.00
2500.00
0 0.25 0.5 1 2 3 4 5 6 9 12 18 24
Hour of treatment
Cumulativefluidbalance
(m
l) Totilac RL
InjuryTrauma, Sepsis, Ischemia, Hypoxia, Cardiogenic
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
119/123
Trauma, Sepsis, Ischemia, Hypoxia, Cardiogenic
capillary leakage
cell volume (swelling effect)Interstitial edema
Intravascular volume
Tissue perfusion
Fluid administrationCrystalloids, Colloids,
Blood, Plasma or Albumin
Intravascular Volume-hemorrhage Hemodynamic failure
cardiac fail reVasomotricity
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
120/123
Low Tissue Perfusion
-vasodilation
-capillary leakage
-urinary losses (DKA)
-cardiac failure
-cardiogenic shockDysregulation
Metabolic acidosis
pH, Bicarbonate, BE
Interstitial Edema
Clinical signs
Hte, Hb, Albumin
Cellular Swelling
(edema)
Natremia
-CO/CI
-MAP
-Urine output
-MV ox sat-(lactate?)
Conclusion
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
121/123
It can be oxidized, recyled, or used as precursor for other energy metabolism
Lactate is a major physiological substrate
Energetic substrate for brain, heart, kidney
Prevention of ischemia-reperfusion injury
It is of major interest in acute conditions
Increase cardiac output
Decrease pulmonary and systemic vascular resistance
Increase oxygen delivery
Increase total urine output
Decrease total fluid balance
Hypertonic Sodium-Lactate possesses several cardiacand hemodynamic properties
Conclusion
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
122/123
Conclusion
It is metabolized and provides energy to almost every cells(including the brain!)
It is a preferred source immediately after ischemia
Its infusion to the patient
improves hemodynamic after cardiac surgery
corrects metabolic acidosis
decreases cellular volume (correction of cellular edema) byattracting intracellular chloride (maintenance of
electroneutrality)
Induces a powerful diuretic effect with a negative fluidbalance, without involving any hypovolemia
Sodium-lactate as new therapeutic conceptin clinical practice and critical care!
-
8/10/2019 Terapi Cairan, HD Monitoring, Totilac Plbg
123/123
Thank You