terapi cairan resusitasi
DESCRIPTION
cairan resusitasi adalah cairan yang digunakan untuk mengganti cairan yg hilangTRANSCRIPT
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Terapi Cairan ResusitasiTerapi Cairan Resusitasi
Iyan DarmawanIyan Darmawan
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RESUSITASIRESUSITASI RUMATANRUMATAN
NUTRISINUTRISIKristaloidKristaloid
Mengganti kehilangan akut (hemorrhage, GI loss, rongga ke3)
Mengganti kehilangan akut (hemorrhage, GI loss, rongga ke3)
1. Kebutuhan normal (IWL + urin+ feses)2. Dukungan nutrisi
1. Kebutuhan normal (IWL + urin+ feses)2. Dukungan nutrisi
KoloidElektrolitElektrolit
Repair
.
RARL/NS
DextranGelatin
KAEN group
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Jenis-Jenis larutan elektrolit
PlasmaPlasma Larutan elektrolitisotonik
Larutan elektrolitisotonik
Larutan elektrolitHipotonik
Larutan elektrolitHipotonik
Normalsaline
Ringerasetat/ laktat
KAEN 3B
290 308 273
D5
290278
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increases ECFincreases ECF
ICF ISF PlasmaICF ISF Plasma
Replace acute/abnormalloss
Replace acute/abnormalloss
Isotonic infusionIsotonic infusion
800 ml 200 ml
• Ringer’s acetate• Ringer’s lactate• Normal saline
• Ringer’s acetate• Ringer’s lactate• Normal saline
1 L of 1 L of
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increases ICF > ECFincreases ICF > ECF
ICF ISF PlasmaICF ISF Plasma
Replace Normal loss (IWL + urine)Replace Normal loss (IWL + urine)
Hypotonic infusionHypotonic infusion
5% dextrose 5% dextrose
85 ml85 ml255 ml255 ml660 ml660 ml
1 L of 1 L of
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increases intravascularincreases intravascular
ICF ISF PlasmaICF ISF Plasma
Hemorrhagic shockBurnHemorrhagic shockBurn
Albumin infusionAlbumin infusion
Albumin 5% Albumin 5%
250-750 ml250-750 ml
500 ml L of 500 ml L of
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increases intravascularincreases intravascular
ICF ISF PlasmaICF ISF Plasma
Hemorrhagic shockBurnReserved for patientsin whom ISF expandedbut intravascular andalbumin is severelydepleted
Hemorrhagic shockBurnReserved for patientsin whom ISF expandedbut intravascular andalbumin is severelydepleted
Albumin infusionAlbumin infusion
Albumin 25% Albumin 25%
300-600 ml over 30-60 min300-600 ml over 30-60 min
100 ml L of 100 ml L of
Ref. Evan R. Geller. Shock & Resuscitation. McGraw Hill, 1993. p 221
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increases intravascularincreases intravascular
ICF ISF PlasmaICF ISF Plasma
Hemorrhagic shockHemorrhagic shock
Plasma Expander infusionPlasma Expander infusion
Dextran HES
Dextran HES
500 m L of 500 m L of
750 ml at 1 hour; 1050 ml at 2 hr
Ref. Evan R. Geller. Shock & Resuscitation. McGraw Hill, 1993. p 225
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Isotonic Crystalloid• RA/RL/NS
• Umumnya dianjurkan jika Ht > 20%
• NS berpotensi menyebabkan asidosis hiperkloremik*
• Kombinasi dg dekstrosa 5% (misal RA-D5, RL-D5, NS-D5) diberikan jika kecepatan infus < 10 ml/kg/jam
Clinical Science (2003) 104, (17–24) (Printed in Great Britain) Clinical Science (2003) 104, (17–24) (Printed in Great Britain)
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• Untuk Diare dg dehidrasi berat pilihan terbaik adalah Ringer Asetat. Jika tidak ada RA pilih RL
• Pada Muntah-muntah pilihan terbaik Normal Saline atau Ringer
• Pada Syok hemoragik/DBD pertimbangkan koloid setelah resusitasi awal dengan RA/RL
Isotonic Crystalloid
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TRAUMA
BLOOD VESSEL
HEMODYNAMIC DISTURBANCE
ORGAN
DAMAGE
TISSUE
BLEEDINGEDEMA IMPAIRED FUNCTION
SHOCK
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Liters
1
Saline Whole Blood
Resuscitation
Acute Hemorrhage
2
3
4
5
1 hour later
Cells
Plasma
HCT : 45%
HCT : 45%
HCT : 45%HCT : 27%
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Classes I – IV Not absolute Clinical guidelines only Further treatment is governed by patient’s response
CLASSIFICATION OF HEMORRHAGIC CLASSIFICATION OF HEMORRHAGIC SHOCKSHOCK
CLASSIFICATION OF HEMORRHAGIC CLASSIFICATION OF HEMORRHAGIC SHOCKSHOCK
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CLASS I CLASS II CLASS III CLASS IV
Blood Loss (mL) Up to 750 750 – 1500 1500 – 2000 > 2000
Blood Loss (% Blood Vol)
Up to 15% 15 – 30 % 30 – 40 % > 40 %
Pulse Rate < 100 > 100 > 120 > 140
Blood Pressure Normal Normal
Pulse Pressure Normal or
Respiratory Rate 14 – 20 20 – 30 30 – 40 > 35
Urinary Output (ml/hr)
> 30 20 – 30 5 – 15 Negligible
CNS / Mental Status
Slightly anxious
Mildly anxious
Anxious, confused
Confiused, lethargic
Fluid Replacement (3:1 Rule)
Crystalloid CrystalloidCrystalloid and blood
Crystalloid and blood
Table 1. ESTIMATED FLUID AND BLOOD LOSSES Table 1. ESTIMATED FLUID AND BLOOD LOSSES *)*) Based on Patient’s Initial PresentationBased on Patient’s Initial Presentation
(For a 70 kg man)(For a 70 kg man)
Table 1. ESTIMATED FLUID AND BLOOD LOSSES Table 1. ESTIMATED FLUID AND BLOOD LOSSES *)*) Based on Patient’s Initial PresentationBased on Patient’s Initial Presentation
(For a 70 kg man)(For a 70 kg man)
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ASSESSMENT & MANAGEMENTASSESSMENT & MANAGEMENTASSESSMENT & MANAGEMENTASSESSMENT & MANAGEMENT
Airway and Breathing:Oxygenate and ventilatePaO2 > 80 mmHg
SaO2 > 95%
CirculationAssess severity (Class I, II, III, IV)Control bleedingTreat underlying cause immediately
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ASSESSMENT & MANAGEMENTASSESSMENT & MANAGEMENTASSESSMENT & MANAGEMENTASSESSMENT & MANAGEMENT
Disability – Cerebral perfussion Exposure/ Environment
related traumaprevent hypothermia
Urine output (Foley catheter) Gastric Decompression
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IV LINE MANAGEMENTIV LINE MANAGEMENTIV LINE MANAGEMENTIV LINE MANAGEMENT
2 large-caliber peripheral IV’s (16 G) Central lines
FemoralJugularSubclavian
Intraosseous Blood for crossmatching
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Flow rate(mL/menit)
200
100
14
Kateter Pendek
Kateter Panjang
16 16 16 ga
2 2 5,5 12 inci
Diameter
Panjang
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IV LINE MANAGEMENTIV LINE MANAGEMENTIV LINE MANAGEMENTIV LINE MANAGEMENT
Warmed crystalloid solution
Rapid fluid bolusAdult : 2 liters Ringer’s Acetate/ LactateChild : 20 ml/kg Ringer’s Acetate/ Lactate
Monitor response to initial therapy
Mencegah Menggigil!!
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40 %40 %
ICFICF
KK
15 %15 %
ISFISF
NaNa
5% 5%
IVFIVF
NaNa
ICFICF
ISFISF
IVFIVF
ICFICF
ISFISF
IVFIVF
ICFICF
ISFISF
IVFIVF
D 5 % Colloid
RL / NS
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Rapid Response
Transient Response
No Response
Vital SignsReturn to normal
Transient improve-ment; recurrence of
BP and HR
Remain abnormal
Estimated Blood loss
Minimal (10-20%)
Moderate and ongoing (20-40%)
Severe (>40%)
Need for more Crystalloid
Low High High
Need for Blood Low Moderate to high Immediate
Blood Preparation
Type and crossmatch
Type – specificEmergency
blood release
Need for Operative Intervension
Possibly Likely Highly likely
Early Presence of Surgeon
Yes Yes Yes
Table 2. RESPONSES TO INITIAL FLUID Table 2. RESPONSES TO INITIAL FLUID RESUSCITATION RESUSCITATION *)*)
*) 2000 ml RL solution in adults, 20 ml/Kg RL bolus in children over *) 2000 ml RL solution in adults, 20 ml/Kg RL bolus in children over 10-15 min10-15 min *) 2000 ml RL solution in adults, 20 ml/Kg RL bolus in children over *) 2000 ml RL solution in adults, 20 ml/Kg RL bolus in children over 10-15 min10-15 min
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VOLUME REPLACEMENTVOLUME REPLACEMENTVOLUME REPLACEMENTVOLUME REPLACEMENT
Warmed fluids Crossmatch, PRBC Type-specific Type O, Rh-negative Autotransfusion Coagulopathy
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REEVALUATE ORGAN PERFUSIONREEVALUATE ORGAN PERFUSIONREEVALUATE ORGAN PERFUSIONREEVALUATE ORGAN PERFUSION
MONITOR : • Vital signs• CNS Status• Skin perfusion• Urinary output• Pulse oximetry• End Tidal CO2• Oxygen Extraction• Acid base
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AVOIDING COMPLICATIONAVOIDING COMPLICATIONAVOIDING COMPLICATIONAVOIDING COMPLICATION
Fluid overload Invasive monitoring (ICU)
CVPPulmonary artery catheter
Other problems :Resuscitation induced haemorrhagePost resuscitation injury
No – Reflow phenomenonReperfusion injury
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RESUSCITATION ENDPOINTSRESUSCITATION ENDPOINTS
• Adequate oxygen delivery; 1,5 kali normal (120-160 ml/menit/m2)
• Systolic > 100 mmHg, diastolic > 50 mmHg until orthostatic-induced changes have disappeared
• Urine output > 0,5 ml/kg/jam• Urine Natrium > 20 mEq/liter
Demling, R.H; Wilson, R.F: Decision Making in Surgical Critical Care. B.C. Decker Inc, 1988. p 63.Demling, R.H; Wilson, R.F: Decision Making in Surgical Critical Care. B.C. Decker Inc, 1988. p 63.
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RESUSCITATION ENDPOINTSRESUSCITATION ENDPOINTS
• Hematocrit > 30; adequate peripheral perfusion
clinically• Physiologically adequate perfusion:plasma lactate
within normal limits
(0,5-1,5 mEq/L), PO2 30 mmHg,
PAWP = 10-14 mmHg• Maintained oxygen saturation
Demling, R.H; Wilson, R.F: Decision Making in Surgical Critical Care. B.C. Decker Inc, 1988. p 63.
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TREATMENT OF HEMORRHAGIC SHOCK
Class II Class III, IV
Use RL/RA estimated requirement (3 L)Fast bolus 2 L RL/RA (10-15 min)BicNat when pH < 7,2
RESPONSE
Obvious
RL/RA 1 L
Moderate
Dextran 40 3-5 ml/kg
Fast bolus 3 L RL/RA (10-15 min)
Moderate few
Dextran 40 15-20 ml/kgTransfusi Darah
RESPONSE
Theatre
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Thank youThank youThank youThank you