terapi cairan.ppt
TRANSCRIPT
TERAPI CAIRAN
Widyati, MClin Pharm, Apt
Departemen Farmasi Rumkital Dr. Ramelan
PENDAHULUAN• TUJUAN: atur cairan tubuh, nutrisi, akses iv• KAPAN ? Shock, dehidrasi, perdarahan, anoreksia,
bowel rest, kelainan GIT, perioperative.• Terapi Cairan: pasok air+ elektrolit+nutrien• KOMPOSISI AIR (60% BB):• INTRASEL : 40-45%• INTERSTITIAL: 11-15%• VASKULAR (plasma): 5%
OSMOLALITAS
Konsentrasi zat terlarut (elektrolit, glukosa, urea, fosfolipid, cholesterol, dan lemak) dlm 1 kg air.
Plasma osmolalitas dan tonisitas dipelihara melalui keseimbangan intake dan ekskresi air
Perubahan tonisitas plasma dideteksi oleh osmoreseptor di hypothalamus
Electrolyte solutionsElectrolyte solutions
PlasmaPlasma IsotonicsolutionsIsotonicsolutions
Hypotonic solutionsHypotonic solutions
Normalsaline
Ringer’sacetate/ lactate
KAEN 3B*
290 308 273
278
D5
290278
* KAEN 3B : contains 50 mmol Na+, 20 mmol K+, 50 mmol Cl-, 20 mmol lactate, 27 g dextrose per L.
BASIC PRINCIPLESBASIC PRINCIPLES
Replace Replace
Maintain Maintain
Repair Repair
Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock
Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock
IWL + urine IWL + urine
Acid base, electrolyte imbalancesAcid base, electrolyte imbalances
RESUSCITATIONRESUSCITATION MAINTENANCEMAINTENANCE
NUTRITIONNUTRITIONCrystalloidCrystalloid
1. Replace acute loss (hemorrhage, GI loss, 3rd space etc)
1. Replace acute loss (hemorrhage, GI loss, 3rd space etc)
1. Replace normal loss (IWL + urine+ faecal)2. Nutrition support
1. Replace normal loss (IWL + urine+ faecal)2. Nutrition support
ELECTROLYTESELECTROLYTES
FLUID THERAPYFLUID THERAPY
Colloid
TERAPI RESUSITASI
• Dosis: (Vol Deplesi x 1/3) + Terapi rumatan + Terapi pengganti
• Penggantian bertahap
TERAPI RUMATAN
• Berikan volume setara dg ekskresi harian
• Terapi cairan juga sbg pengganti makanan
• Kebutuhan cairan bila intake oral • Vol Urin + 700 mL=Vol Infus
• DOSIS: air 2000-2200 ml/hari, Na 80-100mEq/hari, K 40-50 mEq/hari.
Crystalloids: Replacement fluids • Crystalloid = a solution of crystalline solid dissolved in water• Generally are polyionic isotonic fluids • Ringer's, Lactated Ringer's (RL)• 0.9% NaCl (normal saline) is an isotonic solution of Na, Cl, and
water • 5% dextrose is an isotonic solution of dextrose in water; the
dextrose is rapidly metabolized, thus this essentially results in the administration of free water
• Commonly administered during general anesthesia to diminish the cardiovascular effects of anesthetic drugs and replace ongoing fluid losses
• May need to infuse 40 – 90 ml/kg/hr during shock using multiple catheters or fluid pumps
• Replace acute blood loss by administering 3 volumes of crystalloid solution for each 1 volume of blood lost
Crystalloids: Maintenance fluids
• Generally are low in Na and Cl, and high in K • eg, 0.45 % sodium chloride, 2.5 % dextrose
with 0.45 % saline, KaEN • Generally polyionic isotonic or hypotonic
fluids • Used for long term fluid therapy, such as the
ICU setting; not generally used during anesthesia
• May or may not contain dextrose
Laju Kecepatan Pemberian Elektrolit &
glucose
Laju Kecepatan Pemberian Elektrolit &
glucose Na+ 100 mEq/hr
K+ 20 mEq/hr
Ca++ 20 mEq/hr
Mg++ 20 mEq/hr
HCO3
- 100 mEq/hr
Glucosa 0,5 gr/kg/hr ( 4
mg/kg/min)*
Na+ 100 mEq/hr
K+ 20 mEq/hr
Ca++ 20 mEq/hr
Mg++ 20 mEq/hr
HCO3
- 100 mEq/hr
Glucosa 0,5 gr/kg/hr ( 4
mg/kg/min)* * Neonates 6-8 mg/kg/min* Neonates 6-8 mg/kg/min
Colloids
• Synthetic colloids are polydisperse (various molecular weight) and do not readily cross semipermeable membrane.
• Hypertonicity pulls fluids into the vascular space and increase blood volume which effect is longer lasting compared to crystalloid therapy.
• solutions of starch or dextrans (of various molecular weights) • smaller volumes of colloids are as effective as larger volumes of
crystalloids in maintaining intravascular fluid volume • historically have had a number of problems associated with their
use, including allergic reactions, impaired coagulation, and renal damage; solutions available now have less problems associated with their use
• expensive compared to crystalloids Composition of Several Colloidal Fluids
PEMILIHAN CAIRAN PADA BERBAGAI PENYAKIT
HYPONATREMIA
ISOTONIK HYPONATREMIA : Hyperproteinemia, hyperlipidemia
HYPOTONIK HYPONATREMIA:• Hypovolemic: Dehydration, Diarhhea, Vomiting,
Diuretics, ACE inhibitors, Mineralocorticoid deficiency.• Euvolemic: SIADH, Postoperative hyponatremia,
hypothyroid, endurance exercise.• Hypervolemic: Edematous state at CHF, CH, NS,RF HYPERTONIC HYPONATREMIA: Hyperglicemia,
Mannitol, sorbitol, maltose
TREATMENT
• Symptomatic Hyponatremia: usually seen in Na < 120meq/L, if there are CNS symptom correct Na rapidly 1-2 meq/L/h no more 25-30meq/L with NaCl 3% + furosemide
• Asymptomatic hyponatremia: water restriction, 0,9% NaCl
• Hypervolemic Hypotonic Hyponatremia: water restriction , diuretics, 3% NaCl + furosemide, dialysis
HYPOKALEMIA
• Symptoms: muscle weakness, fatigue, muscle cramps, constipation, ileus, broadening T waves, depressed ST segment.
• Treatment:KCl sol + juice, KCl tablet, iv KCl in severe hypokalemia with rates of up to 40 meq/L/h (drip)
TRAUMA KEPALA
• Pasien dengan trauma kepala maupun stroke: stres metabolik hipermetabolism/hiperkatabolisme, hiperglikemia, respon fase akut, dan perubahan sistem imunitas.
TRAUMA KEPALA
• Trauma kepala tertutup: ICP, HT sistemik• Perhatikan kadar Na• Bila Na Normal atau tinggi:KaEN 3B, D5 ½ NS• Bila Na rendah:restriksi cairan,NS,• Perhatikan kadar Glukosa• Bila Hipoglikemi: KaEN MG3, D5 ½ NS• Bila Hiperglikemi: KaEN 3B
TRAUMA KEPALA(LANJUTAN)
• Bila Hipotensi
• Hipotensi pd Trauma Kepalaiskemi
• Terapi cairan perfusi jaringan
• Pemilihan Cairan: RL or NS 3% (resusitasi) sampai BP90 mmHg (systole)
• Monitoring: BP, Glukosa, Na
TRAUMA SPINAL
Shock Neurogenic
Deplesi Relative Intravascular
Resusitasi: RL
GANGGUAN FUNGSI HATI
• Batasi asupan Na pada CH dg ascites
• Rumatan Hepatitis: asam amino ( Amino leban, Tutofusin LC)
• Rumatan pada HE pilih BCAA (Comafusin Hepar)
Gangguan Fungsi Ginjal
• Pada GGK; umumnya batasi asupan K pilih RL untuk maintenance
• Rumatan: AA esensial untuk memenuhi kebutuhan AA namun meminimalisasi uremia (Kidmin)
CAIRAN sbg AKSES IV
• Cairan yg kompatibel: D5, NS
• Dicampur ke dalam cairan, kemudian diinfuskan selama 30’-60’atau 24jam (Dopamin,Heparin). Waspada kompatibilitas.
• Disuntikkan pada injection site dengan cairan infus yang tetap dialirkan.
NUTRISI PARENTERAL
• Def: pemenuhan semua atau sebagian kebutuhan nutrien secara intravena.
• Indikasi Nutrisi Parenteral (Hill, 2000):o Tidak mendapat asupan makanan oral selama > 7
hario Pankreatitiso Keadaan saluran cerna yang tidak memungkinkano Reseksi usus o Malnutrisi
NUTRISI PARENTERAL(LANJUTAN)
• PERIFER• Puasa 3-5hr, makan <75%
3hr, malnourished dg alb<3mg/dl,
• Via vena perifer• Komposisi: karbohidrat
10%, AA 5%,Lipid,mikronutrien
• Osmolaritas: < 900 mOsm/l
• Midline cath kurangi flebitis
• CENTRAL• Puasa > 5hr, malnutrisi,
bowel resection• Via vena central
(subclavia)• Komposisi:
karbohidrat,AA,Lipid, mikronutrien
NUTRISI PARENTERAL
• KARBOHIDRAT : D5%,D10%,D40%,TRIOFUSIN,MANNITOL
• PROTEIN:• Panamin G, TUTOFUSIN, INTRAFUSIN, EAS,
AMINOLEBAN,AMIPAREN• PROTEIN+KH+ELEKTROLIT: AMINOVEL 600• LIPID: • ELEKTROLIT: RL,NS,RD,ASERING
NUTRISI ENTERAL
• Nutrisi enteral adalah pemenuhan nutrien langsung melalui saluran cerna.
• Indikasi: tidak mendapat asupan makan secara oral sedangkan saluran cerna masih berfungsi baik
• Kelebihan nutrisi enteral dari parenteral adalah mengurangi resiko sepsis, penggunaan saluran cerna lebih fisiologis daripada parenteral dimana resiko atrofi vili usus tidak ada
NUTRISI ENTERAL (LANJUTAN)
• cara: pemasangan nasogastric tube pada pasien yang “gag reflex” masih baik, nasoenteric tube, gastrostomy tube, dan jejunostomy tube.