3. Terapi Cairan Electrolyte Balance

2. Terapi Cairan

1. Pendahuluan

60% dari Berat Badan

adalah H2O

Pasien berat 60 kg

|

36 kg adalah air

(36 liter)

|

jumlah ini harus dipertahankankeseimbangan

volume dan komposisielektrolitnya

Guyton,A.C. Buku Ajar Fisiologi,ed.9. EGC,1997.Hal.376 -377

Cairan Tubuh 60 %

Mem

bra

n S

el

Cairan Ekstraseluler20 %

Cairan Intraseluler40 %

Plasma Darah5%

Cairan Interstitial

15 %

Cairan Tubuh

Kompartemen Cairan Tubuh

Permeabel terhadap H2O saja

Permeabel terhadap H2O & Partikel kecil

Cairan Ekstraselular Cairan intraselular(mEq/L) Intravaskular

(mEq/L)Interstisial(mEq/L)

Natrium 140 148 13

Kalium 4,5 5,0 140

Kalsium 5,0 4,0 1x10-7

Magnesium 1,7 1,5 7,0

Klorida 104 115 3,0

Bikarbonat 24 27 10

Fosfat 2,0 2,3 107

Protein 15 8 40

Kadar Elektrolit

Utama H, Gangguan Keseimbangan Air-elektrolit dan Asam Basa; Fisiologi; patofisiologi, Diagnosis dan Tatalaksana, Edisike-2, Jakarta, Balai Penerbit FKUI,2008

Utama H, Gangguan Keseimbangan Air-elektrolit dan Asam Basa; Fisiologi; patofisiologi, Diagnosis dan Tatalaksana, Edisike-2, Jakarta, Balai Penerbit FKUI,2008

DEWASA ANAK

Air 30-40 ml/kgBB/Hari • 10 kg pertama : 4 ml/kg/jam• 10 -20 kg berikut : tambahkan 2 ml/kg/jam•Untuk setiap kilogram diatas 20 kg : tambahkan 1 ml/kg/jam

Natrium 1- 2 mEq/kGBB/Hari 3-4 mEq/kg/24 jam

Kalium 0,5 – 1 mEq/kgBB/hari 2-3 mEq/kg/24 jam

KEBUTUHAN CAIRAN , ELEKTROLIT

Kristaloid

TERAPI CAIRAN

Mengganti

Kehilangan Akut

1. Kebutuhan normal

2. Dukungan nutrisi

Koloid NutrisiElektrolit

Reff. :

Said. A.Latief,et al. Petunjuk Praktis Anestesiologi Edisi ke2. Bagian Anestesiologi dan Terapi Intensif FKUI.2009.hal 139

RUMATANRESUSITASI

Koreksi

• Kurang minum, untukganti urine, keringat, uap nafas

• Defisit cairan akibatkehilangan abnormal

• Karena usus tidakberfungsi, nutrisidiberikan intravena

• CairanMaintenance

• CairanReplacement/ Resusitasi

• CairanNutrition

Indikasi Terapi Cairan

World Health Organization• World Health Organization guidelines recommend that patients with COVID-19 in

respiratory failure should be treated cautiously with intravenous fluids, especially in settings with limited availability of mechanical ventilation.

• Use a conservative fluid management strategy for ARDS patients without tissue hypoperfusion.

• In resuscitation for septic shock in adults, give 250–500 mL crystalloid fluid as a rapid bolus in the first 15–30 minutes and reassess for signs of fluid overload after each bolus.

• If there is no response to fluid loading or if signs of volume overload appear, reduce or discontinue fluid administration.

• Starches are associated with an increased risk of death and acute kidney injury compared to crystalloids. The effects of gelatins are less clear, but they are more expensive than crystalloids. Hypotonic (vs isotonic) solutions are less effective at increasing intravascular volume. Surviving Sepsis also suggests albumin for resuscitation when patients require substantial amounts of crystalloids, however this conditional recommendation is based on low-quality evidence.

Guidelines Fluid Therapy for Covid 19

Source:: https://www.fluidacademy.org/blog-foam/item/fluids-in-covid19.html

Guidelines Fluid Therapy for Covid 19

UK Joint Anaesthetic and Intensive Care Guidelines

•Conservative fluid management strategy in ARDS.•In cases of significant hypotension or circulatory shock, standard circulatory assessment (fluid responsiveness, cardiac output assessment) and administration of an appropriate fluid and/or pressor (where appropriate) should occur.•Balanced electrolyte solutions are preferred to 0.9% saline and colloids.•While fluid overload should be avoided and more conservative administration may help improve respiratory function, this should be carefully balanced against the risk of inducing acute renal impairment.•Care should be exercised in ‘running patients too dry’ in an effort to spare the lungs, as there are increased insensible fluid losses.

Source:: https://www.fluidacademy.org/blog-foam/item/fluids-in-covid19.html

Tujuan Terapi Cairan

1. Untuk mengganti kehilangan cairan dan elektrolit yang sudah hilang.

2. Untuk memenuhi kebutuhan harian cairan dan elektrolit.

3. Mengganti kehilangan cairan tubuh yang masihberlangsung.

4. Untuk mengatasi syok.

Larutan Maintenance KombinasiLarutan Karbohidrat-WIDA D5 / D10-WIDA D5 ¼ NS

CairanIntraseluler C

aira

nIn

ters

titi

al

Pla

sma

CairanEkstraseluler

Distribusi Cairan Intravena

Terjadi Peningkatan volume padaseluruh kompartemen

Erry Leksana. Terapi Cairan dan Darah. Cermin Dunia Kedokteran edisi 177, hal 304-309

3 liter diinfuskan D5

2000 ml 750 ml 250 ml

Pla

smaCairan

Intraseluler

Cai

ran

Inte

rsti

tial

Larutan Pengganti Cairan Ekstraseluler

Terjadi Peningkatan volume pada kompartemen ekstraselular

Erry Leksana. Terapi Cairan dan Darah. Cermin Dunia Kedokteran edisi 177, hal 304-309

Distribusi Cairan Intravena

1 liter diinfuskan-Ringer Lactate-Sodium Chloride 0,9%-WIDABES-ASERING

750 ml 250 ml

Cairan Ekstraseluler

15

Cairan EkstraselulerTerjadi peningkatan volume hanya pada Intavaskuler

Plasma Expanders :- 6% HES 130 in NaCl 0,9% (WIDAHES 130)-6% HES 130 in electrolyte balanced (WIDAHES BES)

Pla

sma

CairanIntraseluler

Cai

ran

Inte

rsti

tial

Erry Leksana. Terapi Cairan dan Darah. Cermin Dunia Kedokteran edisi 177, hal 304-309

Distribusi Cairan Intravena

1 liter diinfuskan6% HES 130

1000 ml

CRYSTALLOID VS COLLOID

1. https://www.openanesthesia.org/crystalloid-vs-colloid-rx/2. Hahn and Lyons, The half-life of infusion fluids, an educational review, Eur J Anaesthesiol2016;33:475–4823. Lira and Pinsky, Choices in fluid type and volume during resuscitation: impact on patient outcomes, Annals of Intensive Care2014,4:38

BALANCED ELECTROLYTE SOLUTION

Balanced electrolyte solution (BES) adalah cairan yang komposisinya mirip dengan plasma

(sodium, potassium, kalsium, magnesium, chloride) dan menjaga keseimbangan asam-basa

dengan bikarbonat atau buffer basa. pH normal darah : 7,35 – 7,45

R. Zander, Fluid Management, Bibliomed – Medizinische Verlagsgesellschaft mbH, Melsungen, 2009.

Strong Ion Difference (SID)

SID adalah jumlah konsentrasi kation kuat dikurangi jumlah

konsentrasi aniot kuat. SID pada normal plasma adalah 30-40 meq/L.

ACID – BASE CONCEPT

SID = KATION - ANION

PLASMA 1L + NaCl 0.9% 1L

Na+ = 140 mEq/L

Cl- = 102 mEq/L

SID= 38 mEq/L

Cation+ = 154 mEq/L

Cl- = 154 mEq/L

SID = 0 mEq/L

Plasma NaCl 0.9%

.

George Y., Easy Way to Understand Stewart’s Acid Base, Centra Communications, 2015.

PLASMA 1L + NaCl 0.9% 1L

= Na+ = (140+154)/2 mEq/L= 147 mEq/L

Cl- = (102+ 154)/2 mEq/L = 128 mEq/L

SID = 19 mEq/L

SID plasma : 19 acidosis

George Y., Easy Way to Understand Stewart’s Acid Base, Centra Communications, 2015.

ASIDOSIS HIPERKLOREMIK

AKIBAT PEMBERIAN LARUTAN Na Cl 0.9%

BALANCED ELECTROLYTE SOLUTION

In vivo SID = 34 meq/l

In vivo SID = total organic anion

In vitro SID = 0*

*Semua larutan balanced, secara in-vitro, memiliki SID = 0

T. Langer et al., Effects of Intravenous Solutions on acid-base equilibrium: from crystalloids to colloids and blood product, Anesthesiology Intensive Therapy, 2014.

Na+ = 140 mEq/L

Cl- = 102 mEq/L

SID= 38 mEq/L

Cation+ = 156 mEq/L

Cl- = 127 mEq/L

Malate = 10 mEq/L

Acetat- = 24 mEq/L

SID = 29 mEq/L

Plasma WIDABES

BALANCED ELECTROLYTE SOLUTION

Acetat & malate cepatdimetabolisme

PLASMA 1L + BALANCED CRYSTALLOID 1L

= Na+ = (140+156)/2 mEq/L= 148 mEq/L

Cl- = (102+ 127)/2 mEq/L = 114.5 mEq/L

Acetat & malate- (metabolized) = 0 mEq/L

SID = 33.5 mEq/L

SID : 33.5 normal dibanding

jika diberikan unbalanced crystalloid

NORMAL pH SETELAH PEMBERIAN BALANCED CRYSTALLOID

PLASMA 1L + BALANCED CRYSTALLOID 1L

Sediaan : infusKemasan : Botol plastik @500mlStorage : < 30 0CNo Reg : DKL 1730504049A1

Indikasi : Penggantian kehilangan cairanekstraseluler dalam kasus dehidrasiisotonik yang disertai asidosis.

K.I : Hipervolemia, gagal jantungkongestif berat, gagal ginjal denganoliguria/anuria, edema berat, hiper-kalemia, hiperkalsemia, alkalosismetabolik

WIDA BES

BALANCED SOLUTION TO MAINTAIN ACID-BASE STABILITY

WIDA BES

1.Bicarbonate concentration increased as early as 15 minutes after the start of an acetateinfusion 1,2,3

Efek basa asetat beronset cepat, konsentrasinya meningkat 15 menit setelah dimulainya proses infus. 60% - 80% dieliminasisebagai C02 dan keluar via paru-paru.1,2,3

2. Acetate metabolism is unchanged in patients with diabetes.Asetat tidak berpengaruh pada gula darah dan insulin, sehingga aman untuk pasien DM. Sedangkan laktat ketika diinfuskan ke

pasien menaikkan kecepatan pembentukan glukosa 3x lipat.1,2,4

1. R. Zander, Fluid Management, Bibliomed – Medizinische Verlagsgesellschaft mbH, Melsungen, 20092. Reddy et al., Crystalloid Fluid Therapy, Critical Care, 2016:20-593. McCague et et al.,Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2011,19:244. Fernandes et al., Intravenous Acetate Elicits a Greater Free Fatty Acid Rebound in Normal than Hyperinsulinaemic Humans, Eur J Clin Nutr. 20125. Pfortmueller et al., Acetate-buffered crystalloid infusate versus infusion of 0.9% saline and hemodynamic stability in patients undergoing renal transplantation, The Central European

Journal of Medicine, 2017.6. Waack et al, L-Malate’s Plasma and Excretion Profile in the Treatment of Moderate and Severe Hemorrhagic Shock in Rats, BioMed Research International, 2016 .7. Dai et al, Ringer’s Malate Solution Protects Against The Multiple Organ Injury and Dysfunction Caused by Hemorrhagic Shock in Rats, SHOCK, Vol. 38, No. 3, pp. 268Y274, 20128. PI Approved BPOM.

BENEFIT

3. Less than 10% of an acetate dose is eliminated via the kidneys

Kurang dari 10% asetat yang dieliminasi di ginjal, sehingga aman untuk pasien dengan gangguan ginjal. 1,5

4. Acetate does not increase oxygen consumption

Asetat tidak menaikkan konsumsi oksigen, sementara laktat menaikkan konsumsi oksigen dengan cepat hingga 30% danberisiko menyebabkan tissue hypoxia (jaringan kekurangan oksigen) 1

5. For every mole of malate oxidized, two moles of bicarbonate are produced

Malate menghasilkan 2 molekul bikarbonate, lebih banyak dibandingkan anion yang lain. 1

1. R. Zander, Fluid Management, Bibliomed – Medizinische Verlagsgesellschaft mbH, Melsungen, 20092. Reddy et al., Crystalloid Fluid Therapy, Critical Care, 2016:20-593. McCague et et al.,Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2011,19:244. Fernandes et al., Intravenous Acetate Elicits a Greater Free Fatty Acid Rebound in Normal than Hyperinsulinaemic Humans, Eur J Clin Nutr. 20125. Pfortmueller et al., Acetate-buffered crystalloid infusate versus infusion of 0.9% saline and hemodynamic stability in patients undergoing renal transplantation, The Central European

Journal of Medicine, 2017.6. Waack et al, L-Malate’s Plasma and Excretion Profile in the Treatment of Moderate and Severe Hemorrhagic Shock in Rats, BioMed Research International, 2016 .7. Dai et al, Ringer’s Malate Solution Protects Against The Multiple Organ Injury and Dysfunction Caused by Hemorrhagic Shock in Rats, SHOCK, Vol. 38, No. 3, pp. 268Y274, 20128. PI Approved BPOM.

BENEFIT

6. Malate increased the median survival time after severe hemorrhagic shock

Malate meningkatkan median (nilai tengah) survival time pada syok perdarahan 6 Efek ini terjadi karena kejadian luka padaorgan (organ injury) berkurang dengan adanya malate 7

7. Similar to physiological plasma.

Komposisi yang menyerupai plasma akan mengurangi tindakan koreksi

Osmolarity: 309 mOsm/l, osmolality: 291 mosmol/kg H2O Cairan bersifat isotonis, cairannya mendekati plasma

sehingga terus berada di pembuluh darah dan mengurangi trauma pembuluh darah.

8. Suitable for pediatric

Asetat & malat bisa digunakan pada anak-anak. 8

BENEFIT

1. R. Zander, Fluid Management, Bibliomed – Medizinische Verlagsgesellschaft mbH, Melsungen, 20092. Reddy et al., Crystalloid Fluid Therapy, Critical Care, 2016:20-593. McCague et et al.,Scandinavian Journal of Trauma, Resuscitation and Emergency Medicine, 2011,19:244. Fernandes et al., Intravenous Acetate Elicits a Greater Free Fatty Acid Rebound in Normal than Hyperinsulinaemic

Humans, Eur J Clin Nutr. 20125. Pfortmueller et al., Acetate-buffered crystalloid infusate versus infusion of 0.9% saline and hemodynamic stability in

patients undergoing renal transplantation, The Central European Journal of Medicine, 2017.6. Waack et al, L-Malate’s Plasma and Excretion Profile in the Treatment of Moderate and Severe Hemorrhagic Shock in

Rats, BioMed Research International, 2016 .7. Dai et al, Ringer’s Malate Solution Protects Against The Multiple Organ Injury and Dysfunction Caused by Hemorrhagic

Shock in Rats, SHOCK, Vol. 38, No. 3, pp. 268Y274, 20128. PI Approved BPOM.

THANKS

MERCY

TERIMA KASIH

有難う御座います– Arigatou Gozaimasu

잘 잘 잘 잘 잘 잘 (jal meokgessseumnida)

رشك -Syukron

谢谢 -xiexie