Download - terapi cairan 2011
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Terapi Cairan
dr. Agustinus Juhardi, MSc, SpAn
Dept. Anestesi dan Reanimasi
RS Mardi Rahayu
Kudus
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Tanda-tanda Syok
• TAKIKARDIATAKIKARDIA• KULIT DINGIN, KERIPUTKULIT DINGIN, KERIPUT• WAJAH, TANGAN BERKERINGATWAJAH, TANGAN BERKERINGAT• GELISAH, CEMAS, BINGUNGGELISAH, CEMAS, BINGUNG• HIPOTENSIHIPOTENSI• TAKHIPNOETAKHIPNOE• OLIGURIAOLIGURIA
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Fisiologi Cairan Tubuh
sdm Plasma4.3%
•Vol darah 7%
•Air tubuh total 60%
•Icv 40%
•Ecv 20%
•IF = ECV-PV
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Pergerakan Air Antar Kompartmen
• Na
• Protein Plasma
• Air berdifusi menyesuaikan osmolalitas
• Tekanan untuk melawan pergerakan air : tekanan osmotik
•Penentu osmolalitas & tonisitas
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Phydrostatic
Poncotic
InterstitialEDEMA
NORMAL
5-10 mmHg
24 mmHg
IVF ISFISF
80% by albumin
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Banyak debat mempertentangkan Colloids or Crystalloids ?
• Sebelum beranjak lebih jauh, mari kita fahami dulu– apakah crystalloids itu
– apakah colloids itu
• Dalam banyak perdebatan, orang bicara crystalloids sebagai satu nama generik untuk larutan elektrolit, dan bicara colloids dengan mencampur adukkan semua larutan bahan bermolekul besar yang memiliki daya onkotik
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Colloids or Crystalloids?
• Colloids itu banyak macamnya :– Albumin 5%, 20%, 25%– Plasma Substitutes
• HES
• Gelatin
• Dextran
• Sifat masing-masing jauh berbeda
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Colloids or Crystalloids?
• Crystalloids itu banyak macamnya :– NaCl 0.9%, NaCl 5%, NaCl 7.5%– Ringer Laktat / Asetat
• Sifat masing-masing jauh berbeda
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Crystalloids• Larutan elektrolit terutama Natrium Chloride
dengan variasi sedikit K, Ca, Mg dan variasi kecil Laktat atau Asetat sebagai pengganti Chloride
• Penentu khasiatnya adalah jumlah Natrium.– Na+ 130-150 mEq memberi replacement isotonic,
equal volume IVF• setelah 30 menit mulai merembes keluar ke ISF
– Na+ diatas 450 mEq memberi replacement hypertonic, menarik cairan ISF masuk ke IVF : hyper-volume IVF
• setelah 30-60 menit mulai merembes keluar ke ISF
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IVF5% ISF 15% ICF 40%
Infusi crystalloids ke IVF akan merembes keluar ke ISFCrystalloids paling sesuai untuk combined deficit IVF + ISF
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Diare, muntaber
1. Interstitial sign : 1. mata cowong, 2. turgor turun, 3. mucosa kering
2. Plasma sign :1. Perfusi lambat2. Nadi naik3. Tekanan darah turun
IVF ISF
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Diare, muntaber, peritonitis
1. Infus cepat untuk mengisi kembali IVF2. Infus lambat untuk mengisi kembali ISF3. (memberikan juga cairan maintenance)4. Crystalloids adalah cairan yang paling tepat untuk
mengisi deficit IVF + ISF
1 2
IVF ISF
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Colloids
• Larutan bahan bermolekul besar dan memiliki kemampuan “oncotic” – menahan molekul air sehingga memiliki
“volume retention”– beredar lama dalam IVF sampai di-ekskresi
atau di-metabolisir
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Colloids
• Colloids alamiah : Albumin• Colloids sintetik :
– Dextran– Gelatin dan derivatnya– Hydroxy-Ethyl Starch (HES)
• Sifat-sifat pembeda :– half-life– distribution volume– IVF retention period– excretion rate and route
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Perdarahan Awal
1. Kehilangan IVF- Perfusi lambat- Nadi naik- Tekanan darah turun
- Colloids adalah cairan pengisi yang paling tepat untuk IVF
IVF ISF
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Perdarahan Lanjut
1. Kehilangan IVF- Perfusi lambat- Nadi naik- Tekanan darah turun
2. Dicoba diisi oleh ISF (transcapillary refill)3. Colloids dapat mengisi IVF tetapi tidak mengisi ISF4. Kombinasi colloids dan crystalloids mengisi IVF + ISF5. Crystalloids jumlah besar dapat mengisi IVF + ISF
IVF ISF
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Colloids or Crystalloids? In which case ?
• Hemorrhage or Hemorrhagic shock ?– Recent Hemorrhagic Shock or Neglected
Hemorrhagic Shock ?– Simple hemorrhage or blunt trauma?
• ECF deficit or Hypovolemic shock ?– Gastroenteritis ?– Dengue Shock Syndrome ?– Burn ?– Toxic shock syndrome ?
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Pasien berdarah|
baringkan dalam posisi shockpasang 2 infus jarum besar
ambil sample darah u/ cari donorperkirakan volume yang hilang
|infus RL 1000 (+ 1000 lagi)
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Perfusi HKMnadi < 100 T-sist > 100
|Lambatkan infus
Perfusi jelek, nadi >100, T-sist <100
|tambah RL lagi
sampai 2-4 x vol. perdarahan
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Crystalloids untuk Perdarahan
1. Infusi cepat mengembalikan IVF
2. Setelah IVF stabil, diteruskan untuk mengembalikan ISF
3. Volume yang diperlukan jadi 2-4x kehilangan IVF
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IVF ISF
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Perdarahan = kehilangan volume H2O, Hb, albumin, Natrium
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H2O
Natrium
Albumin
Eritrosit /Hb
Darah PS RL Dext 5%RL+Alb
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RL 2000
RL 2000
RL 2000
Bleeds1000
Bleeds2000
Hb 14
Hb 10
Hb 7
NORMOvolemia+ANEMIA
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How much RL can be given?
• Until patient shows– perfusion is warm, dry, pink– Slowing pulse rate (ideally < 100)– Increasing BP (ideally > 100)
• What about pulmonary edema ?
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Albumin 4.5 3.0 2.75 2.5 gm/dlP-oncotic 24 20 19 13 mmHg
Virgillio RW et al. Surgery 85:129-139
P-hydrostatic 5-10 mmHg
P-oncotic HES 6% = 29 mmHg
Will prevent thedevelopment ofIntersitial edema
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Keuntungan Plasma Substitute
• Mengisi IVF lebih cepat dari pada RL – Shock time jadi singkat
• Tetap tinggal di IVF lebih lama dp RL– Tidak terjadi intersitial edema
• Mempertahankan tekanan oncotic– Tidak terjadi intersitial edema
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RLRL
RLRLPS
PS
PS
PS
PS
RL RL
normal circulation
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Apa saja yang punya kemampuan “oncotic”?
• Albumin, alamiah, mahal
• Plasma donor, alamiah, bahaya penyakit
• HES, sintetik, lebih murah, aman penyakit– dosis terbatas
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HES
HESNa
Cl
H2O
H2O
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JENIS T-1/2 IVF ISF
HES > 24 jam 100% 0%
Dextran-70 12 jam 90-100% 10-0%
Dextran-40 6-12 jam 80% 20%
Gelatine 4 jam 50% 50%
29Isbister, 1980
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Recommended Maximal Dose
– HES : 20 ml/kg/day 6% solution or 1.2 gm/kg/day
– Dextran : 1.5 gm/kg/day– Gelatin : 1 liter prolongs Bleeding Time
1.7x
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Influence of Different Colloid Solutions on Coagulation Status in Patients Undergoing Cardiac Surgery. J.Boldt. Annals of Cardiac Anesthesia. 2002; 5:166-171
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Terima kasih
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