Terapi Cairan ResusitasiTerapi Cairan Resusitasi

Iyan DarmawanIyan Darmawan

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

Jenis-Jenis larutan elektrolit

PlasmaPlasma Larutan elektrolitisotonik

Larutan elektrolitisotonik

Larutan elektrolitHipotonik

Larutan elektrolitHipotonik

Normalsaline

Ringerasetat/ laktat

KAEN 3B

290 308 273

D5

290278

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

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

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

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

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

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)

• 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

TRAUMA

BLOOD VESSEL

HEMODYNAMIC DISTURBANCE

ORGAN

DAMAGE

TISSUE

BLEEDINGEDEMA IMPAIRED FUNCTION

SHOCK

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%

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

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)

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

ASSESSMENT & MANAGEMENTASSESSMENT & MANAGEMENTASSESSMENT & MANAGEMENTASSESSMENT & MANAGEMENT

Disability – Cerebral perfussion Exposure/ Environment

related traumaprevent hypothermia

Urine output (Foley catheter) Gastric Decompression

IV LINE MANAGEMENTIV LINE MANAGEMENTIV LINE MANAGEMENTIV LINE MANAGEMENT

2 large-caliber peripheral IV’s (16 G) Central lines

FemoralJugularSubclavian

Intraosseous Blood for crossmatching

Flow rate(mL/menit)

200

100

14

Kateter Pendek

Kateter Panjang

16 16 16 ga

2 2 5,5 12 inci

Diameter

Panjang

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!!

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

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

VOLUME REPLACEMENTVOLUME REPLACEMENTVOLUME REPLACEMENTVOLUME REPLACEMENT

Warmed fluids Crossmatch, PRBC Type-specific Type O, Rh-negative Autotransfusion Coagulopathy

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

AVOIDING COMPLICATIONAVOIDING COMPLICATIONAVOIDING COMPLICATIONAVOIDING COMPLICATION

Fluid overload Invasive monitoring (ICU)

CVPPulmonary artery catheter

Other problems :Resuscitation induced haemorrhagePost resuscitation injury

No – Reflow phenomenonReperfusion injury

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.

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.

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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