Post on 26-Dec-2015
description
"New Paradigm of Safe Fluid Therapy- Total Balanced Concept”
(Crystalloid & Colloid)
Indication of Fluid Therapy- Dehidration- Fluid losses during surgery- Acute hypovolemia e.g because of massive blood loss- Acidosis or alkalosis, electrolyte imbalances- Application of drugs
Crystalloid
Colloid
Type of Fluid
Dextran
Albumin
Gelatin
HES(Hydroxyethyl
starch)
NaCl 0.9%/ 0,45%
Other
Ringerfundin®
Mannitol
Glucose 5%
RA
etc.
Electrolyte concentrates
consist of :
electrolytes
& macro molecule
consist of :
electrolytes
consist of : high
concentration of electrolytes
Natural
Syntetis
RL
“ Does the electrolyte composition is a MATTER ?? ”
Sebagian besar cairan kristalloid & koloid yang ada mengandung campuran elektrolit yang tidak fisiologis – un-balanced
Pada awal 1990, mulai dikenal dan didefinisikan “ hyperchloremic acidosis” , pasca infusi cairan NaCl .
Penggunaan dalam jumlah besar dari cairan un-balanced ini dapat berakibat gangguan keseimbangan asam-basa
Respirasi• Hiperventilasi• Penurunan kekuatan otot nafas
dan menyebabkan kelelahan otot• Sesak
Metabolik• Peningkatan kebutuhan
metabolisme• Resistensi insulin• Menghambat glikolisis anaerob• Penurunan sintesis ATP• Hiperkalemia• Peningkatan degradasi protein
Otak• Penghambatan metabolisme dan
regulasi volume sel otak• Koma
Kardiovaskular• Gangguan kontraksi otot jantung• Dilatasi arteri,konstriksi vena, dan
sentralisasi volume darah• Peningkatan tahanan vaskular paru• Penurunan curah jantung, tekanan
darah arteri, dan aliran darah hati dan ginjal
• Sensitif thd reentrant arrhythmia dan penurunan ambang fibrilasi ventrikel
• Menghambat respon kardiovaskular terhadap katekolamin
AKIBAT DARI ASIDOSIS BERATAKIBAT DARI ASIDOSIS BERAT
7Adrogue HJ, Nicolaos EM: Management of life-threatening Acid-Base Disorders,
Review Article; NEJM 1998
Note :Hespan (HES 600/0.75 in NS)
Hextend (HES 670/0.75 in Balance)
Hypercloremic acidosis and the adverse event are minimal in fluid with SID = 28 compare SID = 0
wilkes, Anest Analgesia 2001
Quantitative approach of acid-base equilibrium
COCO22 STRONG ION DIFFERENCESTRONG ION DIFFERENCE WEAK ACIDWEAK ACID
pCOpCO22 SIDSID AAtottot
Control by Control by respiratory respiratory
systemsystem
Electrolyte Electrolyte composition in composition in
plasma plasma ((control by renalcontrol by renal))
CCononccentraentration oftion of protein (protein (control by control by liver and liver and metabolimetabolic c
statusstatus))
VARIABEL INDEPENDENVARIABEL INDEPENDEN
Pharmaceutical contribution
Plasma
NaNa++
142142
KK+ + 44CaCa++++
MgMg++++
ClCl--
103103
HCOHCO33--
2424
KATION ANION
SIDSID
Weak acidWeak acid(Alb-,P-)(Alb-,P-)
SID Plasma = (Kation–Anion) = 40 ± 2
Na+ = 142 mEq/L Cl- = 103 mEq/L
SID= 39 mEq/L 1 L 1 L
WATER EXCESS - HEMODILUTIONWATER EXCESS - HEMODILUTION
Plasma Water
Na+ = 142 /2 = 71 Cl- = 103/2 = 51
SID= 20 mEq/L
SID : 20 SID : 20 a acidosiscidosis dilusi dilusi
2 L
Na+ = 142 mEq/L Cl- = 103 mEq/L
SID= 39 mEq/L
Na + = 154 mEq/L Cl- = 154 mEq/L
SID = 0 mEq/L
1 L 1 L
PLASMA + PLASMA + NaCl NaCl 0.9% 0.9%
Plasma NaCl
Na+ = (142 + 154)/2 = 147 Cl- = (103+154)/2 = 128
SID= 19 mEq/L
1919 = a = acidosiscidosis
2 L
SID Plasma : SID Plasma : 3939
“Balanced Crystalloid & Colloid”
To avoid acid-base imbalances & edema cellular
Fully plasma adapted SID-eff plasma > SID-eff Kristaloid/koloid > 0
Isotonic to plasma
19/04/23 21
“How designing of Balanced Fluid“
Ringerfundin ® Balanced Crystalloid
Ringerfundin ® (Indonesia) = Sterofundin ISO
140 212.5 1
227
Ringerfundin – Plasma - adapted
- Electrolyte balance like in human plasma- Conventional infusion corrective effects
both unwanted and unknown.
Ringerfundin - BEpot= 0
Ringerfundin can be applied to polytrauma patients
Acid Base Balance - BE
Ringerfundin - Low Oxygen consumption
Total consumption of oxygen is reduced for About 30% in the acute phase!
Ringerfundin :
- Low Oxygen consumption
Compare to RL & RA
- Gentle on the liver
Acetate and Malate – metabolized
in all organs and muscle –
(unlike Lactate - only Liver)
AcetateLactate
ANION ORGAN HCO
3-
O
2
02 /HCO3
-
Lactate Liver 1 3 3,0
Actetate
Muscle 1 2 2,0
Malate Muscle 2 3 1,5
Glukon. nn 1 5,5
5,5
Metabolic cost in term of O2 consumption (mol O2 / mol substrat)
Acetate :CH3COONa + 2 O2 CO2 + H2O + NaHCO3
Lactate :CH3– CHOH-COONa + 3O2 2CO2 + 2H2O + NaHCO3
Malate:COONa-CH2-CHOH-COONa + 3 O2 = 2 CO2 + H2O + 2 NaHCO3
Comparison of O2 consumption among anions
Ringerfundin - Isotonic SolutionUSA:Estimated 15,000 pediatric deaths a year attributed to postoperative hyponatremia secondary to infusion of hypotonic solutions
Neurotraumatology:Use of hypotonic solutions (RL & RA) contra-indicated: risk of brain edema
Isotonic
Source:Arieff AI: Editorial: Postoperative hyponatraemic encephalopathy following elective surgery in children. Pediatric Anaesthesia 1998; 8: 1-4Hennes H-J: Schädel-Hirn-Trauma. In: Neuroanästhesie (J-P Jantzen, W Löffler, Hrsg.), Thieme, Stuttgart 2000
misperceptionOsmolarity & Osmolality
Osmolarity & Osmolality- Real osmolality ~ Sum: osmotically active species Plasma 288 mOsm /kg H2O
- Theoretical Osmolarity = Sum: Cation + Anion NaCl 0.9% = Na :154 + Cl :154 = 304 mosm/l
-Osmotical coefficient : ~ 0.93 (protein binding)
- NaCl 0.9% (Na :154 mosm/l + Cl :154 mosm/l)
Theo Osmolarity : 304 mosm/l - Water content 99.7% (mosm/l mosm/kgH2O) - Osmotical coefficient := 0.93 Real Osmolality = 308 x 0.997 x 0.93 = 286 mosm/ kg H2O
Isotonicity ~ Real Osmolality 286 mosm/ kg H2O (Plasma)
R. Zander, Fluid Management, 2009
R. Zander, Fluid Management, 2009
NaCL 0.9% and Ringerfundin (RF)
more Isotonis compare to RL and RA
Plasma Ringer Lactate
(mmol/l)
Ringer Acetate
(mmol/l)
0.9% NaCl (mmol/l)
Ringerfundin (mmol/l)
Electrolyte (mmol/l)
Osmotically active species (mosmol/l)
Na+ 142 142 130 130 154 140
K+ 4.5 4.5 4 4 4
Ca2+ 2.5 1.3* 2.7 2.7 2.5
Mg+ 1.25 0.7 0 0 1
Cl- 103 103 108.7 108.7 154 127
HCO3+ 24 24
Phospate2- 1 1
Sulfate2- 0.5 0.5
Organic acid 1.5 1.5 28 28 29
Proteinate- 20 1
Glucose 5
Urea 5
∑ ∑ = 291 ∑ = 273 ∑ = 273 ∑ = 308 ∑ = 304
Theoritical osmolarity (mosm/l)
291 273 273 308 304
Water content (%) 94 99.7 99.7 99.7 99.7
Theoritical osmolarity (mosm/l)
310 273 273 308 304
Osmotic coefficient 0.93 0.93 0.93 0.93 0.93
Actual osmolality (mosmol/kg H2O)
287 254 254 286 283
Measured osmolality **(mosmol/kg H2O
288 ± 5 253 253 286 286
Osmolarity vs
Osmolality
• NaCl Hypercloremic acidosis• R Lactate Hypotonicity , Lactate metabolism• R Acetate Hypotonicity
[mmol/l] NS Ringer RL RA RFundin Plasma Benefit
Na+ 154 147 130 130 140 142 Na+ responsable for tonicity of fluid
Plasma equivalent of most important electrolytes (i.e Na & K) Less unintended correction
K+ -- 4.0 4 4 4.0 4.5
Ca2+ -- 2.25 2.7 2.7 2.5 2.5 Ca is essential cofactor in coagulation cascade if Ca drop leads prolonged blood coagulation
Mg2+ -- 1.0 -- -- 1.0 0.85 Less unintended correction
Cl- 154 156 108.7 108.7 127 103 Cl- at RF slightly higher in order to achive physiological osmolarity
HCO3 24 Infusion should have physiologi buffer base HCO3- to
maintain base-acidity but due to unstable of HCO3- , pharmaceutical using precursor : Lactate, Acetate, Malat.
RFundin: combine Acetate & Malat instead of Lactate:
1.Acetate/malat metabolize in most tissue cells of body compare to Lactate-clearing organ in liver & kidney
2.Lactate should not be used in hepatic insufficiency Lactate metabolize in liver lactate in solutin lead metabolic acidosis
3.Lactate should not be used in shock with hyperlactademia / lactic acidosis.
Lactate- -- -- 28.0 -- -- 1.5
Acetate- -- -- -- 28.0 24.0
Malate2- -- -- -- -- 5.0
BEpot -24 -24 3.0 2.5 0 No change patient‘s acid-base status
Tonicity [mOsm/l]
[mOsm/lkg)308
286
309
287
273
253
273
253
304
286
310
288
RF more Isotonic than RL & RA, RF will avoid risk hypotonicity concequences i.e at neurotrauma & cerebral edeme that can easily develop in preterm & newborn
Comparison among Crystalloid solution : Designing “Balanced Crystalloid”
Clinical Demands :
Optimization of few criteria leads to one solution for 95% of all patients
Plasma-adapted / Balance / Physiologis
Isotonic
Low O2-Consumption
Several Metabolisation Pathways
BEpot= 0 mmol/l Prof. Dr. Dr. M. Leuwer, Liverpool Univ
Gelatin HES (Hydroxy Etyl Starch) Dextran
Bahan Gelatin sapi Starch / Kanji / Amylum Gula bit
BM 30 – 35 kdl 200 kdl 130 kdl 40 – 70 kdl
MFG Polygeline NaCl RL NaCl RFundin NaCl
Gelofusine (BB)
Haemaccel
-Haes steril-Hemohes (Bb)-Widahes-Hestar
Fimahes
-Voluven-Venofundin (BB)
Tetraspan (Colloid HES Balance)
(BB)
Otsu-tran (OI)
BBraun develop both Gelatin & HES BBraun develop both Gelatin & HES complete & objective information of the profilecomplete & objective information of the profile
49
World of Colloid
50
Different solutions in comparison with plasma
Note especially the differences in sodium and chloride content!
HES 130 in 0.9% saline: i.e : Venofundin-BBraun & Voluven
wilkes, Anest Analgesia 2001
Na+ = 142 mEq/L Cl- = 103 mEq/L
SID= 39 mEq/L
Na + = 154 mEq/L Cl- = 154 mEq/L
SID = 0 mEq/L
1 L 1 L
PLASMA + PLASMA + Colloid Un-Balanced (Colloid Un-Balanced (NaCl) NaCl)
Plasma Colloid/NaCl
Na+ = (142 + 154)/2 = 147 Cl- = (103+154)/2 = 128
SID= 19 mEq/L
SID : 39 SID : 39 1919 : a : acidosiscidosis
2 L
Na+ = 142 mEq/L Cl- = 103 mEq/L
SID= 39 mEq/L 1 L 1 L
PLASMA + PLASMA + Colloid Balanced Colloid Balanced
Plasma Tetraspan ® (Balanced HES)
Na+ = (142 + 140)/2 = 141 Cl- = (103+118)/2 = 110
SID= 31 mEq/L
SID : 39 SID : 39 31 : No acidosis 31 : No acidosis
2 LCation+ = 147 mEq/L Cl- = 118 mEq/L
Malate = 5 mEq/LAcetat- = 24 mEq/L SID = 29 mEq/L
Acetat & malate cepat dimetabolis
me
[mmol/l] Haemaccel Gelofusine Voluven Fimahes Hextend Tetraspan Plasma Benefit
Na+ 145 154 154 138 143 140 142 Na+ responsable for tonicity of fluid
K+ Less unintended correctionK+ 4 3 4 4.5
Ca2+ 3 5 2.5 2.5 Ca2+ is essential cofactor in coagulation cascade if Ca drop leads prolonged blood coagulation
Mg2+ 0.9 1.0 0.85 Less unintended correction
Cl- 145 120 154 125 123 118 103 Cl- influence the SID
HCO3 24 Infusion should have physiologi buffer base HCO3- to maintain base-acidity but due to unstable of HCO3- , pharmaceutical using precursor : Lactate, Acetate, Malat.
RFundin: combine Acetate & Malat instead of Lactate:
1.Acetate/malat metabolize in most tissue cells of body compare to Lactate-clearing organ in liver & kidney
2.Lactate should not be used in hepatic insufficiency Lactate metabolize in liver lactate in solutin lead metabolic acidosis
3.Lactate should not be used in shock with hyperlactademia / lactate acidosis.
Lactate- 20 28 1.5
Acetate- 24
Malate2- 5
Mw (kdl) Polygeline
30MFG
30
HES
130
HES
200
HES
670
HES
130
Albumin
30 -52
DS 0.4 0.5 0.75 0.42
C2:C2 ratio 9 : 1 6 : 1
Duration 2-3 hours 3-4 hours 4 – 6 hours
Comparison among Colloid solution : Designing “Balanced Colloid”
Ringerfundin ® & Tetraspan ® “clinically proven” for Pediatric
Pediatric aged up to 12 years ASA I-III undergoing
perioperative.
Comparison between HES
60
Tetraspan, Colloid Balanced HES 130/0.42
Volume & Duration effect of colloid (in hypovolemic volunteers)
68
0 50 100
150
200
(%)
3.5 % Polygeline
4% Modified Fluid Gelatin6% HES 200/0.5
6% Dextran 706% HES 200/0.62 and HES 450/0.710% HES 200/0.45 and 0.5
10% Dextran 40
~70%
~ 100 %
1oo%
145 %
~ 190 %
~2-3h
~3-4h
~ 4h
~ 3-4h(?)
(?)Same effectand duration!
~ 7-9h~ 4h
0 50 100
150
200
(%)
3.5 % Polygeline
4% Modified Fluid Gelatin6%/10% HES 200/0.5 & HES 130 / 0.4-0.42
6% Dextran 706% HES 200/0.62 and 450/0.7
10% Dextran 40
~50-60%
~ 100/ 145%
1oo- 140 %
~ 190 %
~2-3h
~3-4h, 4-6 h
~3-4/4 -9h
~3-4h(?)
Gelofusine (MFG)
= HES
Karakteristik Gelofusine® , ,modified fluid gelatin (MFG):
Polygelin
Proses suksinilasi gelatin
Urea-linked gelatin
Berat molekul 30,000 Dalton 35,000 Dalton
Bentuk molekul stretched polypeptides
kecil dan globular molecular polypeptide chains
Muatan Bermuatan negatif kuat
sedikit muatan negatif
Benefit Muatan Negative pada molekul Gelofusine®: 1.Mengurangi kebutuhan Clorida pada solution nya Minimal Hypercloremic acidosis2.Volume efek sebanding dg HES
Not all Gelatin are the same
Gelofusine – Minimal Hypercloremic acidosisGelofusine – Minimal Hypercloremic acidosis
compare other Gelatincompare other Gelatin
Reff : SID = 26
Na+ = 142 mEq/L Cl- = 103 mEq/L
SID= 39 mEq/L
Na + = 154 mEq/L Cl- = 120 mEq/LSID = 34 mEq/L
1 L 1 L
PLASMA + PLASMA + Gelofusine Gelofusine
Plasma Gelofusine
Na+ = (142 + 154)/2 = 148 Cl- = (103+120)/2 = 111
SID= 37 mEq/L
SID : 39 SID : 39 3737 = No acidosis = No acidosis
2 L
Efektifitas berdasarkan bentuk molekul & muatan
negatif-
-
-
--
-
-
-
-
-
-
Ukuran pori
Membrane
pemb darah-
-
-
-
Eksresi via urinstretched molekul,
Muatan negatif kuat
MFG (Gelofusine)
BM 30 kdl
Polygeline/ Haemaccel
BM 35 kdl
Globular
Tetraspan ®
Balanced HES
130/0.42
Total “Balanced” solution
Ringerfundin®
Balanced Crystalloid
Gelofusine®
No Dose Limit
colloid gelatin without acidosis
Safety is about anticipation
B.Braun; we value your patient’s life…
Thank You for Your Attention