Terapi Cairan
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TTerapi cairanerapi cairan
dr Nopian Hidayat, SpAndr Nopian Hidayat, SpAn
Departemen Departemen Anestesiologi & Anestesiologi & Intensive CareIntensive CareFKUFKURR / RS. / RS. Arifin AhmadArifin Ahmad
PekanbaruPekanbaru
Fluid CompartmentsFluid CompartmentsFluid CompartmentsFluid Compartments
IntracellularIn
trav
ascu
lar
Intr
avas
cula
r
ExtracellularExtracellular
InterstitialInterstitial
Intracellular
Fluid is in both compartments 50-60% of body weightFluid is in both compartments 50-60% of body weightFluid is in both compartments 50-60% of body weightFluid is in both compartments 50-60% of body weight
¾ of ECF
¼ of ECF
Body Fluid Compartments: Composition
IntracellulIntracellularar
ExtracellularExtracellular
IntravasculIntravascularar
InterstitialInterstitial
Sodium Sodium (mEq/l)(mEq/l) 1010 145145 142142
Potassium Potassium (mEq/l)(mEq/l)
140140 44 44
Calcium Calcium (mEq/l)(mEq/l) <1<1 33 33
Magnesium Magnesium (mEq/l)(mEq/l)
5050 22 22
Chloride Chloride (mEq/l)(mEq/l) 44 105105 110110
Bicarbonate Bicarbonate (mEq/l)(mEq/l)
1010 2424 2828
Phosphorus Phosphorus (mEq/l)(mEq/l)
7575 22 22
Protein Protein (g/dl)(g/dl) 1616 77 22
Kebutuhan sehari Kebutuhan sehari BB : 50 Kg BB : 50 KgVolume : 2000 ml (40-50 cc/Kg)Volume : 2000 ml (40-50 cc/Kg)Natrium : 100-200 mEq (2-4mEq/Kg)Natrium : 100-200 mEq (2-4mEq/Kg)Kalium : 50-1Kalium : 50-1000 mEq (1-0 mEq (1-22 mEq/Kg) mEq/Kg) Kalori : 1500 kcal (30kcal/Kg)Kalori : 1500 kcal (30kcal/Kg)
HypovolemiaHypovolemia
Plasma Osmolality antara 280-290 Plasma Osmolality antara 280-290 mOsm/L (Hipo,iso,hipertonis)mOsm/L (Hipo,iso,hipertonis)
Komposisi cairan kristaloidKomposisi cairan kristaloid
Komposisi cairan kristaloidKomposisi cairan kristaloid
Derajat syokDerajat syok
LR1L
NS1LTwo wide bore iv cannulae Fast
O2 via a mask
Raise the legs
Monitor BP&Pulse
Catheterise & measureUrine output
LR1 L
TUJUAN RESUSITASI CAIRAN
RESTORASI PERFUSI JARINGAN
& PENGIRIMAN O2 KE SEL
MENGURANGI : ISKEMIA JARINGAN
KEGAGALAN ORGAN
Kristaloid VS KoloidKristaloid VS Koloid
Berat molekul ringanBerat molekul ringan Dengan atau tanpa Dengan atau tanpa
mengandung glukosamengandung glukosa Bertahan di sirkulasi Bertahan di sirkulasi
20-30 mnt20-30 mnt Diperlukan 3-4x Diperlukan 3-4x
volume perdarahanvolume perdarahan MurahMurah Contoh : RL, NaCl Contoh : RL, NaCl
0,9%0,9%
Berat molekul besar Berat molekul besar Mengandung protein Mengandung protein
atau polimer glukosa atau polimer glukosa yang besaryang besar
3-6 jam3-6 jam 1:11:1 MahalMahal Contoh : Dextran, Contoh : Dextran,
HES, AlbuminHES, Albumin
0
100
200
300
400
500
600
700
6% Hetastarch 5% Albumin Gelatin Saline
Lamke et al. Plasma volume changes after infusion of various plasma Lamke et al. Plasma volume changes after infusion of various plasma
expanders. Resuscitation. 1976;5:93-102expanders. Resuscitation. 1976;5:93-102..
Plasma volume effect 90 minutes after fluid administrationPlasma volume effect 90 minutes after fluid administration
Volume, mL
Sifat-sifat cairan koloid
Albumin 5 69.000 80 20 >24
Dekstran 70 6 70.000 100 40# 6-12
(20.000 - 175.000)
Dekstran 40 10 40.000 100 2-3
Kanjiheta@ 6 450.000 100 30 >24
(10.000 - 1.000.000)
Kanjipenta 10 264.000 100 40@ 10$
(150.000 - 350.000)
Koloid
Kadar~
(%)
BM
(kisaran dalam d)
Persen
Intravaskular
TekananOsmotikKoloid
(mm Hg)
Masa Paruh
Intravaskular(jam)
* Dimodifikasikan dari Davies MJ. The role of colloids in blood conservation. Int Anesthesiol Clin 1990; 28:205 ~ Dalam formulasi yang biasa dipakai di AS# Data dari Carlson RW, Rattan S, Haupt MT. Fluid resuscitation in conditions of increased permeability. Anesthesiol Rev 1990; 17:14@Kanjiheta dan kanjipenta tersusun dari molekul kanji hidroksietil dengan berbagai BM$ Data dari Rackow EC, Astiz ME, et al. Effects of pentastarch and albumin infusion on cardiorespiratory function and coagulation in patients with severe sepsis and systemic hypoperfusion. Crit Care Med 1989; 17:394
Perioperative fluid therapyPerioperative fluid therapy
Intraoperative fluid Intraoperative fluid replacementreplacement
Hb 8 vs Hb 12 Hb 8 vs Hb 12 O2 delivery nya samaO2 delivery nya samaHb < 7 Hb < 7 O2 delivery O2 delivery
terganggutergangguPerfusi dan Oksigenasi Perfusi dan Oksigenasi jaringan terganggujaringan terganggu
Target Target Pertahankan Hb Pertahankan Hb minimal 7-8 minimal 7-8 (Htc 21-24)(Htc 21-24)
Kecuali : Geriatri, kelainan jantung, Kecuali : Geriatri, kelainan jantung, kelainan paru, sepsis (Hb minimal 10/ kelainan paru, sepsis (Hb minimal 10/ Htc 30)Htc 30)
Contoh Soal :Contoh Soal :
Seorang wanita BB 60 kg, dengan Seorang wanita BB 60 kg, dengan Htc 37. Berapakah jumlah Htc 37. Berapakah jumlah perdarahan yang masih bisa ditolerir perdarahan yang masih bisa ditolerir untuk tetap stabil (ABL)?untuk tetap stabil (ABL)?
Cara MenghitungnyaCara Menghitungnya
EBVEBV
1.1. EBV = 65x60 =3900 mlEBV = 65x60 =3900 ml
2.2. RBCV (37%) = 37%x3900 = 1443 RBCV (37%) = 37%x3900 = 1443 mlml
3.3. RBCV (24%) = 24%x3900 = 936 mlRBCV (24%) = 24%x3900 = 936 ml
4.4. RBCV lost = 1443-936 = 507 mlRBCV lost = 1443-936 = 507 ml
5.5. Allowable Blood Loss (ABL) = 507x3 Allowable Blood Loss (ABL) = 507x3 =1521 ml=1521 ml
Jadi, bila ternyata perdarahan < 20% Jadi, bila ternyata perdarahan < 20% EBVEBV Kristaloid Kristaloid
Perdarahan >20% EBV Perdarahan >20% EBV koloid/Darahkoloid/Darah
Common GuidelinesCommon Guidelines
1.1. 1 labu PRC dapat menaikkan Hb 1 1 labu PRC dapat menaikkan Hb 1 gr/dl atau 2-3% Hctgr/dl atau 2-3% Hct
2.2. 10 ml/kg PRC dapat menaikkan Hb 3 10 ml/kg PRC dapat menaikkan Hb 3 gr/dl atau 10% Hctgr/dl atau 10% Hct
3.3. 4 ml/kg PRC dapat menaikkan Hb 1 4 ml/kg PRC dapat menaikkan Hb 1 gr/dlgr/dl
TERIMA KASIHTERIMA KASIH