dr Iyan Darmawan

Basic Terms

• %

• mmol

• mEq

• mOsm

= g/dl

= mg/MW

MW = molecular weight

= mmol x valence

= Σ mmols of solutes

e.g NaCl 0.9% = 0.9 g/dl = 9 g/L 5% dextrose = 5 g/dl = 50 g/L

e.g. NaCl 9 g/L = 9 x 1000 23 + 35.5= 154 mmol/L

e.g. 1.75 mmol Ca++ = 3,5 mEq

Pedoman berbeda-beda Deteksi gangguan hemodinamik Evaluasi Hemokonsentrasi Nilai normal HR tergantung usia (perhatikan

obat/zat yang dikonsumsi) Oliguria perlu ditelusuri Pemilihan cairan harus tailor-made Monitoring seksama esensial Obesitas

Pasien usia 12 th masuk RS dengan keluhan utama demam sudah 4 hari dan tidak mau makan. Mual & muntah (+)

PF : Gelisah;T 100/80 S 37.5 oC Nadi 120 x/menit, napas 28 kali/menit dalam; akral dingin. Tes turniket (+). TB 120 cm BB 50 kg

Lab: Hct 48%; Trombosit 70.000 D/ DBD

Pemeriksaan fisik tambahan & Cairan apa yang dipilih dan berapa laju tetesan ?

Wanita usia 35 th masuk RS dengan keluhan utama demam sejak 2 hari yl dan tidak mau makan. Mual & muntah (+), kembung dan tidak bisa minum walaupun haus

PF : CM;T 110/70 S 39 oC Nadi 100 x/menit, napas 16 kali/menit; Tes turniket (+).

Lab: Hct 40%; Trombosit 70.000; glukosa 72 mmol/L BUN 25 mg/dl, kreatinin 1.1 mg/dl D/ DBD

Cairan apa yang dipilih dan berapa laju tetesan ?

Syok/Gangguan Hemodinamik ?

Ada Gangguan Elektrolit ?

Metabolik/Nutrisi?

Komorbiditas/insufisiensi, gagal organ?

Shock grades

MAP Pulse Pressure Tachycardia Capilary refill time Peripheral Vasoconstriction Oxygen saturation

MAP (mean arterial pressure) 70-105 mmHg HR (heart rate)

Neonatus (usia 0-30 hari): 70 - 190 detak/menit Bayi (usia 1 - 11 bulan): 80-120 detak/menit Anak 1 sampai 10 tahun: 70 - 130 detak per menit Anak usia > 10 th dan dewasa 60-100 detak/menit

Pulse Pressure (TD sistolik-Diastolik) 30-40 mmHg CRT (capillary refill time) < 2 detik Partial Pressure of Arterial Oxygen (PaO2) 80-100

mmHg Saturasi oksigen darah arteri (SaO2) 95-100% Saturasi vena campur (SvO2) 60-80%

Referensi : http://www.lidco.com/docs/1462Educatioalcard7.pdf. Diunduh 30 Januari 2012

http://www.lidco.com/docs/1462Educatioalcard7.pdf

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RESUSCITATION REPAIR MAINTENANCE PN

CORRECTNUTRITION ST

PERFUSION & OXYGENATION

HOMEOSTASIS/SUPPORTIVE

CORRECTELECT & AB

PARENTERAL FLUID THERAPY

Plasma Osmolarity

• 2 x [Na+] + Glu (mg/dl) + BUN (mg/dl)

18 2.8

• Range 280-290 mOsm/L

• > 296 mOsml/L dehydration

Replacement vs Maintenance fluid

PlasmaPlasma ReplacementReplacement MaintenanceMaintenance

Normalsaline

AR/ LR Typicalmaintenance

290 308 273

NaCl 0.45%-D5

290

154+278

140+150

432

ISOTONIC HYPOTONIC

Dehydration vs Hypovolemia

• Intracellular & Interstitial depletion

• Thirst, oliguria, dry mucous membrane

• Plasma Osmolarity ↑• BUN/creatinine ratio >20

• FeNa* <1 %

• Intravascular depletion• Hemodynamic responses

in initial phase (compensated shock)

• Hypotension, MAP < 60 indicate advanced stage

Both types often coincides

*FeNa = (U/P Na) : (U/P Creat)

RESUSCITATIONRESUSCITATION MAINTENANCEMAINTENANCE

Resuscitation vs Maintenance

Elect of High sodium > 100 mmol/L or synthetic colloid Low or no K+ ~ 10-20 ml/kg/hr (DSS, diarrhea) 2-3 L/10-15 min (hemorrhagic shock)

• Moderate sodium 35-70 mmol/L• K+ based on daily req • 20 drops/min 500 ml/6 hr

Replace acute/abnormalloss

Isotonic infusion

800 ml 200 ml

• ASERING• Lactated Ringer’s• Normal saline

1 L of

increases ECF

ICF ISF Plasma

increases ICF > ECF

ICF ISF Plasma

Replace Normal loss (IWL + urine)

Hypotonic infusion

5% dextrose/ Maintenance sol

85 ml255 ml660 ml

1 L of

increases intravascular

ICF ISF Plasma

Hemorrhagic shockBurnReserved for patientsin whom ISF expandedbut intravascular andalbumin is severelydepleted

Albumin infusion

Albumin 25%

300-600 ml over 30-60 min

100 ml L of

Ref. Evan R. Geller. Shock & Resuscitation. McGraw Hill, 1993. p 221

increases intravascular

ICF ISF Plasma

Hemorrhagic shockDSSLoading reg anes

Plasma Expander infusion

Dextran Gelatin HES

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

Fluid kinetics may be modified in conditions with increased permeability

Even albumin leaks into the interstitial space in sepsis.

UU U

U U U

20%3.5%U U

- + + - + + -

Transvascular Exchange and Organ Perfusion

6% Dextran 70 HES Gelatin Albumin Mannitol Urea Hypertonic sal ine

Fluid permeabil i ty

Albumin permeabil i ty

Muscle volume

Rebound fi l tration

u = unchanged

Holbeck S, Grände PO: Effects on capillary fluid permeability and fluid exchange of albumin, dextran, gelatin, and hydroxyethyl starch in cat skeletal muscle. Crit Care Med 2000, 28:1089-1095

Colloid in increased Capillary permeability?

• In some studies, the use of dextrans and hetastarch was shown to attenuate macromolecular leakage by presumably occluding some of the endothelial “gaps” associated with some conditions (e.g., ischemia, sepsis).

• However, there are concerns over the use of heterogeneous colloid solutions in states of increased permeability because the smaller colloid particles will extravasate into the interstitium and potentially promote edema.

1. Webb AR, Moss RF, Tighe D, et al: A narrow range, medium molecular weight pentastarch reduces structural organ damage in a hyperdynamic porcine model of sepsis. Intensive Care Med 18:348–355, 1992.

2. Zikria BA, King TC, Stanford J, Freeman HP: A biophysical approach to capillary permeability. Surgery 105(5):625–631, 1989.3. Oz MC, FitzPatrick MF, Zikria BA, et al: Attenuation of microvascular permeability dysfunction in postischemic striated muscle by

hydroxyethyl starch. Microvasc Res 50(1):71–79, 1995.4. McGrath AM, Conhaim RL, Myers GA, Harms BA: Pulmonary vascular filtration of starch-based macromolecules: Effects onlung fluid

balance. J Surg Res 65(2):128–134, 1996

HCF

Free Radicals(NO + O2* =Peroxynitrite)

TNF-αIL-8IL-1

IFN-γIL-2TNF-β

IL-4IL-5IL-6IL-10IL-13

Cell apoptosis(Mast cells, Basophil, etc)

Histamine IncreasedVascularPermeability

DF

DHF

VEGF-A

1) Chaturvedi UC, et al . Cytokine cascade in dengue hemorrhagic fever: implicationsfor pathogenesis FEMS Immunology and Medical Microbiology 28(2000) 183-1882) JOURNAL OF VIROLOGY, Feb. 2007, p. 1592–1600

CD4+ T Cells

Th1 Th2

Macrophage

Pro-infllamm

atoric

Anti-infllamat

oric

Vascular endothelial growth factor A (VEGF-A), the most potent permeability-enhancing cytokine, in DHF*

J Virol. 2007 February; 81(4): 1592–1600.

Capillary leakage

vasculitis, reperfusion injury

SIRS, ARDS, pneumonia, sepsis

Pancreatitis, and anaphylaxis.

DHF

Envenomation

What is “sealing effect”?

• Effects of Hydroxyethyl Starch on Lung Capillary Permeability in Endotoxic Rats

• 3.75 and 7.5 mL/kg significantly reduced LPS-induced increases of lung capillary permeability

• antiinflammatory effect of HES, including inhibition of NF-κB activation

Anesth Analg 2004;98:768-774

Which product and correct timing ?

www. moh.gov.my : Management of Dengue Infection in Adults.2 edition 2008.DENGUE GUIDELINES FOR DIAGNOSIS,TREATMENT, PREVENTION AND CONTROL. New Edition 2009Yip WCL. Dengue Haemorrhagic Fever: Current Approaches to Management.Medical Progress October 1980

WARNING SIGNS

• Abdominal pain or tenderness• Persistent vomiting• Clinical fluid accumulation (pleural effusion, ascites)• Mucosal bleed• Restlessness or lethargy• Liver enlargement > 2 cm• Laboratory : Increase in HCT concurrent with rapid decrease in platelet

COMPENSATED SHOCK ISOTONIC CRYS 10 ml/kg/hr

Capillary refill > 2 secNarrowing pulse pressureTachycardiaTachypnoeaCold extremities

Maintenance ONLY ISOTONIC INFUSION

* Ganong WF. Cardiovascular homeostasis in health and disease. In: Review ofMedical Physiology. 22nd Edition. London: McGraw-Hill; 2005:p.630-46.

*

Clear consciousness

Brisk capillary refill time (<2 sec)

Warm and pink extremities

Good volume peripheral pulses

Normal heart rate for age

Normal pulse pressure for age

Normal respiratory rate for age

Normal urine output

Clear consc-shock can be missed if we don’t touch the patientCapillary refill time↑ ( >2 sec)Cool extremitiesWeak peripheral pulses

Tachycardia

Normal syst pressure , raised diastolic; postural hypotensionNarrowing pulse pressure

Tachypnea

Reduced l urine output

Restless or lethargy

Mottled skin, Cap refill time ↑↑

Cold,clammy extremities

Feeble or absent peripheral pulses

Severe tachycardia; bradycardia in late shockNarrowed pulse pressure(<20)

Hyperpnoea/Kussmaul

Oliguria/Anuria

Maintenance solution: 20 drops/min or 3 ml/kg/hr

Replacement solution: 5-10 ml/kg/hr

Replacement solution: Bolus 20 ml/kg (15 min) or colloid

Complete Main-tenance solutionAminofluid

RL,RA,Normal SalineKAEN 3B, NaCl 0.45%/D5

Colloid

Dehydration Hypovolemia/Shock

Na+ 77

Larutan Rumatan

Generasi 1 Generasi 2 Generasi 3

KAEN 3B

AMINOFLUID

Rationale of Maintenance Fluid Tx

• Despite thirst due to hypertonic dehydration, many patients may not be able to ingest enough water and nutrient owing to abdominal discomfort/pain, hepatomegaly

• Elevated levels of cytokines, such as interferons (IFNs), interleukin-2 (IL-2), IL-8, and tumor necrosis factor alpha, have been reported in DHF (1) One of their pleiotrophic effects is delaying gastric emptying

• Patients might experience loss of appetite because of dry mouth (dehydration), malaise and fatigue besides other systemic symptoms (2)

1. Anon Srikiatkhachorn, Chuanpis Ajariyakhajorn, Timothy P. Endy, Siripen Kalayanarooj, Daniel H. Libraty, Sharone Green, Francis A. Ennis, and Alan L. Rothman Virus-Induced Decline in Soluble Vascular Endothelial Growth Receptor 2 Is Associated with Plasma Leakage in Dengue Hemorrhagic Fever J Virol. 2007 February; 81(4): 1592–1600.

2. Othman N.Clinical profile of dengue infection in children versus adults.International Journal of Antimicrobial Agents, Volume 29, Supplement 2, March 2007, Page S435

FATIGUE

An underestimated and undertreated symptom (1)

1. Michael Sharpe BMJ 2002;325:480-4832. Seet RCS, et al. Post-infectious fatigue syndrome in dengue infection. Journal of Clinical Virology Volume

38, Issue 1, January 2007, Pages 1-6

Post-infectious fatigue was observed in approximately 25% of hospitalized patients with dengue infection (2)

Out of 127 patients,

•fever (93.7%) •poor appetite (89.0%) •fatigue (80.3%) •headaches (74.8%) •nausea (69.3%) •chills (69.3%) •muscle pain (62.2%) •and rashes (50.4%)

Seet RCS, et al. Post-infectious fatigue syndrome in dengue infection. Journal of Clinical Virology Volume 38, Issue 1, January 2007, Pages 1-6

E. Blomstrand A Role for Branched-Chain Amino Acids in Reducing Central Fatigue J. Nutr., February 1, 2006; 136(2): 544S - 547S

Serotonin

BBB

Anorexia

Fatigue

BCAA

Tryptophan

Cytokines released during acute infection , including DHF stmulate serotonin

Administration of Amino Acids and Administration of Amino Acids and GlucoseGlucose

Amino acids Amino acids

With NPC

Without NPC

Utilized for protein synthesisUtilized for protein synthesis

Consumed as an expensive energy source

Changes in body weight

(%)0

-10

-20 *

*

Nitrogen balance

-3000

-2000

-1000

0(mgN/kg)

* *Mean ± S.D.Tukey’s group comparison test

*: p < 0.05 vs. the amino acid, glucose, and electrolyte solution group

Urabe H, et al. Yakuri To Chiryo 1994;22 (Supplement):S835

3% Amino acid solution group

Electrolyte solution with 10% glucose group

(n=10) (n=7) (n=10)

Amino acid, glucose, and electrolyte solution group

(n=10) (n=7) (n=10)

Amino acid, glucose, and electrolyte solution group

3% Amino acid solution group

Electrolyte solution with 10% glucose group

When the gut works, use it!

When it doesn’t work, use

Pasien usia 12 th masuk RS dengan keluhan utama demam sudah 4 hari dan tidak mau makan. Mual & muntah (+)

PF : Gelisah;T 100/80 S 37.5 oC Nadi 120 x/menit, napas 28 kali/menit dalam; akral dingin. Tes turniket (+).

Lab: Hct 48%; Trombosit 70.000 D/ DBD

Pemeriksaan fisik tambahan & Cairan apa yang dipilih dan berapa laju tetesan ?

Wanita usia 35 th masuk RS dengan keluhan utama demam sejak 2 hari yl dan tidak mau makan. Mual & muntah (+), kembung dan tidak bisa minum walaupun haus

PF : CM;T 110/70 S 39 oC Nadi 100 x/menit, napas 16 kali/menit; Tes turniket (+).

Lab: Hct 40%; Trombosit 70.000; glukosa 72 mmol/L BUN 25 mg/dl, kreatinin 1.1 mg/dl D/ DBD

Cairan apa yang dipilih dan berapa laju tetesan ?

Take Home Messages

• DHF is dynamic disease, and fluid therapy should be adjusted and monitored

• Maintenance fluid should be encouraged during febrile phase when oral intake is severely compromised

• Recognition of early stage of shock (compensated shock) is mandatory where isotonic (replacement) solution MUST BE ADMINISTERED aggresively

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