TERAPI CAIRAN

Widyati, MClin Pharm, Apt Departemen Farmasi Rumkital Dr. Ramelan

PENDAHULUAN
TUJUAN: atur cairan tubuh, nutrisi, akses iv KAPAN ? Shock, dehidrasi, perdarahan, anoreksia, bowel rest, kelainan GIT, perioperative. Terapi Cairan: pasok air+ elektrolit+nutrien KOMPOSISI AIR (60% BB): INTRASEL : 40-45% INTERSTITIAL: 11-15% VASKULAR (plasma): 5%

OSMOLALITAS
Konsentrasi zat terlarut (elektrolit, glukosa, urea, fosfolipid, cholesterol, dan lemak) dlm 1 kg air. Plasma osmolalitas dan tonisitas dipelihara melalui keseimbangan intake dan ekskresi air Perubahan tonisitas plasma dideteksi oleh osmoreseptor di hypothalamus

Electrolyte solutions
Isotonic solutions 308 273 Hypotonic solutions

Plasma

290

278 278

290

Normal Ringers saline acetate/ lactate

D5

KAEN 3B*

* KAEN 3B : contains 50 mmol Na+, 20 mmol K+, 50 mmol Cl-, 20 mmol lactate, 27 g dextrose per L.

BASIC PRINCIPLES
Replace
Abnormal loss: GIT, 3rd space, Ongoing loss, septic and Hypovolemic shock IWL + urine Acid base, electrolyte imbalances

Maintain Repair

FLUID THERAPY
RESUSCITATION MAINTENANCE

Crystalloid

Colloid

ELECTROLYTES

NUTRITION

1. Replace acute loss (hemorrhage, GI loss, 3rd space etc)

1. Replace normal loss (IWL + urine+ faecal) 2. Nutrition support

TERAPI RESUSITASI
Dosis: (Vol Deplesi x 1/3) + Terapi rumatan + Terapi pengganti Penggantian bertahap

TERAPI RUMATAN
Berikan volume setara dg ekskresi harian Terapi cairan juga sbg pengganti makanan Kebutuhan cairan bila intake oral Vol Urin + 700 mL=Vol Infus DOSIS: air 2000-2200 ml/hari, Na 80100mEq/hari, K 40-50 mEq/hari.

Crystalloids: Replacement fluids

Crystalloid = a solution of crystalline solid dissolved in water Generally are polyionic isotonic fluids Ringer's, Lactated Ringer's (RL) 0.9% NaCl (normal saline) is an isotonic solution of Na, Cl, and water 5% dextrose is an isotonic solution of dextrose in water; the dextrose is rapidly metabolized, thus this essentially results in the administration of free water Commonly administered during general anesthesia to diminish the cardiovascular effects of anesthetic drugs and replace ongoing fluid losses May need to infuse 40 90 ml/kg/hr during shock using multiple catheters or fluid pumps Replace acute blood loss by administering 3 volumes of crystalloid solution for each 1 volume of blood lost

Crystalloids: Maintenance fluids

Generally are low in Na and Cl, and high in K eg, 0.45 % sodium chloride, 2.5 % dextrose with 0.45 % saline, KaEN Generally polyionic isotonic or hypotonic fluids Used for long term fluid therapy, such as the ICU setting; not generally used during anesthesia May or may not contain dextrose

Laju Kecepatan Pemberian Elektrolit & glucose

Na+ K+ Ca++ Mg++ HCO3 Glucosa
100 mEq/hr 20 mEq/hr 20 mEq/hr 20 mEq/hr 100 mEq/hr

0,5 gr/kg/hr ( 4 mg/kg/min)*

* Neonates 6-8 mg/kg/min

Colloids
Synthetic colloids are polydisperse (various molecular weight) and do not readily cross semipermeable membrane. Hypertonicity pulls fluids into the vascular space and increase blood volume which effect is longer lasting compared to crystalloid therapy. solutions of starch or dextrans (of various molecular weights) smaller volumes of colloids are as effective as larger volumes of crystalloids in maintaining intravascular fluid volume historically have had a number of problems associated with their use, including allergic reactions, impaired coagulation, and renal damage; solutions available now have less problems associated with their use expensive compared to crystalloids Composition of Several Colloidal Fluids

PEMILIHAN CAIRAN PADA BERBAGAI PENYAKIT

HYPONATREMIA
ISOTONIK HYPONATREMIA : Hyperproteinemia, hyperlipidemia HYPOTONIK HYPONATREMIA: Hypovolemic: Dehydration, Diarhhea, Vomiting, Diuretics, ACE inhibitors, Mineralocorticoid deficiency. Euvolemic: SIADH, Postoperative hyponatremia, hypothyroid, endurance exercise. Hypervolemic: Edematous state at CHF, CH, NS,RF HYPERTONIC HYPONATREMIA: Hyperglicemia, Mannitol, sorbitol, maltose

TREATMENT
Symptomatic Hyponatremia: usually seen in Na < 120meq/L, if there are CNS symptom correct Na rapidly 1-2 meq/L/h no more 25-30meq/L with NaCl 3% + furosemide Asymptomatic hyponatremia: water restriction, 0,9% NaCl Hypervolemic Hypotonic Hyponatremia: water restriction , diuretics, 3% NaCl + furosemide, dialysis

HYPOKALEMIA
Symptoms: muscle weakness, fatigue, muscle cramps, constipation, ileus, broadening T waves, depressed ST segment. Treatment:KCl sol + juice, KCl tablet, iv KCl in severe hypokalemia with rates of up to 40 meq/L/h (drip)

TRAUMA KEPALA
Pasien dengan trauma kepala maupun stroke: stres metabolik hipermetabolism/hiperkatabolisme, hiperglikemia, respon fase akut, dan perubahan sistem imunitas.

TRAUMA KEPALA
Trauma kepala tertutup: ICP, HT sistemik Perhatikan kadar Na Bila Na Normal atau tinggi:KaEN 3B, D5 NS Bila Na rendah:restriksi cairan,NS, Perhatikan kadar Glukosa Bila Hipoglikemi: KaEN MG3, D5 NS Bila Hiperglikemi: KaEN 3B

TRAUMA KEPALA(LANJUTAN)
Bila Hipotensi Hipotensi pd Trauma Kepalaiskemi Terapi cairan perfusi jaringan Pemilihan Cairan: RL or NS 3% (resusitasi) sampai BP90 mmHg (systole) Monitoring: BP, Glukosa, Na

TRAUMA SPINAL
Shock Neurogenic
Deplesi Relative Intravascular

Resusitasi: RL

GANGGUAN FUNGSI HATI

Batasi asupan Na pada CH dg ascites Rumatan Hepatitis: asam amino ( Amino leban, Tutofusin LC) Rumatan pada HE pilih BCAA (Comafusin Hepar)

Gangguan Fungsi Ginjal

Pada GGK; umumnya batasi asupan K pilih RL untuk maintenance Rumatan: AA esensial untuk memenuhi kebutuhan AA namun meminimalisasi uremia (Kidmin)

CAIRAN sbg AKSES IV

Cairan yg kompatibel: D5, NS Dicampur ke dalam cairan, kemudian diinfuskan selama 30-60atau 24jam (Dopamin,Heparin). Waspada kompatibilitas. Disuntikkan pada injection site dengan cairan infus yang tetap dialirkan.

NUTRISI PARENTERAL
Def: pemenuhan semua atau sebagian kebutuhan nutrien secara intravena. Indikasi Nutrisi Parenteral (Hill, 2000): o Tidak mendapat asupan makanan oral selama > 7 hari o Pankreatitis o Keadaan saluran cerna yang tidak memungkinkan o Reseksi usus o Malnutrisi

NUTRISI PARENTERAL(LANJUTAN)
PERIFER Puasa 3-5hr, makan <75% 3hr, malnourished dg alb<3mg/dl, Via vena perifer Komposisi: karbohidrat 10%, AA 5%,Lipid,mikronutrien Osmolaritas: < 900 mOsm/l Midline cath kurangi flebitis

CENTRAL Puasa > 5hr, malnutrisi, bowel resection Via vena central (subclavia) Komposisi: karbohidrat,AA,Lipid, mikronutrien

NUTRISI PARENTERAL
KARBOHIDRAT : D5%,D10%,D40%,TRIOFUSIN,MANNITOL PROTEIN: Panamin G, TUTOFUSIN, INTRAFUSIN, EAS, AMINOLEBAN,AMIPAREN PROTEIN+KH+ELEKTROLIT: AMINOVEL 600 LIPID: ELEKTROLIT: RL,NS,RD,ASERING

NUTRISI ENTERAL
Nutrisi enteral adalah pemenuhan nutrien langsung melalui saluran cerna. Indikasi: tidak mendapat asupan makan secara oral sedangkan saluran cerna masih berfungsi baik Kelebihan nutrisi enteral dari parenteral adalah mengurangi resiko sepsis, penggunaan saluran cerna lebih fisiologis daripada parenteral dimana resiko atrofi vili usus tidak ada

NUTRISI ENTERAL (LANJUTAN)

cara: pemasangan nasogastric tube pada pasien yang gag reflex masih baik, nasoenteric tube, gastrostomy tube, dan jejunostomy tube.