Klinis Praktis Cairan Resusitasi

8/10/2019 Klinis Praktis Cairan Resusitasi

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CLINICAL PRACTICE

OF FLUID RESUSCITATION

Ririe F Malisie


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The Fluid Management Concept

Basic treatment, necessary in all patients

crystalloid

colloid + crystalloid

Fluidmanagement

Fluid replacement

target: tissues, interstitiumindication: dehydration, maintenance

Volume replacement

target: intravascular space

indication: plasma and blood losses

F

luidmanagem

ent

Specific treatment, necessary in patients with volume (Blood) losses


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IVS

share of water: 60 %

ISS

ICS

Distribution of Fluids

The distribution of fluids within the body

depends on the physico-chemical properties

of the administered solution.

The major properties,

which influence the distribution are:

Colloid osmotic pressure (COP)

Tonicity, i. e. the sodium concentration


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Infusion Fluids

Basically we can distinguish two different types of preparations

used

in fluid therapy:

Crystalloidsare mainly electrolyte solutions like normal

saline (0.9% NaCl), Ringers solution, or balanced solutions

(eg. Ringerfundin).

Colloidsare preparations containing macromolecules like

gelatin (eg. Gelofusine) or hydroxyethyl starches (eg.

Venofundin and Tetraspan).

Crystalloids Colloids&


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Targeted fluid compartment in the body

Crystalloids

Colloids

! They administer fluid MAINLY to the whole extracellular space (ECS),

which is the IVS (intravascular space) and ISS (interstitial space)

! They administer fluid MAINLY to the intravascular space (IVS)


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Crystalloids Colloids

Fluid Therapy

Dextran

Albumin

Gelatin

HES

(Hydroxyethylstarch)

NaCl 0.9%/ 0,45%

Electrolyte

solutions like:

Other fluids

Ringerfundin

Mannitol

Glucose 5%

Lactated Ringersetc.

Ringers solutionElectrolyte

concentrates


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Advantages/ disadvantages of crystalloid fluid resuscitation

Advantages Disadvantages

Balanced electrolyte composition

Buffering capacity, lactate/ acetate

No risk of adverse reactions

No disturbance of hemostasis

Promoting diuresis

Inexpensive

Poor plasma volume support

Large quantities needed

Reduced plasma COP

Risk of overhydration

Risk of edema formation

Risk of hypothermia

Boldt et al. (2004), Table 3.1


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Problems in Colloid Therapy

We are just giving colloidto the patient!

What should happen?

Possible side effectsamongst others can be:

!

Influence on Renal Function!

Influence on coagulation

!Anaphylaxis reaction! Tissue accumulation

!

Acid base balance disturbances


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Hydroxethylstarch (HES) Classification

Tetrastarch (0.4) Pentastarch (0.5)

Hetastarch (0.7)

HES 130 /0.4

HES 130/0.42 HES 200 /0.5 HES 450 /0.7

(Based on the degree of substitution)

(Based on In Vitro Molecular weight)

High molecular weight

HES

Medium Molecular weight

HES

Low molecular weight

HES

HES 450 / 0.7

HES 470 /0.7

HES 200 /0.5

HES 200 /0.62

HES 40 /0.5

HES 70 /0,5

HES 110 /0.5HES 130 /0.4

HES 130/0.42Hemohes,

Haes-steril,Voluven

Venofundin

Tetraspan


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Effects of colloids on kidney function

Gelatins:

Dextrans:

HES:

Renal insufficiency is possible after Dextran 40

Acute renal failure after HES is possible

No negative effect! Improved kidney function!

Latent

increase of

urine viscosity

Enhanced

flow

resistance

Stop of

filtration

Decrease of glomerular

filtration

Dextran

concentration

in proximal

tubuli


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Effect on coagulation

Gelatins HES Dextrans

Factor VIII, vWF

Plateletsadhesionaggregation

Thrombusformation

Blood typing

No effect

No effect

No clinical

effect

No effectIn emergency situations

blood typing prior to infusion!

time

Gelatin dlm dosis besar tidak memperpanjang perdarahan


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Take Home Message

Electrolytes:

sodium, calcium, potassium,magnesium and chloride

The blood buffer is mainlycomposed of bicarbonate -

acetate/malateare

precursors of bicarbonate.

Plasma proteinskeep the

COP of the circulatory system- this can be taken over by

colloids like HES or Gelatin.

plasma 0.9% NaClRingerssolution

Ringer-fundin Tetraspan


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THANK YOU

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Klinis Praktis Cairan Resusitasi