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 solutionsElectrolyte solutions

PlasmaPlasma IsotonicsolutionsIsotonicsolutions

Hypotonic solutionsHypotonic solutions

Normalsaline

Ringer’sacetate/ lactate

KAEN 3B*

290 308 273

278

D5

290278

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

BASIC PRINCIPLESBASIC PRINCIPLES

Replace Replace

Maintain Maintain

Repair Repair

Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock

Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock

IWL + urine IWL + urine

Acid base, electrolyte imbalancesAcid base, electrolyte imbalances

RESUSCITATIONRESUSCITATION MAINTENANCEMAINTENANCE

NUTRITIONNUTRITIONCrystalloidCrystalloid

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

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

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

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

ELECTROLYTESELECTROLYTES

FLUID THERAPYFLUID THERAPY

Colloid

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 80-100mEq/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

Laju Kecepatan Pemberian Elektrolit &

glucose Na+ 100 mEq/hr

K+ 20 mEq/hr

Ca++ 20 mEq/hr

Mg++ 20 mEq/hr

HCO3

- 100 mEq/hr

Glucosa 0,5 gr/kg/hr ( 4

mg/kg/min)*

Na+ 100 mEq/hr

K+ 20 mEq/hr

Ca++ 20 mEq/hr

Mg++ 20 mEq/hr

HCO3

- 100 mEq/hr

Glucosa 0,5 gr/kg/hr ( 4

mg/kg/min)* * Neonates 6-8 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 ½ NS• Bila Na rendah:restriksi cairan,NS,• Perhatikan kadar Glukosa• Bila Hipoglikemi: KaEN MG3, D5 ½ 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’-60’atau 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

hario Pankreatitiso Keadaan saluran cerna yang tidak memungkinkano 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.