basic fluid therapy-merc, des-2012

8/18/2019 Basic Fluid Therapy-MERC, DeS-2012

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Basic Fluid Therapy

Hasanul Arifn

DEPARTEMEN ANESTESIOLOGI DAN TERAPI INTENSIFFaul!as "ed#!eran $S$ MEDAN


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FLUID MANAGEMENT

INTRAVASCULAR VOLUME

HEMODYNAMIC MECHANISM


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4/12/16 3

PRE-LOAD CONTRACTILITY AFTER-LOAD

STROKE VOLUME HEART-RATE

CARDIAC OUTPUT SYSTEMIC

VASCULAR

RESISTANCE

BLOOD

PRESSUREHasanul, 2006

Tissue

Perfusion


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pere!"e# $er%!&!p

H'O ( p!r$i)#e *e)i#

Permeabel terhadapH2O saja

ICF

ISF

VF

E%F

I%F


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TOTAL BODY WATER : 60% TOTAL BODY WEIGHT

+, L

ISF

, *.

/L

ISF IVF ICF

+L '0 L

P%1sio#o.i) prin)ip#es

of f#ui& !n!.een$

Hasanul, 2002pere!"e# $er%!&!p H'O (p!r$i)#e *e)i#

Permeabel terhadapH2O saja


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"ris!al#id

Kristaloid adalah terminology yangdigunakan untuk cairan yang tidak

mengandung molekul molekul besar,sehingga tidak memiliki kekuatan(tekanan) onkotik ( tekanan onkotik = 0)


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"#l#id Kolloid adalah terminology yang

digunakan untuk cairan yangmengandung molekul molekul besar

(≥ 30.000) sehingga memiliki tekananonkotik menaga air teta! dalamkom!artemen intra"askular.


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Teanan On#!i

#ekanan onkotik adalah kekuatan untuk

menahan air (H2$) tidak keluar darikom!artemen intra"askular,

to hold %ater


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"#l#idA#"uin2 HES2

E3p!fusin2

4e#!$ine2 #

"ris!al#id

D562 RL2 RA2

N!C# 7/8

%airan

Nu!risi In$r!fusin2 I9e#ip2

Triofusin 2 #


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ISF

/L

ISF IVF ICF

+L '0 L'5 #

D5W= H&O

:5#

Physiologic principlesof fluid management

3L

' L

Not forresuscitation !!!

EDEMA

hyp#!#nic


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ISF

/L

ISF IVF ICF

+L '0 L:5 #

CRYSTALLO D

RL, RA,

NaCl 0.9%

''5#

Physiologic principlesof fluid management

edema intersitiel

3L

Membutuhkan volume yang

lebih besar,Lebih murah,

Side effek lebih kecil

Is#!#nic 'uid

&dema !eri'er !ada !asien trauma atau !ost o!erati!, tidak meru!akan tanda adekuatnya "olume


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al(u)in

Bila albumin berkurang s/d !"# $OP akan menuruns/d 1/3 dari nilai n%rmal

Plasma hal& li&e 16 jam

'alam 2 jam p%st in&usi# 1 gr albumin akan

menge(pansi intra)askular 2! ( $%nt%h *

1!!! ml albumin " +! gr albumin, akan mengekpansi

intra)askular )%lume sebesar !(2! - 1!!! ml

1!! ml albumin 2" +2 gr albumin, akan mengekpansiintra)askular )%lume sebesar 2(2! - !! ml


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ISF

/L

ISF IVF ICF

+L '0 L;L


of f#ui& !n!.een$

Hasanul, 2002

Albumin-5%1 Lexpensiveexpensive


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ISF

/L

ISF IVF ICF

+L '0 L5 #


of f#ui& !n!.een$

Hasanul, 2002

0

Albumin-25%100 mlexpensiveexpensive

VOLUME

E


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ISF

/L

ISF IVF ICF

+L '0 L;L


of f#ui& !n!.een$

Hasanul, 2002

HES-6%, 200/0.51 L

•Lebih cepat mengkoreksi volume intra vaskular

• Mempertahankan tekananonkotik intravaskular

• Lebih mahal dari kristalloid


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ISF

/L

ISF IVF ICF

+L '0 L: #


of f#ui& !n!.een$

Hasanul, 2002




• sebagian shift ke ISC

+

POLYGELINE(HAEMACCEL)

1 Liter


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ISF

/L

ISF IVF ICF

+L '0 L;

#


of f#ui& !n!.een$

Hasanul, 2002




GELATIN(GELOFUSINE)

1 Liter


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ISF

/L

ISF IVF ICF

+L '0 L;,


of f#ui& !n!.een$

Hasanul, 2009

',

Dextran – 401 L

+0



• volume expand

• Coagulopathy


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ISFISF IVF ICF

+L '0 L


of f#ui& !n!.een$

Hasanul, 2010

/L

7.5%-Hypertonic Saline

?ml

. Subjek untuk penelitian

. Resusitasi cepat, volumesedikit

. Mengurangi cerebraledema


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Hy!ertonic saline

Hpert%ni0 s%luti%ns and hpert%ni0/hper%n0%ti0

s%luti%ns ma impr%)e 0ardi%)as0ular &un0ti%n %n

multiple le)els*displa0ement %& tissue &luid int% the bl%%d 0%mpartment

dire0t )as%dilat%r e&&e0ts in the sstemi0 and pulm%nar0ir0ulati%n#

redu0ti%n in )en%us 0apa0itan0e#

p%siti)e in%tr%pi0 e&&e0ts thr%ugh dire0t a0ti%ns %n

m%0ardial 0ells


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alin hi!ertonika!abila diin'uskan akan memindahkan cairan dari

intraselular ke ekstraselular ( interstitial danintra"askular dengan !erbandingan seuai dengan

!erbandingan "olume kom!artemen)

%lume g akan pindah-

+ kadar a$l hipert%nik * !, ( )%lume a$l

hipert%nik ang diin&uskan


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20 m* +al -.

%lume g akan pindah

- +5 * !, ( 2! m - 2!73 m

%lume ekstrasellular akan bertambah

sebesar * 2! 8 2!73 - 2333 m

dari jumlah ini akan didistribusikan sbb *73 m IF dan 1!! m ISF


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/enecial e1ects o' hy!ertonicsaline solutions %ere re!orted to berather transient.

onseuently, hy!ertonic solutions%ere o'ten mied %ith colloids(detran or H&), and these

solutions sho%ed a !rolongede4cacy.

Hy!ertonic saline

R/ H5


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7

menurun


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9ed Bl%%d $ell

High :; parti0les

+ :; parti0le

+a8# $l # glu0%se,

PERIPHERAL %APILLARIES


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9ed Bl%%d $ell

High :; parti0les

+ :; parti0le

+a8# $l # glu0%se,

CEREBRAL CAPILLARIES

BBB


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Fluid Movement BetweenCapillaries and the Brain

In the presence of an intact BBB

Perpindahan cairan antara capiler dan

extracellular space otak terutama olehgradient osmotik(osmolarity).

Pada jaringan otak, ( tidak seperti pada jaringan di peripheral ), plasma oncotic

pressure kecil perannya dalam prosesperpindahan cairan.


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Clinical implication

Hyperglycemia harus dihindarkan padapasien yang mengalami brain ischemia .

Larutan Dextrose jangan diinfuskan padapasien yang akan menjalani prosedur bedahsyaraf, kecuali dibutuhkan untuk terapi atau

pencegahan hypoglikemia..

$h%pp et al# +177, Str%ke# 1

anier et al# +175, and :etab%lism# 6

atale et al +1!, 9esus0itati%n# 1


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Intraoperative Fluids,Crystalloids

=@ui+is%,%sm%lar t% n%rmal plasma +2!A2 mOsm/,

F l u i d Osmolarity(mOsm/L)

Lactated Ringer’s Solution Acetate Ringer’s Solution

Ringer’s Solution

0.9% Saline

0.45% Saline20% Mannitol

273273

310

308

1541098


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%R*STALLOID

3!


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om!osition resembling !lasma(acetated ringer, lactated ringer)

8ree o' ana!hylactic reaction

7e!laces 98

7a!id in'usion

&asily a"ailable

*o%er cost, chea! :reater urinary ;o%

&asy storage at room tem!erature


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d isad "an tages

32


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ISF

ISFIVF ICF

:5 #

%R*STALLOID

RL+ RA+ Na%l ,-./

''5#

3L

$%nse@uentl large @uantities %& &luid +at least 3 t% 4 times

the a0tual intra)as0ular )%lume de&i0it, ha)e t% be in&used

t% a0hie)e n%rm%)%lemia >hen 0rstall%id &luid regimen is

0h%sen?%a0him B%ldt# :'# Ph'# In$r!oper!$i9e f#ui& $%er!p1-)r1s$!##oi&=)o##oi& &e"!$eCONFERENCIAS MA4ISTRALES %l 27 Supl 1 2!! pp S23AS27

se"ere dilution o' !lasma !roteinconcentration is accom!anied by

a (critical) reduction

in !lasma $ %ith the risk o'increasing interstitial edema and

com!romise organ !er'usion


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ISF ISFIVF ICF

+L '0 L/L

7.5%-Hypertonic Saline

?ml

. Subjek untuk penelitian

. Resusitasi cepat, volume

sedikit. Mengurangi cerebraledema

%lume g akan pindah - + kadar a$l hpert%nik *

! , ( )%lume a$l hpert%nik ang diberikan


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/enecial e1ects o' hy!ertonicsaline solutions %ere re!orted to berather transient.

onseuently, hy!ertonic solutions%ere o'ten mied %ith colloids(detran or H&), and these

solutions sho%ed a !rolongede4cacy.

Hy!ertonic saline

R/ H5


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Hy!ertonic saline

Hpert%ni0 s%luti%ns and hpert%ni0/hper%n0%ti0

s%luti%ns ma impr%)e 0ardi%)as0ular &un0ti%n %n

multiple le)els*displa0ement %& tissue &luid int% the bl%%d 0%mpartment

dire0t )as%dilat%r e&&e0ts in the sstemi0 and pulm%nar

0ir0ulati%n#

redu0ti%n in )en%us 0apa0itan0e#

p%siti)e in%tr%pi0 e&&e0ts thr%ugh dire0t a0ti%ns %n

m%0ardial 0ells


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*7 ( racemic * > 5 isomer) a!!ears toha"e a !roin;ammatory e1ect, but thismay be ameliorated by modication o'its com!osition.

7inger olution, 7inger S SOLUTION IN HAEMORRHA4IC SHOCK2

NO6 AND THE FUTURE

MA K%!n;2 ?P 4!rner'

35


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?icrocirculation,tissue $2

< massi"e crystalloid resuscitation alone is less likely toachie"e adeuate restoration o' blood ;o% and tissue $2 (Funk# et al# 1)

*actated 7inger@s solution did not restoremicro"ascular !er'usion su4ciently. (Aang et al , BCC0)

olloids are able to restore microcirculatory !er'usion

more than crystalloids (*ang.K, 200B)

37


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haracteristic o' the substance oncentration ()

?olecular Aeight ( D0, 200,B30,-0)

5egree o' subtitution (0.- E 0.E 0.D) attern o' substitution (2F6)

H &

6"H& 13!/!42

3


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?olecular Aeight

In$r!9!s)u#!r persis$en)e

Tissue s$or!.e

?olecular Aeight

41


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Haemostasis and Coagulation

9edu0ti%n %& &a0t%r III and )%n ;illebrandCs

&a0t%r a0ti)it Impairment %& platelet &un0ti%n

In0reases in the


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Interference with haemostasis and

coagulation depend on : M, degree!molar" of substitution and #$%#& ratio

MW, degree (molar) ofsubstitution and C2/C6

ratio

effect


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'() *+D (+*L -+#/I0+

Hyperoncotic Renal Failure

(Moran and Kapsner)

Generation of a high plasma COP wichcounteracts the hydrostatic pressure

gradient in the glomerulus

Avoidance of hyperoncotic colloid

solutions


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4


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HES 130/0./11.!H & (B30F0.DFC)


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0GELATIN1

45


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2ela!in $ksi!oligelatin oligelin

Gela!in p#lisusina!

uksinilasi menghasilkan !elebaran strukturmolekul, yang !ada akhirnya akan

meningkatkan e'ek "olumedibandingkan dengan gelatin tan!asuksinilasi.


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4

ISFISF IVF ICF

:-

#

Hasanul# 2!!2

• More rapidly correcthypovolemia

•

Maintain intravascularoncotic pressure

• anaphylactoid

• shift to ISF

2!!A3!!

ml

4e#!$in; L


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Thank you for


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7e!lace acuteF


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increases 98 &8increases 98 &8

I%F ISF Plas)a

7e!lace +ormalloss (9A* I urine)

7e!lace +ormalloss (9A* I urine)

detroseF ?aintenance sol detroseF ?aintenance sol

54 )l&44 )l66, )l

B * o'

H1po$oni) infusion

basic fluid therapy-merc, des-2012

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