fluid managementuntuk mahasiswa saja
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Fluid Management
SupartoAnesthesia Department
Medical Faculty Christian Krida Wacana University
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Osmosis
Osmosis is the movement of water (solvent
molecules) across a semipermeable membrane
from a compartment in which the nondiffusable
solute (ion) concentration is lower to acompartement in which the solute concentration
is higher (Ganong 2003)
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Osmotic pressure
Is the pressure that must be applied to the
side with more solute to prevent a net
movement of water across the membrane to
dilute the solute
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Osmolality is the number of particles (osmoles) in
a kilogram of fluid;
Osmolarity is the number of particles in a liter of
fluid.
These terms are often used interchangeablybecause the density of water is 1 kg/L. Normal
serum osmolality is around 285-295 mOsm/L.
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Tonicity, describe the osmolarity of a solution
relative to plasma Isotonic, solutions that have the same
osmolarity as plasma (no transfer of fluid intoor out of cells occurs)
Hypertonic, those with higher osmolarity (cellsshrink)
Hypotonic, those with lower osmolarity (cells
swell)
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Jenis dan Jumlah cairan tubuh
Cairan tubuh 60%
CES 20% CIS 40%
Cairan interstitial
15%
Plasma darah
5%
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Distribusi cairan tubuh manusia dewasa:
Total Body Water :
(M) 60% BB (600ml/kg) (F) 50% BB (500ml/kg)
Whole Blood (M) 66ml/kg, (F) 60 ml/kg
Blood represents about 11-12% of the total bodyfluid Marino PL. The ICU Book 3rded; 2007: 211-229
Average blood volume(Morgan & mikhails Clinical Anesthesiology, 5thEd)
Neonates: Premature 95 ml/kg, Full term 85 ml/kg
Infants 80 ml/kg
Adult: Men 75 ml/kg, Women 65 ml/kg
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In nonobese individuals, the blood volume varies in
direct proportion to the body weight, averaging 70
ml/kg for lean men and woman (stoelting 4thed; 658)
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Kebutuhan pada orang dewasa
Air 25-40ml/kgBB/hari, or 1.5ml/kg/jam
Kalium 1mEq/kgBB/hari
Natrium 2 mEq/kgBB/hari
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Holliday-Segar Formula for Maintenance Fluid
Requirements by Weight
Wt (kg) Water
ml/day ml/hr
0-10 100/kg 4/kg
11-20 1000+50/kg for
each kg >10
40+2/kg for
each kg >10
>20 1500+20/kg for
each kg >20
60+1/kg for
each kg >20
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Faktor modifikasi kebutuhan cairan
Kebutuhan Ekstra Penurunan kebutuhan
Demam (10%-12% setiap
1C >37C)
Hiperventilasi
Suhu lingkungan tinggi
Aktivitas ekstrem
Setiap kehilangan
abnormal
Hipotermia (12% setiap 1C
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What Fluid?
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Pemberian Infus
Terapi Cairan
Resusitasi Rumatan
KoloidKristaloid Elektrolit Nutrisi
Ring As
Ring Laktat
Ringer fundin
Gelofusine
Hes
Dextran
Albumin
Aminofluid
KAEN
Clinimix
Aminofluid
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Type of Fluid
Crystalloid (RL, NS, D5%)
Small molecules (< 8000 dalton)
Colloid (Albumin, Dextran, Hetastarch) Large molecules (> 8000 dalton)
Red blood cells (WB, PRBC)
To increase the oxygen carrying capacity of blood
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Crystalloid VS Colloid resuscitation
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Crystalloid:
Distributed in the
extracellular fluid
only 25% of the infused
volume will remain in thevascular space and expand
the plasma volume
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Crystalloids are categorized by their tonicity, a
synonym for osmolality. A fluid that's isotonic has thesame number of particlesthe same osmolalityas
plasma.
Therefore, an isotonic solution won't promote the
shift of fluids into or out of the cells, causing them to
swell or shrink.
Ringer Asering and lactated Ringer's (LR) solution are
two of the most commonly used isotonic fluids.
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Dextrose 5% in water (D5W) is another isotonic
crystalloid. However, it's not used for resuscitation
because, as its glucose is metabolized, this fluid
quickly becomes hypotonic. In fact, D5W is a good source of free water. As with
other hypotonic fluids, such as 0.45% NS, the water
quickly shifts out of the vascular bed and into the
cells, by way of osmosis.
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Colloids
Advantages
Volume expansion
Longer duration of
action
Disadvantages
Anaphylaxis
Expensive
Poss coagulopathy
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Crystalloids
Advantages
Easily available
Free of anaphylactic
reaction
Economical
Disadvantages
Shorter duration of
action
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P i i fl id
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Perioperative fluid management
Female 25 yo. 50 kg for tonsilectomy
NPO for 8 hours.
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Preoperative fluid deficit
NPO deficit: 1.5ml/kg/jam x 8 jam = 75ml/jam
Replace in 1sthour, 2ndhour, 3rdhour
600 ml deficit: 300ml 1st, 150ml 2nd, 150ml 3rd
OR
4x10 + 2x10 + 1x30 = 90ml/jam x 8 jam = 720ml
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Intraoperative fluid requirement
Preop deficit: 600ml
Maintenance: 1.5ml/kg/jam: 75ml
Replace redistribution and evaporative surgical fluid
losses (controversial) : 2ml x 50kg = 100ml
Blood loss
Degree of tissue trauma Additional fluid requirement
Minimal (herniotomi) 0-2 ml/kg
Moderate (cholecystectomy) 2-4 ml/kgSevere (bowel resection) 4-8 ml/kg
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Replacing blood loss
Hb
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Case: female, 50Kg, ht 35% How much blood loss will decrease her hematocrit
to 30%?
Estimated blood volume: 50kg x 70ml = 3500ml
Red blood cell volume35% = 3500ml x 35%= 1225ml
Red blood cell volume 30% = 3500ml x 30%= 1050ml
Red cell loss at 30%= 1225-1050 = 175ml
Allowable blood loss= 3x 175ml = 525ml
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Clinical guidelines:
1 unit PRC will increase Hb 1 g/dl and Ht 2-3% in
adults
10 ml/kg transfusion of PRC will increase Hb by 3g/dl and Ht 10%
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Tatara T, Nagao Y, Tashiro C. The effect of duration of
surgery on fluid balance during abdominal surgery: a
mathematical model. Anesth Analg 2009; 109:211-6
Showed that infusion rates of between 2-18.5ml/kg/h insurgery of duration 6 h, the therapeutic window
narrowed to between 5-8 ml/kg/h, after which asignificant increase in interstitial fluid was seen
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Introduction to shock
Combination of hemodynamic parameters
Mean Arterial Pressure < 60 mmHg
Systolic blood Pressure < 90 mmHg
Clinical: UO
Metabolic Acidosis
Kegagalan sirkulasi dlm mencukupi kebutuhanO2 jaringan tubuh
First.Identify the cause of shock
Reverse tissue hypoperfusion
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Class III
Loss 30-45% of BV (20-30ml/kg) Decompensated phase (hypotension, UO 2 mEq/L)
25 ml/kg
Class IV
Loss > 45% (>30ml/kg)
Irreversible phase (UO 4 to 6 mEq/L)
35 ml/kg
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Severity of Blood Loss
Variable I II III IV
SBP Normal Normal
Pulse 100 >120 >140
RR 14-20 20-30 30-40 >35
Mental
status
Anxious Agitated Confused Lethargic
BL (ml) 2000
BL (%) 40
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Stadium Shock
Stadium Kompensasi:
Transcapillary refill replenish 15% of blood
volume (interstitial fluid into capillaries)
Sekresi Vasopressin, RAA retensi air, sodium
dlm sirkulasi refleks simpatis
Resistensi sistemik
Resistensi Arteriol diastolic pressure
HR
Manifestasi: taki, gelisah, kulit pucat dan dingin,
pengisian kapiler lambat (> 2 detik)
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Stadium Dekompensasi:
Perfusi jaringan buruk O2
Metabolisme anaeroblaktat asidosis
Penumpukan CO2Asam Karbonat
Kontraklititas miokardium terhambat
Gangguan metabolisme energy Na+/K+ pump di
tingkat selulerKerusakan sel
Pelepasan mediator vaskuler: histamin, serotonin,cytokines
Vasodilatasi arteriol
Permiabilitas kapiler venous return , Cardiac output
Manifestasi: taki, TD , oliguria, kesadaranmenurun, asidosis, perfusi perifer buruk
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Stadium Irreversible
Kerusakan dan kematian selmulti organ
failure
Manifestasi: nadi tak teraba, TD takterukur, anuria
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The end point of the fluid resuscitation
phase is
restoring peripheral perfusion and BP and
returning increased heart rate toward
normal.
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Atasi penyebab
Traditional end point of volume
resuscitation
MAP 65-70mmHg
Capillary refill time < 2 seconds
UO > 0.5 ml/kg/hour (adults)
O2 ssat > 95%
CVP 8-12 mmHg
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Kasus:
Seorang laki-laki 55 tahun, 60 kg, datang ke UGD dengan
kesadaran menurun. Riwayat diare dan muntah 1 hariSMRS.
PF: KU: tampak lemas, Sakit sedang. TD 90/45mmHg, HR120x/min, RR 25x/min, T 38C, mata tampak cekung, bibir
dan mukosa mulut sangat kering, turgor kulit menurun,lain2 dalam batas normal
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DEHIDRASI
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Back to the case.
Kasus:
Seorang laki-laki 55 tahun, 60 kg, datang ke UGD dengankesadaran menurun. Riwayat diare dan muntah 1 hari
SMRS.PF: KU: tampak lemas, Sakit sedang. TD 90/45mmHg, HR120x/min, RR 25x/min, T 38C, mata tampak cekung, bibirdan mukosa mulut sangat kering, turgor kulit menurun,lain2 dalam batas normal
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Step I: focus on emergency management
IV fluid 20ml/kg isotonic crystalloid
Additional boluses if needed
Step II: focuses on deficit replacement
daily fluid requirements (100-50-20) +
Fluid deficit Total step II:
of the volume administered in 8 hr
of the remainder administered in 16 hr
Check electrolyte
*Emedicine.medscape.com
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Case
Defisit: 60 kg x 10% = 6 kg = 6 L = 6000 ml
Bolus: 20 ml x 60 kg = 1200 ml/30 menit-1 jam
Sisa defisit: 4800 ml
50% (2400 ml) dalam 8 jam pertama
50% (2400 ml) dalam 16 jam berikutnya
Terapi Cairan dan Elektrolit SMF Anestesi & Terapi intensif FK UNDIP
dr. Ery Leksana, Sp.An.KIC
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Hb and Hct
Poor correlation between blood volume defisit
and Hb in acute hemmorrhage,dilutional
decrease in Hb and Hct, NEVER be used toevaluate acute blood lossMarino PL. The ICU Book 3rded; 2007:211-229
Appropriate treatment of hypovolemia is
volume replacment!!
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Estimating the Volume Resuscitation Volume
1. Estimate normal blood volume2. Estimate % loss of blood volume
3. Calculate volume deficit
4. Determine resuscitation volume
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Example:
M, ideal body weight 70 kg with GI bleeding, HR 135
bpm, class II hemorrhage (15ml/kg)
15x70 = 1050ml
Crystalloid: 1050/0.25 = 4200ml
Colloid: 1050/0.75 = 1400ml
Resuscitation with crystalloid 3x than with colloid
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Conclusion
Understand the stages of hypovolemic shockand associated pathophysiological changes
Early detection of compensated shock so that
fluid can be given adequately Know how much fluid must be given
Indication of blood transfusion
How to know the success of resuscitation
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Tell me, Ill forget
Show me, I may remember
But involve me and Ill understand
Thank you