Advanced Neuro Critical Care Support

ANCCS

KESEIMBANGAN
CAIRAN DAN
ELEKTROLIT

Advanced Neuro Critical Care Support

ANCCS

PENDAHULUAN

Elektrolit
darah, jaringan, sel tubuh.
konsentrasi dalam cairan tubuh bervariasi
Kation utama : Na+l ( CES ), K+
Anion utama : Cl- , HCO3- (CES), fosfat (CIS)
Na+ penting dalam mengendalikan volume cairan
tubuh total
K+ ,
penting dalam mengendalikan volume sel.
multifungsi
Hukum Netralitas listrik : jumlah muatan-muatan negatip
harus sama dengan jumlah muatan-muatan positip dalam
setiap bagian.
Gangguan elektrolit yang sering mengancam nyawa :
gangguan Na+, K+, Ca2+, Mg2+, PO42-

Advanced Neuro Critical Care Support

ANCCS

Electrical
Neutrality
Mg++ Ca++

Na+

lactate

PO4- -

K+
H+

alb-

CO2

SO4- -, OH -, others

Cl-

Advanced Neuro Critical Care Support

ANCCS

Keseimbangan Cairan

Osmosis dan osmolaritas tekanan dari gradien konsentrasi

air Perpindahan air melalui membran dari daerah dengan
konsentrasi zat terlarut yang rendah ke daerah dengan
konsentrasi zat terlarut tinggi sampai kedua konsentrasi
sama.
Ditentukan oleh jumlah partikel di dalam larutan,nilai sama
disemua kompartemen (285 mOsm/lr ).
Rumus Osmolaritas:
2(Na+K) + GD/1.8 + BUN/2.8.

Difusi
substansi yang bergerak dari area dengan konsentrasi lebih
tinggi ke daerah konsentrasi yang rendah.perpindahan ion
dan molekul.
Filtrasi
Tekanan hidrostatik dalam kapiler menyaring cairan yang
keluar dari kompartemen vascular ke dalam cairan intra
seluler.
Tonicity Efek osmosis cairan pada sel : 2 cairan harus
mempunyai osmolaritas yang seimbang tetapi berbeda tonisitas

Advanced Neuro Critical Care Support

ANCCS

Keseimbangan Air
OSMOLARITAS
Ditentukan oleh jumlah partikel
di dalam larutan
Nilai sama dari macam-macam
cairan tubuh (285 mOsm/liter).
Rumus Osmolaritas:
2(Na+K) + GD/1.8 + BUN/2.8.

Advanced Neuro Critical Care Support

ANCCS

Hormone
Keseimbangan cairan
dan
elektrolit
ADH

Aldosterone
Atrial Natriuretic Peptide

MORE IMPORTANT

Non hormonal: aktivasi simpatis

Advanced Neuro Critical Care Support

ANCCS

Advanced Neuro Critical Care Support

ANCCS

TERMINOLOGI
%
: gr/dl
AA, lipid, glukosa
D5%
: 50 gr/L
Mmol
: mgr/Berat molekul, berat atom
NaCl 0,9% 9gr=9000mgr (BA Na23, Cl 35,5)
Na 154 Mmol, Cl 154 Mmol
Meq : Mmol x valensi
1,75 Ca ( valensi2) = 3,5 Meq
M osm
: Jumlah Mmol dalam zat terlarut (liter)
mEq/L = mg% X 10 X k
Berat molekul
NaCl 3% = 3000 X 10 X 1 = 517 mEq/L
58
NaCl 0,9% = 900 X 10 X 1 = 155 mEq/L
58

Advanced Neuro Critical Care Support

ANCCS

mEq/L = mg% X 10 X k
Berat molekul
NaCl 3% = 3000 X 10 X 1 =
517 mEq/L
58
NaCl 0,9% = 900 X 10 X 1 =
155 mEq/L
58

ANLS OKTOBER 2009

Advanced Neuro Critical Care Support

ANCCS

KOMPOSISI ELEKTROLIT
EKSTRASEL DAN INTRASEL

Advanced Neuro Critical Care Support

ANCCS

PERAN DAN FUNGSI

ELEKTROLIT
Na :denganCLmempertahankan volume dan osmolaritas ,
asam basa cairan tubuh,energi potensial di NMJ
K+ :eksitabilitas neuromuskular, sintesa protein,proses
enzimatisenergi sel, mengatur rime jantung (Ca, Na)
Cl- : osmolaritas ECF dg Na, mengatur balans cairan,
asam
basa,pertukaran O2dg CO2 HB, komponen
asamlambung
Ca++: Fungsi neuromuskular,koagulasi darah, asam basa,
aktifasi enzim, pertumbuhan tulang dan gigi.
Mg++: fungsi neuromuskular,kardial,aktifasi enzim,
Na+K+pump, Metabolisme ATP,
Zn++: kofaktor enzim, metabolisme nutrien, membran
sel, imunitas dan perbaikan jaringan

Advanced Neuro Critical Care Support

ANCCS
Osmoreceptors
stimulated

ADH
release
thirst

HOMEOSTASIS
DISTURBED
[Na] in ECF
HOMEOSTASIS
[Na] in ECF normal

Homeostasis
restored

Homeostasis
restored
HOMEOSTASIS
DISTURBED
[Na] in ECF
Osmoreceptors
inhibited

ADH
release
thirst

Urinary water loss

water gain

Additional water
dilutes ECF,
volume

Water loss
Concentrates ECF
volume

Urinary water loss

Water gain

The Homeostatic Regulation of normal [Na] in Body Fluid

Advanced Neuro Critical Care Support

ANCCS

Hypernatremia

Hipernatremi adalah kenaikan

kadar Natrium
di dalam darah > 145 mmol/L

Gangguan
keseimbangan
air
mempengaruhi
kadar Na,yaitu dapat menyebabkan
hipernatremi atau hiponatremi

Advanced Neuro Critical Care Support

ANCCS

Hypernatraemia([Na]>150mEq/L)
Assess ECF volume

Hypovolaemia
Renal losses
Diuretics
Osmotic diuresis
Diab.Insipidus

Extrarenal losses

Hyperaldosteronism
Vomiting, diarrhea
Skin,Respiratory

Euvolaemia

Hypervolaemia

Renal losses

Diab.Inspidus

Extrarenal losses
vomiting, diarrhea ,
sweating, respiratory

Iatrogenic

Hypertonic saline or
Na-bic, admintr.
Cushing syndr.

Advanced Neuro Critical Care Support

ANCCS

a Normal
b. Kehilangan cairan
saja
c.Hipotonik krn
Kehilangan Natrium
d. hipotonik krn
kehilangan Na,K.
e. Hipertonik krn
Asupan
natrium bertambah

Advanced Neuro Critical Care Support

ANCCS

Efek hipernatremi pada otak

dan respon adaptasi

Advanced Neuro Critical Care Support

ANCCS

Penatalaksanaan

Pengobatan hipernatremi
membutuhkan 2 pendekatan, yaitu :
- Mengatasi penyakit yang mendasari,
mis. : menghentikan kehilangan
cairan dari gastro intestinal,
menghentikan pemberian laktulosa
dan diuretik, mengatasi
hiperkalsemia dan hipokalemi
- Koreksi hipertonisitas

Advanced Neuro Critical Care Support

ANCCS

Treatment of
hypernatraemia
Low ECFV
: Isotonic saline, then hypotonic fluids IV
(<300ml/h) or

PO free water

High ECFV: loop diuretics, Replace with hypotonic fluids if

nessecary
Correction Na level should < 0.5mEq/L/h, or
<1.0 mMeq/L/h for acute hyper Na
Treat underlying condition e.g Diabetes Inspidus:
Desmopressin
When hypovolemia has been corrected:
current TBW x current [Na] = normal TBW x normal
[Na]
current TBW = normal TBW x (140/current[Na])
TBW deficit = normal TBW current TBW
= 0.6 BW (kg) current TBW
= (0.6xBW)(1 140/current [Na])

Advanced Neuro Critical Care Support

ANCCS

Rumus pemberian cairan untuk

mengatasi hipernatremi

ANLS OKTOBER 2009

Advanced Neuro Critical Care Support

ANCCS

Hyponatraemia (Na+ < 130

mEq/L)

Pseudohyponatraemia
Plasma osmolality normal (hyperlipidemia,
hyperproteinemia)
Plasma osmolality increased (hyperglycemia, mannitol,
glycerol, glycine)

Hypotonic or True hyponatraemia

If ECFV : deficit of both TBW and salt, but more Na than
water has been lost
If ECFV : excess of both TBW and salt, but TBW is more
than total body Na
If ECFV normal : TBW has without change in total body
Na.

Advanced Neuro Critical Care Support

ANCCS
Hyponatraemia (Na < 135 mEq/L )

measure plasma osmolality

normal or increased
Hypotonic hyponatraemia

Pseudohyponatraemia
Assess ECF volume

hypovolaemia
hypervolaemia
non-renal losses
Oedema states
diarrhea, vomiting
skin losses
failure
third spacing
nephrosis
renal losses
diuretics, renal failure

euvolaemia
SIADH
hypothyroidism
adrenal insufficiency

CCF
renal

psychogenic polydipsia
cirrhosis

Advanced Neuro Critical Care Support

ANCCS

Pathogenesis of CNS
symptoms

Advanced Neuro Critical Care Support

ANCCS

Hyponatremia flow chart

Advanced Neuro Critical Care Support

ANCCS

SIADH v.s. Cerebral Salt

Wasting
SIADH

CSW

Serum Na

ECFv

Normal

UNa

UOSM

Urine volume

N or

Serum urate

N or

Urine urate

N or

Advanced Neuro Critical Care Support

ANCCS

mEq/L = mg% X 10 X k
Berat molekul
NaCl 3% = 3000 X 10 X 1 = 517
mEq/L
58
NaCl 0,9% = 900 X 10 X 1 =
155 mEq/L
58

Advanced Neuro Critical Care Support

ANCCS

Treatment of
hyponatraemia

Low ECF

asymptomatic: replace with isotonic saline

symptomatic: replace with hypertonic saline

Normal ECF
asymptomatic: frusemide diuresis + isotonic
saline
symptomatic : frusemide + hypertonic saline

High ECF
asymptomatic : frusemide diuresis
symptomatic: frusemide diuresis + hypertonic
saline

Advanced Neuro Critical Care Support

ANCCS

Koreksi hiponatremia,
euvolemik

Langkah I : Hitung water excess

BB X 60% X (1 - Na+)
125

Langkah II : Hitung waktu koreksi

Selisih Na+
Kecepatan koreksi

125 Na+
0,5 mEq L perjam

Langkah III: Hitung kehilangan cairan per jam

Water excess
Waktu koreksi

Langkah IV : Berikan Furosemide IV untuk menaikkan output

urine (dewasa 40 mg IV, anak 1 mg/kg IV)
Monitor output urine, kadar Na urine dan plasma tiap jam.
Ganti kehilangan Na+ lewat urine (volume urine X kadar
Na+urine) dengan NaCl 3% (1 ml NaCl 3% = 0,5 mEq Na+)
Urine output jam selanjutnya harus ditambahkan dengan
volume NaCl yang diberikan untuk menggantikan Na+.
Bila urine out put berlebih dari target berikan D5W
Bila urine output sangat kurang tambahkan furosemide.

Advanced Neuro Critical Care Support

ANCCS

Koreksi hiponatremia,
hipovolemik

Defisit Na+ = Na+ terbaca Na+ normal

Kecepatan Koreksi : 0,5 mEq/L perjam. (1-2 mEq/jam)
Contoh :
Na pasien = 115 mEq/L, Nilai normal 125 meq/L
BB 70 kg, pasien dewasa laki-laki.
Defisit Na total = Defisit Na X BB X 60% = (125-110) X 0,6 X 70 =
630 mEq/L.
Jika memakai NaCl 0,9%:
630 mEq X 1 L 0,9 NaCl = 4,06 liter NaCl dibutuhkan.
155
Waktu diperlukan 15 : 0,5 mEq = 30 jam
4,06 L NaCl 0,9% diberikan 30 jam 135 ml/jam
Berapa jika memakai NaCl 3% ???

Advanced Neuro Critical Care Support

ANCCS

Rx Hyponatremia

Na deficit = TBW(kg) x (desired [Na] - actual

[Na])(mmol)

Kapan koreksi cepat?

Acute (<24h) severe (< 120 mEq/L) Hyponatremia
Mencegah odem otak atau memperbaiki odem otak

Symptomatic Hyponatremia (Seizures, coma, etc.)

Terapi symptoms

CEPAT: 3% NS, 1-2 mEq/L/h sampai:

Symptoms membaik
Selama 3-4 jam atau Na serum mencapai 120 mEq/L

Koreksi lambat
0.5 mEq/L/h with 0.9% NS , restriksi cairan. 24
jam koreksi < 10-12 mEq/L/d mencegah
myelinolysis

Advanced Neuro Critical Care Support

ANCCS

Severe hyponatremia

Advanced Neuro Critical Care Support

ANCCS

Central Pontine
Myelinolysis

Several hours to
several days after
correction
Related to correction
of > 12 meq/24 hours
or 18 meq/48 hours
Tremor, incontinence,
hyperreflexia,
dysarthria, dysphagia,
quadriparesis,
quadriplegia,
mutism/locked-in
syndrome

Advanced Neuro Critical Care Support

ANCCS

Hiperkalemia
Pseudohiperkalemia: hemolysis,
leucocytosis(>50.000),thrombocytosi
s
(>1000000/ml)
Gangguan ekskresi renal: renal
failure, drugs(ACE inhib., K sparing
diuretics, NSAIDs)
Intake >>: K supplements, massive
transfusion)
Perpindahan Transcellular : acidosis,
b-blockers, insulin deficiency,
succinylicholine, rhabdomyolysis.

Advanced Neuro Critical Care Support

ANCCS

Clinical approach
Hyperkalemia
Hyperkalaemia

Pseudohyperkalaemia
Haemolysis
Leucocytosis (>50.000/ml)
Thrombocytosis(>1.000.000/ml)
Impaired renal excretion
Renal failure
Drugs:
ACE inhibitors
K-sparing diuretics
NSAIDS

Transcellular shifts
Acidosis
Beta-blockers
Insulin deficiency
Succinylcholine
Rhabdomyolysis
Excess intake
K-supplement
Massive transfusion

Advanced Neuro Critical Care Support

ANCCS

Hiperkalemia
CVS: tall peak T waves,
prolonged PR interval, loss of
P waves, widened QRS, VT, VF
and cardiac arrest.
Neuromuscular: weakness,
areflexia, paralysis and
paraesthesia

Advanced Neuro Critical Care Support

ANCCS

ECG characteristic :
HYPERKALEMIA
Peaking T
Shortening QT interval

Rhythm : atrial &

ventricular rhythm regular
Rate : normal
P wave : low amplitude
(mild), wide & flattened p
wave (moderate), posible
indiscernible (severe)
PR interval : normal or
prolonged
QRS complex: widened
Segmen ST : may be
elevated (severe)
T wave : tall T
QT interval : shortened

Advanced Neuro Critical Care Support

ANCCS

Hyperkalemia

Tall T
Shortening QT interval
Prolonged PR interval

Wide QRS complex

Advanced Neuro Critical Care Support

ANCCS

PenangananHiperkalemia
1.Direct membrane antagonism (cardiac
toxicity) :
IV Ca-gluconas, CaCl2 10% 10 ml, over 2-5 minute
2.Transcellular shift of K:
a.IV dextrose 50% 50ml + IV 5-10 unit RegularInsulin
b.IV Na.Bicarbonate 50-100mEq infused over 5-10
min
3.Enhanced clearance from body
- diuretics: IV frusemide 10-20mg
- haemodialysis/CRRT
- ion exchange resins (Resonium A PO 15g q 8h or
enema 30g q8h)

Advanced Neuro Critical Care Support

ANCCS

Hipokalemia
Transcellular shifts:
insulin, glucose, beta-agonist, alkalosis
Renal K saving ( urine K<30mEq/L)
G-I losses: diarrhea, nasogastric
Renal K wasting ( urine K >30mEq/L)
diuretics, Mg depletion, dehydration,
Mineralocorticoid excess,
Alkalosis,
Amphotericin-B

Advanced Neuro Critical Care Support

ANCCS

HIPOKALEMIA

Flat T wave
U wave appearance

Rhythm : atrial & ventricular

rhythm regular
Rate : normal limit
P wave : normal size and
configuration, tall P (severe
hypokalemia)
PR interval : may be prolonged
QRS complex : normal or
possibly widened (prolonged in
severe hypocalemia)
ST segment : depressed
T wave : decreased amplitude,
flat or inverted, fusion T wave
with prominent U wave
(severe)
QT interval : indiscernible as the
T wave flattens
U wave : prominent U wave,
fusion with T wave

Advanced Neuro Critical Care Support

ANCCS

Hipokalaemia
Hypokalaemia
Measure urine K+

Transcellular shifts
Insulin administr.
wasting
Glucosa administr.
K>30mEq/L/d)
Alkalosis
-agonist

renal-K+ saving
(Urine-K<30mEq/L/d)

GI losses
diarrhea
nasogastric

renal-K+
(Urine-

Renal losses
Diuretics
Mg depletion
Dehydration
Mineralocorticoid
excess
Alkalosis
Amphotericin-B

Advanced Neuro Critical Care Support

ANCCS

Hipokalemia

CVS: fattened or inverted T Waves, U

waves, Arrhytmia (in digitalis th/. Or Mg)
Neuromuscular: muscle weakness, ileus
and paralysis.
Renal: Nephrogenic Diabetes Insipidus.
TREATMENT:
Replacement rate 10-30 mEq/h diluted in
100-200 NS/D5% ( central vein)

Advanced Neuro Critical Care Support

ANCCS

HIPERKALSEMIA
Dapat terjadi pada
hiperparatiroidisme,tumor
ganas yg mengeluarkan
PTH,Intoksikasi vitaminD
Intoksikasi vit. A,Hipertiroid
,Insufisiensi adrenal,Milk Alkali
Syndrome

Advanced Neuro Critical Care Support

ANCCS

Kalsium
PTH: from parathyroid
activate osteoclasts
enhance intestinal absorption
increase kidney reabsorption
most calcium in bones as calcium
phosphate
PO4- reabsorbed in proximal tubules
regulated by PTH

Advanced Neuro Critical Care Support

ANCCS

HIPOKALSEMIA
Etiologi dapat terjadi pada defisiensi vitamin
D, makanan kurang lemak, sindrom
malabsorbsi( gastrektomi, pankreatitis, obat
pencahar), renal insufisiensi, gangguan fungsi
hati, obat anti kejang, Hipoparatiroidism,
Pseudohipoparatiroidism ,Keganasan
,Hipofosfatemia.
Penatalaksanaan dengan koreksi defisiensi
dengan kalsium iv( Ca.Gluconat/ klorida 10%)
atau peroral (Ca.Gluconas/karbonat);dapat
Disertai pemberian vit.D dosis besar

Advanced Neuro Critical Care Support

ANCCS

Hipokalsemia

Rhythm : regular atrial &

ventricular hythm
Rate : normal limit
P wave : normal size &
configuration
PR interval : normal limit
QRS complex : normal limit
Segmen ST : prolonged
T wave : normal size &
configuration, may become
flat or inverted
Interval QT : prolonged

Advanced Neuro Critical Care Support

ANCCS

HIPOFOSFATEMIA

Etiologi pada pemberian Antasid,

pengikat fosfat dosis besar ,Luka bakar
luas ,Diet rendah fosfat,Alkalosis
respiratorik ,Ketoasidosis diabetik .
Gejalaklinis dapat timbul kerusakan
eritrosit ,gangguan fungsi
lekosit,gangguan fungsi trombosit
,gangguan fungsi saraf rabdomiolisis.
Penatalaksanaan dengan pemberian
garam fosfat peroral/intravena

Advanced Neuro Critical Care Support

ANCCS

HIPERFOSFATEMIA
Etiologi pada pemberian fosfat yang
berlebihan peroral/enema/ enteral,
pada gagal ginjal akut/kronik
,Pemberian sitostatik akan terjadi
sitolisis sehingga fosfor keluar
kedalam darah. Gejalaklinis dapat
terjadi tetani oleh karena penekanan
kadar kalsium, pengendapan kalsium
pada jaringan lunak .

Advanced Neuro Critical Care Support

ANCCS

ANLS OKTOBER 2009

Advanced Neuro Critical Care Support

ANCCS

NEXT LECTURE

49