The Role of Crystalloid, Colloid and Blood in

Fluid Therapy

Ike SR
FK UNPAD/RSHS
Bandung
 Septic Shock

• Kombinasi antara
– Distributive
– Kardiogenik
– Hipovolemik
• Bentuk syok yang sering terjadi di klinis
• Merupakan kelanjutan dari proses SIRS dan sepsis
 Terapi cairan

jantung
Sistim vena
Sistim arteri/
kapiler
Preload Contractility Afterload

Diperlukan volume
intravaskuler yang
cukupÆ
Frank Starling
 Kematian akut pada sindroma syok

dalam 28 - 30 hari Hospital

2 - 3 jam (%) (%) death (%)

Syok septik
31 - 63

Syok kardiogenik
44 48

Syok hemoragik
25 - 35 30 - 54
(trauma)

N Eng J Med 2001; 344:699 JAMA 2005; 294:448 N Engl J Med 1994; 331:1105
JAMA 2002; 288: 862 Circulation 2005; 112: 1992 J Trauma 1998; 45:545
 Class I Class II Class III Class IV
Blood loss Up to 750 750-1500 1500-2000 >2000
Blood loss Up to 15% 15-30% 30-40% >40%
( % EBV)
9Pulse rate <100 >100 >120 >140
9Blood Normal Normal Decrease Decrease
pressure
9Pulse Normal or Decrease Decrease Decrease
pressure decrease
9Respiratory 14-20 20-30 30-35 >35
rate
9Urine >30 20-30 5-15 No UO
output
9CNS/ Slightly Mildly anxious Anxious and Confused and
mental status anxious confused lethargic

Fluid crystalloid crystalloid Crystalloid/ Crystallloid/

replacement colloid colloid
 Prinsip dasar terapi cairan

Kehilangan cairan abnormal

Resusitasi / • GIT
mengganti • 3rd space
defisit cairan • Ongoing loss
• septic
• syok Hipovolemik

Maintenance IWL + urine

Keseimbangan asam basa

Repair
keseimbangan elektrolit
 Cellular Cells
VO2 metabolisme
Lymphatic
Interstitial system
space 7 mmHg BOP IFHP O2 BOP IFHP
28 mmHg 0 mmHg 28 mmHg 0 mmHg

Waste product 8 mmHg

BHP 30 O2O2
Delivery in
+CO2
blood
mmHg
C
(DO2)
Venous end Arterial end
o
p
Bbb MIKROSIRKULASI y
Bbbb ri
DO2 = Cardiac Output x CaO2 ( arterial O2 content ) g
ht
Mikrosirkulasi harus dimonitor oleh karena makrosirkulasi yang baik tidak
menjamin mikrsirkulasi yang baik
The Integration of Fluid Volume Regulation and Sodium
Ion Concentrations in Body Fluids

Figure 27.5
 Volume Replacement Therapy
with

Crystalloids + Colloids

Lactated Ringer's
(Normal) Saline

Natural -------------Synthetic--------------
Albumin Gelatin Dextran HES
solutions solutions Solutions
PPS
But not every colloid for every indication!
 Kapan menggunakan kristaloid ?

• Di Emergensi Æ mudah didapat dan murah

• Dehidrasi
• Mengisi volume intravaskuler sementara,
interstisial, dan volume intraselular
• Rekomendasi ATLS 2000 cc pertama Æ
kristaloid
 Kristaloid vs Koloid

Kristaloid Koloid
Intravascular persistance Singkat Bertahan > lama
Stabilisasi hemodinamik Transient Bertahan lebih lama
Kebutuhan cairan > Banyak > sedikit
Risiko edema jaringan + Kurang
Perfusi sistim kapiler tidak sempurna > baik
Risiko anafilaksis - +
Plasma COP menurun Dpt dipertahankan
Harga Murah > mahal
Colloids fluid loading leads to greater increase in
preload recruit table LVSWI Æ due to higher COP Æ
caused by greater plasma volume ( PV ) expansion

Volume effect is >>>

Colloid loading gives higher CI, PV, and GEDVI
 Kejadian histopatologis iskemik ( pemeriksaan PA)
pada kematian karena syok

Hipovolemik Sepsis Kardiogenik

n = 102 (%) n = 93 (%) n = 197 (%)
Jantung 37 17 100

Paru-paru 55 65 10

Jantung 25 18 11

Hati 46 30 56

Intestine 9 26 16

Pankreas 7 6 3

Otak 6 3 4
McGovern VJ, Pathol Annu 1984;19:15
• Saline or colloids Æ do not affect permeability
• HES decrease permeability due to endothelial protections
• LIS ( lung Injury Score ) may slightly increase in colloid Æ
estimated by ↓ respiratory compliance Æ caused by increase
ITBV which IV volume was included ( increased volume due
to increased COP )
ITBV
Proporti
on of
patients
without
ARF
Creatinin concentration over 28 days
 Effects of Colloid solutions on
hemostasis and coagulation

Gelatins HES Dextrans

Factor VIII, vWF No effect

Platelets
adhesion No
aggregation effect
Thrombus No clinical
formation effect
In emergency situations
Blood typing No effect ! blood typing before infusion
 WHO principles for the clinical use of blood
components [WHO (1998a)]

• The patients Hb level, although important, should not be the

sole deciding factor in starting transfusion. The decision to
transfuse should be supported by the need to relieve clinical
signs & symptoms & prevent significant morbidity &
mortality
• The clinician should be aware of the risks of transfusion-
transmissible infection in the blood components that are
available for the individual pt**

** It should be noted that the rates of non-infective

complications are probably higher than those of infective
complication
 WHO principles for the clinical use of blood
components [WHO (1998a)]

• Transfusion should be prescribed only when the

benefits to the pt are likely to outweigh the risks
• The clinician should record the reason for
transfusion clearly
• A trained person should monitor the transfused pt
& respond immediately if any adverse effects
occur
 FDA guidelines
• RBC should not be given for
– volume expansion
– for improvement of general sense of well being
– to accelerate wound healing
– as hematinic agent
• Platelet should not be given for prophylaxis, either
after CPB or massive transfusion
• FFP should not be used for
– volume expansion
– as nutritional supplement
– for prophylaxis, either after CPB or massive
transfusion
Hb 7-14
Rekomendasi dari Transfusi Sel Darah Merah
Indikasi

• Hb <7g/dL Æ hampir selalu indikasi untuk

transfusi darah merah
– Dapat ditunda bila tidak terdapat tanda2
klinis hipoksia yang jelas
– Dapat ditunda bila pasien mendapat
terapi yang dapat meningkatkan Hb Æ
seperti erythropoietin /EPO
Rekomendasi transfusi sel darah merah Æ PRC
Indikasi

• Bila Hb 7 – 10 g/dL :
– Keuntungan pemberian transfusi PRC
tidak jelas
– Transfusi PRC dapat dilakukan bila
terdapat hipoksia yang jelas
Æhypoxemia
 Transfusi Sel Darah Merah Æ PRC
Indikasi

• Hb ≥ 10g/dL Æ tidak perlu transfusi PRC

– kecuali Æ pasien2 yang memerlukan
kemampuan transport O2 yang lebih
tinggi
• COPD yang berat
• Iskemia jantung
Pemberian transfusi pada keadaan ini harus
dengan alasan yang jelas dan tertulis
DO2 = Cardiac Output x CaO2 ( arterial O2 content )

(Hb x SpO2 x1,34 )+ ( 0,003 x PaO2)

Stroke Vol x HR

Volume x contractility
}
Combine thoracic epidural and general anesthesia
elective colorectal resection Æ ASA I – III
 Na = 140 meq/l
Kesimpulan

Capillary membrane
K = 4 meq/l

Na = 140 meq/l
K = 4 meq/l

Cell membrane
Intra Cellular Space
Intravascular Space

5% 40%
Na = 8 meq/l
15% K = 151 meq/l

RBC Interstitial Glucose solution

Space

Untuk memperbaiki DO2 Æ Curah

Colloid crystalloids
Jantung dan O2 content Æ transfusi