Terapi Cairan pada Anak

Sakit Kritis

Yogi Prawira
Ketua Divisi Emergensi dan Rawat Intensif Anak
FKUI-RSCM
Jakarta
 Tubuh tersusun atas trilyunan sel  membentuk
struktur berbeda-beda  fungsi berbeda
 Tiap sel berperan mempertahankan lingkungan
sekitarnya supaya tetap seimbang (homeostasis)
↓
Diperankan oleh 3 komponen:
cairan, elektrolit dan asam-basa
↓
Tubuh berfungsi optimal
• Cairan : komponen terbesar tubuh  persentase terhadap BB terus
berubah sesuai umur
• Setelah pubertas  laki-laki > wanita  Obesitas <<

Umur Total cairan tubuh

terhadap berat badan (%)
Bayi baru lahir 77
6 bulan 72
2 tahun 60
16 tahun 60
20 – 39 tahun
Pria 60
Wanita 50
40 – 59 tahun
Pria 55
Wanita 47
• Secara fungsional cairan tubuh  2 kompartemen, dipisahkan oleh
membran semipermeabel
• Komposisi elektrolit kedua kompartemen :
• Intraseluler : K+, PO4-
• Ekstraseluler : Na+, Cl-, HCO3-

% terhadap berat Volume (Liter )

badan
Cairan Intraseluler ( CIS ) 40 28
Cairan Ekstraseluler ( CES ) 20 14
Interstitial ( 15 ) ( 11 )
Intravaskuler (5) (3)
Total cairan tubuh 60 42

Keterangan : untuk laki – laki, BB 70 kg

 Bila terdapat beda konsentrasi antar 2 kompartemen 
cairan bergerak dari cairan konsentrasi <  >
“OSMOSIS”
 Besar tekanan untuk melawan osmosis  “tekanan
osmotik”
 Jumlah total partikel dalam cairan yang menyebabkan
osmosis  OSMOL

Osmolaritas  Osmol/L air

Osmolalitas  Osmol/kg air

 Osmolalitas  jumlah partikel terlarut
dalam air
 Nilai normal 280-290 mOsm/kg
 Osmolalitas plasma (Posm):

Posm (mOsm/kg) = 2[Na (mEq/L)] + BUN

(mg/dL)/2.8] + [Glucose (mg/dL)/18]
Tonisitas : gradien tekanan osmotik antar 2 kompartemen

NaCl 0,9% NaCl 0,45% NaCl 3%

(308 mOsm/L) (154 mOsm/L) (1030 mOsm/L)
 TERAPI CAIRAN : Jenis? Jumlah?

 Berdasar komposisi :
 Kristaloid
 Koloid : alami, sintesis
 Kombinasi
 Berdasar tonisitas :
 Isotonis
 Hipertonis
 Hipotonis
 Kristaloid dan koloid
kristaloid koloid

Kandungan Zat dengan BM rendah (< 8 rb D) BM > 8 rb D spt protein, glukosa

Dengan atau tanpa glukosa berpolimer besar
Tekanan onkotik Rendah  cpt terdistribusi ke slrh Tinggi  lbh byk dan lama
ruang ekstraseluler menetap di ruang intravaskuler
Efek volume Lebih baik dari koloid Kurang baik dibanding kristaloid
interstitial
Efek edem perifer Lebih sering dibanding koloid Lebih jarang dibanding kristaloid

Efek edem paru Sama dengan koloid Sama dengan kristaloid

Aspek lain Murah, mudah didapat, mudah
disimpan, tidak toksik, reaction free
Contoh Saline, RL, D5%, dll
Mahal, risiko alergi, anafilaktik,
efek pd hemostatik, fungsi ginjal
Albumin, produk darah, fraksi
protein plasma, koloid sintetik
(HES, gelatin)
Distribusi cairan dalam ruang tubuh
Distribusi cairan IV bilamana 1000 ml larutan diberikan secara cepat pada
pasien dengan BB 70 kg dalam waktu 1 jam

LARUTAN PLASMA INTERSTITIAL INTRASEL

Albumin 5 % 1000 - -
Polygeline 700 300 -
Dextran 40 1600 -260 -340
 Dextran 70 1300 -130 -170
NaCl 0,9 % 200 800 -
NaCl 1,8 % 320 1280 -600
NaCl 0,45 % 141 567 292
Ringer Laktat 200 800 -
Dextrose 5 % 83 333 583

 Molekul dextran yang lebih besar bertahan lebih lama didalam sirkulasi
tetapi memberikan aktifitas osmotik lebih kecil
 CAIRAN KRISTALOID
 NaCl 0,9 % ( NORMAL SALINE )

o Kandungan Na+ dan Cl- tinggi baik untuk koreksi awal

deficit CES dengan hiponatremia, hipokloremia dan alkalosis
metabolik
o Pemberian volume besar sebabkan dilutional hyperchloremic
acidosis karena kandungan Cl yang tinggi
o Tidak memasok kalori

Na + Cl – Osmolaritas
( mEq/L ) (mEq/L ) ( mOsm/L )
Saline 154 154 308
Plasma 140 100 290 ± 10
 PLASMA + NaCl 0.9%

Plasma NaCl 0.9%

Na+ = 140 mEq/L Na+ = 154 mEq/L

Cl- = 100 mEq/L Cl- = 154 mEq/L
SID = 40 mEq/L 1 liter SID = 0 mEq/L 1 liter

SID : 40 
ASIDOSIS HIPERKLOREMIK AKIBAT
PEMBERIAN LARUTAN Na Cl 0.9%

Plasma

= Na+ = (140+154)/2 mEq/L= 147 mEq/L

Cl- = (100+ 154)/2 mEq/L= 127 mEq/L

SID = 20 mEq/L 2 liter

SID : 20  Asidosis
  RINGER LAKTAT ( RL )

o Cairan fisiologis jika volume besar diperlukan

o Baik untuk keadaan deficit CES, kehilangan melalui
saluran cerna, intra-operatif dan cairan pilihan pada
kasus trauma

Na + K+ Ca ++ Cl – laktat Osmolaritas
( mEq/L ) ( mEq/L ) ( mEq/L ) ( mEq/L ) (mEq/L ) ( mOsm/L )
RL 131 5 4 111 29 * 276
Plasma 140 4 3 102 24 290 ± 10

* Sebagai laktat
PLASMA + Larutan RINGER LACTATE

Plasma Ringer laktat

Laktat cepat
dimetabolisme

Cation+ = 140 mEq/L

Na+ = 140 mEq/L Cl- = 111 mEq/L
Cl- = 100 mEq/L Laktat- = 29 mEq/L
SID= 40 mEq/L 1 liter 1 liter
SID = 0 mEq/L

SID : 40
 Normal pH setelah pemberian
RINGER LACTATE

Plasma

= Na+ = (140+140)/2 mEq/L= 140 mEq/L

Cl- = (100+ 111)/2 mEq/L = 105 mEq/L
Laktat- (termetabolisme) = 0 mEq/L 2 liter
SID = 34 mEq/L

SID : 34  lebih alkalosis dibanding jika diberikan NaCl 0.9%

 MEKANISME PEMBERIAN NA-
BIKARBONAT PADA ASIDOSIS

Plasma;
asidosis Plasma + NaHCO3
hiperkloremik

25 mEq
NaHCO3 HCO3 cepat
Na+ = 140 mEq/L Na+ = 165 mEq/L dimetabolisme
Cl- = 130 mEq/L Cl- = 130 mEq/L
SID =10 mEq/L 1 liter 1.025 SID = 35 mEq/L
liter

SID  : 10  35 :  Alkalosis, pH kembali normal  namun mekanismenya bukan

karena pemberian HCO3- melainkan karena pemberian Na+ tanpa anion kuat yg
tidak dimetabolisme seperti Cl- sehingga SID   alkalosis
DEKSTROSA / GLUKOSA 5 % ( D 5 )

o Cairan rumatan pada pasien dengan pembatasan asupan

natrium, hipernatremia, hiperkalemia
o Sebagai larutan untuk pemberian obat secara IV
o Untuk suplai kalori dan mencegah ketosis : glukosa 10 % (
tidak cukup dengan glukosa 5 % )

Elektrolit Kalori (kcal/l) Osmolaritas ( mOsm/L )

D5% 0 170 272
D10% 0 340 500
CAIRAN KOMBINASI GLUKOSA & NaCl

Untuk cairan pemeliharaan, misal :

1. D 5 ¼ NS + KCL untuk kebutuhan rutin harian, memasok ± 200
Kkal/L
2. D 5 ½ NS sering dipakai sebagai cairan pemeliharaan pada
periode post – operasi. Tambahan kalium dapat
dipertimbangkan. Memasok ± 200 Kkal/L
 D 5 ½ NS = Dekstrose 5 % + NaCl 0,45 %
 D 5 ¼ NS = Dekstrose 5 % + NaCl 0,225 %

Elektrolit (mEq/L) Kalori (kcal) Osmolaritas ( mOsm/L )

D51/2NS Na : 77 170 406
Cl : 77
D51/4NS Na : 39 170 321
Cl : 39
 TUJUAN TERAPI CAIRAN :
o Mempertahankan status hidrasi dan perfusi jaringan yang adekuat
serta keseimbangan elektrolit

 MENILAI ADEKUAT TERAPI CAIRAN :

o Observasi tanda – tanda vital
o Pemeriksaan fisik
o Pengukuran asupan dan keluaran cairan
o Berat badan
o Urine output
o Elektrolit serum
o Monitoring invasif, bila perlu
 DASAR – DASAR TERAPI CAIRAN

 Tiga prinsip terapi cairan IV :

 Ganti sesuai jumlah dan jenis cairan yang hilang
 Perhitungkan kehilangan abnormal yang akan terjadi
 Perhitungkan kebutuhan normal cairan ( cairan maintenance )

 KEBUTUHAN CAIRAN INTRAVENA =

CAIRAN MAINTENANCE + KEHILANGAN ABNORMAL
  4 ALASAN UTAMA PEMBERIAN CAIRAN
INTRAVENA :

 Resusitasi
 Rehidrasi

 Pemberian cairan rumatan

 Menjaga akses ke vena untuk pemberian obat

 Holliday M, Segar W. Pediatrics 1957; 19:823–832

IKATAN DOKTER ANAK INDONESIA 24

 Cairan Rumatan

Berat Badan (kg) Air (ml)

0-10 100 ml/kg

10-20 1000 + 50 ml/kg

>20 1500 +20 ml/Kg

- K+ 1 mEq/1000 ml air
- Na+ 2 mEq/1000 ml air 0,2 NS + 10 mEq KCl/L/24 jam
- Cl- 3 mEq/1000 ml air

IKATAN DOKTER ANAK INDONESIA 25

Persentasi Kehilangan
Cairan Normal
Pernapasan 20%

Kulit 30%

Urine 50% terukur

Total 100%

IKATAN DOKTER ANAK INDONESIA 26

BAHAYA YANG BERHUBUNGAN DENGAN TERAPI CAIRAN INTRAVENA

 Bahaya mikrobiologik
o Cairan merupakan nutrisi untuk mikroorganisme dengan adanya
kandungan karbon, nitrogen, fosfat, trace elements, dekstrosa
o Kontaminasi karena :
 Mikroba udara pada waktu membuka tutup botol

 Open system tanpa menggunakan filter

 Sentuhan ( touch )

 Penambahan obat

 Pirogen

o Penambahan obat dapat menyebabkan :

 Kontaminasi ( 8 % )

 Drug incompatibilities

 Drug bioavailability : absorpsi insulin ke botol dan selang infus,

potensi antibiotik hilang dll

 Particulate Matter : karet, selulosa, glass crystals, serat, jamur
 Pemakaian infus set :
o Disposible --- kendala harga
o Alat pengatur volume : tidak ada atau salah dalam pemakaian
 Interaksi ( incompatibilities dan ketidakstabilan alat )
 Efek yang mungkin terjadi karena total parenteral nutrisi
( hyperalimentation ) : dehidrasi osmotik, deplesi elektrolit, sensitisasi
terhadap peptida
 TERAPI CAIRAN PADA KEGAWATAN ANAK

 Sel endotel kapiler bocor  molekul protein keluar ke Ruang Interstitial

 IVV 
 Timbul edema perifer dan paru :
o Hipoksemia
o Penurunan transport O2 ( DO2 ) Jaringan perifer
o Penurunan konsumsi O2 ( VO2 )
 Kontroversi koloid / kristaloid
o Prokoloid :
• Tekanan onkotik plasma dipertahankan
• Akumulasi cairan interstitial minimal
o Kristaloid :
• Koloid mahal, berisiko bila masuk ke ruang interstitial, apabila
terperangkap dapat menyebabkan edema
 ALBUMIN VERSUS KOLOID SINTETIK
 PASIEN GAWAT / KRITIS :
o Hipoalbuminemia ok
• Penurunan sintesis protein oleh hepar ( oleh karena defisit nutrisi
atau kerusakan hepar )
• Peningkatan kehilangan albumin dari ruang intravaskular
( pasca operasi, albumin merembes ke ruang interstitial)
• Kebocoran vaskular ( sepsis, DBD berat ) kehilangan albumin
300 %
o Pro albumin :
• Baik untuk ekspresi ruang intravaskular
• Pertahankan tekanan onkotik
o Albumin :
• Mengikat konstituen plasma lipofilik dan obat – obat asam
• Bila ada hipoalbuminemia, obat – obat mungkin mempunyai
kadar plasma normal, mungkin pula mempunyai fraksi bebas
abnormal tinggi dengan konsekuensi efek terapeutik dan toksik
yang lebih besar
 INDIKASI ALBUMIN

 Sindrom distress respirasi

o Edema
o hipoalbuminemia
 Tambahan pada NP total
 Polisitemia neonatus
 Hiperbilirubinemia, Ht > 70 %
 Pasca operasi jantung
 Sepsis oleh karena meningococcus
 ALBUMIN
 Berat molekul 69.000 dalton
 Membatasi perpindahan cairan ke ruang Interstitial ( 49
g/dalton didalam plasma, 1 g/dalton diruang Interstitial )
 Pertahankan volume plasma ( PV ) dan volume cairan
interstitial ( IFV ) Albumin 5 % ( 500 ml ) / Albumin 25 % (
100 ml ) = 3,5 – 4,5 jam
 Albumin 5 %  isoonkotik ( TOK = 19 mmHg ) 
mempertahankan PV
 Albumin 20 % dan 25 % dari ruang Interstitial ke
Intravaskular  100 ml Albumin 20 %  300 ml
 GELATIN
Gelofusin
 Haemaccel

 Each 100 ml contains :

Polygeline Polypeptides of degraded gelatin,
Electrolytes in m mol / litre :
Na+ 145, K+ 5.1, Ca++ 6.25, Cl- 145
Mean molecular weight 30,000
 Physico-Chemical Data
pH of the infusion solution 7.3 ±0.3
 Presentation
Infusion bottles of 500ml.
 Fluid Volume Deficit (Hypovolemia)

 Fluid Volume Excess (Hypervolemia)

 Gain: solid foods, drinks; thirst center
 Loss: water and electrolytes move in a
variety of ways, sensible and insensible
 Kidneys

 Skin

 Lungs

 GI tract
 Signs and Symptoms of Volume
Disturbances
System Volume Deficit Volume Excess

Generalized Weight loss Weight gain

Decreased skin turgor Peripheral edema
Cardiac Tachycardia Increased CO
Orthostasis/hypotension Increased CVP
Collapsed neck vein Distended neck veins
Murmur
Renal Oliguria, Azotemia

Gastro- Ileus Bowel edema

intestinal
Pulmonary Pulmonary edema
 Dehydration
 Oral fluid replacement, ORT
 IV Therapy
Check closely for fluid overload, check
vital signs and I&O
 Drug: antiemetic, antibiotic
 Treatment based on problems
 Fluid overload
 Drug: osmotic diuretics, loop diuretic
 Weights, I&O, serum electrolytes, EKG
 Check IV fluids hourly
 Assessment of cardiopulmonary, renal,
mental, skin
 Diet: restrict fluid and sodium
Sodium Homeostasis
 Serum sodium concentration is associated
with control of plasma osmolarity (Posm)

 ADH: regulator of serum osmolarity

 Na+ deficit = 0.60 x BW x (140-Na+plasma)

 Serum sodium value < 135 mEq/L
Hyponatremia
Relative water excess
Plasma Osmolality
Pseudohyponatraemia
HyperlipidaemiaNormal Decreased Increased
Hypertonic Hyponatremia
(Triglyceride > 50 mmol/l)
Pseudohyponatraemia Hypertonic Hyponatremia
Hyperlipidaemia
(Triglyceride > 50 mmol/l)
Urinary (Na) Hyperglycaemia
Hyperglycaemia
Hyperproteinaemia
Hyperproteinaemia
(Total Protein > 150 g/l)
(Total Protein > 150 g/l)

< 20 mmol/l > 20 mmol/l

Acute water overload*

ECV Increased intake plus ECV

Hypovolaemia
Drugs Chronic water overload*
RenalOedemasodium retention*
ExtrarenalHypovolaemia
sodium loss** EuvolaemiaRenal sodium loss**
Hypovolaemia
SIADH Euvolaemia
Stress: physical,
Renal sodium
Cirrhosis Extrarenal sodium Acute water overload*
DiureticsRenal sodium Chronic water overload*
retention*
Vomiting, Diarrhoea
loss** loss** Drugs
psychogenic
Increased intake plus SIADH
Cirrhosis Vomiting, Diarrhoea Hypovolaemia Diuretics Drugs
Cardiac failure
Skin loss Drugs Addison’s disease Chronic renal failure
Cardiac failure Skin loss
Hypothyroidism, Chronic renal
Addison’s disease failure
Nephrotic syndrome Stress: physical, Salt-losing nephritis Hypothyroidism
Nephrotic syndrome psychogenic Salt-losing nephritis
Hypothyroidism
Isolated cortisol deficiency
Hypocortisolism,
Hypothyroidism,
Hypocortisolism,
Renal insuficiency Isolated cortisol deficiency
*Dilutional hyponatraemia Renal insuficiency
** depletional hyponatraemia
 Depends on rate of hyponatremia
 Increased ICP (brain edema) serum [Na+]
< 125 mEq/l (rapid onset)
 Anorexia, nausea, vomiting
 Muscle twitching/weakness/ cramping
 Headache
 Lethargy, confusion, seizures
 Is the hyponatremia severe ?
(Na) < 125 mmol/l)

Yes No

Are there symptom ? Significant

(confusion, atasia, headache, seizures, obtundation) Sequelae unlikely

Yes No

What is the duration of the hyponatremia ? Hyponatraemia likely chronic

Acute (< 48 h)
Emergency correction with
hypertonic (3%) saline (1-2 mL/kg
hourly until (Na) > 125 mmol/L)
Urgene intervention
Chronic/ unknown (> 48 h) unnescessary. Assess
ECF volume and correct
(Na) at hourly rate of
Urgene correction with 0.9% saline or, about 0.5 mmol/l
until symptoms resolve, with hypertonic
(3%) saline (1-2 mL/kg hourly); there
after, correct at rate of about 0.5 mmol/L
hourly with 0.9% saline

What is the ECF volume status ?

Contracted Normal or near normal Expanded

Discontinue offending
medications, restore intravascular
volume with 0.9% saline, given
intravenously; then give salt and
water orally
Role out hypothyroidism and
hypoadrenalism, discontinue
offending medications, restrict
fluids to 750 – 1500 mL/d; give
demeclocycline 600 mg/d
Optimize treatment of
underlying problems (cardiac,
hepatic, renal; restrict salt and
water intakes, give diuretics
 Case 1

2 months baby boy (BW 5 kg) brought to ER with

seizure. Physical exam revealed sunken eye and
fontanella. There was episode of diarrhea since 2
days ago. Laboratory finding  Sodium level 114
mEq/L.
Langkah pertama : koreksi cepat
Anda memutuskan pemberian salin 3% untuk koreksi
cepat natrium dengan target 120 mEq/L

Jumlah NaCl = 0.6 x 5 kg x (120-114)= 18 mEq Na+

3% NaCl = 0.5mEq/L atau ± 36 mL larutan NaCl 3%

atau

(1.2 mL/kg) NaCl 3% meningkatkan kadar natrium ± 1

mEq/L

1.2 mLx5kg x (120-114) = 36 mL larutan NaCl 3%

 Langkah kedua: koreksi lambat

Target :
meningkatkan kadar natrium 12 mEq/L dari baseline 120
mEq/L

0.6 x 5 kg x (132-120) = 36 mEq/L tambahan natrium yang

dibutuhkan selama 24 jam kemudian

Defisit/sisanya dikalkulasi dan ditambahkan serta diberikan

selama
12-24 jam
 Varies depending on fluid volume

 Fluid shifts from IC to EC space 

cellular shrinkage: confusion, coma,
intracranial hemorrhage

 Most commonly signs of dehydration

 Serum sodium value > 145 mEq/L
Relative water deficit
Hypernatraemia

Extracellular
volume

Euvolaemia Hypervolaemia Hypovolaemia

Salt gain
IV bicarbonat
Salt gain
IV bicarbonat
IV hypertonic saline
Urine/plasma IV hypertonic saline Urine/plasma
Osmolality Oral salt
Oralingestion
salt ingestion Osmolality
Mineralocorticoid
Mineralocorticoidexcess
excess
Diabetes Insipidus
Neurogenic:
<1 =1 >1 >1 =1
congenital
Diabetes Insipidus Osmotic
trauma Diuresis
Osmotic Extrarenal
Diuresis Pure WaterPure
Extrarenal Extrarenal
Depletion hypotonic
Extrarenal Osmotic fluiddiuresis
Osmotic diuresis
Neurogenic: glucose, urea, sodium Water Depletion hypotonic fluid
neoplasia
congenital
glucose, urea, sodium intake:
Inadequate depletiondepletion
Inadequate intake:
Glucose, urea,
Glucose, urea,
sodiumsodium
infection
trauma too old, too young, GI: vomiting, diarrhea
neoplasia too old, too young, too
too sick GI: vomiting,
sick
to drink, to drink, diarrhea
Nephrogenic: Skin: excessive
infection no access to no access to water
water sweating
congenital
Nephrogenic: lesion thirst Skin:
centre excessive sweating
renal disease
congenital lesion thirst centre
oesophageal
renal disease
hypercalcaemia obstruction
hypercalcaemia oesophageal obstruction
hypokalaemia
hypokalaemia

Hypovolaemia
Correction of volume
deficit
Administer isotonic saline
Treatment for etiology of
losses
Correction of water deficit
Calculate water deficit
Administer 0.45% saline,
5% dextrose or oral water,
replacing deficit and
ongoing losses
Hypernatraemia
Extracellular volume
Euvolaemia Hypervolaemia
Correction of water deficit Removal of sodium
Administer 0.45% saline, Discontinue offending
5% dextrose or oral water, agents
replacing deficit and Furosemide
ongoing losses Hemodialysis
Follow serum [Na}
Long term therapy
Central DI
Pharmacologic therapy
Nephrogenic DI
Correction of [K] and [Ca]
Removal offending drugs
Low sodium diet
Pharmacologic therapy
 Calculation of TBW deficit and replacement
volume: The calculation of free water deficit is
based on assumption that the product of TBW
and plasma sodium concentration is always
constant
 Current TBW X Current P Na = Normal TBW X
Normal P Na Current TBW = Normal TBW X
(140/Current P Na)
 TBW deficit (L) = Normal TBW – Current TBW

Example: Assume that the child with weight of 10

kg has plasma sodium of 160 mEq/L. The normal
TBW will be 0.5 X 10 = 5 L. The current TBW is 5
X 140/160 = 4.375 L.

The TBW deficit is 5 - 4.375 = 0.625 L.

 Replacement of volume: The volume of
replacement fluid needed to correct the water
deficit is determined by the concentration of
sodium in the replacement fluid.

 Replacement of volume (L) = TBW deficit X (1/1-x)

(x = replacement fluid Na/154). If the replacement
fluid is 0.45 normal saline, the replacement volume
will be 0.625 X (1/0.5) = 1.25 L
 Dehidrasi Hipernatremia
 Penting untuk koreksi lambat
 Rekomendasi  tidak lebih dari 0.5
mEq/L/jam atau 12 mEq/L/hari

Kalkulasi :
 Free water deficit =
(Berat badan dlm kg x 0.6) x 1 – (Na+ target /Na+sekarang)
(1000mL/L)
ATAU
 4 ml/kg free water ~ dapat menurunkan kadar
natrium 1 mEq/L
 Case 2

10 month old child (8 kg) came to ER with a chief

complaint acute watery diarrhea. Clinical findings
showed mild-moderate dehydration. Sodium level
was157 mEq/L.
 Dehidrasi hipernatremia

 Free water deficit = (8x0.6) x 1 – (145/157) x (1000 mL/L)

365 mL = 4.8 x 0.076 (1000 mL/L)

 Kalkulasi cepat :
4mL x 8kg x 12mEq/L = 384 mL free water

 Jumlah cairan rumatan untuk anak dengan berat badan 8-kg

(100mL/kg x 8) = 800 mL/24 jam

 1 L dari ½ normal saline = 500 mL free water

 1 L dari ¼ normal saline = 750 mL free water

1 L D5 ½ NS akan memberikan 400 mL free water, dan merupakan

starting point yang baik
Potassium Homeostasis
 K+ is major IC cation.
 ECF : 2% of total body potassium
 Total IC K+ ~ 40-50 mmol/kg BW
 ECF K+ ~ 1 mmol/kg BW
 Effect: muscle contraction + nerve
conduction
 Losses from GI, Kidney or skin
 Rarely, transcellular flux of K+
 Vomiting
 Extracellular vol contraction  elevated
aldosterone  1. renal Na+ reabsorption
2. increased K+ secretion
 Massive burn: tissue brakedown + fluid
loss
 Cardiac arrhythmias
 ECG
 Early: T-wave flattening or inversion
and depressed ST segment
 Late: U waves and prolonged Q-T int

 Weakness (< 2.5 mEq/l)

 Flaccid paralysis with respiratory
compromise
 Ileus
63
 Correction of plasma [K+] follow by
repletion of the total body K+ deficit
 Take time for [K+] to be transferred into
cells
 Concentration 40 mEq/l (peripheral iv)
 Rate <20-40 mEq/hr or 0.3-0.5 mEq/kg/hr
 ECG mornitoring
 HIPOKALEMIA

Protokol konservatif IV replacement:

3.0-3.5 mEq/L  0,25 mEq/kg of IV KCl dalam 1

jam

2.5-3.0 mEq/L  0.5 mEq/kg of IV KCl dalam 2 jam

<2.5 mEq/L  0.75/L of IV KCl dalam 3 jam

Periksa kadar kalium di pertengahan

====>>>> HIPOKALEMIA SIMTOMATIS

 HIPOKALEMIA

IV replacement :

• Pada IV tunggal, KCl tidak melebihi 0.5 mEq/kg/jam,

maksimum dosis 10 mEq dalam 1 jam

• Diberikan melalui jalur vena sentral

• Jalur perifer : kalium jangan melampaui 40 mEq/L

 Hypokalemia
Hypokalemia Serum K < 3 mEq/dL

- Severe muscle weakness

- Paralytics ileus
- ECG abnormalities

YES
IV KCL 0,3-0,5 mEq/kg in
No NS over 1 hour under
cardiac monitoring
History, examination, ABG
No Response

Metabolic acidosis Metabolic alkalosis

IV KCL 1 mEq/kg under
current medications can be
- Diarrhea - Emesis or nasogastric repeated (Max in peripheral
- Distal RTA loss vein = 40 mEq/kg and in
- Diabetic - Aldosterone excess central = 60 mEq/kg
ketoacidosis - Diuretic therapy
- Bartter syndrome
- Gitelman syndrome ECG Normal or
asymptomatic

Treat the Cause Conservative dosing

- Oral KCl 1-2 mEq/kg/day

- Fruits and vegetables (e.g banana
 Sudden
 Rapid administration

 Transcellular flux of K
+

Severe metabolic acidosis, insulin

deficiency, Rhabdomyolysis
 Sustained
 Impairment of renal K
+ excretion

Oligulic renal dysfunction

 Pseudo-hyperkalemia
 K
+ from red cell or platelets
 Weakness and myocardial irritability
 ECG
 High peak T-wave
 Widening of QRS complex
 Ventricular fibrillation
 Mild  conservative treatment
 Severe  therapeutic modalities
 Acute myocardial
infarction
Tall but broad-based
and asymmetrical
 Mechanism of Time
Treatment
action frame
Antagonizes effects of
IV calcium Seconds to
hyperkalemia on the
gluconate minutes
cell membrane
Glucose, Insulin, Translocation of K+
30-60 min.
sodium bicarb. into cells
Rectal or orally Binds and hastens 1-4 hr
K+ binding excretion of K+ into (rectal)
resins colon >6 hr (oral)
Movement across a
Dialysis Immediate
concentration gradient
 CALCIUM
HOMESTASIS
 Total body calcium ~ 1000 g
 Bone 99%

 ECF 1%

Free 40%
Bound albumin 50%
 Only free ionized is active (4.5-5.5 mg/dl)
 Ionized Ca++ = Total serum calcium – 0.8
x serum albumin
 CALCIUM HOMEOSTASIS

PTH = Parathyroid D3 = Vit D

CT = Calcitonin

BONE reservoir
excretion

RENAL INTESTINAL
source

Total Serum Ca
Ion complex + Prot. Bound Ca+

PH
 Most frequent cause : low serum albumin
 Others:
 Acute pancreatitis

 Massive soft tissue infection

 Small-bowel fistulalle

 Hypoparathyroidism

 Massive blood transfusion : citrate

 Manifestation: < 8 mg/dl

 Numbness at tip of fingers
 Tetany or seizure
 Trousseau´s sign or Chovstek´s sign
 ECG: prolonged Q-T interval
Directed to underlying caused
Asymptomatic 75mg/kg/day elemental Ca
divided into 6 equal doses PO
Symptomatic medical emergency
IV Replacement therapy

Solution Elemental Ca osmolarity

10% CaCl2 27mg (1.36mg/L) 2000 mOsm
10% CaGluc. 9 mg (0.46 mEq/L) 680 mOsm
NOTE FOR IV. REPLACEMENT
1. Used large central vein if possible (Cacl2), for
peripherial line Ca gluc, is the preferred sol.
2. IV bolus elemental Ca 75-150mg slowly
over 10 minutes, diluted in 100ml Nacl 0,9%
 Cacl2 10% : 0,1ml/kg/IV
Ca gluc 10% : 2ml/kg/IV
3. Follow with a continous infusion of 1-2 mg
elemental Ca/kg/hour for 6 – 12 hours
 Most frequent cause (90%) : Primary
hyper parathyroidism and malignant
disease
 Confusion, lethargy, coma, muscle
weakness, anorexia, N/V, pancreatitis and
constipation
 Produce:
 Renal stone

 DI and polyuria

 ECG: shortened Q-T interval.

 Common  Less common
Primary Inherited disease
hyperparathyroidism MEN type I, II
Adenoma Familial
Carcinoma hypocalciuric/hypercalcemia
Hyperplasia Granulomatous disease
Malignancy Drug induced
Humoral hypercalcemia Lithium, Vitamin D, A
Lytic bone disease Thiazides, Aminophyline
Ectopic 1,25(OH)2 vitamin Estrogens
D production Milk-alkaline syndrome
Immobilization
Renal failure
Neonatal hypercalcemia
 AGENT DOSE COMMENT
Isotonic Nacl 10 ml/kg/hr Hydration and correct
hypovalemia
Furosemide 1 mg/kg/q 6 hr Maintain urine output
100-200 ml/hr
Calcitonin 4-8 /kg/24 hr Only works 1-7 days
(down regulated)
Hydrocortisone 0,05 mg/kg/q 6 hr Used as an
Prednisone 1-2 mg/kg/q 6 hr adjunct to CT
Pamidronate 90 mg continious Biphosphanates
Infusion for 24 hrs inhibit
Etidronate 15-50 mg/kg 4 hrs osteo clastic activity
Gallium Nitrate 200 mg/m2 BSA by Inhibition of
continious infusion Bone resorption &
for 5 days nephrotoxic
 Hypercalcemia should be corrected before elective surgery
 Catatan Kunci

Kebutuhan cairan rumatan untuk 10 kg

01 pertama 100 ml/kg, 10 kg berikutnya 50

ml/kg dan selanjutnya 20 ml/kg

Kebutuhan rumatan K+, Na+ dan Cl- adalah 1,

02 2 dan 3 mEq/kg/1000 ml air

Dalam keadaan normal, proporsi air yang

03 keluar dari tubuh: 50% melalui urine, 30%

melalui kulit, dan 20% melalui pernapasan

IKATAN DOKTER ANAK INDONESIA 82

 Catatan Kunci
Dehidrasi isotonik direhidrasi dengan cairan

04 isotonik, dehidrasi hipotonik dengan cairan

isotonik dan Na+, dehidrasi hipertonik
dengan cairan isotonik dan H2O

Kecepatan maksimal koreksi kalium 0,5

05 mEq/kg/jam

06 Obat untuk tatalaksana akut hiperkalemia

antara lain adalah kalsium, insulin, bikarbonat

dan salbutamol

IKATAN DOKTER ANAK INDONESIA 83