TERAPI CAIRAN PADA ANAK

SETYA BUDHY SMF/LAB ILMU KESEHATAN ANAK RS. DR SAIFUL ANWAR/FK UNIVERSITAS BRAWIJAYA MALANG

PENDAHULUAN (1)
2

CAIRAN PEMILIHARAAN DIPERLUKAN UNTUK

MEMPERTAHANKAN CAIRAN DAN NUTRISI DI DALAM KESEIMBANGAN NORMAL HIPOVOLEMIA DAN HIPOVOLEMIC SYOK SANGAT SERING DIJUMPAI DI BIDANG PEDIATRIK MENEGAKKAN DIAGNOSIS DINI DAN TERAPI CAIRAN YANG CEPAT DAN TEPAT ADALAH PENTING JIKA TIDAK DIOBATI DENGAN TEPAT, AKAN MENYEBABKAN MORTALITAS TINGGI TERAPI CAIRAN MEMILIKI PERAN PENTING UNTUK MENURUNKAN MORTALITAS

PENDAHULUAN (2)
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VOLUME RESUSITAS 1 PADA PASIEN SAKIT KRITIS

PATHOGENESIS PATHOPHYSIOLOGI YANG MENJADI PENYEBAB UTAMA PENYAKIT IVV, Na, AIR, DAN PROTEIN PLASMA

PENDAHULUAN (3)
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TATA-LAKSANA CAIRAN PADA ANAK 1. PEMELIHARAAN : MEMPERTAHANKAN CAIRAN DAN NUTRISI DALAM KESEIMBANGAN NORMAL
2.

VOLUME PENGGANTI : UNTUK MENGGANTI GANGGUAN-GANGGUAN APAPUN DARI CAIRAN TUBUH VOLUME RESUSITASI : UNTUK MEMULIHKAN BERKURANGNYA INTRA VOLUME

3.

FAKTOR-FAKTOR YANG MEMPENGARUHI TERAPI CAIRAN

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MENINGKATKAN

DEMAM (12% SETIAP 1C > 37C) HYPERVENTILATION MENINGKATNYA TEMPERATUR SEKITAR AKTIFITAS TINGGI KEHILANGAN CAIRAN ABNORMAL

MENURUNKAN

HYPOTERMIA (12% SETIAP 1C > 37C) KELEMBABAN TINGGI OLIGOURIA ATAU ANURIA TIDAK ADA AKTIFITAS MENAHAN CAIRAN (HF)

Table 1. Maintenance fluid requirements for children

Fluid regime/adjustment Baseline 1 day of age 2 days of age 3 days of age < 10 kg 10-20 kg > 20 kg Factors that decrease requireme nt 50 ml kg-1day-1 75 ml kg-1day-1 100 ml kg-1day-1 100 ml kg-1day-1 1000 ml day-1 + 50 ml kg-1day-1 for every kg over 10 kg 1500 ml day-1 + 20 ml kg-1day-1 for every kg over 20 kg

Humidified gases

X 0.75

Paralyzed High ADH (e.g. IPPV or coma) Hypothermia High ambient humidity Renal failure

X 0.7 X 0.7 -12% per 0C core temp is < 370C X 0.7

X 0.3/free fluids

Table 1. Maintenance fluid requirements for children (contd)

Fluid regime/adjustment Factors that increase requireme nt Full activity and oral feeds

X 1.5/free fluids

Fever
Room temp over 31 0C Hyperventilation Preterm neonate (< 1.5 kg) Radiant heater Phototherapy Burns day 1 Burns day 2 +

+ 12% per 0C core temp is > 37

+ 30% per 0C X 1.2

X 1.2
X 1.5 X 1.5 + 4% per 1% of body surface area affected + 2% per 1% of body surface area affected

Tabel 2. Fluid composition in the Neonates

Pre-term neonatu s 60%

Kompartemen tubuh

Infant

Dewasa (pria)

Dewasa (wanita)

Manula

Ekstraselular Intravaskular Interstitial Intraselular Total cairan tubuh

29% 4% 25% 48% 77%

15% 4% 11% 45% 60%

15% 5% 10% 35% 50%

20% 6% 15% 25% 45%

30% 90%

Daily Fluid and Electrolyte Requirement in Infant & Children

BW
Up to 10 kg 11 20 kg

Fluid (daily)
100 ml/kgBW 1000 ml/kgBW + 50ml/kg (Every kg over 10 kg) 1500 ml/kgBB + 20ml/kg (every kg over 20 kg)

> 20 kg

Body Fluid Hemeostasis

Intake & Output always

the same .
Homeostasis

Intake

Output

disturbances must be directly corrected

Equilibrium Body Fluid

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The Fluid Management Concept

Volume replacement

Fluid management

target: intravascular space

indication: plasma and blood losses colloid + crystalloid

crystalloid Fluid replacement target: tissues, interstitium indication: dehydration, maintenance

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Fluid management

Fluid Therapy
Crystalloids
Electrolyte solutions like:
NaCl 0.9%/ 0,45% Ringers solution Lactated Ringers Ringerfundin

Colloids Albumin Dextran Gelatin HES (Hydroxyeth

yl starch)

Other fluids
Glucose 5% Mannitol

Electrolyte concentrates
etc.

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KEUNTUNGAN/KERUGIAN RESUSITASI CAIRAN

13

KRISTALOID

PADA

KEUNTUNGAN
KOMPOSISI ELEKTROLIT SEIMBANG BUFFER LACTATE / ACETATE TIDAK ADA RESIKO ALERGI (ANAPILAKSIS) TIDAK ADA GANGGUAN HEMOSTASIS MURAH

KERUGIAN
PERAN VOLUME PLASMA RENDAH DIPERLUKAN DALAM JUMLAH BESAR PLASMA COP RENDAH RESIKO OVERHIDRASI RESIKO EDEMA

BOLDT ET. AL. (2004)

KRISTALOID : DIDISTRIBUSIKAN KE SELURUH RUANG EXTRASELULER DIINDIKASIKAN DAN SANGAT EFEKTIF BILA TERJADI PENGOSONGAN RUANG EXTRASELULER KOLOID : BERADA SECARA LUAS DI DALAM RUANG INTRAVASKULER SANGAT EFEKTIF BAGI PASIEN DENGAN HIPOVOLEMIK

14

KONTROVERSI KOLOID - KRISTALOID

15

KOLOID MEMPERTAHANKAN TEKANAN OSMOTIK, MEMPERKECIL AKUMULASI CAIRAN INTERSTITIAL KRISTALOID MENURUNKAN TEKANAN OSMOTIK SEHINGGA DAPAT MENYEBABKAN EDEMA PARU PRO KOLOID

BIAYA TINGGI DAN RESIKO TINGGI (KOMPLIKASI) PRO KRISTALOID

TERAPI PENGGANTIAN CAIRAN

16
KRISTALOID KOLOID

RINGER LAKTAT NORMAL SALINE

ALBUMIN

GELATIN

DEXTRAN

HES

Macrocirculation:

END-POINT FLUID RES. IN HYPOVOL SHOCK

Microcircula tion

Conciousness, BP, PP/MAP/CVP:8-12mmHg SaO2 >92%, SvcO2 >70%, Cap.refill time <2, Diuresis
Data B : t = 38oC; HR= 120 x/min; MAP= 60 mmHg

Microcirculation:
Lactate serum < 2mmol/l

Data A : t = 36,8 oC; HR= 65 x/min; MAP= 82 mmHg

Hypoperfusion

Reperfusion

deBaker, Am J Respir Crit Care Med 166:98104,2002

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Choice of Fluid Resuscitation

CRYSTALOID: RL RA NaCl 0.9%
Not effective for iv Pro-coagulant effect DVT effect/ emboli

Effective for iv HES: Sealing HES: Makro+ Mikrosirkulasi

COLLOID: GELATIN DEXTRAN HES Albumin

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Zornow, MH et al.: Fluid Management In Patients With Traumatic Brain Injury. New Horizons 3:488-498, 1995
(added by presenter)

5% Albumin 25% Albumin 5% Dextrose

Increased PV (ml) 1,000 1,000 1,000

Infused volume (ml) 1,000 250 14,000

Increased Increased ISS (ml) ICV (ml)

-750 3,700 9,300

RL
HES 200/0.5 6% MFG 4% Dextran 40 10%

1,000
1,000 1,000 1,000

4,700
1,000 1,000 500-600

3,700

-400/-500

PV plasma volume;ISS interstitial fluid volume;ICV intracellular volume;RL lactated Ringers solution,MFG=modified 19 fluid gelatin

The relative distribution of crystalloid and colloid solutions in the intra- and extravascular fluid space at equilibrium (within 30 min to 1 hour of infusion)
Fluid Intravascular Extravascular 80% 30% 80-85% 30-45% Normal capillary permeability Crystalloid 20% Colloid 70% Crystalloid 15-20% Colloid 60-70%

Increased capillary permeability

Increased capillary permeability + cell membrane dysfunction Crystalloid 10-15% Colloid 50-60% 85-90% 40-50%

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Effects of Synthetic Colloids

Retaining of fluid in the IVS Oncotic pressure

increased IV volume Venous flow back (preload)

Hemodilution

Improved rheology

Hematocrit

Cardiac output
CO

Flow resistance DO2

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Arterial oxygen concentration CaO2

KOLOID YANG IDEAL

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EFEK KUAGOLUPATI, HEMOLISIS SEDIKIT

PENGGANTIAN VOLUME CEPAT PEMULIHAN HEMODINAMIK BAIK

PENINGKATAN MUKROSIRKULASI
PENINGKATAN TEKANAN ONKOTIK PLASMA MENINGKATKAN DO2 DAN FUNGSI ORGAN

METABOLISME / PEMBUANGANNYA CEPAT

SERTA TOLERANSINYA BAIK

MASALAH DALAM TERAPI CAIRAN

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EFEK SAMPING YANG MUNGKIN SEKALI TERJADI:

PENGARUH

PADA FUNGSI RENAL PENGARUH PADA KOAGULASI REAKSI ANAFILAKTIK AKUMULASI JARINGAN GANGGUAN KESEIMBANGAN ASAM BASA

KEGUNAAN KOLOID
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MENGISI KEMBALI IVF LEBIH CEPAT DARI PADA

KRISTALOID WAKTU SYOK MENJADI PENDEK BERADA LEBIH LAMA DI DALAM IVF DIBANDING KRISTALOID TIDAK ADA INTERSTITIAL EDEM MEMPERTAHANKAN EFEK TEKANAN ONKOTIK TIDAK ADA INTERSTITIAL EDEMA

Colloid Disadvantages
Gelatin Anaphyl.Rx Coag.effect No No HES No Yes (HMW) Dextran Severe Yes

Renal
Liver Tissue Acc Dose restriction in RF

No
No No No

Yes (HMW)
May be Yes (HMW) Yes (HMW and MMW)

High dose
No No No

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Effects of PVR solutions on haemostasis and coagulation

Gelatins Factor VIII, vWF Platelets Adhesion Aggregation Thrombus formation Blood typing No effect No effect HMW- HES Dextrans

No clinical effect No effect In emergency situation blood typing prior to infusion

!
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Hydroxethylstarch (HES) Classification

(Based on the degree of substitution)
Tetrastarch (0.4) Pentastarch (0.5) Hetastarch (0.7)

HES 130 /0.4 HES 130/0.42

HES 200 /0.5

HES 450 /0.7

(Based on In Vitro Molecular weight)

High molecular weight HES HES 450 / 0.7 HES 470 /0.7 Medium Molecular weight HES HES 200 /0.5 HES 200 /0.62 , widahes, Low molecular weight HES HES 40 /0.5 HES 70 /0,5 HES 110 /0.5 HES 130 /0.4 HES 130/0.42

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Effects of colloids on kidney function

Gelatins:
No negative effect! Improved kidney function!

Dextrans: Renal insufficiency is possible after Dextran 40 HES:

Acute renal failure after HES is possible

Decrease of glomerular filtration

Dextran concentration in proximal tubuli

Latent increase of urine viscosity

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Enhanced flow resistance

Stop of filtration

 FLUID MANAGEMENT

NO HEMODYNAMIC STABIL??

FLUID CHALENGE

GOOD PERIPHERAL PERFUSION HR AND MAP( N) Sao2 > 92%

NON-SHOCK YES MANAGEMENT

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FLUID - CHALENGE
RESPONSIVE TO FLUID CHALENGE

(20ml/kg <10 min) Crystalloid or Colloid

1. YES
FLUID REPLACEMENT / RESUSCITATION (Shock management)

STABIL

RONKHI CVP

FLUID RESTR FUROSEMIDE

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RESPONSE TO FLUID CHALENGE

COLD EXTREMITY

2.

NO
INOTROPIC NO

VASOPRESOR

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Fluid Resuscitation in Shock

Compensated shock : Crystalloid or

Colloid 10 m l/ kg/ 20 30 min, until 3x Decompensated shock : Colloid and or Crystalloid 20 ml / kg / <10 min, 3x
PERIPHERAL PERFUSION, Hb, Ht, platelet,
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Peripheral Perfusion: Bad

HEMORRHAGE SEVERE VASC. LEAKAGE

REFFERAL HOSPITAL

WITH PICU FACILITY

INVASIVE HEMODYNAMIC MONITORING : cvp, SvcO2 LACTATE SERUM, BGA, ELECTROLYTE,ECHOCADIOGRAM CHEST- X RAY
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PESAN AKHIR
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DIAGNOSIS AWAL DARI KOMPENSASI SYOK

RESUSITASI CAIRAN UNTUK HIPOVOLEMIK

SYOK PADA ANAK DENGAN KOLOID ATAU KRISTALOID PENGIRIMAN AWAL (KE RUMAH SAKIT RUJUKAN) PADA HIPOVELEMIK SYOK BERKEPANJANGAN (RESUSITASI CAIRAN 3X GAGAL)

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