Textbook Reading

Disorders of Electrolytes
(in surgical patients)
TAV/ARZ

Pendahuluan
Penatalaksanaan cairan dan elektrolit sangat
esensial dalam perawatan kasus bedah
(perioperative care)
Gangguan keseimbangan tersebut dapat terjadi
pre,intra&post (operasi)
Sering menyertai pada kasus2 critical ill
(trauma & sepsis)
Topik ini dikhususkan hanya pada gangguan
keseimbangan elektrolit
Na dan K merupakan elektrolit utama yang
perlu pembahasan

13/

Komposisi Cairan Tubuh

TOTAL BODY WEIGHT 100%

TOTAL BODY WATER 60%
ICF 40%

ECF 20%
IVF
5%

Kompartemen cairan tubuh

Komposisi elektrolit dalam cairan

Natrium
Fungsi Natrium
Regulasi osmolalitas plasma
Mengatur permeabilitas membran sel
Berperan dalam konduksi impuls dan saraf
Kadar normal : 135 -145 mEq/L
Kebutuhan per hari: 2-4 mEq/kgBB/hari

Hyponatremia

13/

Manifestasi klinis

Sistem organ
Central nervous system
Musculoskeletal
Gastrointestinal
Cardiovascular
Tissue
Renal

Hyponatremia
Nyeri kepala, confusion, hyper-or hypoactive deep tendon
reflexes, kejang, koma, peningkatan TIK
Kelemahan, kelelahan otot, muscle cramps/twitching
Anorexia, nausea, vomiting, diare
Hypertension and bradycardia
Lacrimation, salivation
Oliguria

Diagnostic
Approach

Terapi Hiponatremia (basic principles)

ECF
Osmolalitas

Volume expansion dg 0,9%

saline

ECF N
ECF

Restriksi cairan dg diuretik

Osmolalitas
N
No spesific therapy
Osmolalitas

Treatment
Urea(antinatriuretic&osmotic diuresis):40mg in 150cc
normal saline IV every 8h
Hypertonic saline
Loop diuretik
Vasopressin antagonis(aquaresis than diuresis):conivaptan
20-40 mg daily
Severe hiponatremi (Na<120meq/l): correction!
Total Na required: Na desired-Na measured X TBW
TBW : male 0,6 X weight(kg); female 0,5 X weight(kg)
*maximum correction is 8-12 meq/day or 130 meq after correction
*Asymptomatic : increase the sodium level by no more than 0.5-1
meq/L/h
*Symptomatic: (Na<120 meq/L) Increase the sodium level by no more
than 1meq/L per hour until the serum Na level reaches 130 meq/L or
neurologic symptoms are improved

13/

Rapid correction of
hyponatremia

central Pontine myelinolysis

Seizures, weakness/paresis,
akinetic movements,
unresponsiveness

Permanent brain damage

Death

13/

Hypernatremia

Iatrogenic
Selalu hiperosmoler
Respon tubuh: haus dan release ADH

Etiologi

Renal

Hiperglikemia, manitol, diet

tinggi protein (produksi urea),
diabetes incipidus

Non
Renal

Diare
Insensible losses (fever &
burn)

Free water
loss

Sodium
intake

13/

Manifestasi klinis

Body system
Central nervous system
Musculoskeletal
Cardiovascular
Tissue
Renal
Metabolic

hypernatremia
Restlessness, lethargy, ataxia,
irritability, tonic spasms,delirium,
seizures, coma
weakness
Tachycardia, hypotension,
syncope
Dry sticky mucous membranes,
red swollen tongue,decreased
saliva and tears
Oliguria
Fever

Diagnostic
Approach

Terapi Hipernatremia

Free water
loss

Sodium
intake

D5% atau NaCl 0,45% iv/oral

Water defisit = [left (serum sodium140)/140] x TBW (liters)
Or:
Change in serum Na+ = (infusate Na+ serum Na+) (TBW + 1)

Diuretik (furosemide)

The rate of fluid administration:

1. Acute hypernatremia: a decrease in
serum sodium of no more than 1meq/h and
12meq/d

1. Chronic hypernatremia: a decrease in

serum sodium of no more than 0.7meq/L/h

13/

Kalium
Kation terbanyak di tubuh(98% intraseluler)
Keseimbangannya diatur oleh Na-K ATPase
pump
Ekskresi terbanyak melalui ginjal
Uptake-nya di intraseluler dipengaruhi oleh
insulin dan beta2 reseptor
Fungsi Kalium: eksitabilitas membran dan
fungsi sel
Kadar normal kalium: 3,5 5 mEq/L
Kebutuhan per hari : 1 mEq/kgBB/hr

Kalium
Rata-rata kebutuhan K per hari: 50-100meq/d
Rata-rata ekskresi melalui ginjal: 10-700meq/d
Kadar K dipengaruhi oleh:
Surgical stress
Injury
Acidosis
Tissue catabolism

Penyebab hipokalemia
Intake yg inadekuat:

Diet yang kurang

Pemberian cairan infus yg tdk mengandung K
Pemberian TPN yg tdk mengandung K

Ekskresi K yang berlebihan:

Hyperaldosteronism
obat2an

GI / renal losses:

Direct loss (diarrhea)

Renal loss (gastric fluid, either as vomiting or high nasogastric output)

Gejala klinis hipokalemia

System
Gastrointestinal
Neuromuscular
Cardiovascular
ECG changes

hypokalemia
Ileus, constipation
Decreased reflexes, fatigue, weakness,
paralysis
Arrest
U-waves
T-wave flattening
ST-segment changes
Arrhythmias

13/

Department of Surgical Education, Orlando Regional

Medical Center/adult electrlyt replacement protocols
2008

Department of Surgical Education, Orlando Regional

Medical Center/adult electrlyt replacement protocols
2008

Penyebab hiperkalemia
Peningkatan intake:

Potassium supplementation
Blood transfusions

Endogenous load/destruction:
Hemolysis atau rhabdomyolysis
Crush injury
Gastrointestinal hemorrhage

peningkatan release:

Acidosis
Rapid rise of extracellular osmolality (hyperglycemia or mannitol)

Impaired excretion:

Potassium-sparing diuretics
Renal insufficiency/failure

Gejala klinis hiperkalemia

System

hyperkalemia

Gastrointestinal
Neuromuscular
Cardiovascular

Nausea/vomiting ,colic, diarrhea

weakness, paralysis, respiratory failure
Arrhythmia, arrest

ECG changes

Peaked T waves (early change)

Flattened P wave
Prolonged PR interval (first-degree block)
Widened QRS complex
Sine wave formation
Ventricular fibrillation

13/

13/

13/

Treatment of symptomatic hyperkalemia

Potassium removal
Kayexalate
Oral administration is 15-30 g in 50-100 mLof 20% sorbitol
Rectal administration is 50 g in 200 mL 20% sorbitol
Dialysis

Shift potassium
Glucose 1 vial of D50% and regular insulin 5-10 units intravenous
Bicarbonate 1 vial intravenous

Counteract cardiac effects

Calcium gluconate 5-10 mL of 10% solution

Calcium
Fungsi utama:
Transmisi impuls saraf
Kontraksi otot jantung
Faktor pembekuan darah
Pembentukan gigi dan tulang
Kontraksi otot
29

http://lpi.oregonstate.edu/infocenter/minerals/calcium/capth.html
30

Kalsium

Kebutuhan harian: 1-3g

Asidosis meningkatkan fraksi kalsium yang terionisasi oleh karena menurunkan

ikatan dengan protein

Hiperkalsemia

Penyebab : Hiperparatiroidism dan malignansi

Gejala: Gangguan neurologis, kelemahan otot dan nyeri, disfungsi renal, mual,
muntah, nyeri perut, hipertensi, aritmia, peningkatan toksisitas terhadap obat2an
digitalis

EKG : pemendekan QT interval, pemanjangan PR&QRS interval, peningkatan QRS

voltage, T wave flattening & widening, AV block->arrest

13
Hipokalsemia
penyebab: pancreatitis, infeksi soft tissue yang luas, gagal
ginjal,fistula enteral, hypoparathyroidism, tumor lysis syndrome,
massive blood transfusion with citrate binding
Gejala: parestesia wajah dan ekstremitas, kram otot, stridor,
tetani, kejang, hyperreflexia, Trousseaus sign, Chvosteks sign,
penurunan kontraktilitas jantung, gagal jantung
EKG : prolonged QT interval, T wave inversion, heart block, Vfib

Koreksi hipokalsemia
Normalized calcium level <4.0 mg/dL:
With gastric access and tolerating enteral
nutrition:
Calcium carbonate suspension 1250 mg/5 mL q6h
per gastric access;
Recheck ionized calcium level in 3 d
Without gastric access or not tolerating enteral
nutrition:
Calcium gluconate 2 g IV over 1 h x 1 dose;
Recheck ionized calcium level in 3 d

IVF Composition

Solution

Na CL K

HCO3 Ca

Mg mOsm

Extracellular
fluid

142 103 4

27

Lactated
Ringer's

130 109 4

28

0.9% Sodium
chloride

154 154

280310
273
308

D50.45%
77 77
Sodium chloride

407

D5W

253

3% Sodium

13

Kebutuhan harian
Sodium: 1-2 mEq/kg/d
Potassium: 0.5-1 mEq/kg/d
Calcium: 800 - 1200 mg/d
Magnesium: 300 - 400 mg/d
Phosphorus: 800 - 1200 mg/d

13

Lets do some exercise..

13

Laki2 40 tahun dengan crush injury extremitas

inferior D, perawatan hari ke 3 post amputasi above
knee..sepsis teratasi.. cardiac arrest..
What do you think? What do you do?

13

Pre-Arrest Rhythm Strip

Diagnosis?
HYPERKALEMIA

Treatment

CaGluk. 10% - 1 ampule (10cc)

Sodium Bicarbonate - 1 ampule
D40 & Insulin 10 U
Kayexalate

13

13

Perempuan 42 tahun dengan papillary ca throid post

op.total thyroidectomy hari ke-o.Dia mengeluh
kesemutan dan tebal di sekitar bibir. ECG QT
interval memanjang.

What do you think? What do you do?

HYPOCALCEMIA
Chvosteks sign facial muscle spasm
Trousseaus sign - carpal spasm
Treatment
monitor ECG
IV calcium (ca gluk. 10cc)
follow up labs
oral calcium supplements
normal is 1 gram/day
(800-1200mg/d)

13

13

Laki2 56 th (70kg) dgn post op TURP hari ke-0,

penurunan kesadaran, T 170/100;N 64; prod.urine
50cc/4 jam

What do you think? What do you do?

13

Na 115 mEq/L

HIPONATREMIA

dilutional(hiper

volemi)

Terapi:
1. 0,6 x 70kg x (125-115)= 420 meq (kebutuhan total)
2. kecepatan pemberian perjam tidak boleh lebih dari 0.5 meq/L/jam
: 0.6 x 70kg x 0.5 meq/l/jam = 21 meq/jam (maksimal)
3. 3% Nacl mengandung Na 513 meq/Liter
[ rate/jam ]/513 x 1000= # ml/hr
Maka : 21 meq/jam x 1000 ml = 40,93 ml/jam
513 meq/L
Lama pemberian = 420 meq : 21 meq/jam = 20 jam
Order: infuse Nacl 3% 40 ml/jam selama 20 jam. (800ml/20jam)
4. selesai koreksi lanjutkan dengan restriksi cairan

13

wanita 41th (70kg) dgn combustio gr IIAB 58%,

lethargy, N 120; Na 165meq/l; K 3,0 meq/l

What do you think? What do you do?

HIPERNATREMIA

(Insensibl

e loss)

TBW: (0.5 x 70) = 35 L

D5 %
(0 meq/l Na 165meq/l) (35 + 1) = - 4.6 meq/l
The goal is to reduce his serum sodium by no more than 10 mmol/L in a 24-hour period.
Thus, (10 4.6) = 2.17 L of solution is required.
About 1-1.5 L will be added for obligatory water loss to make a total of up to 3.67 L of D5
W over 24 hours, or 153 cc/h.