Clinical Signs
Adequacy of Perfusion
Urine output
Mental status
Capillary refill
Skin color
Temperature
Pulse rate
Signs of low perfusion
Oliguria
Hypotension
Syok
Syok kompensasi
Sistim homeostasis masih berfungsi
Syok dekompensasi
Sistim homeostasis sudah terganggu
Syok ireversibel
Sistim homeostasis sudah gagal
Clinical Assessment
Dehydration and Shock
Compensated shock
History
Physical findings
Decompensated shock
At the point of loss of blood pressure the
end organ injury is often irreversible
Clinical Assessment
Dehydration and Shock
Nelsons Textbook of Pediatrics
3- 5% dehydration
alert, moist membranes, normal pulses
6 - 9 % dehydration
lethargy, sunken eyes, weak pulses
> 10 % dehydration
drowsy, very sunken eyes, pulses impalpable
5
Clinical Assessment
Dehydration and Shock
Rogers Textbook of Pediatric Intensive Care
5% dehydration
pale, dry membranes, decreased skin turgor
10% dehydration
lethargy, very dry membranes, increased pulse
15% dehydration
lethargic to coma, mottled, cracked membranes,
tachycardia
Clinical Assessment
Dehydration and Shock
WHO criteria = mild, moderate, severe
Mild (3-5%)
slightly dry buccal mucous membranes,
increased thirst
Moderate (6-9%)
sunken eyes, sunken fontanel, loss of skin
turgor, dry membranes.
Severe (>9%)
moderate dehydration + signs of overt shock
7
Clinical Assessment
Dehydration and Shock
Sunken eyes
Capillary refill
Clinical examination
Sensitivity
33 % for 6-10% dehydration
71 % for >10% dehydration
The Fundamentals
of Therapy in Dehydration
Boluses
Maintenance Fluids
Replacing of Deficit
The Fundamentals
Therapy in Dehydration
Rapidly delivered IV fluids
Make children with dehydration better
quickly
10
Bolus cairan
Pemberian bolus cairan IV / IO pada
semua bentuk syok kecuali syok
kardiogenik
Tujuan : Menyelamatkan otak dari
hipoksia dan iskemia
The Fundamentals
Therapy in Dehydration
Boluses
20 cc/kg of NS or LR
May be repeated every 10 minutes X 3.
If not responsive to 60cc/kg over 30 to
45 minutes
The next intervention
Boluses with 5% albumin
Pressors
12
Terapi cairan
Resusitasi ABC
Bolus kristaloid 10-30 ml/kgbb IV/IO 6-10
menit
Nilai perfusi sistemik
Laju denyut jantung dan nadi, tekanan
darah, diuresis.
Bila masih syok : Bolus kristaloid kedua
Nilai perfusi sistemik
Bila masih syok : Bolus kristaloid atau koloid
sampai perfusi membaik dan syok teratasi
13
14
The Fundamentals
Therapy in Dehydration
Replacing of Deficit
Over and above maintenance
Over 24 hours
Mild
: 50 cc/kg
Moderate
: 100 cc/kg
Severe
: 150 cc/kg
15
16
Pemantauan CVP
Pemantauan tekanan atrium kanan
Indikasi
Bila dalam 1-2 jam jumlah cairan > 50100 ml/kgbb
Diuresis 1ml/kg/jam
17
Pemantauan CVP
CVP / tekanan atrium kanan : < 10
mmHg
Fungsi miokard baik
Terapi cairan dapat diteruskan
18
Pemantauan CVP
CVP / tekanan atrium kanan : > 10
mmHg
Disfungsi miokard
Penurunan kontraktilitas ventrikel
Peningkatan resistensi vaskular paru (after
load)
Syok kardiogenik
The Fundamentals
Therapy in Dehydration
Maintenance Fluids
Isonatremic dehydration (Na = 130 -150)
Children under 5
D5 1/4 NS for
First 10 kg : 4 cc/kg/hr
Next 10 kg : 2 cc/kg/hr
Thereafter 1 cc/kg/hr
20
The Fundamentals
Therapy in Dehydration
The choice of fluid to be used
Based on the clinical situation.
The primary defect is a decreased
intravascular volume.
Assuming membrane permeability is normal
1 gram albumin holds 14-15 cc of water in the PV
1 gram starch holds 16-17 cc of water in the PV
21
Isotonic Crystalloid
Na
Cl
NS
154
154
LR
130
109
Lactate
Ca
28
Mg
22
Colloid
Na
5% Albumin
154
25% Albumin
145
154
23
Cairan resusitasi
Kristaloid : NS, RL, dan RA
Koloid
: Albumin, FFP,
hetastarch,
gelatin
dextran, dan
24
Cairan resusitasi
Kristaloid
Koloid
Murah
Reaksi sensitivitas
(-)
Di ruang
intravaskular
sebentar
Perlu 4-5 kali defisit
Edema paru
Lebih mahal
Reaksi sensitivitas
(+)
Di ruang
intravaskular lebih
lama
Lebih efisien mengisi
ruang intravaskular
25
Cairan resusitasi
Darah, fresh frozen plasma,
komponen darah
Mengganti kehilangan darah
pada trauma
Terapi paliatif koagulopati
Diberikan sesudah bolus
kristaloid
26
Isonatremia
Isotonik-Hipovolemia
Hitung defisit
Hitung maintenance
Air
Na
Air
Na
Isonatremia
Isotonik-Hipovolemia
Contoh
Dehidrasi 10%: (BB : 5 kg 4.5 kg)
Defisit air : 500 ml
Defisit Na : 500 ml x 154 mEq/L
= 77 mEq
Maintenance air
: 5 (kg)x100 mL/kg = 500 ml
Maintenance Na
: 5 (kg)x3 mEq/kg = 15 mEq
Total H2O / 24 hr = 500+500 = 1000 ml
Total Na /24 hr
= 77 + 15 = 92 mEq
28
Therapy
Hyponatremia-Isotonic
Treat underlying disorder
29
Therapy
Hyponatremia -Hypertonic
Treat underlying disorder
Correcting fluid deficit initially with
isotonic saline
Insulin to decrease glucose
Hypotonic saline to correct free water
deficit
30
Therapy of
Hyponatremia-Hypotonic
Hypovolemic
Isotonic saline
Hypervolemic
Water restriction, salt restriction, diuretic
therapy
Isovolemic:
Chronic : Water restriction
Acute
Hypertonic solutions
Furosemide
31
Hiponatremia
Hipotonik-Hipovolemia
Hiponatremia
Hipotonik-Hipovolemia
Contoh
Dehidrasi 10% (BB : 5 kg 4.5 kg) Na 125 mE/L
Jumlah Na: hiponatremia isonatremia
Na = (NaD-NaA) x TBW mEq
Na = (135-125)
x 0.6 x 5
= 30 mEq
Defisit air
= 500 ml
Defisit Na
= 500 ml x 154 mEq/L = 77 mEq
Maintenance air = 5 (kg) x 100 ml/kg
= 500 ml
Maintenance Na = 5 kgx3 mEq/kg Na = 15 mEq
Total air/24 jam = 500 + 500
= 1000 ml
Total Na/24 jam = 30+77+15
=122 mEq
33
Therapy
Hyponatremia-Hypotonic
Severe hyponatremia with CNS symptoms
3% saline is given in 5 cc/kg bolus until
seizures stop
Each of these boluses should increase the
plasma Na by 5 meq/L.
Hypertonic saline at a rate 2 mEq/liter/hour
Diuretic
34
Hyponatremia
HypotonicHypervolemic
Water restriction
Salt restriction
Diuretic
35
Hypotonic
Hyponatremia-Isovolemic
Chronic
Water restriction
Acute
Hypertonic solutions
Furosemide
36
Hyponatremia
Hypotonic-Hypovolemic
Initial resuscitation
Isotonic saline as for isotonic
dehydration
37
Therapy of Hyponatremia
Asymptomatic hyponatremia.
More conservatively
Water restriction and salt intake
Intravenous normal saline
38
Therapy of Hyponatremia
Severe hyponatremia with CNS symptoms
3% saline is given in 5 cc/kg bolus until
seizures stop
Each of these boluses should increase the
plasma Na by 5 meq/L.
Hypertonic saline at a rate 2 mEq/liter/hour
Diuretic
Rapid correction of hyponatremia.
Central pontine myelinolysis
39
Hyponatremia
Hypotonic-Hypovolemic
Rapid correction of hyponatremia.
Central pontine myelinolysis
The specific rate : debated
Close monitoring and slow correction
40
Therapy
Hypernatremia-Hypovolemic
Initial resuscitation
Identical to isonatremic dehydration
Replace the fluid deficit evenly over 48
hours with D5 1/2 NS
Normal saline if renal function is adequate
Hypotonic solutions in presence of marked
renal failure
41
Therapy
Hypernatremia-Hypovolemic
The rate of deficit replacement
The sodium concentration of the fluid
Several underlying principles
1) careful, frequent monitoring of serum
sodium and osmolarity
2) attempt to lower serum sodium slowly, < 1
meq/L/hr
3) monitor clinically for changes in mental
status and seizures
42
Hypernatremic
Hypovolemic
Complications
Concomitant hypocalcemia and hyperglycemia
Intracerebral thrombosis and hemorrhage
Rupture of bridging vessels of the subarachnoid
and subdural spaces when the CNS volume
contracts.
Cerebral edema
During the resuscitation and rehydration phase
The ECF osmolarity falls and fluid is shifted
intracellulary.
43
Therapy
Hypernatremia-Hypovolemic
Hypotonic fluid loss is the most common form
of hypernatremia.
It is caused by gastroenteritis, osmotic
diuresis.
Signs of intravascular depletion are evident.
Treatment involves replacement volume with
normal saline, followed by correction of the
free water deficit.
44
Hiponatremia
Hipotonik-Hipovolemia
Hipernatremia isonatremia
Selanjutnya
Sesuai : IsonatremiaIsotonik-Hipovolemia
45
Hiponatremia
Hipotonik-Hipovolemia
Contoh
Hiponatremia
Hipotonik-Hipovolemia
Contoh
47
Hiponatremia
Hipotonik-Hipovolemia
Maintenance Air
= 500 ml
5 (kg) x 3 mEq/kg
= 15 mEql
Maintenance Na
Hiponatremia
Hipotonik-Hipovolemia
Hati-hati:
= 2 x maintenance +
= (2x500) + (1 x 500)
Na = 2 x maintenance +
= (2x15)+(1x5)
1 x defisit
=1500 ml
1 x defisit
= 35 mEq
49
Therapy
Hypernatremia-Isovolemic
Therapy
Partial DI
Chlorpropamide, carbamazepine, clofibrate
Therapy
Hypernatremia-Hypervolemic
Therapy
Diuresis
Replacing urinary losses with water
51
Therapy
Hypernatremia
Diabetes Insipidus (CDI)
Treatment
Desmopressin (dDAVP) 0.1 - 0.4 cc intranasally or
intrabucally every 8 to 12 hours.
52
Therapy
Hypernatremia
Nephrogenic DI
Renal tubular unresponsiveness to
endogenous ADH.
Etiology
Kidney disease, Lithium
Treatment
Remove offending drug
Thiazide diuretics paradoxically decrease urine
volumes.
53
Therapy
Hypernatremia
Nephrogenic DI (NDI)
Characterized by renal tubular
unresponsiveness to endogenous ADH.
Etiology:
Kidney disease, Lithium
Treatment:
Remove offending drug.
Thiazide diuretics paradoxically decrease urine
volumes.
54
Therapy
Hypernatremia
Nephrogenic DI (NDI)
Characterized by renal tubular unresponsiveness to
endogenous ADH.
Etiology:
Kidney disease, Lithium
Therapy
Hypernatremia
Hypovolemic hypernatremia
Normal saline if renal function is adequate
Hypotonic solutions in presence of marked renal
failure
56
Therapy
Hypernatremia
Isovolemic hyponatremia
Central diabetes insipidus
Vasopressin
Lysine vasopressin
DDAVP
Partial DI
Chlorpropamide
Carbamazepine
Clofibrate
57
Therapy
Hypernatremia
Hypervolemic hypernatremia
Diuresis
Replacing urinary losses with water
58
Intraoperative
Fluid Infusion Rates
Minimal Trauma 4 ml/kg/hr
Moderate Trauma 6 ml/kg/hr
Severe Trauma 8 ml/kg/hr
Example: 20 kg child, NPO for 6 hours, undergoing
one hour hernia repair.
Deficit = 40 cc/hr for 1st 10 kg BW + 20 cc/hr for
2nd 10 kg BW = 60 cc/hr
6 hours of NPO X 60 cc/hr = 360 preop deficit
Intraop losses = 6 cc/kg/hr X 20 kg X 1 hr = 180 cc
plus blood loss
59
Hypertonic Saline
Hypertonic Saline with Dextran
(HSD)
Hypernatremic fluids increase PV
60
Potasium
61
Potassium balance
Internal Balance
1. Acidosis
K+ moves from the intracellular to the extracellular
compartment in exchange for H+
2. Insulin
Stimulates K+ uptake by muscle and hepatic cells.
3. Aldosterone
Makes cells more receptive to the uptake of K+ and
increases renal excretion of K+
62
Potassium balance
Internal Balance
4. Epinephrine
Combined alpha and beta receptor
stimulation releases K+ from the liver
Beta-receptor stimulation enhaces K+ uptake
by muscle and liver
The end result is a decrease in serum K+
5. Propranolol impairs cellular uptake of K+.
63
Potassium balance
B. External Balance - Renal Potassium
Excretion
1. An acute or chronic increase in K+ intake
leads to increased secretion in the distal
convoluted tubule.
2. A sodium load will increase flow past the
distal tubule and cause K+ wasting. The
converse is true too.
3. A mineralcorticoid deficiency leads to K+
retention and Na+ wasting, just as excess
leads to opposite changes.
64
Potassium balance
External Balance - GI Potassium Excretion
Fecal excretion of K+ normally is small
Diarrhea disorders, K+ loss increases
significantly.
65
Potassium disorders
Hypokalemia
The serum potassium is only a fair reflection
of total body potassium.
Work up:
Urinary K+ and Cl
Arterial pH and HCO3
History and PE
Current medications
Causes: Many
66
Potassium disorders
Hypokalemia
Treatment
Repletion of K+
Removal of the cause of hypokalemia.
Emergency situation
Potassium disorders
Hyperkalemia
Potassium is released from cells
At times of stress, injury, acidosis
The kidney is able to regulate potassium well
Hyperkalemia is rarely a problem.
In the presence of renal failure
Hyperkalemia becomes a common problem.
68
Potassium disorders
Hyperkalemia
It is generally treated if
Clinical features
Cardiac abnormalities
69
Potassium disorders
Hyperkalemia
Hyponatremia and acidosis
Potentiate the adverse effects of
hyperkalemia on the heart.
Peaked T waves
Flattening of P waves
Prolonged PR interval
Widening of the QRS
Sine Wave pattern
V Fib/cardiac arrest.
70
Potassium disorders
Hyperkalemia
Treatment
Restrict Exogenous K+
Calcium gluconate - 10 to 30 ml of 10%
solution over 3 to 5 minutes
NaHCO3 - 50 to 100 ml of 7.5% solution
Hyperventilation will also create an alkalosis
and drive K+ into cells
Avoid hypoventilation,
71
Potassium disorders
Hyperkalemia
Treatment
Glucose insulin
DKA
Initial resuscitation is the same as for other conditions
of dehydration
The importance of using isotonic saline must be
emphasized.
How to prevent the most feared complication of this
condition, cerebral edema.