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Terapi Cairan Pediatri

Ririe Fachrina Malisie


Subbagian Pediatri Gawat Darurat
Pediatric Intensive Care Unit/PICU
Bagian Ilmu Kesehatan Anak
RSUD Arifin Achmad/FKUR
1

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

Sensitivity of 81%. Specificity of 27%.

Capillary refill

Sensitivity 91% for >10% dehydration (95%


CI = +/- 16%)

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

The amount of fluid to be administered


Quantitated by continuous evaluation of the
response to that which is infused.

10

Bolus cairan
Pemberian bolus cairan IV / IO pada
semua bentuk syok kecuali syok
kardiogenik
Tujuan : Menyelamatkan otak dari
hipoksia dan iskemia

Meningkatkan preload dan curah jantung


Mengembalikan volume sirkulasi efektif
Mengembalikan oxygen-carrying capacity
Mengoreksi gangguan metabolik
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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

Jumlah cairan resusitasi


Satu jam pertama
: 40-80 ml
/kgbb
Beberapa jam berikut
: 200 ml/kgbb
Peningkatan volume intravaskular 30%
tidak mempengaruhi tekanan atrium
kanan

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

Batas terapi cairan


Disfungsi miokard
Tekanan vena sentral
Kebocoran vaskular dan edema
Curah jantung dan perfusi perifer tidak
meningkat

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

Pemberian bolus cairan dihentikan


Obat resusitasi
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The Fundamentals
Therapy in Dehydration
Maintenance Fluids
Isonatremic dehydration (Na = 130 -150)
Children under 5
D5 1/4 NS for

Children 5 and older


D5 1/2 NS for

First 10 kg : 4 cc/kg/hr
Next 10 kg : 2 cc/kg/hr
Thereafter 1 cc/kg/hr

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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

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Isotonic Crystalloid
Na

Cl

NS

154

154

LR

130

109

Lactate

Ca

28

Mg

22

Colloid
Na
5% Albumin

154

25% Albumin

145

Plasma Protein Fraction


6% Hetastarch
Dextran 40

154
23

Cairan resusitasi
Kristaloid : NS, RL, dan RA
Koloid
: Albumin, FFP,
hetastarch,
gelatin

dextran, dan

Darah dan komponen darah


Cairan mengandung dekstrosa
tidak diberikan secara bolus

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

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Cairan resusitasi
Darah, fresh frozen plasma,
komponen darah
Mengganti kehilangan darah
pada trauma
Terapi paliatif koagulopati
Diberikan sesudah bolus
kristaloid

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Isonatremia
Isotonik-Hipovolemia

Hitung defisit

Hitung maintenance

Air
Na
Air
Na

Asumsi : isotonik ~ NaCl 0.9%


(NaCl 0.9% = 154 mEq Na/L H2O)
27

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
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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

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Hiponatremia
Hipotonik-Hipovolemia

Hitung jumlah natrium :


hiponatremia isonatremia
Selanjutnya :
Sesuai : IsonatremiaIsotonik-Hipovolemia
32

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
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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
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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.
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Hiponatremia
Hipotonik-Hipovolemia

Hitung jumlah air

Hipernatremia isonatremia
Selanjutnya

Sesuai : IsonatremiaIsotonik-Hipovolemia

45

Hiponatremia
Hipotonik-Hipovolemia
Contoh

Dehidrasi 10% (BB : 5 kg 4.5 kg) Na 170 mE/L

Jumlah air hipernatremiaisonatremia = X


(X+TBW) x NaD = TBW x NaA
X = (NaA/NaD) x TBW- (TBW) ml
X = (170/145) x (0.6x4.5)(0.6x4.5) = 465 ml
46

Hiponatremia
Hipotonik-Hipovolemia

Contoh

Dehidrasi 10% (BB : 5 kg 4.5 kg) Na 170 mE/L

Defisit air = 500 ml


Defisit Na = 500-465 = 35 mL (NaCl 0.9%)
= 35ml x 154 mEq/L = 5 mEq

47

Hiponatremia
Hipotonik-Hipovolemia
Maintenance Air

5 (kg) x 100 ml/kg

= 500 ml

5 (kg) x 3 mEq/kg

= 15 mEql

Maintenance Na

Jumlah Air/24 jam = 500 + 500 ml = 1000 ml


Jumlah Na/24 jam = 5 + 15 mEq = 20 mEq
48

Hiponatremia
Hipotonik-Hipovolemia
Hati-hati:

Dehidrasi sel edema sel (otak)

Koreksi dalam 48 jam


Air

= 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

Central diabetes insipidus


Vasopressin
Lysine vasopressin
DDAVP

Partial DI
Chlorpropamide, carbamazepine, clofibrate

Nephrogenic diabetes insipidus


Correct the underlying disorder
Thiazides
Prostaglandin synthesis inhibitors
50

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

Treatment: Remove offending drug. Thiazide diuretics


paradoxically decrease urine volumes.
7. Treatment of hypernatremia
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.
55

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

Nephrogenic diabetes insipidus


Correct the underlying disorder
Thiazides
Prostaglandin synthesis inhibitors

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

Osmotic attraction of water from the intracellular and


extracellular spaces
Transient translocation of interstitial fluid into the PV.

After infusion of 7.5% saline

PV should be expanded by a volume equal to the infused


volume.

Addition of hyperoncotic colloid to the


hypernatremic solution

Increase the PV increment further, up to 7 times the


infused volume.

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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

In the presence of arrhythmias

K+ can be replaced intravenously by a solution


containing 40 to 60 meq/l
Infused at a rate of no more than 40 meq/hour
Any magnesium deficiency must be corrected in order
to correct the hypokalemia.
67

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

There is an abrupt rise from normal to >6.5 meq/liter


Any level is associated with EKG changes

Clinical features

Involve neuromuscular abnormalities, with weakness,


paresthesias, paralysis, as well as GI complaints of nausea,
vomiting, colic, and diarrhea.

Cardiac abnormalities

The most feared sequelae of hyperkalemia


Include conduction defects as well as dysrhythmias.

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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

500 ml of 10% dextrose plus 10 units regular


insulin or 50 - 100 gm with 10 -20 units regular
insulin

Lasix, ethacrynic acid, or bumex


Oral or rectal sodium or calcium polystyrene
with sorbitol
Peritoneal dialysis or hemodialysis
Transvenous pacemaker
72

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.

The management of this hyperosmolar state that the total


volume of fluid given over the first 24 hours may be important
in the development of cerebral edema.27
Over the first ten years patients had fluids replaced with
isotonic saline over six hours.
Over the second ten years, the patients had their fluids
replaced with half normal saline over a 24 hour period.
During each period, there were six cases of cerebral edema.28
73

Acute Bacterial Meningitis


High prevalence of hyponatremia and
elevated ADH levels in children with bacterial
meningitis.
Fluid restriction in these patients, though
there was no clear, unbiased, data.
Powell et al demonstrated that these patients
with inappropriately elevated ADH levels,
Given appropriate fluid resuscitation, decreased
their ADH levels.30

Data from India has actually suggested that


fluid restriction may be deleterious.31
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