Terapi Cairan

Jajang Sujana Mail

Instalasi Rawat Intensif
RS Al Islam Bandung

JUMLAH DAN DISTRIBUSI CAIRAN TUBUH

TOTAL BODY FLUID

INTRACELLULAR
INTRACELLULAR
FLUID(ICF)
(ICF)
FLUID

60% BW (50 L)

EXTRACELLULAR
EXTRACELLULAR
FLUID
FLUID(ECF)
(ECF)

20% BW (15L)

40 % BW (35 L)

INTRAVASCULAR
INTRAVASCULAR
FLUID(PLASMA)
(PLASMA)
FLUID
5 % BW (3,5 L)

INTERSTITIIL
INTERSTITIIL
FLUID
FLUID
15 % BW (11,5 L)

TOTAL BODY FLUID

stomach

Extracellular
fluid: 20 % BW

lungs

intestines

Blood plasma: 5% BW
Interstitiil fluid: 15 % BW

Intracellular fluid: 40 % BW

skin
kidney

ICF

Membran sel
Dinding kapiler

PLASMA

INTERSTITIIL FLUID

PLASM
A

3L

INTER
STITIIL

INTRA
CELLULAR

14
L

Na+

EXTRA
CELLULER
TOTAL BODY WATER

K+

25 L

28 kg

NON-FLUID
MASS

BODY FLUID ELECTROLYTES

- NON IONS: DEXTROSE, UREUM, CREATININE
- IONS (SALTS):
CATIONS: Na+, K+, Ca++, Mg++
ANIONS:
HCO3-, Cl-, PHOSPHATE, PROTEIN,
ORGANIC ACID.
ELECTROLYTES AND PROTEIN
PRESSURE
DETERMINANT.
INTRACELLULAR
FLUID

OSMOTIC

EXTRACELLULAR
FLUID

MAIN
CATION

KALIUM (K+)

NATRIUM (Na+)

MAIN
ANION

PHOSPHATE
(PO4-)

CHLORIDE (Cl-)

PERMEABILITAS MEMBRAN
PENGHALANG UTAMA PERPINDAHAN SOLUTE
ZAT-ZAT YANG LARUT DALAM LEMAK (O2, CO2, UREA) > ZAT
ZAT YANG LARUT DALAM AIR (ION-ION DAN GLUKOSA)
BERBANDING TERBALIK DENGAN UKURAN SOLUTE (Na DAN
GLUKOSA > PROTEIN).
PARACELLULAR PATHWAY

OSMOLALITAS: JUMLAH PARTIKEL YANG TERLARUT PER

KILOGRAM LARUTAN
OSMOLARITAS: JUMLAH PARTIKEL YANG TERLARUT PER
LITER LARUTAN
1 MOL (MMOL): BERAT MOLEKUL (ATOM) DALAM GRAM
(MG)
EQUIVALENT:

JUMLAH ION YANG DAPAT DIGANTI ATAU

BERKOMBINASI DENGAN 1 GRAM
HIDROGEN

MOLALITAS: JUMLAH MOL DARI SUATU SOLUTE PER 1000

GRAM SOLVENT.
MOLARITAS: JUMLAH MOL DARI SUATU SOLUTE PER
LITER SOLVENT

PERGERAKAN AIR, OSMOSIS,

DAN TEKANAN OSMOSIS
DITENTUKAN OLEH 2 KEKUATAN:
TEKANAN OSMOSIS (OSMOTIC PRESSURE)
- TEKANAN YANG DIPERLUKAN UNTUK
MENCEGAH MIGRASI AIR
- BERGANTUNG PADA JUMLAH PARTIKEL
TANPA
MEMANDANG UKURAN ATAU
MUATAN LISTRIK

TEKANAN HIDRAULIK/ HYDROSTATIK

(HYDRAULIC PRESSURE)

OSMOSIS
OSMOTIC
PRESSURE

PERMEABLE MOLECULES, WATER

NON PERMEABLE MOLECULES

EQUILIBRIUM STATE

SUBSTANCE
ADDED

PLASMA
OSMOLALITY

PLASMA
SODIUM

ECF
VOLUME

ICF
VOLUME

NaCl
Water
Isotonic
NaCl

URINE
SODIUM

PERTUKARAN CAIRAN ANTARA

INTERSTITIIL FLUID DAN INTRAVASCULER FLUID

TEKANAN OSMOTIK (PLASMA ONKOTIK PRESSURE)

TEKANAN HIDROSTATIK

FUNGSI ELEKTROLIT
UMUM
- MEMPERTAHANKAN OSMOLALITAS CAIRAN TUBUH
- REAKSI KIMIA
EKSITABILITAS MEMBRAN
KONTRAKSI OTOT, TRANSMISI IMPUL
SARAF.

KHUSUS:
- Ca++
- H+

PEMBEKUAN DARAH
pH TUBUH

- NaHCO3, NaH2PO4
PERUBAHAN pH

PENYANGGA

KESEIMBANGAN CAIRAN
CAIRAN MASUK = CAIRAN KELUAR
CAIRAN MASUK:
AIR MINUM
MAKANAN
HASIL OKSIDASI
CAIRAN KELUAR:
URINE
KERINGAT
SALURAN NAPAS
FESES

WATER INTAKE (mL/day)

Source
Ingested
water
Water
content
of food
Water of
oxidation

Total

Obligator
y

Electiv
e

400

1000

850

WATER OUTPUT (mL/day)

Source

Obligator Elective
y

Urine

500

Skin

500

Respirat
ory tract

400

Stool

200

1000

350

1600

1000

1600

1000

FUNGSI CAIRAN TUBUH

REAKSI METABOLISME

NUTRIENT

INTEGRITAS SIRKULASI

OSMOLALITAS TUBUH

TERMOREGULASI

TERAPI CAIRAN
RESUSITASI

KRISTALLOIDKOLOID

GANTI KEHILANGAN AKUT

(HEMORRHAGI, GI LOSS,
3rd SPACE)

RUMATAN

ELEKTROLIT

NUTRISI

- GANTI KEHILANGAN

NORMAL
(IWL+URINE+FESES)
- SUPPORT NUTRISI

Ion distribution
COMPARTMENT

CATION

ANION

SUITABLE
SOLUTION

ICF

K+ Mg++

HPO4Protein

Containin
g K+,Mg++
and HPO4-

PLASMA

Na+

ClHCO3Protein

High
Na+and Cl-

ISF

Na+

ClHCO3-

ECF

PRINSIP-PRINSIP
DASAR
Penggantian

Kehilangan tidak normal: GIT,

rongga ke3, kehilangan yang
sedang terjadi, shock septik d
hipovolemik

Rumatan

IWL + urine

Memperbaiki
defisit

Ketidak seimbangan asam bas

elektrolit

PEMILIHAN CAIRAN
Penggantian : RA, RL, NS
Rumatan: N/2 + D (adult) + K+ 20 mEq
N/4 + D (chlldren) + K+ 20 mEq
Perbaikan defisit : NaHCO3 8,4%
KCl 25 mEq/25 ml
NaCl 3%

FLUID AND ELECTROLYTE DEFISIT BEFORE SURGERY

- NPO 6 12 HOURS
- INSENSIBLE LOSS CAUSED BY FEVER, HYPERVENTILATION
AND PERSPIRATION.

FLUID LOSS DURING SURGERY

- BLEEDING
- OTHER FLUID LOSS
- EVAPORATION
- FLUID TRANSLOCATION / SEQUESTRATION
RENAL DISFUNCTION
- DECREASE GFR
- INCREASE ADH

Kebutuhan
Demam
Restless/delirium
Temperatur lingkungan
hangat
Hiperventilasi

Kebutuhan
Hipothermi
Kelembaban tinggi
Oliguria/anuria
Penurunan kesadaran
Retensi/oedema
Peningkatan tekanan
intrakranial

Rasionalisasi larutan
rumatan

Redistribusi cairan
Kebutuhan basal Kalium dan natrium
Konsentrasi elektrolit dalam larutan infus
Larutan Ready for use meminimalkan
resiko komplikasi

CLASSIFICATION OF ACUTE BLOOD LOSS

CLASS

II

III

IV

<750

750 - 1500

1500 - 2000

> 2000

BLOOD LOSS (%
EBV)

< 15%

15 30 %

30 40 %

> 40%

PULSE (x/mnt)

< 100

> 100

> 120 weak

BLOOD PRESSURE

N/

N/

CAPILLARY REFILL

14 - 20

20 30

30 - 40

> 40

DIURESIS (ml/hr)

>30

20 - 30

10 20

0 10

MENTAL STATUS

N/restless

restless/a
nxiety

somnolence

somnolenc
e/coma

FLUID THERAPY

Crystalloi Crystalloid
d/RL 2,5 L /RL+Colloi
or Colloid
d1L
1L

Crystalloid+
blood/RL
1 L+Colloid
0,5 L+Blood
1-1,5 L or
PRC 0,50,75 L

Crystalloid
+
Blood/RL
1 L+Colloid
1 L+Blood
2 L or PRC
1
L+Colloid

BLOOD LOSS (ml)

RESPIRATORY RATE

SYMPTOMS AND DEGREE OF DEHYDRATION

CLINICAL SIGNS
I

- SKIN TURGOR
-TACHYCARDIA
-THIRSTY, DRY TONGUE

II

- SKIN TURGOR
- TACHYCARDIA, WEAK PULSE
- THIRSTY, WRINKLED TONGUE

III

- SKIN TURGOR
- WEAK PULSE, ALMOST NOT
PALPABLE
- SEVERE HYPOTENSION
- SUNKEN EYES, WRINKLED TONGUE
- CYANOTIC ACRAL
- STUPOR, COMA, SHOCK
-MARKED DEPRESSED ANTERIOR
FONTANELLA

DEGREE
MILD

MODERATE

SEVERE

FLUID
DEFICIT
3 5 % BW

5 10 % BW

> 10 % BW

DAILY NORMAL REQUIREMENT OF

FLUID AND ELECTROLYTES
- ADULT: 30 35 ml/kgBW/day, Na+ 1-2
mmol/kgBW/day,
K+ 1 mmol/kgBW/day
- INFANT AND CHILD:
BODY WEIGHT
FLUID REQUIREMENT PER
HOUR
0 10 kg

4 ml/kgBW/hr

10 20 kg

40 + 2 ml/kgBW/hr over 10 kg

> 20 kg

60 + 1 ml/kgBW/hr over 20 kg

RATES OF FLUID ADMINISTRATION TO REPLACE

THIRD SPACES LOSSES
FLUID
SHIFT

OPERATION

RATES
(CRYSTALLOID)

MINOR

TENDON REPAIR,
TYMPANOPLASTY

03
ml/kgBW/hr

MODERATE

HYSTERECTOMY, INGUINAL
HERNIA

6 ml/kgBW/hr

MAYOR

TOTAL HIP REPLACEMENT,

ABDOMINAL CASE WITH
PERITONITIS

9 ml/kg BW/hr

ESTIMATED BLOOD VOLUME

AGE
NEONATES
PREMATURE
- FULLTERM
INFANT
ADULT
- MALE
- FEMALE

BLOOD VOLUME
95 ml/kg BW
85 ml/kgBW
80 ml/kgBW
75ml/kgBW
65 ml/kgBW

POST OPERATIVE FLUID AND ELECTROLYTE MANAGEMENT

GOALS ! ! !
- TO PROVIDE DAILY REQUIREMENT OF WATER, ELECTROLYTE AND
CALORI / NUTRITION
- FLUID REPLACEMENT:
-FEVER
-GASTRIC FLUID LOSS VIA NGT OR VOMITING
-HYPERVENTILATION OR TRACHEOSTOMY WITHOUT
HUMIDIFICATION
- TO CONTINUE REPLACE FLUID DEFISIT DURING SURGERY
- CORRECTION OF ELECTROLYTE / FLUID IMBALANCE

Konsentrasi K+ standar dalam larutan

i.v.
1. Konsentrasi: <40 mEq/L
2. Kec pemberian: <20 mEq/hr

< 40mEq/L
KCl

3. Dosis harian : <100 mEq/day

4. Monitor ECG and K+ serum
5. U r i n e output: >0.5 ml/kg/hr

KCl bolus

Kecepatan pemberian
Elektrolit & glukosa
Na+
K+
Ca++
Mg++

100 mEq/hr
20 mEq/hr
20 mEq/hr
20 mEq/hr
-

HCO3

Glucosa
mg/kg/min)*

100 mEq/hr
0,5 gr/kg/hr ( 4

* Neonates 6-8 mg/kg/min

COMPOSITION OF CRYSTALLOID
Solution

Tonicity

5%
Dextrose
in water
(D5W)

Hypo
(253)

Na+
(mEq/L)

Cl(mEq/L)

K+
(mEq/L)

Ca2+
(mEq/L)

Glucose
(g/L)
50

Normal
Saline

Iso (308)

154

154

D5 NS

Iso (330)

38,5

38,5

50

D5 NS

Hyper
(407)

77

77

50

D5 NS

Hyper
(561)

154

154

50

Isi 273)

130

109

Hyper
(525)

130

109

RL
D5 RL

Lactate
(mEq/L)

28
50

28

CRYSTALLOID VS COLLOID
Crystalloid

Colloid

Advantages

- Inexpensive
- Promotes
urinary flow
- Fluid of choice
for initial
resuscitation of
trauma/hemorrh
age
- Expands
intravascular
volume
- Restores 3rd
spaces losses

-More sustained intravascular

-Volume increase (1/3 still intravascular
at 24 hrs)
- Maintain or increase plasma oncotic
pressure
-Requires smaller volume for equal
effects
-Less peripheral oedem (more fluids
remains intravascular)
-May lower intracranial pressure

Disadvantage
s

- Dilutes colloid
osmotic pressure
- Promotes
peripheral
oedem
- Higher
incidence of
pulmonary
oedem
- Requires large
volume
- Effects are
transient

-Expensive
-May produce coagulopathy (dextrans
and hetastarch)
-With capillary leaks may potentiate
fluid loss to the interstitium
-Impairs subsequent crossmatching of
blood (dextran)
-Dilutes clotting factors and platelet
-Decrease platelet adhesiveness
(absorption onto platelet membrane
reseptor)
-Potential blocking of renal tubules and
reticuloendothelial cells in the liver

Colloids

Production

Type

Molcular
Weight
(103)

Halflife
intravasc
uler

Indication

Plasma
protein

Human plasma

Serum
human
albumin

50

4-15 days

-Volume substitute
- Hypoprotein
emia
- Hemodilution

Dextran

Leuconostoc
mesenteroid B
512

D 40, 70

60-70

6 hrs

-Hemodilution
-Microcirculation
disturbance

Gelatine

Hydrolisis animal
collagen

- Modified
gelatine
-Urea linked
- Oxypoly
gelatine

35

2-3 hrs

-Volume substitute

Starch

Acid hydrolisis
and ethylene
oxide from
soybeans and
maize

- Hydroxi
ethylstarch

450

6 hrs

-Volume substitute
-Hemodilution

Polyvinyl
pyrrolido
ne (PVC)

Polymer
synthetic vynil
pyrrolidone

- Subtosan
--Peristone

50
25

-Volume substitute

Conclusion