Trauma / Perioperative Pt
S. Sunatrio
S. Sunatrio 1
TUJUAN RESUSITASI CAIRAN
O2 via a mask
Monitor BP&Pulse
ICV ( 28 L ) ECV ( 14 L )
RBC PV
(3L)
Blood Volume (5 L)
IF = ECV- PV
S. Sunatrio 4
Separation of Total Body Water
Osmotic and Colloid-Osmotic Pressure ( COP )
(Starling 1896)
TBW
ICS ECS
280 mOsm/l 280 mosm/l
K-ions Na-ions
Edema threshold : COP 20-15 mmHg - Albumin 2.5 g/dl - TP 5.0 g/dl (??)
Normal values : Albumin 3.5 - 5.5 g/dl, TP 6.0 - 8.0 g/dl
S. Sunatrio 5
Blood volume distribution
Blood volume of ~ 5 - 6 l =100% ( ~ 7% of Bw)
Blood Volume
5 - 6 l = 100%
Capillary system
5 - 10%
Crystalloids Colloids
Lactated Ringer's
Normal Saline
S. Sunatrio 7
KOMPOSISI CAIRAN IV
CAIRAN GLUKOSA Na+ Cl- laktat Osmolaritas
(g/L ) (mEq/L) (mEq/L) (mEq/L) (mOsm/kg)
D5W 50 0 0 0 252
LRS 0 130 109 28 273
D5W / LRS 50 130 109 28 525
0,9 % Saline (NS) 0 154 154 0 308
6 % HES 0 154 154 0 310
5 % Albumin/NS 0 154 154 0 310
25 % Albumin 0 154 154 0 310
(rata2) ( rata2)
S. Sunatrio 8
Sifat-sifat cairan koloid
Tekanan
Kadar~ BM Persen Osmotik Masa Paruh
Koloid
(%) (kisaran dalam d) Intravaskular Koloid Intravaskular
(mm Hg) (jam)
Albumin 5 69.000 80 20 >24
(20.000 - 175.000)
(10.000 - 1.000.000)
(150.000 - 350.000)
* Dimodifikasikan dari Davies MJ. The role of colloids in blood conservation. Int Anesthesiol Clin 1990; 28:205
~ Dalam formulasi yang biasa dipakai di AS
# Data dari Carlson RW, Rattan S, Haupt MT. Fluid resuscitation in conditions of increased permeability. Anesthesiol Rev
1990; 17:14
@Kanjiheta dan kanjipenta tersusun dari molekul kanji hidroksietil dengan berbagai BM
$ Data dari Rackow EC, Astiz ME, et al. Effects of pentastarch and albumin infusion on cardiorespiratory function and
S.coagulation
Sunatrio 9 in patients with severe sepsis and systemic hypoperfusion. Crit Care Med 1989; 17:394
PV EXPANSION WITH ADMINISTRATION OF
250 mL OF SELECTED FLUIDS
D5W 18 70 162
LRS 50 200 0
5 % Albumin 250 0 0
25 % Albumin 1000 -750 0
S. Sunatrio 10
EFEK INFUS 1 L CAIRAN PADA KOMPONEN TUBUH
S. Sunatrio 11
Lamke et al. Plasma volume changes after infusion of various plasma
expanders. Resuscitation. 1976;5:93-102.
Volume, mL
700
600
500
400
300
200
100
0
6% Hetastarch 5% Albumin Gelatin Saline
S. Sunatrio 12
Average initial volume effect of synthetic
colloids in % of infused volume
Volume Effect Duration
3.5 % Polygeline
~70% ~2-3h
3-4% Modified Fluid Gelatin
6% HES 200/0.5
6% HES 130/0.4 ~ 100% ~3-4h
6% Dextran 70
6% HES 200/0.62 and 450/0.7
10% HES 200/0.45 and 0.5
~ 145% ~3-9h
S. Sunatrio 13
PV = Volume cairan infus (PV / Vd)
S. Sunatrio 14
BB 70 Kg PV= Vd= 3 L
2 L = Volume infus ( 3 L / 3 L )
S. Sunatrio 15
BB 70 Kg PV = 3 L
Vd = 14 L
2 L = volume infus ( 3 L / 14 L )
S. Sunatrio 16
BB 70 Kg PV = 3 L
Vd = 42 L
2 L = volume infus ( 3 L / 42 L )
S. Sunatrio 17
Crystalloid Solutions are
distributed over the entire
Extracellular Space.
And therefore crystalloids are
indicated and most effective
when this space is depleted.
S. Sunatrio 18
Colloids
They remain largely within
the Intravascular Space.
Therefore, colloids are
most effective
in hypovolemic patients.
S. Sunatrio 19
ADAKAH PENGARUH
MACAM CAIRAN RESUSITASI
TERHADAP
HASIL AKHIR ?
S. Sunatrio 20
Volume replacement Therapy Three
distinct situations:
S. Sunatrio 21
Blood loss during surgery
In most cases of surgery blood loss
is witnessed,
can be measured and
replaced immediately by
appropriate solutions.
Crystalloids and Colloids help to
prevent major interstitial fluid shifts and
hypovolemia
S. Sunatrio 22
Trauma and delayed resuscitation:
Blood loss is associated with interstitial fluid
loss:
colloid infusion until hemoglobin
decreases to about 8-10 g/dl.
Crystalloids in a dose of 5-15ml/kg/h
if the renal function is maintained and the
patient has
no brain or lung trauma.
Otherwise limitation of crystalloids.
S. Sunatrio 23
Late hemorrhagic shock and sepsis:
S. Sunatrio 24
Colloid Infusion and COP in Sepsis and
Late Hemorrhagic Shock
Co-factors: clinical aspect, intake and output
Measurement of COP and Hct,
Colloid infusion and wait for 1-2 hours
S. Sunatrio 26
Effects of Synthetic Colloids
Retaining of fluid Oncotic
in the IVS pressure
increased IV
Hemodilution
volume
CO DO ca O2
2
S. Sunatrio 27
Perdarahan hebat:
S. Sunatrio 28
S. Sunatrio 29
Pengamatan Sunatrio :
S. Sunatrio 30
Pengamatan Sunatrio :
S. Sunatrio 31
Ditunjang data:
Meningkatkan kapasitas pembawa O2 dan transport
O2 ke jaringan
Tidak terbukti :
1. Mengurangi risiko infeksi
2. Promosi penyembuhan luka
3. Meningkatkan general well being
S. Sunatrio 32
Perdarahan akut
S. Sunatrio 33
BB 70 kg Hb 15 g %
Normal basal Kebutuhan O2 = 280 mL
TRANSFUSI :
~ Bila Hb < 7 mg/dL (Ht < 21%)
~ Jarang bila Hb > 10 mg/dL (Ht 30%)
~ 7 < Hb < 10 mg/L : manfaat tdk jelas!!
RISIKO TRANSMISI VIRAL & BAKTERIAL
MODULASI IMUN SEKUNDER
S. Sunatrio 35
RCT:
Hb 7-9 mg% atau 10-12 mg% tidak ber
beda dalam morbiditas dan mortalitas
Russell JA. Fluid Strategy in ARDS: The concept of maintaining peripheral
perfusion. In H Burchardi G, GJ Dobb, J Bion, RP Delinger (eds) WB
Saunders. London 1997p; 17-42.
S. Sunatrio 36
HEMATOKRIT
%
40 NORMAL
OPTIMAL
35
TOLERABEL
30
25
20
15
10
5
0
S. Sunatrio 37
Tidak ada Hb optimal universal
Pada psn normal biarkan Ht rendah
dan beri terapi besi & diet tinggi
protein bukannya darah
Transfusi ditentukan kasus per
kasus
S. Sunatrio 38
Muda sehat 20%
Gagal ginjal kronik 18-22%
Syok septik 30%
Sesudah syok berat 30-40%
PJK 35%
Penyakit paru kronik berat > 40-50%
S. Sunatrio 39
S. Sunatrio 40
FDA, USA :
S. Sunatrio 41
S. Sunatrio 42
Healy et al. Lactated Ringers is superior to normal saline in a model of massive hemorrhage
and resuscitation. J Trauma. 1998;45:894-899.
HASIL
Resusitasi cairan dgn RL survival rate >>
HASIL
Asidosis mengganggu motilitas
gastro-pilorus
S. Sunatrio 43
Dexter et al : berdampak negatif
pd RBF & GFR
Peningkatan terjadinya
asidosis metabolik hiperClemia
yg selama ini dianggap tdk
berdampak negatif & akan hilang dgn
sendirinya ternyata dpt mengganggu
perfusi organ akhir &
mekanisme pertukaran sel.
S. Sunatrio 44
Asidosis metabolik
hiperkloremik
Tdk selalu dikenali klinikus
Asidosis metab intraop yg menetap,
walau telah diberi cairan mungkin
diinterpretasikan sbg hipovolemia yg
belum teratasi dgn baik
NaCl 0,9% abnormalitas & asidosis
metab hiperkloremik mungkin ditangani
secara tdk tepat
S. Sunatrio 45
Solution Balanced-Fluid Group Saline Group
Colloid Hextend Hespan
Hetastarch 60 g/L (6%) Hetastarch 60 g/L (6%)
+ +
Na 143 mmol/L Na 154 mmol/L
Cl - 124 mmol/L Cl - 154 mmol/L
Ca + 2.5 mmol/L
+
K 3 mmol/L
Magnesium 0.45 mmol/L
Glucose 0.99 g/L
Lactate 28 mmol/L
S. Sunatrio 46
HASIL
2/3 ps yg diberi Hespan + 0,9% NaCl
asidosis metabolik hiperClemia pd
akhir pembedahan.
Pasien yang diberi Hextend + RL
tidak menunjukkan asidosis
metabolik hiperClemia.
S. Sunatrio 47
ANDA DAPAT MENCEGAH
ASIDOSIS HIPERKLOREMIK
DENGAN MEMBERIKAN
KOMBINASI
KOLOID & RL
S. Sunatrio 48
EFEK PRO-KOAGULAN KRISTALOID
In vitro:
Ruttmann TG, James MF, Viljoen JF. Haemodilution induces a
hypercoagulable state. Br J Anaesth. 1996;76:412-414.
In vivo:
Ng KF, Lo JW. The development of hypercoagulability state, as
measured by thrombelastography, associated with intraoperative
surgical blood loss. Anaesth Intensive Care. 1996;24:20-25.
S. Sunatrio 49
Gan TJ et al. Hextend, a physiologically balanced plasma expander for large volume
use in major surgery: a randomized phase III clinical trial. Hextend Study Group. Anesth
Analg. 1999;88:992-998.,
HASIL
Sama efektif utk hipovolemia.
A : ~ profil koagulasi > baik (TEG)
~ perdarahan <
B : Kanjiheta 6% dlm NS hipokoagulasi
S. Sunatrio 50
Ringer laktat
EFEK PRO-KOAGULAN
EFEK SAMPING
(TROMBOSIS VENA DLM,
EMBOLISME PARU)
S. Sunatrio 51
KRISTALOID vs KOLOID:
area persetujuan
Resusitasi dgn cairan selain dari darah secara praktis
sangat bermanfaat
Anemia ternyata ditoleransikan lebih baik drpd
hipovolemia. Pd perdarahan akut pd orang sehat
anemia dpt ditoleransikan sampai 50%, sedangkan
hipovolemia hanya 30%
Kelebihan cairan dgn kedua macam lar merupakan
peristiwa yg tdk diinginkan
Mempertahankan TOK plasma dipostulasikan sbg
tujuan th/ cairan yg diinginkan; lar koloid lebih
efektif dlm mempertahankan tekanan osmotik koloid
S. Sunatrio 52
KRISTALOID vs KOLOID:
area persetujuan
LAR. KOLOID MERUPAKAN BENTUK PENGGANTIAN
VOL DARAH YG LEBIH EFISIEN DRPD LAR KRISTALOID.
UTK MENCAPAI TITIK AKHIR TERTENTU DIPERLUKAN
LEBIH SEDIKIT LAR KOLOID DRPD LAR KRISTALOID
LAR KOLOID LEBIH MAHAL DARI KRISTALOID, LAR
KRISTALOID TDK MENYEBABKAN Rx ANAKFILAKTOID
YG DPT TERJADI DGN KOLOID, MESKIPUN Rx SPT INI
JARANG TERJADI PADA SYOK
HEMODILUSI SEBELUM TRANSFUSI DGN KRISTALOID
ATAU KOLOID BERMANFAAT PADA RESTORASI VOL
DARAH
S. Sunatrio 53
KOLOID vs KRISTALOID
utk ekspansi ruang intravaskular
Pro koloid :
Koloid mempertahankan TOK &
meminimalkan akumulasi cairan
interstisial
Kristaloid mekan TOK
edema paru
Pe an TOK laju mortalitas
S. Sunatrio 54
KOLOID vs KRISTALOID
ukt ekspansi ruang intravaskular
Pro kristaloid :
Mencela beaya & risiko th/koloid
Koloid keluar ke interstisium &
terperangkap edema
S. Sunatrio 55
Hauser CJ, Shoemaker WC, Turpin I, Goldberg SJ. Oxygen
transport responses to colloid and crystalloids in critically ill surgical
patients. Surgery 1980; 150:811-6.
S. Sunatrio 56
Appel PL, Shoemaker WC. Evaluation of fluid therapy in
adult respiratory failure. Crit Care Med 1981; 9:862-9.
S. Sunatrio 57
Pasien sakit kritis
Mekanisme kompensasi terhadap
kelebihan cairan
Edema interstisial gagal organ
Utk penanganan hipovolemia koloid >
baik
S. Sunatrio 58
Scheinkestel CD, Tuxen DV, Cade JF et al. 1989
Rady M. 1994
Resusitasi cairan pd ps dng syok
S. Sunatrio 59
MORTALITAS
KOLOID vs KRISTALOID
S. Sunatrio 60
KOMENTAR terhadap
META-AN SCHIERHOUT
Intervensi & karakteristik ps tdk
sebanding kesimpulan?
Regimen resusitasi berbeda-beda
Tipe koloid atau kristaloid, konsentrasi
& protokol utk menentukan jumlah
cairan yg diperlukan: bervariasi
S. Sunatrio 61
Kritikan Webb (2000)
thd 3 meta-an yg melaporkan mortalitas dng koloid > drpd
kristaloid meski tdk bermakna
S. Sunatrio 62
Webb AR. The appropriate role of colloids in managing fluid imbalance: a
critical review of recent meta-analytic findings. Crit Care 2000; 4 Suppl 2: S26-
32.
S. Sunatrio 63
Shih FJ. Colloids versus crystalloids for
emergency patients. Accid Emerg Nurs 1998; 6(3): 130-2.
S. Sunatrio 64
Cochrane Injuries Group Albumin Reviewers. Human albumin administration in
critically-ill patients: systemic review of randomized controlled trials. BMJ 1998; 317:235-240. (META-
ANALISIS)
Albumin vs kristaloid
Risiko kematian pd albumin > tinggi dari
kristaloid
Limitasi bias pd seleksi penelitian
De Backer D. Which colloids in critically-ill patients?. The proceeding book of
Refresher Course Lectures 10th ESA Aniversary Meeting and 24th EAA Annual
Meeting Euroanaesthesia 2002; p: 171-75. (META-ANALISIS)
S. Sunatrio 65
S. Sunatrio 66
Study on the extra-vascular diffusion of hydroxyethyl
starch in a case of increased capillary permeability
Guidet B et al. Clinical Intensive Care 1994; 5: 93-94
S. Sunatrio 67
The influence of volume therapy and pentoxifylline
infusion on circulating adhesion molecules in trauma
patients
Boldt J et al. Anaesthesia 1996; 52: 529-535
S. Sunatrio 68
S. Sunatrio 69
S. Sunatrio 70
S. Sunatrio 71
S. Sunatrio 72
S. Sunatrio 73
S. Sunatrio 74
S. Sunatrio 75
S. Sunatrio 76
There was overall no beneficial effect of albumin on
mortality in this 55 studies including 3500 pts
S. Sunatrio 77
S. Sunatrio 78
SAFE Study
New England J Med 2004;350:2247-56
S. Sunatrio 79
SAFE Study
New England J Med 2004;350:2247-56
Indications of colloid/crystalloids
should not be evaluated globally
but indication by indication
S. Sunatrio 80
S. Sunatrio 81
S. Sunatrio 82
S. Sunatrio 83
S. Sunatrio 84
S. Sunatrio 85
S. Sunatrio 86
S. Sunatrio 87
Albumin
Mahal
Makin tdk popular
Hipoproteinemia sendiri tdk
menyebabkan edema paru
Tdk ada bukti lebih baik drpd kristaloid
dlm mortalitas
Kurang efektif drpd koloid sintetik
Keuntungan tidak ada, jadi jangan dipakai
S. Sunatrio 88
S. Sunatrio 89
CRYSTALLOID vs COLLOID
End point mortality
Assuming mortality 20%
(risk ratio 1.02)
Need to study 159,000 patients in each
group
Avie LR Shapiro
S. Sunatrio 90
Prof. J. Boldt in:
Volume Therapy
Springer Verlag Berlin Heidelberg
New York Hong Kong London
2000, p76
S. Sunatrio 91
S. Sunatrio 92
The Crystalloid versus Colloid Controversy:
A Colloid versus Colloid Debate?
S. Sunatrio 93
Without controversy
there is no progression.
S. Sunatrio 94
There was overall no beneficial effect of albumin on
mortality in this 55 studies including 3500 pts
S. Sunatrio 95
Meta-analysis : Colloid vs Crystalloids
What is a statistician?
S. Sunatrio 96
Crystalloid vs Colloid : Analysis on Mortality
Power Analysis
Critically ill Pts
assuming a 15% baseline MR
S. Sunatrio 97
Crystalloid vs Colloid : Analysis on Mortality
Power Analysis
Critically ill Pts
assuming a 1% baseline MR
S. Sunatrio 98
CRYSTALLOID vs COLLOID
Avie LR Shapiro
S. Sunatrio 99
The Crystalloid versus
Colloid controversy:
S. Sunatrio 100
S. Sunatrio 101
KRISTALOID >>
edema interstisial
OTAK EDEMA, DST
JANTUNG KINERJA
PARU OKSIGENASI
PENCERNAAN TRANSLOKASI
BAKTERIAL
PERIFERAL PENYEMBUHAN
LUKA
S. Sunatrio 102
Gan TJ. Impact of Resuscitation Fluid Choice on Quality of Surgical Recovery.
Symposium intra-operative Plasma Volume Optimization and Postoperative Outcome,12 th World Congress
of Anaesthesiologists Montral, Canada. June, 2000.
80
RL
P = .03
70 Hextend
Hespan
60 P = .01
Patients,
50
%
40 P = .08
30 P = .02
P = .01
20
10
0
nausea rescue postop pain double vision periorbital
antiemetic edema
S. Sunatrio 103
S. Sunatrio 104
KOLOID vs KRISTALOID
Pemberian koloid selama pembedahan
berhubungan dgn perbaikan profil
penyembuhan & kenyamanan pasien yg lebih
baik, dibanding dgn pemberian kristaloid.
Perbedaan ini mengakibatkan :
memperpendek masa rawat RS
beaya lebih kecil
S. Sunatrio 105
S. Sunatrio 106
TRAUMA BERAT
ICV < NORMAL
ECV >>> NORMAL
RASIO KRISTALOID : KOLOID
=68:1
(NORMAL = 3 - 4 : 1)
S. Sunatrio 107
Sinha HA, Baron BJ, Buckley MC, et al. Fluid
restriction versus early resuscitation in hemorrhagic
shock. J Trauma 1994; 37:1015
S. Sunatrio 108
Efek koloid yg menguntungkan
mekan TOK
mekan volume darah
sealing effect (HES 100-300 kD)
Mengembalikan aliran darah regional pd
hipovolemia
mekan viskositas, mengganggu formasi
Rouleau, mekan daya adesif leukosit
S. Sunatrio 109
Efek koloid yg merugikan
S. Sunatrio 110
Terapi cairan rasional
Perkiraan defisit air tiap kompartemen cairan
fisiologis
Krsitaloid / koloid yg tepat utk resusitasi
kompartemen yg memerlukan
Pengurangan ruang intravaskular :
- laju jantung
- TD , TVS
- Urin
S. Sunatrio 111
Pemilihan
Kristaloid vs Koloid
Ikuti prinsip dasar fisiologis yg telah
mapan
Bukan oleh karena resusitator pemakai
kristaloid atau koloid
Ditentukan oleh ps
Pertahankan kadar Hb & faktor koagulasi
S. Sunatrio 112
Terapi cairan
Pertimbangan kuantitatif & kualitatif
Optimasi prabeban dengan volume
intravaskular
Bolus dititrasi
Menilai efek pada prabeban & keluaran
ventrikular
Sifat masing-masing cairan
dipertimbangkan
S. Sunatrio 113
PERTIMBANGAN KUALITATIF
Dilema : darah
(CaO2 - CvO2 ) ( C.O.x 10 ) > VO2
Elektrolit , faktor asam-basa
Kontroversi koloid vs kristaloid
S. Sunatrio 114
RESUSITASI CAIRAN
Disesuaikan untuk setiap pasien
Penilaian kontinyu respons terhadap terapi
Cairan >> Morbiditas
Cairan << Kegagalan organ
Kehadiran dokter
S. Sunatrio 115
DEFEKT PILIHAN
primer cairan
S. Sunatrio 116
S. Sunatrio 117
S. Sunatrio 118
S. Sunatrio 119
S. Sunatrio 120
S. Sunatrio 121
Pilihan koloid
S. Sunatrio 122
Pilihan koloid
Syok berat krn dehidrasi poligelin
Perdrhan baru syok ringan isoonkotik
Syok berat hiperonkotik
Kebocoran kapiler HES 100-300 kD
S. Sunatrio 123
Ruang interstisial otak Sawar darah otak
Lumen kapiler
Partikel dg BM tinggi
(misal albumin, dekstran)
Jaringan
Partikel dg BM rendah
(msal Na+, Cl-, glukosa)
Plasma
S. Sunatrio 124
KAPILER SEREBRAL
LUMEN VASKULAR RUANG INTERSTISIAL
7A
H2 O H2 O
Na+ Na+
ion-ion kecil ion-ion kecil
P P
BBB
Kapiler
Partikel dg BM tinggi
(misal albumin, dekstran)
Partikel dg BM rendah
(misal Na+, Cl-,glukosa)
Sesudah berbagai cedera otak (misal iskemia, kontusio), mungkin terjadi
kerusakan BBB yang memungkinkan lolosnya partikel-partikel dengan BM rendah
dan tinggi dari lumen kapiler (yaitu kapiler menjadi bocor). Pada kasus berat bahkan
mungkin terjadi ekstravasasi sel darah merah ke dalam interstisial, pemberian larutan
baik hiperosmolar maupun hiperonkotik tidak bermanfaat untuk mengurangi
pembentukan edema pada area yang mengalami cedera. Larutan hiperosmolar masih
mungkin bermanfaatpada area yang jauh dari area cedera di mana BBB masih tetap utuh.
S. Sunatrio 126
KAPILER PERIFERAL
LUMEN VASKULAR RUANG INTERSTISIAL
65 A
H2O H2O
Na+ Na+
ion-ion kecil ion-ion kecil
P P
S. Sunatrio 128
PENGGANTIAN VOL/ TDK
EDEMA SEREBRI
EXPANSI VOL
BEREFEK
A OSMOLALITAS SERUM
S DIPERTAHANKAN
A TEK HIDROSTATIK SEREBRAL
TDK SECARA NYATA
L
KRISTALOID vs KOLOID ?
S. Sunatrio 129
KRANIOTOMI
S. Sunatrio 130
ICP AIR OTAK
NaCl 0,9% -
RL
NaCl HIPERTONIK
HES NaCl 0,9% - -
S. Sunatrio 131
Hypertonic fluids
lesser amounts can provide rapid vol
expansion & improve haemodynamics
decreasing tissue edema, ICP & brain water
can be combined with colloid sol to
prolong their plasma vol expansion effects
combined with 6% HES improve
neurologic fc & CPP in pts with traumatic
brain injury
S. Sunatrio 132
KRANIOTOMI
Th/CAIRAN:
PAKAI KRISTALOID ISOTONIK (RL &
NaCl 0,9%) UTK SEMUA KEADAAN
KECUALI RESUSITASI VOLUME UTK
SYOK & UTK PERTAHANKAN
OSMOLALITAS SERUM NORMAL
BATASI JUMLAH RL 1-3 L (TAMBAH NS
KP)
S. Sunatrio 133
DEKSTRAN
S. Sunatrio 134
Resusitasi cairan pd kombustio
24 jam pertama :
kehilangan integritas kap pd jar yg rusak
kehilangan cairan isotonik & albumin dari
kompartemen IV ke jar sekitar luka
Beri kristaloid vol > utk ekspansi cairan
ekstraselular
Sesudah 24 jam :
beri koloid vol >
beri kristaloid vol <
S. Sunatrio 135
Current status of burn resuscitation
Yowler,C.J. et al., Case Western Reserve University, Cleveland, Ohio, USA
Clin Plast Surg 2000 Jan;27(1):1-10
First Hour:
On the ambulance: 500-1000 ml Colloid (e.g. Gelatin)
Ad admission: 500 ml Colloid + 1000 ml LR
Crystalloid
vs
Colloid
S. Sunatrio 138
Meta-analysis
Observation: Compensatory fluid administration for
preoperative dehydration improves outcome?
Medline search (1966-2001)
17 papers met inclusion criteria
Two groups:
< 1 litre (nine studies)
1 litre (eight studies)
Conclusion: Fluid to compensate preoperative dehydration
reduces postoperative drowsiness & dizziness
Holte K. Kehlet H. acta Anaesthesil Scand 2002;46(9):1089-93
S. Sunatrio 139
System Review
S. Sunatrio 140
Data Collection
S. Sunatrio 141
Groups
Crystalloid preloading
Colloid vs crystalloid (preloading)
S. Sunatrio 142
Results
91 papers from MEDLINE, 23 randomized
controlled trials (RCT)
23 RCT are divided into three categories
1. Comparison of large & small vol crystalloids
2. Colloid vs crystalloid or different colloid regimens
3. Mechanical or pt positioning as a means of increasing
preload
S. Sunatrio 143
The result of system review
S. Sunatrio 144
Crystalloid vs Colloid
S. Sunatrio 145
Clinical Data
S. Sunatrio 146
Intravascular remaining vol at 30 min
after fluid infusion
Groups IVRV(L) %
RL 0.430.20 28
S. Sunatrio 149
Zhongshan Hospital
16 pts with hepatic carcinoma
hyper-vol hemodilution before anesthesia
hyper-vol hemodilution after anesthesia
General+epidural anesthesia
25mL/kg Ringers within 30 min
Conclusion:
Hyper-volume hemodilution is better
S. Sunatrio 150
Ruijin Hospital
150 ASA I & II pts undergoing abd surgery
A: normal rate infusion of crystalloid
B: rapid infusion of crystalloid
C: rapid infusion of colloid
Protocol:
Group A, Ringers(15mL/kg/h) started on anesthetic induction
Group B, 7mL/kg & 13mL/kg Ringers within 20min before & after
induction respectively. And then 15mL/kg/h until 40mL/kg
Group C, 7mL/kg & 13mL/kg 6%HES within 20min before & after
induction respectively. 15mL/kg/h (1:1 Ringers/6%HES) until 40mL/kg
S. Sunatrio 151
Ruijin Hospital-conclusion
Rapid infusion on induction has some
prophylaxis to hypotension. Crystalloid &
colloid at same infused vol have similar
prophylaxis
Although rapid infusion of crystalloid &
colloid at same rate & vol on induction, CVP
increase was greater in HES group, indicating
vol expanding effect of HES is better than
Ringers.
S. Sunatrio 152
TERAPI CAIRAN
Pendekatan Seimbang
Terampil dalam terapi dengan
kedua macam larutan
(Kristaloid & Koloid)
S. Sunatrio 153
Terapi Cairan
RESUSITASI RUMATAN
Repair
Mengganti kehilangan 1. Kebutuhan normal
akut (hemorrhage, (IWL + urin+ feses)
GI loss, rongga ke3) 2. Dukungan nutrisi
S. Sunatrio 154
RL atau Ringer Solution bukan untuk rumatan
K+ 4 4 20 20 1 meq/kg
Glukosa - - 27 100
S. Sunatrio 155
TERAPI CAIRAN
RESUSITASI RUMATAN
S. Sunatrio 156
APA YG KITA MILIKI PENTING
NAMUN
YG LEBIH PENTING LAGI :
APA YG BISA KITA PERBUAT
DGN APA YG KITA MILIKI
S. Sunatrio 157
S. Sunatrio 158