FLUID MANAGEMENT

INTRAVASCULAR VOLUME

HEMODYNAMIC MECHANISM
 PRE-LOAD CONTRACTILITY AFTER-LOAD

STROKE VOLUME HEART-RATE

CARDIAC OUTPUT SYSTEMIC

VASCULAR
RESISTANCE

BLOOD Tissue
PRESSURE Perfusion
Hasanul, 2006
29/09/2017 3
 ICF
Permeabel terhadap
H2O saja

ISF

IVF

permeabel terhadap
H2O & particle kecil
Physiologic principles
of fluid management

TOTAL BODY WATER : 60% TOTAL BODY WEIGHT

60 kg 36 L
Permeabel terhadap
H2O saja

9L 3L 24 L

ISF
ISF IVF ICF

permeabel terhadap H2O & Hasanul, 2002

particle kecil
 Kristaloid
Kristaloid adalah terminology yang digunakan untuk
cairan yang tidak mengandung molekul molekul
besar, sehingga tidak memiliki kekuatan (tekanan)
onkotik ( tekanan onkotik = 0)
 Koloid
Kolloid adalah terminology yang digunakan
untuk cairan yang mengandung molekul
molekul besar ( 30.000) sehingga memiliki
tekanan onkotik menjaga air tetap dalam
kompartemen intravaskular.
 Tekanan Onkotik

Tekanan onkotik adalah kekuatan untuk

menahan air (H2O) tidak keluar dari
kompartemen intravaskular,

to hold water
 Koloid Kristaloid
Albumin, HES,
D5W, RL, RA,
Expafusin, NaCl 0.9%
Gelatine, dll

Cairan Nutrisi
Intrafusin, Ivelip,
Triofusin , dll
Physiologic principles
of fluid management hypotonic

Not for
D5W= H2O
resuscitation !!!
3L
EDEMA

9L 3L 24 L
750ml 250 ml 2L
ISF
ISF IVF ICF
Physiologic principles
of fluid management Isotonic fluid
Membutuhkan volume yang
lebih besar, CRYSTALLOID
Lebih murah, RL, RA,
3L
Side effek lebih kecil
NaCl 0.9%
edema intersitiel

9L 3L 24 L
2250ml 750 ml
ISF
ISF IVF ICF

Edema perifer pada pasien trauma atau post operatip , tidak

merupakan tanda adekuatnya volume intravaskular
albumin
Bila albumin berkurang s/d 50%, COP akan menurun
s/d 1/3 dari nilai normal
Plasma half life 16 jam
Dalam 2 jam post infusi, 1 gr albumin akan
mengexpansi intravaskular 20 x
Contoh :
1000 ml albumin 5% (50 gr albumin) akan mengekpansi
intravaskular volume sebesar 50x20 = 1000 ml
100 ml albumin 25% (25 gr albumin) akan mengekpansi
intravaskular volume sebesar 25x20 = 500 ml
Physiologic principles
of fluid management

Albumin-5%
expensive 1L

9L 3L 24 L
1L
ISF
ISF IVF ICF

Hasanul, 2002
Physiologic principles
of fluid management

Albumin-25%
expensive 100 ml

VOLUME
EXPANDERS

9L 3L 24 L
400 500 ml
ISF
ISF IVF ICF

Hasanul, 2002
Physiologic principles
of fluid management

Lebih cepat mengkoreksi

volume intra vaskular
Mempertahankan tekanan HES-6%, 200/0.5
onkotik intravaskular 1L
Lebih mahal dari kristalloid

9L 3L 24 L
1L
ISF
ISF IVF ICF

Hasanul, 2002
Physiologic principles
of fluid management

Lebih cepat mengkoreksi

volume intra vaskular
POLYGELINE
Mempertahankan tekanan (HAEMACCEL)
onkotik intravaskular 1 Liter
Lebih mahal dari kristalloid
sebagian shift ke ISC

9L 3L
24 L
300 700 ml

ISF
ISF IVF ICF

Hasanul, 2002
Physiologic principles
of fluid management

Lebih cepat mengkoreksi

volume intra vaskular
GELATIN
Mempertahankan tekanan (GELOFUSINE)
onkotik intravaskular 1 Liter
Lebih mahal dari kristalloid

9L 3L
1000
24 L
ml
ISF
ISF IVF ICF

Hasanul, 2002
Physiologic principles
of fluid management

Lebih cepat mengkoreksi

volume intra vaskular
Dextran 40
Mempertahankan tekanan 1L
onkotik intravaskular
volume expand
Coagulopathy

9L 3L 24 L
260 1600 340
ISF
ISF IVF ICF

Hasanul, 2009
Physiologic principles
of fluid management

Subjek untuk penelitian

7.5%-Hypertonic
Resusitasi cepat, volume
Saline
sedikit
Mengurangi cerebral
edema

9L 3L 24 L
?ml
ISF
ISF IVF ICF

Hasanul, 2010
 Hypertonic saline
Hypertonic solutions and hypertonic/hyperoncotic
solutions may improve cardiovascular function on
multiple levels:
displacement of tissue fluid into the blood compartment
direct vasodilatory effects in the systemic and pulmonary
circulation,
reduction in venous capacitance,
positive inotropic effects through direct actions on
myocardial cells.
 Salin hipertonik
apabila diinfuskan akan memindahkan cairan dari
intraselular ke ekstraselular ( interstitial dan
intravaskular dengan perbandingan seuai dengan
perbandingan volume kompartemen)

Volume yg akan pindah

=
( kadar NaCl hipertonik : 0.9) x volume NaCl
hipertonik yang diinfuskan
 250 mL NaCl 7.5%

Volume yg akan pindah

= (7.5 : 0.9) x 250 mL = 2083 mL
Volume ekstrasellular akan bertambah
sebesar : 250 + 2083 = 2333 mL
dari jumlah ini akan didistribusikan sbb :
583 mL IVF dan 1500 mL ISF
 Hypertonic saline
Beneficial effects of hypertonic saline
solutions were reported to be rather
transient.
Consequently, hypertonic solutions were
often mixed with colloids (dextran or HES),
and these solutions showed a prolonged
efficacy.

R/HSD
 SVR
menurun
 PERIPHERAL CAPILLARIES

Interstitial Space

Capillary Lumen

Interstitial Space

Red Blood Cell

High MW particles
(Albumin, HES)

Low MW particle
(Na+, Cl , glucose)
CEREBRAL CAPILLARIES

Brain Interstitial Space

Capillary Lumen

Brain Interstitial Space

BBB

Red Blood Cell

High MW particles
(Albumin, HES)

Low MW particle
(Na+, Cl , glucose)
Fluid Movement Between
Capillaries and the Brain
In the presence of an intact BBB

Perpindahan cairan antara capiler dan

extracellular space otak terutama oleh
gradient osmotik (osmolarity).
Pada jaringan otak, ( tidak seperti
pada jaringan di peripheral ), plasma
oncotic pressure kecil perannya
dalam proses perpindahan cairan.
Clinical implication

Hyperglycemia harus dihindarkan pada

pasien yang mengalami brain ischemia .
Larutan Dextrose jangan diinfuskan pada
pasien yang akan menjalani prosedur bedah
syaraf, kecuali dibutuhkan untuk terapi atau
pencegahan hypoglikemia..
Chopp et al., (1988). Stroke, 19.
Lanier et al., (1987). Anesthesiology, 66.
Ljunggren et al. (1974). Brain Research, 77.
Myers et al., (1976). Journal of Neuropathology and Experiemental Neurology, 35
Smith et al. (1986). Journal of Cerebral Blood Flow and Metabolism, 6.
Natale et al. (1990). Resuscitation, 19.
Intraoperative Fluids,
Crystalloids
Equi(iso)osmolar to normal plasma (290-295 mOsm/L)
F l u i d Osmolarity
(mOsm/L)
Lactated Ringers Solution 273
Acetate Ringers Solution 273
Ringers Solution 310
0.9% Saline 308
0.45% Saline 154
20% Mannitol 1098
30
Advantages
Composition resembling plasma
(acetated ringer, lactated ringer)
Free of anaphylactic reaction
Replaces ISF
Rapid infusion
Easily available
Lower cost, cheap
Greater urinary flow
Easy storage at room temperature

31
32
severe dilution of plasma protein CRYSTALLOID
concentration is accompanied by
a (critical) reduction RL, RA, NaCl 0.9%
in plasma COP with the risk of
increasing interstitial edema and
compromise organ perfusion 3L

750 ml 2250ml

IVF ISF ICF

ISF

Consequently large quantities of fluid (at least 3 to 4 times

the actual intravascular volume deficit) have to be infused
to achieve normovolemia when crystalloid fluid regimen is
chosen.
Joachim Boldt, M.D., Ph.D, Intraoperative fluid therapy-crystalloid/colloid debate
CONFERENCIAS MAGISTRALES Vol. 28. Supl. 1 2005 pp S23-S28 33
Subjek untuk penelitian
Resusitasi cepat, volume
sedikit
7.5%-Hypertonic Saline
Mengurangi cerebral
edema

9L 24 L
3L
?ml
IVFISF ISF ICF

Volume yg akan pindah = ( kadar NaCl hypertonik :

0.9 ) x volume NaCl hypertonik yang diberikan
 Hypertonic saline
Beneficial effects of hypertonic saline
solutions were reported to be rather
transient.
Consequently, hypertonic solutions were
often mixed with colloids (dextran or HES),
and these solutions showed a prolonged
efficacy.
R/HSD
Hypertonic saline
Hypertonic solutions and hypertonic/hyperoncotic
solutions may improve cardiovascular function on
multiple levels:
displacement of tissue fluid into the blood compartment
direct vasodilatory effects in the systemic and pulmonary
circulation,
reduction in venous capacitance,
positive inotropic effects through direct actions on
myocardial cells.
 proinflammatory effect

LR ( racemic L & D isomer) appears to

have a proinflammatory effect, but this
may be ameliorated by modification of its
composition.
Ringer Solution, Ringer Acetate

HARTMANNS SOLUTION IN HAEMORRHAGIC SHOCK,

NOW AND THE FUTURE
MA Khan1, JP Garner2

37
 Microcirculation,
tissue O2
A massive crystalloid resuscitation alone is less likely
to achieve adequate restoration of blood flow and
tissue O2 ( Funk, et al, 1995)

Lactated Ringers solution did not restore

microvascular perfusion sufficiently. (Wang et al
, 1990)

Colloids are able to restore microcirculatory

perfusion more than crystalloids (Lang.K, 2001)

38
 HES
Characteristic of the substance
Concentration (%)
Molecular Weight ( 450, 200,130,70)
Degree of subtitution (0.7 ; 0.5; 0.4)
Pattern of substitution (C2/C6)

6%HES 130/0.42 ; 9

39
 Development of HES
450/0.7 Balanced
Hetastarch >500/>0.7

70/0.5
200-260/0.5
200/0.62
Penta-Hexa
130/0.4
130/0.42 ; 9 Balanced
Tetra 130/0.42

1st 2nd
3rd gen HES 4rd gen.HES
gen.HES gen.HES
40
Molecular Weight
Molecular Weight

Intravascularpersistence
Tissue storage

41
 Haemostasis and Coagulation

Reduction of factor VIII and von Willebrands

factor activity
Impairment of platelet function
Increases in the APTT

42
 Interference with haemostasis and
coagulation depend on : MW, degree
(molar) of substitution and C2/C6 ratio

MW, degree (molar) of

substitution and C2/C6 effect
ratio

43
 HES AND RENAL FUNCTION
Hyperoncotic Renal Failure
(Moran and Kapsner)

Generation of a high plasma COP wich

counteracts the hydrostatic pressure
gradient in the glomerulus

Avoidance of hyperoncotic colloid

solutions
44
45
 H E130/0.4/11.2
HES S (130/0.4/9)

46
47
 gelatin
Oksipoligelatin
Poligelin

Gelatin polisuksinat

Suksinilasi menghasilkan pelebaran struktur

molekul, yang pada akhirnya akan
meningkatkan efek volume dibandingkan
dengan gelatin tanpa suksinilasi.
 More rapidly correct
hypovolemia
Maintain intravascular
oncotic pressure

anaphylactoid Gelatin
1000 mL
shift to ISF

200-300 700-800
ml ml

ISF
ISF IVF ICF

Hasanul, 2002
49
 Isotonic infusion

ICF ISF Plasma

750 ml 250 ml
 Hypotonic infusion

ICF ISF Plasma

660 ml 255 ml 85 ml