Vito Mahendra

CAIRAN TUBUH

Jumlah cairan tubuh tergantung

 Umur
 Jenis kelamin
 Jumlah lemak tubuh
 Body Fluid Compartments:
2/3
ICF:
55%~75%

X 50~70% TBW
lean body weight

3/4 Extravascular
Interstitial
Male (60%) > female (50%)

 Most concentrated in skeletal muscle 1/3 fluid
 TBW=0.6xBW ECF
 ICF=0.4xBW
 ECF=0.2xBW

Intravascular
1/4 plasma
 DISTRIBUSI CAIRAN TUBUH

LAKI-LAKI PEREMPUAN BAYI

60 50 75

 Didalam sel 40 30 40

 Di luar sel 20 20 35
 Plasma 5 4 5
 Intersisial 15 16 30
GAMBAR SKEMATIS

BERAT BADAN (60 KG)

CAIRAN TUBUH TOTAL

36 L = 60%
Intra Sel Ekstra Sel
( 24 L = 40% ) ( 12 L = 20% )

Intersisial Plasma
( 9L = 15%) (3l = 5% )

K+ PO -
4 Na + Cl -

Rongga Ke 3
 KESEIMBANGAN INPUT  OUT PUT CAIRAN / 24JAM
( UNTUK BB + 60 KG )

CAIRAN MASUK CAIRAN KELUAR

Minuman : 800 – 1500 ml Urin : 800 – 1500 ml
Makanan : 500 – 700 ml Tinja : 0 – 250ml
Hasil oksidas : 250 ml Insensible loss : 600 ml
 Schwartz, principles of surgery, 9ed

Komposisi cairan tubuh

Elektrolit (mEq/L)
Cairan Tubuh Na K Cl HCO3
ICF 10 150 5 10
Plasma 142 4.5 100 25
Usus Halus 120 20 110 30
Pankreas 130 15 80
Empedu 140 5 40
Jarrel & Carabasi (1991)
 Terapi Cairan
 Larutan Parenteral
dan Elektrolit
 Tipe cairan tergantung status volume pasien & tipe
komposisi abnormal tubuh
GI losses  RL / NaCl 0,9% (koreksi vol. ekstrasel)
 RL mengandung laktat yg akan dirubah menjadi bikarbonat
o/ hepar (laktat stabil dlm cairan i.v)
 NaCl  asidosis hiperkloremik (ideal koreksi vol disertai
hiponatremi, hipokloremi, alkalosis metabolik)
• Larutan Parenteral
 Alternatif cairan resusitasi
 Alternatif cairan resusitasi
 Albumin  berhubungan dengan reaksi alergi
 Dextran  lbh digunakan sbg penurun viscous darah
 Hidroxyethyl starch  faktor von willebrand & faktor
VIII (koagulopati)
 Gelatin  memperpanjang coagulation time
(koagulopati)
Kebutuhan Cairan Maintanace
 Dewasa :
1 - 2 ml/kg/jam
 Atau (norton)
Berat (kg) ml/kg/jam ml/kg/hr
10 ke-1 4 100
10 ke-2 2 50
Per kg >2 1 20
• Catatan :
Tiap kenaikan t 1oC di atas 37oC  tambah
cairan 10-15% (12,5%) dari total maintenance
KEBUTUHAN CAIRAN REPLACEMENT
(KEBUTUHAN REHIDRASI)

Dehidrasi Dewasa Anak

Dh ringan 4% 5%
Dh sedang 6% 10%
Dh berat 8% 15%

Dari TBW
TBW :
-Bayi : 80%x BB (dalam gr)
-Anak : 70%x BB
-Dewasa : 60%x BB
Tanda Dehidrasi
Dehidrasi Gejala
Heart rate(10-15%) di atas nilai normal
Selapur lendir agak kering
Ringan
Urin pekat
ProdUksi air mata <
Tanda di atas tambah berat
Turgor kulit menurun
Sedang Oliguria
Mata cekung
Ubun-ubun cekung
Tanda di atas >>
Tekanan darah ↓
Berat
Pengisian kapiler terlambat (> 2 detik)
Asidosis
 Preoperatif
 Kebutuhan cairan & elektrolit harian
air : 35 - 40 cc/kgBB/24 jam atau 1 - 2cc/kgBB/jam
Natrium: 1-3 mEq/kgBB/24 jam
Kalium : 1-2 mEq/kgBB/24 jam
Chlorida : 1-3 mEq/kgBB/24 jam
 Cat :
1. kenaikan panas 1 oC koreksi 12,5% maintenance
2. Cairan elektrolit diberikan sesuai kebutuhan, kekurangan
ditambah D5% / D10%
Tetesan Cairan per menit
 Makro: ∑ cairan (cc)
∑ jam x 3
(1 cc=20 tetes)

 Mikro: ∑ cairan (cc)

∑ jam

 Transfusi: ∑ cairan (cc)

∑ jam x 4
(1cc=15 tetes)
Terapi cairan intraoperatif
 Tdk ada formula khusus
 Anestesi  hipovolemi (koreksi preop inadekuat)
 Hal yg perlu diketahui
 Koreksi defisit cairan sebelumnya
 Kemungkinan hilang intraop (perdarahan, penguapan)
 Maintenance
 Albumin/ koloid  tdk bermanfaat thdp fs jantung &
cegah akumulasi cairan paru intraop
Terapi cairan
 Larutan isotonik
postoperatif
 Evaluasi resusitasi (TV, prod.urin, CVP)
 1-2 hr post op ganti D5% 0,45 NS
bila fs ginjal baik  koreksi kalium
 Cek prod NGT/drain, muntah, + maintenance
 Keadaan khusus
 Kelebihan cairan postop (paling sering)
 Tetap awasi bila ada dehidrasi
NUTRISI
 NUTRITION CARE PROCESS
Admission and
diet order by MD No assessment Discharge
Planning
Not at
Step 1: Patient screening within Risk
24 h of admission No inpatient care
At Risk Evaluation required any longer

Step 2: Patient Assessment

within 48 h of admission
Patient monitoring

Development of
Step 3: Nutrition Care Plan Implementation
(NCP) of NCP; timely

Modified from JPEN 26(1)Suppl.2002, 7SA

Subjective global assessment (SGA)

1. Weight changes

2. Changes in dietary intake

3. Gastroinstestinal symptoms

4. Functional capacity

5. Link between disease & nutritional requirements

6. Physical exam focused on nutritionnal aspects

Detsky AS, et.al. JPEN/1987;11;8-15

1. Weight changes
 Chronic : Over the last six week
 Acute : During the past two week
 Weight loss >10-15% within 6 months  UNDER NUTRITION

2. Dietary intake
 No change
 Changes: - Duration
- Type: * Inadequate conventional diet
* Total liquid diet
* Clear liquid diet (hypo caloric)
* Fasting
3. Gastro intestinal symptoms
 Nausea
 Vomitus
 Diarhea
 Anorexia

4. Functional capacity
 Dysfunction
- duration
- Type
* ambulatory
* bedridden
5. Ilness & nutritional requirement
Hospital risk factors:

1. No Risk Factor 21%

2. Cancer 29,7%
3. Mental illness including alkohol abuse 9,3%
4. Endocrine, Nutritional, Metabolic &
immune disease 11%
5. Respiratory ilness 14%
6. Diseases of digestive system 14%

This condition may affect the nutritional intake

6. Physical examination
 Loss of subcutaneous fat  Chweing/ swallowing
 Muscle wasting problems
 Ankle edema  Angular stomatitis
 Sacral edema  Fractures or bone pain
 Ascites  Glossitis
 Mouth, teeth, gum  Skin alteration
problems
CLASSIFY

 Well nourished (A)

 Moderately malnourished or
suspected malnutrition (B)
 Malnourished (C)
CRITERIA FOR SEVERE UNDERNUTRITIONS
ESPEN GUIDELINES 2009
(Clinical nutriton 2009(28), 378-386

One of the following:

1. Weight loss >10-15% within 6 months
2. BMI <18 kg/m2
3. Subjective global assessment (SGA): C
4. Serum albumin <3 g/L with no evidence of hepatic or
renal dysfunction
Nutrients
 Protein 4 kcal / g
 Carbohydrates
enteral 4 kcal / g
parenteral 3.4 kcal / g
 Lipids 9 kcal / g
 Water
 Vitamins
– Water soluble
– Fat soluble
 Minerals
– Electrolytes
– Trace elements and ultra trace minerals
 Malnutrition
Ideal Weight
Actual Weight

In malnutrition, energy expenditure must be calculated

based on actual body weight.
 Obesity
Ideal Weight
Actual Weight

In obesity, energy expenditure must be calculated on ideal

weight.
Calculating Basal Energy
Expenditure
 Harris-Benedict Equation
– Variables
gender, weight (kg), height (cm), age (years)
Men:
66.47 + (13.75 x weight) + (5 x height) – (6.76 x age)
Women:
655.1 + (9.56 x weight) + (1.85 x height) – (4.67 x age)

Calorie requirement = BEE x activity factor x stress factor

Calorie Calculation
“Rule of Thumb”

Calorie requirement = 25 to 30 kcal/kg/day

Determining Protein
Requirements
 Body weight
 Age
 Type of protein
 Daily requirements:
 Healthy
 0.8 to 1.0 g/kg/day
 Stressed state
 1.0 to 2.0 g/kg/day depending on condition
Carbohydrates
 Provide 50% to 60% of total calories
 Necessary to maintain protein anabolism
 Produces 4 kcal/g by mouth or enterally and 3.4
kcal/g intravenously
Fat Recommendations
 Source of energy and essential fatty acids
 Linoleic acid: 2 to 7 g/day
 Provide 20% to 30% of total calories
 1 g/kg/day
 In special disease management
 45+% of total calories from fat may be beneficial
 Glycemic control
 Reduction of CO2 production
 Calorie Distribution Shift in
Catabolism
NORMAL CATABOLIC
15%
25% 25%
30%
Protein
Fat Protein
Fat

CHO CHO

60% 45%
Vitamins
Fat Soluble Vitamins
 Vitamin A – Vitamin E
 Vitamin D – Vitamin K

Water Soluble Vitamins

 Folic Acid – Thiamin
 Pantothenic Acid – Vitamin B6
 Biotin – Vitamin B12
 Niacin – Vitamin C
 Riboflavin
Minerals
Sodium Zinc
Potassium Copper
Chloride Chromium
Calcium Manganese
Phosphorus Selenium
Magnesium Iodine
Iron
Zinc and wound healing
 Zinc is an essential component of multiple
metaloenzym, including RNA and DNA-
polymerases
 Role in cellular proliferation and protein
synthesis
 Zinc deficiency: alteration in the immune
system (thymic atrophy, lymphopenia, T-cell
impairement, decrease granulocyte function)
 Zinc suplementation: rapid reepithelization
and accelerated the healing of chronic venous
leg ulcer.
( Albina JE: Nutrition & wound Healing)
POST OPERATIVE NUTRITION
 START LOW and GO SLOW
 BIASA DIMULAI HARI PERTAMA DENGAN DOSIS
AWAL MAKSIMAL 50% KEBUTUHAN
 HARI KE II BISA DINAIKKAN 75%
 HARI KE III BILA MEMUNGKINKAN SUDAH
MENCAPAI MENDEKATI 100%
ESPEN GUIDELINES ON ENTERAL NUTRITIONFOR
SURGICAL PATIENTS
 Use nutritional support in patients with severe nutrition
for 10-14 days prior to major surgery even if surgery has to
be delayed
 No specific risk of aspiration may drink clear fluid 2 hours
or solid 6 hours before anesthesia
 Oral intake including clear fluid can be initiated within
hours after colon resection, based on the individual
tolerance
 Nasojejunal or nedle jejunostomy are recommended for
patient undergoing major surgery
 EN preferably with immuno-modulating substrates
(arginine, Ω-3 fatty acid and nucleotides) preoperatively
independent of the nutritional risk for those patients.

www.espen.org 2007
WHEN IS POST-OPERATIVE PARENTERAL
NUTRITION INDICATED
 Undernourished patients in whom enteral nutrition is not
feasible or not tolerated (A),
 Post-operative complications impairing gastrointestinal
function who are unable to receive and absorb adequate
amounts of oral/ enteral feeding at least 7 days (A)
 Combination EN-PN should be considered if indicated
for nutritional support but >60% energy need cannot be
met via enteral route: (high out-put entero-cutan fistula)
(C), or partial gastrointestinal obstruction (C)
 Prolonged gastrointestinal failure PN is life saving.

ESPEN Guidelines on Parenteral Nutrition: Surgery

Clinical nutrition 28 (2009): 378-386
Summary
 Nutrients are necessary to maintain life
 Nutrient utilization depends on availability (fasting) and
inflammatory response (stress)
 Energy requirements vary according to patient’s clinical
condition
 Caloric distribution and protein intake vary according to
patient’s metabolic status
Koreksi Elektrolit Abnormal yang
Mengancam Nyawa
 Sodium
 Hipernatremia
 Pd pasien hipovolemik  dahulukan koreksi dehidrasi

 Hiponatremi
 Ringan : restriksi cairan
 Berat : penambahan sodium
 Dapat digunakan 3% normal saline
Koreksi elektrolit : Kalium
 Harga Normal : 3,5 – 5,1

 Koreksi Hipokalemi ( < 3,5 meq/L)

Defisit Ringan : KCl oral
Aspar K / KSR 1 tab/ 8jam
 Manifestasi Klinis
Kelemahan otot, kurang reaktif thd stimulus, distensi
abdomen, ileus paralitik, hipotensi postural,
gangguan jantung, abnormalitas pelepasan insulin
 Syarat pemberian infus K
 Konsentrsi < 40 meq/L (preparat KCL perdrip)
 Kecepatan 10 meq/jam
 Jumlah < 100 meq/hari
 EKG monitor, periksa kadar K serum
 Urin > 0,5 ml/kg/jam
 Koreksi Hipokalemi
Defisit K+ : ∆ K+ x BB x 0,8
Maintanance :
Dewasa 1 meq/BB/hr
Anak 2 meq/BB/hr

6 jam I : Defisit + ¼ maintanance

6 jam II : ¼ maintanance
6 jam III : ¼ maintanance
6 jam IV : ¼ maintanance
 Sediaan : KCl flacon 25 cc (25 meq/fl)
Calsium (8,5 – 10,5 mg/dL)
HiperCa (> 10,5 mg/dL)
 Koreksi = Ca serum + (0,8 x ∆ albumin)
 Jika fungsi ren baik : 1-2 L NS + furosemide 80-100 mg tiap
12 jam selama 24 jam I
 Jika fungsi ren terganggu  hemodialisa
 Prednison 60 mg/hr PO atau hidrokortison suksinat 200-300
mg IV
 Bifosfonat (hambat aktiv. Osteoklast)
 Pamidronat 60-90 mg IV selama 4-24 jam
 Disodium etadronat 7,5 mg/kG IV tiap hr selama 4 jam untuk
3-7 hari
 Plikamisin (mitramisin) 25 μg/kg IV dlm 500 ml D5% selama 3-
6 jam, dpt diulang bbrp kali dg selang 24-48 jam
HipoCa
• Jika ada tetani  10 ml Ca glukonas 10% dalam
100 cc D5% bila perlu diulang dg infus (60 mL
Ca glukonas dlm 500 mL D5% dg kecepatan 0,5-
2 mg/kg/jam) Ukur Ca tiap beberapa jam
• Jika asimptomatik : Ca oral + vit D
 Koreksi Albumin (Gram)

Keterangan :
• ∆ Albumin X BB x 0,8 D= desired albumin
Max : 1 gram /Kg BB level(nilai abnormal)

atau A= actual albumin level

(D-A) BW X 40 X 2 gr BW=Body weigh

40=Normal Plasma Volume
100
100= untuk satuan mjd 100ml
Nilai normal = 3,5-5,5