Terapi Cairan Dalam Praktek

Sehari-hari
dr. Sumara Niman,Sp.An
 Physiology of normal fluid balance

Total body water (TBW)

60% body weight

Extracellular fluid (ECF) Intracellular fluid (ICF)

33% TBW ( 20-25 %TBW) 67% TBW ( 30-40% TBW)
Na+ = 145 mmol/L Na+ = 12 mmol/L
K+ = 4 mmol/L K+ = 150 mmol/L
Cell membrane, permeable to water but
5% not most ions or protein
Intertitial fluid
TBW
75% ECF ( 15 % BW) Intravascular fluid/ plasma
Protein =/- 25% ECF (8% TBW), Protein +++
apillary wall, permeable to water & ions,
C
but most protein
2
 Type of Fluid
Colloid Crystalloid Other
Natural Albumin NaCl 0.9%/ Glucose 5%
0,45%
Dextran RL Mannitol
Syntetis Gelatin Electrolyte
RA
concentrates
HES
(Hydroxyethyl starch) Ringerfundin® etc.

consist of : consist of : consist of : high

electrolytes electrolytes concentration of
electrolytes
&
macro molecule

3
Indication of Fluid Therapy
-Dehidration
-Fluid losses during surgery
-Acute hypovolemia e.g because of massive blood loss, Sepsis,
Dengue
-Acidosis or alkalosis, electrolyte imbalances
-Application of drugs
 Perbedaan Terapi berdasarkan kompartemen cairan
Terapi kasus Terapi kasus hypovolemia
dehidrasi
 penggantian kehilangan
 penggantian kehilangan cairan di cairan di ruang intravascular (=
semua ruang extracellular kehilangan darah)

 fluid replacement  volume replacement

Kristaloid Koloid
5 5
 Volume therapy
target: intravascular space
indikasi: plasma & blood losses (> 25%)
koloid + kristaloid

Fluid management
Fluid management

Kristaloid
Fluid substitution
target: jaringan, interstitial space
indikasi: dehidrasi, maintenance
Basic treatment, dibutuhkan oleh semua pasien

6
 Crystaloid & Colloid

Crystalloid Colloid

IC

IS
Colloid  IV
Crystalloid  ECS

(IV) (IV)

7
Sodium (Na+) Clorida (Cl) Colloid
Quantitative approach of acid-base equilibrium
 pH atau [H+] DALAM PLASMA
DITENTUKAN OLEH

DUA VARIABEL

Menentukan
VARIABEL VARIABEL
INDEPENDEN DEPENDEN

Primer (cause) Sekunder (effect)

pH

9
01/08/2018 Stewart PA. Can J Physiol Pharmacol 61:1444-1461, 1983.
 VARIABEL INDEPENDEN

CO2 STRONG ION DIFFERENCE WEAK ACID

pCO2 SID Atot

Electrolyte Concentration of
Control by
composition in protein (control by
respiratory
plasma liver and metabolic
system
(control by renal) status)

Pharmaceutical contribution
 SID………
Plasma composition :

Mg++
Ca++
K+ 4 HCO3-
24 SID
Weak acid
(Alb-,P-)

Na+
142
Cl-
103

KATION ANION
SID Plasma = (Kation–Anion) = 40 ± 2
 PLASMA + NaCl 0.9%

Plasma NaCl

Na+ = (142 + 154)/2 = 147

Na+ = 142 mEq/L Na + = 154 mEq/L

Cl- = (103+154)/2 = 128 2L
Cl- = 103 mEq/L Cl- = 154 mEq/L
SID= 19 mEq/L
SID= 39 mEq/L 1L SID = 0 mEq/L 1L

SID : 39  19 : acidosis
 Osmolarity & Osmolality
- Real osmolality ~ Sum: osmotically active species
 Plasma 288 mOsm /kg H2O

- Theoretical Osmolarity = Sum: Cation + Anion

 NaCl 0.9% = Na :154 + Cl :154 = 304 mosm/l

-Osmotical coefficient : ~ 0.93 (protein binding)

- NaCl 0.9% (Na :154 mosm/l + Cl :154 mosm/l)

 Theo Osmolarity : 304 mosm/l

- Water content 99.7% (mosm/l mosm/kgH2O)
- Osmotical coefficient := 0.93
 Real Osmolality = 308 x 0.997 x 0.93
= 286 mosm/ kg H2O
Isotonicity ~ Real
Osmolality 286 mosm/ kg H2O (Plasma)
nder, Fluid Management, 2009
Effects of Osmolarity on Cell Volume

15
[mmol/l] NS Ringer RL RA RFundin Plasma Benefit

Na+ 154 147 130 130 140 142 Na+ responsable for tonicity of fluid
Plasma equivalent of most important electrolytes (i.e Na & K)
K+ -- 4.0 4 4 4.0 4.5
 Less unintended correction
Ca2+ -- 2.25 2.7 2.7 2.5 2.5 Ca is essential cofactor in coagulation cascade  if Ca drop
 leads prolonged blood coagulation

Mg2+ -- 1.0 -- -- 1.0 0.85 Less unintended correction

Cl- 154 156 108.7 108.7 127 103 Cl- slightly higher in order to achive physiological osmolarity

HCO3 24 Infusion should have physiologi buffer base HCO3 to

maintain base-acidity but due to stability -> using
Lactate- -- -- 28.0 -- -- 1.5
precursor : Lactate, Acetate, Malat.
Acetate- -- -- -- 28.0 24.0 RFundin: combine Acetate & Malat instead of Lactate:
Malate2- -- -- -- -- 5.0 1.Acetate/malat metabolize in most tissue cells of body
compare to Lactate-clearing organ in liver & kidney
2.Lactate should not be used in hepatic insufficiency 
Lactate metabolize in liver  lactate in solutin lead metabolic
acidosis
3.Lactate should not be used in shock with hyperlactademia /
lactic acidosis.

BEpot -24 -24 3.0 2.5 0 No change patient‘s acid-base status

Tonicity RF more Isotonic than RL & RA, will avoid risk of neurotrauma
[mOsm/l] 304 309 273 273.4 304 308 & cerebral edeme that can easily develop in preterm &
[mOsm/lkg) 286 256 256 286 288 newborn
 Clinical Demands :

Optimization of few criteria leads to one solution for 95% of all patients

 Plasma-adapted / Balance / Physiologis

 Isotonic
 Low O2-Consumption
 Several Metabolisation Pathways
 BEpot= 0 mmol/l
Prof. Dr. Dr. M. Leuwer, Liverpool Univ

17
Crystalloids- Balanced Solution (BEL)
Composition
NaCl  Hypercloremic
1. Sodium 140 mmol/l acidosis Sterofundin- iso

R Lactate  Hypotonicity
2. Potassium 4 mmol/l , Osmolarity 309
3. Calcium 2,5 mmol/l
4. Magnesium 1 Lactate
mmol/l metabolism Buffer 34

R Acetate 127
5. Chloride Hypotonicity
mmol/l
6. Acetate 24 mmol/l Calcium 2.5
7. Malate 5 mmol/l
Osmolarity 309 mosmol/l Magnesium 1

Potassium 4
Is BEL physiological?
Osmolarity: yes Chloride 127

Cations: yes Sodium 140

Anions: compromise
Buffer: yes Total 37

0 25 50 75 100
BEL is almost physiological! deviation from normal (mmol/l)
Ringerfundin ® Balanced Crystalloid

Isotonis Hypotonis Hypotonis Isotonis

Pengganti plasma sintetik yang ideal sebaiknya:

1. Iso-onkotik dan isotonik

2. Memiliki efek volume yang sedang dan dapat diperkirakan waktu paruhnya
dalam intravaskular
3. Tidak meningkatkan viskositas plasma
4. Dapat diekskresikan ginjal atau dipecah dengan cepat tanpa penyimpanan
intrasel
5. Tidak memiliki aktivitas farmakologis yang merugikan selain efek volume

21
Pengganti plasma sintetik yang ideal
sebaiknya:

6. Tidak memiliki efek samping atau infeksi

tertentu
7. Tidak mahal dan dapat disimpan dalam suhu
ruangan untuk jangka panjang

22
 World of Colloid

Gelatin HES (Hydroxy Etyl Starch) Dextran

Baha Gelatin sapi Starch / Kanji / Amylum Gula bit

n

BM 30 – 35 200 130 40 – 70
kdl
MFG Polygeline

Sol NaCl NaCl NaCl Ringer NaCl Ringerfundin NaCl

Laktat / Balanced

Gelofusin Haemaccel -Haes steril Fimahes -Voluven Tetraspan Otsutran

e (BB) (HES 130
-Hemohes -Venofundi
Balance)
-Widahes n
(BB)
-Hestar

23
 PLASMA + Colloid Un-Balanced (NaCl)

Plasma Colloid/NaCl

Na+ = (142 + 154)/2 = 147

Na+ = 142 mEq/L Na + = 154 mEq/L

Cl- = (103+154)/2 = 128 2L
Cl- = 103 mEq/L Cl- = 154 mEq/L
SID= 19 mEq/L
SID= 39 mEq/L 1L SID = 0 mEq/L 1L

SID : 39  19 : acidosis
 PLASMA + Colloid Balanced

Acetat &
malate cepat
dimetabolisme

Plasma Tetraspan ®
(Balanced HES)

Na+ = (142 + 140)/2 = 141

Cation+ = 147 mEq/L
Na+ = 142 mEq/L Cl- = 118 mEq/L
Cl- = (103+118)/2 = 110 2L
Cl- = 103 mEq/L Malate = 5 mEq/L
SID= 31 mEq/L
SID= 39 mEq/L 1L Acetat- = 24 mEq/L 1L
SID = 29 mEq/L

SID : 39  31 : minimal acidosis

Minimal coagulation changes for HES Balanced compare to HES Un-
balanced (HES/NaCl)
Volume & Duration effect of colloid (in hypovolemic volunteers)

3.5 % Polygeline ~50-60%

~70% ~2-3h
~2-3h (?)
4% Modified Fluid Gelatin (MFG)
4% Modified Fluid Gelatin Same effect
6%/10% HES 200/0.5 &
6% HES 200/0.5
~ 100/
100 %145%
~3-4h ~3-4h, 4-6and
h duration!
HES 130 / 0.4-0.42

6% Dextran 70 1oo% ~ 4h
6% Dextran 70 and HES 450/0.7
HES 200/0.62 1oo- 140 % ~3-4/4
~ 7-9h -9h
6%
10%HES
HES200/0.62
200/0.45and
and450/0.7
0.5 145 % ~ 4h

10% Dextran 40
(?) ~ 190 % ~3-4h
~ 3-4h

0 50 100 150 200 (%)

27 (Gelofusine®) compareable volume effect with HES 200 and 130

MFG
Filter molekul melalui pori glomerulus ginjal

Mw < 10 000 Dalton Free passage

Mw = 10 000 - 50 000 Dalton Impair passage
Mw > 50 000 Dalton No passage

Semakin besar BM suatu molekul (koloid)  semakin “tidak mudah”

melewati ginjal  konsekuensi akumulasi di ginjal / plasma  Berkaitan
dengan DOSIS MAKSIMAL

Note :
Kidney barrier:
50,000 - 60,000 Dalton
28
29
 Faktor yang mempengaruhi eliminasi preparat HES :
 Molecular weight (Mw) / Berat Molekul (BM) :
Semakin kecil BM semakin mudah degradasi
Co. HES BM 200 kdl dan HES BM 130 kdl
 Molar substitution (MS) / Derajat Subsitusi (DS) :
6 Hydroxyethyl per 10 glucose units  MS = 6/10 = 0.6 : Semakin kecil MS semakin cepat.
Co. HES 200/ 0.5, HES 130/ 0.42
 C2/C6 ratio:
ratio dari nomor substituents pada carbon atom nomor 2 kemudian 6
Semakin kecil rasio C2/C6 semakin cepat degradasi,
Co. 9:1 dan 6:1

MS >> C2/C6 > Mw

30
 Eliminasi HES

Enzymatic
hydrolysis

Kidney barrier:
50,000 - 60,000 Dalton

31
31
Akumulasi - HES 200

Boldt (2003), Lehmann et al. (2007)

32
32
Fast and complete clearance Tetraspan® HES 130/0.42

HES 130/0.42/6:1
Tidak ada akumulasi
walaupun stl dosis
besar / berulang

Lehmann et al. (2007)

33
Effective and Safe
Tetraspan® HES 130/0.42/6:1 vs HES 130/0.4/9:1

Tetraspan (HES 130/0.42/6:1)

HES 130/0.4/9:1

Tetraspan HES 130/0.4/9:1

Lehmann G, Acta Anaesthesiologica Scan, 2005

Dosis Maksimal yang direkomendasikan dalam
Pedoman Tatalaksana DBD Depkes 2008 :

???

???

“Life saving product  Safety  Dosis Maksimal”

35
36
Human Serum Albumin

37
38
39
40
41
42
 EFEK SAMPING DAN DOSIS ALBUMIN
Reaksi alergi tipe lambat : DOSIS :
➢Demam ➢Dewasa: sd 2
g/kg/BB/24 jam
➢Menggigil (40 mL albumin
➢Mual-muntah 5%/kgBB/24 jam)
➢Anak: 0,5 – 1 gram
➢Urtikaria /kgBB
➢Salivasi meningkat. ➢( 10-20 ml albumin 5
%/kgBB/24 jam )
➢Rate : rapid / slow

Blood transfus. 2009; 7 : 216-34. 19

 Distribusi cairan dalam ruang tubuh
Distribusi cairan IV bilamana 1000 ml larutan diberikan secara cepat
pd pasien dengan BB 70 kg dalam waktu 1 jam
LARUTAN PLASMA INTERSTIIL INTRASEL
Albumin 5 % 1000 - -
Polygeline 700 300 -
Dextran 40 1600 -260 -340
> Dextran 70 1300 -130 -170
Na Cl 0.9 % 200 800 -
Na Cl 1.8 % 320 1280 -600
Na Cl 0.45 % 141 567 292
Ringer Lactat 200 800 -
Dextrose 5 % 83 333 583

Molekul Dextran yang lebih besar bertahan lebih lama

didalam sirkulasi tetapi memberikan aktifitas osmotik
13
lebih kecil
 Kristaloid dan koloid
Kristaloid Koloid

Kandungan Zat dengan BM rendah (< 8 rb D) BM > 8 rb D spt protein, glukosa

Dengan atau tanpa glukosa berpolimer besar
Tekanan onkotik Rendah →cpt terdistribusi ke Tinggi→ lbh banyak dan lama menetap
seluruh ruang ekstraseluler di ruang intravaskular
Efek volume interstiil Lebih baik dr koloid Kurang baik dibanding kristaloid

Efek edema perifer Lebih sering dibanding koloid Lebih jarang dibanding kristaloid

Efek edema paru Sama dengan koloid Sama dengan kristaloid

Aspek lain Murah, mudah didapat, mudah Mahal, risiko alergi, anafilaktik, efek pd
disimpan, tidak toksik, reaction free hemostatik, fungsi ginjal

Contoh Saline, RL, D 5 % Albumin, produk darah, fraksi

protein plasma, koloid sintetik ( HES,
Gelatin ) 47
TERIMA KASIH