TERAPI CAIRAN TRIASE

Eko Waskito

Perkenalan
Tempat/ Tgl Lahir: Pematangsiantar
10 April 1979

Pendidikan Dokter FK USU, selesai Jan 2005 Pendidikan Dokter Spesialis Anestesiologi & Terapi Intensif FK USU, masuk Januari 2010

Staf RSUD Kota Jantho Kabupaten Aceh Besar

Istri: Dr. Ari Gusnita (PPDS Neurologi FK USU) Anak: Aqila Lutfiyah M. Rafif Aditya

Pelatihan: ATLS, ACLS, Resusitasi Neonatus, Psikiatri Akut, dll

Organisasi: Kabid Litbang HMI FK USU Manajer Op. MER-C Medan Koord. Kesehatan PKPA Medan Seksi Ilmiah IDI Aceh Besar Member Of Indonesian Society of Perinatology Publikasi: Artikel di Media Cetak 35 bh

Niat: Hidup adalah memberi

PHYSIOLOGY TOTAL BODY FLUID 60% BW

INTRACELLULAR FLUID (ICF) 40 % BW

EXTRACELLULAR FLUID (ECF) 20% BW

TRANSCELLULAR FLUID 1-3 % BW

INTRAVASCULAR FLUID
5 % BW

INTERSTITIIL FLUID
15 % BW

60% dari berat badan adalah H2O

Pasien berat 50 kg 30 kg adalah air (30 liter)

Interstitial Fluid (ISF) 15% BB

ECF

Intra Vascular Fluid (IVF) 5% BB

Intra Cellular Fluid (ICF) 40% BB

ECF IVF 5% ISF 15% ICF 40%

2500 ml

7500 ml

pada pasien 50 kg ISF merupakan buffer / cadangan yang lebih besar daripada IVF

ECF IVF 5% ISF 15% ICF 40%

Infusi cairan elektrolit ke IVF akan merembes keluar ke ISF Komposisi IVF dan ISF sama

Kehilangan cairan yang sering terjadi

Gastro Air Natrium Kalium

intestinal loss

Perdarahan
Air Natrium Kalium Albumin Eritrosit

2
Gastro-intestinal loss IVF

1
ISF

Diare, muntaber, peritonitis

1. Interstitial sign : 1. mata cowong, 2. turgor turun, 3. mucosa kering 2. Plasma sign : 1. Perfusi lambat 2. Nadi naik 3. Tekanan darah turun

infus
1 2 2 1

IVF

ISF

Terapi Infus untuk Diare, muntaber, peritonitis

1. Infus cepat untuk mengisi kembali IVF 2. Infus lambat untuk mengisi kembali ISF 3. (memberikan juga cairan maintenance)

2 1 IVF Perdarahan 1. Kehilangan IVF Perfusi lambat Nadi naik Tekanan darah turun 2. Dicoba diisi oleh ISF (transcapillary refill), 100 cc / jam ISF

infus
1

Terapi infus untuk Perdarahan

1. Infusi cepat mengembalikan IVF 2. Setelah IVF stabil, diteruskan untuk mengembalikan ISF 3. Volume yang diperlukan jadi 2-4x kehilangan IVF

IVF

ISF

Efek Syok Pada Tingkatan sel

LOW-FLOW, POOR PERFUSION

HYPOXIA
ANAEROBIC METABOLISM

ACIDOSIS

DECREASED CELLULAR ENERGY EFFICIENCY

Efek syok pada tingkatan sel

CELL MEMBRANE FAILURE: DIRECT Endotoxin Complement INDIRECT Failure to maintain normal Na+, K+ or Ca2+ gradient Decreased oxidative phosphorylation
OSMOTIC GRADIENT

Na+ entry into cell

Water entry into cell

CELLULAR EDEMA

IMPAIRED INTRACELLULAR METABOLISM

PRE-LOAD

CONTRACTILITY

AFTER-LOAD

STROKE VOLUME

HEART-RATE

CARDIAC OUTPUT

SYSTEMIC VASCULAR RESISTANCE

BLOOD PRESSURE

PERDARAHAN

HILANG VOLUME
HILANG ERITROSIT

Pasang infusi pada vena besar

1. Vena cubiti, basilica 2. Vena jugularis ext (posisi kepala-leher tetap in-line) 3. Vena subclavia

4. Vena saphena magna

21

FLUID REPLACEMENT
Class I Class II

3 : 1 Rule

Class III Class IV

Crystalloid Crystalloid + Colloid ? Crystalloid +Colloid, Blood Crystalloid +Colloid, Blood

Pola kerja penanganan shock perdarahan

Penderita datang dengan perdarahan Pasang infus jarum kaliber besar, sample darah Ukur tekanan darah, hitung nadi, nilai perfusi, produksi urine Tentukan estimasi jumlah perdarahan, minta darah

Guyur cepat Ringer Laktat atau NaCl 0.9% [hangat, 390C] 3x prakiraan lost-volume [1-2 liter]

Evaluasi

evaluasi

Pulse-Rate [x/min.] Blood-Pressure Pulse-Pressure Respiratory Rate Urine out-put [ml/hour] Mental status/CNS

normal

Management selanjutnya

Rapid response,

perdarahan <20% Transient response, perdarahan 20-40% BV ongoing loss resusitasi tdk adekwat

KOLLOID HES 200/0.5

transfusi Minimal, no response Tindakan bedah segera Transfusi darah

Hasanul, 2003

Estimated Fluid and Blood Losses Based on Patients Initial Presentation

Class I
Blood-Loss[ml] Blood-loss [%BV] Pulse-Rate [x/min.] Blood-Pressure Pulse-Pressure ->750 ->15% <100 Normal N or increased

Class II
750-1500 15-30% >100 Normal Decreased

Class III
1500-2000 30-40% >120 Decreased Decreased

Class IV
>2000 >40% >140 Decreased Decreased

Respiratory Rate
Urine out-put [ml/hour]

14-20
>30

20-30
20-30

30-35
5-15

>35
Negligible

Mental status/CNS

Slightly anxious

Midly anxious

Anxious and confused

Confused and lethargic

BV = 70 ml/kg

How to Resuscitate the Circulation ?

CaO2 = (SaO2 x Hb x 1.34) + (PaO2 x 0.0031) DO2 = CO x CaO2

SV x HR
PRELOAD, CONTRACTILITY

R/ Fluid

Fluids

Third space loss into interstium and tissues

3:1 rule of crystalloid for every ml of blood loss

ATLS: 2 liters of crystalloid through large bore IV

for early treatment of hemorrhagic shock.

Fluids

Crystalloid Colloid Hypertonic saline Darah

Fima RL Totilac

CRYSTALLOID VS COLLOID
Crystalloid
Advantages - Inexpensive - Promotes urinary flow - Fluid of choice for initial resuscitation of trauma/hemorrhage - Expands intravascular volume - Restores 3rd spaces losses

Colloid
-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

Disadvantages

- Dilutes colloid -Expensive osmotic pressure -May produce coagulopathy (dextrans and - Promotes peripheral hetastarch) oedem -With capillary leaks may potentiate fluid loss to - Higher incidence of the interstitium pulmpnary oedem -Impairs subsequent crossmatching of blood - Requires large (dextran) volume -Dilutes clotting factors and platelet - Effects are transient -Decrease platelet adhesiveness (absorption onto platelet membrane reseptor) -Potential blocking of renal tubules and reticuloendothelial cells in the liver -Possible anaphylactoid reaction with dextran

Isotonic crystalloids
Advantages
Cheap Easy to store and warm Established safety Predictable rise in cardiac output Large volumes needed Dilutional coagulopathy Increase cytokine activation No oxygen carrying capacity May Increase ICP

Disadvantages

Composition of iv Crystalloid
Na Cl
Plasma 0.9%NS LR 14 1 15 4 13 1 103 154 111

K
4-5 ---2

Ca
5 ---3

Buffer
Bicarb ---Lactate

pH
7.4 5.7 6.4

Fima RL

Fima NS

Fima D5

Ringer Asetat

Ringer Laktat vs NaCl 0,9%

Lowery 1971(Surg Gynecol Obstet)

Vietnam war study LR v NS Healthy soldiers No difference in outcome

Ringer Laktat vs NaCl 0,9%

Waters 2001 (Aneth Analg)

Patients undergoing aortic aneurysm repair

NS
More volume (~500-1000ml) Hyperchloremic acidosis Dilutional coagulopathy

Todd (J. Trauma 2007; 62:636-9)

Swine bled via liver injury & resuscitated to MAP 90mmHg NS More volume Hyperchloremic acidosis Dilutional coagulopathy

Ringer Laktat vs NaCl 0,9%

Conclusion
No mortality difference Ringer Laktat Lower overall volume More buffering capacity NaCl 0,9% Metabolic acidosis Dilutional coagulopathy Preferred fluid outside of US Probably no difference for prehospital or early fluid resuscitation.

Colloids

Keuntungan
Volume lebih kecil
Sedikit udem pulmonum

Bertahan dalam intravascular space

Cepat mengembalikan hemodinamik normal.

Kemasan lebih kecil. Mempunyai efek antioksiden dan antiinflamasi.

Colloids

Kerugian
Penularan penyakit. Peningkatan perdarahan. Reaksi alergi. Gagal Ginjal Dosis maksimal : 20-50mL/kg Harga lebih mahal.

Jenis cairan yang beredar : Kristalloid ( D5W, RL, RA, NaCl ) Hypertonic Saline Kolloid ( Albumin, Fima HES) Cairan Nutrisi ( Aminofluid, Intrafusin, Ivelip, Triofusin)

Blood Disadvantages

Cost Compatability/error
Incorrect blood-1:40,000 (death 1:2million)

Immune complications
1:40,000

Infection
Sepsis 1:500,000 (RBCs) 1:50,000 (platelets) Hep B 1:250,000 Hep C & HIV 1:2million

Storage requirements Citrate toxicity Hypocalcemia Hyperkalemia ?

Fluid Terapi

VOLUME INTRAVASKULAR

MEKANISME HEMODINAMIK

Physiologic principles of fluid management

TOTAL BODY WATER : 60% TOTAL BODY WEIGHT

60 kg

36 L

9L
ISF ISF

3L
IVF

24 L
ICF

Physiologic principles of fluid management

Not for resuscitation !!!

D5W= H2O
3L
EDEMA

9L
ISF ISF

3L
IVF

24 L
2L
ICF

750ml 250 ml

Intra venous fluid replacement

Fluid Resuscitation

Physiologic principles of fluid management Require large volume Cheaper

CRYSTALLOID

Fewer adverse side effects

3L

RL, RA, NaCl 0.9%

EDEMA

9L
2250ml ISF ISF

3L
750 ml IVF

24 L
ICF

Physiologic principles of fluid management

expensive

Albumin-5% 1L

9L
ISF ISF

3L
1L IVF

24 L
ICF

Physiologic principles of fluid management

expensive

Albumin-20%
Cth:Octalbin 20%

100 ml

9L
400 ISF ISF

3L
500 ml IVF

24 L
ICF

Intra venous fluid replacement Fluid Resuscitation

Physiologic principles of fluid management More rapidly correct hypovolemia

Maintain intravascular oncotic pressure

More expensive

HES-6%, 200/0.5 (Fimahes) 1L

9L
ISF ISF

3L
1L
IVF

24 L
ICF

How to Resuscitate the Circulation ?

R/ Oxygen
CaO2 = (SaO2 x Hb x 1.34) + (PaO2 x 0.0031) DO2 = CO x CaO2

SaO2 , PaO2

Terapi Oksigen

5-6 L/m

2-4 L/m

Goal terapi oksigen

SaO2, SpO2, 96-98% PaO2, 80 mmHg

How to Resuscitate the Circulation ?

R/ WholeBlood, PRC

CaO2 = (SaO2 x Hb x 1.34) + (PaO2 x 0.0031) DO2 = CO x CaO2

How to Resuscitate the Circulation ?

CaO2 = (SaO2 x Hb x 1.34) + (PaO2 x 0.0031) DO2 = CO x CaO2

SV x HR
PRELOAD, CONTRACTILITY

R/ Vasoaktive Inotropic

Hasil terapi infusi

Sirkulasi membaik lalu stabil
good response, normovolemia

Sirkulasi membaik lalu merosot lagi

transient response, masih hipovolemia, ada perdarahan berlanjut. Resusitasi tidak adekuat? Infus dengan koloid

Sirkulasi tidak membaik

no response, masih tetap hipovolemia Tindakan bedah segera kemungkinan ada perdarahan yang masih berlangsung.
57

soal
Pasien 32 tahun, datang post partum, lahir diluar rumahsakit. Tidak sadar, nafas 10 x/menit, Nadi tidak teraba, Tensi tidak terukur, muka pucat Apa yang Sdr lakukan ?

soal
Pasien laki-laki, umur 25 tahun, datang ke rumahsakit akibat KLL, tabrakan motor yg dikendarainya dengan mobil. Tidak sadar, nafas 8 x/menit, Nadi tidak teraba, Tensi tidak terukur, muka pucat. Apa yang Sdr lakukan ?

Terima kasih