FLUID AND ELECTROLITE

RESUSCITATION

Andi Salahuddin
DEPARTEMENT OF ANESTHESIOLOGIST , INTENSIVE CARE
AND PAIN MANAGEMENT HASANUDDIN UNIVERSITY
2007

 Fluid and electrolite disturbance

Emergency

Death

Most common
conditions include

Diarrhea
Vomiting
Peritonitis
Ileuses obstructive
Starvation
Burn
Sepsis
Hyperglycemia

Issue ?

Pulmonary edema
Hypernatremia and hyperchloremia.
SIRS & MODS ( dr. P.Gosling, emerg
Med J 2003; 20:306 - 315 )

HOW TO MANAGE ?

Distribution of fluids
Fluid demand.
Crystalloid or colloid
Paths approach

60% BB = Air

Distribution of Fluids

ICF

ISF

IVF
Dextrose 5%

40 %

15%

5%

RL, NaCl 0.9%

Colloid
-Blood
-Plasma
-Plasma expander

SODIUM AND WATER HOMEOSTASIS

AFTER INJURY

Summary of the endocrine responses to acute injury,

which are directed towards maintaining
perfusion of essential organs and retention of water and sodium.

KEBUTUHAN DASAR
ELEKTROLIT
Kebutuhan K + : K + x BB x 0,4
- Kecepatan pemberian max 20
mEq/jam
- atau 200 mEq / 24 jam
- Produksi urine 1 ml / Kg BB / jam
- 1 2 mEq / Kg BB / 24 jam

Kebutuhan Na + : Na + x BB x 0,6
- 2 3 mEq / Kg BB / 24 jam

JENIS CAIRAN YANG

DIGUNAKAN
1. Cairan pemeliharaan (maintenance)
- jumlah cairan yang digunakan / 24 jam
2. Cairan defisit
- jumlah kekurangan cairan yang terjadi.
3. Cairan pengganti (replacement)
a) Sekuesterasi (cairan third space)

b) Pengganti darah yang hilang

c) Pengganti cairan yang hilang melalui
drainage, fistel dan maag slang

The Crystalloids
Crystalloids are a group of intravenous fluid in which
may be:
Ionic solution
Ringer lactate/ acetate
NaCl physiologic (0.9% saline)
Hartmans solution
Etc
Mostly iso-osmolar = isotonic
Cheap, easy to manufacture
Has no immunologic reaction
Mainly confined to the extracellular fluid
Non ionic
Dextrose 5%
Maltose 10%
Etc
Distributed to intracellular space

Electrolyte Comparison
Between RL & NaCl 0.9%

Na+

K+

Ca+

Cl-

Lactate

Osm.

Plasma

140

103

300

Ringer Lactate

130

109

28

273

NaCl

154

154

308

The Colloids
Colloids are fluids which contain oncotic
particles, therefore exert an oncotic pressure
Blood
Plasma
Albumin
Artificial colloids = plasma expander

Gelatins, from collagen (Haemaccel & Gelofusine)

Dextran is a polysaccharides (Dextran 70 & 40)
HES (Hydroxyethyl starch) e.g. hemohes 6% / 10%

Intravenous fluid
Fluid
Dextrose 5%
Crystalloids
Dextrose 5% + NaCl 0.45%
Dextrose 5% in Ringers
RL/ Asering
NaCl 0.45%
NaCl 0.9%
NaCl 0.3%
Manitol 20%
Colloids
Plasma
Albumin 5%
Kanji heta 6% in NaCl 0.9%
40 Dextran 10% in NaCl 0.9%
70 Dextran 6% in NaCl 0.9%

Dextrose
Na+
(g/dL)
(mEq/L)

Cl(mEq/L)

50

50
50

Osmolarity
(mosmol/L)

Oncotic P
(mmHg)

278

77
130
130
77
154
513

154
154
154

77
109
109
77
154
513

154
154
154

405
525
275
154
308
1026
1098
295
290
~310
~310
~310

21
19
31
169
19

DEHIDRAS
Defisit cairan interstitiel dengan gejalaI:
- turgor kulit yang jelek
- mata cekung
- ubun-ubun cekung (bayi & anak)
- mukosa bibir dan kornea kering

Defisit cairan intravaskular dengan

gejala :
- hipotensi, takikardi
- vena-vena kolaps
- Capillary refilled time memanjang
oligouri
syok ( renjatan )

DEHIDRASI DITINJAU DARI

DEFISIT CAIRAN &
ELEKTROLIT
1. Dehidrasi ringan ( defisit 4% BB )
2. Dehidrasi sedang ( defisit 8% BB )
3. Dehidrasi berat ( defisit 12% BB )
4. Syok ( defisit lebih dari 12% BB )

JENIS-JENIS
DEHIDRASI

1.Dehidrasi hipertonik (hipernatrem

2.Dehidrasi hipotonik (hiponatremik

3.Dehidrasi isotonik

DEHIDRASI HIPOTONIK
( HIPONATREMIK )

Pada anak dengan diare yang

minum banyak air atau cairan
hipotonik atau diberi infus
glukosa 5 %.

Kadar natrium rendah (<130

mmol/L)

Osmolaritas serum (<275

DEHIDRASI HIPERTONIK
( HIPERNATREMIK )

Biasa terjadi setelah intake cairan

hipertonik
(natrium, glukosa, laktosa)
selama diare
Kehilangan air >> kehilangan natrium
Konsentrasi Na > 150 mmol/L
Osmolaritas serum meningkat (>295
mmol/L)
Haus, iiritable

24

3
+ 4 L colloids

+ 4 L crystalloids

24

12

+ 4 L dextrose

28

24

TERAPI CAIRAN
Rumatan

Resusita
si
Kristaloid

Koloi
d

Mengganti kehilangan
akut
(Syok, dehidrasi,
hipovolemik)

Air + Elektrolit +
Nutrisi
Memasok
kebutuhan
harian

Rumatan / Kg /
Hari

AIR
30-50
ml

Na
2-4
mEq
KALORI
20-30
KCal

K
1-2
mEq

NUTRISI

PROTEIN
0,5-1 gr

Kebutuhan Air dan

Elektrolit /Hari
Dewasa

Anak-anak

Cairan

Sesuai berat
30-50 cc / Kg BB
badan

Natriu
m

2-3 mEq / Kg BB 2-4 mEq / Kg BB

Kalium 1-2 mEq / Kg BB 2,5 mEq / Kg BB

Extra

Rumatan
Normal
asupan
oral

30-50 ml /
Kg

Demam

IWL
Normal
pengerluara
n urine

25 ml /
Kg

Kehilanga
n
abnormal

Insensible Water Loss

Dewasa

Anak

Bayi

Kehilangan
air

42 ml / 100 kal
Kulit = 800 ml
Paru = 400 ml

300-600 ml /
hari

75-300 ml / h

Keringat

10-20 ml / 100
kal (aktifitas
minimal)
50 ml / 100 kal
(aktifitas berat)

Tidak
bermakna

Urine

84 ml / 100 kal
= 1500 ml

90 ml / 100 kal
= 500-800 ml

100 ml / 100
kal = 200-500
ml

4 ml
/ 100 kal Collins
4 ml / 1996
100 kal
Dikutip
dari : Fluids and
Electrolytes,
Feses

4 ml / 100 kal

KEHILANGAN CAIRAN &

PILIHAN PENGGANTI
Kandunga
n
rata-rata

Kehilangan

(mmol/L)
Na
+

K+

Cairan pengganti yg
sesuai

Darah

14
0

Ringer asetat / RL / NaCl 0,9 % /

Koloid / Produk darah

Plasma

14
0

Ringer asetat / RL / NaCl 0,9 % /

Koloid

Rongga ketiga

14
0

Ringer asetat / RL / NaCl 0,9 %

Nasogastrik

60

10

NaCl 0,45 % + KCl 20 mEq / L

Sal cerna atas

11

5-

NaCl 0,9 % (periksa K + dengan

JENIS CAIRAN
RUMATAN
Nama
Produk

K+

Cl -

HPO4
-

140

130

109

28

NaCl 0,9 % 154

154

Dextrose
5%

27,0

108

Ringer
Laktat

Lakta Dextros
t
e (g/l)

Kalori
(kcal/
l)

Mg
++

Plasma

Na
+

PERKIRAAN KEHILANGAN CAIRAN

DAN DARAH

Resuscitation
= Reverse The Dying Process
Fluid Resuscitation

Krisis Napas

O2, Napas Buatan

Krisis Sirkulasi

Cairan & Obat-obat vasoaktif

UGD

ECF
Minum

Urine
1 mL/kg/jam

Metabolisme
350 mL/m2

SI
700 mL/m2

Infus
Na 1-3 mEq/kg
K 1-2 mEq/kg
ICF

Extra

Normal Oral Intake

30-50 mL/kg
Fever

S&I
Normal Urine Output

Abnormal Losses

25 mL/kg

DEFISIT
5%
: haus, mukosa kering
5-10% : turgor, tensi, nadi
>10% : SHOCK, urine = 0
REHIDRASI
50%
8 jam

50%
16 jam
++ Maintenance

Untuk pasien tanpa syok

M = Maintenance
Laki-laki 60 tahun, berat badan 50 kg
D/ CVA, coma, paralytic ileus
M:

50 kg x 50 mL = 2500 mL
50 kg x 3 mEq = 150 mEq Na = 1000 mL RL/ RD
+ 1500 mL D5/ D10

Bila ragu-ragu kurangi 20%

Setelah 24 jam, cek urine !

Too much
Penyakit paru
dec. cordis
edema
R/
Too little
Tidak sembuh

Shock
Gagal ginjal

R/
Usus

Perdarahan
Derajat shock

Status trauma

10 - 30 - 50% EBV

Tanda dehidrasi
3 - 5 - 10% BB

RL/NS
Transfusi Hb < 8

RL/NS saja

Air
30-50 mL

Na
2-4 mEq

Kalori
20-30 kkal

/kg/hari

K
1-2 mEq

Nutrients

Protein
0,5-1 gram

M+R
Wanita 25 tahun, 50 kg
D/ Hiperemesis gravidarum
Muntah 1000 mL/ hari, minum (-), makan (-)
M : 50 kg x 50 mL = 2500 mL
50 kg x 3 mEq = 150 mEq Na = 1000 mL RL/ RD
+ 1500 mL D5/ D10
R : 1000 mL

50% RL/RD/NS
50% D5

Total 24 jam 1500 mL RL/ RD + 2000 mL D5/D10

Dehidrasi = ECF deficit

BB 50 kg: ileus, peritonitis, GE
M = 2500 mL + R (defisit)
Dehidrasi 5% BB = 2500 mL
Interstitial sign +++
50% - 8 jam 50% - 16 jam
R 1250 + M 800 . R 1250 + M 1700

Dehidrasi = ECF deficit

BB 50 kg: ileus, peritonitis, GE
M = 2500 mL + R (defisit)
Dehidrasi 10% BB = 5000 mL
Plasma sign +++
20-40 mL/kg diguyur 1-2 jam
Jam I

: 1000-2000 mL guyur

Sisa: 50% - 8 jam 50% - 16 jam

R 2000 + M 800 . R 2000 + M 1700

IVF

ISF

ICF
2

Usus

Infus

II

III

I = rehidrasi cepat
II = rehidrasi lambat

Rehidrasi cepat
RL/NS cepat
Bolus 20 mL/kg dalam 30-60 menit
Kalau perlu diulang

IVF stabil
Tensi >100, nadi <100
Perfusi hangat kering
Sisa defisit lebih lambat

Tentukan Jumlah Cairan

Tentukan Macam Cairan
Tentukan Kecepatan

Bleeding
RL 2-4 x loss
Ikuti perfusi nadi tensi
HD baik
Hb > 8 mg/dL

Hb < 8 mg/dL

Cairan
Pelan-pelan

Transfusi
Pelan-pelan

HD jelek

Transfusi cepat

Kapan Korban Meninggal?

VOLUME darah hilang 1/3
ERITROSIT hilang 2/3
BB 50 kg, volume: 50x70 mL = 3500 mL
Bila berdarah 1200 mL
Bila Hb < 5 gr/dL

Ny. S. 30 tahun, KET

Preop

Op

Postop

Tensi

80

110

120

110

Nadi

148

108

100

80

Perfusi

7,0

6,5

8,6

Hb

RL 1500 + 2000

WB 500