Cairan

Resusitasi
Teddy Ferdinand
 • Sudah dikenal pengunaannya sejak 180 tahun yang lalu
• Tindakan resusitasi menggunakan cairan intravena bervariasi

Intravenous • Bergantung tempat, kebiasaan dan ketersediaan cairan

Fluid • Tidak ada cairan yang lebih hebat, semua ada kekurangan dan
kelebihan
• Harus dipahami komposisi dan kegunaannya bedasarkan
fis io lo g i
Fisiologi
Cairan
Intravaskuler
Fisiologi
Cairan
Intravaskuler
Fisiologi
Cairan
Intravaskuler
Fisiologi Cairan Intravaskuler
Anatomi
Endothel
Anatomi
Endothelial
Anatomi Endothelial
What’s
New in
2020?
 Pemberian
Cairan Intravena
What Have We Use?

Crystallo Colloid Blood

id

• Inexpensiv • Expensive • Rare

e • Less • Expensive
• Save Interstiti • Dangerous
• Interstiti al edema • Less
al edema • Acute Interstiti
KIDNEY al edema
Injury
 Osmolaritas

Status asam basa (pH)

Pemilihan
Cairan Komposisi elektrolit
Intravena Nilai SID (Strong Ion Difference)

Efek ke Glycocalyx
 Cairan Resusitasi
• Kristalloid
• Kolloid
Cairan
Intravena Cairan Nutrisi
• Karbohidrat
• Protein
• Lemak
Cairan
Intravena
Kristalloid
 • Ringer lactate
Cairan • Normal Saline
Kristalloid • Asering
• What’s New? This is 2020!
Crystalloid

NaCl 0,9%
• Since 1890
• "Normal" Saline?
• More hypertonic
• Chloride level are almost 1,5 times more than human plasma
• It’s strong ion difference differ than human plasma (0 mEq/L Vs 40 mEq/L)
• Hyperchloremic Metabolic Acidosis
Crystalloid

Ringer Lactate
Sydney Ringer’s experiment,1880
Alexis Hartmann then modified it to be a better solution
SID approaching human plasma (29 mEq/L Vs 40 mEq/L)
Crystalloid

Acetate Vs Lactate
• Acetate metabolized more rapidly than lactate
• Acetate metabolism does not result in changes in glucose or insulin concentrations, whereas
exogenously administered lactate can be converted to glucose via gluconeogenesis resulting in
hyperglycaemia
• Acetate may protect against malnutrition by replacing fat as an oxidative fuel without affecting glucose
oxidation, or causing hyperglycaemia
Upnormal
Saline?
RL Vs NS
Plasma-
Lyte
Kristalloid
Kolloid
 Albumin

Cairan Komponen darah (FFP, TC)

Kolloid Sintetis Kolloid (HES, Dextran, Gelatin, Tetrastarch)

What’s New? This is 2020!

Cairan
Kolloid
HES
Novel Intravenous Fluid
Transfusi
Darah
 Trasfusi Darah

Sel Darah Merah Plasma

 Whole Blood (WB)
Transfusi
Sel Darah Packed Red Cell (PRC)
Merah
Washed Packed Red Cell (W-PRC)
 Fresh Frozen Plasma (FFP)
Transfusi
Plasma Thrombocyte Concentrate (TC)
Darah
Cryoprecipitate (Cryo)
Kapan Kita
Transfusi
Apa?
Transfusi Sel
Darah Merah
 • Des cri pti o n:
• 450 mL whole blood in 63 mL anticoagulant‐preservative
solution of which Hb will be approximately 1.2 g/100mL and
haematocrit (Hct) 35‐45% with no functional platelets or labile

Whole
coagulation factors (V and VIII) when stored at +2°C to +6°C.
• Inf ecti o n ri s k:

Blood
• Capable of transmitting an agent present in cells or plasma
which was undetected during routine screening for TTIs, i.e.
HIV, hepatitis B & C, syphilis and malaria.
• Indi cati o ns :
• Red cell replacement in acute blood loss with hypovolaemia.
• Exchange transfusion.
 • Des cri pti o n:
• 150‐200 mL red blood cells from which most of the plasma
Packed has been removed. Hb concentration will be approximately
20 g/100 mL (not less than 45 g per unit) and Hct 55‐75%.
Red • Inf ecti o n ri s k:

Cell
• Same as for whole blood.
• .Indi cati o ns :
• Replacement of red cells in anaemic patients.
 • Des cri pti o n:
Washed • 150‐200 mL red blood cells from which most of the plasma
has been removed. Hb concentration will be approximately
Packed 20 g/100 mL (not less than 45 g per unit) and Hct 55‐75%.

Red
• Inf ecti o n ri s k:
• Same as for whole blood.

Cell • .Indi cati o ns :

• Replacement of red cells in anaemic patients.
Transfusi
Plasma
 • Des cri pti o n:
• FFP is plasma prepared from whole blood, either from the
primary centrifugation of whole blood into red cells and
Fresh Frozen plasma or from a secondary centrifugation of platelet rich
plasma. The plasma is rapidly frozen to –25°C or colder within
Plasma 8 hours of collection and contains normal plasma levels of
stable clotting factors, albumin, immunoglobulin and Factor VIII
at a level of at least 70% of normal fresh plasma.
 • Inf ecti o n ri s k:
Capable of transmitting any agent present in cells or plasma which was
undetected by routine screening TTIs, including HIV, hepatitis B and C,
syphilis and malaria.
• i ndi cati o ns :
Fresh Frozen • Massive blood transfusion.

Plasma • Acute DIC if there are coagulation abnormalities and patient is bleeding.
• Liver disease, with abnormal coagulation and bleeding – prophylactic use
to reduce prothrombin time (PT) to 1.6‐1.8 x normal for liver biopsy.
• Cardiopulmonary bypass surgery – use in the presence of bleeding but
where abnormal coagulation is not due to heparin. Routine perioperative
use is not indicated.
 • Precauti o ns :
• Acute allergic reactions are not uncommon, especially with rapid infusions.
• Severe life‐threatening anaphylactic reactions occasionally occur.
• Do s ag e: 10-15 mL/kg.
• Admi ni s trati o n:

Fresh Frozen
• Should be ABO compatible.
• Infuse as soon as possible after thawing.

Plasma •
•
Labile coagulation factors rapidly degrade; use within 6 hours of thawing.
FFP may be beneficial if PT and/or partial thromboplastin time (PTT) >1.5 times
normal.
• FFP for volume expansion carries a risk of infectious disease transmission and
other transfusion
• reactions (e.g. allergic) that can be avoided by using crystalloid or colloid
solutions.
 • Des cri pti o n:
• TCs are prepared from units of whole blood that have not been allowed to cool below +20°C. A
single donor unit consists of 50‐60 mL plasma that should contain ≥55 x 109 platelets.
• Unit o f is s ue:
• PCs may be supplied as a pooled unit, i.e. platelets prepared from 4‐6 donor units containing at
least 240 x 109 platelets.

Thrombocyte • Do s ag e:
• 1 single donor units containing at least 240 x 109 platelets should raise the platelet count by

Concentrate 20‐40 x 109/L. Increment will be less if there is splenomegaly, disseminated intravascular
coagulation (DIC) or septicaemia.
• Indicati o ns :
• Treatment of bleeding due to:
Thrombocytopenia.
Platelet function defects.
Prevention of bleeding due to thrombocytopenia as in bone marrow failure.
 • Des cri pti o n:
• Cryo‐AHF is prepared from FFP by collecting the precipitate
formed during controlled thawing at +4°C and re‐suspending
in 10‐20 mL plasma. It is stored at –25°C or colder for up to 1
Cryoprecipitate year after the date of phlebotomy. Cryo‐AHF contains about
half the Factor VIII and fibrinogen as a pack of fresh whole
blood: e.g. Factor VIII: 80‐100 iu/ pack; fibrinogen: 150‐300
mg/ pack.
• Inf ecti o n ri s k: As for plasma
 • Indi cati o ns :
As an alternative to Factor VIII concentrate in the treatment
of inherited deficiencies of:
Cryoprecipitate • von Willebrand Factor (von Willebrand’s disease).
• Factor VIII (haemophilia A).
• As a source of fibrinogen in acquired coagulopathies; e.g. DIC.
• Can be used in isolated Factor XIII deficiency.
Transfusion trigger (adults)

• One unit of whole blood/PRBC can increase Hb by 1g/dL in an adult or Hct by 3% (Hb of unit must be
>75%).
• Perioperative transfusion:
• – 8g/dL for patient undergoing cardiovascular surgery, orthopaedics and acute GI bleeding.
• Chronic anaemia: 7g/dL in adults.
• Acute blood loss:
– 30% of volume of blood.
 • plasma and albumin are more effective than semisynthetic colloids
such as hydroxy- ethyl starch (HES) at preserving and restoring the
Fluids endothelial glycocalyx, reducing vascular permeability, and reducing

that platelet and leukocyte adhesion in pre-clinical studies

• in a mouse model of hemorrhage where fresh frozen plasma (FFP)
Preserve attenuated the increase in vascular permeability, human albumin had

the
almost no effect
• whereas in a rat model of hemorrhage, albumin restored the glycocalyx
Glycocalyx thickness to 81 ± 31% of the baseline, compared to the full restoration
achieved by FFP, but better than the 42 ± 21% of that from 0.9% saline
 • In cell culture and animal models of endothelial glycocalyx injury, FFP
consistently attenuates glycocalyx shedding and the associated increase
Fluids in vascular permeability and leukocyte adhesion, and in animal models
it also attenuates acute lung injury and gut inflammation following
that hemorrhagic shock

Preserve • FFP starts repairing the endothelial glycocalyx within 1 h, and this
appears to be mediated via not only the cessation of ongoing shedding,
the but also by up-regulation of endothelial glycocalyx component

Glycocalyx
production
• The mechanism by which FFP restores the endothelial glycocalyx,
reduces endothelial permeability, and attenuates early inflammation is
not clear.
Fluids • Crystalloids have no ability to restore the endothelial
that glycocalyx
Preserve • Artificial colloids do have some protective and restorative
the properties through an unknown mechanism, but they are
Glycocalyx inferior to albumin and FFP in this regard
TERIMA KASIH