Pharmaceutical

Care
Pada Pasien
dengan Terapi
Cairan
Dr. Widyati, MClin Pharm
Seminar Clinical and Pharmaceutical
Aspect of Fluid Therapy,
type, dose and timing
of intravenous fluid
administration.???
Outline
Pharmacist Role in Fluid Therapy
Fluid Stewardship
7Ds of Fluid Therapy
Empat Fase Terapi Cairan
Fluid Therapy Pada Berbagai Kondisi
Reviewing IV Prescriptions
Monitor Terapi Cairan
Cases:
Pharmacist Role in
Fluid Therapy

• The pharmacist-led intervention to

implement the NICE guideline of fluid
therapy was effective in improving
prescribing practice by increasing
consistency with the guideline in
amount of fluid prescribed (Sarah K. et
al.,, 2019)
• Decreasing the incidence of fluid
associated complications including
fluid overload, increased creatinine
levels and electrolyte disturbances.
Fluid stewardship

• The primary goal of fluid

stewardship is to optimize
intravenous (IV) fluid administration,
minimize the detrimental effects of
inappropriate fluid administration,
and thereby potentially improve
clinical outcome
• Ada 4 indikasi utama terapi cairan
resuscitation, maintenance,
replacement and nutrition (enteral or
parenteral).
Malbrain, M. L., Van Regenmortel, N., Saugel, B., De Tavernier, B., Van Gaal, P., Teboul, J., Rice, T. W., Mythen, M., & Monnet, X. (2018). Principles of fluid management and stewardship in septic shock: It is
time to consider the four D’s and the four phases of fluid therapy. Annals of Intensive Care, 8(1), 1-16. https://doi.org/10.1186/s13613-018-0402-x
1. Drug

• Pertimbangan dalam pemilihan dan penetapan jumlah

Terapi Cairan:
1. Compounds: crystalloids versus colloids,
synthetic versus blood derived, balanced versus
unbalanced, intravenous versus oral.
2. Farmasetika: osmolalitas, tonicity, pH,
electrolyte composition (chloride, sodium,
potassium, etc.) and levels of other metabolically
active compounds (lactate, acetate, malate, etc.)
are all equally important.
3. Clinical factors (underlying conditions, kidney or
liver failure, presence of capillary leak, acid–base
equilibrium, albumin levels, fluid balance, etc.)
 Resusitasi
• Rapid fluid administered to restore perfusion
• It is generally agreed that large volumes of fluid are required in the short
term. Isotonic crystalloid solutions (see p273) are often recommended in the
first instance (unless a patient has had a significant haemorrhage and a
haemoglobin level below 7g/dl, in which case a blood transfusion may be
necessary).
• However, 80–90 per cent of the infused volume of sodium chloride (NaCl) 0.9
per cent will eventually leave the intravascular compartment.

• Target outcome: central venous pressure of 8 to 12 mm Hg, vasopressors to

attain a mean arterial blood pressure of 65 to 90 mm Hg, and red blood cell
transfusions or inotropes to attain a central venous oxygen saturation of at
least 70%
Fluid Maintenance
Overloading with salt and water during
resuscitation is often unavoidable and can
take days or weeks to resolve, so it is
important to switch as soon as possible to a
regimen that matches physiological needs
more closely, to avoid further overloading.
The basal requirements for young adults
are approximately[3]:
1–1.4mmol/kg/day of sodium;
0.7–0.9mmol/kg/day of potassium
30ml/kg/day of water.

• Elderly patients are more likely to have cardiac, respiratory and renal
impairment, and have a lower reserve capacity than younger patients.
Khususnya pada pasien berisiko:
• Cardiac disease — tissue perfusion maybe reduced and there is a risk
of fluid retention and overload;
• Renal disease — it may be difficult to remove excess fluid, so there is
a risk of fluid overload;
• Cerebrovascular disease — patients are likely to have complex
requirements and it may be difficult to maintain electrolyte and fluid
balance.
Replacing Losses
• Where patients are losing fluid through gastrointestinal (GI) drains or
fistulae, maintenance regimens need to be adjusted accordingly to
account for additional losses. Many replacement regimens involve
administering 1L bags of NaCl 0.9 per cent with added potassium.
• However, excessive administration of these bags provides large
amounts of chloride which may contribute to metabolic acidosis (see
p273). This may be aggravated if the fluid lost also contains large
amounts of bicarbonate.
•
Vascular Leakage
• Inflammation, resulting from sepsis, trauma or burns, causes a sharp
increase in vascular permeability. Consequently, there is leakage of
plasma proteins, electrolytes and water from the intravascular
compartment into the interstitial space. Vascular permeability returns
to normal over the next 12 hours, but affected patients may need
large amounts of IV fluids to maintain adequate tissue perfusion.
• Crystalloids are commonly used although high molecular weight
colloid solutions can also be given, in smaller quantities, to restore
intravascular volume.
•
Vascular Leakage
• Crystalloid solutions rapidly leak into the interstitial space and can
cause significant tissue oedema. This can be uncomfortable, but can
also reduce mobility and compromise organ function. For example,
there is evidence that crystalloid infusions cause small bowel oedema
and this may impair gastrointestinal function by causing intolerance
to enteral feeding and postoperative nausea and vomiting.
• Also, increased cerebral oedema can worsen the prognosis for
patients who have undergone brain surgery or head trauma.
• Colloid solutions (eg, starches, gelatin, albumin) are also effective for
volume replacement. They are advantageous because they provide
volume expansion without the risk of fluid overload and oedema.
Antidiuretic hormone
• In the immediate postoperative period, there is intense activation of
antidiuretic hormone and the renin-aldosterone-angiotensin system.
• This results in active sodium retention and a low urine output. The
capacity to excrete salt and water returns to normal over the next few
days.
• If urine output is used to determine organ perfusion, it will be
underestimated and excess fluids may be prescribed as a result.
 Perioperative management
Goal-directed therapy Restricted fluid therapy
• The process of optimising a patient’s • Restricted fluid therapy describes
fluid status is known as goal-directed the process of replacing only the
therapy. This approach involves fluid that is lost and maintaining
adjustments of cardiac preload, constant body weight, instead of
afterload, and contractility, using following a standard recipe (usually
vasodilators and inotropes, to balance 2–2.5L fluid) for all patients.
oxygen delivery with oxygen demand
(Rivers, 2001)
• This approach requires careful
• Goal-directed protocols are intended to monitoring of fluid input and output,
ensure the patient’s heart is producing and body weight.
its maximum stroke volume. This
approach usually requires invasive
monitoring techniques, such as central
venous pressure monitoring.
2. Duration

• The longer the delay in fluid

administration, the more
microcirculatory hypoperfusion and
subsequent organ damage related to
ischaemia–reperfusion injury.
3. Dosing
• Similar to other drugs, choosing the right dose
implies that we take into account the
pharmacokinetics and pharmacodynamics of
intravenous fluids
• Pharmacokinetics of intravenous fluids depends on
distribution volume, osmolality, tonicity, oncoticity
and kidney function. Eventually, the half-time
depends on the type of fluid, but also on the patient’s
condition and the clinical context
• Applying this concept, it is possible, by simulation, to
determine the infusion rate that is required to reach
a predetermined plasma volume expansion. Volume
kinetics may also allow the quantification of changes
in the distribution and elimination of fluids (and
calculation of the half-life) that result from stress,
hypovolemia, anaesthesia and surgery
4. De-Escalation

• the final step in fluid therapy is to

consider withholding or withdrawing
resuscitation fluids when they are no
longer required.
• Like for antibiotics (Table 1), the
duration of fluid therapy must be as
short as possible, and the volume
must be tapered when shock is
resolved.
Empat Fase Terapi Cairan Pada Pasien Kritis
Resusitasi
• rapid fluid administered to restore perfusion
• Target outcome: central venous pressure of 8 to 12 mm Hg,
vasopressors to attain a mean arterial blood pressure of 65
to 90 mm Hg, and red blood cell transfusions or inotropes to
attain a central venous oxygen saturation of at least 70%
(Fernando G Zampieri et al., 2023)
• Administration of fluid boluses is appropriate in the
Resusitasi and optimization phases, but each bolus should be
followed by reassessment of the need for ongoing fluid
administration.
• In haemodynamically unstable patients, inotropic and/or
vasopressor agents should be started at the same time as
fluid resuscitation to correct intravascular volume depletion.
 • Occurs within hours and is the phase of
ischaemia and reperfusion. Positive fluid
balance seen during this phase which a
biomarker of the severity of illness.

optimization • Optimization (the risks and benefits of additional

fluids to treat shock and ensure organ perfusion
are evaluated)
• Targets: MAP >65 mmHg, CI >2.5 L/min/m2,
 • Fluid therapy is used only when there is a signal
of fluid responsiveness
• This phase evolves over days and fluid is
needed for maintenance and replacement of
normal losses:
stabilization • Monitor daily body weight, fluid balance and
organ function
• Targets: Neutral or negative fluid balance;
 excess fluid accumulated during treatment of critical
illness is eliminated

Evacuation limiting fluid administration and administering diuretics

improved the number of days alive without mechanical
ventilation compared with fluid treatment to attain higher
intracardiac pressure (14.6 vs 12.1 days; P < .001), and it
reported that hydroxyethyl starch significantly increased
the incidence of kidney replacement therapy compared
with saline (7.0% vs 5.8%; P = .04), Ringer lactate, or
Ringer acetate.(Fernando G Zampieri, 2023)
 Komplikasi
Hyponatremia
Risiko pada penggunaan larutan
hipotonik.
Pasien dengan SIADH sebaiknya
pilih larutan isotonik
Volume Overload
Dapat terjadi pada pasien
gangguan jantung, gagal ginjal
yang mendapat cairan dg volume
berlebih. Manifestasi: Udema Paru,
udema perifer, hepatomegali
Hyperkalemia
Patien dengan gagal ginjal yang
mendapat larutan mengandung
Kalium akan mengalami kesulitan
kliring Kalium
Metabolic Acidosis
Normal Saline dapat memperparah
asidosis metabolic (Kraut JA,
Madias NE.), 2012)
Reviewing IV prescriptions
• Tanpa Akses ke Data Klinik
• It is simply a prescription review. This
only allows pharmacists to identify
basic problems with the prescription,
and does not enable them to make a
full contribution to patient care.
• This principle also applies to IV
prescriptions. A comprehensive
treatment review is only undertaken
with knowledge of a patient’s
diagnosis and pathophysiological
status.
 Pengkajian Resep (Dengan Akses Data Klinik )
• When calculating the daily • a systolic blood Low blood pressure can
requirement of sodium for a pressure of less than be caused by epidural
patient, pharmacists should 100 mm of mercury analgesia. It is easy to
remember that several IV (mmHg), a tachycardia
greater than 90 beats assume for hypotensive
medicines deliver a
considerable sodium load. per minute, prolonged patients who have
capillary refill or cold recently received an
• Vancomycin 1g in 250ml peripheries, epidural that their low
NaCl 0.9 percent infusion, tachypnoea, blood pressure is drug-
given twice a day —
77mmol of sodium per day; • Prescribing the induced.
incorrect type, volume However, hypovoleamia
and/or rate of cannot be excluded,
intravenous fluids can especially for patients
have a detrimental
effect on the patient who have suffered large
preoperative fluid losses.
 Contoh Kasus
• A 78-year-old male is admitted to a surgical
admissions ward with acute abdominal pain.
• The consultant instructs a junior doctor to start
intravenous fluids.
• After three days, the patient’s biochemistry
results are reviewed — he has a plasma
sodium level of 154mmol (normal range: 135–
145mmol). On investigation, it is found that he
has only received sodium chloride (NaCl) 0.9
per cent as his fluid maintenance regimen.
The infusion had been commenced three days
earlier, and the patient had received a new 1L
bag every 8–10 hours thereafter.
• Different doctors had repeated the prescription
of the infusions, most likely at the request of
the nurses managing the patient, who had
replaced each bag with another bag of the
same fluid. This case demonstrates the need
to plan fluid replacement regimens and not
prescribe it on a “bag by bag” basis.
• An 84-year-old female is admitted to hospital with
pneumonia.
• She is started on IV fluid maintenance treatment
shortly after her admission because she is unable
to eat or drink.
• Three days later, she is found to be in acute heart
failure and her fluid balance was 4L positive (her
fluid output was 4L less than the amount of fluid
she had received) since her admission.
• Diuretic therapy was started and her heart failure
resolved. The initial IV fluid regimen had been for
2L of glucose 4%/NaCl 0.9% with 20mmol/L of
potassium every 24 hours, but the charts showed
that a higher volume of fluid had been
administered.
• On investigation, it was found that all infusions
had been administered without the aid of an
infusion device. When administered in this way,
some infusions are not delivered accurately. It
appears that infusions intended for administration
over 12 hours had been given over 8–10 hours,
resulting in more fluid than intended being
administered.
 Monitoring
• Fluid responsiveness indicates a condition in which a patient will respond to fluid
administration by a significant increase in stroke volume and/or cardiac output or
their surrogates. A threshold of 15% is most often used for this definition, as it is the
least significant change of measurements of the techniques that are often used to
estimate cardiac output (Monnet X, Marik PE, Teboul JL. Prediction of fluid
responsiveness: an update. Ann Intensive Care. 2016;6(1):111.)
• Resusitasi: MAP, CVP
• TD, HR, RR
• Urine output
• Kondisi Klinis: lemas, kesadaran,
• Laboratory Findings

• BUN/creatinine: Can be elevated secondary to prerenal acute kidney

injury from decreased renal blood flow due to decreased intravascular
volume
• Transaminases: Can see an elevation in AST or ALT due to
hypoperfusion of hepatic tissue and subsequent tissue hypoxia
causing hepatocyte injury, also known as “shock liver.”
• Hemoconcentration: Can see elevated hematocrit due to a relative
abundance of red blood cells relative to intravascular fluid volume
 Terapi cairan adalah terapi yang paling banyak digunakan pada
kondisi akut mapun kritis.

Manajemen terapi cairan adalah aspek kritis dalam perawatan

pasien. Setiap pasien membutuhkan pertimbangan yang hati-hatidari
kebutuhan individualnya

Apoteker dapat berperan penting dalam terapi cairan melalui Fluid

Stewardship
Kesimpulan
Hal ini akan mengurangi insiden komplikasi terkait terapi cairan.

Asas terapi cairan pada pasien kritis adalah ROSE