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Emergency Medicine Lunch Symposium
Makassar, 7th April 2013
dr. Budhi Santoso
Medical Consultan of PT Otsuka Indonesia

SHORT CURICULUM VITAE

1.Name
2.Place/date of birth
3.Address
4.Marial status
5.Alumny

:
:
:
:
:

6.Working Experienced :

Budhi Santoso
Jakarta, 17 Mei 1967
Mampang Indah II, Blok D2, Depok Sawangan
Married with 4 children
Medical Faculty of Brawijaya Univ, Malang,1993
6.1.
6.2.
6.3.
6.4.

Cipete Clinic, Jakarta (1993-1994)
Puskesmas Moro Seneng-Kepri, Riau (1994-1997)
Schering AG (Med Advisor: 1998-2000)
Otsuka Indonesia (Med-Consultant: 2001-2007)

7.Training Experienced :
7.1. GCP advance course, Schering AG-Berlin, 1998
7.2. Communication on Family Planning, Sweden 1999
7.3. AUCOGS Congress, Philadelphia-USA, 2000
7.4. Schering internal leadership course, Dusit, Thailand, 2
7.5. Critical Care Annual and Pensa Meeting: Bali 2002
7.6. ATLS advanced, RSCM 2003
7.7. Indonesian GCP, RSCM 2004
7.8. Critically ill in children: Malang, 2005.
7.9. Critical care workshop, Surabaya, 2006, 2007
7.10.Aminofluid Workshop,Tokushima, Japan, 2008, 2010
7.11.Espen Congress, Barcelona Spain, Sept 2012

7.12.Safety, Efficacy and PV joint seminar, Japan-Indonesian FDA,
2013

Cairan Infus
@#$%^&,

Wes,… ewes,..ewes,…
bablas angine......

Yang penting
kasih obat,
infus no.
12 ?

Ente harus makan
obat seumur hidup !!!

Waduh, lama
amat, dok !!
Enggak, lama,
Tergantung berapa
lama Ente hidup !!!

Fisiologi infus saat masuk tubuh 3.Infus Rasional bila paham 4 hal: 1. et all 2010 . Pemilihan infus yang tepat Lobo. Patofisiologinya yang sering (Resusitasi vs Rumatan) 4. Indikasinya 2.

2010*** .Facts: CAIRAN RESUSITASI YANG “LAZIM” DIPAKAI Fluid Osm NS 308 RL 273 Intracell Risk of Lactate distribution Hyperchloremic acidosis + (Cl.155.154 mEq/L) + RA 273 - - - D5 278 + - - RS 310 - + (Cl.5 mEq/L) Otsuka NCE internal surveys data.

faring tidak hiperemis.Alb 3. K+ 3.5 .? Simulasi kasus: Pasien pria 20 th masuk RS dg keluhan utama demam sudah 5 hari tidak turun. BP 105/80 HR 94 RR 12. bibir pecah-pecah. lidah kering & agak kotor. BB 70 kg TB 165 D/ demam tifoid (konfirmasi serologis) Na+ 150. Cl 102. letih.5 BUN 20. insomnia dan dyspepsia PF: KU somnolen pucat.glukosa 70. kreat 1.

9 g/sachet . dimana tidak ada asupan oral sama sekali karena pasien dispepsia dan anoreksia Jika pasien diberi (1 L Asering + 1 L Aminofluid) + 2 Sachet PROTEN PRODUK AA (g) NPC (g) Total kalori(kcal) 1 L ASERING - - 1 L AMINOFLUID 30 75 420 2 Sachet PROTEN 20 53 424* TOTAL 50 128 844 Na+ (mEq) K+ (mEa) 130 4 35 20 165* 24 * ada lemak 5.Simulasi kasus: demam tifoid.

dimana tidak ada asupan oral sama sekali karena pasien dispepsia dan anoreksia Jika pasien diberi 1 L KAEN MG3 + 1 L Aminofluid + 2 Sachet PROTEN PRODUK AA (g) NPC (g) Total kalori(kcal) Na+ (mEq) K+ (mEa) 1 L KAEN MG3 - 100 400 50 20 1 L AMINOFLUID 30 75 420 35 20 2 Sachet PROTEN 20 53 424* TOTAL 50 128 1232 85 40 * ada lemak 5.simulasi kasus : demam tifoid.9 g/sachet .

Harian Tambahan mikromineral. amino 4:2:1 (misal 25 kg: 4 x10+2x10+1 x5  500 ml/6 jam 65ml/jam . tra Element dan as. DSS)  2-3 L/10-15 menit (perdarahan)  Natrium rendah (50-100 mEq) Kalium sesuai keb.DESIGN TERAPI CAIRAN IV RESUSITASI     RUMATAN  Infus Natrium > 100 mEq/L  atau koloid 20-30 ml/kg/jam (diare.

Historical Perspective of Infusion Preparation Resuscitation Maintenance .

Otsuka could offer to you .

Hypovolemic shock Stable Hemodynamic .

ASERING First Line Ringer’s acetate ® Fluid Resuscitation Therapy ® Acetate Ringer’s .

hemorrhagic shock. DSS with or whithout hepatic insufficiency • Intra operative • Priming solution for cardiopulmonary bypass (CPB) • Safe replacement fluid for children . burn.Indication’s of ASERING® • First line in replacement fluid for resuscitation: gastroenteritis.

Regional Guidelines on Dengue / DHF Prevention and Controll. 2001. Parenteral Fluid Therapy in Stroke Patients. Hardi Pranata. . of Communicable Disease.O. 1999. 2001. akan meningkatkan tonisitas infus menjadi ISOTONIK. Proceeding of PIT PERDOSSI.O. • Pada stroke akut. W. untuk pasien Demam Berdarah Dengue (DBD).H. Proceeding of PIT PERDOSSI. SEA Dept.H. pemberian ASERING sesuai dengan konsep menghindari LAKTAT. Regional Publ. 29.® ASERING Ringer’s acetate First Line Fluid Resuscitation Therapy • Direkomendasikan oleh W. Darmawan I. • Pencampuran ASERING dengan 20% MgSO4 sebanyak 10 cc. Clinical Experience of Ringer’s acetate with Magnesium sulphate adminstration in Acute Ischemic Stroke.

Heimberger DC.39. 32 . Kecepatan metabolisme asetat 250-400 mEq/jam . Loren A et al.( 3) 3.Roland RW. Handbook of Clinical Nutrition. asetat lebih cepat mengkoreksi asidosis. Lund T. Asetat memerlukan sedikit O2 dan melepaskan sedikit CO2. 2.Mosby 1997 3. ( 2 ) 2. Metabolisme asetat terutama di otot.( 4 ) 4.3197 . Anderud T. tepat untuk menggantikan kehilangan akut cairan ekstraseluler. Ringer acetate solution in clinical practice. Medimedia. Tidskr Nor Laegenforen 1989. tidak terganggu pada kelainan hati (1) 1. Oxidation of lactate and acetate in rat skeletal muscle. Intensive Care of Patients with Burns.M. Komposisi mirip dengan plasma. sedangkan laktat 100mEq/jam. 4. Journal of Applied Physiology 1997 .3199. p.Asering ® Benefit: 1.1999 . 83 ( 1 ) : p.

25 .75 • ASERING® 7 • Normal saline 6.General Benefit Average pH • Ringer’s lactate 6.

Letis A. Story D. CI.60 for Haemaccel-Ringer's vs. With Plasmalyte. Smith B. Plasmalyte 148 vs Polygeline+ Ringer in 22 patients With the Haemaccel-Ringer's prime. Poustie S.50).15 for Plasmalyte.0062).AR as priming solution in CPB Anesthesiology 2000 Nov. . P = 0. 7. Bellomo R.00-11.50 mEq/l. Hayhoe M. +9. the acidosis was induced by an increase in unmeasured anions. Bennett M Role of pump prime in the etiology and pathogenesis of cardiopulmonary bypass-associated acidosis.93(5):1170-3 Liskaser FJ. The resolution of these two processes was different because the excretion of chloride was slower than that of the unmeasured anions ( base excess from t1 to t3 = -1. +1. the metabolic acidosis was hyperchloremic ( Cl-. most probably acetate and gluconate.

..D.. Fabritius.D.D. M.... Pott..D..Sci. M.D. Ph.D. 2012DOI: 10. M. as compared with those who received Ringer's acetate. Anders Åneman...D. Ph. M.. M. Ph..D.D.. Morten Bestle. Andersen. D. Lasse H.D.D. M. Klaus J. M..Sci.D.D.D. M.P. M. Morten H. M.D. 367:124-134July 12. Maria L. Jonathan O...D.D. M. M. M. and had fewer days alive without renal-replacement therapy and fewer days alive out of the hospital. were more likely to receive renal-replacement therapy. Frank C.D.1056/NEJMoa1204242 Hydroxyethyl Starch 130/0.D. Robert Winding... M.D. Nicolai Haase.D.D. Lone M. Madsen.D. M.M.. Jonas Nielsen.D. White.D.. Jyrki Tenhunen. M... Lars Quist. M.. Ph. M. Anne-Lene Kjældgaard.42 versus Ringer's Acetate in Severe Sepsis Anders Perner.D. Asger Bendtsen. Lars B. Morten Steensen.D. M..D. Guttormsen. and Jørn Wetterslev. Holst. Thea P.D...D.D....D.. M. Ph... Frederik Mondrup. M.D.. had a higher risk of death at 90 days.D. M. M.. patients with severe sepsis who received fluid resuscitation with HES 130/0. Thornberg. Gudmundur Klemenzson. Ph..42. Anne B.. M. for the 6S Trial Group and the Scandinavian Critical Care Trials Group In conclusion. M.D. M.D. M. . Pawel Berezowicz.D. M.. Per Winkel. Peter Søe-Jensen.D. Jørgen Wiis. M. Ph..N Engl J Med 2012. Ph. Poulsen. Elkjær..M. M.. M. D. M... M.. Møller. Kristian Strand.. Møller. Ph.H. Katrin Thormar. Kristian R. Jeanie M.D.D. Ph.D.D.

Hindra Irawan Satari. Demam Berdarah Dengue.DBD III & IV O2 2-4 L/menit RA/RL 20 ml/kg bolus dalam 30 menit Syok teratasi RA/RL 10 ml/kg/jam Syok tidak teratasi Teratasi Dextran 40 10-20 ml/kg Tidak Teratasi Stabil dalam 24 jam RA 5 ml/kg/jam Stop < 48 jam 3 ml/kg/jam Ht turun Ht tetap/naik FFP 10 ml/kg Dextran 20 ml/kg Sri Rezeki. FKUI.1999 .

RSUD Dr Soetomo/FKUnair. Tatalaksana DBD terkini.Asering / Diagram 9. Soegeng. Alur tatalaksana Pemberian cairan Derajat IV Prof. 2006 .

ASERING & KAEN 3B kompatibel dengan obat dibawah ini: •Nicholin •Trental •Sermion •Tagamet •Primperan * Internal Laboratory Data (QA OI Factory) •MgSO4 •Syntocinon •Aminophylline •Adonna .

JAN’ 2012 .

rongga ke3) Memepercepat penyembuhan . Menjaga homeostasis haria akut (hemorrhage. 2.TERAPI CAIRAN RESUSITASI Kristaloid Koloid RUMATAN Elektrolit NUTRISI Aminofluid Seri KA-EN Mengganti kehilangan 1. Terapi suportif GI loss.

in Ringers are still widely used for maintenance therapy ***** What are the impacts ? .Facts: • RL • 5% Dextrose • 5% Dextr.

saya pakai RL 20tts/i maintenance tidak hipernatremi....Bisa bisanya Otsuka aja... kan ? . tidak hipokalemi ?? iya tanpa cek serum Na atau K nya. tuh.

Ilustrasi BB Dewasa (Org Indonesia) : ± 50 kg Kebutuhan Air 2000 mL RL 2 L KA-EN 3B® 2 L Natrium 50 – 100 mEq 260 mEq 100 mEq Kalium 45 – 65 mEq 8 mEq 40 mEq Infus RL bukan Untuk Terapi Rumatan .

com/ped/topic2982. 2004.Anak BB = 20 kg Kebutuhan Air 1.5 L KA-EN 3B®. Emedicine.com/ped/topic2954. : 1.htm Infus RL bukan Untuk Terapi Rumatan . J. Rice H.G.50 mEq 6 mEq 30 mEq Ref.5 L RL 1.C.emedicine. 1.5 L Natrium 60 – 100 mEq 195 mEq 75 mEq Kalium 20 . www. and Michael G. 2003 July. Fluid Therapy for the Pediatric Surgical Patient.emedicine. Neonatology Considerations for the Pediatric Surgeon. Piwko. Emedicine. www.htm 2.

Acta Med Indones. Page: 115-120 Widodo D. The prevalence of hypokalemia in hospitalized patients with infectious diseases problems at Ciptomangun-kusumo Hospital Jakarta. 2.4 Nasronudin RS Sutomo 110 36. The Prevalence of hypokalemia and Hyponatremia in Infectious Diseases Hospitalized Patients. Untung.38(4):202-5 Nasronudin et al.5. p 732-734 .9 52.No 12. Marissa Ira.36 50. 3. Ed: Dec 2004.Prevalences of Hypokalemia Chief Investigator Centre No of % hypokalemia patients on admission % hypokalemia on Discharge Untung Sudomo RSPAD 100 28 45 Djoko Widodo RSCM 105 22. Gastroenterogy hepatoloy and digestive endoscopy vol. Sudomo. 2006.91 1. Medika 2006 Vol XXXII. Setiawan B. Khie Chen.

.

How does maintenance fluid therapy evolve? .

Na+ 35 K+ 20 Na+ 50 K+ 20. glu 27 g Na+ 77 .

3% AA. High NPC (glucose . lipid) NEOPAREN/MIXID .Pasien Rawat-Inap (di Jepang) Dehydrated Previously well-nourished Good appetite Dehydrated Previously well-nourished Or slightly undernourished Metabolically Non-stressed Anorexia Fatigue Fluid & basic electrolyte maintenance Complete Electrolyte. 5-10% glucose maintenance KAEN3B AMINOFLUID Previously malnourished Or undernourished or Metabolically stressed Hypoalbuminemia Debilitated If EN entirely impossible Parenteral Nutrition : 10 % AA.

K. Cl. P) + Zinc By SS 2006-2007 36 .5 % Amino acids 3% Aminofluid Electrolytes (Na.AMINOFLUID ® Glucose 7. Ca. Mg.

¥ protein-sparing ef. •Recommended by ASPEN GUIDELINES 2008 .5-5 g Asam amino AA 60 g - - 0.8 g/kg/hari Glukosa 150 g ¥ 54 g - •kebutuhan basal untuk homeostasis K+ adalah 20-30 mEq/hari (10). Komposisi Aminofluid dibandingkan RL dan KAEN3B KAEN3B Ringer’s lactate ASPEN guideline(2) Komposisi Aminofluid Air 2000 2000 2000 30-40 ml/kg/hari Na+ 70 100 260 1-2 mEq/kg/hari K+ 40 40 8 1-2 mEq/kg*/hari Cl- 70 100 218 sesuai kebutuhan Mg++ 10 - - 8-20 mEq/hari Ca++ 10 - - 10-15 mEq/hari P 20 - - 20-40 mEq/hari Zn 10 µmol - - 2. • kebutuhan basal asam-aminopada pasien nonstressed.Tabel 1.

Blomstrand A Role for Branched-Chain Amino Acids in Reducing Central Fatigue J. Nutr.547S .. February 1.BCAA BBB Appetite Fatigue (Serotonin) Tryptophan 80% (Serotonin) E. 2006. 136(2): 544S .

dry tongue & mouth LOSS OF APPETITE Cytokines (TNF. trauma or for post operative pts Infeksi/Trauma 1 Inflammation.IL-6) serotonin Melanocortin 2 Delayed gastric emptying 3 Tryptophan/BCAA ratio centrally combat fatigue syndrome .3 GOLDEN WAYS Why Aminofluid® is particularly helpful in infection. fever.IL-1. hyperventilation Dehydration.

dyspeptic patients • Gastrointestinal diseases.9% NaCl) • Stroke (after metabolic and electrolyte correction) Precautions: •Renal Failure associated with hyperkalemia •Heart Failure •Small children . gastroparesis • Acute Infectious diseases • Early post operative maintenance (straightforward surgery) • Hyperemesis gravidarum (after 0. colonoscopy. post resuscitation of severe diarrhea.Best Recommended in Following Conditions: • Febrile illnesses • Dehydrated and anorexic.

Penyakit Gastrointestinal DBD Infeksi akut/ Demam Hiperemesis gravidarum Neurologi Aminofluid Diabetes Mellitus Postoperatif Sepsis .

.

POD1 + ASERING-5 NPC AA Na+ K+ 500 kcal 30 g 165 mEq 24 mEq .

POD 2 + NPC AA Na+ K+ 600 kcal 60 g 70 mEq 40 mEq .

POD 3 (stress metabolic sedang/berat) + NPC AA Na+ K+ 300 kcal 80 g 35 mEq 20 mEq .

Rekomendasi Cairan solumix DBD grade I d Aminofluid 500 mL pOsm: 816 mOsm/L Na : 35 mEq K : 20 mEq Asering 500 mL pOsm: 274 mOsm/L Na : 130 mEq K : 4 mEq pOsmotik menjadi 545 mOsml/L Na : 82.5 mEq .

Hypovolemic shock Stable Hemodynamic .

AMINOFLUID .

JAN’ 2012 .

.

4.Take Home Message 1. misal: KAEN 3B (Na+ 50 mEq. DKA. Patofisiologi dehidrasi dan hipovolemi. 3. 2. Agar rasional memberikan infus pahami 4 hal: Indikasi. mencegah asidosis laktat pada neonatus saat SC Kaen series di desain memenuhi kebutuhan maintenance dasar. K+: 20mEq and glucose 27 gr) Aminofluid didesain sebagai infus maintenace terkini yang sekaligus bisa mengatasi dehidrasi. seperti: maintain suhu utama perioperatif. Fisiologi. Asering (AR) pilihan utama infus resusitasi dan memiliki kelebihan dibanding RL atau NS. CPB. mencegah anorexia dan mengatasi fatigue sehingga mempercepat penyembuhan pasien rawat inap . Sediaan infus yang ada dipasaran.

tidak rasional .Mencegah infus tidak adekuat.

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Have a nice day…… .