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VOLUME

VOLUME
RESUSCITATION
RESUSCITATION
IN SHOCK STATE
IN SHOCK STATE
Prof. dr. Achsanuddin Hanafie, SpAn, KIC
Departemen / SMF – Anestesiologi dan Terapi Intensif
FK-USU/RSUP H. Adam Malik Medan

TOTAL BODY WATER
Female,
Female, 80
80 Kg
Kg

16 L 32 L

12 L 4L

INTERSTITIAL IV
SPACE SPACE

EXTRACELLULAR INTRACELLULAR
SPACE SPACE

TBW 48 L

FLUID COMPARTMENS
FLUID COMPARTMENS

ICF ISF Intravascular .

Hanafie .A.

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Plasma and intracellular electrolyte Plasma and intracellular electrolyte Plasma Intracellular Cations : Sodium (Na+ ) 142 mEq 10 mEq Potassium (K+ ) 4 mEq 160 mEq Calcium (Ca++ ) 5 mEq Magnesium (Mg++ ) 3 mEq 35 mEq 154 mEq/L 205 mEq/L Anions : Chloride (Cl – ) 103 mEq 2 mEq Bicarbonate (HCO 3 ¯ ) 27 mEq 8 mEq Phosphate (HPO4¯ ) 2 mEq 140 mEq Sulfate (SO4¯ ) 1 mEq Organic acids 5 mEq Protein 16 mEq 55 mEq 154 mEq/L 205 mEq/L .

5 1 103 114 10 27 30 100 2 2 20 1 1 .mEq/L ICF ECF Komposisi 15 elektr Plasma 142 Interstitial 144 150 4 4 2 5 2. 5 5 63 16 6 .5 27 3 1.

Hanafie .A.

400 ml – Air 300 ml • Kulit TOTAL = 2500 ml – Keringat 400 ml TOTAL = 2500 ml .JUMLAH CAIRAN MASUK DAN KELUAR DALAM JUMLAH CAIRAN MASUK DAN KELUAR DALAM SEHARI PADA ORANG DEWASA SEHAT SEHARI PADA ORANG DEWASA SEHAT MASUK KELUAR • Pencernaan • Ginjal – Cairan 1200 ml – Urine 1500 ml • Makanan cair • Saluran cerna – Air 1000 ml – Faeces 200 ml • Paru • Oksidasi makanan – Udara eks.

FLUID COMPARTMENS AND FLUID COMPARTMENS AND CELLULAR MEMBRANE THEIR MEMBRANES THEIR MEMBRANES PASSIVELY PASSIVELY PERMEABLE FOLLOWING PERMEABLE ONLY OSMOTIC ONLY TO TO WATER. PRESSURE FOLLOWING OSMOTIC PRESSURE WATER. EXCEPT EXCEPT CELLS AND PROTEIN. GRADIENTS GRADIENTS CAPILLARY MEMBRANE PASSIVELY PASSIVELY PERMEABLE PERMEABLE TO TO ALL. FOLLOWING CELLS AND PROTEIN. FOLLOWING PRESSURE PRESSURE GRADIENTS GRADIENTS . ALL.

HEMORRHAGE THAT OCCURS IN 15 OR 30 MINUTES.   SHOCK .   FOR EXAMPLE.EFFECTS OF RAPID LOSS OF 2 LITERS OF ISOTONIC FLUID.

  MILD DEHYDRATION . THE LOSS IS NOW  SHARED BY THE ENTIRE  EXTRACELLULAR SPACE.   FOR EXAMPLE.EFFECTS OF SLOW LOSS OF 2 LITERS OF ISOTONIC FLUID. DIARRHEA THAT  OCCURS OVER A 6 ‑ 12 HPI  PERIOD.

 BUT NOW  THE SLOW LOSS IS OF GREATER  THE SLOW LOSS IS OF GREATER  MAGNITUDE. BUT THE  WOULD STILL BE PRESERVED.EFFECTS OF SLOW LOSS OF 4 LITERS OF ISOTONIC FLUID. BUT THE  INTERSTITIAL RESERVOIR IS SEVERELY  INTERSTITIAL RESERVOIR IS SEVERELY  DEPLETED.   DIARRHEA OR VOMITING WOULD  DIARRHEA OR VOMITING WOULD  STILL BE GOOD EXAMPLES. BUT NOW  STILL BE GOOD EXAMPLES.    SEVERE DEHYDRATION . DEPLETED. HEMODYNAMICS  WOULD STILL BE PRESERVED. HEMODYNAMICS  MAGNITUDE.

 A LOSS OF THAT  MAGNITUDE OVER SIX OR EIGHT  HOURS WOULD SEVERELY  COMPROMISE BOTH INTERSTITIAL  PLUS INTRAVASCULAR SPACES.   SEVERE DEHYDRATION PLUS SHOCK .   ASSUMING NO REPLACEMENT HAS  BEEN GIVEN.EFFECTS OF SLOW LOSS OF SIX LITERS OF ISOTONIC FLUID.

Indication of Fluid Volume Indication of Fluid Volume Replacement Replacement   Hypovolemia   ARDS  Shock  Acute Lung Injury (ALI)  Burns  Acute Liver Failure  Hypoalbuminemia  Stroke  Surgery  Pancreatitis in ICU  Trauma  Cardiopulmonary By Pass .

SHOCK SHOCK HYPOVOLEMIC HYPOVOLEMIC .

reduced cardiac output .reduced cardiac output .reduced oxygen supply inadequate inadequate circulation circulation endotoxine endotoxine vasoconstriction release release vasoconstriction inadequate perfusion inadequate perfusion inadequate inadequatecapillary capillaryflow flow intestine intestine tissue organ kidney tissue organfailure failure kidney ischemia ischemia . Hypovolemia and Shock Hypovolemia and Shock reduced reducedblood bloodvolume volume .reduced oxygen supply septic septicshock shock .

PRE-LOAD CONTRACTILITY AFTER-LOAD PRE-LOAD CONTRACTILITY AFTER-LOAD STROKE VOLUME HEART-RATE STROKE VOLUME HEART-RATE CARDIAC OUTPUT TOTAL PERIPHERAL CARDIAC OUTPUT TOTAL PERIPHERAL RESISTANCE RESISTANCE BLOOD PRESSURE BLOOD PRESSURE .

PRINSIP DASAR TERAPI SYOK PRINSIP DASAR TERAPI SYOK Tujuan umum : Tujuan umum : Meningkatkan transport oksigen ke jaringan Meningkatkan transport oksigen ke jaringan                           Target terapi utama : Target terapi utama : Resusitasi cairan Resusitasi cairan Meningkatkan Kontraksi jantung – inotropik Meningkatkan Kontraksi jantung – inotropik Meningkatkan tahanan sistemik – vasopresor Meningkatkan tahanan sistemik – vasopresor .

PENYEBAB HIPOVOLEMIA HEMORRHAGIC NON - HEMORRHAGIC .

HEMORRHAGIC HEMORRHAGIC  Trauma  Trauma  Vascular  Vascular  Gastrointestinal  Gastrointestinal  Retro peritoneal  Retro peritoneal  Obstetric and Gynecology  Obstetric and Gynecology .

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Penetrating Torso Trauma .

Head Injury .

Korban tabrakan truk terjepit bak besi .

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Pedestrian versus car .

Internal Bleeding Liver rupture Internal Bleeding Liver rupture .

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Increased Vascular Capacitance 3. External Fluid Loss 2. Interstitial Fluid 1. Increased Vascular Capacitance Sepsis  Sepsis  Anaphylaxis  Anaphylaxis  Toxins / Drugs  Toxins / Drugs . External Fluid Loss 2. NON-HEMORRHAGIC NON-HEMORRHAGIC 1. Interstitial Fluid Dehydration Redistribution  Dehydration  Vomiting  Redistribution Thermal injury  Vomiting  Thermal injury  Diarrhea  Trauma  Diarrhea  Trauma  Polyuria  Anaphylaxis  Polyuria  Anaphylaxis 3.

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Fluid Fluid Therapy Therapy .

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Resuscitation Hypovolemic shock Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Fluid!! Vasopressors if unable to keep MAP > 65 .

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PENATALAKSANAAN SYOK HIPOVOLEMIK PENATALAKSANAAN SYOK HIPOVOLEMIK Pemeriksaan Jasmani : Pemeriksaan Jasmani : Airway and Breathing Airway and Breathing Sirkulasi – Kontrol perdarahan Sirkulasi – Kontrol perdarahan Disability – Pemeriksaan neurologi Disability – Pemeriksaan neurologi Exposure – Pemeriksaan Lengkap Exposure – Pemeriksaan Lengkap Dilatasi Lambung – Dekompresi Dilatasi Lambung – Dekompresi Pemasangan kateter urine Pemasangan kateter urine Akses Pembuluh Darah Akses Pembuluh Darah Terapi Awal Cairan Terapi Awal Cairan .

CNS (Status Mental) Sedikit Cemas Agak Cemas Bingung Lesu Penggantian Cairan Kristaloid Kristaloid Kristaloid Kristaloid (Hukum 3 : 1) dan Darah dan Darah . PERKIRAAN KEHILANGAN DARAH KELAS 1 KELAS 2 KELAS 3 KELAS 4 Kehilangan darah (ml) Sampai 750 750 .40 > 35 ( x / menit ) Produksi urine (ml/jam) > 30 20 .20 20 .2000 > 2000 Kehilangan darah Sampai 15 % 15 – 30 % 30 – 40 % > 40 % (% volume darah) Denyut Nadi ( x / menit ) < 100 > 100 > 120 > 140 Tekanan Darah Normal Normal Menurun Menurun Normal atau Tekanan Nadi Menurun Menurun Menurun Naik Frekwensi Pernafasan 14 .30 5 – 15 Tidak berarti Cemas.30 30 .1500 1500 . Bingung.

keriput • Mata cowong • Turgor • Turgor • Turgor • URINE • Pekat • Pekat . Tanda-tanda defisit cairan ekstraselular RINGAN SEDANG BERAT • CNS • Respon baik • Mengantuk • Refleks tendon • Apatis • Anestesi pada • Respon lambat akral • Anoreksia • Stupor • Aktifitas turun • Koma • KARDIOVASKULAR • Takikardia • Takikardia • Sianosis • Hipotensi • Hipotensi • Nadi lemah • Akral dingin • Vena kolaps • Nadi tak-teraba • Detak jantung jauh • JARINGAN • Mukosa lidah • Lidah kecil. • Atonia kering lunak. turun • Oliguria • DEFISIT • 3 – 5 % BB • 6 – 8 % BB • 10 % BB .

Goals of clinical fluid therapy Goals of clinical fluid therapy Maintenance or achievement of Maintenance or achievement of normovolemia and haemodynamic normovolemia and haemodynamic stability. Maintenance of an adequate plasma colloid Maintenance of an adequate plasma colloid osmotic pressure (COP) osmotic pressure (COP) . stability. different fluid compartment. Restitution of the fluids balance between the Restitution of the fluids balance between the different fluid compartment.

Enhancement of microvascular blood flow. Normalization of oxygen delivery to Normalization of oxygen delivery to tissue cells and cellular metabolism tissue cells and cellular metabolism Prevention of reperfusion type of injury Prevention of reperfusion type of injury . Goals of clinical fluid therapy Goals of clinical fluid therapy Enhancement of microvascular blood flow. Prevention of cascade system activation and Prevention of cascade system activation and increased blood coagulability. increased blood coagulability.

THE NEXT STEP HOW TO GIVE WHAT TO GIVE HOW MUCH TO GIVE .

5 x VD Colloid RV = 1. Determine resuscitation volume (RV) 4. Estimate normal blood volume (BV) 1.A SIMPLE METHOD FOR DETERMINING A SIMPLE METHOD FOR DETERMINING RESUSCITATION VOLUME RESUSCITATION VOLUME 1. Calculate volume deficit (VD) 3. Estimate % loss of blood volume 3. Determine resuscitation volume (RV) Whole Blood RV = VD Whole Blood RV = VD Colloid RV = 1. Calculate volume deficit (VD) VD = BV x % Loss VD = BV x % Loss 4. Estimate normal blood volume (BV) (70 ml/kgBB) (70 ml/kgBB) 2. Estimate % loss of blood volume 2.5 x VD Crystalloid RV = 4 x VD Crystalloid RV = 4 x VD .

0 – 1.0 Hemorrhage 750 ml ( 15 % ) L Colloid Class II 1.0 – 1.5 L whole blood ( 30 – 40 % ) or 1. Intravenous fluid replacement in Hemorrhagic shock Class I 2.0 Hemorrhage > 2000 ml L Colloid + 2.0 L Ringer Lactate + 0.5 L Ringer Lactate solution or 1.0 L whole blood or ( > 40 % ) equal volumes concentrated red cells and polygelatin or hetastarch .5 L Hemorrhage 1500 – 2000 ml Colloid + 1.5 L Ringer Hemorrhage 800 – 1500 ml.5 L equal volumes of concentrated red cells and polygelatin Class IV 1.0 L Ringer Lactate solution + 1. Lactate solution ( 15 – 30 % ) Class III 1.0 L Colloid + 1.

DASAR PEMIKIRAN DASAR PEMIKIRAN PERDARAHAN PERDARAHAN VOLUME DARAH VOLUME & DARAH ERITROSIT&HILANG ERITROSIT HILANG S/D 25 % > 30 % S/D 25 % > 30 % SYOK EXITUS SYOK EXITUS .

HITUNG NADI. RL.5 – 1 ml/KgBB/jam S/D 2 – 4 X LOST VOLUME A A HEMODINAMIK BAIK HEMODINAMIK JELEK HEMODINAMIK BAIK HEMODINAMIK JELEK B C . RA. PENANGANAN SYOK PERDARAHAN PENANGANAN SYOK PERDARAHAN PENDERITA DATANG DENGAN PERDARAHAN PENDERITA DATANG DENGAN PERDARAHAN PASANG INFUS JARUM BESAR. SAMPEL DARAH NILAITEKANAN UKUR PERFUSI. NADI < 100 x/menit HEMODINAMIK BAIK HEMODINAMIK JELEK PERFUSI HANGAT.9 % RL. UKUR TEKANAN DARAH. NADI <KERING 100 x/menit URIN : 0. ml/KgBB/jam S/D 2 TERUSKAN – 4 X LOST VOLUME CAIRAN PERFUSI KERING URIN : 0. TERUSKAN CAIRAN TDS > 100. DARAH. NaCl 0. NaCl S/D 2 – 4GROJOG X LOST VOLUME CEPAT S/D 2 – 4 X LOST VOLUME HEMODINAMIK BAIK HEMODINAMIK JELEK TDS > 100. MINTA DARAH TENTUKAN ESTIMASI JUMLAH PERDARAHAN. PRODUKSI URIN TENTUKAN ESTIMASI JUMLAH PERDARAHAN. SAMPEL DARAH NILAI PERFUSI. PRODUKSI URIN NADI.9 % MINTA DARAH GROJOG CEPAT0. RA. HITUNG PASANG INFUS JARUM BESAR.5 – 1HANGAT.

berikan PRC “O” Bila pasien sudah mendapat PRC “O” > 4 unit. transfusi Bila pasien sudah mendapat PRC “O” > 4 unit. berikan transfusi. berikan PRC “O” tidak tersedia. atau Hct < 25 %. berikan transfusi. biasanya tidak perlu pemberian AA Infus dilambatkan. Tetapi BB Jika Hb < 8 gr % . bila golongan darah yang sama tidak tersedia. tunda transfusi sampai sumber menghentikan perdarahan. Infus dilambatkan. biasanya tidak perlu pemberian transfusi transfusi Jika Hb < 8 gr % . transfusi selanjutnya tetap berikan dengan golongan “O”. kecuali sudah lewat 14 hari sudah lewat 14 hari . tunda transfusi sampai sumber perdarahan terkuasai perdarahan terkuasai Berikan segera transfusi. bila golongan darah yang sama CC Berikan segera transfusi. Tetapi bila sedang dilakukan tindakan pembedahan untuk bila sedang dilakukan tindakan pembedahan untuk menghentikan perdarahan. kecuali selanjutnya tetap berikan dengan golongan “O”. atau Hct < 25 %.

9 % Gelatin HES . PILIHAN TERAPI CAIRAN RESUSITASI KRISTALOID KOLOID RL Albumin RA Plasma RSol Dextran NaCl 0.

CRYSTALLOID CRYSTALLOID ADVANTAGES ADVANTAGES Balanced electrolyte composition Balanced electrolyte composition Buffering capacity (lactate/acetate) Buffering capacity (lactate/acetate) No risk of adverse reaction No risk of adverse reaction Minimal effect on haemostasis Minimal effect on haemostasis Promoting diuretics Promoting diuretics Inexpensive Inexpensive .

CRYSTALLOID CRYSTALLOID DISADVANTAGES / RISK DISADVANTAGES / RISK Poor plasma volume support Poor plasma volume support Large volume needed Large volume needed Overhydration / oedema formation Overhydration / oedema formation Reduced plasma COP (Colloid Oncotic Reduced plasma COP (Colloid Oncotic Pressure) Pressure) Hypothermia Hypothermia .

COLLOID COLLOID ADVANTAGES ADVANTAGES  Good intravascular persistence  Good intravascular persistence  Moderate volume required  Moderate volume required  Plasma COP moderately altered  Plasma COP moderately altered  Minor risk of tissue oedema  Minor risk of tissue oedema  Enhanced microvascular blood flow  Enhanced microvascular blood flow  Moderation of SIRS  Moderation of SIRS .

COLLOID COLLOID DISADVANTAGES / RISK DISADVANTAGES / RISK Volume overload Volume overload Disturbed haemostasis Disturbed haemostasis Tissue accumulation Tissue accumulation Adverse effects on renal function Adverse effects on renal function Anaphylactoid reaction Anaphylactoid reaction More expensive More expensive .

Changes Changes of of fluid fluid compartments compartments Compartment Compartment Crystalloids Crystalloids Colloids Colloids intravascular intravascular interstitial interstitial .

∏t = 25 ECF 80% 500ml = 100 ml volume plasma .Crystalloids Crystalloids ∏c .

8 0.75 - 0.25 .0.2 0.0.25 .2 0. Crystalloid for plasma volume support Crystalloid for plasma volume support .8 11LL Edema Edema crystalloid crystalloid .75 - 0.volume of distribution Plasma Plasma Interstitium Cell Interstitium Cell 0.

Anesthesiology 1992.Neuro : Colloids and cerebral ischemia Evans blue (μg/g tissue) Edema Schell. 77: 86-92 .

5 200-260/0.62 130/0.5 200/0. 450/0.62 Balance 200/0. MS>0. Balanced HES Balanced HES (MW>500KD.7 Hextend®– USA) USA) 70/0.42 130d 130 .42 130/0.5 70/0.4 d 130/0.4 Balance 130/0.5 200-260/0.7 450/0.7 (MW>500KD.7 Hextend®– HMW/HMS HMW/HMS MS>0.

X Dextrans ? Dextrans X FFP FFP COLLOIDS COLLOIDS Albumin Albumin Gelatins Gelatins HES HES .

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6% WIDAHES 130/0.42 .

OOO O 6% HES 130 / 0.4 / 9 Concentration C2/C6 (Mw) ratio(MS) Molar Substitution Mean molecular weight (9:1) .

have no side effects (allergy. IDEAL FLUID IDEAL FLUID promptly restore the intravascular volume promptly restore the intravascular volume not increase the extravascular water not increase the extravascular water have no side effects (allergy. tissue accumulation) tissue accumulation) cheap cheap . coagulopathy. coagulopathy.

RESPON CEPAT A. RESPON SEMENTARA C. RESPON SEMENTARA B. RESPON MINIMAL ATAU TANPA RESPON C. RESPON CEPAT B. RESPON MINIMAL ATAU TANPA RESPON . RESPON TERHADAP RESUSITASI RESPON TERHADAP RESUSITASI CAIRAN AWAL CAIRAN AWAL A.

Kembali ke Tanda Vital Tensi dan Nadi kembali Tetap Abnormal Normal Turun Dugaan Kehilangan Minimal (10 – Sedang.Banyak Segera Type Specific Persiapan Darah Type Specific Emergency dan Cross match Operasi Mungkin Sangat Mungkin Hampir Pasti Kehadiran Dini Ahli Perlu Perlu Perlu Bedah . masih ada Berat ( > 40 % ) Darah 20%) (20 – 40 % ) Kebutuhan Kristaloid Sedikit Banyak Banyak Kebutuhan Darah Sedikit Sedang . RESPON TERHADAP PEMBERIAN CAIRAN AWAL RESPON TERHADAP PEMBERIAN CAIRAN AWAL RESPON RESPON TANPA CEPAT SEMENTARA RESPON Perbaikan sementara.

KOMPLIKASI RESUSITASI CAIRAN KOMPLIKASI RESUSITASI CAIRAN  Pulmonary Edema  Pulmonary Edema  Myocardium Edema  Myocardium Edema  Mesenteric Effects  Mesenteric Effects  Integumentary  Integumentary  Central Nervous System Effects  Central Nervous System Effects .

Fluid Administration The Debate .

Drawbacks of over-used Crystalloids .

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The fluid goes Right Here!! .

. Positive tube sign. Kerley B’s. homogenously distributed throughout the lungs. Cardiomegaly. No Kerley B’s. Pulmonary Edema via CXR Pulmonary Edema via CXR Cardiogenic Non-Cardiogenic Bilateral infiltrates predominately in Diffuse Bilateral patchy infiltrates lung bases.

Sequelae patologis Sequelae karena patologis kelebihan karena cairan kelebihan pada sistim cairan pada sistim organ organ .

MONITORING YANG DIPERLUKAN SEBAGAI PEDOMAN
MONITORING YANG DIPERLUKAN SEBAGAI PEDOMAN
DALAM TERAPI CAIRAN
DALAM TERAPI CAIRAN
& ECG monitoring
ECG monitoring
&
& Pulse oxymetri
& Pulse oxymetri

& End tidal CO
& End tidal CO2
2
& Arterial catheter
& Arterial catheter
& Pulmonary artery catheter
& Pulmonary artery catheter
& Central venous catheter
& Central venous catheter
& Urinary catheter
& Urinary catheter

EEN
NDDPPO
OIIN
NTTSS
1. CVP = 15 mm Hg
1. CVP = 15 mm Hg
2. MAP = > 65 mmHg
2. MAP = > 65 mmHg
3. Blood lactate , < 4 mmol/L
3. Blood lactate , < 4 mmol/L
4. Base deficit - 3 - + 3 mmol/L
4. Base deficit - 3 - + 3 mmol/L
5. Urine : 0,5 - 1 ml/KgBB/hr
5. Urine : 0,5 - 1 ml/KgBB/hr
6. Wedge pressure = 10 - 12 mmHg
6. Wedge pressure = 10 - 12 mmHg
7. Cardiac index > 3 L/min/m2 2
7. Cardiac index > 3 L/min/m
8. Oxygen uptake (Vo2) > 100 mL/min/m2 2
8. Oxygen uptake (Vo2) > 100 mL/min/m

Ventilation Volume replacement Pharmacotherapy
Ventilation Volume replacement Pharmacotherapy

baseline
VO22 oxygen consumption
MAP

DO22 oxygen delivery
CI cardiac index
COP colloid osmotic pressure
infusion BV blood volume
organ failure
survival critical

SUCCESSFUL FLUID THERAPY SUCCESSFUL FLUID THERAPY Cardiac index Cardiac index CICI Oxygen delivery Oxygen delivery DO DO2 2 Oxygen consumption Oxygen consumption VO VO22 Vascular resistance… Vascular resistance… pulmonary PVR PVR pulmonary systemic SVR SVR systemic .

Kesimpulan Kesimpulan Pengetahuan fisiologi dari kesimbangan cairan dan elektrolit mutlak diperlukan Riwayat penyakit. pemeriksaan klinis dan laboratorium sangat dibutuhkan dalam menentukan strategi terapi resusitasi cairan Pemilihan cairan ditentukan berdasarkan keadaan klinis pasien Diperlukan monitoring yang tepat dalam menilai hasil dari terapi cairan resusitasi .

THANK YOU A. Hanafie ‘12 .