New Paradigm in Volume

New Paradigm in:Volume

Replacement
Total Balanced Concept
Replacement :
Total Balanced Concept
Prof. dr. Achsanuddin Hanafie, SpAn, KIC
Departemen / SMF – Anestesiologi dan Reanmasi
FK-USU/RSUP H. Adam Malik Medan
 Hypovolemia and Shock
Hypovolemia and Shock
reduced
reduced blood
blood volume
volume septic
septic
- reduced cardiac output
- -reduced
reduced cardiac output
oxygen supply
- reduced oxygen supply shock
shock
inadequate
inadequate
circulation
circulation
endotoxine
endotoxine
vasoconstriction release
release
vasoconstriction
inadequate perfusion
inadequate perfusion
inadequate capillary flow
inadequate capillary flow
intestine
intestine
tissue
tissue
ischemia organ
organfailure
failure kidney
kidney
ischemia
 autologous blood
autologous
withdrawalblood
withdrawal
acute normovolemic
Volume
Volume
acute normovolemic
hemodilution (ANH)
hemodilution (ANH)
Pre-intra- and
Replacement
Replacement
Pre-intra- and
postoperative
postoperative
priming of the
priming of the
CPB circuit
CPB circuit
ICU (shock, sepsis
ICU (shock, sepsis
Pancreatitis)
Pancreatitis)
 H2O Albumin
capillary leak

Injury
Inflamatory
mediators
Injury
NaCl
 HH2OO
2 NaCl
NaCl

Injury
Injury
Inflam
ator y med iators

Albumin
Albumin

SYSTEMIC CAPILLARY LEAK

SYSTEMIC CAPILLARY LEAK
Changes
Changes of
of fluid
fluid compartments
compartments
Compartment
Compartment Crystalloids
Crystalloids Colloids
Colloids

intravascular
intravascular

interstitial
interstitial
Crystalloids
Crystalloids

∏c - ∏t = 25

ECF 80%
500ml = 100 ml
volume plasma
 Crystalloid for plasma volume support
Crystalloid for plasma volume support
- volume of distribution

Plasma
Plasma
Interstitium
Interstitium
Cell
Cell 0.25 - 0.2
0.25 - 0.2

0.75 - 0.8
0.75 - 0.8

11LL
Edema
Edema crystalloid
crystalloid
Neuro : Colloids and cerebral ischemia

Evans blue (μg/g tissue)

Edema

Schell, Anesthesiology 1992; 77: 86-92

 Stewart
StewartApproach
Approach
• Merupakan pendekatan alternatif secara fisikokimiawi atau kuantitatif
• Merupakan pendekatan alternatif secara fisikokimiawi atau kuantitatif
• 3 faktor independen yang mempengaruhi asam basa yaitu: SID, Total Asam lemah dan
• 3 faktor independen yang mempengaruhi asam basa yaitu: SID, Total Asam lemah dan
PaCO2
PaCO2
• SID adalah selisih jumlah kation kuat dikurangi jumlah anion kuat
• SID adalah selisih jumlah kation kuat dikurangi jumlah anion kuat
• Semakin besar SID  alkalosis, semakin kecil SID  asidosis
• Semakin besar SID  alkalosis, semakin kecil SID  asidosis
• Nilai normai SID 40 2 mEq / L
• Nilai normai SID 40 2 mEq / L
• Cairan infus bertujuan tidak mempengaruhi gangguan keseimbangan asam basa
Cairan infus bertujuan tidak mempengaruhi gangguan keseimbangan asam basa
• tubuh
tubuh
dengan cara memodifikasi nilai SID plasma
dengan cara memodifikasi nilai SID plasma
Kation Kuat = ion bermuatan positif 
diwakili oleh natrium

Anion Kuat = ion bermuatan negatif 

diwakili oleh klorida
 Perubahan
Plasma
keseimbangan
Asam Basa akibat
Na+ = 140 mEq/L
pemberian larutan Cl- = 102 mEq/L
infus
SID = 38 mEq/L

+ NaCl 0.9% + Ringerfundin

+ RL

Plasma Plasma Plasma

Na+ = (140+154)/2 mEq/L= 147 mEq/L
Cl- = (102+ 154)/2 mEq/L= 128 mEq/L
SID = 19 mEq/L
SID : 19  Asidosis
Na+ = (140+137)/2 mEq/L= 139 mEq/L Na+ = (140+154)/2 mEq/L= 147 mEq/L
Cl- = (102+127)/2 mEq/L= 114 mEq/L
Cl- = (102+ 109)/2 mEq/L= 105 mEq/L
Asetat & Malat
Laktat (termetabolisme) = 0 mEq/L
(termetabolisme) = 0 mEq/L
SID = 34 mEq/L SID = 33 mEq/L
14
SID : 34  lebih alkalosis SID : 33  lebih alkalosis
 0.9% em i c
c h lo r
HyNaCl
pe r
i d osis
ac
Consequences
 Risk of Un-Balanced Fluid:
Risk of Un-Balanced Fluid:
• Development of Hyperchloremic acidosis
• Development of Hyperchloremic acidosis
with the consequences :
with the consequences :
• Nausea
• Nausea
• Vomiting
• Vomiting
• Headache
• Headache
• Delayed first urination
• Delayed first urination
• Disturbed Blood Coagulation
• Disturbed Blood Coagulation
• Impairment patient Acid-base Status
• Impairment patient Acid-base Status
• Base excess associated mortality
• Base excess associated mortality
Fluid Balanced
 NEW

Balanced crystalloids Balanced

Balanced crystalloids Balancedcolloids
colloids
(e.g. Ringerfundin®) (e.g. Tetraspan®)
(e.g. Ringerfundin®) (e.g. Tetraspan®)
A total balanced volume replacement
strategy using a new balanced
hydroxyethyl starch preparation (6%
HES 130/0,42) in patients undergoing
major abdominal surgery

J. Boldt, T. Schollhorn, J. Munchbach, M. Pabsdorf

J. Boldt, T. Schollhorn, J. Munchbach, M. Pabsdorf

European Journal of Anesthesiology 2006; 1 - 6

European Journal of Anesthesiology 2006; 1 - 6
 PPAATTIIEENNTTSS

30 consecutive patients scheduled for

elective first-time major abdominal
surgery for intestine cancer
Prospective, randomized, double-blind
study
Time of volume therapy: 24 hrs
Sterofundin ISO = Ringerfundin
 Creatinine clearance (ml min-1)

200
mL min -1

190

180

170

160

150

140

130

120
Balanced group
110 unbalanced
group
100
Baseline End of surgery 5 th ICU 1st POD
 Beta-NAG (U g-1 creatinin)
U g -1 creatnine

20

18

16

14

12

10 Balanced group
unbalanced
8 group
6

0
Baseline End of surgery 5 th ICU 1st POD
 Alpha-1 microglobulin (mg L-1)

50
Mg L-1

40

30

Balanced group
unbalanced
20 group

10

0
Baseline End of surgery 5 th ICU 1st POD
 Comparison Balanced and
Un-balanced solution

Use Total Balanced solution (crystalloid & colloid) can avoid

Use Totaldevelopment
Balanced solution (crystalloid &
of hypercloremic colloid) can avoid
acidosis
development of hypercloremic acidosis
 Comparison Balanced and
Un-balanced solution

Use Total Balanced solution (crystalloid & colloid) can avoid

Use Totaldevelopment
Balanced solution (crystalloid &
of hypercloremic colloid) can avoid
acidosis
development of hypercloremic acidosis
Infl am
mati on

Ba
Blaanc
re laned
pr la c v
epce edolu
lacm vom
eemnt luem
en e
t
Coa gu l
ati on

Ba
Blaanc
re laned
pr la c v
epce edolu
lacm vom
eemnt luem
en e
t
much
less

_
_
 A Head-to-Head Comparison of the in
Vitro Coagulation Effects of Saline-Based
and Balanced Electrolyte Crystalloid and
Colloid Intravenous Fluids

Anthony M. Roche, Michael F. M. James, Elliott Bennett-

Guerrero and Michael F. Mythen

Anesth Analg 2006; 102; 1274-9

Kidn
Kidneys
eys
Ba
Blaan
re lace
rpelacncdevo
plae d lu
cmee vom
mnt luem
en e
t
Ca r d
Cardiac
surg iac
surgery
ery Ba
Blaan
re lace
rpelacncdevo
plae d lu
cmee vom
mnt luem
en e
t
 Conclusions
A total balanced volume replacement
strategy including a balanced HES and a
balanced crystalloid solution resulted in
moderate beneficial effects on acid-base
status, inflammation, endothelial
activation, and kidney integrity
compared to a conventional unbalanced
volume replacement regimen
Pt s c
Pts comfor
omfot
rt
Ba
Blaan
re lace
rpelacncdevo
plae d lu
cmee vom
mnt luem
en e
t
Saline
Saline solution
solution vsvs LRLR in
in volunteers
volunteers
N=18 (cross over)
N=18 (cross over)

90

80

70

60

50 Saline

40 Ringer

30

20

10

0
CNS Changes Abdominal discomfort

Williams et al Anesthesia and Analgesia 1999

 Postoperative
Postoperative Vomiting
Vomiting
10

6 HES/NS
HEX/LR
5

0
Vomitng Events

Williams et al Anesthesia and Analgesia 1999

OUTC
OUTCOME
O ME
Ba
Blaanc
re laned
pr la c v
epce edolu
lacm vom
eemnt luem
en e
t
 acid-base status

perfusion
inflamation

Balanced fluids
kidney function
organ function

hemostasis
“Designing “Balanced Crystalloid”
“Designing “Balanced Colloid”
 Argument against
balanced solutions?
NO........
NO........
THANK YOU