Safe Fluid Therapy In Brain Injury

“Total Balanced Concept”

Joni Wahyuhadi
Metabolism Consequences
of B.I Head Injury

Cytokines
Katabolic Hormones
Prostaglandins
Glukagon
Cortisol
other

Acute Systemic Injury altered

phase vasculer
response permeability
Immuno
Hypercatabolism
modulation
Altered gastric emptying
Hyperglycemia
and gut permeability 
Hipermetabolis State

Central Insult Px Brain Injury

Systemic Insult

• Hypermetabolism – hypercatabolism
• Acute phase respons   EE,  protein turn over
• Decreased Imun state
• Altered glucose metabolism
• Increase cytokine and hormon level
• Gastric ulceration
• Altered mineral metabolism
 Balance solution - Plasmalike Electrolytes

[mmol/l] NS Ringer RL RA RFundin Plasma

Electrolyte balance Na+ 154 147 130 130 140 142

like in human plasma K+ 4.0 4 4 4.0 4.5

=> physiological composition closely Ca2+ 2.25 2.7 2.7 2.5 2.5
resembling humanplasma needed
Mg2+ 1.0 1.0 0.85
Conventional infusion solutions can
Cl- 154 156 108.7 108.7 127 103
produce a number of corrective
effects – HCO3 24

both unwanted and unknown. Lactate- -- -- 28.0 -- -- 1.5

Acetate- -- -- -- 28.0 24.0

Malate2- -- -- -- -- 5.0
Ringerfundin does not affect electrolyte
BEpot -24 -24 3.0 2.5 0 0±2
equilibrium
Tonicity
[mOsm/l] 304 309 273 273.4 304 308
[mOsm/lkg) 286 256 256 286 288
Balanced solution –
should be „Isotonic“

USA:
Estimated 15,000 pediatric deaths a year
attributed to postoperative hyponatremia
secondary to infusion of hypotonic
solutions

Neurotraumatology:
Use of hypotonic solutions (RL & RA)
contra-indicated: risk of brain edema Isotonic
Hypotonic IV Fluids and Intracranial Pressure
(ICP)
288 to 280 mosmol/kg H2O
 All body fluids have the same osmotic
pressure as plasma (osmolality)
 The rigidly shaped skull contains 3
incompressible fluid compartments (Brain,
Blood, CNS)
 Intracranial compartment responses to a
change in plasma osmolality:

A decrease in plasma osmolality by

approximately 3% (288 to 280
mosmol/kg H2O), invariably results in an
increase in brain volume by 3%, causing
a decrease in blood and/or CSF volume
by as much as 30%.
Hyponatremic Encephalopathy
Sodium
Osmolarity
H2O- shift into cells
intracranial pressure
Encephalopathy
Brain herniation
Permanent brain injury
Death
Hall JE. Medical Physiology. Saunders, 2011
The Goals Of Fluid, Nutritional and
Metabolic support are :

1. Keseimbangan cairan dan kalori

2. Cegah penurunan berat badan
3. Pertahankan fungsi mukosa usus
4. Hemostasis glukosa
5.  status immune
6. Maintain Normal ICP
Kebutuhan Nutrisi

Energi
1. Harris –Benedict Equation
x faktor stres
2. Rule of Thumb
3. Indirect kalorimetri
1. Basal Energy Expediture (BEE)
Formula : Harris Benedict
 Calorie Calculation
2. “Rule of Thumb”
Calorie requirement = 25 to 30 kcal/kg/day

Kebutuhan protein :
• Normal : 0,8-1 g/kg/day
• Mild stress : 1-1,2 g/kg/day
• Moderate stress : 1,2-1,4 g/kg/day
• Severe stress : 1,4-2 g/kg/day
 Cara Pemberian Nutrisi

“ If the gut works, use it”

1. Enteral Nutrition :
- oral supplements
- tube feeding  prox jejenum, ok :
• Motilitas gaster terganggu
• Stress gastritis
• Resiko emesis dan aspirasi
2. TPN
 Cara pemberian nutrisi
• Early enteral nutrition “ If the gut
works, use it”  meteorismus.?
BU.?, cek prod NGT
• Start low, go slow
• Tujuan enteral :
• Menjaga integritas mukosa
• ↗ visceral blood flow
• Proteksi thd gastric ulcer
• Kontrol glukosa lebih baik
• ↘ komplikasi infeksi
CAIRAN dan ELEKTROLIT
 Cairan dan Elektrolit
A. Children

water

K : 2,5 mEq / Kg BW / day

elektrolit
Na : 3 mEq / Kg BW / day
 Cairan dan Elektrolit
B. Adult
Water 25 – 40 ml / Kg BW / day
K+  1 mEq / Kg BW / day
Na2+  ± 2 mEq / Kg BW / day
Cairan dan Elektrolit
Terapi Cairan
Safe Fluid Therapy In Brain Injury
“Total Balanced Concept”

Terima Kasih Banyak

 Koreksi Elektrolit
NATRIUM
• Paling menentukan osmolalitas darah
• Kelainan Na: neuronal dan neuromuscular junction
• Kadar N : 135 – 145 mg/L
• HipoNa  < 120mg/L
Tx : NaCl 3%  Na >125mg/L retriksi cairan
Na <120 mg/L (140-x).BB.0,6
• HiperNa  >160mEq/l
Tx: D5% {(x-140)x BBx 0,6} : 140 = L
 Koreksi Elektrolit
KALIUM
• Penting untuk mempertahankanmembran potensial
listrik
• Kelainan K : sistem kardiovascular,neuromuscular,
GIT
• N : 3,5-5,5 mEq/L
• hipoK : <3 mEq/L
• Tx : KCl (4,5-X) x BB x 0,3 mEq
• HiperK :>6 mEq/L
• Tx : insuline 10u + D5% 500cc, Lasix (ekskresi K)
Kelainan cairan dan elektrolit
pada Cedera Otak
Kesimpulan terapi cairan
• Tidak ada resusitasi cairan yang paling
ideal
• Cegah pemberian cairan dextrose dan
cairan hiposmolar
• Jaga pasien dalam keadaan :
• Normovolemia
• Normotension
• Cegah hipoosmolar
• Cegah hiperglikemia
WISH US LUCK