Penanganan cairan & elektrolit
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Transcript of Penanganan cairan & elektrolit
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Dr. Akhmad Mahmudi, Sp BA
TERAPI CAIRAN,
ELEKTROLIT
DAN ASAM BASA
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KOMPOSISI KIMIA TUBUH
LEMAK
MASSA TUBUH
NON LEMAK
73 % AIR
(Data dari Beddoe dkk 1984)
PRIA UMUR 40 TAHUN
LEMAK(TG):15 KgSubkutanIntermuskularIntraabdomenIntratorakalPROTEIN:12,8 KgMINERAL & GLIKOGEN4,2 KgAIR 42,1 KG -
TOTAL BODY WATER ( ASHCRAFT )
UMUR%
Gestasional 12 minggu94
12 minggu 32 minggu80
Aterm
3-5 hari78
-3 5
Neonatus 75 - 80
Children 65 - 75
Young Man60
Young Woman50
Over 60 years man50
Over 60 years women45
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Gangguan Cairan, Elektrolit dan Asam-Basa Perioperatif
PreoperatifPuasa terlalu lamaKehilangan cairan/elektrolitAsam-basa (Asidosis/alkalosis metabolik)Durante operatifKehilangan cairan/elektrolitAsam-basa (Respiratorik & Metabolik)PostoperatifKehilangan cairan (NGT,drain)Iatrogenik -
DIARE
KEMBUNG
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PROGRAM CAIRAN :
JUMLAH CAIRANJENIS CAIRANCARA PEMBERIANMONITORING -
Replacement therapy
NGT atau drainThird-Space LossThe Quadrant Scheme (educated guesses)Setiap kuadran abdomen = + maintenanceDisesuaikan dengan pantauan keluaran urin.Trauma bedahRingan : + 1 2 ml/kg/jamSedang : + 4 ml/kg/jamBerat : + 6 ml/kg/jamKehilangan cairan diganti dengan komposisi hampir sama -
Jumlah cairan :
1. Defisit cairan / dehidrasi
a. Dehidrasi Ringan : 5% ( 50ml/kgbb x TBW )
b . Dehidrasi Sedang : 10% (100ml/kgbb x TBW )
c. Dehidrasi Berat : 15% (150ml/kbbb x TBW )
* Tonisitas darah:Hipotonis,isotonis,hipertonis
2. Maintenance
Neonatus: 24 jam post operatif dikurangi 30%
3. Perkiraan cairan hilang dalam 24 jam
( on going loss )
2&3 modification to Fluid intake ( see table )
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Dehidrasi
Derajat dehidrasiRingan 5%Sedang 10%Berat 15%Jenis dehidrasiIsotonik (Na 130 150 mEq/L)Hipotonik (Na 150mEq/L) -
Dehidrasi
Kekurangan cairan akibat puasaKebutuhan cairan perjam x lama puasaRehidrasiTanda syok (atasi syok segera)Sisa cairan rehidrasi diberikanIsotonik : cepat ( -
MAINTENANCE ( ASHCRAFT )
* Daily Fluid Requirements
Weight Volume
Premature (< 2kg )150 ml / kg
Neonatus & infant (2-10 kg )100ml/kg for first 10kg
Infant & children (10-20kg )1000ml+50ml/kg over 10 kg
Children ( > 20 kg )1500ml+20ml/kg over 20 kg
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Maintenance therapy
Jumlah cairan menurut Holliday Segar100/50/20 ml/Kg/hari atau4/2/1 ml/kg/jamElektrolit Na : 3 4 mEq/kg/hariK : 2 3 mEq/kg/hariCl : 3 4 mEq/kg/hari - Sheet1TABLE :MODIFICATION TO FLUID INTAKEDecreaseAdjustmentHumidified Inspired airX 0.75Basal state (eg pa ralysed )X 0.7High ADH (IPPV,brain injury )X 0.7Hypothermia- 12 % per CHigh room humidityx 0.7Renal failurex 0.3 (+urine output )Sheet2Sheet3
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Increase
Full activity + oral feedsX 1.5
Fever+ 12 % per C
Room temperature > 31 C+ 30 % per C
HyperventilationX 1.2
Neonate - preterm (1-1.5 kg )X 1.2
- radiant heaterX 1.5
- photo terapyX 1.5
Burn - first day+ 4% per 1%
area burn
- Subsequently+ 2% per 1%
area burn
- Sheet1STANDART PAEDIATRICMAINTENANCE SOLUTIONUMURLAR.KRISTALOID1-2 hariD10% ( tak boleh elektrolit )3-7 hariD5% NaCl 0,18 % *< 1 thD5% NaCl 0,225 % *< 10 thD5% NaCl 0,45 % ** Tambahkan Maintenance KCl 7,5 %Sheet2Sheet3
- Sheet1Useful Intravenous Solutions CommerciallyAvailableSolutionDextroseNaClKLactateCagm/lmEq/lD5 %50-----D10 %100-----N/1-D550154154---N/2-D5507777---N/4-D55038.538.5---N/5-D5503131---R L-130108.74282.7Aminofusin Paed-301025-10Intra Lipid 10 %------Sheet2Sheet3
- Sheet1TERAPI CAIRAN & NUTRISINAMA PRODUKElektrolit ( Meq / L )KALORIA AOsmNa +K +Ca ++Cl -( Kkal )( gr / L )( mOsm / L )ASERING13043109--273KA-EN 3 B502050108-290KA-EN MG3 ( 500 ml in 1000 ml )5020-50400-695AMIPAREN2----100888PAN ENTERAL 1 sachet----40030278ANJURAN PEMBERIAN TERAPI :HARI 1HARI 2HARI 3 - dst2 btl ASE + 2 btl KAEN 3 B4 btl KAEN 3 B2 btl KAEN 3B + SOLUMIX2 sachet PAN ENTERAL ( pagi & sore )2 sachet PAN ENTERAL ( pagi & sore )( AMI + KN MG3 )908 Kcal1016 Kcal3 sachet PAN ENT (pagi,siang,sore )1508 KcalPenggunaan OTSU NS/OTSU D5 (100 ml) utk. pemberian dgn int. IV drip :- ANTIBIOTIK- ANALGESIK- VITAMINSheet2KOMPOSISI LARUTAN ELEKTROLIT DAN NUTRISI YANG RASIONALPRODUKElektrolit ( mEq / L )DextroseSorbitolProteinBCAAVitKaloriKemasanOsmotikKeteranganNa +K +Ca++Mg++Cl -MaleatLaktatAsetatgr/Lgr/Lgr/L%Kcal/LmlmOsm/LKa En 1 B38.5---38.5---37.5----150500285RasionalKa En 3 A6010--50-20-27.0----108500290RasionalKa En 3 B5020--50-20-27.0----108500290RasionalKa En MG35020--50-20-100----400500695Rasional500/1000ASERING13043-109--28------500273RasionalPAN AMIN G----52----5027.27.9-308500507ASKESAMINOVEL 6003525-53822-35-100508.8+6005001320ASKESAMIPAREN2------120--10030-400500888ASKESNON RASIONALRASIONALKASUS PENYAKIT DALAM :N/4 - D5 ( D5 - 1/4 NS )Ka En 1 BHARI IASERING 4 BTLN/2 - D2.5 , N/2 - D5 ( D5 - 1/2 NS )Ka En 3 AHARI II + IIIKN 3B 2 BTL + PAN AMIN 2 BTLRD5, RL + D5Ka En 3 BHARI IV dstKN MG3 2 BTL+PAN AMIN / AMINOVEL / AMIPARENRL + D-10Ka En MG3( SESUAI KEBUTUHAN ) 2 BTLRLASERING ( RA )KASUS BEDAH ( POST OP ) :HARI IKN 3 B / KN MG3 4 BTLHARI II + IIIKN MG3 2 BTL + PAN AMIN G / AMIPAREN 2 BTLHARI IV dstKN MG3 2 BTL + AMIPAREN 2 BTLSheet3KOMPOSISI LARUTAN KA EN DAN ASERINGKOMPOSISI ELEKTROLIT ( mEq/L )NAMA PRODUKOSMOLARITASNa+Cl-K+Ca++AsetateLactate-GlukosaKaloriKEMASANmOsm/LKcal/LKaeN 1 B28238.538.537.5150500KaeN 3 A2906050102027108500KaeN 3 B2905050202027108500KaeN MG369550502020100400500500/1000Asering273.4130108.742.728500
- Sheet1Distribution Comparative :KompartemenUmurNeonatusChildrenAdultCESPlasma : 1121Intersisil : 3CIS132Transeluler : 1 % - 3 % BBSheet2Sheet3
- Sheet1ADH : antidiuretic hormoneIPPH : intermittent positive pressure ventilationINSENSIBLE WATER LOSSUmur Neonatus/kgbb/hrUmr/kgbb/hrUdara bebas tanpa kelembaban28 ccBayi50-60 ccHumidified isolette14 ccAnak40 ccPemanasan40 - 45 ccRemaja30 ccSheet2Sheet3
- Sheet1Doses and Formulae in Paediatric Fluid andElectrolyte Therapy1. Albumin 25 %- Undiluted : 2 - 4 ml/kg- 5% in 5 % dextrose or saline : 10-20 ml/kg2. Bicarbonate( number of mmol of deficit )< 5kg : BE X wt ( kg ) X 1/2 (give 1/2 of this )> 5kg : BE X wt ( kg ) X 1/3 (give 1/3 of this )3. PotasiumMaximum 0,5 mmol/kg/h, requirement 2-4mmol/day, 1 g KCl = 13,3 mmol K+4. SodiumDepletion : ml 20% NaCl =Weight X 0,2( 140 - serum Na + ), requirement 2-6 mmol/kg/day. 1 g NaCl = 17,1 mmol/Na+5. Calcium- Chloride 10% (0,7mmol/l Ca++) max 0,2 ml/kg/iv stat. Requirement 1,5 ml/kg/day- Gluconate 10 % (0,22mmol/ml Ca++ )Maximum 0,5 ml/kgIV, Stat.requirement5 ml/kg/day6. Magnesium- Chloride 0,48 g/5ml (1mmol/ml Mg++ ):0,4mmol (0,4ml)/kg/dose slow IV 12 hourlySulphate 50% ( 2mmol/ml Mg ++ ):0,4mmol(0,2ml )/kg/dose slow IV 12 hourlySheet2Sheet3
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Kasus 1
Maintenance:Air :100ml/hari/kg x 4 kg = 400 ml/hariNa dan Cl : 3 mEq/kg/hari = 12 mEqK : 2 mEq/kg/hari = 8 mEqReplacement (orogastrik)Air : 75 mlNa: 70mEq/l = 5 mEqCl: 100mEq/L = 7,5 mEqK : 10mEq/L = 1 mEqReplacement (third-space loss)4 kuadran = 4 x maintenance = 400 mL
By laki-laki 3minggu, berat 4 kg ,ileo-ileostomi karena malrotasi (volvulus),cairan keluar dari penghisap orogastrik 75 ml, hematokrit 40v%, urine 120 ml. -
Kasus 1
MaintenanceOrogastrikThird-spaceAir (ml)40075400Na (mEq)125Cl (mEq)127,5K (mEq)81Cairan400 mlD5/0,25NS + 8 mEq KCl75 mlD5/0,5 NS + 1 mEq KCl400 ml RL atau D5/RL -
Kasus 2.
Maintenance Air 100/50/20 ml/kg/hari = 1500 ml Na 60 mEq/hari Cl 60 mEq/hari K 20 mEq/hariOrogastric lossAir 800 mlNa 56 mEq/800mlCl 80 mEq/800mlK 8 mEq/800mlThird-space LossTidak ada
Anak laki, 5 tahun, 20Kg 3 hari pascabedah splenektomi, kehilangan cairan orogastrik 24 jam sebelumnya 800 ml, urin 1200 ml -
Kasus 2
MaintenanceOrogastrikThird-spaceAir (ml)15008000Na (mEq)6056Cl (mEq)6080K (mEq)208Cairan1500 mlD5/0,25NS + 20 mEq KCl800 mlD5/0,5 NS + 8 mEq KCl0 -
TABLE : MODIFICATION TO FLUID INTAKE
Decrease Adjustment
Humidified Inspired air X 0.75
Basal state (eg pa ralysed ) X 0.7
High ADH (IPPV,brain injury ) X 0.7
Hypothermia - 12 % per C
High room humidity x 0.7
Renal failure x 0.3 (+urine output )
STANDART PAEDIATRIC
MAINTENANCE SOLUTION
UMURLAR.KRISTALOID
1-2 hariD10% ( tak boleh elektrolit )
3-7 hariD5% NaCl 0,18 % *
< 1 th D5% NaCl 0,225 % *
< 10 thD5% NaCl 0,45 % *
* Tambahkan Maintenance KCl 7,5 %
Useful Intravenous Solutions Commercially
Available
SolutionDextroseNaClKLactateCa
gm/lmEq/l
D5 %50-----
D10 %100-----
N/1-D550154154---
N/2-D5507777---
N/4-D55038.538.5---
N/5-D5503131---
R L-130108.74282.7
Aminofusin Paed-301025-10
Intra Lipid 10 %------
NAMA PRODUKOSMOLARITASNa+Cl-K+Ca++AsetateLactate-GlukosaKaloriKEMASAN
mOsm/LKcal/L
KaeN 1 B28238.538.537.5150500
KaeN 3 A2906050102027108500
KaeN 3 B2905050202027108500
KaeN MG369550502020100400500
500/1000
Asering273.4130108.742.728500
KOMPOSISI ELEKTROLIT ( mEq/L )
KOMPOSISI LARUTAN KA EN DAN ASERING
Distribution Comparative :
KompartemenUmur
NeonatusChildrenAdult
CESPlasma : 1121
Intersisil : 3
CIS132
Transeluler : 1 % - 3 % BB
ADH : antidiuretic hormone
IPPH : intermittent positive pressure ventilation
INSENSIBLE WATER LOSS
Umur Neonatus/kgbb/hrUmr/kgbb/hr
Udara bebas tanpa kelembaban28 ccBayi50-60 cc
Humidified isolette14 ccAnak 40 cc
Pemanasan 40 - 45 ccRemaja30 cc
Doses and Formulae in Paediatric Fluid and
Electrolyte Therapy
1. Albumin 25 %- Undiluted : 2 - 4 ml/kg
- 5% in 5 % dextrose or saline : 10-20 ml/kg
2. Bicarbonate( number of mmol of deficit )
< 5kg : BE X wt ( kg ) X 1/2 (give 1/2 of this )
> 5kg : BE X wt ( kg ) X 1/3 (give 1/3 of this )
3. PotasiumMaximum 0,5 mmol/kg/h, requirement 2-4
mmol/day, 1 g KCl = 13,3 mmol K+
4. SodiumDepletion : ml 20% NaCl =Weight X 0,2
( 140 - serum Na + ), requirement 2-6 mmol
/kg/day. 1 g NaCl = 17,1 mmol/Na+
5. Calcium- Chloride 10% (0,7mmol/l Ca++) max 0,2 ml
/kg/iv stat. Requirement 1,5 ml/kg/day
- Gluconate 10 % (0,22mmol/ml Ca++ )
Maximum 0,5 ml/kgIV, Stat.requirement
5 ml/kg/day
6. Magnesium- Chloride 0,48 g/5ml (1mmol/ml Mg++ ):0,4
mmol (0,4ml)/kg/dose slow IV 12 hourly
Sulphate 50% ( 2mmol/ml Mg ++ ):0,4mmol
(0,2ml )/kg/dose slow IV 12 hourly