Peranan Koloid Dlm Th. Cairan
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OLEH
Dr. UNDANG KOMARUDIN, Sp.An
INSTALASI ICU & ANESTESI
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Terapi cairan
Resusitasi
Kristaloid
Koloid
Tuj / - Mengganti kehilangan
Akut cairan tubuh
RumatanElektrolit
Nutrisi
Tuj / -Memelihara
keseimbangan tubuh
dan nutrisi
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TUJUAN TERAPI CAIRAN
Mempertahankan status hidrasi dan perfusi jaringan yang adekuat
serta keseimbangan elektrolit
Terapi cairan penting : Pada kasus pasien kritis
Trauma
Peri operatif
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PRINSIP TERAPI CAIRAN
Ganti sesuai jumlah & jenis cairan yang hilang
Hitung kehilangan Abnormal
Hitung kebutuhan normal harian / Maintenance
Kebutuhan cairan iv = Cairan Maintenance +
Kehilangan Abnormal
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PRIORITAS TERAPI CAIRAN
Memberi volume sirkulasi Adekuat
kematian ok . Syok hipovolemik bukan Anemi akut
Memperbaiki kapasitas daya angkut Oksigen darah setelah
status Vol. Intra Vaskuler di perbaiki
Perbaiki / Normalisasi status koagulasi
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Tindakan untuk
Memelihara
Mengganti Milien Interior dalam batas fisiologi
Dengan cairan Kristaloid / Elektrolit
Koloid / plasma exspanderSecara i.v
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Terapi Cairan untuk mengganti defisit cairan
Puasa sebelum dan sesudah pembedahan
Mengganti :Kebutuhan rutin saat pembedahan
Perdarahan
Cairan yang pindah ke ruang ke III
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Mengganti defisit cairan
Puasa
2 cc/kg BB / Jam
Kebutuhan Rutin
4- 2- 1
Perdarahan
20 % Kristoid
10 % pada anak tranfusin
Pembagian Cairan berdasarkan Komposisi
Kristaloid
Koloid
Campuran
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Monitor Adekuat terapi cairan
Observasi tanda vital
Pem. fisik
Intake Output
BB
urin Output
Kreatinin Serum
Monitoring Infansif
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INTRAVENOUS FLUIDS
A. CRYSTALLOIDS:
• COMPOSITION: SIMILAR TO EXTRACELLULAR FLUID
• INEXPENSIVE, AVAILABLE, NO CROSS MATCH, NO ALLERGIC / ANAPHILACTIC REACTION, SIMPLE STORAGE
• AS EFFECTIVE AS COLLOID IN APPROPIATE AMOUNT
• HALF LIFE IN INTRAVASCULAR SPACE: 20 – 30 MINUTES
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B. COLLOIDS
- NATURAL COLLOIDS:- PLASMA PROTEIN FRACTION 5%- HUMAN ALBUMIN 5% AND 2,5%
- SYNTHETIC COLLOIDS- DEXTRAN 40 AND 70- HYDROXYETHYL STARCH (HETASTARCH) 6% AND 10 % -GELATIN
- MODIFIED FLUID GELATIN - UREA LINKED GELATIN - OXYPOLY GELATIN
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CRYSTALLOID VS COLLOID
Crystalloid Colloid
Advantages - Inexpensive- Promotes urinary flow- Fluid of choice for initial resuscitation of trauma/hemorrhage- Expands intravascular volume- Restores 3rd spaces losses
-More sustained intravascular-Volume increase (1/3 still intravascular at 24 hrs)- Maintain or increase plasma oncotic pressure-Requires smaller volume for equal effects-Less peripheral oedem (more fluids remains intravascular)-May lower intracranial pressure
Disadvantages - Dilutes colloid osmotic pressure- Promotes peripheral oedem- Higher incidence of pulmpnary oedem- Requires large volume- Effects are transient
-Expensive-May produce coagulopathy (dextrans and hetastarch)-With capillary leaks may potentiate fluid loss to the interstitium-Impairs subsequent crossmatching of blood (dextran)-Dilutes clotting factors and platelet-Decrease platelet adhesiveness (absorption onto platelet membrane reseptor)-Potential blocking of renal tubules and reticuloendothelial cells in the liver-Possible anaphylactoid reaction with dextran
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Cairan Infus
Kristaloid
Koloid
Campuran
Cairan Kristaloid
BM rendah < 8000 Dalton
Dengan asam tanpa glukosa
Tek. onkotik rendah → cepat terdisbusi ke ekstrasel
Efek volume intersortial
potensial → edema paru, edema perifer
Mudah , murah, tidak beresiko,bebas reaksi
Cairan RL, RA, NaCl, D5 %.
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Cairan tanpa elektrolit
D 5% & D 10%
Cepat keluar sirkulasi
Mengisi ruang intersitial
Hanya 5% yang tinggal di sirkulasi
Tidak tepat terapi hipovelemik
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Cairan infus yang di berikan
1. Kristaloid
2. Koloid
3. Campuran
Cairan Koloid
BM tinggi > 8000 Dalton
Tek. Onkotik tinggi → di intravasculer lama
Jarang → edema perifer
Resiko , alergi , ARF, gangguan himolitik
Cairan internal, Albumin , FPP,
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Koloid / Plasma exspander
Dapat berupa
Polimer dexstrosa → dexstra 40/70
Gelatin →Hemacin,Gelafindin,Gelafusin
Turunan Kanji – HES = Hidroksil,etil, STA CCH
Terapi cairan
Resusitasi → Mengganti kehilangan akut
Expafusin,fima HES, Wida HES
Kristaloid
Koloid
Rumatan → Monitor kebutuhan harian
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Distribusi cairan iv → 1 lt untuk 20 kg dalam 1 jam
Larutan Plasma Intersitial IntraAlbumin 5%
Polygelatin
Dexstran 40
Dexstran 70
NaCl 0,9 %
KCl
D 5%
1000
700
1600
1300
200
200
83
-
300-260-130
800
800
333
-
-
-340
-170
-
-
583
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Koloid Natural
Plasma protein
Human, serum Al bumin
FFP
Koloid artificial/ sintetik
Dextran
Gelatin
Hydroxyethil
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Plasma protein
Sebagai pengganti cairan4% & 5% larutan plasma protein yang di
pasteurisasiMengandung - 15% Globulin - 85% AlbuminPenggunaan : Mengganti cairan pada kasus kehilangan protein tetapi tidak sebagai sumber nutrisi
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Human Serum Albumin
20% dan 25% larutan HSA Dihasilkan dari plasma manusia / placenta BM 69.000 D Penyebarannya merata Mempunyai - kapasitas tekanan onkotik - Kapasitas ikatan Air : 17 ml Air / gram Albumin Pengganti cairan ideal Mahal Penggunaan : Sebagai pengganti volume pada kasus hipovolemi dan proteinemi (Protein < 5 gr/ml)
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Fresh Frozen Plasma (FFP)
Dipisahkan dan dibekukan dalam 6 jam setelah diambil dari donor
Sebagai pengganti cairan dgn resiko infeksi Hepatitis & AIDS
Kurang efektif
Indikasi pada : - Pengganti isolaties banyak faktor dan pembekuan - Coumarin antagonis - Transfusi darah massive - Defiasi anti trombin III - Therapi / defiasi Imune - Therapi / Trombocytofeni
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Koloid Artificial / Sintetik
Volume sebanding dengan koloid natural
Tidak ada resiko infeksi
Mudah dan tidak mahal Sehingga koloid artificial >> digunakan dari padakoloid natural sebagai pengganti volume.
Efek Samping : - Resiko Alergi & Anafilaktoid - Gangguan Hemostatik
- ARF - Gangguan Cross match - Overload
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Dextran Ada 2 macam larutan : Dextran 40 BM 40.000 Dextran 70 BM 60.000
Larutan D-40 : Larutan 10% dlm NaCl 0,9% Larutan D-70 : Larutan 10% dlm NaCl 0,9%
Larutan D-40 : - Hiper onkotik terhadap plasma - Setiap Gr D-40 : - Menarik 20-25 ml H2O = 2x - Exvesi Ginjal - Redistribusi ke interstesial
- 4 Jam di Intravascular - Setiap Gr D-70 : - Menarik 200-500 ml.
Indikasi : - Syok Hipovolemik - Memperbaiki aliran darah perifer
Dosis : 1,5 – 2 gr / kg BB / Hr ~ 20 cc / Kg BB / Hr
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Gelatin / Haemacel BM 35.000 bervariasi 5000 – 50.000 Waktu paruh dalam plasma ekspander 2-3 Jam Mengandung 3,5% larutan polygelatine + Na+K+Ca+Cl Tekanan onkotik 25-28 mmHg Efek Volume 2x Tidak ada efek : - Gangguan pembekuan darah/
fibrinolitik - Gangguan Cross Match
Efek Samping : Histamin reaksase berupa : Pruritus, Rash, Fushing, Urticaria
Dosis : < 2,5 L / Hr
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Hydroxy Ethyl Starch (HES)
Tepung sintetik mirip glikogen
BM 450.000 HES 450 / 0,7 200.000 HES 200 / 0,5 40.000 HES 40 / 0,5
Indikasi : - Hipovolemi - Syok pd pembedahan, Trauma,Sepsis dan luka bakar
Efek samping : - Coagulopati - … Paru - Anafilaksis
Dosis : 20 cc / Kg BB / Hr
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Pembedahan Trauma Perdarahan Lain
Perdarahan
Penilaian kehilangan darah (%)
< 20% 20 – 40%40 – 50% 60 – 100 % > 100%
Nihil Kristaloid
1-2 Unit SDM + Krist ~ Darah Lgkp
SDM + Plasma Koloid
SDM + Plasma Koloid
Darah lengkap
Trombosit
FFDP,SPPS,Koloid
Darah lgkp/SDM+FFP/
Darah lgkp+FFP/FFDP SDM+FFP/FFDP+SPPS
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