Fluid Managementuntuk Mahasiswa Saja

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Fluid Management

SupartoAnesthesia Department

Medical Faculty Christian Krida Wacana University


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Osmosis

Osmosis is the movement of water (solvent

molecules) across a semipermeable membrane

from a compartment in which the nondiffusable

solute (ion) concentration is lower to acompartement in which the solute concentration

is higher (Ganong 2003)


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Osmotic pressure

Is the pressure that must be applied to the

side with more solute to prevent a net

movement of water across the membrane to

dilute the solute


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Osmolality is the number of particles (osmoles) in

a kilogram of fluid;

Osmolarity is the number of particles in a liter of

fluid.

These terms are often used interchangeablybecause the density of water is 1 kg/L. Normal

serum osmolality is around 285-295 mOsm/L.


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Tonicity, describe the osmolarity of a solution

relative to plasma Isotonic, solutions that have the same

osmolarity as plasma (no transfer of fluid intoor out of cells occurs)

Hypertonic, those with higher osmolarity (cellsshrink)

Hypotonic, those with lower osmolarity (cells

swell)


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Jenis dan Jumlah cairan tubuh

Cairan tubuh 60%

CES 20% CIS 40%

Cairan interstitial

15%

Plasma darah

5%


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Distribusi cairan tubuh manusia dewasa:

Total Body Water :

(M) 60% BB (600ml/kg) (F) 50% BB (500ml/kg)

Whole Blood (M) 66ml/kg, (F) 60 ml/kg

Blood represents about 11-12% of the total bodyfluid Marino PL. The ICU Book 3rded; 2007: 211-229

Average blood volume(Morgan & mikhails Clinical Anesthesiology, 5thEd)

Neonates: Premature 95 ml/kg, Full term 85 ml/kg

Infants 80 ml/kg

Adult: Men 75 ml/kg, Women 65 ml/kg


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In nonobese individuals, the blood volume varies in

direct proportion to the body weight, averaging 70

ml/kg for lean men and woman (stoelting 4thed; 658)


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Kebutuhan pada orang dewasa

Air 25-40ml/kgBB/hari, or 1.5ml/kg/jam

Kalium 1mEq/kgBB/hari

Natrium 2 mEq/kgBB/hari


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Holliday-Segar Formula for Maintenance Fluid

Requirements by Weight

Wt (kg) Water

ml/day ml/hr

0-10 100/kg 4/kg

11-20 1000+50/kg for

each kg >10

40+2/kg for

each kg >10

>20 1500+20/kg for

each kg >20

60+1/kg for

each kg >20


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Faktor modifikasi kebutuhan cairan

Kebutuhan Ekstra Penurunan kebutuhan

Demam (10%-12% setiap

1C >37C)

Hiperventilasi

Suhu lingkungan tinggi

Aktivitas ekstrem

Setiap kehilangan

abnormal

Hipotermia (12% setiap 1C


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What Fluid?


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Pemberian Infus

Terapi Cairan

Resusitasi Rumatan

KoloidKristaloid Elektrolit Nutrisi

Ring As

Ring Laktat

Ringer fundin

Gelofusine

Hes

Dextran

Albumin

Aminofluid

KAEN

Clinimix

Aminofluid


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Type of Fluid

Crystalloid (RL, NS, D5%)

Small molecules (< 8000 dalton)

Colloid (Albumin, Dextran, Hetastarch) Large molecules (> 8000 dalton)

Red blood cells (WB, PRBC)

To increase the oxygen carrying capacity of blood


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Crystalloid VS Colloid resuscitation


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Crystalloid:

Distributed in the

extracellular fluid

only 25% of the infused

volume will remain in thevascular space and expand

the plasma volume


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Crystalloids are categorized by their tonicity, a

synonym for osmolality. A fluid that's isotonic has thesame number of particlesthe same osmolalityas

plasma.

Therefore, an isotonic solution won't promote the

shift of fluids into or out of the cells, causing them to

swell or shrink.

Ringer Asering and lactated Ringer's (LR) solution are

two of the most commonly used isotonic fluids.


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Dextrose 5% in water (D5W) is another isotonic

crystalloid. However, it's not used for resuscitation

because, as its glucose is metabolized, this fluid

quickly becomes hypotonic. In fact, D5W is a good source of free water. As with

other hypotonic fluids, such as 0.45% NS, the water

quickly shifts out of the vascular bed and into the

cells, by way of osmosis.


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Colloids

Advantages

Volume expansion

Longer duration of

action

Disadvantages

Anaphylaxis

Expensive

Poss coagulopathy


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Crystalloids

Advantages

Easily available

Free of anaphylactic

reaction

Economical

Disadvantages

Shorter duration of

action


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P i i fl id


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Perioperative fluid management

Female 25 yo. 50 kg for tonsilectomy

NPO for 8 hours.


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Preoperative fluid deficit

NPO deficit: 1.5ml/kg/jam x 8 jam = 75ml/jam

Replace in 1sthour, 2ndhour, 3rdhour

600 ml deficit: 300ml 1st, 150ml 2nd, 150ml 3rd

OR

4x10 + 2x10 + 1x30 = 90ml/jam x 8 jam = 720ml


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Intraoperative fluid requirement

Preop deficit: 600ml

Maintenance: 1.5ml/kg/jam: 75ml

Replace redistribution and evaporative surgical fluid

losses (controversial) : 2ml x 50kg = 100ml

Blood loss

Degree of tissue trauma Additional fluid requirement

Minimal (herniotomi) 0-2 ml/kg

Moderate (cholecystectomy) 2-4 ml/kgSevere (bowel resection) 4-8 ml/kg


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Replacing blood loss

Hb


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Case: female, 50Kg, ht 35% How much blood loss will decrease her hematocrit

to 30%?

Estimated blood volume: 50kg x 70ml = 3500ml

Red blood cell volume35% = 3500ml x 35%= 1225ml

Red blood cell volume 30% = 3500ml x 30%= 1050ml

Red cell loss at 30%= 1225-1050 = 175ml

Allowable blood loss= 3x 175ml = 525ml


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Clinical guidelines:

1 unit PRC will increase Hb 1 g/dl and Ht 2-3% in

adults

10 ml/kg transfusion of PRC will increase Hb by 3g/dl and Ht 10%


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Tatara T, Nagao Y, Tashiro C. The effect of duration of

surgery on fluid balance during abdominal surgery: a

mathematical model. Anesth Analg 2009; 109:211-6

Showed that infusion rates of between 2-18.5ml/kg/h insurgery of duration 6 h, the therapeutic window

narrowed to between 5-8 ml/kg/h, after which asignificant increase in interstitial fluid was seen


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Introduction to shock

Combination of hemodynamic parameters

Mean Arterial Pressure < 60 mmHg

Systolic blood Pressure < 90 mmHg

Clinical: UO

Metabolic Acidosis

Kegagalan sirkulasi dlm mencukupi kebutuhanO2 jaringan tubuh

First.Identify the cause of shock

Reverse tissue hypoperfusion


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Class III

Loss 30-45% of BV (20-30ml/kg) Decompensated phase (hypotension, UO 2 mEq/L)

25 ml/kg

Class IV

Loss > 45% (>30ml/kg)

Irreversible phase (UO 4 to 6 mEq/L)

35 ml/kg


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Severity of Blood Loss

Variable I II III IV

SBP Normal Normal

Pulse 100 >120 >140

RR 14-20 20-30 30-40 >35

Mental

status

Anxious Agitated Confused Lethargic

BL (ml) 2000

BL (%) 40


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Stadium Shock

Stadium Kompensasi:

Transcapillary refill replenish 15% of blood

volume (interstitial fluid into capillaries)

Sekresi Vasopressin, RAA retensi air, sodium

dlm sirkulasi refleks simpatis

Resistensi sistemik

Resistensi Arteriol diastolic pressure

HR

Manifestasi: taki, gelisah, kulit pucat dan dingin,

pengisian kapiler lambat (> 2 detik)


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Stadium Dekompensasi:

Perfusi jaringan buruk O2

Metabolisme anaeroblaktat asidosis

Penumpukan CO2Asam Karbonat

Kontraklititas miokardium terhambat

Gangguan metabolisme energy Na+/K+ pump di

tingkat selulerKerusakan sel

Pelepasan mediator vaskuler: histamin, serotonin,cytokines

Vasodilatasi arteriol

Permiabilitas kapiler venous return , Cardiac output

Manifestasi: taki, TD , oliguria, kesadaranmenurun, asidosis, perfusi perifer buruk


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Stadium Irreversible

Kerusakan dan kematian selmulti organ

failure

Manifestasi: nadi tak teraba, TD takterukur, anuria


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The end point of the fluid resuscitation

phase is

restoring peripheral perfusion and BP and

returning increased heart rate toward

normal.


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Atasi penyebab

Traditional end point of volume

resuscitation

MAP 65-70mmHg

Capillary refill time < 2 seconds

UO > 0.5 ml/kg/hour (adults)

O2 ssat > 95%

CVP 8-12 mmHg


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Kasus:

Seorang laki-laki 55 tahun, 60 kg, datang ke UGD dengan

kesadaran menurun. Riwayat diare dan muntah 1 hariSMRS.

PF: KU: tampak lemas, Sakit sedang. TD 90/45mmHg, HR120x/min, RR 25x/min, T 38C, mata tampak cekung, bibir

dan mukosa mulut sangat kering, turgor kulit menurun,lain2 dalam batas normal


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DEHIDRASI


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Back to the case.

Kasus:

Seorang laki-laki 55 tahun, 60 kg, datang ke UGD dengankesadaran menurun. Riwayat diare dan muntah 1 hari

SMRS.PF: KU: tampak lemas, Sakit sedang. TD 90/45mmHg, HR120x/min, RR 25x/min, T 38C, mata tampak cekung, bibirdan mukosa mulut sangat kering, turgor kulit menurun,lain2 dalam batas normal


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Step I: focus on emergency management

IV fluid 20ml/kg isotonic crystalloid

Additional boluses if needed

Step II: focuses on deficit replacement

daily fluid requirements (100-50-20) +

Fluid deficit Total step II:

of the volume administered in 8 hr

of the remainder administered in 16 hr

Check electrolyte

*Emedicine.medscape.com


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Case

Defisit: 60 kg x 10% = 6 kg = 6 L = 6000 ml

Bolus: 20 ml x 60 kg = 1200 ml/30 menit-1 jam

Sisa defisit: 4800 ml

50% (2400 ml) dalam 8 jam pertama

50% (2400 ml) dalam 16 jam berikutnya

Terapi Cairan dan Elektrolit SMF Anestesi & Terapi intensif FK UNDIP

dr. Ery Leksana, Sp.An.KIC


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Hb and Hct

Poor correlation between blood volume defisit

and Hb in acute hemmorrhage,dilutional

decrease in Hb and Hct, NEVER be used toevaluate acute blood lossMarino PL. The ICU Book 3rded; 2007:211-229

Appropriate treatment of hypovolemia is

volume replacment!!


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Estimating the Volume Resuscitation Volume

1. Estimate normal blood volume2. Estimate % loss of blood volume

3. Calculate volume deficit

4. Determine resuscitation volume


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Example:

M, ideal body weight 70 kg with GI bleeding, HR 135

bpm, class II hemorrhage (15ml/kg)

15x70 = 1050ml

Crystalloid: 1050/0.25 = 4200ml

Colloid: 1050/0.75 = 1400ml

Resuscitation with crystalloid 3x than with colloid


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Conclusion

Understand the stages of hypovolemic shockand associated pathophysiological changes

Early detection of compensated shock so that

fluid can be given adequately Know how much fluid must be given

Indication of blood transfusion

How to know the success of resuscitation


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Tell me, Ill forget

Show me, I may remember

But involve me and Ill understand

Thank you

Fluid Managementuntuk Mahasiswa Saja

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