Terapi Cairan.ppt
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TERAPI CAIRAN
Widyati, MClin Pharm, Apt
Departemen Farmasi Rumkital Dr. Ramelan
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PENDAHULUAN• TUJUAN: atur cairan tubuh, nutrisi, akses iv• KAPAN ? Shock, dehidrasi, perdarahan, anoreksia,
bowel rest, kelainan GIT, perioperative.• Terapi Cairan: pasok air+ elektrolit+nutrien• KOMPOSISI AIR (60% BB):• INTRASEL : 40-45%• INTERSTITIAL: 11-15%• VASKULAR (plasma): 5%
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OSMOLALITAS
Konsentrasi zat terlarut (elektrolit, glukosa, urea, fosfolipid, cholesterol, dan lemak) dlm 1 kg air.
Plasma osmolalitas dan tonisitas dipelihara melalui keseimbangan intake dan ekskresi air
Perubahan tonisitas plasma dideteksi oleh osmoreseptor di hypothalamus
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Electrolyte solutionsElectrolyte solutions
PlasmaPlasma IsotonicsolutionsIsotonicsolutions
Hypotonic solutionsHypotonic solutions
Normalsaline
Ringer’sacetate/ lactate
KAEN 3B*
290 308 273
278
D5
290278
* KAEN 3B : contains 50 mmol Na+, 20 mmol K+, 50 mmol Cl-, 20 mmol lactate, 27 g dextrose per L.
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BASIC PRINCIPLESBASIC PRINCIPLES
Replace Replace
Maintain Maintain
Repair Repair
Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock
Abnormal loss: GIT, 3rd space,Ongoing loss, septic and Hypovolemic shock
IWL + urine IWL + urine
Acid base, electrolyte imbalancesAcid base, electrolyte imbalances
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RESUSCITATIONRESUSCITATION MAINTENANCEMAINTENANCE
NUTRITIONNUTRITIONCrystalloidCrystalloid
1. Replace acute loss (hemorrhage, GI loss, 3rd space etc)
1. Replace acute loss (hemorrhage, GI loss, 3rd space etc)
1. Replace normal loss (IWL + urine+ faecal)2. Nutrition support
1. Replace normal loss (IWL + urine+ faecal)2. Nutrition support
ELECTROLYTESELECTROLYTES
FLUID THERAPYFLUID THERAPY
Colloid
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TERAPI RESUSITASI
• Dosis: (Vol Deplesi x 1/3) + Terapi rumatan + Terapi pengganti
• Penggantian bertahap
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TERAPI RUMATAN
• Berikan volume setara dg ekskresi harian
• Terapi cairan juga sbg pengganti makanan
• Kebutuhan cairan bila intake oral • Vol Urin + 700 mL=Vol Infus
• DOSIS: air 2000-2200 ml/hari, Na 80-100mEq/hari, K 40-50 mEq/hari.
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Crystalloids: Replacement fluids • Crystalloid = a solution of crystalline solid dissolved in water• Generally are polyionic isotonic fluids • Ringer's, Lactated Ringer's (RL)• 0.9% NaCl (normal saline) is an isotonic solution of Na, Cl, and
water • 5% dextrose is an isotonic solution of dextrose in water; the
dextrose is rapidly metabolized, thus this essentially results in the administration of free water
• Commonly administered during general anesthesia to diminish the cardiovascular effects of anesthetic drugs and replace ongoing fluid losses
• May need to infuse 40 – 90 ml/kg/hr during shock using multiple catheters or fluid pumps
• Replace acute blood loss by administering 3 volumes of crystalloid solution for each 1 volume of blood lost
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Crystalloids: Maintenance fluids
• Generally are low in Na and Cl, and high in K • eg, 0.45 % sodium chloride, 2.5 % dextrose
with 0.45 % saline, KaEN • Generally polyionic isotonic or hypotonic
fluids • Used for long term fluid therapy, such as the
ICU setting; not generally used during anesthesia
• May or may not contain dextrose
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Laju Kecepatan Pemberian Elektrolit &
glucose
Laju Kecepatan Pemberian Elektrolit &
glucose Na+ 100 mEq/hr
K+ 20 mEq/hr
Ca++ 20 mEq/hr
Mg++ 20 mEq/hr
HCO3
- 100 mEq/hr
Glucosa 0,5 gr/kg/hr ( 4
mg/kg/min)*
Na+ 100 mEq/hr
K+ 20 mEq/hr
Ca++ 20 mEq/hr
Mg++ 20 mEq/hr
HCO3
- 100 mEq/hr
Glucosa 0,5 gr/kg/hr ( 4
mg/kg/min)* * Neonates 6-8 mg/kg/min* Neonates 6-8 mg/kg/min
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Colloids
• Synthetic colloids are polydisperse (various molecular weight) and do not readily cross semipermeable membrane.
• Hypertonicity pulls fluids into the vascular space and increase blood volume which effect is longer lasting compared to crystalloid therapy.
• solutions of starch or dextrans (of various molecular weights) • smaller volumes of colloids are as effective as larger volumes of
crystalloids in maintaining intravascular fluid volume • historically have had a number of problems associated with their
use, including allergic reactions, impaired coagulation, and renal damage; solutions available now have less problems associated with their use
• expensive compared to crystalloids Composition of Several Colloidal Fluids
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PEMILIHAN CAIRAN PADA BERBAGAI PENYAKIT
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HYPONATREMIA
ISOTONIK HYPONATREMIA : Hyperproteinemia, hyperlipidemia
HYPOTONIK HYPONATREMIA:• Hypovolemic: Dehydration, Diarhhea, Vomiting,
Diuretics, ACE inhibitors, Mineralocorticoid deficiency.• Euvolemic: SIADH, Postoperative hyponatremia,
hypothyroid, endurance exercise.• Hypervolemic: Edematous state at CHF, CH, NS,RF HYPERTONIC HYPONATREMIA: Hyperglicemia,
Mannitol, sorbitol, maltose
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TREATMENT
• Symptomatic Hyponatremia: usually seen in Na < 120meq/L, if there are CNS symptom correct Na rapidly 1-2 meq/L/h no more 25-30meq/L with NaCl 3% + furosemide
• Asymptomatic hyponatremia: water restriction, 0,9% NaCl
• Hypervolemic Hypotonic Hyponatremia: water restriction , diuretics, 3% NaCl + furosemide, dialysis
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HYPOKALEMIA
• Symptoms: muscle weakness, fatigue, muscle cramps, constipation, ileus, broadening T waves, depressed ST segment.
• Treatment:KCl sol + juice, KCl tablet, iv KCl in severe hypokalemia with rates of up to 40 meq/L/h (drip)
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TRAUMA KEPALA
• Pasien dengan trauma kepala maupun stroke: stres metabolik hipermetabolism/hiperkatabolisme, hiperglikemia, respon fase akut, dan perubahan sistem imunitas.
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TRAUMA KEPALA
• Trauma kepala tertutup: ICP, HT sistemik• Perhatikan kadar Na• Bila Na Normal atau tinggi:KaEN 3B, D5 ½ NS• Bila Na rendah:restriksi cairan,NS,• Perhatikan kadar Glukosa• Bila Hipoglikemi: KaEN MG3, D5 ½ NS• Bila Hiperglikemi: KaEN 3B
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TRAUMA KEPALA(LANJUTAN)
• Bila Hipotensi
• Hipotensi pd Trauma Kepalaiskemi
• Terapi cairan perfusi jaringan
• Pemilihan Cairan: RL or NS 3% (resusitasi) sampai BP90 mmHg (systole)
• Monitoring: BP, Glukosa, Na
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TRAUMA SPINAL
Shock Neurogenic
Deplesi Relative Intravascular
Resusitasi: RL
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GANGGUAN FUNGSI HATI
• Batasi asupan Na pada CH dg ascites
• Rumatan Hepatitis: asam amino ( Amino leban, Tutofusin LC)
• Rumatan pada HE pilih BCAA (Comafusin Hepar)
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Gangguan Fungsi Ginjal
• Pada GGK; umumnya batasi asupan K pilih RL untuk maintenance
• Rumatan: AA esensial untuk memenuhi kebutuhan AA namun meminimalisasi uremia (Kidmin)
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CAIRAN sbg AKSES IV
• Cairan yg kompatibel: D5, NS
• Dicampur ke dalam cairan, kemudian diinfuskan selama 30’-60’atau 24jam (Dopamin,Heparin). Waspada kompatibilitas.
• Disuntikkan pada injection site dengan cairan infus yang tetap dialirkan.
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NUTRISI PARENTERAL
• Def: pemenuhan semua atau sebagian kebutuhan nutrien secara intravena.
• Indikasi Nutrisi Parenteral (Hill, 2000):o Tidak mendapat asupan makanan oral selama > 7
hario Pankreatitiso Keadaan saluran cerna yang tidak memungkinkano Reseksi usus o Malnutrisi
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NUTRISI PARENTERAL(LANJUTAN)
• PERIFER• Puasa 3-5hr, makan <75%
3hr, malnourished dg alb<3mg/dl,
• Via vena perifer• Komposisi: karbohidrat
10%, AA 5%,Lipid,mikronutrien
• Osmolaritas: < 900 mOsm/l
• Midline cath kurangi flebitis
• CENTRAL• Puasa > 5hr, malnutrisi,
bowel resection• Via vena central
(subclavia)• Komposisi:
karbohidrat,AA,Lipid, mikronutrien
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NUTRISI PARENTERAL
• KARBOHIDRAT : D5%,D10%,D40%,TRIOFUSIN,MANNITOL
• PROTEIN:• Panamin G, TUTOFUSIN, INTRAFUSIN, EAS,
AMINOLEBAN,AMIPAREN• PROTEIN+KH+ELEKTROLIT: AMINOVEL 600• LIPID: • ELEKTROLIT: RL,NS,RD,ASERING
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NUTRISI ENTERAL
• Nutrisi enteral adalah pemenuhan nutrien langsung melalui saluran cerna.
• Indikasi: tidak mendapat asupan makan secara oral sedangkan saluran cerna masih berfungsi baik
• Kelebihan nutrisi enteral dari parenteral adalah mengurangi resiko sepsis, penggunaan saluran cerna lebih fisiologis daripada parenteral dimana resiko atrofi vili usus tidak ada
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NUTRISI ENTERAL (LANJUTAN)
• cara: pemasangan nasogastric tube pada pasien yang “gag reflex” masih baik, nasoenteric tube, gastrostomy tube, dan jejunostomy tube.